Every finding on record at Remington Transitional Care of Richardson

Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #1 received care in accordance with professional standards when the resident, who was diagnosed with type II diabetes, did not have any orders or monitoring tools to monitor for hyper/hypoglycemia when he re-admitted to the facility on [DATE]. This failure could place residents at risk of not receiving appropriate treatment, which could result in a decline in health and serious harm. Findings included: Record review of Resident #1's face sheet, dated 08/29/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included Metabolic Encephalopathy (brain does not function properly due to underlying metabolic disturbances), End Stage Renal Disease (kidneys have permanently lost most of their function and no longer adequately filter waste products and excess fluid from blood), Type 2 Diabetes Mellitus with Hyperglycemia (chronic condition characterized by blood sugar (hyperglycemia) due to the body's inability to use insulin effectively). Record review of Resident #1's care plan, dated 08/08/25, reflected Resident #1 was diagnosed with Diabetes Mellitus. The facility's interventions included: checking fasting serum blood sugar as ordered by doctor, monitoring, documenting, and reporting as needed any signs or symptoms of hyperglycemia or hypoglycemia, monitoring, documenting, and reporting as needed any signs and symptoms of infection to any open areas which included redness, pain, heat, swelling or pus formation., and a dietary consult for nutritional regimen and ongoing monitoring.Further review of this document reflected Resident #1 was not care-planned for a behavior of refusing care or treatment. Record review of Resident #1's order summary report, dated 08/11/25, reflected the following:Hyperglycemia and Hypoglycemia monitoring every shift for diabetic monitoring for diabetic monitoring. Start date 08/11/25; end date: 08/18/25. Record review of Resident #1's PPS MDS Assessment, dated 08/14/25, reflected BIMS was incomplete without any codes. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to substantial assistance with most ADLs. For mobility, Resident #1 required substantial assistance with most mobility activities and required a manual wheelchair. Record review of Resident #1's progress notes from MD on 08/23/25 at 09:13AM reflected the following: Chief complaint: Encounter for pain management. History of Present Illness (HPI): Visit for chronic pain management after recent re-admission to the facility. Recently hospitalized for a syncopal episode (sudden fainting) secondary to a drop in blood sugars and blood pressure. [Resident #1] Has no memory of the event or transport to the hospital. [Resident #1] Reports he was told he complained of difficulty breathing at the time. [Resident #1] denies any recent falls. [Resident #1] Reports current pain management regimen is effect, allowing participation in therapy services. Record review of Resident #1's hospital records, dated 08/26/25, reflected in part the following: admit date and Time: 8/26/2025/4:49 AMHistory of present illness: [Resident #1] is a 66 y.o. male and presents with new back pain after [Resident #1] fell out of his bed early this morning August 26, 2025 at his nursing home and also present with new confusion. Bedside nurse also reports recent administration of IV glucose as [Resident #1] is hypoglycemic (low blood sugar) with blood sugar in the 50s.POCT Glucose:-08/26/25 at 5:32 AM- 91 (reference range 70-110 mg/dL)-08/26/25 at 8:31 AM- 74 (reference range 70-110 mg/dL). An interview on 08/29/25 at 08:00AM was attempted with Resident #1's RP; however, she was unavailable to be interviewed. In an interview and observation at the local hospital on [DATE] at 08:25AM, Resident #1 stated he was at the hospital due to hurting his back from a fall. Resident #1 stated he fell out the bed on 08/26/25 at approximately 4:00AM when he attempted to turn over. Resident #1 could not recall if he felt weak or fatigued at the time of fall. Resident #1 stated he was diabetic, and the facility was aware. Resident #1 stated he told the facility that he needed a snack at 12:00AM and 4:00AM due to low blood sugar; however, he could not remember if he was receiving them. He also stated the facility did not check his blood sugars. Resident #1 was expressive and receptive to language; however, he seemed to have confusion regarding details of events. Resident #1 was lying in hospital bed with no visible marks, bruises or obvious injuries. In an interview on 08/29/25 at 12:32 PM, CNA A stated she was employed at the facility for 5 months. She stated she worked on the first floor East and West. She also stated she picked up additional shifts but mainly worked in the morning. She stated she worked the night shift on 08/25/25. CNA A stated she first worked with Resident #1 on the night on 08/25/25, and she was not aware that the resident was diabetic. CNA A stated she did not know that Resident #1 was supposed to get a snack at nighttime. She stated the nurses gave snacks to the diabetic residents. She stated there were snacks in a refrigerator available for all residents. CNA A stated she did not know Resident #1 if Resident #1 was getting his blood sugar checked because the nurses were responsible for doing it if needed. In an interview on 08/29/25 at 01:30PM, the MD stated he had been a doctor for over two decades. The MD stated Resident #1 was his patient at the local hospital as well as the facility. The MD also stated he was familiar with the case. The MD stated although resident was diagnosed with type II diabetes, he was not insulin-dependent; therefore, he did not need an order for any insulin or oral medication for diabetes. The MD stated he refused to order treatment or monitoring for Resident #1's diagnosis of type II diabetes. He stated Resident #1 had previously refused medication for his diabetes. The MD also stated resident was non-compliant with care and would not have allowed staff to check his blood sugar, so he was not going to order it. The MD also stated Resident #1's diabetes was diet-controlled; however, he was unable to say how Resident #1's diabetes was monitored without any MD orders in place. The MD stated resident received bloodwork when he was in the hospital and his A1C levels (test to measure average amount of sugar in blood) indicated he was no longer diabetic. The MD stated Resident #1 had problems of weakness which caused his falls due to renal failure and non-compliance with dialysis and had nothing to do with the MD or facility doing anything wrong. The MD stated even at home, Resident #1 was non-compliant with dialysis and did not his check blood sugar. The MD stated low blood sugar could possibly cause weakness. He stated some other symptoms included was sweating, shakiness and confusion. The MD contributed Resident #1's overall weakness and decline in health to end-stage renal failure and non-compliance with dialysis and care but was unable to state how diabetes was being ruled out since it was not being monitored. In an interview on 08/29/25 at 1:54 PM, the DON stated Resident #1 was a diagnosed with diabetes and he was also on dialysis. She stated Resident #1 was very non-compliant with his dialysis treatments. She stated Resident #1 was also a fall risk because he thought he could still do things independently and refused to call for help. The DON stated Resident #1 went to the hospital on [DATE] after the nurse found that he was not acting like himself and was less responsive, and he was currently at the hospital after having a fall on 08/26/25. The DON stated Resident #1 also had a fall the previous day on 08/25/25, and both falls occurred around 3:00 AM-4:00 AM. She stated Resident #1 had multiple comorbidities and the incidents could have been caused by many things including weakness related to low blood sugar, missing dialysis treatments, and even from receiving dialysis treatments. The DON could not recall the MD giving specific orders for Resident #1 to have overnight snack for his blood sugar; however, she stated snacks are always offered to residents at bedtime, especially residents with diabetes. In an interview on 08/29/25 at 02:57PM, RN B stated she worked at the facility for 8 years, 6:00AM-6:00PM shift. RN B stated she did not know Resident #1; however, she worked with other residents who were diagnosed with diabetes. She stated not all diabetics required insulin. She stated she checked blood sugar levels per the MD orders. RN B stated some residents had blood sugars checked often, and others were only checked as needed. RN B stated while on her shift, she would assess all residents with diabetes for symptoms of hyperglycemia/hypoglycemia. RN B stated symptoms of hypoglycemia was sweating, confusion, slurred speech, lethargic, shaking, and weakness. RN B also stated a resident with type II diabetes could have falls. She stated if any diabetic residents had symptoms, she checked their blood sugar even without doctor's orders based on her training as a nurse. In an interview on 08/29/25 at 04:24PM, LVN C stated she worked overnights with Resident #1 on 08/25/25. LVN C around 10:00PM, she gave Resident #1 3 cups of jello and a protein snack, and the resident finished all of it. She stated Resident #1 did not display any signs of hypoglycemia before going to bed. LVN C stated although she assessed Resident #1 for hypoglycemia, she did not document it anywhere. LVN C stated if a resident had a blood sugar monitoring tool ordered, it would show on the MAR for the nurses to sign off on; however, Resident #1 did not have one in place when she worked with him on 08/25/25-08/26/25. LVN C stated she found Resident #1 on the floor around 3:00 AM on 08/26/25, and the resident told her that he had fallen out of bed and was in pain. LVN C stated she completed an assessment and checked his vital signs, and Resident #1 did not have any symptoms of hypoglycemia.; however, he was sent to the hospital due to complaining of pain in his head and back. LVN C stated as a nurse she knew to check for symptoms of hypoglycemia during any assessment for residents who were diagnosed with diabetes, even if there was not an order in place to do so. LVN C was able to state symptoms of hypoglycemia included sweating, shaking, and confusion. Further interview on 08/29/25 at 06:32PM, the DON stated it was her responsibility to ensure that residents had appropriate orders in place, and if they did not she would have to discuss it with the MD. She stated the facility would put a monitoring tool in place to assess all residents with diabetes for hypoglycemia and hyperglycemia; however, Resident #1 went to the hospital on 8/20/25 and the system discontinued all his orders. She stated it was her responsibility to ensure that all of Resident #1's orders were made active as appropriate when he returned to the facility, but she was working the floor that day and forgot to check them. The DON stated if a resident was diagnosed with type II diabetes with no physician orders or hyperglycemia/hypoglycemia monitoring tool in place, it could place the resident at risk of being hyperglycemic/hypoglycemic. The DON stated not everyone had the same signs and symptoms of hypoglycemia; however, some of the signs and symptoms included confusion, sweating, shakiness, and unresponsiveness which could include weakness. In an interview on 09/02/25 at 05:13PM, Resident #1's RP stated Resident #1 was admitted to the facility on [DATE]. Resident #1's RP stated while at the facility, Resident #1 had an incident where his blood sugar was low, and he became extremely lethargic for two days and the facility allowed him to sleep. Resident #1's RP stated staff attempted to talk to Resident #1, but he did not respond. Resident #1's RP stated he went to the hospital (on 8/20/25) and found out his blood sugar was low. The RP stated the facility was not checking the resident's blood sugars. The RP also stated there was a second incident at the facility when Resident #1 had a fall, and she believed that was also due to low blood sugar. The RP stated Resident #1 was currently still at the hospital with a fractured back. Investigator requested the facility's policy on diabetic care from the DON and was informed the facility did not have one. The DON stated they followed guidelines from American Diabetes Association.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items in the freezers were stored, sealed, and not exposed to air in accordance with the professional standards for food service. 2. The facility failed to ensure dented cans were placed in a separate storage area. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the walk-in freezer and dry storage on 06/10/2025 at 9:20 am revealed the following: - 1 food service company name stamped on box with a date of 5/15, no other label on box to identify item, the bag of hot dog/sausage links was in a large bag inside of the box that was left open and it was not sealed. - 1 6 lb 15 oz can of Pinto Beans best by date March 2027 dented on the front top right. - 1 6 lb 15 oz can of Pinto Beans best by date April 2027 dented on the front top seal. During an interview with Assistant DM on 06/11/2025 at 11:17 am, she said kitchen staff who removed food items from the freezer were responsible for putting the food item back in freezer, labeled with open date and properly sealed. Assistant DM said if there was not a great big dent (on cans) we'll keep it. She said if dented cans were used nothing could potentially harm the residents. Interview with the DM on 06/11/2025 at 11:20 am, revealed all kitchen staff who remove food items from the freezer were responsible for putting the food item back, labeled and sealed properly. DM stated if there's a big dent we'll keep it. She clarified a big dent is two fingers. The DM stated if residents were served food from a dented can, it could potentially harm them with botulism. On 06/12/2025 at 1:25 pm a record review of the facility's Food Storage Policy, dated October 1, 2018, section 3e revealed: store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record review of the facility's Food Storage Policy, dated October 1, 2018, there was nothing pertaining to can storage. On 06/12/2025 at 2:45 pm spoke to regional administration who stated the facility doesn't have a specific policy related to dented can's. Review of the U.S. FDA Food Code 2022 reflected: Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Review of the U.S. FDA Food Code Chapter 3 FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.

Based on interviews, and record reviews the facility failed to ensure residents who entered the facility received care and treatment consistent with professional standards of practice to prevent pressure ulcers and a resident with pressure ulcers receives necessary treatment and service to promote healing and/or prevent further development of skin breakdown or pressure ulcers, for one (Resident #282) of four residents reviewed for prevention and maintenance of pressure ulcers. The facility failed to ensure Resident #282, who was identified as entered the facility with a pressure sore to the sacrum and was at risk of developing additional pressure ulcers, received necessary treatment and services thru use of a low air mattresses, which was chosen as prophylaxis by the Wound Care physician to prevent the development of or worsening of pressure ulcers. This failure could place residents at risk of developing pressure ulcers or worsening of existing pressure ulcers. The findings included: Record review of Resident #282's 5-day MDS assessment dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE] and discharged from the facility on 05/10/2024. Resident #282 had diagnoses which included: hypertension (high blood pressure), non-Alzheimer's dementia (confusion), and pressure areas (skin condition). Resident #282 was a BIMs score of 3 reflecting she was severely cognitively impaired, and unable to make decisions for herself and required one staff for assistance with activities of daily living. Further review of Resident #282's reflected she was incontinent of bowel and bladder, was dependent of for transfers, and bathing. Resident #282 had one unstageable pressure ulcer upon admission, receiving pressure ulcer care. Review of Resident #282's comprehensive plan of care dated 04/5/2024 with revisions dated 05/24/2024 reflected no noted goals or approaches for her behaviors related to her offloading her heels. Further review reflected, Problem: Resident #282 has pressure ulcers . left heel and right heel, that developed on 05/10/24, and unstable to sacrum (from admission) : goal: resident's pressure ulcer will show signs of healing and remain free of infection Intervention: Administer treatments as ordered . Focus: interventions: . pressure redistribution mattress as ordered by physician when in bed Further review reflected Problem: the resident is at risk for impaired skin integrity .goal the resident will understand the risks associated with my choice to not adhere to prevent skin breakdown and maintain skin integrity . Record review of Resident #282's May 2024 Physician Orders indicated . a group two pressure reduction mattress (low air loss rotating mattress) ordered 04/05/2024. Record review of Resident #282's May 2024 weight log indicated Resident #282 was 93 pounds. Record Review of Resident #282's Initial Wound Evaluations and Management Summary dated 05/10/2024 by Wound Care physician reflected two wounds: the left heel Length 3.0, Width 3.0 cm, Depth-not measurable and right heel Wound Size=Length 3.0, Width 1.0 cm., Depth- not measurable both with duration less than one day. The evaluation also reflected wound detail friction blister from rubbing heels on sheet. Record review of Resident #282's Skin-Acute Care Plan dated 04/05/2024 and revised 05/10/2024 documented Pressure Ulcer: unstageable lower sacrum .present on admission ., decreased mobility, incontinence, friction/shear . off-load wound, float heels and legs . group-2 Mattress (low air loss mattress) Approach: Pressure relief device: Air Mattress; Reposition every two hours; Treatment as ordered . In an interview on 06/10/2025 at 2:00 p.m. with Wound Care physician revealed she had provided care to Resident #282 during her stay at the facility. The Wound Care physician stated Resident #282 entered the facility with wounds on her sacrum and had developed pressure areas on her right and left heel while at the facility. The Wound Care physician stated she had met with the family and had instructed them on how a different type of mattress would be better than the mattress brought from the hospital, but the family felt the hospital's mattress was better. The Wound Care physician stated the resident was mobile in the bed and she would remove the pillows the staff was using to offload her feet and legs; the resident would throw them on the floor. The Wound Care physician stated this had opened the possibility for Resident #282 to develop wounds on her feet, since she would rub and lay her feet on the hard surface of the Group one mattress. Group two mattress would have allowed her feet to have alternating air pressure. The Group one mattress does not allow that. The Wound Care physician stated Resident #282 was here for a month, the mattress should have been changed during that time. The Wound Care physician stated, There would have been no guarantee the low air loss mattress would have helped, but how would we have known if we did not try. In an interview on 06/11/22024 at 02:33 p.m. RN E stated she was taking care of Resident #282 while she was here. RN E recalled going into Resident 282's room and she would be on a mattress overlay that was from the hospital. RN E stated not a mattress that the Wound Care physician would recommend, as it does not offer pressure protection. RN E stated the mattress is just a blow up that is placed over the mattress and then covered by a sheet. The Wound Care physician always recommends that the residents with high risk to develop skin issues should be on low air loss rotation mattress, allowing the body to have increased and decreased pressure at different time on each area of the body. RN E stated she did inquire as to why Resident #282 was not on a low-air loss mattress and was told the family had refused and wanted to use the mattress provided by the hospital. RN E stated that the resident was mobile in the bed and could remove the pillows that were placed under her heels and legs. The resident would remove the pillows and throw them on the floor consistently. RN E stated Resident #282 did develop wounds on the heels of her feet because she would remove the pillows and her feet would just sit on that hard blow-up mattress. Interview with the DON on 06/12/2025 at 2:00 p.m. revealed she was aware Resident #282 had a pressure ulcer upon admission and had developed pressure areas on each heel. Resident #282 used an air overlay mattress, from the hospital. The DON stated Resident #282's mattress had no adjustable air setting, it was just blown up and laid over the top of the mattress on the bed. The DON stated the purpose of the low air loss mattress was to prevent and treat pressure injuries, this is what the Wound Care physician had ordered, but the family did not want to use it. The staff tried to keep her feet offloaded with pillows, but the resident would remove them and throw them on the floor from the time that she admitted on [DATE] until she discharged on 05/10/24. Resident #282 never was on the ordered mattress (requested by the family) during her stay. The DON stated Resident did develop the pressure ulcers on both of her feet on 05/10/24. Review of the undated Medline Supra CXC Low Air Loss and Alternating Pressure Mattress Manufacturer Recommendations documented .Use for prevention and stage 1 through 4 pressure ulcers; pump alarms to indicate low pressure, Adjustable to patients' weight for customized therapy, 300 lb weight capacity .Directions for Use: .Pressure adjust knob controls the air pressure output. When turning clockwise the output pressure will increase. [NAME] versa for decreasing air pressure. Please consult your physician for a suitable setting . Record review of the facility policy titled Skin Management and Pressure Ulcer Prevention, dated 10/11/22, revealed the following [in part]: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, other altered skin integrity, and to provide treatment and services to heal pressure ulcer/injury and/or altered skin integrity, prevent infection and the development of additional pressure ulcers/injuries. It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and skin management. 1. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 2. Assessment of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale on all residents upon admission/re-admission, weekly x four weeks, then quarterly or whenever the resident's condition changes significantly. b. The tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include, but are not limited to: i. Impaired/decreased mobility and decreased functional ability: ii. Co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus. iii. Drugs such as steroids that may affect healing. iv. Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency. v. Resident refusal of some aspects of care and treatment. vi. Cognitive impairment. vii. Exposure of skin to urinary and fecal incontinence. viii. Under nutrition, malnutrition, and hydration deficits; and ix. The presence of a previously healed pressure injury. c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. d. Assessments of pressure injuries and altered skin integrity will be performed by a licensed nurse and documented on the Skin Observation Tool. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. e. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task.

Based on interview, and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's medical, nursing, and mental and psychosocial needs for one (Resident #282) of six residents reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan to address Resident #282's behaviors (pulling the pillows out under legs and feet and throwing on the floor) related to offloading of her heels to prevent pressure area to the heels. The family refusing to allow the pressure relieving mattress the wound care physician had ordered; instead used an inappropriate mattress overlay the family had brought from the hospital. This failure could place all residents at risk of not receiving individualized care and services to meet their needs. Findings included: Record review of Resident #282's 5-day MDS assessment dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE] and discharged from the facility on 05/10/2024. Resident #282 had diagnoses which included: hypertension (high blood pressure), non-Alzheimer's dementia (confusion), and pressure areas (skin condition). Resident #282 was a BIMs score of 3 reflecting she was severely cognitively impaired, and unable to make decisions for herself and required one staff for assistance with activities of daily living. Review of Resident #282's comprehensive plan of care dated 04/5/2024 with revisions dated 05/24/2024 reflected no noted goals or approaches for her behaviors related to her offloading her heels. Further review reflected, Problem: Resident #282 has pressure ulcers . left heel and right heel that had developed on 05/10/2024.: goal: resident's pressure ulcer will show signs of healing and remain free of infection Intervention: Administer treatments as ordered . Focus: interventions: . pressure redistribution mattress as ordered by physician when in bed Review of the Braden Scale for Predicting Pressure Sore Risk dated 04/05/2024 reflected Resident #282 was a candidate for High Risk due to sensory perception, moisture, activity, mobility, nutrition, friction, and shear. In an interview on 06/10/2025 at 2:00 p.m. with Wound Care physician revealed she had provided care to Resident #282 during her stay at the facility. The Wound Care physician stated Resident #282 entered the facility with wounds on her sacrum and had developed pressure areas on her right and left heel while at the facility on 05/10/2024. The Wound Care physician stated she had had met with the family and had instructed them on how a different type of mattress would be better than the mattress brought from the hospital, but the family felt the hospital's mattress was better. The Wound Care physician stated the resident was mobile in the bed and she would remove the pillows the staff was using to offload her feet and legs; the resident would throw them on the floor. The Wound care physician stated the mattress should have been changed this could have prevented the further develop of other wounds on the resident, and if we did not try how would we have known if it would work or not. In an interview on 06/12/2025 at 12:30 p.m. with the DON revealed the MDS Coordinator was responsible for all MDS assessments and comprehensive care plans and she (the DON) could not believe there was no mention of Resident #282's behaviors/family refusal related to her pressure areas treatment and prevention in the care plan. The DON stated she was aware of Resident #282's behaviors related to throwing the pillows on the floor that had been placed under her feet and legs, and the family refusing to use the ordered mattress by the Wound Care physician. The DON stated she wished the family would have agreed to the low air loss mattress. She stated the facility had tried to get the family to be involved, but they were not interested. The DON stated everything that was discussed should have been documented by the nursing staff and then placed in the plan of care. In an interview on 06/12/2025 at 1:00 p.m. with the MDS Coordinator revealed she was responsible for developing and implementing residents' care plans. The MDS Coordinator revealed she received her information about resident changes through the staff, the documentation or observation. MDS coordinator stated, Resident #282's behaviors related to her pressure ulcers (throwing the repositioning pillows on the floor and the family refusing to use the ordered mattress by the Wound Care physician)were unknown to her. If there were behaviors to address, she would certainly want to know and should have been told by the nursing staff. Review of the facility's Policy and Procedure Comprehensive Care Plans dated October 2022 reflected, . Compliance Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. B. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. 7. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care of treatment, and treatment alternative/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (Resident #63) of three residents reviewed for adequate supervision to prevent accidents. The facility failed to ensure resident safety, as evidenced by: The facility failed to ensure supplies for glucometer testing (blood sugar) and intravenous supplies (to give medication through veins) were secured or attended by authorized staff when LVN A's medication cart for Hall 100 was left with glucose testing solution, glucose testing strips, alcohol swabs, and clave connectors (to connect tubing for intravenous medication delivery) sitting on top of the cart. This failure could result in resident access and ingestion of prescribed treatment medications and obtaining harmful supplies leading to a risk for harm. Findings included: An observation on 06/10/2025 at 10:20 a.m. revealed LVN A was preparing to administer an intravenous antibiotic to a Resident #29 on Hall 100. LVN A told the surveyor she had to step away from her medication cart. The Hall 100 medication cart was left in the hallway outside of room [ROOM NUMBER] locked, not in direct site of the LVN in charge of the hallway. LVN A left the medication cart with: 1) Evencare glucose control solution (2 vials), 2) Evencare blood Glucose test strips (one box), alcohol swap pad (4), and calve connectors for intravenous tubing connectors (2) on top of the medication cart. An observation and interview on 06/10/2025 at 10:25 a.m. revealed an unidentified resident walking up to the unattended medication cart on Hall 100 and picking up one of the boxes of glucose testing solution. The unidentified resident told the surveyor he was just checking out what that was in case he needed it and then smiled and stated, I was just kidding, I was looking for the nurse for some pain medications. An observation and interview on 06/10/2025 at 10:47 a.m. revealed LVN A walked back to the medication cart on Hall 100. The LVN A immediately stated, she was so sorry the supplies had been left on top of the cart. LVN A stated she had obtained the supplies as she needed them to use later. The LVN stated after she obtained her supplies, she should have locked them up in the medication cart. LVN A stated the medication cart must not have any supplies or medications left on top of the cart unattended, so the residents, staff, and visitors could not take the medication/supplies that were on the cart and be endangered. In an interview on 06/12/2025 at 12:20 p.m. with the DON revealed the medication carts should never have any supplies or medications left on top of them unattended. The DON stated there would be more in-services completed to remind the staff of the importance of drug/supplies security. If the residents were allowed to get supplies off of the top of the carts, it could cause danger and possible injury to the resident. Review of the Policy and Procedure Medication Carts and Supplies for Administering Meds revised October 2019 reflected, The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents . med carts: 3. Do not leave the medication cart unlocked or unattended in the resident care areas procedure: 10. The licensed nurse or medication aide should maintain a clean top surface on the medication cart .

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #29) of four resident's observed for infection control in that: LVN A failed to clean the scissors prior to or after usage during Resident #29's treatments. Placing the unclean scissors back on the treatment cart. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: Review of Resident #29's 5-day MDS assessment, dated 05/26/2025, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: diabetes, diabetic wound of the right heel, post-surgical wound of the right, and heart failure. Resident #29 BIMs score of 15 indicated the resident had intact cognition. Review of the Resident #29's plan of care dated 05/21/2025 with updates reflected goals and approaches to include wound care to a surgical wound right planter foot and a diabetic wound to the right heel. Review of the consolidated physician orders dated May 2025 reflected: order dated 05/23/2025 cleanse diabetic wound right foot apply alginate calcium with silver once daily, cover with abdominal pad for the next thirty days, and cleanse the post-surgical wound of right planter foot daily and apply an abdominal pad and wrap with gauze roll daily for the next thirty days. Observation on 06/10/2025 at 1:00 p.m. revealed LVN A went to the treatment cart and started preparing to perform wound care for Resident #29's diabetic wound on the right foot and the post-surgical wound of the right planter foot. LVN A did use hand gel and washed her hands prior to collecting supplies. The LVN took the calcium alginate/silver from the package, took scissors out of the drawer, without cleaning the scissors cutting off the top of the package. The LVN put the scissors with the supplies without cleaning them. LVN A gathered her supplies and entered Resident #29's room. LVN A washed her hands, put on her gloves, and gown used the scissors to remove the gauze on the post-surgical wound. LVN A cleaned the wounds with normal saline and then applied the silver nitrate to the wound on the diabetic wound. LVN A did not clean the scissors prior to using to cut the clean gauze placed on the post-surgical wound on the right planter foot. LVN A placed the scissors on the overbed table, removed her gloves, washed her hands, then took the scissors out of the room placing them on top of the treatment cart, and then placed the scissors back in the drawer of the treatment cart without cleaning them. In an interview on 06/10/2025 at 1:20 p.m., LVN A stated she was to prepare before completing the treatment with gathering her supplies, placing them on a clean area in the room, wash her hands, and placed on her gown and her gloves. LVN A stated she did not think of cleaning the scissors prior to using them because they were on the treatment cart and she thought the scissors were already cleaned, she said she did not clean them afterwards because she was nervous about completing the treatments correctly. She stated the risk would be spread of infection. In an interview on 06/12/2025 at 12:25 p.m., the DON (also infection control coordinator) stated the expectation was for the staff to clean all equipment used prior to using on residents and after using on residents. That included all direct care equipment, which included scissors. The DON stated she would have to complete more infection control in-serves for equipment cleaning in between residents, she had just completed an in-service on infection control recently with all direct care staff. The DON stated the risk in not cleaning the scissors would be cross contamination. If performing treatments, the nurse was to provide a clean surface to place wound care supplies on, and equipment should always be sanitized before and after usage. Review of the in-services given in the past three months reflected an in-service dated May 10th, 2025, for infection control and cleaning of equipment. LVN A had attended the meeting. Review of the facility's policy Infection Prevention and Control Program dated May 2023, reflected, The facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the . of soiled contaminated equipment .development and transmission of communicable diseases and infections . 10. Equipment protocol. a. all reusable items and equipment requiring special cleaning, disinfection . shall be cleaned in accordance with our current procedures governing the cleaning.

Based on observation, interview, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 4 residents (Resident #1) reviewed for parenteral fluids. The facility failed to manage Resident #1's PICC line dressing per professional standards and per the physician's order. This failure placed residents at risk of developing an infection. Findings included: Record review of Resident #1's Admission MDS Assessment revealed the resident was a [AGE] year-old male, who admitted to the facility on [DATE] with the following diagnoses: Sepsis, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region; Pressure Ulcer of Sacral Region, Stage 4; and CKD. Resident #1 had a BIMS summary score of 15 which suggested intact cognition. The Admission MDS Assessment revealed Resident #1 admitted with a Central IV Access. Record review of Resident #1's care plan, initiated 05/01/24, reflected interventions for the care of the PICC line site that included routine inspection and dressing changes as scheduled and as needed. Record review of Resident #1's active Physician Orders reflected: - Start Date 05/01/2024: Monitor PICC line site for redness, tenderness, edema, excessive bleeding at site, chest/neck/ear pain, numbness or tingling of affected arm/hand. Notify MD of abnormal findings every shift. - Start Date 05/05/2024: Dressing change to PICC site one time a day every Sun. - Start Date 05/05/2024: Change needleless connector to each lumen one time a day every Sun for PICC patency. Record review of Resident #1's May 2024 TAR reflected the following orders were signed off by the ADON on 05/12/24: - Change needleless connector to each lumen one time a day every Sun for PICC patency at 8:00 AM - Dressing change to PICC site one time a day every Sun at 8:00 AM - Measure the circumference of the PICC line mid-upper arm QD and PRN every day shift at 6:00 AM - Monitor PICC line site for redness, tenderness, edema, excessive bleeding at site, chest/neck/ear pain, numbness or tingling of affected arm/hand. Notify MD of abnormal findings every shift at 6:00 PM During an observation and interview on 05/13/24 at 10:57 AM, Resident #1 appeared clean, groomed, and dressed in a hospital gown. Resident #1 was observed in a semi-sitting position in bed. Resident #1 had a double lumen PICC line (two separate [purple; red] lumens [tubing] with ports) to the right upper arm covered by a transparent dressing dated 05/12/24 for IV antibiotics/fluids administration. The purple lumen did not have a needleless connector attached and the red lumen did not have a disinfectant cap placed over the end of the needleless connector to help prevent contamination. Resident #1 was Alert, attentive, and oriented to level of awareness of self, place, time, and situation. Resident #1 denied concerns about PICC line site or timeliness of care provided. During an observation and interview on 05/13/24 at 11:15 AM, LVN C said that each lumen had a needleless connector and disinfectant caps when she assessed Resident #1's PICC line site to the right upper arm. LVN C could not explain why the purple lumen was missing a needleless connector and the red lumen did not have a disinfectant cap. A sterile dressing change was observed to Resident #1's PICC line site at the right upper arm. There were no signs of redness, swelling, bleeding, or any other drainage around the catheter site was noted. One special disinfectant wipe was used to clean each lumen before placing a needleless connector to each lumen. Each port was flushed with 10 cc - 15 cc normal saline before a disinfectant cap was placed at the end of the connector. LVN C was observed appropriately connecting the scheduled IV antibiotic for administration. During an interview on 05/13/24 at 1:35 PM, the ADON indicated that she performed the task of changing Resident #1's PICC line dressing, applied new connectors to each lumen, and covered with disinfectant caps after each lumen was flushed on Sunday, 05/12/24. The ADON said that sterile dressings to PICC sites including the needleless connectors to the lumens should be changed every 7 days and PRN as reflected on the TAR. The ADON said that disinfectant caps should be placed over the end of the connector when the PICC line was not in use. During an interview on 05/13/24 at 1:42 PM, the DON indicated nurses were expected to change PICC/IV/CVC dressing changes every Sunday as scheduled/PRN and document. The DON stated the purpose of changing PICC/IV/CVC dressings every 7 days and as needed if appeared soiled or pulled away from the skin, place residents at risk of infection associated with IV therapy. The DON was unable to locate IV management policies. The DON stated steps of procedure for PICC/IV/CVC dressing change was reviewed with the nursing staff and ensured staff understood. The DON stated surveillance was conducted throughout the day to monitor maintenance of PICC/IV/CVC to avoid complications. During an interview on 05/13/24 at 2:00 PM, the NFA was not able to speak to the process of how central line dressings were changed and stated that the DON oversaw nursing clinical training and competency. The NFA could not produce related policies to IV Management.

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 to help prevent the development and transmission of communicable diseases and infections for two of three staff members (CNA A and CNA B) reviewed for infection control procedures. CNA A failed to perform hand hygiene after direct contact with residents while serving meals on the hallways, and CNA B failed to perform hand hygiene while delivering water to three residents. This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #246's annual MDS assessment, dated 04/30/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #246 had diagnoses which included: septicemia (infection that has spread to the bloodstream), urinary tract infection (within the last 30 days), hypertension (increased blood pressure), diabetes (increased sugar levels), and tracheostomy (tube surgically placed in trachea to maintain airway). Resident #246 was cognitively intact with a BIMS score of 15 and required assistance of one staff member for activities of daily living. Record review of Resident #196's annual MDS assessment, dated 05/06/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #196 had diagnoses which included: left hip osteoarthritis (degenerative joint disease that causes joint damage), coronary heart disease (disease of heart's major blood vessels), peripheral vascular disease (poor circulation to limbs), pulmonary fibrosis (lung tissue is damaged and scarred), and a personal history of malignant neoplasm of breast (history of breast cancer). Resident #196 as cognitively intact with a BIMS score of 15 and required assistance of one staff member for activities of daily living. Record review of Resident #85's annual MDS assessment, dated 04/11/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #85 had diagnoses which included: Parkinson's disease (muscle and nerve disease), cellulitis of left finger (infection of left finger), hypertension (increased blood pressure), dysphagia (difficulty swallowing), and weakness. Resident #85 was cognitively intact with a BIMS score of 15 and required assistance of one staff member for activities of daily living. Record review of Resident #98's annual MDS assessment, dated 05/05/24 (not completed), revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The cognitive status in MDS had not been completed at the time of exit on 05/9/24. Record review of Resident #98's face sheet revealed diagnoses which included: enterocolitis due to clostridium difficile (bacterial infection of intestines), severe protein-calorie malnutrition (inadequate protein intake), acute systolic (congestive) heart failure (heart does not pump blood as well as it should), atrial fibrillation (irregular rhythm of the heart), and stage 4 pressure ulcer of sacral region (sore on area above the tailbone that extends to muscle, tendon, or bone). Resident #98 required assistance of staff for activities of daily living. Record review of Resident #248's annual MDS assessment, dated 05/03/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #248 had diagnoses which included: morbid (severe) obesity (overweight), anxiety (mood disorder), hypertension (increased blood pressure), hyperlipidemia (high levels of fat particles in the blood), and depression (mood disorder). Resident #248 as cognitively intact with a BIMS score of 15 and required assistance of one staff member for activities of daily living. Record review of Resident #97's annual MDS assessment, dated 05/08/24 (not completed), revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #97 had diagnoses which included: urinary tract infection, renal insufficiency (kidney function is decreased), hypertension (high blood pressure), cerebrovascular accident (stroke), hypertension (increased blood pressure), hyperlipidemia (high levels of fat particles in the blood), and diabetes (increased sugar levels). Resident #97 required assistance of one staff member for activities of daily living. The cognitive status in MDS had not been completed at the time of exit on 5/9/24. Observation on 05/07/24 at 12:18 PM, revealed CNA A was pushing the meal cart down the hallway. CNA A was observed to enter Resident #246, #248, and #97's rooms touching each door handle and set up the residents' lunch trays, adjusted the overbed tables, unwrapped the utensils, and removed the tops off of the drinks for each resident. CNA A did not complete hand hygiene before going to the next resident. CNA A then returned to Resident #246's room and removed a pair of gloves from the box in the room. He then sat the gloves down and did not use them, repositioned the bedside table, and adjusted the items on the tray. CNA A then used utensils on the tray to feed Resident #246. After feeding the resident, CNA A left the room without washing hands or using hand sanitizer. Hand sanitizer was located on walls in hallways between rooms. Observation on 05/09/24 at 10:44 AM, revealed CNA B pushed the water cooler down the hall without gloves to the front of Resident #196's door, did not perform hand hygiene, touched the door handle and went inside Resident #196's room. Then CNA B went inside Resident #85's room and verbally offered water. CNA B then left that room and went inside Resident #98's room. CNA B did not perform hand hygiene before going to each resident's room. CNA B then used the white scoop on the side of the cooler and filled two cups. She took both cups into Resident #85's room, gave one cup to Resident #85 and adjusted the bedside table with bare hands. CNA B then took the other cup to Resident #98's room, placed the cup of water on the bedside table, and touched the bedside table. CNA B touched the door handle and left the room. CNA B did not perform hand hygiene during the observation. Hand sanitizer was located on walls in hallways between rooms. An interview on 05/08/24 at 12:37 PM, CNA A stated they should always wash their hands when removing gloves or use hand sanitizer. CNA A also stated when passing trays sometimes they use hand sanitizer, but if they are using gloves, they don't have time to perform hand hygiene between residents. An interview on 05/09/24 at 1:07 PM, the DON stated when passing trays CNAs were expected to complete hand hygiene between each resident. The DON also stated CNAs were expected to complete hand hygiene between residents when administering water. Record review of the facility's policy Infection Prevention and Control Program dated 5/13/23 revealed: Standard Precautions a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 1 (Resident #16) of 1 resident's reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #16 after thy returned from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care. Findings included: Record review of Resident #16's, admission MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included end stage renal failure (when kidneys suddenly become unable to filter waste products from blood), dependence on renal dialysis, (procedure to cleanse the blood), and Hypertension (increased blood pressure). Resident #16 had a BIMs score of 12, which reflected she was cognitively alert and oriented and able to make decisions for herself. The MDS section O related to special treatments, procedures, and programs reflected Resident #16 received dialysis. Record review of Resident #16's care plan, dated 04/26/2024, reflected Resident #16 received dialysis related to renal failure and was at risk for the potential complications related to dialysis. Needed hemodialysis to rule out end stage renal failure. Resident #16 will have no signs of complication from dialysis through next review. Obtain vital signs and weight per protocol. Report significant changes in pulse, respiration, and blood pressure to the physician. Record review of Resident #16's physician's order, dated 04/19/2024, reflected Hemodialysis every Monday, Wednesday, and Friday at 5:45 a.m. Further review reflected no orders to assess the access area prior to dialysis or post dialysis. Further review reflected orders to assess the access area prior to dialysis and after dialysis for the physician orders for the months of May 2024. Record review of Resident #16's EHR reflected inconsistent nursing documentation from 04/20/24 through 05/07/2024, regarding Resident #16's dialysis, monitoring of the resident's post-dialysis vital signs, or the assessment of the access area. Further review of the nurse's notes reflected on 04/24/24 it was documented by LVN E the resident returned from dialysis with vital signs checked and no assessment of the shunt; on 04/29/24 there was an assessment of shut after return; and on 05/01/2024 it was documented the resident returned from dialysis, but no assessment of the shunt. There were no assessments noted in the nursing progress notes about assessing the shunt from 04/20/24 through 05/07/24. Record review of Resident #16's dialysis communication forms reflected dialysis communication forms with no information on the resident's assessment and observation post-dialysis section on 04/22/2024, 04/24/2024,04/26/2024, 04/29/2024 (filled out but no assessment of the shunt), 05/01/2024, 05/03/2024, and 05/06/24 (filled out but no assessment of the shunt). Interview on 05/07/2024 at 10:30 a.m. with Resident #16 revealed when she returned from dialysis on the day shifts, the nurses did not assess her access area. Resident #16 stated she knew they were supposed to assess the access area, but they never did. The staff were sometimes busy with other responsibilities or their medication pass. Resident #16 stated she had asked, but the staff forget. She said she knew what to watch for herself, she really did not want to bother them . Interview on 05/08/2024 at 1:10 p.m. with LVN C revealed she was aware she was supposed to send Resident #16 and any dialysis residents with the dialysis communication form when she/they left for dialysis. The nurse on the next shift would collect the form when the resident returned from dialysis. LVN C stated she knew she was supposed to take the vital signs before she/they left and check to make sure the dressing on the access area was intact. LVN C stated if the access area was not assessed there could be a negative outcome, such as bleeding or infection, for the resident. LVN C stated the responsibility should be the charge nurse, but thought that the assessment should occur after dialysis, rather than before. Interview on 05/09/2024 at 11:31 a.m. with the DON revealed it was the nurses responsibility to send dialysis residents with a communication form to dialysis and get the form back when the resident returned to the facility. That was so, if there were orders from dialysis or changes, it was noted. She stated her expectation was for the nurses to perform post-dialysis assessments when the residents returned from dialysis and document on the dialysis communication forms on dialysis days. She stated failure to monitor the vital signs and access sight after dialysis, staff would not note the change of condition, bleeding, and whether the vitals were stable. The DON stated that if there were no orders given the nurses should call the physician and receive orders. It was basic nursing to know they must assess the access area before and after dialysis, as well as vital signs. She stated the risk for not assessing the vitals were that Resident #16 could be unstable and the shunt (special access used for dialysis treatment) could be bleeding. She stated the facility would do an in-service and monitor. Interview on 05/08/2024 at 2:40 p.m. with LVN D revealed when there was a resident that is going to dialysis, the nurse was to assesses the resident before they leave, to include wight, vital signs, and the access area (if it is a shunt the thrill and bruit, shunt (special access used for dialysis treatment), document on the communication form. When the resident returns form dialysis the nurse should reassess the resident, that would include vital signs, the dressing on the access area and the thrill and bruit. LVN D stated failure to monitor and assess resident's post dialysis put them at risk of low blood pressure and bleeding. In an interview on 04/30/24 at 2:30 p.m. revealed the DON there was no policy available for dialysis or dialysis documentation.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 5 residents reviewed for clinical records. The facility failed to ensure staff documented need for Resident #1 to receive oxygen treatment. This failure could affect residents that received medications and place them at risk of inaccurate or incomplete clinical records. Findings included: Review of Resident #1's undated electronic face sheet a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of hypokalemia (a lower-than-normal potassium level in your bloodstream), Hypernatremia (common electrolyte problem), hyperosmolality (loss of water also makes the blood more concentrated than normal), dementia without behavior disturbance, dysphagia (swallowing difficulties) Review of Resident #1's admission MDS Assessment, dated 10/18/23, reflected a BIMS score was not completed. The MDS did not indicate that oxygen was required for Resident #1. Review of the care plan completed 10/18/23 revealed the resident required assistance with act of daily living. The care plan did not indicate that oxygen was required for Resident #1 Review of Resident#1' nursing note dated 10/29/23 at 7:42PM authored by RN #1 revealed Resident #1's oxygen level was at 95% and resident on 3 liters of oxygen via nose cannula. There was no documentation of Resident#1's oxygen being low, nor the physician or family being notified of the resident receiving oxygen. Review of the electronic physician orders dated 11/07/23 revealed no order for oxygen. Review of the standing orders revealed oxygen per nose cannula to keep oxygen stats above 92 percent. Interview on 11/07/2023 at 1:45PM with RN #1 revealed he had worked in the facility for 4 years. He stated upon checking the oxygen levels for Resident #1 her oxygen was low. RN#1 stated he did not document the low oxygen level and only documented the oxygen level at 96%. RN #1 revealed there was a standing order which stated if the resident oxygen were below 92% then oxygen should have been given. RN#1 stated he was not sure how long Resident#1 was on oxygen due to his shift ending. RN#1 stated he did not notify the doctor nor family regarding oxygen being given. RN#1 stated he forgot to document the low oxygen level. Review of Resident #1's nursing notes dated 10/30/23 at 7:19 AM author by RN#2 revealed Resident #2 was met with oxygen at 3 liters via nose cannula. RN#2 noted Resident #1's oxygen saturation dipping when not on oxygen. RN#2 recorded Resident#1's oxygen status at 78%. RN #2 did not document that the physician was notified, nor an order given to continue oxygen . Review of Resident #1's nursing notes dated 10/30/23 at 3:43PM authored by the infectious disease doctor, revealed hypoxia on room air and Resident #1 on 2 liters of oxygen via nose cannula. There was no documentation of an order give for continued use of oxygen. Interview on 11/07/23 at 2:15PM with RN#2 revealed during rounds she noted that Resident#1 was receiving 3 liters of oxygen. She stated she attempted to remove the oxygen and Resident#1's oxygen saturation dropped to 78%. RN #2 stated she provided 3 liters of oxygen via nose cannula. RN#2 stated she contacted the physician and as given a verbal order to continue oxygen and a x ray was order. RN#2 stated she thought she documented the contact that was made with the physician. Interview on 11/07/23 at 3:00PM with the DON revealed there was a standing order for oxygen levels below 92%. The DON she did not think there was a need to get an order to continue oxygen due to the standing order being in place. The DON stated she did not think there was a risk to residents due not obtaining the order or contacting the physician due to the current standing order. Review of the facility policy Documentation of medical record dated 06/24/22, revealed Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two of six residents (Resident #35 and #210) observed for infection control. CNA A failed to perform hand hygiene during while providing incontinence care to Resident # 35. CNA B failed to perform hand hygiene during while providing incontinence care to Resident # 210. This failure could placed the residents at risk for infection. Findings include: Record review of Resident #35's face sheet dated 3/15/23 reflected he was [AGE] years old male. He was admitted to the facility on [DATE]. He was admitted with fracture of tibia (larger of the two bones in the lower leg), respiratory failure, heart failure, difficult walking and need for assistance with personal care. Review of Resident #35's care plan initiated 2/13/23 reflected the resident had an ADL self-care performance deficit related to Orthopedic surgery and the intervention was for the resident to be assisted by staff for toileting. Observation on 03/13/23 at 10:40 AM revealed CNA A providing incontinent care for Resident #35. CNA A was in Resident #45's room when she left and stated she was going to get wipes. When CNA A came back in the room, she gloved without performing hand hygiene and proceeded to providing the resident with care. CNA A cleaned the resident and removed the dirty brief, the resident was soiled in urine. CNA A then placed the dirty brief in the trash can and cleaned the resident's bottom. After cleaning the resident without any form of hand hygiene or change of gloves, CNA A applied the clean brief, fastened the brief, and assisted the resident to position in bed. After care, CNA A completed hand hygiene. In an interview on 03/13/23 1at 2:02 PM with CNA A regarding the Resident #35's care, CNA A stated she was supposed to complete hand hygiene before and after care. Asked about in between care, CNA A stated after cleaning the resident she was supposed to clean her hands and change gloves before applying the clean brief. CNA A stated she was supposed to complete hand hygiene to prevent the spread of infection. CNA A stated she had completed a hand hygiene and infection control in-service about two months ago. Record review of Resident #210's face sheet dated 3/15/23 reflected she was [AGE] year old female. She was admitted to the facility on [DATE]. She was admitted with acute kidney failure, type 2 diabetes, altered mental status, hypertension, gout, and acute respiratory failure. Review of Resident #210's care plan initiated 03/07/23 reflected the resident had an ADL self-care performance deficit and the intervention was for the resident to be assisted by staff for toileting. Observation on 03/15/23 at 10:29AM reflected CNA B providing incontinent care to Resident #210. CNA B was observed entering Resident #210's room gloved without any form of hand hygiene and explained to the resident that she was to provide incontinent care. CNA B positioned the resident and unfastened her brief, then proceeded to cleaning the resident. When CNA B had completed cleaning, she took off the dirty brief and placed it on the edge of the bed. Without any form of hand hygiene or change of gloves, CNA B proceeded to apply the clean brief. After CNA B applied the clean brief, she picked up the dirty brief that was at the edge of the bed, and placed it in the trash can. With the same dirty gloves, CNA B covered the resident, positioned the resident, and moved the bedside table closer to the resident. After care, CNA B completed hand hygiene In an interview on 03/15/23 at 12:11 PM with CNA B she stated she was to complete hand hygiene before and after care and after taking off Resident #210's dirty brief. CNA B stated she was supposed to clean her hands when she initially started to provide care, and after she cleaned the resident before applying the clean brief. CNA B also stated she was supposed to take off the dirty gloves before touching the resident's bedding and bed side table. CNA B stated she was to complete hand hygiene for infection control, and she stated she was in-serviced on infection control about a month ago. In an interview on 03/15/23 at 1:05 PM with the DON, she stated infection control was important during care. The DON stated during care the staff were to use the hand sanitizer or wash hands if they were physically soiled. The DON stated the staff were expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff were supposed to change gloves and use hand sanitizer when taking off the dirty brief before applying the clean. The DON stated hand hygiene was to be completed for infection control. DON said she was the infection preventionist and in-service on infection control completed within a month ago. Record review reflected the facility completed an in-service on 02/27/23 for hand hygiene. Review of the facility policy dated 10/24/22 and titled Hand Hygiene reflected, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, interviews, and record review, the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents for 4 (Resident #1, Resident #2, Resident #3 and Resident #4) of 12 residents reviewed for medication storage. The facility failed to ensure medication and medication supplies were secured or attended by authorized staff. This failure could result in resident access and ingestion of medications leading to a risk for harm and possible drug diversion. Findings included: In an observation and interview on 12/22/22 at 9:55 AM revealed Resident #2 had a syringe left on top of her dresser. Resident #2 stated she did not know if the syringe was left from last night or from this morning. Resident #2 stated her nurse gives her insulin twice a day. Syringe was left in clear view and accessible to staff, residents, and visitors. In an observation and interview on 12/22/22 at 10:00 AM LVN A revealed that syringes should be disposed of in the sharpie container in the bathroom after used. LVN A stated Resident #2 is not at risk because she is aware. Record review of Resident #2's MDS assessment, undated, reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . BIMS not assessed. In an observation and interview on 12/22/22 at 11:48 AM revealed Resident #1had two Nicotine l containers, jar of icy hot on her bedside table .Observed a [MEDICATION(S)] pen on top of the dresser. Medication was left in clear view and accessible to staff, residents, and visitors. Resident #1 stated she takes the Nicotine Lozenges whenever she needs one. Resident #1 stated the staff administers her insulin when she needs it. In an interview on 12/22/22 at 11:55 AM with LVN B, she stated residents should not have medications and their room. LVN B stated residents have to have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated Resident #1 is endangered of overdosing. Record review of Resident #1's MDS assessment, undated, reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . BIMS not assessed. In an observation and interview on 12/22/22 at 12:15 PM revealed Resident #3 had [MEDICATION(S)] 100, 000 USP and 2 roll on Biofreeze on bedside table. Resident #3 stated she mixes the powder with Aquaphor and used it throughout the day. Resident #3 stated she got the Biofreeze from physical therapy. Medication was left in clear view and accessible to staff, residents, and visitors. Record review of Resident #3's MDS assessment, undated reflected Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . BIMS moderately impaired. In an interview and observation 12/22/22 at 12:25PM revealed Resident #4 had Presevision 2 [MEDICATION(S)] 2 chewables on her bedside table. Resident #4 did not know what the chewable were for. Medication was left in clear view and accessible to staff, residents, and visitors. Record review of Resident #4's MDS assessment, undated reflected Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . BIMS not assessed In an interview on 12/22/22 at 12:40 PM with DON revealed some residents can self-administer medication. Record review of Resident #1, Resident #2, Resident #3 and Resident #4 revealed no self-administer medication assessment was documented. In an interview on 12/22/22 at 12:55 PM with the Administrator revealed there were no Resident who self-administer their own medication. Administrator stated that during morning rounds rooms should be checked for visible medication and medication supplies that need to be locked and secured. Record review of facility policy revealed Medication policies, 1. A written order for bedside storage of medication is present in the resident's medication records.

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 one (Resident #5) of five residents reviewed for pain. The facility failed to administer Resident #5's, as needed, narcotic [MEDICATION(S)] Acetaminophen tablet 7.5milligram (mg) when the medication was requested on 04/11/22 at 5:30 am for pain to prevent discomfort . This failure could place residents at risk for unnecessary pain, stress, irritability, aggressive behavior fear of treatment, seeking other means of managing pain and decreased quality of care. Findings included: Review of Resident #5's face sheet dated 04/14/22 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was her own responsible party. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's care plan dated 04/07/22 revealed the resident had an ADL performance deficit. The resident had limited mobility. Resident #5 was on pain medication therapy, the facility will administer the pain medication as ordered by the physician and document the effectiveness and side effects Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No other times was reflected on the MAR. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Narcotic Count sheet for Resident #5 [MEDICATION(S)] Acetaminophen tablet 7.5milligram (mg) medication revealed the following: 04/09/22 medication was provided at 1:05pm, 7:05pm and 11pm 04/10/22 medication was provided at 11:39 am, 6:20pm, 10pm 04/11/22 medication was provided at 9:07am, 4:30pm and 8:12pm An interview with Resident #5 on 04/13/22 at 10:04 am revealed she was not receiving her pain medications once she informed the aides at the facility. She would press her call light when she was able to get her pain medication and staff was slow to respond. She stated on 04/11/22 at 5:30 am she was in severe pain and CNA A responded. She informed him she wanted her pain medications from the facility nurse, at 6am. She continued to inquire about her pain medication, the aide informed her had informed the nurse. She stated she also told another aide at 5:30am and no medication was provided. She stated after laying in the bed in pain for over 3 hours, she sent a text message to a facility representative at 8:53 am on 04/11/22, requesting her pain medications. Review of Resident #5's cell phone on 04/14/22 at 11:49 am reflected a text message I don't know what is going on but I asked for my pain meds at 520am it almost 9am an I still have not seen anyone it's been like this since I got here. The facility staff responded at 8:54am on 04/11/22 revealed she would inform the DON and ADM immediately. An interview with the DON on 04/14/22 at 11:56 am revealed the facility representative was the Marketer for the facility. She provided the resident her phone number during the admission process. The facility representative did send her the message and she informed the nurse to provide the resident pain medication as ordered. She had not spoken with the aide or the nurse regarding Resident #5 receiving her medications. An interview at 12:41 pm with CNA A on 04/14/22 revealed he had worked at the facility on 04/11/22 and was assigned to Resident #5. He stated while doing rounds at approximately 6:30am, Resident #5 informed him, she wanted her pain medications. He stated the resident stated she had been requesting the pain medication since 5:30am and she had not received her medication. He stated he informed the assigned nurse (name unknown). He stated the resident may have received the pain medications 2-3 hours later. An interview with LVN B on 04/14/22 at 1:23 pm revealed she was the assigned nurse for Resident #5 on 04/11/22. She was scheduled to work at the facility 6am to 6pm, however she arrived at the facility at 7:15 am. She was not told by the aide the resident had requested medications after she arrived at the facility. She stated the previous nurse did not communicate the resident had requested medication. She received a message from the DON on 04/11/22 stating to provide pain medication to Resident #5.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 out of 5 residents (Resident # 5) whose medical records were reviewed for medication administration. The facility failed ensure Resident #5's MAR and narcotic count sheet were accurate to reflect the narcotic [MEDICATION(S)] Acetaminophen tablet 7.5milligram (mg) medication provided to the resident. This failure could place residents at risk of not receiving needed care or treatments by misleading care providers regarding what care or treatments residents have or have not received. Findings included: Review of Resident #5's face sheet dated 04/14/22 reflected she was a [AGE] year old female admitted to the facility on [DATE]. Her diagnoses included Spinal stenosis, lumbar region, difficulty walking and neuromuscular dysfunction of bladder. The resident was her own responsible party. Review of the physician orders for April 2022 for Resident #5 reflected [MEDICATION(S)] Acetaminophen tablet 7.5milligram (mg) given every 6 hours as needed for Moderate to severe pain, start date 04/08/22 and discharge date [DATE]. Review of Resident #5's care plan dated 04/07/22 revealed the resident had an ADL performance deficit. The resident had limited mobility. Resident #5 is on pain medication therapy, the facility will administer the pain medication as ordered by the physician and document the effectiveness and side effects Review of the Medication Administration Record (MAR) for Resident #5 revealed the resident was prescribed [MEDICATION(S)] Acetaminophen tablet 7.5milligram (mg) given every 6 hours as needed for pain. The MAR reflected on 04/11/22 revealed the resident only received the medication at 9:07 am. No other times was reflected on the MAR. The MAR also reflected the resident only received the medication once on 04/09/22 at 7:02 am, again on 04/10/22 at 11:39am. Review of the Narcotic Count sheet for Resident #5 [MEDICATION(S)] Acetaminophen tablet 7.5milligram (mg) medication revealed the following 04/09/22 medication was provided at 1:05pm, 7:05pm and 11pm 04/10/22 medication was provided at 11:39 am, 6:20pm, 10pm 04/11/22 medication was provided at 9:07am, 4:30pm and 8:12pm An interview with LVN B on 04/14/22 at 1:23 pm revealed she was the assigned nurse for Resident #5 on 04/11/22. She stated she had documented on the narcotic count sheet and Resident #5's MAR. She did not know why the MAR and the count sheet did not reflect the same information. She stated it must have been an error with the system that did not reflect properly on the MAR. An interview with the DON on 04/14/22 at 1:45 pm revealed she had reminded all the nurses nurse to ensure they documented properly on the MAR . She stated the MAR and count sheets for Resident #5 did not match and the MAR was not accurate. Review of the facility's Controlled Substance Prescriptions revision date 10/01/19 reflected Each controlled substance prescription is documented in the resident's medical record with the date, time and signature of the person receiving the prescription. The prescription is recorded on the physician order sheet, the telephone order sheet or posted elsewhere in the record and recorded on the Medication Administration Record (MAR).

Based on interviews, record reviews, and facility document review, the facility failed to: A. Ensure Resident #71 was assessed by a qualified nutrition professional resulting in the potential development of additional pressure injuries. B. Ensure Resident #125, who was admitted with pressure injuries, was assessed by a qualified nutrition professional. C. Ensure Resident #110 was assessed by a qualified nutrition professional, resulting in a [CONDITION(S)] resident receiving tube feedings and water flushes per family request. D. Ensure Nutrition and Dietetic Technician, Registered (NDTR) NN received oversight and collaboration from Registered Dietitian Nutritionist (RDN) OO and the physician prior to initiating nutrition recommendations. This deficient practice had the potential to affect all residents. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.60 (Food and Nutrition Services) at a scope and severity of L. The Immediate Jeopardy (IJ) began on 11/10/2021 when NDTR NN assessed residents outside of their scope of practice. The Administrator was notified of the IJ and provided with the IJ template on 12/03/2021 at 7:42 PM. A Removal Plan was requested. An acceptable Removal Plan was received on 12/05/2021. The IJ was determined to be removed on 12/06/2021, after the survey team performed onsite verification that the Removal Plan had been implemented. Findings included: A review of the Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for NDTR revealed the RDN and NDTR roles in the nutrition care process and workflow element .The RDN's role for nutrition screening is to perform or obtain and review nutrition screening data whereas the NDTR's role is to perform or obtain nutrition screening data .The RDN's role for nutrition assessment is to perform via in-person, or facility/practitioner assessment application system or Health Insurance Portability and Accountability Act (HIPAA) compliant video conferencing telehealth platform and document results of assessment whereas the NDTR's role is to assist with, or initiate data collection as directed by the RDN or per standard operating procedures and begin documenting elements of the nutrition assessment for finalization by the RDN .The RDN's role for nutrition diagnosis is to determine nutrition diagnosis whereas the NDTR's role is per RDN-assigned task, communication and provide input to the RDN .The RDN's role in nutrition intervention/plan of care is to determine or recommend nutrition prescription and initiate interventions. When applicable, adhere to established and approved disease or condition-specific protocol orders from the referring practitioner whereas the NDTR's role is to implement/oversee standard operating procedures, assist with implementation of individualized patient interventions and education as assigned by the RDN .The RDN's role in nutrition monitoring and evaluation is to determine and document outcome of interventions reflecting input from all sources to recognize contribution of NDTR/nutrition care team members to patient experience and quality outcomes whereas the NDTR's role is to implement/oversee .duties performed by other nutrition, foodservice staff .standard operating procedures; complete, document and report to the RDN and other team members the results and observations of patient specific assigned monitoring activities .The RDN's role in discharge planning and transitions of care is to coordinate and communicate nutrition plan of care for patient discharge and/or transitions of care whereas the NDTR's role is to assist with or provide information as assigned by the RDN. A review of the Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Nutrition and NDTR revealed .NDTRs work under the supervision of an RDN when in direct patient/client nutrition care and may work independently in providing general nutrition education to healthy populations, consulting in foodservice, conducting nutrient analysis, and collecting data .The RDN is responsible for nutrition care assigned to and completed by the NDTR and is accountable to the patient, employer, and regulator .Federal and state rules and regulations for health care facilities specify that the qualified dietitian must supervise the nutritional aspects of the patient care and provide nutrition assessments and dietary counseling. NDTRs working in skilled or long-term care facilities as the food and nutrition director work in collaboration with the facility's RDN to address a resident's diet or nutrition-related orders when the physician has delegated diet-order writing to the dietitian .NDTRs provide nutrition care services for patients under the supervision of the RDN to address prevention and treatment of acute and chronic diseases and conditions and the promotion of overall health and wellness .NDTR's duties include to implement and monitor nutrition interventions, as assigned by the RDN to meet the nutritional needs of the patients including but not limited to, prescribed diets, snacks/nourishments, nutritional supplements, and data collection for nutrition support therapies .NDTRs assist with implementation and monitoring of the patient's nutrition intervention plan, which is developed and directed by the RDN. A review of the Texas Administrative Code Title 16: Economic Regulation, Part four: Texas Department of Licensing and Regulation, Chapter 116: Dietitians, Subchapter A: General Provisions, Rule §116.2: Definitions dated 10/01/2016 revealed: - Nutrition assessment is the evaluation of the nutritional needs of individuals and groups based on appropriate biochemical, anthropometric, physical, and dietary data to determine nutrient needs and recommend appropriate nutritional intake, including enteral and [MEDICATION(S)] nutrition. Nutrition assessment is an important component of medical nutrition therapy. - Nutrition services means assessing the nutritional needs of individuals or groups and determining resources and constraints in the practice; establishing priorities, goals, and objectives that meet nutritional needs and are consistent with available resources and constraints; providing nutrition counseling in health and disease; developing, implementing, and managing nutrition care systems; or evaluating, making changes, and maintaining appropriate standards of quality in food and nutrition care services. - Registered Dietitian is a person who is currently registered as a dietitian by the Commission on Dietetic Registration. - Dietitian is a person licensed under the Act. - Licensee is a person who holds a current license as a dietitian issued under the Act. A review of the Texas Administrative Code for Nursing Facility Requirements for Licensure and Medicaid Certification, Subchapter L: Food and Nutrition Services, Rule §554.1102: Staffing dated 03/24/2020 revealed, The facility must employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population. A qualified dietitian has completed 900 hours of supervised dietetics practice under the supervision of an RDN and is licensed as a dietitian by the state of Texas. A review of the Consultant NDTR job description, dated 08/01/2012, revealed, The primary duty of the NDTR is the provision of medical nutrition therapy for clients, which includes nutritional assessment, care planning, monitoring, and revision of the care plan as indicated under the supervision of the RDN. Job duties include the assessment of the status of all high-risk clients, including clients with skin breakdown, on tube feeding or [MEDICATION(S)] nutrition and clients with significant weight loss, a minimum of monthly as needed. A review of DTR NN's Food Safety/Sanitation and Assessment Training Evaluation Tool for NDTR, completed by a previous RDN, dated 12/24/2018, revealed, not applicable (N/A) next to licensed in the state. A review of DTR NN's Food Safety/Sanitation and Assessment Training Evaluation Tool for NDTR, completed by a previous RDN, dated 12/24/2018, revealed, RDN only sees tube feeding and renal residents. A review of NDTR NN's Assignment of Duties, dated 12/24/2018, revealed the facility's previous dietitian delegated duties to NDTR NN to do assessments on new admissions, annual assessments, tube feedings, pressure ulcers, significant weight loss, [CONDITION(S)], diagnosis of protein-calorie malnutrition, completion of the Minimum Data Set (MDS), completion of care plans, attendance at nutrition risk meetings, completing of monthly reports and quality assurance surveys. The facility did not provide a delegation of duties signed by RDN OO. A review of NDTR's Food Safety/Sanitation and Assessment Training Evaluation Tool for NDTR completed by the Account Manager, dated 12/03/2020, revealed a check mark next to licensed in state. The facility did not provide a Texas dietitian's license for NDTR NN. A review of NDTR's Food Safety/Sanitation and Assessment Training Evaluation Tool for NDTR, completed by the Account Manager, dated 12/03/2020, revealed NDTR NN has been willing to cover facilities for other RDNs. 1. A review of Resident #71's face sheet revealed the facility admitted the resident with diagnoses of malignant lung neoplasm, acute [CONDITION(S)], protein-calorie malnutrition, and adult failure to thrive. A review of Resident #71's initial nursing evaluation, dated 11/09/2021, revealed a wound to the left knee, multiple wounds to the left toes, wounds to the left posterior lateral foot, a wound to the left hip, a wound to the left upper thigh, and a decubitus (pressure) ulcer to the sacrum. A review of Resident #71's Dietary RD (Registered Dietitian) - Nutrition Therapy Assessment, completed by NDTR NN, dated 11/10/2021, revealed no pressure injuries. A review of Resident #71's Dietary RD - Nutrition Therapy Assessment, completed by NDTR NN, dated 11/10/2021, revealed, Resident estimated needs based on hospital weight, [electronic medical record] weight is significantly lower at 119 pounds. Resident states they have a good appetite. No food dislikes stated. Declined need for snacks/supplements; says they are eating enough at meals. Has [CONDITION(S)] and is undergoing [CONDITION(S)]. Recommend to: 1) reweigh to confirm current body weight 2) discontinue Ensure (nutrition supplement) three times a day. Goal is to maintain weight plus or minus five percent and continue [by mouth] intake of greater than 50 percent. Follow up as needed. The nutrition assessment was signed by NDTR NN with dietitian next to NDTR NN's name. No documentation was provided that RDN OO had signed off on NDTR NN's nutrition assessment or recommendations. Resident #71 developed additional wounds in the facility after admission on 11/09/2021. During an interview on 12/04/2021 at 9:30 AM, the Owner of the RDN contract company stated NDTR NN was not aware Resident #71 had wounds when they completed the nutrition assessment and should have only calculated the calorie needs. 2. A review of Resident #125's face sheet revealed the facility admitted the resident on 11/15/2021 with diagnoses of [CONDITION(S)] of bilateral lower limbs, acute kidney failure, congestive heart failure, acidosis, and dysphagia. A review of Resident #125's initial nursing evaluation, dated 11/15/2021, revealed right ankle and heel wounds with excoriation and redness to the sacrum. A review of Resident #125's medication administration record (MAR), dated December 2021, revealed treatment orders for a left heel stage four pressure wound, a left lateral foot unstageable deep tissue injury (DTI), a left fifth toe wound, a left buttock wound, a right anterior ankle wound, a right shin wound, a left heel wound, and a right lateral ankle wound. A review of Resident #125's MAR, dated November 2021 and December 2021, revealed no ordered nutritional supplements. A review of Resident #125's medical record revealed no RDN nutrition assessments or nutrition interventions from 11/15/2021 to 12/06/2021, a period of 21 days. During an interview on 12/06/2021 at 1:15 PM, Registered Nurse (RN) H stated the facility admitted Resident #125 with multiple wounds. Per RN H, Resident #125 was not on any nutritional supplements to aid in wound healing and received all their nutrition through the food they ate at meals During an interview on 12/06/2021 at 1:45 PM, RDN OO stated Resident #125 did not have a nutrition assessment completed since admission on 11/15/2021. Per RDN OO, Resident #125 was a high-risk resident with wounds, and it was important to be seen by RDN OO to ensure appropriate nutrition interventions were in place to aid in wound healing. RDN OO noted there was no set protocol for nutrition interventions for residents with wounds, describing that RDN OO and NDTR NN determined appropriate interventions based on a resident's weight, food intake, diagnoses, and any other contributing factors. RDN OO reported newly admitted residents should have a nutrition assessment done within a few days of admission, noting RDN OO and NDTR NN staggered their visits to the building. RDN OO completed new admission and high-risk resident nutrition assessments on three Mondays per month, and NDTR NN completed nutrition assessments every Wednesday and Thursday. NDTR NN emailed their nutrition recommendations to RDN OO on Thursdays, and RDN OO reviewed them on Mondays when they were in the building. RDN OO further stated Resident #125 should have had a nutrition assessment completed, and RDN OO planned to complete one that day. 3. A review of Resident #110's face sheet revealed the facility admitted the resident on 11/29/2021 with diagnoses of critical illness [CONDITION(S)], end stage renal disease, stage four pressure ulcer, generalized [CONDITION(S)], gastrostomy status, [CONDITION(S)] (high potassium), and dependence on renal [CONDITION(S)]. A review of Resident #110's Dietary-RD (Registered Dietitian) Nutrition Therapy Assessment, completed by NDTR NN, dated 12/01/2021, revealed Resident #110 was receiving a reduced concentrated sweets (RCS), mechanical soft diet, and nectar thick liquids with approximately 50% oral intake. Resident #110 was tolerating the mechanical soft diet and had a stage four pressure ulcer to the lower sacrum. A review of Resident #110's Dietary-RD Nutrition Therapy Assessment, completed by NDTR NN, dated 12/01/2021, revealed, Resident estimated needs increased related to wound and [CONDITION(S)] treatment, but calories overestimated as resident is obese. Resident is eating well but not drinking much [sic] fluids. Resident is receiving water flushes of 60 mL [milliliters] every 12 hours. (Family member) wants tube feeding on because they feel (Resident #110) isn't eating enough. To honor (family member's) persistence, recommend nocturnal feeding of Nepro at 35 mL per hour x 12 hours (per family member's request) to provide 744 calories, 34g [grams] protein, 305 mL plus water flushes of 200 mL every four hours. Goal is to continue eating greater than 50%, tolerate tube feeding, and aid in wound healing. Follow up as needed. The nutrition assessment was signed by NDTR NN with dietitian next to NDTR NN's name. The facility provided no documentation or other evidence that RDN OO signed off on NDTR NN's nutrition assessment or recommendation. A review of Resident #110's medication administration record (MAR), dated December 2021, revealed an order for enteral feeds (tube feeding) of Nepro at 35 mL per hour via gastrostomy tube for 12 hours, to be initiated at 7:00 PM and stopped at 7:00 AM starting on 12/01/2021. During an interview on 12/06/2021 at 1:45 PM, RDN OO stated NDTR NN should not initiate tube feeding orders. Per RDN OO, all residents with orders for a tube feeding would be assessed and followed up on by either RDN OO or NDTR NN. During an interview on 12/01/2021 at 1:50 PM, NDTR NN stated they were contracted for ten hours per week to provide nutrition recommendations and kitchen sanitation audits. NDTR NN further stated they completed nutrition assessments for new admissions and follow-up assessments for residents on tube feedings, [CONDITION(S)], and therapeutic diets. NDTR NN stated they sent their recommendations to kitchen and nursing staff for new orders to be put into the electronic medical record (EMR). NDTR NN further stated they adjusted orders for tube feeding flow rates, water flush rates, and administration changes from continuous to bolus feedings, based on the resident's needs and preferences. Per NDTR NN, diet order recommendations were implemented within 72 hours, and tube feeding order changes were implemented the same day. NDTR NN stated the physician or nursing staff consulted NDTR NN for needed changes with tube feeding rates, formula, administration, or water flush rates, and the order changes would be implemented immediately. During an interview on 12/02/2021 at 2:41 PM, the Assistant Director of Nursing A (ADON) stated NDTR NN emailed nutrition recommendations to the nursing department, and the ADON placed the recommendations into the EMR as a new physician's order. The ADON received nutrition recommendations from both NDTR NN and RDN OO such as any diet changes, supplements, tube feeding adjustments, and any total [MEDICATION(S)] nutrition (TPN) orders. When the ADON received the recommendations, the ADON put the new orders into the EMR. Per the ADON, the nutrition recommendations from the NDTR and RDN were implemented once placed into the EMR and did not receive physician approval. During an interview on 12/02/2021 at 11:00 AM, the Medical Director (MD) stated RDN OO emailed nutrition recommendations to the nursing department, who put the new orders in the EMR. Per the MD, nutrition recommendations included tube feeding administration and rate changes, TPN changes, and supplement orders for residents with wounds or significant weight loss. The MD did not sign off on any nutrition recommendations before they were implemented. The MD stated they assumed NDTR NN consulted with RDN OO on every order but was not sure how RDN OO oversaw NDTR NN's recommendations. During an interview on 12/02/2021 at 11:20 AM, the Director of Nursing (DON) stated RDN OO and NDTR NN completed new admission nutrition evaluations, diet changes, and initiation of or changes to supplements, tube feedings, and TPN. The DON then stated they were not sure when NDTR NN consulted with RDN OO, but RDN OO's consultation should have been documented in each nutrition assessment. The DON compared the roles of a NDTR and RDN to a Certified Nursing Assistant (CNA) and Registered Nurse (RN), wherein a CNA should not perform duties requiring an RN qualification. During an interview on 12/02/2021 at 11:49 AM, RDN OO stated they were contracted for 24 hours per month. NDTR NN was in the building every Wednesday and Thursday, and RDN OO came in three Mondays per month. RDN OO and NDTR NN saw high risk residents such as those with tube feeding, [CONDITION(S)], wounds, significant weight changes, and any other therapeutic diet changes for nutrition and hydration recommendations. RDN OO further stated NDTR NN made their own recommendations to the nursing department without consulting RDN OO. NDTR NN's recommendations went to the nursing department, who put them in the EMR as new orders. Per RDN OO, NDTR NN only called RDN OO if they had questions. RDN OO noted most of NDTR NN's assessments consisted of newly admitted residents and physician consultations because NDTR NN was in the building more often. If NDTR NN thought a tube feeding flow rate, water flush rate, or administration change was needed, NDTR NN sent the recommendation to the nursing department for implementation without consulting RDN OO. During an interview on 12/04/2021 at 9:30 AM, the Owner of the RDN contract company stated that, in general, they hired NDTRs to work in collaboration with RDNs. Per the Owner, NDTR NN was working within their scope of practice if they had a competency evaluation completed. The Owner stated NDTR NN did not work independently, noting the Vice President (VP) of Operations and the Account Manager, who were dietitians, provided training and oversight to NDTR NN. The Owner of the RDN contract company further stated that RDN OO did not know what training NDTR NN received and was not aware of the monthly and quarterly nutrition assessment audits conducted by the Account Manager. Per the Owner, an NDTR's scope of practice depended on the individual, their competency, and their assigned dietitian. The Owner identified that NDTR NN did not replace RDN OO, explaining that they worked in collaboration. Per the Owner, RDN OO did not know that the VP of Operations and the Account Manager oversaw all NDTR NN's assessments. During an interview on 12/04/2021 at 3:00 PM, the Certified Dietary Manager (CDM) stated they did not know who the Account Manager of the RDN contract company was, and they had never met RDN OO. During an interview on 12/04/2021 at 4:28 PM, the Account Manager stated they provided NDTR NN training as needed, based on their annual performance reviews. Per the Account Manager, NDTR NN completed nutrition assessments independently, but if they had a question, they should call RDN OO and, if RDN OO was not available, NDTR NN could call the Account Manager if needed, noting NDTR NN should go through RDN OO first. The Account Manager further stated they did not routinely review NDTR NN's nutrition assessments or recommendations before they were implemented. The Account Manager noted it was important to catch high risk patients such as those with wounds, [CONDITION(S)], tube feedings, and/or weight loss to ensure they were provided adequate nutrition to resolve wounds and prevent any further weight loss. During an interview on 12/04/2021 at 4:50 PM, the Administrator stated they expected NDTR NN to know their scope of practice in an acute rehabilitation setting. The Administrator assumed RDN OO and NDTR NN were working together on nutrition assessments and thought RDN OO checked NDTR NN's assessments and recommendations. The Administrator did not know there was a difference in scope of practice before that day and compared the NDTR and RDN to a nurse going to a physician for guidance on what to do. The Administrator stated it was important for NDTR NN to work within their scope of practice to help prevent resident weight loss, help resolve wounds, and ensure tube-feeding patients were appropriately assessed. During an interview on 12/06/2021 at 12:15 PM, RDN OO stated they were in the building three Mondays per month, and NDTR NN was in the building every Wednesday and Thursday. RDN OO explained that NDTR NN and RDN OO were in the facility on different days and saw a different set of residents when in the building. Per RDN OO, NDTR NN sent an email with a list of residents seen and their recommendations to RDN OO on Thursday, and RDN OO reviewed them the following Monday to see who NDTR NN had seen. RDN OO did not know how soon nutrition recommendations were implemented once the nursing department received them. The Administrator was notified of the IJ and provided with the IJ template on 12/03/2021 at 7:42 PM. The facility's Removal Plan included: On 12/04/2021, RD [RDN OO] and Dietetic Technician [NDTR NN] reviewed the intervention for their collaboration and how they would work as a team to execute the needs of the patients while the DTR [NDTR NN] was still working inside their scope of practice. This review was included in the training done by their parent company and their supervisors and is outlined in the in-service that was provided to them. The following are the topics reviewed. RD and DTR Standards and Scope of Practice. Review of the Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Nutrition and Dietetics Technicians, Registered, Expectations of RD/DTR collaboration/communication. On 12/04/2021 per the removal plan, the facility initiated a complete audit of dietary recommendations. Patients #71, #91, #102, and #110, were reviewed by a clinical team to ensure compliance with dietary recommendations and the RD reviewed the recommendations to ensure compliance. The Removal Plan also included: On 12/04/2021, staff re-education was completed with the contracted RD and the DTR on working within their scope of practice and ensuring compliance with regulatory requirements regarding the scope of practice for a DTR versus the scope of practice for an RD. The education was completed by two supervisors of these associates at their parent company's contract dietetic company. Consultant dietitian or designee to complete weekly rounds for four weeks to audit patients with dietary recommendations to ensure compliance. DON or designee to complete random audits to ensure compliance and report to Quality Assurance Performance Improvement (QAPI) meeting monthly for three months. Both associates completed their in-services, so there will be no need for a plan for associates coming for later shifts to be put in place. An ad hoc QAPI was held on 12/04/2021 with the Administrator, DON, MD, and two other persons present to discuss the above plan. The IJ was removed on 12/06/2021 at 12:30 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Onsite verification of the implementation of the Removal Plan was conducted during the survey. The survey team confirmed through interviews with RDN OO and NDTR NN they reviewed the interventions for their collaboration and how they would work as a team to execute the needs of the patients. On 12/05/2021, the Account Manager provided re-education to RDN OO and DTR NN on working within their scope of practice and the expectations of the RDN/NDTR collaboration/communication. On 12/05/2021, the DON and ADONs initiated an audit of the dietary recommendations by looking at NDTR NN's recommendations and ensuring accuracy on the MAR.

Based on observations, interviews, and record reviews, the facility failed to provide the care and services to prevent the development and delay of healing of pressure ulcers for one (Resident #71) of three residents reviewed for pressure ulcers. This had the potential to affect the five facility identified residents with pressure ulcers and the 29 residents receiving preventative care. Resident #71 was admitted to the facility on [DATE] and, according to the initial nursing evaluation, the resident had wounds to the left knee, multiple wounds on left toes, wounds to left posterior lateral foot, left hip, left upper thigh, sacrum, and left lower back. No description or measurement of the wounds was documented at the time of admission. No assessment was done to determine the resident's risk for pressure injury development. Wound orders were sent from the hospital but were not initiated at the facility. No preventative interventions were initiated. The nutritional assessment did not identify the resident having pressure ulcers. The resident was seen by the wound physician on 11/12/2021 and measurements, descriptions, and recommendations for treatment and interventions were made from the wound physician. The facility implemented the treatment orders, and an air mattress and other recommendations were not implemented. The wound physician identified 11 skin issues, three being pressure related to the sacrum, left lateral ankle, and left lateral foot. The other areas were identified as abrasions or skin tears. The wounds were not documented on by the nursing staff, except for the treatment being done on the skilled administration record ([NAME]). The resident was seen again by the wound physician on 11/19/2021, and a new deep tissue injury (DTI) was observed to the resident's right heel. Recommendations for skin prep were made with offloading and float heels, and these recommendations were not followed through and initiated. The facility failed to properly assess Resident #71's risk for pressure ulcer development, properly assess existing pressure ulcers, provide recommend treatment to wounds, implement interventions to prevent wound development in a timely manner, follow up on recommendations form the wound physician, and provide an adequate nutritional assessment and supplements for wound healing. These failures resulted in the resident developing pressure ulcers on the bilateral heels and prevented the progression of healing for existing pressure ulcers to the left lateral foot, ankle, and sacrum. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Pressure Ulcers) at a scope and severity of J. These failures placed the facility in an Immediate Jeopardy situation requiring immediate action to be taken to prevent the further decline in resident pressure ulcers and prevent the development of new unidentified pressure ulcers. The facility Administrator and the Corporate Consultant were notified of the Immediate Jeopardy situation and provided the IJ template on 12/03/2021 at 5:42 PM. A Removal Plan was requested. A Removal Plan was accepted and the IJ was determined to be removed on 12/07/2021, after the survey team performed onsite verification, on 12/21/2021, that the Removal Plan had been implemented. Findings included: A policy on pressure ulcer prevention and treatment was requested from the facility on 12/03/2021. The facility provided photocopies from an unnamed nursing textbook on how to care for pressure ulcers which included the following, Comprehensive skin assessment shouldn't be a one-time event limited to admission. Repeat it regularly to determine whether changes in skin condition have occurred. Document a complete skin assessment and interventions use to prevent pressure ulcers. Update the care plan as required. Except for brief periods, avoid raising the head of the bed more than 30 degrees to prevent shearing forces. Apply heel protection devices to prevent heel pressure ulcers. The device should completely offload pressure from the heels. Turn and reposition the patient everyone to two hours or more frequently as required. A review of the face sheet revealed the facility admitted Resident #71 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident had severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of six out of 15. Further review of the MDS indicated the resident required extensive assistance of one person for activities of daily living (ADLs) including bed mobility, transfer, toileting, and bathing and limited assistance of one person for personal hygiene. The resident was always incontinent of bowel and bladder. The resident had two stage 4 pressure ulcers (full-thickness skin and tissue loss) and one unstageable pressure ulcer (an ulcer that has full-thickness tissue loss but is either covered by extensive necrotic tissue or by eschar) upon admission. A review of the hospital discharge instructions, dated 11/09/2021, indicated the following: -On sacrum and spine area, apply Venelex ointment twice daily and cover with a foam dressing. -On left great toe, paint with [MEDICATION(S)] twice daily and leave open to air. -On left lateral foot (more proximal wound), clean with wound cleanser and paint with [MEDICATION(S)] twice daily and leave open to air. -On scrotum, apply 50/50 mixture of protective ointment and barrier cream twice daily and as needed (PRN) for soiling. -On left knee and left lateral foot (most distal) clean with wound cleanser, apply Aquacell AG (a type of wound dressing) cut to fit and cover with a foam dressing three times a week on Monday, Wednesday, and Friday. -Turn every two hours, using wedges and glide sheet. -Continue to keep heels elevated. A review of the Initial Nursing Evaluation- skin integrity section, dated 11/09/2021, indicated the resident had a wound to the left knee, multiple wounds to the left toes, wounds to the left posterior lateral foot, left hip, left upper thigh, and decubitus (pressure) ulcer to the sacrum, bruises to the bilateral upper extremities, and tiny wounds to the back. A further review of the evaluation revealed no measurements or description of the wounds were documented. A review of the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders did not include dressing orders (what to cover the wounds with after the Venelex was applied). The instructions for wound care from the hospital were not followed. A further review of the orders indicated the resident was to receive Ensure and a house shake with meals. A review of the November 2021 skilled administration record ([NAME]) revealed the order for the Ensure did not get scheduled and was not documented as being administered. A review of the initial Baseline/Advanced Care Plan, dated 11/09/2021, indicated the resident had pressure ulcers. Interventions included: -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing (no specific frequency was indicated) measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the physician. -Avoid positioning the resident on (no specific location was indicated). -Educated the resident/family/caregiver as to causes of skin breakdown: including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. -Inform the resident/family/caregivers of any new area of skin breakdown. -Monitor dressing (no specific frequency was indicated) to ensure it was intact and adhering. Report lose dressing to the treatment nurse. -Monitor/document/report PRN any changes in skin status, appearance, color, wound healing, signs and symptoms of infection, wound size, stage. -Teach resident/family the importance of changing positions for preventions of pressure ulcers. Encourage small frequent position changes. -The resident needs monitoring/reminding/assistance to turn/reposition at least every two hours, more often as needed or requested. -Treat pain as per orders prior to treatment/turning, to ensure the resident's comfort. -Weekly treatment documentation to include measurement of each are of skin breakdown width length, depth, type of tissue and exudate. A review of the Nutrition Therapy Assessment, dated 11/10/2021, indicated the resident had no pressure injuries and the only supplement listed was Ensure, not the house shake, and recommendations were made to discontinue the order for Ensure. This assessment was completed by the Nutrition and Dietetic Technician, Registered (NDTR) NN and not a Registered Dietitian. A review of the initial wound evaluation and management summary by the wound physician, dated 11/12/2021, indicated the resident had eleven wounds that were assessed, three that were classified as pressure wounds. Wound #1 was an unstageable deep tissue injury (DTI) of the lower sacrum, wound #6 was a stage 4 pressure wound of the left lateral ankle, and wound #7 was a stage 4 pressure wound of the left lateral foot. Wound #1 to the sacrum measured 6.5 centimeters (cm) by 8.0 cm with an unmeasurable depth. The surface area of the wound was 52 cm and was considered a cluster wound with light serous (clear to slightly yellow in color) exudate (drainage). The surrounding tissue was DTI (purple/maroon) in color. The wound bed had 40% granulation (new connective tissue) tissue and 60% skin. The plan was to apply hydrogel with silver and cover with a gauze island dressing with border once daily and recommended to off-load the wound, reposition per facility protocol, have a gel cushion for the chair, and a group-2 mattress (air). Wound #6 to the left lateral ankle measured 2.0 cm by 2.3 cm with an unmeasurable depth. The surface area was 4.6 cm with light serous exudate. The wound bed had 100% slough (dead tissue separating from living tissue), which was surgically debrided to remove necrotic (dead) tissue and establish the margins of viable tissue. The plan was to apply hydrogel with silver and cover with a gauze island dressing with border once daily and recommended to off-load the wound and reposition per facility protocol. Wound #7 to the left lateral foot measured 2.0 cm by 2.1 cm by 0.3 cm. The surface area of the wound was 4.2 cm with light serous exudate. The wound bed had 30% necrotic tissue, 50% slough, and 20% viable tissue and was surgically debrided. The plan was to apply hydrogel with silver and cover with a gauze island dressing with border once daily and recommended to off-load the wound and reposition per facility protocol. According to the November 2021 CPO, the following orders were received on 11/12/2021: -Clean stage 4 pressure wound on the left lateral ankle and left lateral foot with wound cleanser, pat dry, apply hydrogel and cover with dry protective dressing daily. (The order did not specify hydrogel with silver). -Clean unstageable DTI of the lower sacrum with wound cleanser, pat dry, apply hydrogel and cover with dry dressing daily. (The order did not specify hydrogel with silver). -Air mattress every shift. The order for Venelex to open wound twice a day continued with no clarification to indicate what wounds it was to be applied to or what type of dressing it was to be covered with. Review of Resident #71's record revealed no further documentation of the wounds until the resident was seen by the wound physician the following week on 11/19/2021. No weekly skin assessment or wound documentation was completed by the nursing staff. A review of the wound evaluation and management summary by the wound physician, dated 11/19/2021, revealed the resident had a new pressure area, wound #12, an unstageable DTI to the right heel that measured 2.4 cm by 3.7 cm with an unmeasurable depth. The surface area was 8.88 cm. The plan was to apply skin prep to the area once daily, off-load the wound, float heels in bed and elevate legs. A further review of the evaluation indicated wound #1 to the lower sacrum measured 6.5 cm by 7.5 cm with an unmeasurable depth. The surface area was 48.75 cm with light serous exudate. The wound bed had 40% granulation and 60% skin with no change in the treatment plan. Wound #6 to the left lateral ankle measured 2.0 cm by 2.3 cm with an unmeasurable depth. The surface area was 4.6 cm with light exudate. The wound bed had 100% slough and was surgically debrided with no change to the treatment plan. Wound #7 to the left lateral foot measured 2.0 cm by 2.0 cm by 0.3 cm. The surface area was 4.0 cm with light serous drainage. The wound bed had 30% necrotic tissue, 50% slough and 20% viable tissue and was surgically debrided with no change to the treatment plan. A review of the November 2021 CPO revealed no new orders were initiated for wound care to the newly identified pressure area to the right heel (wound #12), and the recommendations for off-loading the wounds, elevating the legs and floating the heels from the wound physician were not being followed. A review of Resident #71's record revealed no further documentation of the wounds until the resident was seen by the wound physician the following week, on 11/26/2021. No weekly skin assessment or wound documentation was completed by the nursing staff. A review of the comprehensive care plan, initiated 11/10/2021 and last revised 11/17/2021, indicated the resident had pressure ulcers or potential for pressure ulcer development related to mobility limitations, malnutrition, and debility (the care plan indicated to see orders and wound doctor notes). Interventions included: -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the physician. -Inform the resident/family /caregivers of any new area of skin breakdown. -Monitor dressings to ensure it is intact and adhering. Report loose dressing to treatment nurse. -Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. -Weekly treatment documentation to include measurement of each area of skin breakdowns width. Length, depth, type of tissue and exudate. The care plan did not include recommendations from the wound physician, including the air mattress, off-loading the wounds, repositioning, elevating the lower extremities, or floating the heels. A review of the wound evaluation and management summary by the wound physician, dated 11/26/2021, indicated wound #1 to the lower sacrum measured 6.5 cm by 6.0 cm with an unmeasurable depth. The surface area was 39 cm with light serous exudate. The wound bed had 40% granulation and 60% skin with hyper-granulation tissue present within the wound margins that was chemically cauterized to facilitate healing. No change was made to the treatment plan. Wound #6 to the left lateral ankle measured 2.0 cm by 2.3 cm with an unmeasurable depth. The surface area was 4.6 cm with light exudate. The wound bed had 100% slough and was surgically debrided. There was no change in the wound progress and no change to the treatment plan. Wound #7 to the left lateral foot measured 2.0 cm by 2.0 cm by 0.3 cm. The surface area was 4.0 cm with light serous drainage. The wound bed had 30% necrotic tissue, 50% slough and 20% viable tissue and was surgically debrided. There was no change in the wound progress and no change to the treatment plan. Wound #12 to the right heel measured 2.4 cm by 3.7 cm with an unmeasurable depth. The surface area was 8.88 cm. There was no change to the wound progress and no change to the recommended treatment plan. A review of the November 2021 CPO revealed the recommendations for the treatment to wound #12 to the right heel were not initiated again for the second week. A review of the comprehensive care plan revealed it was not updated with the recommendations from the wound physician for the second week. A review of the record revealed no further documentation of the wounds until observations were made by the surveyor on 12/01/2021 (see below). No weekly skin assessment or wound documentation was completed by the nursing staff. A review of a progress notes by the infectious disease nurse practitioner (IDNP), dated 11/28/2021, indicated the resident had multiple wounds in different stages of healing, including two open wounds to the lateral foot with [CONDITION(S)] (reddening) around both wound with a question of possible arterial problem and need for an arterial doppler. The note indicated the resident was to be started on [MEDICATION(S)] (an antibiotic) orally for ankle wounds and sacrum wound that was a DTI with a small opening that had [CONDITION(S)] around it. (This progress note was a late entry done on 12/03/2021 at 11:32 AM after being requested from the surveyor after observations of wound care were done with the wound physician and IDNP). The arterial doppler was not ordered until 12/03/2021. A review of the December 2021 CPO indicated an order was put in on 12/01/2021 for bilateral heel protectors to be on while in bed every shift. The recommendations for treatment to the right heel, wound #12, from the wound physician were still not initiated. Observations during wound care for Resident #71 on 12/01/2021 at 2:05 PM performed by the Assistant Director of Nursing (ADON) CC and Registered Nurse (RN) H revealed the resident had three new wounds that were not identified previously by the facility, including a deep tissue injury (DTI) to the left heel, the DTI to the right heel (previously identified by the wound physician) and a scab to the right great toe. ADON CC stated she was the nurse that rounded with the wound care physician, and she thought the DTI to the right heel was new (even though it had been identified by the wound physician two weeks earlier on 11/19/2021). The resident had inflatable heel protectors in place and was lying on an air mattress. The ADON contacted the physician and got orders to discontinue the heel protectors and initiated floating the resident's heels and skin prep to be applied to the newly identified wounds. A review of the December 2021 CPO indicated there were new orders as of 12/01/2021 to discontinue the heel protectors and begin offloading bilateral heels while in bed and to apply skin prep to the DTIs on the bilateral heels daily after cleansing with wound cleanser. A further review of the orders revealed the order for the house shakes with meals was discontinued on 12/01/2021, and the Venelex ointment was discontinued on 12/01/2021. A review of a nursing progress note, dated 12/01/2021, indicated a DTI was found to the left heel and right great toe during wound care, and the nurse noticed the inflatable heel protectors were not inflating well. Orders were obtained to discontinue the protector boots and start elevating the bilateral heels on pillows and off-load the heels while in bed. A review of a weekly pressure ulcer evaluation, dated 12/01/2021, indicated the resident had a pressure area to the left heel that developed 12/01/2021 and was described as a deep tissue injury (DTI) that was dark red/purple in color. No measurements were documented. (This was the only weekly pressure ulcer evaluation found in the resident's record for any of the pressure ulcers the resident had). A review of a progress notes by the infectious disease nurse practitioner (IDNP), dated 12/01/2021, indicated the resident was currently on [MEDICATION(S)] (an antibiotic) orally for ankle wounds and a sacrum wound that was a DTI with a small opening that had [CONDITION(S)] around it. The note indicated the IDNP discussed off-loading the resident's heels with the nurse and that pillows were under the heels. (This progress note was a late entry done on 12/03/2021 at 11:40 AM after being requested from the surveyor after observations of wound care were done with the wound physician and IDNP). Observations on 12/02/2021 at 7:59 AM revealed Resident #71 was lying in bed on their back with the head of the bed elevated greater than 45 degrees. The resident was wearing the inflatable heel protectors with the sheet pulled tightly across the resident's feet. Continuous observations were done from 7:59 AM until 11:30 AM. The resident was not provided any care during that time, including repositioning or incontinent care. The resident slowly slid down in the bed until their feet were off the edge of the bed. During an observation and interview with ADON CC, on 12/02/2021 at 11:30 AM while observing the condition Resident #71 was currently in, she stated the inflatable heel protectors should not have been on because they were causing increased pressure to other parts of the resident's legs. The ADON removed the inflatable heel protectors, and a new DTI was observed on the resident's left lateral lower leg. The ADON stated the resident's heels should be floated with pillows and the resident's position should be changed at least every two hours. The ADON stated she was going to put an order in the system for the resident to be turned and repositioned every two hours and was going to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . With the assistance of Certified Nurse Aide (CNA) P, the resident was repositioned up in the bed with a pillow placed under their legs to float the resident's heels off the mattress. ADON CC educated CNA P to reposition the resident at least every two hours using pillows to off-load pressure to the resident's wounds. During an interview on 12/02/2021 at 11:50 AM, CNA P stated she did not normally work on the 3rd floor. She stated she thought Resident #71 would call if they needed assistance and that the resident did not need to be repositioned because they were on an air mattress. A review of a nursing progress note, dated 12/02/2021, indicated the wound physician was contacted about the DTI found on the left lower leg, and new orders were obtained to apply skin prep daily and turn the resident every two hours. The note indicated the staff was informed to monitor and turn the resident every two hours. During an interview on 12/02/2021 at 2:41 PM, the Director of Nursing (DON) stated if a resident was on an air mattress, they did not need to be repositioned because the bed did the repositioning for the resident. The DON stated the facility wounds were monitored during wound care and documented on the skilled administration record ([NAME]). The DON stated if there was a change in the wounds, the nurse would contact the physician and get new orders. The DON stated the facility should have followed the wound care orders received from the hospital for Resident #71, and the air mattress should have been implemented immediately. She stated she was unsure why that did not happen. She stated the wound physician came twice a week. The DON stated that on Tuesdays the wound physician saw any newly admitted residents or residents with newly identified wounds and saw all other wounds on Fridays. The DON stated ADON CC did rounds with the wound physician and was responsible to follow up on any recommendations made. A review of the December 2021 CPO indicated orders were entered on 12/02/2021 for a sitting program three times a day, for the resident to be turned every two hours while in bed, and for skin prep to be applied to the wound to the left lateral lower leg. Observations on 12/03/2021 at 8:15 AM revealed Resident #71 was lying on their left side with their heels directly on the mattress. The wound physician was in to see the resident at 10:05 AM and identified a total of five new skin issues since the last visit (11/26/2021). The new areas were a DTI to the left heel, a scabbed areas to the right great toe, the left great toe (distal to the previous wound), the tip of the 3rd left toe, and a DTI to the lateral left lower leg. The DTI to the right heel opened and the wound physician debrided the wound, removing the top layer of skin. The wound physician attempted to debride the wound to the left lateral foot after applying [MEDICATION(S)] to numb the area, but the resident was not able to tolerate the pain associated with the procedure. The wound physician stated they were concerned the resident had arterial venous problems that was causing the delay of wound healing and the development of new wounds and was ordering a doppler study to be done, even though pulses were felt in the resident's feet. The wound physician was not aware the resident was not being followed by the dietitian and thought the resident was on a supplement for wound healing. The wound physician stated that if the staff had been following the recommendations, it was less likely for the resident to develop new areas. They stated the resident still needed to be repositioned, even if they were on an air mattress, and the staff needed to make sure direct pressure was not being applied to the existing wounds. The infectious disease nurse practitioner (IDNP) was also present during the wound rounds with the wound physician. She stated she started the resident on an antibiotic for the wounds to the left lower extremity, not the sacrum, and they were started because there was a delay in healing. She acknowledged that a progress note indicating the need for the antibiotic had not been entered and stated one would be done for the 11/28/2021 visit and the 12/03/2021 visit. A review of the wound evaluation and management summary by the wound physician, dated 12/03/2021, indicated wound #1 to the lower sacrum measured 6.5 cm by 6.0 cm with an unmeasurable depth. The surface area was 39 cm with light serous exudate. The wound bed had 40% granulation and 60% skin. There was no change to the wound progress and no change to the treatment plan. Wound #6 to the left lateral ankle measured 2.8 cm by 2.5 cm with an unmeasurable depth. The surface area was 7 cm with light serous exudate. The wound bed had 50% slough and 50% granulation tissue and was surgically debrided. There was deterioration in the wound progress and no change to the treatment plan. Wound #7 to the left lateral foot measured 2.0 cm by 1.5 cm by 0.3 cm. The surface area was 3.0 cm with light serous drainage. The wound bed had 30 % necrotic tissue, 50% slough, and 20% viable tissue and was surgically debrided. There was improvement with the wound progress and no change to the treatment plan. Wound #12 to the right heel measured 3.0 by 3.0 cm with an unmeasurable depth. The surface area was 9.0 cm. The wound was surgically debrided, and the treatment plan was to apply hydrogel with silver and cover with a gauze island dressing with a border daily, off-load the wound, float heels in bed, and elevate legs. The wound physician classified the wound to the resident's left heel (Wound #16) as an arterial wound that measured 3.0 cm by 4.0 cm with no measurable depth. The surface area was 12 cm and was 99% skin with a fluid filled blister and dried fibrinous exudate (scab). The plan was for skin prep to be applied daily, elevate legs, and off-load the wound. The wound physician classified the wound to the left lateral leg as an arterial wound that measured 9.5 cm by 1.0 cm with an unmeasurable depth. The surface area was 9.5 cm and was 99% skin with dried fibrinous exudate (scab). The plan was to apply skin prep daily, elevate the legs and off-load the wound. A bilateral lower extremity arterial doppler was recommended. A review of the progress notes by the IDNP, dated 12/03/2021, indicated the resident had a new cluster of wounds on the left lateral lower extremity and recommended to continue the [MEDICATION(S)] for now and order an arterial doppler. A review of the December 2021 CPO revealed updated orders were received on 12/03/2021 to include: -Clean stage 4 pressure wound to left lateral wound with wound cleanser, pat dry and apply hydrogel with silver and cover with a dry Opti-foam dressing daily at bedtime. -Cleanse wound to sacrum with wound cleanser and pat dry with 4 x 4 gauze. Apply hydrogel with silver and cover with a gauze border dressing at bedtime. -Cleanse unstageable right heel wound with wound cleanser and pat dry with 4 x 4 gauze. Apply hydrogel with silver and cover with a gauze island border dressing daily. Offload heels in bed. -4 ounces house shake with meals for wound care. -Multivitamin one tablet daily. -Vitamin C 500 milligrams (mg) twice daily. -Arterial doppler to bilateral lower extremities. The wound orders for the stage 4 pressure wound to the left lateral ankle did not include the hydrogel with silver as recommended by the physician. A review of the radiology interpretation of the findings of the bilateral lower extremity Doppler arterial ultrasound, dated 12/03/2021, indicated the resident had findings consistent with severe peripheral arterial disease (PAD). These results indicate the resident was at an even higher risk for wound development without preventative interventions being implemented. According to a nursing progress note, dated 12/03/2021 at 9:37 PM, the resident's doppler results were shared with the wound physician and, according to the results, the resident had severe arterial disease, the wounds were arterial in nature, and the resident required a vascular consult. A review of the comprehensive care plan, last revised 11/17/2021, was not updated with interventions to prevent the resident from developing new pressure areas or to aide in the healing of existing pressure ulcers. A review of the manufacturer's instructions from Direct Supply for the Panacea Air Max mattress Resident #71 was lying on indicated the product was only one element of care in the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/05/2021 at 1:14 PM, Licensed Vocational Nurse (LVN) DD stated residents should also be reminded and/or assisted to reposition themselves at least every two hours and more often if they had skin integrity issues, regardless if they were on an air mattress or not. During an interview on 12/07/2021 at 8:16 AM, the Administrator stated she received a report of the all the facility wounds weekly that included measurements and description. This report was requested from the Administrator at that time and was not provided. The Administrator stated a facility-wide skin audit had been done the day before, and no new skin issues were identified. The facility Administrator and the Corporate Consultant were notified of the Immediate Jeopardy situation and provided the IJ template on 12/03/2021 at 5:42 PM. The facility submitted a Removal Plan on 12/06/2021 at 11:13 AM. Removal Plan: A facility wide skin audit of all residents at risk was completed by the clinical team for possible similar failures found in the survey. The skin assessments were reviewed for accuracy by the clinical team and if required, update the care plan as needed. This was completed 12/04/2021. Effective 12/04/2021, the Director of Nursing (DON) or designee will review current resident skin assessments for completion and accuracy and review and implement nutritional recommendations upon approval from the Medical Doctor (MD). MD recommendations given for skin and

Based on interviews, record review, and document review, it was determined the facility failed to honor Resident #90's wishes to die a dignified death by failing to honor a signed do not resuscitate (DNR) order when the resident was found unresponsive on [DATE] and nursing staff called 911 and initiated cardiopulmonary resuscitation (CPR). This resulted in Resident #90 receiving CPR for over a period of ten minutes against the resident's wishes. This affected one (Resident #90) of 17 residents reviewed for code status. This failure placed residents who were to not to receive full code measures at risk of an undignified death. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.10 (Advanced Directives) at a scope and severity of J. The IJ began on [DATE] when Licensed Vocational Nurse (LVN) K failed to honor Resident #90's advanced directive. LVN K found Resident #90 unresponsive and administered CPR to Resident #90 when there was a signed DNR on file in Resident #90's electronic medical record (EMR). The Administrator was notified of the IJ and provided with the IJ template on [DATE] at 5:42 PM. A Removal Plan was requested. An acceptable Removal Plan was received on [DATE]. The IJ was determined to be removed on [DATE], after the survey team performed onsite verification that the Removal Plan had been implemented. Findings included: A policy regarding the deficient practice was requested from the Director of Nursing (DON) on [DATE]. No policy was received by the end of the survey. The facility admitted Resident #90 to the facility as a long-term care resident. A comprehensive Minimum Data Set assessment was not completed for Resident #90. A review of physician orders, dated [DATE], identified that the resident was a full code. A review of the care plan, initiated on [DATE], identified Resident #90 desired full code measures. A review of Resident #90's DNR directive revealed it was signed by the resident and physician prior to admission to the facility on [DATE]. Further review revealed it was scanned into Resident #90's medical chart on [DATE]. A review of progress notes, dated [DATE] at 11:15 PM by Licensed Vocational Nurse (LVN) K, revealed that, at 10:40 PM, a certified nursing assistant (CNA) called LVN K to the resident's room, and LVN K found Resident #90 unresponsive. A code blue was called out, CPR was initiated per the resident's face sheet, and 911 was called by LVN GG. At 10:50 PM, emergency medical technicians (EMTs) arrived at the facility and took over CPR. The EMTs requested Resident #90's medical history documentation. LVN GG went to obtain the information and discovered Resident #90's signed DNR. The EMTs were notified and CPR was stopped. Resident #90's family member, the DON, and the physician were notified. An interview on [DATE] at 7:02 PM with LVN K revealed there was no current binder in the facility that staff could check for a resident's code status. LVN K stated she checked the face sheet in the electronic medical record and the 24-hour nurses' report, but that was not always accurate. LVN K stated the report was not always accurate because of agency staff. LVN K stated agency staff did not always update information in the report. LVN K stated that, on [DATE], a CNA came and got her to inform her that Resident #90 was not responding. LVN K went to the resident's room and found that Resident #90 showed no response. LVN K got the crash cart and asked LVN GG to check the resident's code status. The face sheet indicated the resident was a full code. LVN K stated LVN GG called 911 and LVN K initiated CPR. LVN K stated when EMS arrived, they took over CPR and asked for additional information, so LVN GG went to access the electronic medical record to print the requested documents. LVN K said LVN GG came back and showed EMS Resident #90's signed DNR, and at that time EMS stopped CPR. LVN K stated it was the Administrator and the DON's responsibility to ensure the correct code status was in the resident's electronic medical record. LVN K stated that after the incident neither the DON nor the Administrator had a discussion with her or instructed her to complete any in-service or training related to code status or advanced directives. An interview on [DATE] at 7:23 PM with LVN GG revealed he checked the face sheet in an electronic medical record to get a resident's code status. LVN GG stated some residents had their code status hung on the inside door of the resident's closet in their room, but he was unsure why only some residents had it there and others did not. LVN GG stated that, on [DATE], a CNA told LVN K to check on Resident #90. LVN K went into the resident's room, and he went to the electronic medical record to check the code status for Resident #90, which was listed as full code. LVN GG stated LVN K performed CPR on Resident #90 until EMS arrived, and they took over CPR. LVN GG stated he went back to the computer to print off some documents that EMS requested to take with them to the emergency room (ER), and that is when he discovered Resident #90's signed DNR scanned into the electronic medical record. LVN GG stated he printed off the DNR, showed it to EMS providers, and CPR was stopped. LVN GG stated he was never asked to write a statement and never received any training related to code status or advanced directives after the event. An interview on [DATE] at 1:53 PM with the DON revealed staff should be looking in the resident's electronic medical record at the front screen for a resident's code status. The DON stated it was the facility's protocol that all residents were a full code until they provided documentation of a signed DNR. The DON stated social services had a book placed at each nurses' station with DNR information. The DON stated social services printed out copies of signed DNRs and placed them in those books. The DON stated a resident's care plan, and the electronic medical record were checked to ensure the correct codes status was reflected, but not the face sheet. The DON stated she did not know how to access a resident's face sheet in the electronic medical record. The DON stated the DON and ADONs were responsible for oversight to ensure that all the resident's information in the electronic medical record reflected the correct code status. The DON stated Resident #90 was a cancer patient and had been on hospice prior to admission to the facility. Per the DON, the family had approved the use of a new drug for treatment, and the resident had shown some improvement and had come to the facility as a full code. The DON stated the receptionist received the DNR form by the family on [DATE], which was a Saturday. The DON was unable to say which receptionist received the form. The DON stated that, on [DATE], Resident #90 was found unresponsive and nursing staff looked in the resident's electronic medical record and saw that the information listed for Resident #90's code status was a full code. The DON stated the staff that received the signed DNR form should have contacted social services and made them aware. The DON stated any documents received by family should not be scanned in before it had been reviewed by social services. The DON stated the Administrator conducted training in relation to code status with staff. An interview on [DATE] at 3:15 PM with the Administrator revealed the incident was not reported to Texas Health and Human Services (HHS), and the facility did not investigate after CPR was performed on a resident that had a signed DNR in their electronic medical record. The Administrator stated she did not feel there was any outcome to the resident and therefore she did not feel it should have been reported. When the Administrator was asked how she knew there was no outcome, the Administrator stated because the resident had already passed when CPR was being administered. An interview on [DATE] at 9:40 AM with Social Worker (SW) O revealed SW O met with new residents for an introduction and verified the code status of the resident at that time. SW O stated if there was a change to the code status, SW O notified the DON since the DON was the only one who could change the code status in the electronic medical record system. SW O stated residents must provide a copy of a signed DNR and would remain a full code until the DNR was received. SW O stated there was no form that residents signed acknowledging they were aware they were to be provided full code measures until the DNR was provided to the facility. SW O stated as soon as staff were aware that a code status was changed, they emailed the DON and all of the ADONs that the code status had changed. SW O stated that when the facility received a DNR, SW O checked to ensure the validity of the form, a copy was sent to the DON and the ADONs, and it was uploaded into the electronic medical record system. SW O stated she typically received a response from the DON that a DNR had been received, but if she did not by the end of the day she would send another email. SW O stated if staff received a DNR after hours, it could be scanned in and an email should be sent to the DON, the ADONs, and SW O. SW O stated she was not aware of the change in Resident #90 code status. SW O stated she did not receive training on code status in the last few months. An interview on [DATE] at 11:15 AM with the Receptionist revealed any advanced directive documents that were received were processed immediately. The Receptionist stated if staff received a signed DNR, staff should send an email to social services, the Administrator, the DON, and the ADONs, notifying them that the documents were scanned into the resident's electronic medical record. Then the signed copy should be placed in social services' box. The Receptionist stated they used to keep a hard copy of the signed DNRs and place them in a plastic sleeve with a red background that was placed in the resident's room, but that was not the facility's current process. The Receptionist stated most of the time the signed DNR was given to a receptionist to be scanned into a resident's electronic medical record. The Receptionist stated she was currently not able to document in a resident's electronic medical record. The Receptionist stated the employee number who scanned Resident #90's DNR into the electronic medical record was hers, and she did work on [DATE]. However, the Receptionist stated she was unable to find any documentation that an email was sent to staff notifying them that Resident #90 had a DNR that was scanned into the electronic medical record or that nursing staff, social services, or the DON were made aware of the DNR. On [DATE] at 3:43 PM, an interview with Resident #90's power of attorney (POA) revealed the family had a pre-admission meeting with the DON, and she was made aware that the resident was a DNR, and that the paperwork would be sent to the facility. The POA stated the form was hand delivered to the facility on Friday, [DATE], and handed to a female described by hair color at the front desk. The POA stated that, after the incident occurred, staff contacted her about the resident passing, but facility staff never informed the POA that CPR was administered to the resident after the resident coded. The POA stated when they got to the hospital, a law enforcement officer stated, Staff at the facility tried really hard to save your [parent], and that was how the POA became aware of what had occurred at the facility. Removal Plan: Facility initiated an audit of current patients on [DATE]. This audit reviewed the code status listing in the medical record versus the actual code status that the patient has in place for themselves. The audit includes the availability of the DNR in the patient's chart as well as the red sign is in place in the patient's room in the patient's closet, if the patient was not a full code. Audit completed on [DATE] and current patients were noted to have the correct code status in their medical record, and if pertinent a copy of the DNR in their file as well as the red sign in the patient's closet. On [DATE], the facility initiated a facility wide training/inservice to re-educate associates on the proper way to handle, identify and ensure that the code status is correct on the patient in their medical record. The re-education included the process when a DNR is brought to the community after regular business hours and the exact way to notify the appropriate team members on the arrival of the DNR to the community. Once the DNR is received it is reviewed by the social services department or the designee listed below for proper signature. The nurse supervisor or the nurse attending the patient is then notified by the designee and the code status is changed in the electronic medical record. Finally, a copy of the RED DNR symbol is placed inside the patient's room by the patient's attending nurse and due to training they receive regarding the placement of the red sign, clinical and non-clinical staff will know that the patient is a DNR. If the DNR is received after hours, the same process that is explained above is implemented to ensure the associate who receives it is to notify the chain of command. The system is 5 associates deep and includes 3 social workers, director of nursing and then finally the administrator. The team is notified verbally in the order stated previously. The associate must speak with someone verbally on the chain to complete the process of notification. Once one of the 5 designees has been notified, the process above, which includes reviewing the signatures, having the attending nurse update the medical record in electronic medical record, and then finally placing the red sign in the patient's room is completed which allows the facility staff to be aware of the DNR. Effective [DATE], Social Services Director or designee will audit the process for accuracy weekly. Results to be reported to the administrator weekly for 4 weeks to ensure compliance. Effective [DATE], the Administrator and/or designee will conduct separate bi-weekly audits of the same process listed above to ensure that the system and its steps to ensure proper code status are being completed. This will be done for three months to ensure compliance. Administrator and/or designee will bring findings to QAPI [quality assurance performance improvement] meeting monthly for three months for review. Associates who have not been in serviced due to their schedule will be in serviced by facility leadership prior to the beginning of their shift. An Ad hoc QAPI meeting being held [DATE] with the Administrator, Director of Nursing, Medical Director and two other persons present to discuss the above plan. Onsite Verification: A review of eleven resident rooms with a signed DNR status revealed red signs with DNR status placed inside the closet door of all eleven rooms. A review of an audit for all current resident's code status revealed the correct code status information was reflected in all areas of the medical records. Review of in-service trainings revealed staff were in-serviced on [DATE], in relation to code status. Interviews with nursing and receptionist staff revealed staff received an in-service and were knowledgeable of the appropriate process of notifications and processing of a signed DNR when it was hand delivered to the facility. The IJ was determined to be removed on [DATE], after the survey team performed onsite verification that the Removal Plan had been implemented.

Based on observations, record review, and interviews, the facility failed to provide treatment and services in accordance with professional standards of practice for one (Resident #111) of three residents reviewed for non-pressure wounds. The facility failed to honor Resident #90's wishes to die a dignified death by failing to honor a signed do not resuscitate (DNR) order when the resident was found unresponsive on [DATE] and nursing staff called 911 and initiated cardiopulmonary resuscitation (CPR). This resulted in Resident #90 receiving CPR for over a period of ten minutes against the resident's wishes. This affected one (Resident #90) of 17 residents reviewed for code status. The facility failed to properly assess and monitor Resident #111's wounds and follow up on recommendations made by the wound physician. This failure placed residents who were to not to receive full code measures at risk of an undignified death. This had the potential to affect residents with wounds and residents at risk for skin breakdown. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.10 (Advanced Directives) at a scope and severity of J. The IJ began on [DATE] when Licensed Vocational Nurse (LVN) K failed to honor Resident #90's advanced directive. LVN K found Resident #90 unresponsive and administered CPR to Resident #90 when there was a signed DNR on file in Resident #90's electronic medical record (EMR). The Administrator was notified of the IJ and provided with the IJ template on [DATE] at 5:42 PM. A Removal Plan was requested. An acceptable Removal Plan was received on [DATE]. The IJ was determined to be removed on [DATE], after the survey team performed onsite verification that the Removal Plan had been implemented. This had the potential to affect residents with wounds and residents at risk for skin breakdown. Findings included: A policy regarding the deficient practice was requested from the Director of Nursing (DON) on [DATE]. No policy was received by the end of the survey. The facility admitted Resident #90 to the facility as a long-term care resident. A comprehensive Minimum Data Set assessment was not completed for Resident #90. A review of physician orders, dated [DATE], identified that the resident was a full code. A review of the care plan, initiated on [DATE], identified Resident #90 desired full code measures. A review of Resident #90's DNR directive revealed it was signed by the resident and physician prior to admission to the facility on [DATE]. Further review revealed it was scanned into Resident #90's medical chart on [DATE]. A review of progress notes, dated [DATE] at 11:15 PM by Licensed Vocational Nurse (LVN) K, revealed that, at 10:40 PM, a certified nursing assistant (CNA) called LVN K to the resident's room, and LVN K found Resident #90 unresponsive. A code blue was called out, CPR was initiated per the resident's face sheet, and 911 was called by LVN GG. At 10:50 PM, emergency medical technicians (EMTs) arrived at the facility and took over CPR. The EMTs requested Resident #90's medical history documentation. LVN GG went to obtain the information and discovered Resident #90's signed DNR. The EMTs were notified and CPR was stopped. Resident #90's family member, the DON, and the physician were notified. An interview on [DATE] at 7:02 PM with LVN K revealed there was no current binder in the facility that staff could check for a resident's code status. LVN K stated she checked the face sheet in the electronic medical record and the 24-hour nurses' report, but that was not always accurate. LVN K stated the report was not always accurate because of agency staff. LVN K stated agency staff did not always update information in the report. LVN K stated that, on [DATE], a CNA came and got her to inform her that Resident #90 was not responding. LVN K went to the resident's room and found that Resident #90 showed no response. LVN K got the crash cart and asked LVN GG to check the resident's code status. The face sheet indicated the resident was a full code. LVN K stated LVN GG called 911 and LVN K initiated CPR. LVN K stated when EMS arrived, they took over CPR and asked for additional information, so LVN GG went to access the electronic medical record to print the requested documents. LVN K said LVN GG came back and showed EMS Resident #90's signed DNR, and at that time EMS stopped CPR. LVN K stated it was the Administrator and the DON's responsibility to ensure the correct code status was in the resident's electronic medical record. LVN K stated that after the incident neither the DON nor the Administrator had a discussion with her or instructed her to complete any in-service or training related to code status or advanced directives. An interview on [DATE] at 7:23 PM with LVN GG revealed he checked the face sheet in an electronic medical record to get a resident's code status. LVN GG stated some residents had their code status hung on the inside door of the resident's closet in their room, but he was unsure why only some residents had it there and others did not. LVN GG stated that, on [DATE], a CNA told LVN K to check on Resident #90. LVN K went into the resident's room, and he went to the electronic medical record to check the code status for Resident #90, which was listed as full code. LVN GG stated LVN K performed CPR on Resident #90 until EMS arrived, and they took over CPR. LVN GG stated he went back to the computer to print off some documents that EMS requested to take with them to the emergency room (ER), and that is when he discovered Resident #90's signed DNR scanned into the electronic medical record. LVN GG stated he printed off the DNR, showed it to EMS providers, and CPR was stopped. LVN GG stated he was never asked to write a statement and never received any training related to code status or advanced directives after the event. An interview on [DATE] at 1:53 PM with the DON revealed staff should be looking in the resident's electronic medical record at the front screen for a resident's code status. The DON stated it was the facility's protocol that all residents were a full code until they provided documentation of a signed DNR. The DON stated social services had a book placed at each nurses' station with DNR information. The DON stated social services printed out copies of signed DNRs and placed them in those books. The DON stated a resident's care plan, and the electronic medical record were checked to ensure the correct codes status was reflected, but not the face sheet. The DON stated she did not know how to access a resident's face sheet in the electronic medical record. The DON stated the DON and ADONs were responsible for oversight to ensure that all the resident's information in the electronic medical record reflected the correct code status. The DON stated Resident #90 was a cancer patient and had been on hospice prior to admission to the facility. Per the DON, the family had approved the use of a new drug for treatment, and the resident had shown some improvement and had come to the facility as a full code. The DON stated the receptionist received the DNR form by the family on [DATE], which was a Saturday. The DON was unable to say which receptionist received the form. The DON stated that, on [DATE], Resident #90 was found unresponsive and nursing staff looked in the resident's electronic medical record and saw that the information listed for Resident #90's code status was a full code. The DON stated the staff that received the signed DNR form should have contacted social services and made them aware. The DON stated any documents received by family should not be scanned in before it had been reviewed by social services. The DON stated the Administrator conducted training in relation to code status with staff. An interview on [DATE] at 3:15 PM with the Administrator revealed the incident was not reported to Texas Health and Human Services (HHS), and the facility did not investigate after CPR was performed on a resident that had a signed DNR in their electronic medical record. The Administrator stated she did not feel there was any outcome to the resident and therefore she did not feel it should have been reported. When the Administrator was asked how she knew there was no outcome, the Administrator stated because the resident had already passed when CPR was being administered. An interview on [DATE] at 9:40 AM with Social Worker (SW) O revealed SW O met with new residents for an introduction and verified the code status of the resident at that time. SW O stated if there was a change to the code status, SW O notified the DON since the DON was the only one who could change the code status in the electronic medical record system. SW O stated residents must provide a copy of a signed DNR and would remain a full code until the DNR was received. SW O stated there was no form that residents signed acknowledging they were aware they were to be provided full code measures until the DNR was provided to the facility. SW O stated as soon as staff were aware that a code status was changed, they emailed the DON and all of the ADONs that the code status had changed. SW O stated that when the facility received a DNR, SW O checked to ensure the validity of the form, a copy was sent to the DON and the ADONs, and it was uploaded into the electronic medical record system. SW O stated she typically received a response from the DON that a DNR had been received, but if she did not by the end of the day she would send another email. SW O stated if staff received a DNR after hours, it could be scanned in and an email should be sent to the DON, the ADONs, and SW O. SW O stated she was not aware of the change in Resident #90 code status. SW O stated she did not receive training on code status in the last few months. An interview on [DATE] at 11:15 AM with the Receptionist revealed any advanced directive documents that were received were processed immediately. The Receptionist stated if staff received a signed DNR, staff should send an email to social services, the Administrator, the DON, and the ADONs, notifying them that the documents were scanned into the resident's electronic medical record. Then the signed copy should be placed in social services' box. The Receptionist stated they used to keep a hard copy of the signed DNRs and place them in a plastic sleeve with a red background that was placed in the resident's room, but that was not the facility's current process. The Receptionist stated most of the time the signed DNR was given to a receptionist to be scanned into a resident's electronic medical record. The Receptionist stated she was currently not able to document in a resident's electronic medical record. The Receptionist stated the employee number who scanned Resident #90's DNR into the electronic medical record was hers, and she did work on [DATE]. However, the Receptionist stated she was unable to find any documentation that an email was sent to staff notifying them that Resident #90 had a DNR that was scanned into the electronic medical record or that nursing staff, social services, or the DON were made aware of the DNR. On [DATE] at 3:43 PM, an interview with Resident #90's power of attorney (POA) revealed the family had a pre-admission meeting with the DON, and she was made aware that the resident was a DNR, and that the paperwork would be sent to the facility. The POA stated the form was hand delivered to the facility on Friday, [DATE], and handed to a female described by hair color at the front desk. The POA stated that, after the incident occurred, staff contacted her about the resident passing, but facility staff never informed the POA that CPR was administered to the resident after the resident coded. The POA stated when they got to the hospital, a law enforcement officer stated, Staff at the facility tried really hard to save your [parent], and that was how the POA became aware of what had occurred at the facility. Removal Plan: Facility initiated an audit of current patients on [DATE]. This audit reviewed the code status listing in the medical record versus the actual code status that the patient has in place for themselves. The audit includes the availability of the DNR in the patient's chart as well as the red sign is in place in the patient's room in the patient's closet, if the patient was not a full code. Audit completed on [DATE] and current patients were noted to have the correct code status in their medical record, and if pertinent a copy of the DNR in their file as well as the red sign in the patient's closet. On [DATE], the facility initiated a facility wide training/inservice to re-educate associates on the proper way to handle, identify and ensure that the code status is correct on the patient in their medical record. The re-education included the process when a DNR is brought to the community after regular business hours and the exact way to notify the appropriate team members on the arrival of the DNR to the community. Once the DNR is received it is reviewed by the social services department or the designee listed below for proper signature. The nurse supervisor or the nurse attending the patient is then notified by the designee and the code status is changed in the electronic medical record. Finally, a copy of the RED DNR symbol is placed inside the patient's room by the patient's attending nurse and due to training they receive regarding the placement of the red sign, clinical and non-clinical staff will know that the patient is a DNR. If the DNR is received after hours, the same process that is explained above is implemented to ensure the associate who receives it is to notify the chain of command. The system is 5 associates deep and includes 3 social workers, director of nursing and then finally the administrator. The team is notified verbally in the order stated previously. The associate must speak with someone verbally on the chain to complete the process of notification. Once one of the 5 designees has been notified, the process above, which includes reviewing the signatures, having the attending nurse update the medical record in electronic medical record, and then finally placing the red sign in the patient's room is completed which allows the facility staff to be aware of the DNR. Effective [DATE], Social Services Director or designee will audit the process for accuracy weekly. Results to be reported to the administrator weekly for 4 weeks to ensure compliance. Effective [DATE], the Administrator and/or designee will conduct separate bi-weekly audits of the same process listed above to ensure that the system and its steps to ensure proper code status are being completed. This will be done for three months to ensure compliance. Administrator and/or designee will bring findings to QAPI [quality assurance performance improvement] meeting monthly for three months for review. Associates who have not been in serviced due to their schedule will be in serviced by facility leadership prior to the beginning of their shift. An Ad hoc QAPI meeting being held [DATE] with the Administrator, Director of Nursing, Medical Director and two other persons present to discuss the above plan. Onsite Verification: A review of eleven resident rooms with a signed DNR status revealed red signs with DNR status placed inside the closet door of all eleven rooms. A review of an audit for all current resident's code status revealed the correct code status information was reflected in all areas of the medical records. Review of in-service trainings revealed staff were in-serviced on [DATE], in relation to code status. Interviews with nursing and receptionist staff revealed staff received an in-service and were knowledgeable of the appropriate process of notifications and processing of a signed DNR when it was hand delivered to the facility. The IJ was determined to be removed on [DATE], after the survey team performed onsite verification that the Removal Plan had been implemented. A policy on wound care was requested from the facility on [DATE]. The facility provided photocopies from an unnamed nursing textbook on how to care for pressure ulcers which included the following, Comprehensive skin assessment shouldn't be a one-time event limited to admission. Repeat it regularly to determine whether changes in skin condition have occurred. Document a complete skin assessment and interventions use to prevent pressure ulcers. Update the care plan as required. Except for brief periods, avoid raising the head of the bed more than 30 degrees to prevent shearing forces. Apply heel protection devices to prevent heel pressure ulcers. The device should completely offload pressure from the heels. Turn and reposition the patient everyone to two hours or more frequently as required. A review of the face sheet indicated the facility admitted Resident #111 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had no cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. A further review of the MDS indicated the resident required extensive assistance of one to two people for activities of daily living (ADLs), including bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The resident was occasionally incontinent of bowel and bladder. The MDS indicated the resident had diabetic foot ulcers and an infection of the foot. A review of the initial nursing evaluation, skin integrity section, dated [DATE], indicated Resident #111 had a diabetic ulcer to the left foot. There was no description of the wound or measurements. The evaluation indicated it was still in progress and was not signed off and dated as being completed. No other skin integrity issues were documented. A review of a nursing progress note, dated [DATE], indicated Resident #111 had a left foot ulcer with a dressing. A review of the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a progress note by the infectious disease nurse practitioner (IDNP), dated [DATE], indicated the resident had two wounds to the lateral left midfoot and the wound team was to follow. This was the first documentation of there being more than one wound to the left foot. A review of the comprehensive care plan, dated [DATE], indicated the resident had a pressure ulcer or potential for pressure ulcer development. The resident also had potential/actual impairment to skin integrity of the . (no specific location was documented). Interventions included the following: - Administer treatments as ordered and monitor for effectiveness. - Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the physician. - Monitor dressing to ensure it was intact and adhering. Report loose dressing to treatment nurse. - Monitor/document/report as needed (PRN) any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. - Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue, and exudate. - Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. - Encourage good nutrition and hydration to promote healthier skin. - Keep skin clean and dry. Use lotion on dry skin. Do not apply on injury. - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. A review of the record revealed no documentation by nursing staff of the wound to the left foot documenting the location, size, appearance, and stage. During observations and interview on [DATE] at 12:16 PM, Resident #111 was sitting in their wheelchair in their room. The resident had a bordered dressing on the left foot, and the resident stated they had sores on that foot and that was the reason they were at the facility. The resident also had multiple bruising and scabbed abrasions to the bilateral forearms. The resident stated they thought they got those when they slid off the bed a few days earlier but was not sure. A review of the wound evaluation and management summary by the wound physician, dated [DATE], indicated the resident currently had three wounds that were being monitored. Wound #2 to the left plantar foot was classified as a diabetic wound that measured 0.8 centimeters (cm) by 1.0 cm by unmeasurable depth. The surface area was 0.80 cm with moderate serous (clear to slightly yellow in color) exudate (drainage). The wound bed had 100% slough (dead tissue separating from living tissue) that required surgical excisional debridement to remove necrotic (dead) tissue and establish the margins of viable tissue. The treatment plan was to apply [MEDICATION(S)] blue foam three times a week, covered with an ABD (thick gauze pad) pad and kerlix gauze, and recommended elevating the legs. Wound #8 to the left lateral foot was classified as a diabetic wound that measured 2.3 cm by 2.0 cm by unmeasurable depth. The surface area was 4.6 cm with moderate serous exudate. The wound bed had 20% necrotic tissue, 40% slough, and 40% granulation (new connective tissue) tissue that required surgical debridement. The treatment plan was to apply [MEDICATION(S)] blue foam three times a week, covered with an ABD pad and kerlix gauze, and recommended elevating the legs. Wound #9 to the right forearm was classified as a skin tear that measured 8.0 cm by 0.9 cm with an unmeasurable depth. The surface area was 7.2 cm with no exudate and had dried fibrinous exudate (scab). The treatment was to apply skin prep once daily and to off-load the wound. The wound evaluation was not part of the resident's electronic health record (EHR) and was not provided to the surveyor until [DATE]. A review of the [DATE] CPO revealed orders were received on [DATE] for the following: · Clean diabetic wound to the left lateral foot with wound cleanser, pat dry, apply [MEDICATION(S)] Blue (a type of wound dressing) three times a week. · Clean plantar foot wound with wound cleanser, pat dry, and cover with a dry protective dressing three times a week. The recommendations made from the wound care physician on [DATE] for the wounds on the left foot to be covered with an ABD pad and wrapped with kerlix were not initiated. The recommendation for the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the comprehensive care plan, dated [DATE], indicated it was not updated with the updated wound orders or recommendations to elevate the legs and off-load the wound to the right forearm. A review of the resident's electronic health record (EHR) on [DATE] revealed no documentation by the nursing staff of the wounds to the resident's left foot except for signing off that the treatment had been completed on the skilled administration record ([NAME]). A review of the [DATE] [NAME] indicated the resident had one wound to the left foot. There was no documentation in the record of the skin tear to the right forearm or the abrasions and bruising to the bilateral upper extremities. No weekly skin assessments were documented as being completed by the nursing staff. During an interview on [DATE] at 12:04 PM, Registered Nurse (RN) H stated she had only worked on the hallway once before, and she had not done the dressing change to Resident #111's foot, so she did not know what it looked like. After reviewing the resident's orders, she stated it looked like the resident had one or two wounds on the left foot. RN H stated she had not noticed the abrasions or bruises to the forearms but thought the resident might have gotten them when the resident slid off the bed a few days earlier. RN H stated the wounds were monitored by one of the Assistant Directors of Nursing (ADONs). During an interview on [DATE] at 2:05 PM, ADON CC stated the facility did not have a wound nurse, but the nurse assigned to the residents on the hall was responsible for providing the wound care. ADON CC stated a wound physician came to the facility and assessed all the wounds twice a week on Tuesdays and Fridays, and she was the nurse that rounded with the physician and followed up on the recommendations that were made by the wound physician. ADON CC stated if a resident developed a new skin condition, the nurse on the floor should notify the physician and get orders for treatment, then the area would be reassessed by the wound physician when they came in. ADON CC stated she must have missed the order for the treatment to Resident #111's skin tear and stated she was not aware the resident had any other skin issues on the resident's upper extremities. During an interview on [DATE] at 2:41 PM, the Director of Nursing (DON) stated the facility wounds were monitored during wound care by the floor nurses, and documented on the skilled administration record ([NAME]). The DON stated if there was a change in the wounds, the nurse would contact the physician and get new orders. She said the wound physician came twice a week. The DON stated that on Tuesdays the wound physician saw any newly admitted residents or residents with newly identified wounds and saw all other wounds on Fridays. The DON stated ADON CC did rounds with the wound physician and was responsible to follow up on any recommendations made. During an interview on [DATE] at 8:16 AM, the Administrator stated she received a report of the all the facility wounds weekly that included measurements and description. This report was requested from the Administrator at that time and was not provided by the end of the survey.

Based on record review and interviews, the facility failed to conduct COVID-19 testing based on parameters set forth by the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS). Specifically, the facility failed to test all residents and employees during an outbreak situation or according to the facility's county level of community transmission. This had the potential to affect all residents in the facility. Findings included: According to the Centers for Disease Control (CDC) Infection Control for Nursing Homes, last updated 09/10/2021, In nursing homes located in counties with substantial to high community transmission, unvaccinated health care professionals (HCP) should have a [CONDITION(S)] test twice a week. When responding to a newly identified COVID-19 infected HCP or resident, perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately and if negative, again five to seven days later. If additional cases are identified, testing should continue every three to seven days until there are no new cases for 14 days. According to the Centers for Medicare and Medicaid Services (CMS) in a QSO-20-38-NH memo, last updated 09/10/2021, staff testing of COVID-19 is based on the facility's county level of community transmission. Testing frequency of unvaccinated staff is as follows: -Low (blue) less than 5% = no testing recommended. -Moderate (yellow) 5.0% to 7.99% = once a week testing. -Substantial (orange) 8%-9.99% = twice a week testing. -High (red) greater than 10% = twice a week testing. A review of the facility's line list for COVID-19 (a spreadsheet that keeps track of staff and residents that have tested positive for COVID-19) revealed three residents and two staff members had tested positive for COVID-19 in September 2021, and three residents had tested positive for COVID-19 since 10/01/2021. Resident #306 tested positive for COVID-19 on 10/04/2021, and Resident #308 tested positive on 10/18/2021. The positive COVID-19 test for Resident #307 was on 11/02/2021. This kept the facility in outbreak status until 11/16/2021, requiring all residents and staff, regardless of vaccination status, to be tested every three to seven days, according to CDC guidelines. A review of the weekly COVID-19 tests results for the residents from 10/07/2021 through 11/23/2021 revealed the following: -On 10/07/2021, the resident in room [ROOM NUMBER] was not tested . -On 10/27/2021, the residents in rooms [ROOM NUMBERS] were not tested . -On 11/04/2021, the residents in rooms [ROOM NUMBERS] were not tested . -On 11/11/2021, the residents in Rooms 102 (second week in a row) and 107 were not tested . According to a daily COVID-19 report, dated 10/19/2021, the facility had 83 staff members. A review of the COVID-19 Staff Testing Logs from 10/03/2021 through 11/20/2021 revealed the following: -28 staff members were tested from 10/04/2021-10/09/2021, two were tested twice. -36 staff members were tested from 10/10/2021-10/16/2021, ten were tested twice. -29 staff members were tested from 10/17/2021-10/23/2021, three were tested twice. -15 staff members were tested from 10/24/2021-10/30/2021, three were tested twice. -27 staff members were tested from 10/31/2021-11/06/2021, six were tested twice. -25 staff members were tested from 11/07/2021 -11/13/2021, none were tested twice -21 staff members were tested from 11/14/2021-11/20/2021, two were tested twice. The facility was no longer in outbreak status as of 11/16/2021. A review of the facility's county transmission rate (obtained from https://covid.cdc.gov/covid-data-tracker ) from 11/16/2021 to 12/04/2021 indicated the county was at a substantial-to-high level. According to CDC guidelines, due to the county transmission rate, all unvaccinated staff should have been tested twice a week. A review of the COVID-19 Staff Testing Logs from 11/21/2021 through 11/27/2021 indicated 12 staff members were tested . None of the 12 staff members were tested twice that week. According to the staff summary of vaccination status, dated 11/30/2021, the facility had 100 staff members; 21 were not vaccinated and one had only one dose of the vaccine. A review of the COVID-19 Staff Testing Logs from 11/28/2021 through 12/04/2021 indicated seven staff members were tested . None of the seven staff members were tested twice that week. According to the staff summary of vaccination status, dated 12/03/2021, the facility had 99 employees. Twenty were not vaccinated, and one had only one dose of the vaccine. During an interview on 12/03/2021 at 1:45 PM, Assistant Director of Nursing (ADON) C stated she was also the Infection Control Preventionist (ICP). She stated she became certified in 2019. ADON C stated as of 11/20/2021, the facility was no longer in outbreak status, and since the county transmission rate for last week was less than 5% the unvaccinated staff and residents were tested for COVID-19 once a week. ADON C did not know what the county transmission rate was. ADON C stated she had been doing the testing for staff and residents up until approximately three to four weeks ago. ADON C stated the Assistant Administrator was not a nurse but was trained on how to properly perform the test, and she was the person who tested the residents and some of the staff. She stated other staff were tested by their managers. ADON C stated all the results went to the Administrator. During an interview on 12/06/2021 at 10:16 AM, ADON B stated he had been tested for COVID-19 twice weekly for several months, and it recently changed to weekly because the facility was no longer in outbreak status. During an interview on 12/06/2021 at 10:23 AM, ADON CC stated she was tested weekly for COVID-19. She stated she did recall being tested more than once in a week but could not remember when it was. During an interview on 12/06/2021 at 1:12 PM, Dietary Aide (DA) E stated the staff that were not vaccinated were being tested every two weeks for COVID-19. During an interview on 12/06/2021 at 1:32 PM, Certified Nurse Aide (CNA) MM stated she started working at the facility on 10/23/2021. She was unvaccinated and was tested for COVID-19 weekly. During an interview on 12/06/2021 at 1:53 PM, CNA P stated she was unvaccinated, and she was tested for COVID-19 weekly. During an interview on 12/06/2021 at 1:55 PM, Licensed Vocational Nurse (LVN) PP stated he was tested every week. During an interview on 12/06/2021 at 2:02 PM, Registered Nurse (RN) H stated she started working at the facility in September 2021 and had not been tested since she had been there. During an interview on 12/06/2021 at 1:45 PM, the Director of Nursing (DON) stated there was no specific person responsible for ensuring all staff and residents were tested weekly. She stated ADON C used to do all the testing, but now the Assistant Administrator usually tested the residents, but any nurse could do it. The DON stated it was documented on a form that was turned into the Administrator. The DON stated each department was responsible for testing their own staff. The DON stated the staff signed the testing log, and that was compared with the staffing for that day to ensure all staff were tested . She stated this was given to the Administrator and was sent to the corporate office. The DON stated she was not aware that all staff and residents were not being tested . During an interview on 12/07/2021 at 8:13 AM, the Administrator stated the facility tested all people in the facility during an outbreak. She stated each department did their own testing and gave her a report that she submitted to the state. She stated it was kept on one spreadsheet. This spreadsheet was requested and not provided by the end of the survey. An attempt was made on two different occasions to interview the Assistant Administrator, but they were unavailable. The facility provided procedures for how to perform a COVID-19 test but did not have any policies specific to who or when testing should occur. On 12/03/2021 at 1:45 PM, ADON C stated that they follow CDC and CMS guidelines.

Based on interview and record review, and facility policy review, the facility failed to implement a standardized menu with recipes and diet extensions that were reviewed by the facility's Registered Dietitian Nutritionist (RDN). This deficient practice had the potential to affect 61 residents who received meals from the facility kitchen. Findings included: A review of the facility's Menu Planning policy, dated 10/01/2018 and revised on 06/01/2019, revealed, A standardized menu which meets the nutritional recommendations of the residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences will be used. Menus will be prepared for each facility by their food vendor. The menus will be for a five-week cycle and will include a week at a glance menu, alternates, diet extensions for all diets offered for each day, nutritional analysis, standardized recipes, a production guide and an order guide. The menus are reviewed and approved by the Consultant Dietitian. Intermittent changes must also be reviewed and approved by the Consultant Dietitian. The menu will be signed and dated by the Consultant Dietitian. During an interview on 12/01/2021 at 1:40 PM, the Certified Dietary Manager (CDM) stated they were not using a standardized menu. The CDM had been there for three weeks, and the kitchen had a three-week rotating menu that was created by the previous manager. There were no recipes or diet spreadsheets for kitchen staff to refer to when serving renal, diabetic, or heart healthy therapeutic diets. There were also no recipes or guidance for kitchen staff on appropriate serving sizes or how to prepare foods for the pureed or mechanical soft consistencies. The menu the kitchen was following was posted on the wall in the kitchen and was not available anywhere else. The kitchen staff had previous education on adequate serving sizes and what foods were appropriate for therapeutic diets. The CDM further stated the current menu they were serving had not been approved by a dietitian. During an interview on 12/01/2021 at 1:45 PM, the Cook stated they had no recipes or diet spreadsheets. The Cook stated they just cooked up what was listed on the posted menu and added in ingredients they thought went into each dish. During an interview on 12/01/2021 at 1:50 PM, the CDM stated when they first started three weeks earlier, the kitchen staff were just making different foods to serve the residents. The CDM recently found their food vendor's approved menus with spreadsheets and recipes in the computer and planned to implement that menu the following week. The CDM stated the Account Manager, who was an RDN, approved and signed off on the food vendor's menu cycle that day (12/01/2021). A review of the RDN Approval for Current Menu Cycle for the upcoming vendor's menu cycle to be implemented revealed, This current menu has been reviewed and approved for the Fall/Winter 2021/2022 menu cycle for all facilities, and was signed by the Account Manager on 12/01/2021. During an interview on 12/02/2021 at 1:35 PM, RDN OO stated Nutritionist Diet Technician, Registered (NDTR) NN oversaw food service from the kitchen. RDN OO did not go in the kitchen or monitor any part of food service such as the menus or serving of therapeutic diets. RDN OO did not approve the current three-week rotating menu and did not know who approved the menu. RDN OO stated it was important for the menus to be approved by an RDN, so the residents received the nutrients they needed to maintain their nutritional status. RDN OO further stated they did not know if the menu was sufficient to meet the needs of the residents; they would have to look at the menu to determine that. RDN OO thought the kitchen had recipes and diet spreadsheets but was not sure. RDN OO again stated they did not go into the kitchen and did not know if NDTR NN did any training with the kitchen staff. During an interview on 12/03/2021 at 1:00 PM, the Administrator stated the CDM had only been there for three weeks, and they were using a three-week rotating menu. The Administrator thought the previous director created the menu and trained staff to make the foods on the menu. The Administrator thought the kitchen had recipes and diet spreadsheets, so staff knew what to serve residents on therapeutic diets. The Administrator did not know if RDN OO knew the kitchen did not have recipes or diet spreadsheets or if RDN OO knew the menu had not been approved by a dietitian. RDN OO and NDTR NN were in the facility often and should have caught that the kitchen did not use recipes or had guidance on what to serve for therapeutic diets. The Administrator stated it was important to follow recipes and diet extensions because otherwise they did not know if what they were serving to residents was balanced or of the appropriate consistency. The Administrator further stated NDTR NN oversaw the kitchen, and RDN OO did not go into the kitchen.