Every finding on record at San Rafael Nursing and Rehabilitation Center

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 1 nutrition rooms for storage, preparation, and sanitation. 1. The facility failed to ensure the kitchen followed their cleaning schedules and the floor was slick. 2. The facility failed to ensure the ice cream freezer was clean and defrosted. 3. The facility failed to ensure the ice machine was clean and the door closed properly. 4. The facility failed to ensure the oven doors and the area behind the oven were clean. 5. The facility failed to ensure there were no personal items in refrigerator B. 6. The facility failed to ensure the handwashing sink and paper towels functioned properly. 7. The facility failed to ensure the steam table wells were clean. 8. The facility failed to ensure boxes of product were at least 18 inches from the ceiling in the walk-in freezer. 9. The facility failed to ensure food items in the walk-in freezer were sealed properly. 10. The facility failed to ensure there was no expired enteral feeding in the nutrition room. These failures could place residents at risk of food contamination and foodborne illness. Findings were: Observation and initial tour of the kitchen on 05/26/26 at 10:45 am revealed the entire floor was slick to walk on. The ice cream freezer had ice build-up on all four walls that was approximately 1 1/2 inches thick. The seals had a removable brown/black substance on them. The ice machine door was nearly falling off, and there was a removable black substance on the ice chute. The gas ovens on the stove were not on, were not being used, and the handles were heavily coated with a sticky substance. The area behind the stove had roach traps that were covered with roaches, a rotting tomato, and a film of what appeared to be grease and dirt on the baseboards, floor, and electrical conduit. There was an unlabeled 16-ounce bottle of water in the back of refrigerator B. The handwashing sink had no hot water, there was no cold-water when the cold-water spigot was turned on, and it was connected to copper tubing that was connected to a valve that was in the off position. The paper towel dispenser at the handwashing sink did not work. Five of five steam table wells had a flaking yellowish substance covering the bottoms and up the sides. The walk-in freezer had boxes less than 18 inches from the ceiling, potentially impeding the fire sprinklers. There was a 1-gallon zip-type bag with cheese in it that was unsealed and open to air in the walk-in freezer. In an interview with DA B on 05/26/26 at 10:55 am, she said I'm not gonna lie. I don't know how long it's been since the area behind the stove had been cleaned. She said staff in the kitchen were always so busy, the cleaning did not always get done. In an interview with DA A on 05/26/26 at 10:56 am, she said she started working at the facility about 9 months ago. She said she did the best she could to keep the kitchen clean and was unaware of the cleaning schedule. In an interview with the DM on 05/26/26 at 11:00 am, she said the ice cream freezer needed to be defrosted, and the lid was not closing. She said the seals had mold on them and needed to be cleaned. She said the ice machine door had been a problem for a while and needed to be replaced. She said the black substance on the ice chute was mold and needed to be cleaned. She said the area behind the stove had been cleaned a few days ago. Then she said it did not look like it had been cleaned for a while. She said they were not using the oven because it did not stay lit. She said it had been that way for about 9 months, and she assumed the MS knew, but never followed up. She said the bottle of water in refrigerator B should not have been there, and after asking the staff, no one claimed it. She said she was unaware of the handwashing sink and paper towels being out of order. She said she was unaware the boxes in the walk-in freezer were stacked less than 18 inches from the ceiling and could impede the fire sprinklers. She said the cheese should have been sealed properly. She said the steam table wells were cleaned daily, but they did not look clean. In an interview with the MS on 05/27/26 at 4:40 pm, he said kitchen staff used the electronic work order system to tell him (most of the time) when the kitchen needed repair. He said he was unaware of the oven not working. He said the ice machine needed to be replaced because the door had been messed up a couple of weeks ago when someone ran into it while it was open. He said he tried to put it back on the best he could. He said he could not find a replacement for the door. Observation/return visit and interview with the DM on 05/27/26 at 4:45 pm, she said she had been having problems with employees not cleaning properly and had to let them go. She said staff were checking off the cleaning schedules without doing the job. She said she was not checking on them as often as she should. She said staff had been trained and in-serviced on cleaning regularly. In a phone interview with the RD on 05/28/26 at 9:52 am, she said she was aware of the sanitation issues in the kitchen, as she had done a sanitation audit earlier this month. She said her walk-throughs were conducted monthly on the 2nd Fridays. She said the DM was new and had potential, so she took her on her last walk-through to point out what she saw and explain to the DM what she needed to know for the audits. She said boxes too close to the ceiling in the walk-in freezer were addressed with the DM. She said she suggested the DM get a tape measure and mark the wall with 18 inches so everyone would know not to stack boxes any higher than that. She said she would email a copy of her latest audit. She said she did not know why the kitchen was not serving ice in the drinks, because they should be. She said she would suggest the DM put up a sign in the kitchen listing residents with food allergies, so no one would be serving something that could potentially harm the residents with food allergies. Record review of the daily and weekly kitchen cleaning schedules for May 4-28, 2026, revealed a 26-point daily schedule that included cleaning ovens, hand sink/paper towels, ice machine wipe- down, refrigerator/freezer, and steam table. The 20-point weekly schedule included all sinks/floors, freezers-clean/organize, ice machine-wash and sanitize bin, and pipes behind equipment. All items for the daily and weekly schedules had been checked and/or signed as having been done. Record review of kitchen in-services dated 03/20/26-cleaning. 04/03/26-job duties, dress code, policy hygiene procedures. 05/15/26-cleaningness. 05/26/26-maintaining cleanliness of the ice machine, deep freezer, behind stoves, cleaning cups and bowls, keeping lids on trash cans, beard guards, sealing items properly. Record review of the RD's kitchen audit dated 05/08/25 titled, Kitchen Sanitation Checklist revealed 7 areas of focus: Under Storerooms: All items covered, labeled, dated; marked no. Items stored on racks .18 inches from sprinkler heads; marked yes with a comment-check box on top left. Walls, floors, ceilings, vents and doors; marked no with a comment- floor needs sweeping. General Sanitation: Daily cleaning schedule completed and followed; marked no with a comment- available but not filled out. All floors, walls, ceilings and work areas are clean; unmarked with a comment- floors need sweeping. All carts and racks clean and in good repair; unmarked with carts circled and a comment- need to be washed. Pot Washing Area: 3-Compartment Sink Log PPM (Parts Per Million) recorded daily; marked no with a comment- will start. Record review of the kitchen facility policy revised August 2018, titled, Handwashing/Hand Hygiene under policy statement. This facility considers hand hygiene the primary means to prevent the spread of infections. Under policy interpretation, 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Record review of the kitchen facility policy revised October 2017, titled, Receiving Food and Storage under policy statement, foods shall be received and stored in a manner that complies with safe food handling practices. Under policy interpretation, 1. Food services, or other designated staff, will always maintain clean food storage areas. References: FDA Food Code 2022 Ch. 2-4 Hygienic Practices 2-401 Food Contamination Prevention 2-401.11 Eating, or Drinking; An EMPLOYEE shall eat, drink, or use any form of TOBACCO PRODUCTS only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES; or other items needing protection cannot result. Ch. 3-305 Preventing contamination from the premises 3-305.11 Food Storage; FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Ch. 4-202 Cleanability 4-202.11 Food-Contact Surfaces. (A)Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have smooth welds and joints 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. (C) Except as specified in (D) of this section, if used with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned throughout the day at least every 4 hours.

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 dining rooms reviewed, and 1 of 5 residents (Resident #127) reviewed for infection control practices. The facility failed to ensure CNA-F performed proper or adequate hand hygiene while assisting with dining on 05/26/2026.The facility failed to ensure CNA-F did not wipe her nose on her hand while assisting with dining on 05/26/2026.The facility failed to ensure CNA-F correctly passed cups while assisting with dining on 05/26/2026. The facility failed to ensure the CNA-G performed proper or adequate hand hygiene during wound care on 05/27/2026.The facility failed to ensure CNA-G did not place a dirty heel protector over Resident #127's CDI wound dressing during wound care on 05/27/2026. The facility failed to ensure the WCN knew the correct way to perform proper or adequate hand hygiene during wound care on 05/27/2026.The facility failed to ensure the WCN placed a clean barrier between Resident #127's wound and the dirty bed sheet during wound care on 05/27/2026. These failures and deficient practices could place residents at risk for cross-contamination and infection.The findings included:In a dining room observation on 05/26/2026 between 12:15 PM and 1:15 PM during lunch, CNA-F was observed to perform hand hygiene with ABHS multiple times in which she only rubbed her hands approximately 5-6 seconds after applying the ABHS. CNA-F was also observed twice to wipe her nose on the back of her hand in between passing out the residents' trays. CNA-F was also observed multiple times to pass cups while holding the cups at the tops where the residents would be placing their mouths to drink.In an interview on 05/26/2026 at 3:53 PM, CNA-F stated she was not aware she had been passing the cups by the tops until it was brought to her attention by another staff member. She stated she knew to hold them by the handle or pass them from the bottom. She also was not aware of how long she had rubbed her hands after applying hand sanitizer, but she thought she should be rubbing them for 21-22 seconds after applying hand sanitizer. She stated 5-6 seconds was not enough time to rub hands until ABHS dried. CNA-F stated she should not have wiped her nose on the back of her hand, but she should have gotten a tissue for her nose, then performed hand hygiene afterward. Record review of Resident #127's face sheet, dated 05/28/2026, revealed he was a [AGE] year-old male with an admission date of 05/15/2026. Diagnoses included Complications of Amputation Stump (significantly affects wound healing to an amputation site), and Type 2 Diabetes (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body).Record review of Resident #127's physician order summary revealed an order dated 05/25/2026 to cleanse stage 4 left heel with wound cleanser, apply Medihoney (a topical medication use to promote wound healing, skin protection, and infection control), Calcium Alginate, cover with ABD pad, and wrap with kerlix (a type of rolled gauze bandage) every day and PRN. In an observation of wound care on 05/27/2026 at 2:45 PM, CNA-G was observed to only scrub hands for 6 seconds during hand washing prior to assisting with wound care. Then, the WCN was noted to start wound care without placing a clean barrier between Resident #127's leg and the dirty bed sheet. The WCN was noted to perform hand hygiene with ABHS multiple times throughout wound care in which she only rubbed hands together for approximately 3-6 seconds each time, and she would then hold hands up and fan them for 1-2 seconds each time. After the dressing was applied, CNA-G and the WCN were noted to put the residents dirty heel protector on over the CDI dressing which was just placed. In an interview on 05/28/2026 at 7:59 AM, CNA-G stated she should have scrubbed her hands for 20 seconds, and she did not think 6 seconds was long enough to scrub her hands for. CNA-G stated hand hygiene was done to clean the hands and prevent getting anything dirty from the hands onto the patient to prevent cross contamination. CNA-G also stated she should have changed out the dirty heel protector and used the clean heel protector after wound care was completed. She also stated she or the WCN should have placed a clean barrier between the leg and the dirty sheets on the bed.In an interview on 05/28/2026 at 8:07 AM, the WCN stated she knew she did not rub her hands long enough to let the ABHS dry, which was why she was holding her hands up and fanning them in the air. She was not sure how long she should have rubbed her hands together with the ABHS but stated at least until they were dry. The WCN stated hand hygiene was done to prevent cross contamination to the patient. The WCN stated she should have placed a clean barrier between Resident #127's leg and the dirty bed sheet, as well as she should not have put the dirty heel protector on top of Resident #127's wound with new CDI dressing.In an interview on 05/28/2026 at 4:48 PM, the ADON, who was also the IP, stated the staff should have put enough hand sanitizer on their hands to cover all surface areas of both hands, then rubbed their hands together in a scrubbing motion until completely dry, which should have taken approximately 20 seconds. The ADON stated this was done to kill germs and prevent cross contamination. The ADON stated 3-6 seconds was not long enough to rub hands after applying enough ABHS. He also stated the staff should be passing cups and glasses in the dining room by grabbing the handle or at the bottom of the cup to prevent cross contamination. Record review of the facility's Hand Hygiene Policy, revised August 2019, revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections 2. All personnel shall follow the handwashing / hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Procedure: Washing Hands: 2. Rub hands vigorously for at least 15 seconds covering all surfaces of the hands and fingers. Using Alcohol-Based Hand Rubs: 1. Apply generous amount of product to palm of hand and rub hands together. 2. Cover all surfaces of hands and fingers until hands are dry.Record review of CDC Clean Hands: About Hand Hygiene for Patients in Healthcare Settings, dated 02/27/2022, revealed How to clean hands with an alcohol-based hand sanitizer:1. Put product on hands and rub hands together.2. Cover all surfaces until hands feel dry.3. This should take around 20 seconds. https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html

Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program so the facility is free of pests and rodents for 1 of 1 kitchen, 1 of 3 medication storage rooms (100 hall), and 2 of 20 resident rooms (Resident #4 and Resident #92) reviewed for pests.The facility failed to have pest control effectively treat the kitchen for roaches.The facility failed to ensure effective pest control for the medication room on the 100-hallThe facility failed to ensure pest control effectively treated the rooms of Resident #4 and #92 from roaches.This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.Findings included: Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program so the facility is free of pests and rodents for 1 of 1 kitchen, 1 of 3 medication storage rooms (100 hall), and two resident rooms (Resident #4 and Resident #92) reviewed for pests. The facility failed to have pest control effectively treat the kitchen for roaches. The facility failed to ensure effective pest control for the medication room on the 100-hall The facility failed to ensure pest control effectively treated the rooms of Resident #4 and #92 from roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Findings included: Record review of Resident #92's face sheet dated 05/26/26 revealed a [AGE] year old male initially admitted on [DATE] with a diagnosis of Diabetes Mellitus(a chronic metabolic disorder characterized by high blood sugar due to insufficient insulin production or cellular resistance to insulin), depression (a group of conditions associated with the elevation or lowering of a person's mood), Dementia (A group of thinking an social symptoms that interferes with daily functioning), Peripheral Vascular Disease Peripheral Vascular disease (a slow progressive circulation disorder characterized by the narrowing or blockage of blood vessels outside the heart). Record review of Resident #4's face sheet dated 05/26/26 revealed a [AGE] year-old male initially admitted on [DATE] with a diagnosis of Diabetes Mellitus(a chronic metabolic disorder characterized by high blood sugar due to insufficient insulin production or cellular resistance to insulin) , Hypertension(a chronic condition where blood force against artery walls is to high) CVA(Cerebrovascular accident commonly known as a stoke is when blood flow to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients resulting in brain cells beginning to die in minutes), Anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities)and heart failure the heart muscle is too weak too stiff to pump enough oxygen-rich blood to meet your body's needs. Observation of the area behind the stove in the kitchen on 05/26/26 at 10:45 am revealed several roach traps that were covered with roaches, a rotting tomato, and a film of what appeared to be grease and dirt on the baseboards, floor, and electrical conduit. Observation of the medication storage room on the 100-Hall on 05/27/26 at 2:59 PM revealed a spider about 1 inch in diameter was scampering on the floor. In an observation and interview on 05/26/2026 at 10:48 AM with Resident #92 was sitting at the edge of bed and was watching TV and he stated he saw small roaches in his room from time to time in the bathroom. Resident #92 stated she thinks they come through the wall trim that in some spots has come apart from the wall. Resident #92 stated he does not like the small roaches as they could possibly go into your ear or nose. Resident #92 stated it was worse before but recently he does not see large roaches like he used to but sometimes sees small ones on the bathroom floor. Resident #92 stated he doesn't see well but can see shapes and see small brown dots moving on the floor if not roaches maybe so other bug. In observation and interview on 05/26/2026 at 10:55 AM with Resident #4 he was observed lying in his bed covered and resting. Resident #4 was difficult to understand but could nod yes or no questions the state surveyor asked. Resident #4 nodded yes that he had seen roaches in his room. Resident #4 could not state when he saw the roaches but did nod yes to the roaches being big when he saw them in the room. In an interview with DA B on 05/26/26 at 10:55 am, she said I'm not going to lie. I don't know how long it's been since the area behind the stove had been cleaned. She said she was not surprised to see the roaches back there. She said staff in the kitchen were always so busy; the cleaning did not get done. In an interview with DA A on 05/26/26 at 10:55 am, she said there were roaches in the kitchen since she started working there about 9 months ago. She said she had never seen the roaches in or around the food but knew they were in the kitchen. In an interview with the DM on 05/26/26 at 11:00 am, she said the area behind the stove had been cleaned a few days ago. Then she said it did not look like it had been cleaned for a while. She said the roaches had been a problem, and the pest control company put the sticky pads behind the stove but did not know when. In an interview with the DM on 05/27/26 at 4:45 pm, she said she had been having problems with employees not cleaning properly and had to let them go. She said staff were checking off the cleaning schedules without doing the job. She said she was not checking on them as often as she should. In an interview with the ADON on 05/28/26 at 4:53 PM, the ADON stated he saw the spider in the 100-hall medication room. The ADON stated he had not seen a spider in that room before. The ADON stated he killed the spider as soon as he saw it. The ADON stated he had only seen gnats in the medication room. The ADON stated the small insects could contaminate medications if they were allowed to stay there. Record review of the daily and weekly kitchen cleaning schedules for May 4-28, 2026, revealed a 20-point weekly schedule that included all floors, and pipes behind equipment. All items for the weekly cleaning schedules had been checked and/or signed as having been done. In an Interview on 05/28/2025 4:42 PM with the maintenance man he stated the facility had a pest control log where any sightings of pests would be logged by the staff. The Maintenance man stated the pest log is checked daily and then he called the pest control company to come and treat the facility if needed. The Maintenance man stated the pest control company was contracted to come in and treat for pests every week or as needed. He said the facility was treated for pests indoors and outdoors. The maintenance man also stated the facility had increasing their visits from monthly to weekly so the pest control company could keep the pest problem under control. The maintenance man stated maintenance staff would do repairs to any walls and closets that have holes to prevent any new pests from entering the facility. The maintenance man stated the kitchen staff was going to keep the kitchen clean to avoid any pests from trying to enter the facility. The Maintenance man stated housekeeping will keep up with resident personal food in containers in their rooms. The housekeepers are instructed to keep all rooms free of clutter and old food. Record review of kitchen in-services dated 03/20/26-included cleaning. 05/15/26-included cleanliness. 05/26/26-included maintaining cleanliness behind stoves. In record review of the Scope Pest Control company weekly receipts for pest control dated 01/05/26 to 04/30/26, and the last pest control weekly visit was on 04/30/2026 and sprays for flies, roaches and other pests. There were no extra dates added for additional visits. In record review of the Pest control Policy, the state surveyor asked twice for the policy, and it was not provided. The Dietary Manager and the Maintenance Man were asked for the policy, and it was not provided to the surveyor. In record review of the Pest Control Policy dated May 2008 stated Our facility shall maintain an effective pest control program. 1.This Facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 8 medication carts (Nurse Cart 1 and Nurse Cart 2) and 2 of 2 supply rooms (nurses' supply room and general supply room) reviewed for storage. The facility failed to keep medication carts free from expired supplies and unnecessary food/drink items. Nurse Cart 2 contained LVN C's personal items, drinks, and snacks at 3:25 PM on 05/27/26. Nurse Cart 1 contained expired COVID tests at 3:53 PM on 05/27/26.The facility failed to keep the nurses' supply room and the general supply room free from expired supplies. The failure could place residents in the facility at risk of receiving treatment from expired supplies and contamination of medications.Findings included:1. During an observation at 3:25 PM on 05/27/26, a bottle of soda was found in the drawer of Nurse Cart 2. Further observation revealed one small bag full of pens and another larger bag with an unopened granola bar snack inside in another drawer of Nurse Cart 2. During an observation at 3:53 PM on 05/27/26, the bottom drawer of Nurse Cart 1 contained a small box of 2 COVID tests. The expiration date on the small box revealed the tests expired on 10/31/25. During an interview at 3:30 PM on 05/27/26, LVN C stated she was in charge of Nurse Cart 2 for her shift. LVN C stated the soda and two bags of items in Nurse Cart 2 were hers. LVN C stated she knew she was not supposed to store her drink or snacks in the medication cart. LVN C stated the other two bags had her personal items in them. LVN C stated she did not know she was not supposed to store her personal items in the medication cart. LVN C stated there was a risk of contaminating the medications if food and drinks were stored alongside them. During an interview with the DON at 6:07 PM on 05/28/26, the DON stated medication carts were only supposed to contain things related to the administration of medication to residents. The DON stated nurses were not supposed to keep personal snacks, drinks, or personal items in the medication carts. The DON stated food and drinks could attract bugs leading to contamination of medication in the carts. The DON stated expired supplies should not be stored in the medication carts. The DON stated expired supplies should be removed and disposed of properly. 2. Observation of the nurses' storage room and interview with the DON on 05/28/26 at 12:00 pm revealed multiple cases of enteral feeding stacked randomly, not by use by dates, on the shelves and floor. One of the cases had a use by date of 05/01/26. There were 31 total Lopez valves (a special valve with stopcocks used on gastrostomy tubes for enteral feeding, flushing, and administering medications); 4 were dated 07/01/25, 10 dated 09/01/25, 5 dated 08/01/25, and 2 dated 03/01/26. The DON said yes, they have expired. He said the nurses or whoever gets the milk (meaning enteral feed) for the residents should be checking the dates at the time they get it from the supply closet. He said the facility was supposed to be using the first in, first out system (meaning the oldest date should be used first). He said the supply room person was taking a resident out of town to an appointment and was unavailable for an interview. Observation of the general storage room on 05/28/26 at 12:10 pm revealed 11 straight catheters (for urine testing) dated 03/28/25. 4, IV (intravenous) tubing caps dated 01/18/25. The DON said yes, they have expired. He said the supply room person was responsible for removing expired supplies from all supply closets. He said he was ultimately responsible because expired items if used on residents could cause illness from cross contamination. He said the supply room person was taking a resident out of town to an appointment and was unavailable for an interview. Record review of the facility policy Storage of Medications dated November 2020 revealed the following policy: .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.Record review of the facility policy Receiving Food and Storage revised October 2017 reflected under policy, interpretation and implementation: Dry foods that are stored in bins will be removed from original packaging, labeled and dated ( use by date). Such foods will be rotated using a first in - first out system.

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #47) reviewed for documentation. The facility failed to ensure Resident #47's blood pressures were documented on 13 separate occasions for May 2026. This failure could place residents at risk for errors in care and treatment and not receiving the services needed to attain or maintain their highest practicable physical well-being. The findings included: Record review of Resident #47's face sheet dated 05/28/26 indicated a [AGE] year-old-male admitted on [DATE] with the diagnoses of Cerebrovascular Disease (condition affecting blood flow and blood vessels in the brain), Essential Hypertension (high blood pressure), Hypotension (low blood pressure). Record review of Resident #47's May 2026 physician order summary report indicated Midodrine (used to treat symptomatic orthostatic hypotension/low blood pressure) Oral Tablet 10mg. Give 10mg by mouth two times a day for hypotension. Hold if Blood Pressure Greater than 110/60, start dated 03/09/26. Vital Signs every month, every day and night shift every month, start date; 06/05/2025. Record review of Resident #47's May 2026 Medication Administration Record indicated there were no blood pressures documented on the following days Midodrine was administered; -05/01/26 5pm-BP not taken-LVN N-05/02/26 9am-BP not taken-LVN N-05/02/26 5pm-BP not taken-LVN N-05/03/26 9am-BP not taken-LVN N-05/03/26 5pm-BP not taken-LVN N-05/05/26 9am-BP not taken-LVN N-05/06/26 5pm-BP not taken-LVN N -05/07/26 5pm-BP not taken-LVN N-05/12/26 5pm-BP not taken-LVN N-05/20/26 5pm-BP not taken-LVN N-05/25/26 9am-BP not taken-LVN N-05/25/26 5pm-BP not taken-LVN N -05/26/26 9am-BP not taken-LVN N Record review of Resident #47 2026 vital sign log indicated there were no blood pressures documented for the days listed above. Record review of Resident #47's Care Plan dated 05/18/26 indicated The resident has hypotension. Give medication as ordered. Monitor for side effects and effectiveness. Midodrine . Interview with LVN M on 05/28/26 at 5:32 pm she stated the blood pressure was taken before administering Midodrine. She sometimes gave the medication if it was outside the parameters of 110/60 depending on the resident because she knew the residents and their blood pressure and how the medication would affect their blood pressure. If the medication is given when a resident's blood pressure is over parameters of 110/60 it could lead to the resident having rapid heart rate which could lead to tachycardia (Rapid heart rate) and stroke. Blood pressures readings not documented in the Medication Administration Record it was assumed the blood pressure was not taken and it would be a medication error. It is important to document, so you have proof that you took the blood pressure and administered the medication. Interview with the DON on 05/28/26 at 6:30 pm revealed he stated Nurses and Med Aides should take blood pressures of residents before administering any blood pressure altering medication. You need to get a baseline so you can make medication adjustments as needed. The DON stated that he ran a report daily indicating which blood pressures were taken and documented and the ADONs check it daily. However, since they had been short staff and busy with other issues, they have not monitored any documentation in the past 2 weeks. Record review of facility's Administering Medication Policy revised 04/2019 indicated Medications are administered in a safe and timely manner as prescribed 23. As required or indicated for medication, the individual administering the medication records in the Resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug.

Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for four of 27 residents (Resident #1, Resident #3, Resident #47, and Resident #123) reviewed for medication errors. The facility failed to hold Resident #1's midodrine (blood pressure medication) when Resident #1's blood pressure was outside of physician's parameters on May 6th, 13th, 14th, and 21st of 2026.The facility failed to hold Resident #3's Midodrine when Resident #3's blood pressure was outside of the physician's parameters on May 5th, May 6th, May 7th, May 8th, May 10th, May 13th, May 18th, May 20th, May 21st, May 22nd, May 23rd, May 24th, May 26th, May 27th, and May 28th.The facility failed to hold Resident #123's midodrine when Resident #123's blood pressure was outside of physician's parameters on May 23rd, 25th, 26th and 28th of 2026.The facility failed to hold Resident #47's midodrine when Resident #47's blood pressure was outside of physician's parameters on May 1st, May 2nd, May 3rd, May 5th, May 6th, May 7th, May 12th, May 20th, May 25th, May 26th, 2026. These failures could place residents at risk of complications such as increased blood pressure, exacerbation of symptoms, and potential hospitalization.Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for four of 27 residents (Resident #1, Resident #3, Resident #47, and Resident #123) reviewed for medication errors. The facility failed to hold Resident #1's midodrine (blood pressure medication) when Resident #1's blood pressure was outside of physician's parameters on May 6th, 13th, 14th, and 21st of 2026.The facility failed to hold Resident #3's Midodrine when Resident #3's blood pressure was outside of the physician's parameters on May 5th, May 6th, May 7th, May 8th, May 10th, May 13th, May 18th, May 20th, May 21st, May 22nd, May 23rd, May 24th, May 26th, May 27th, and May 28th.The facility failed to hold Resident #123's midodrine when Resident #123's blood pressure was outside of physician's parameters on May 23rd, 25th, 26th and 28th of 2026.The facility failed to hold Resident #47's midodrine when Resident #47's blood pressure was outside of physician's parameters on May 1st, May 2nd, May 3rd, May 5th, May 6th, May 7th, May 12th, May 20th, May 25th, May 26th, 2026. These failures could place residents at risk of complications such as increased blood pressure, exacerbation of symptoms, and potential hospitalization. The findings included: 1. Record review of Resident #1's face sheet dated 05/27/26 revealed a [AGE] year-old male with an initial admission date of 07/23/25 and current admission date of 04/26/26. Resident #1's pertinent diagnosis included Heart Failure (condition where the heart muscle is too weak or too stiff to pump blood efficiently throughout the body). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 15 indicating his cognition was intact. Record review of Resident #1's Comprehensive Care Plan dated 05/26/26 revealed the focus The resident has hypotension (Low blood pressure) initiated on 08/05/25. An intervention listed for this focus included Give medications as ordered. Monitor for side effects and effectiveness. - midodrine initiated on 08/05/25. Record review of Resident #1's order summary on 05/26/26 revealed an active order for midodrine HCL oral tablet 10 MG Give 1 tablet by mouth three times a day for hypotension HOLD IF BP GREATER THAN 110/60 initiated on 04/27/26. Record review of Resident #1's MAR for May 2026 revealed midodrine was administered at the following dates and time slots with associated blood pressures:May 6th, 2026, at 9:00 PM - 134/76 by RN DMay 13th, 2026, at 9:00 PM - 126/66 by RN DMay 14th, 2026, at 9:00 PM - 132/68 by RN DMay 21st, 2026, at 9:00 AM - 128/66 by MA E During an interview with RN D at 4:00 PM on 05/28/26, RN D stated administering midodrine to a resident that already had high blood pressure could cause it to go too high leading to harm and possibly a stoke. RN D stated she may have been in the habit of passing medications and not paying attention to the parameters of the resident. RN D stated according to the MAR it looked like she administered midodrine outside of parameters to Resident #1 on May 6th, May 13, and May 14th. RN D stated she should not have administered midodrine to Resident #1 at those times with the recorded blood pressures. During an interview with MA E at 4:14 PM on 05/28/26, MA E stated administering midodrine to a resident that already had high blood pressure could cause it to go too high leading to harm. MA E stated according to the MAR it looked like she administered midodrine outside of parameters to Resident #1 on May 21st. MA E stated she should not have administered midodrine to Resident #1 at that time with the recorded blood pressure. MA E stated she was not sure why she gave the midodrine to Resident #1 on May 21st, when his blood pressure was outside the physician's parameters. During an interview with the DON at 6:07 PM on 05/28/26, the DON stated midodrine was used to raise a resident's blood pressure. The DON stated giving midodrine to a resident with high blood pressure could cause them to be hospitalized . The DON stated if a resident's blood pressure was outside of the physician's parameters, it should not have been administered. 2. Record review of Resident #3's face sheet, dated 05/27/26, revealed a [AGE] year-old male with an original admission date of 12/03/2024, and a current admission date of 04/04/2026. Resident #3's pertinent diagnoses include Hypotension (low blood pressure). Record review of Resident #3's Quarterly MDS Assessment, dated 04/10/2026 revealed a BIMS score of 08, which indicated moderately impaired cognition. The MDS assessment also revealed Resident #3 had an active diagnosis of Orthostatic Hypotension (a sudden drop in blood pressure when standing up). Record review of Resident #3's Comprehensive Care Plan, reviewed 05/28/2026, revealed the focus The resident has hypotension initiated on 12/12/2025. Interventions for Resident #3 included Give medications as ordered. Monitor for side effects and effectiveness. - midodrine. Record review of Resident #3's physician order summary on 05/28/2026 revealed an active order started on 04/05/2026 for Midodrine 10 MG; Give 10 MG by mouth every 8 hours for hypotension; Hold if SBP (systolic blood pressure - the top number of the blood pressure) was greater than 110. Record review of Resident #3's MAR for May 2026 revealed Midodrine was administered on the following dates and times outside of recommended parameters:May 5th, 2026 at 12:00 AM - 115/63 - Administered by: the WCNMay 5th, 2026 at 4:00 PM - 118/58 - Administered by: MA-EMay 6th, 2026 at 12:00 AM - 115/62 - Administered by: LVN-KMay 6th, 2026 at 4:00 PM - 116/52 - Administered by: MA-EMay 7th, 2026 at 12:00 AM - 118/68 - Administered by: RN-DMay 8th, 2026 at 4:00 PM - 116/56 - Administered by: MA-EMay 10th, 2026 at 4:00 PM - 136/75 - Administered by: the ADONMay 13th, 2026 at 4:00 PM - 116/52 - Administered by: MA-EMay 18th, 2026 at 8:00 AM - 113/56 - Administered by: MA-EMay 20th, 2026 at 4:00 PM - 115/56 - Administered by: MA-EMay 21st, 2026 at 12:00 AM - 128/74 - Administered by: LVN-LMay 22nd, 2026 at 12:00 AM - 126/76 - Administered by: LVN-LMay 23rd, 2026 at 4:00 PM - 112/66 - Administered by: LVN-MMay 24th, 2026 at 12:00 AM - 128/74 - Administered by: LVN-LMay 26th, 2026 at 12:00 AM - 132/76 - Administered by: LVN-LMay 27th, 2026 at 12:00 AM - 134/79 - Administered by: LVN-LMay 28th, 2026 at 12:00 AM - 128/74 - Administered by: LVN-L Attempted to interview Resident #3 on 05/28/2026, but he had an extremely difficult time trying to understand questions or express himself. In an interview on 05/28/2026 at 3:55 PM, RN-D stated Midodrine was administered to patients with low blood pressure to bring the blood pressure up. RN-D stated if the patient's blood pressure was already elevated, and Midodrine was administered, it could have caused the blood pressure to continue to rise, and this could have caused the patient harm or to even have a stroke (a sudden interruption of blood flow to the brain). RN-D stated she thought she just administered the medication by accident out of habit of just administering all of the patient medications and not paying enough attention to the physician's parameters. RN-D stated the parameters were there to help protect patients, and the times she administered Midodrine outside of the ordered parameters, she should have held it. In an interview on 05/28/2026 at 4:14 PM, MA-E stated Midodrine was used to bring up the blood pressure when it was too low. MA-E state Midodrine orders should have parameters to determine if the medication should be administered or held, and these orders and parameters should have been followed. MA-E stated if Midodrine was administered outside of the parameters, the blood pressure could have continued to rise and caused the resident to have symptoms of high blood pressure. She stated she was not sure why she gave the medication outside of parameters, but it was just an accident or misunderstanding. In an interview on 05/28/2026 at 4:48 PM, the ADON stated he sometimes worked the floor passing medications, and he realized he had administered blood pressure medication outside of parameters by mistake. The ADON stated Midodrine was used to bring up low blood pressure, and if the resident's blood pressure was already elevated, it could have continued to rise. He stated this could have caused the resident harm, and it was an honest mistake. 3. Record review of Resident #123's face sheet, dated 05/26/26, revealed a [AGE] year-old female with an admission date of 05/22/2025. Resident #123's diagnoses included Schizophrenia (A Chronic mental health condition that affects a person's thoughts, feelings, and behaviors), Depression (a group of conditions associated with the elevation or lowering of a person's mood), Anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Hypotension low blood pressure, is generally defined as readings lower than 90/60 mm/Hg. Record review of Resident #123's MDS comprehensive assessment had not been completed as she had on been admitted to the facility on [DATE]. Record review of Resident #123's physician orders started 05/22/2026 revealed an active order for Midodrine 5mg, take 1 tablet by mouth three times a day for hypotension and give if blood pressure is less than 90/50.05/23/26 - B/P 111/67 at 9:00 a.m. - Midodrine administered by LVN C05/25/26 - B/P 90/60 at 9:00 a.m. Midodrine administered by LVN C05/25/26 - B/P 103/56 at 5:00 a.m.-Midodrine administered by MA-I05/26/26 - B/P 92/55 at 9:00a.m.- Midodrine administered - MA-I05/28/25 - B/P 99/67 at 9:00 a.m.-Midodrine administered by LVN-C In an interview and observation on 05/28/2028 at 10:47 AM with Resident #123 was lying in bed alert and able to answer question and she stated she felt good and had not experienced any dizziness, light headedness, headache, nausea, or weakness since she arrived at the facility on 05/22/2026. In an interview on 05/28/2026 at 4:33 PM with LVN C, she stated she worked here for almost 2 years. LVN C stated Midodrine is used to bring up blood pressure. LVN C stated a typical order for Midodrine will state to hold if blood pressure is over 90/50 mm/Hg. LVN C stated if blood pressure is already elevated and you administer it; the blood pressure would continue to rise. LVN C stated an in-service on following physician's orders was conducted today and are given quarterly. LVN C stated determining to administer medication was a nursing judgment if the blood pressure was off by a couple of points. LVN C stated maybe the nurse should call and clarify the order with the doctor before administering. LVN C stated she was not sure why she had administered the medication on 05/23/2026 and which was the date she was admitted , but today I thought the medication was held. LVN C stated I may have given the morning dose, but held the afternoon dose because I wanted to call the doctor to clarify the order. In an interview on 05/28/2026 at 4:48 PM with ADON and Infection Control, stated he has worked floor sometimes as needed. The ADON stated Midodrine is used to bring low blood pressure up a regular reading. The ADON stated If residents' blood pressure is already elevated and you administer Midodrine, it will continue to rise. The ADON stated he thought it was just an honest mistake giving the resident the medication outside of parameters by the nursing staff. The ADON stated he does not recall any residents having elevated blood pressures after the medication was administered. Vital signs should be documented in the MAR when administering blood pressure medication, including midodrine. The ADON stated the nurse must trigger the vital signs box in order for it to trigger on the MAR. The ADON stated If the resident's medications are listed or documented in the MAR, then the medication was given without checking the blood pressure, which could negatively affect the residents and possibly harm or cause a stroke. In an interview 05/28/26 at 6:05 PM, the MDS Coordinator stated she entered the orders for Resident #123 and entered the order for the medication as the physician ordered. The MDS Coordinator stated she verified the parameters with the physician were not normal parameters for this medication. The MDS Coordinator stated she entered the orders as he instructed and would never change them unless instructed by the MD. The MDS Coordinator stated if a resident's blood pressure was slightly outside of parameters, she would use her nursing judgement and administer the medications. In an interview with the DON he stated reports are ran each morning to monitor errors in documentation of resident medical information entered during each shift. The DON stated the ADON's are responsible for running reports and reviewing them for errors and missing documentation in each area of treatment. 4. Record review of Resident #47's face sheet dated 05/28/26 indicated a [AGE] year-old-male admitted on [DATE] with the diagnoses of Cerebrovascular Disease (condition affecting blood flow and blood vessels in the brain), Essential Hypertension (high blood pressure), Hypotension (low blood pressure). Record review of Resident #47's May 2026 physician order summary report indicated Midodrine (used to treat symptomatic orthostatic hypotension/low blood pressure) Oral Tablet 10mg. Give 10mg by mouth two times a day for hypotension. Hold if Blood Pressure Greater than 110/60, start dated 03/09/26. Vital Signs every month, every day and night shift every month, start date; 06/05/2025. Record review of Resident #47's May 2026 Medication Administration Record indicated there were no blood pressures documented on the following days Midodrine was administered; 05/01/26 5pm-BP not taken LVN N-05/02/26 9am BP not taken LVN N-05/02/26 5pm-BP not taken LVN N05/03/26 9am BP not taken LVN N-05/03/26 5pm-BP not taken LVN N-05/05/26 9am-BP not taken LVN N-05/06/26 5pm-BP not taken LVN N-05/07/26 5pm-BP 120/73 LVN N-05/12/26 5pm-BP not taken LVN N-05/20/26 5pm-BP not taken LVN N-05/25/26 9am-BP not taken LVN N-05/25/26 5pm-BP not taken LVN N-05/26/26 9am-BP110/78 Administered by LVN N Record review of Resident #47 2026 vital sign log indicated there were no blood pressures documented for the days listed above. Record review of Resident #47's Care Plan dated 05/18/26 indicated The resident has hypotension. Give medication as ordered. Monitor for side effects and effectiveness. Midodrine . Interview with LVN M on 05/28/26 at 5:32 pm she stated the blood pressure was taken before administering Midodrine. She sometimes gave the medication if it was outside the parameters of 110/60 depending on the resident because she knew the residents and their blood pressure and how the medication would affect their blood pressure. If the medication is given when a resident's blood pressure is over parameters of 110/60 it could lead to the resident having rapid heart rate which could lead to tachycardia (Rapid heart rate) and stroke. If Blood pressures readings are not documented in the Medication Administration Record it was assumed the blood pressure was not taken and it would be a medication error. It is important to document, so you have proof that you took the blood pressure and administered the medication. Interview with the DON on 05/28/26 at 6:30 pm revealed he stated Nurses and Med Aides should take blood pressures of residents before administering any blood pressure altering medication. You need to get a baseline so you can make medication adjustments as needed. The DON stated that he ran a report daily indicating which blood pressures were taken and documented and the ADONs check it daily. However, since they had been short staff and busy with other issues, they have not monitored any documentation in the past 2 weeks. Record review of facility's Administering Medication Policy revised 04/2019 indicated Medications are administered in a safe and timely manner as prescribed 23. As required or indicated for medication, the individual administering the medication records in the Resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug. Record review of the facility's policy Administering Medications dated April 2019 revealed the following policy: .4. Medications are administered in accordance with prescriber orders, including any required time frame.10. The following information is checked/verified for each resident prior to administering medications:a. Allergies to medications; andb. Vital signs, if necessary.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was developed and implemented for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified for 2 (Resident #2 and Resident #75) out of 5 residents reviewed for care plans.The facility failed to review or revise Resident #2's care plan to include all smoking related privileges, restrictions, and concerns.The facility failed to review or revise Resident #75's care plan to include all smoking related privileges, restrictions, and concerns.These failures could place residents at risk for receiving inadequate care and services.The findings included:Record review of Resident #2's face sheet dated 05/28/2026 revealed a [AGE] year-old male with an original admission date of 02/22/2022 and a current admission date of 092025. Diagnoses included Hemiplegia and Hemiparesis (paralysis or weakness to one side of the body, which was common after a stroke), Other Lack of Coordination, Type 2 Diabetes (a chronic condition which occurs when the body cannot use insulin effectively, leading to high blood sugar levels).Record review of Resident #2's care plan initiated 07/15/2023 and revised on 01/16/2026 revealed Resident #2 was a smoker. Interventions for this care plan included Resident #2 can smoke unsupervised. Resident #2's care plan did not address all smoking related privileges, restrictions, and concerns.Record review of Resident #2's Kardex, reviewed 05/28/2026, revealed Resident #2 can smoke unsupervised, but it did not identify all smoking related privileges, restrictions, and concerns.Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #75's face sheet dated 05/28/2026 revealed a [AGE] year-old male with an original admission date of 04/19/2023 and a current admission date of 10/07/2025. Diagnoses included Hemiplegia affecting Right Dominant Side (paralysis or weakness to one side of the body, which was common after a stroke), Other Seizures (seizures which were not defined or classified as Epilepsy or recurring), and Type 2 Diabetes (a chronic condition which occurs when the body cannot use insulin effectively, leading to high blood sugar levels).Record review of Resident #75's care plan initiated 11/14/2025 revealed Resident #75 was a smoker. Interventions for this care plan included Resident #75 can smoke unsupervised. Resident #75's care plan did not address all smoking related privileges, restrictions, and concernsRecord review of Resident 75's Kardex, reviewed 05/28/2026, revealed Resident #75 can smoke unsupervised.Record review of Resident #75's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated moderately impaired cognition. In an interview on 05/26/2026 at 4:10 PM, Resident #2 stated he was considered a safe smoker and could smoke by himself and keep his own lighter and cigarettes on him. He stated he had no problem with keeping up with and hanging onto his cigarettes and lighters. He was noted to be sitting in the hallway holding a lighter in his hand and had an unlit cigarette hanging from his mouth.In an interview and observation on 05/27/2026 at 10:45 AM, Resident #75 stated he was considered a safe smoker and was allowed to keep his own lighter and cigarettes with him. He was noted to be sitting in the hallway holding his lighter in his hand.In an interview on 05/28/2026 at 9:00 AM with the MDS nurse, she stated MDS was responsible for updating the care plans, and if a resident was considered a safe smoker, then they could smoke unsupervised. She stated it was assumed they would have their cigarettes and lighters on them. She stated lighters and cigarettes did not have to be care planned since the residents were safe smokers and care planned to smoke unsupervised. She stated these items could be care planned, but they did not have to be since the fact the residents were able to smoke unsupervised was care planned. She stated even though the policy stated all smoking related privileges should be care planned, this did not mean they had to care plan they were safe smokers, or they were allowed to carry cigarettes or lighters. The MDS nurse also stated they (the facility) did not track the residents who had lighters to keep up with them or keep a count on them in the facility, so they would not be able to determine if or when a lighter was lost or if a resident who was incompetent or not a safe smoke found it. In an interview on 05/28/2026 at 12:30 PM, CNA-J stated she would review the Kardex as well as ask the nurse to determine residents' likes, dislikes, needs and wants. CNA-J stated the Kardex did not always show information regarding safe smokers and non-safe smokers, but activities kept a list of all of the smokers and who was a safe smoker and who was not. CNA-J stated there were certain residents which she was used to seeing smoke on their own, so she knew they were safe smokers, but if she saw someone she did not know was a safe smoker or was unsure, she would have asked activities if they were safe smokers since activities kept a list. CNA-J stated she knew Residents #2 and #75 were safe smokers because she had seen them smoking on their own with their own supplies. In an interview on 05/28/2026 at 6:10 PM, the DON stated if residents were considered safe smokers, it was care planned, they could smoke unsupervised. The DON also stated cigarettes and lighters were privileges and should have been care planned. The DON stated they (the facility) did not track the safe smoker residents' smoking equipment, such as lighters, so they would not have known what one looked like if or when it went missing. He stated he hoped the resident would be competent enough to remember what the lighter looked like, and hopefully they would not fear losing smoking privileges, and they would tell someone if they lost their lighter. The DON stated if an incompetent resident found a lighter, they could burn themselves or start a fire.Record review of the facility's Smoking policy, revised July 2017, revealed Policy Statement: This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation: 9. Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to the issues. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. 13. Residents are not permitted to give smoking articles to other residents.

Based on interview and record review the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 2 residents (Resident #17 and Resident #9) of 5 residents whose care plans were reviewed. The facility failed to ensure Resident #17's comprehensive care plan was developed and implemented after starting anticoagulant (blood thinner) medication on 05/29/25. The facility failed to ensure Resident #9's care plan was revised to accurately reflect the most current anti-anxiety medication status. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services, and the implementation of a personalized plan of care to address their specific needs. Findings included:1.Record review of Resident #9's face sheet dated 09/25/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Pertinent diagnoses included Generalized Anxiety Disorder and Schizoaffective Disorder, Bipolar Type (a mental health condition with both symptoms of schizophrenia [a chronic mental health condition characterized by disruptions in thought, perception, and behavior] and a mood disorder). Record review of Resident #9's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which revealed intact cognition. The MDS assessment also revealed Resident #9 had active diagnoses of anxiety disorder and schizophrenia. Record review of Resident #9's physician orders, revised 07/11/2025, revealed an order for clonazepam (a medication used to treat anxiety disorders) 0.5 MG, give 1 tablet by mouth three times per day for schizophrenia bipolar disorder.Record review of Resident #9's comprehensive care plan, initiated 07/14/2024, revealed a care plan for anti-anxiety medication with interventions to include administer anti-anxiety medications as ordered by physician: administer clonazepam 0.5mg, give 1 tablet by mouth two times a day for anxiety. In an interview on 9/25/2025 at 12:45 PM, ADON-B stated Resident #9's care plan should have been updated to three times a day instead of twice a day. ADON-B stated the MDS nurse should have updated the care plan when the order changed since she was the one who updated clinical care plans, and if the care plans were not updated appropriately, a resident may not receive the care they needed. In an interview on 09/25/2025 at 3:45 PM, the MDS nurse stated the care plan should have been updated to reflect the clonazepam increasing from twice per day to three times per day, and she was not sure how or why it got missed. She stated it was ultimately her responsibility to update the clinical portion of the care plan so it showed the most current information for the resident, and if care plans were not updated accurately, residents may not get the care they needed. In an interview on 09/25/2025 at 3:55 PM, the DON stated the MDS nurse updated the clinical portion of the comprehensive care plan. He also stated sometimes the ADONs updated the care plans with acute issues discussed in the morning meeting, but ultimately it was the MDS nurse's responsibility to make sure the care plan was updated. The DON stated care plans were updated so staff had the most up to date and accurate information regarding a resident's care. 2.Record review of Resident #17's face sheet dated 09/24/25 reflected a [AGE] year-old-male with an original admission date of 09/17/21. Diagnoses included heart disease, hypertension (high blood pressure), and type two diabetes (insufficient insulin production in the body). Record review of Resident #17's physician orders dated 05/07/25 reflected: Lisinopril oral tablet 10 MG by mouth one time a day for hypertension. Hold if blood pressure is less than 110/60. Record review of Resident #17's care plan initiated on 05/15/25 did not reflect the use of antihypertension medications. Record review of Resident #17's quarterly MDS dated [DATE] reflected a BIMS of 13 (cognition intact) and an active diagnosis of hypertension. In an interview on 09/25/2025 at 3:15 pm, the MDS nurse stated the care plan should have been updated to reflect Resident #17's use of hypertensive medications. The MDS nurse stated she was not sure how or why it got missed but she was ultimately responsible for updating the clinical portion of the care plan, so it reflected the most current information. The MDS nurse stated if care plans were not updated accurately, residents may not get the care they needed. In an interview on 09/25/25 at 3:26 pm, the RMDS stated hypertensive medications should be care planned so staff are aware to monitor for signs and symptoms of hypertension. The RMDS stated care plans were reviewed daily but were audited approximately every 3 months. The RMDS could not state why Resident #17's hypertensive medications had not been care planned. In an interview on 09/25/2025 at 3:40 pm, the DON stated the MDS nurse updated the clinical portion of the comprehensive care plan and ultimately it was the MDS nurse's responsibility to make sure the care plan was updated. The DON stated care plans were updated so staff had the most up to date and accurate information regarding a resident's care. Record review of facility's Care Plans, Comprehensive Person-Centered dated December 2016 reflected: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan will: G. Incorporate identified problem areas; H. incorporate risk factors associated with identified problems; K. reflect treatment goals, timetable and objectives in measurable outcomes; O. reflect currently recognized standards of practice for problem areas and conditions. 8. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 12. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on Interviews and record reviews, the facility failed to ensure the director of nursing did not serve as a charge nurse when the facility had an average daily occupancy of 60 or higher for 4 days (08/03/25, 08/11/25, 09/08/25, and 09/14/25) reviewed for DON staffing in the last 2 months. The facility failed to ensure the DON did not work as a charge nurse for 4 different shifts in August and September 2025 while the average census was above 60. This failure could lead to dividing the DON's attention, preventing them from performing duties assigned to the DON leading to possible harm to a resident. The findings included:Record review of the daily clinical staff schedules revealed the DON was scheduled to work as charge nurse from 2:00 PM - 6:00 PM on 08/03/25 in the 100 hall, 6:00 AM - 6:00 PM on 08/11/25 in the 300 hall, 6:00 AM - 6:00 PM on 09/08/25 in the 100 hall, and 6:00 AM - 6:00 PM on 09/14/25 in the 300 hall. Record review of the resident census data from the facility revealed the daily census for 08/03/25 was 118, 08/11/25 was 121, 09/08/2025 was 116, and 09/14/25 was 116. In an interview with ADON B on 09/25/25 at 1:50 PM, ADON B stated a charge nurse was a nurse that was in charge of residents on a hall. ADON B stated there multiple charge nurses working at a time. ADON B stated there were typically 5 charge nurses working during the 6:00 AM - 6:00 PM shift and 3 charge nurses for 6:00 PM - 6:00 AM. ADON B stated the DON had come in and worked as a charge nurse when they were short-staffed. ADON B stated she had seen the DON working as a change nurse. ADON B stated the DON was used as a last resort to fill in as a charge nurse if they could not find anyone else. In an interview with the ADM on 09/25/25 at 3:09 PM, the ADM stated the DON has filled in as a charge nurse on the halls a few times. The ADM stated the DON was the last person on the list to call when a charge nurse was needed. The ADM stated they did not schedule the DON to work as a charge nurse ahead of time, but that he only ever filled in for another nurse. The ADM stated if the DON was scheduled on a daily basis to work as a charge nurse they would not be able to perform their DON duties effectively. In an interview with the DON on 09/25/25 at 3:28 PM, the DON stated he had worked as a nurse on the floor at the facility approximately four times in the past 2 months. The DON stated when he worked as a floor nurse he was not able to perform all of his responsibilities as a DON. The DON stated he was never scheduled to work on the floor ahead of time. The DON stated he would find out he was needed to fill in as a floor nurse about an hour before he was needed to be at the facility. A facility policy was requested from the ADM on 9/25/25 at 3:40 PM regarding the DON working as a charge nurse but the ADM stated the facility did not have a policy covering that.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 2 of 5 residents (Resident #2 and Resident #16) reviewed for pharmacy services. 1. The facility failed to administer Resident #2's Clonidine (a medication used to treat high blood pressure) per the prescribed order and blood pressure parameters in June of 2025. 2. The facility failed to administer Resident #16's Clonidine (a medication used to treat high blood pressure) per the prescribed order and blood pressure parameters in September of 2025. These failures could place residents at risk for complications and jeopardize their health and safety. Findings Included: 1.Record review of Resident #2's face sheet, dated 09/25/2025, revealed a [AGE] year-old female with an original admission date of 04/22/2025, and a current admission date of 09/05/2025. Pertinent diagnosis included Essential Primary Hypertension (high blood pressure). Record review of Resident #2's quarterly MDS assessment, dated 06/20/2025, revealed a BIMS score of 13, which revealed intact cognition. The MDS also revealed an active diagnosis of hypertension. Record review of Resident #2's physician orders, started 06/11/2025 and revised 07/22/2025, revealed an order for Clonidine 0.1 MG, give one tablet by mouth every 8 hours as needed for a systolic blood pressure greater than 170 or a diastolic blood pressure greater than 100. Record review of Resident #2's care plan for hypertension, initiated 06/23/2025 and revised 07/29/2025, revealed an intervention to give anti-hypertensive medications as ordered, to include Clonidine 0.1 MG. Record review of Resident #2's June 2025 MAR revealed Clonidine 0.1 MG, give one tablet by mouth every 8 hours as needed for a systolic blood pressure greater than 170 or a diastolic blood pressure greater than 100. The MAR also revealed Resident #2's day shift blood pressure on 06/21/2025 was 172/103, taken by LVN-D, but no prn Clonidine was administered. In an interview on 09/24/2025 at 3:00 PM, ADON-B stated LVN-D was a good nurse and always checked her residents blood pressures and administered their medication appropriately. ADON-B stated she was not sure why LVN-D did not administer Resident #2's blood pressure medication. She stated if a resident's blood pressure was already elevated, and they did not receive their blood pressure medication, and the blood pressure continued to rise, the resident could have had a stroke and possibly death. In an interview on 09/25/2025 at 2:30 PM, LVN-D stated she did not remember Resident #2 having an order for clonidine, but she remembered her having some issues with her blood pressure being elevated around this time. LVN-D stated she was not sure why she did not give the clonidine because she did not remember Resident #2's blood pressure ever being that elevated or the Clonidine order itself. She stated maybe she wrote the number down wrong or maybe she got distracted. LVN-D stated she did not recall Resident #2 ever complaining of signs or symptoms of excessively elevated blood pressure around this time, such as headache, dizziness, or chest pain. LVN-D stated if Resident #2's blood pressure had continued to rise, she could have had a stroke or heart attack. In an interview on 09/25/2025 at 3:55 PM, the DON stated nurses should always recheck an elevated blood pressure and administer any prn blood pressure medication the resident had. The DON also stated if a blood pressure was already elevated, and the prn medication was not administered, the blood pressure could have continued to rise, and the resident could have had a stroke. In an interview on 09/25/2025 at 4:33 PM, Resident #2 stated she took blood pressure medication for her blood pressure because sometimes it got high, and she stated the nurses at the facility was good about checking her blood pressure and giving her medication to her. Resident #2 denied remembering being told her blood pressure ever being 172/103 in June 2025, as well as she denied ever feeling or having symptoms of her blood pressure being that high such as headache, dizziness, or blurred vision. She stated she knew when her blood pressure was high and did not remember it being high. 2. Record review of Resident #16's face sheet dated 09/25/25 reflected a [AGE] year-old-male with an original admission date of 10/16/20. Diagnoses included acute chronic kidney failure, hypertension (high blood pressure), congestive heart failure (long-term condition in which the heart cannot pump blood well enough to meet the body's needs), and type two diabetes (insufficient insulin production in the body). Record review of Resident #16's care plan dated 12/12/23 reflected: Resident #16 had hypertension. Interventions included: Give anti-hypertensive medications as ordered. Record review of Resident #16's physician orders dated 03/06/25 reflected: Clonidine HCI oral tablet 0.1 by mouth every 6 hours as needed for a systolic greater than 160 and a diastolic greater than 100. Record review of Resident #16's blood pressure log reflected: 9/20/2025 08:20 164 / 66 mmHg; 9/20/2025 06:48 164 / 66 mmHg. Record review of Resident #16's September 2025 MAR reflected Clonidine HCI oral tablet 0.1 MG was not given for any days in September. In an interview on 09/25/25 at 9:23 am, LVN C stated sometimes when he administered blood pressure medication, the previous blood pressure was populated, and he would not change it. LVN C stated he would check resident's blood pressure prior to administration but sometimes would not record it. LVN C stated if blood pressure medication was not given as ordered, the resident's blood pressure could decline, the resident could become dizzy or hypotensive (low blood pressure), and experience headaches or fainting. In an interview 09/25/25 at 10:00 am, Resident #16 stated he would get his blood pressure checked daily but could not say if he got his blood pressure medication as needed. In an interview on 09/25/2025 at 2:02 pm, ADON B stated it was important to document blood pressures accurately to understand where the resident was at. ADON B also stated it was important to see if the blood pressure medication needed to be held, if Resident #16 needed any additional medications, or if the physician needed to be contacted in case the blood pressure was out of parameters. ADON B stated Resident #16 could experience a possible stroke, hypertension or death if Resident #16's was given the blood pressure medication outside of parameters. ADON B stated there was no current process for auditing blood pressure. In a phone interview on 09/25/25 at 2:28pm, MA E stated she was new to the facility and worked at another facility where their computers were bigger, and she was simply not used to this facility's small computers. MA E stated if Resident #16's blood pressure was out of parameters then she would have given the medication. MA E stated if Resident #16's blood pressure was not documented then she did not know what to say. MA E stated she always took blood pressure on the residents that required them. MA E stated she did not use the same blood pressure as before, and if they were the same blood pressures, then that's what they were. MA E stated she did not know what else to say as she had always taken residents blood pressures and documented accurately. In an interview on 09/25/2025 at 3:55 PM, the DON stated nurses should always recheck an elevated blood pressure and administer any prn blood pressure medication the resident had. The DON also stated if a blood pressure was already elevated, and medication was not administered as ordered, the blood pressure could have continued to rise, and the resident could have had a stroke. Record Review of the facility's Administering Medications policy, dated December 2012, reflected: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medication must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals). Refer to Liberalized Medication Pass Policy if used. 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on interviews and record review, the facility failed to maintain clinical records that were accurately documented for 3 (Resident #1, Resident #2,and Resident #16) of 5 residents reviewed for medical records. 1. The facility failed to ensure Resident #1's vital signs were accurately documented in the MAR on 08/15/25.2. The facility failed to ensure Resident #2's blood pressure was accurately documented in the MAR during the month of September 2025.3. The facility failed to ensure Resident #16's blood pressure was accurately documented for the month of September 2025. These failures could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. The findings included:1. Record review of Resident #1's face sheet dated 09/25/25 reflected a [AGE] year-old male with an original admission date of 11/03/23. Diagnoses included end stage renal disease (when the kidneys lose the ability to remove waste and balance fluids), hypertension (high blood pressure), anemia (low levels of healthy red blood cells to carry oxygen in the body), and type two diabetes (insufficient insulin production in the body). Record review of Resident #1's physician orders active as of 08/15/25 reflected in part: Vital signs twice daily, every day shift for 14 Days. Start date: 08/12/25. Vital signs twice daily in the evening for 14 Days. Start date: 08/12/25. Record review of Resident #1's August 2025 vital signs log reflected in part: 08/15/25 9:06 AM by LVN D: blood pressure 115/62, temperature 97.7, pulse 86, respiratory rate 18, and O2 sats 98. There was no other entry for 08/15/25 as Resident #1 was not in the facility again until 08/18/25 because he was admitted to the hospital on [DATE] at 11:38 AM. Record review of Resident #1's August MAR reflected in part: LVN D documented Resident #1's blood pressure as 115/62, temperature 97.7, pulse 86, respiratory rate 18, and O2 sats as 98 in the space for the 6:00 AM vital signs. LVN C documented Resident #1's blood pressure as 115/62, temperature 97.7, pulse 86, respiratory rate 18, and O2 sats as 98 in the space for the 6:00 PM vital signs. 2. Record review of Resident #2's face sheet dated 09/25/25 reflected a [AGE] year-old female with an original admission date of 04/22/25. Diagnoses included chronic kidney disease (when the kidneys are damaged and can't filter blood as well as they should), dependence on renal dialysis (process of filtering blood through a machine to remove excess water and toxins in the blood when the kidneys no longer function), hypotension (low blood pressure), hypertension (high blood pressure), and type 1 diabetes (a lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels). Record review of Resident #2's care plan reflected in part: Resident #2 had hypertension. Interventions included: Give anti-hypertensive medications as ordered. Resident #2 had episodes of hypotension (low blood pressure) at dialysis r/t end stage renal disease. Interventions included: Give medications as ordered. Monitor for side effects and effectiveness. Record review of Resident #2's physician orders reflected in part: HOLD medications on dialysis days, every day shift every Mon, Wed, Fri. Start date: 07/30/25 at 6:00 am. End date: 09/05/25 at 8:48 am. May hold medications on dialysis days. every shift every Mon, Wed, Fri related to Dependence on renal dialysis. Start date: 09/24/25 at 10:00 pm. Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth two times a day for HTN Hold for Systolic BP <110 or HR<60. Start Date: 06/11/25 at9:00 am. D/C Date:09/05/25 at 8:48 am. Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth two times a day for HTN. HOLD IF BP <110/60. Start date: 09/06/25 at 9:00 am. Record review of Resident #2's September 2025 blood pressure log and documentation of blood pressures for Losartan administration on the September 2025 MAR reflected in part: Log: 09/01/25 at 8:30 am 148/80 by LVN H MAR: 09/01/25 at 9:00 am: BP X by MA F. MAR: 09/01/25 at 5:00 pm: BP X by MA F. Log: 09/03/25- no 9:00 am or 5:00 pm blood pressure recorded. MAR: 09/03/25 at 9:00 am: BP X by MA F. MAR: 09/03/25 at 5:00 pm: BP X by MA F. Log: 09/08/25- no 9:00 am blood pressure recorded. MAR: 09/08/25 at 9:00 am: BP X by MA F. Log: 09/10/25 at 1:00 am 142/63 by ADON A. Log: 09/10/25 at 11:47 am 132/78 by LVN C. Log: 09/10/25- no 9:00 am or 5:00 pm blood pressure recorded. MAR: 09/10/25 at 9:00am: BP 142/63 by LVN C. MAR: 09/10/25 at 5:00 pm: BP 132/78 by LVN C. Log: 09/11/25- no 9:00 am blood pressure recorded. MAR: 09/11/25 at 9:00 am: BP 132/78 by LVN C. Log: 09/11/25 at 5:21 pm 122/77 by LVN C. MAR: 09/11/25 at 5:00 pm: BP 132/78 by LVN C. Log: 09/14/25 at 5:13 pm 177/58 by LVN G. Log: 09/15/25- no 9:00 am blood pressure recorded. MAR: 09/15/25 at 9:00 am: BP 177/58 by LVN C. Log: 09/15/25 at 5:12 pm 134/87 by LVN C. MAR: 09/15/25 at 5:00 pm: BP 177/58 by LVN C. Log: 09/16/25 at 12:13 am 142/84 by ADON A. Log: 09/16/25- no 9:00 am or 5:00 pm blood pressure recorded. MAR: 09/16/25 at 9:00 am: BP 142/84 by LVN C. MAR: 09/16/25 at 5:00 pm: BP 142/84 by LVN C. Log: 09/22/25- no 9:00 am blood pressure recorded. MAR: 09/22/25 at 9:00 am: BP X by LVN D. 3.Record review of Resident #16's face sheet dated 09/25/25 reflected a [AGE] year-old-male with an original admission date of 10/16/20. Diagnoses included acute chronic kidney failure, hypertension (high blood pressure), congestive heart failure (long-term condition in which the heart cannot pump blood well enough to meet the body's needs), and type two diabetes (insufficient insulin production in the body). Record review of Resident #16's care plan dated 12/12/23 reflected: Resident #16 had hypertension. Interventions included: Give anti-hypertensive medications as ordered. Record review of Resident #16's physician orders dated 03/06/25 reflected: Clonidine HCI oral tablet 0.1 by mouth every 6 hours as need for a systolic greater than 160 and a diastolic greater than 100. Record review of Resident #16's blood pressure log reflected: 9/20/2025 08:20 164 / 66 mmHg 9/20/2025 06:48 164 / 66 mmHg 9/24/2025 09:06 141 / 81 mmHg 9/24/2025 06:42 141 / 81 mmHg 9/19/2025 08:36 157 / 66 mmHg 9/19/2025 08:30 157 / 66 mmHg In an interview on 09/25/25 at 9:23 am, LVN C stated sometimes when he administered Resident #2's and Resident #16's blood pressure medication, the previous blood pressure would populate, and he would not change it. LVN C stated he would check Resident #2's and Resident #16's blood pressure prior to administration but sometimes did not record the blood pressure. LVN C did not have a reason why Resident #2's or Resident #16's blood pressure was not accurately recorded. LVN C stated it was important to update and record each blood pressure to ensure correct medication administration. In an interview 09/25/25 at 9:40 am, Resident #16 stated he would get his blood pressure checked daily but could not state if he was getting his medication as needed. In an interview on 09/25/2025 at 10:00 am, the DON stated Resident #2's and Resident #16's blood pressure should have been taken and accurately documented to assess vitals and see where the patients were at. The DON stated Resident #2's and Resident #16's blood pressures could have fluctuated, and the medication needed would not have been given. The DON stated in-service on medication administration was done at least annually and as needed. In an interview on 09/25/24 at 1:05 pm, ADON B stated vital signs could be entered manually into the vital signs page. She stated if nurses or medication aides did not check a blood pressure before giving or holding a blood pressure medication, the resident's blood pressure could go too low or too high and cause hospitalization, stroke, or even death. ADON B stated medication administration was in-serviced about every month, but she was not sure when the last one was. In an interview on 09/25/2025 at 2:02 pm, ADON A stated it was important to document blood pressures accurately to understand where the resident was at and to see if the medication needed to be held or if the physician needed to be contacted in case the blood pressure was out of parameters. ADON A stated Resident #16 could experience a possible stroke, hypertension or death if given the blood pressure medication outside of parameters. ADON A stated there was no current process for auditing blood pressures. ADON A stated the blood pressure usually fluctuated and would not typically be the same in the morning and in the evening or for consecutive days. In an interview on 09/25/25 at 2:13 pm, LVN D stated she checked Resident #2's blood pressure that morning (9/22/25) but she did not give her the Losartan because she was going to dialysis and there was an order to hold her medications on dialysis days. LVN D stated vital signs were checked every time before blood pressure medications were given. LVN D stated medication administration was in-serviced every few months, but she was not sure when the last one was. It covered following doctor's orders, documenting, and checking blood pressures/vital signs before giving medications. In a phone interview on 09/25/25 at 2:28 pm, MA E stated she was new to the facility and worked at another facility where their computers were bigger. MA E stated she was not used to the facility's small computers. MA E stated if Resident #16's blood pressure was not documented then she did not know what to say as she would have documented and gave medication as ordered. MA E stated she always took blood pressures on the residents that required them. MA E stated she did not use the same blood pressure previously recorded and if the blood pressures were recorded the same, then they were the same. MA E kept stating she just started at the facility and had vision problems. MA E stated she did not know what to say as she always took resident blood pressures and documented what the blood pressures were at that time. In an interview on 09/25/25 at 4:10 pm, Resident #2 stated the staff usually checked her blood pressure a couple of times a day. She stated she used to be on a lot of blood pressure medication, but since she got back from the hospital, she only took one. In an interview on 9/25/25 at 4:22 pm, LVN H stated typically the medication aide checked blood pressures for morning medications. For Resident #2, the nurse checked it before she went to dialysis and when she got back from dialysis. She stated the last medication administration in-service may have been sometime last month. In an interview on 09/25/25 at 4:53 pm, MA F stated Resident #2 was a dialysis patient who usually had very high blood pressure. MA F stated some nurses (did not say which ones) told her not to give blood pressure medication on days she was going to dialysis. MA F stated if she did not give blood pressure medications, she documented it in the progress notes that it was not given and would document the blood pressure in the vital signs tab. MA F stated she checked blood pressures before she administered any blood pressure medications and she did not know why it did not show up in the vital signs log or the MAR. MA F stated if the blood pressure was not checked it could cause the resident to bottom out and end up in the hospital. She stated she had not yet been in-serviced on medication administration, but she was oriented and observed for 3 days when she started working at the facility in the middle of June. 3. Record review of Resident #16's face sheet dated 09/25/25 reflected a [AGE] year-old-male with an original admission date of 10/16/20. Diagnoses included acute chronic kidney failure, hypertension (high blood pressure), congestive heart failure (long-term condition in which the heart cannot pump blood well enough to meet the body's needs), and type two diabetes (insufficient insulin production in the body). Record review of Resident #16's care plan dated 12/12/23 reflected: Resident #16 had hypertension. Interventions included: Give anti-hypertensive medications as ordered. Record review of Resident #16's physician orders dated 03/06/25 reflected: Clonidine HCI oral tablet 0.1 by mouth every 6 hours as need for a systolic greater than 160 and a diastolic greater than 100. Record review of Resident #16's blood pressure log reflected: 9/20/2025 08:20 164 / 66 mmHg 9/20/2025 06:48 164 / 66 mmHg 9/24/2025 09:06 141 / 81 mmHg 9/24/2025 06:42 141 / 81 mmHg 9/19/2025 08:36 157 / 66 mmHg 9/19/2025 08:30 157 / 66 mmHg In an interview on 09/25/25 at 9:23 am, LVN C stated sometimes when he administered Resident #16's blood pressure medication, the previous blood pressure would populate and he would not change it. LVN C stated he would check Resident #16's blood pressure prior to administration but sometimes did not record the blood pressure. LVN C did not have a reason why Resident #16's blood pressure was not accurately recorded. LVN C stated it was important to update and record each blood pressure to ensure correct medication administration. In an interview 09/25/25 at 9:40 am, Resident #16 stated he would get his blood pressure checked daily but could not state if he was getting his medication as needed. In an interview on 09/25/2025 at 10:00 am, the DON stated Resident #16's blood pressure should have been taken and accurately documented to assess vitals and see where the patient was at. The DON stated Resident #16's blood pressure could have fluctuated, and the medication needed would not have been given. In an interview on 09/25/2025 at 2:02 pm, ADON A stated it was important to document blood pressures accurately to understand where the resident was at and to see if the medication needed to be held or if the physician needed to be contacted incase the blood pressure was out of parameters. ADON A stated Resident #16 could experience a possible stroke, hypertension or death if given the blood pressure medication outside of parameters. ADON A stated there was no current process for auditing blood pressures. ADON A stated the blood pressure usually fluctuated and would not typically be the same in the morning and in the evening. In a phone interview on 09/25/25 at 2:28pm, MA E stated she was new to the facility and worked at another facility where their computers were bigger. MA E stated she was not used to the facility's small computers. MA E stated if Resident #16's blood pressure was not documented then she did not know what to say as she would have documented and gave medication as ordered. MA E stated she always took blood pressures on the residents that required them. MA E stated she did not use the same blood pressure previously recorded and if the blood pressures were recorded the same, then they were the same. MA E kept stating she just started at the facility and had vision problems. MA E stated she did not know what to say as she always took resident blood pressures and documented what the blood pressures were at that time. Record review of the facility's Charting and Documentation dated July 2017 reflected: Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record: b. Medications administered; c. Treatments or services performed 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; e. whether the resident refused the procedure/treatment;

Based on interview and record review the facility failed to ensure menus met the needs of residents in accordance with established national guidelines for 1 (R#1) of 4 residents reviewed for pureed diets.The facility provided R#1 with a whole hot dog when R#1 required a puree diet, leading to a choking incident on 10/16/25 that required the use of the Heimlich maneuver and resulted in anoxic brain injury. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 10/16/25 and ended on 10/17/25. The facility corrected the non-compliance before the investigation began.This failure could place residents that require specialized diets at risk of choking, hospitalization, and death.Record review of the Resident #1's admission Record dated 10/22/25 revealed Resident #1 was a 66year old female admitted to the facility on [DATE]. Resident #1 was admitted with multiple diagnoses which included: unspecified dementia with agitation (a cognitive disorder that causes a gradual decline in a person's ability to make decisions, remember things, solve problems, and communicate effectively), abnormalities of gait and mobility (altered ability of walking), Lack of coordination, muscle wasting and atrophy (multiple sites), schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder). Record review of an MDS dated [DATE] revealed Resident #1 had a BIMS score of 00 which indicated Resident #1 was severely cognitively impaired. The MDS also revealed Resident #1 required substantial assistance (helper doing more than half the effort) during meals and Resident #1 required mechanically altered diet (e.g. pureed food, thickened liquids). Record review of Resident #1's physician orders dated 10/22/2025 revealed an order for regular diet, pureed texture, and nectar consistency with start date of 7/17/2025. Record review of Resident #1's care plan revealed Resident #1 requires supervision/setup assistance by 1 staff to eat initiated 1/16/2025. Resident #1's care plan also revealed Resident #1 required a regular diet, pureed texture, and nectar consistency initiated on 7/18/2025. Record review of the Provider Investigation Report revealed on 10/16/2025 at about 6:45 p.m., CNA B provided a food tray to Resident #1 that was not checked by a nurse before it was sent to Resident #1's room to assist Resident #1 to eat. Record review of Methodist hospital Records dated 10/20/2025 revealed Resident #1's assessment and plan included Encephalopathy likely secondary to anoxic brain injury (not enough oxygen getting to the brain). Record review of statement dated 10/16/2025 written by CNA B, revealed CNA B went to assist Resident #1 to eat. CNA B's statement indicated she placed Resident #1's food tray on the bedside table and moved the tray closer to Resident #1 and that is when Resident #1 grabbed a whole hotdog from the plate and started eating the hotdog. CNA B's statement noted CNA B tried telling Resident #1 to hold on, but Resident #1's skin coloring started to change prompting CNA B to call for assistance and the ADON came in immediately to assist Resident #1. On 10/21/2025 attempts to contact CNA B were unsuccessful due to recording of disconnection of phone service. During an interview on 10/21/2025 at 3:32 p.m., the ADON stated on 10/16/2025 about 6:30p.m., she was called to the room of Resident #1 by CNA B and noticed Resident #1 was choking. The ADON stated she performed the Heimlich maneuver and performed a finger sweep which recovered what looked like regular texture bread and meat from the mouth of the resident. Resident #1 was still not breathing adequately and became unconscious. The ADON stated she started performing CPR, called a Code Blue, and EMS was called to the facility. During a phone interview on 10/21/2025 at 4:38 p.m., the dietary aide stated a CNA gave the wrong texture of food to Resident #1 on the evening of 10/16/2025 and this caused the resident to choke. The dietary aide stated his job is to cook the food and to serve the correct texture. The dietary aide stated he was the first one to see the meal tickets and the first one to plate the food and this included the protein, the starch and the vegetables for all residents. The dietary aide stated Resident #1's tray should have been pureed texture. The dietary aide stated the trays may have gotten mixed up and possibly an alternate meal was given to the Resident #1. During an interview on 10/27/25 at 9:30 a.m., the kitchen manager stated he found out there was choking incident from the dietary aide on 10/16/2025. The Kitchen Manager stated he asked the kitchen staff what happened, and they stated they sent out a puree diet for Resident #1. The Kitchen Manager stated the staff members informed him there was multiple requests for alternate food items from the menu and the food trays may have gotten mixed up. The kitchen manager stated it is wrong that Resident #1 did not get the correct diet type. The kitchen manager stated he performed an investigation on what happened in the kitchen by interviewing staff, assessing meal plans, making plans of correction, ensuring plans of correction are followed completed and implemented. The kitchen manager stated he performed this investigation with the assistance of the DON and the Administrator. During an interview on 10/27/2025 at 9:50 a.m., the DON stated he was informed Resident #1 choked on a hotdog which ended in Resident #1 being sent out of the facility on 10/16/2025. The DON stated he and the Administrator investigated the incident of Resident #1 receiving a hotdog. The DON stated the investigation revealed the kitchen staff sent an incorrect tray out of the kitchen for Resident #1 that ended in Resident #1 choking and being sent to the hospital. The DON stated Resident #1's food should have been pureed. The DON stated it is the expectation for staff to check all trays before being served to all residents. The DON stated staff did not follow policy and procedure due to Resident #1 receiving an incorrect food tray. During an interview on 10/21/2025 at 11:55 a.m., the Administrator stated he was informed Resident #1 choked on a hotdog in the facility the evening of 10/16/2025. The Administrator stated an investigation was completed and included auditing all tray tickets to confirm matching diet orders, collecting statements from staff members, and finding the root cause of Resident #1 receiving an incorrect tray. The Administrator stated the investigation revealed the kitchen sent out an incorrect tray to Resident #1. The Administrator stated it was expected practice for all trays to be correct when they are sent out of the kitchen and for all trays to be checked by a nurse before residents receive their food trays. The Administrator also stated all staff have been trained to ensure a nurse checks all trays before the food is served to the residents, including Resident #1. A review of the facility policy Therapeutic Diets dated 2001 Medpass (revised October 2021) revealed #1 Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet., #2 A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). , and #4 A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. Record review of facility's plan of action dated 10/16/2025 revealed:1. The dietary staff members and C.N.A who passed the tray before the nurse could check it were terminated on 10/16/2025 .2. DON and ADON completed 100% audit on all tray cards to ensure they match physician orders was completed on 10/16/2025.3. COO completed 100% audit on all care plans for residents with mechanically altered diets completed on 10/16/2025.4. Administrator informed staff Hot dogs are no longer allowed to be served at the facility- regardless of the occasion.5. DON/ADON/Admin conducted education on 10/16/2025:o All dietary and direct care staff trained on how to read a tray card- Diet Type, Diet Texture, and Fluid ConsistencyS They should know examples of Type- Regular, Renal, LCS, No added SaltS They should know examples of Texture- Regular, Mechanical Soft, PureedS They should know examples of Fluid Consistency- Thin, Nectar, Honeyo All dietary and direct care staff in-serviced on the requirement of a nurse checking the tray cards versus what is on the tray prior to CNA's serving them. The CNA's need to be the second check prior to service residents' tray to verify it matches.o All dietary staff and Charge Nurses in-serviced on process not allowed to give food to staff for a resident unless the nurse is the one who comes and asks for it.o When and how to do the Heimlich.o All direct care staff in-serviced on Code Blue and what to do when there has been a Change of Condition.*Anyone hired after 10/16/2025 will not work the floor until education has been received 6. Ad Hoc QAPI conducted with IDT team and Medical Director.7. Menu reviewed to remove hot dog, sausage, grapes, raw carrots, cherry tomatoes, hard candy, nuts, and peanut butter. Dietitian informed of changes. Monitoring Actions: -Admin/DON/ or ADON will audit breakfast, lunch, and dinner service weekly to ensure process is being followed.-Admin/DON/or ADON will review tray cards weekly to ensure they match physician orders. Record review of in-service dated 10/17/2025 revealed 112 staff in-serviced. In-service topics: tray ticket auditing, facility will no longer serve hotdogs, all food items will be served by dietary, Charge nurses to check tray tickets prior to passing out trays and performing the Heimlich maneuver. Record review of in-service dated 10/17/2025 revealed 14 dietary staff in-serviced. In-service topics: meal trays are to be signed/initialed after the nurse has verified that the diet, texture and liquid consistency is correct, if a resident is requesting anything extra from the kitchen, the nurse will have to request it. If a resident is requesting an alternative: a) the nurse will have to request the alternative, b) verify the diet, texture and liquid consistency, and sign/initial the tray ticket when the alternative has been verified. Observation of lunch and dinner service on 10/23/2025 revealed kitchen staff matching tray tickets to the diet type listed on meal tickets for the 100 hall, nurses verified and initialed all meal trays on the cart for the 100 hall, and one pureed diet tray sent back to the kitchen upon request for an alternative meal and nurse verified by initialing meal ticket that a pureed diet was provided to the resident by matching the ticket with the food type.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one resident (Resident #5) of three residents reviewed for skin irregularities. When Resident #5 was readmitted into the facility on [DATE], LVN E failed to complete a thorough and accurate head-to-toe assessment that included assessing what was under Resident #5's right arm dressing/bandage. This failure could compromise a resident's skin integrity, which could increase the risk for progressive skin complications. Record review of the Resident #5's admission Record dated 10/24/2025 revealed Resident # 5 was a [AGE] year-old male who was initially admitted on [DATE] and readmitted on [DATE]. Resident #5 was admitted with multiple diagnoses which included: cerebral infarction (stroke), muscle wasting and atrophy, intellectual disabilities, hemiplegia (paralysis of a limb) and hemiparesis (weakness of a limb). Record review of Resident #5's care plan date initiated 10/02/2025 revealed The resident has actual impairment to skin integrity of the Right antecubital fossa r/t Coban wrap. Goal: the resident's minor skin injury of the right antecubital fossa will be healed by the next review date. Interventions: encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, identify/document potential causative factors and eliminate/resolve where possible, monitor the site for infection for 72hours.Record review of Resident #5's MDS Quarterly dated 10/13/2025 revealed, Resident #5 had a BIMS score of 15 which indicated intact cognition. Additionally, Resident #5 needed setup/cleanup assistance with the majority of his ADLs. Resident #5 was not coded for major skin irregularity or wounds. Record review of Resident #5's progress notes from 09/17/2025 through 09/25/2025 revealed no mention or assessment of Resident #5's arm. Record review of Resident #5's progress note dated 09/26/2025 at 15:32 (3:32PM) the LMSW documented LMSW spoke to resident to follow up with him regarding the Coban wrap left on his forearm. During an interview and observation on 10/24/2025 at 11:38AM Resident #5 stated he recalled an incident where a bandage was left on his arm for days and felt tight, however he could not recall the date of the incident. Resident #5 stated he had no concerns about the dressing issue and verbalized no concerns. Upon initial observation, Resident #5 had no visible sign of skin irregularities on his arms. During a phone interview on 10/24/2025 at 12:47PM the local area advocate ([NAME]) stated she was notified by a family member regarding a complaint that Resident #5 had a dressing on his arm for roughly 8 days without any clinical staff member assessing underneath the dressing. The [NAME] stated when she arrived in the facility on either 9/24/2025 or 9/25/2025, she entered Resident #5's room and saw Resident #5 with a neutral color dressing to elbow, with red discoloration to the very same area. The [NAME] stated while she spoke to Resident #5, he never exhibited any sign or symptom of distress and was very pleasant. The [NAME] stated she conversed with Resident #5 and found no immediate concerns for Resident #5 and left the facility. During an interview on 10/24/2025 at 1:43PM, LVN E stated while the administrator was present, that she requested the administrator to be present during the interview. LVN E stated when Resident #5 returned to the facility roughly after lunch around 12:30pm-1:30pm on 09/17/2025. LVN E stated she recalled Resident #5 entering the facility on a stretcher and noticed he had a beige colored dressing/covering on Resident #5's arm but could not recall which arm. LVN E stated she worked at least 4-5 days between 09/17/2025-09/24/2025 and asked on 09/17/2025 and 9/18/2025 to observe what was underneath the bandage/dressing, but Resident #5 was resistant to care. LVN E stated in-hindsight she should have advocated to see what was under the bandage/dressing as not only part of her professional scope of practice but also to ensure there were no negative or immediate concerns for skin irregularities. LVN E stated her concern with Coban dressings was if the dressing was too tight, there could be a loss of blood circulation, skin irritation, and/or possible wound, but reiterated Resident #5 never expressed or exhibited any sign or symptoms of distress or concern. LVN E stated she should have conducted a more thorough head-to-toe assessment to ensure there were no concerning irregularities; however verbalized Resident #5 did not exhibit or express anything of a compromising nature regarding any skin irregularities. LVN E stated going forward; she will advocate in a more assertive manner when conducting a head-to-toe assessment as a precautionary intervention, to ensure the well-being of all her patients. LVN E stated she attended an in-service regarding removing Coban dressing upon all assessments. LVN E stated roughly after 09/22/2025 she observed Resident #5 with slight redness to his forearm and reiterated going forward; she will complete a thorough head-to-toe assessment for any newly admitted /readmitted resident. During an interview on 10/25/2025 at 4:00PM, the DON stated LVN E should have completed a thorough head-to-toe assessment when Resident #5 was readmitted into the facility. The DON stated these types of thorough assessments are to ensure there are no concerning skin irregularities and if any skin irregularities are observed, the facility would enact a plan to mitigate any progression of those skin irregularities. The DON stated all staff members have been in-serviced and educated regarding the facility's expectation that all clinical nursing staff members are to observe and assess underneath all dressings and Coban dressings as a preventative measure to ensure the well-being and skin integrity of all residents. The DON stated had the dressing been too tight, or if there was a skin irregularity under the dressing, there could be a loss of circulation, a wound progression or formation of infection, however reiterated there the well-being of Resident #5 was intact, and there was never any concern for Resident #5's skin integrity.Record reviewed the facility's Abuse &Neglect; removal of tourniquet/Coban in-service dated 09/25/2025 was reviewed.Record reviewed the facility's in-service regarding bands are to be removed on all new admissions and readmissions. If a resident refuses, make sure the nurse is notified-so it can be documented and care planned dated 10/17/2025 was reviewed. Record review of the facility's Pressure Ulcer/Skin Breakdown-Clinical Protocol revised dated April 2018 documented, the staff/practitioner will examine the skin of newly admitted resident for evidence of existing pressure ulcers or other skin conditions.

Based on record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for one resident (Resident #5) of three residents reviewed for total body skin assessment documentation. 1. When Resident #5 was readmitted into the facility on [DATE], LVN E failed to document a bandage on Resident #5's forearm/elbow area. 2. When Resident #5's skin irregularity was assessed on 09/25/2025, LVN F failed to document and detail the right arm skin impairment. These failures could affect residents who require care and monitoring and place them at risk of not receiving the care and services to meet their needs. Record review of the Resident #5's admission Record dated 10/24/2025 revealed Resident # 5 was a [AGE] year-old male who was initially admitted on [DATE] and readmitted on [DATE]. Resident #5 was admitted with multiple diagnoses which included: cerebral infarction (stroke), muscle wasting and atrophy, intellectual disabilities, hemiplegia (paralysis of a limb) and hemiparesis (weakness of a limb).Record review of Resident #5's care plan date initiated 10/02/2025 revealed The resident has actual impairment to skin integrity of the Right antecubital fossa r/t Coban wrap. Goal: the resident's minor skin injury of the right antecubital fossa will be healed by next review date. Interventions: encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, identify/document potential causative factors and eliminate/resolve where possible, monitor the site for infection for 72hours.Record review of MDS Quarterly dated 10/13/2025 revealed Resident #5 had a BIMS score of 15 which indicated intact cognition. Additionally, Resident #5 needed setup/cleanup assistance with majority of his ADLs. Resident #5 was not coded for major skin irregularity or wound.Record review of Resident #5's Nursing Skin Observation Tool dated 09/25/2025 revealed LVN F documented Redness noted to right forearmDuring a phone interview on 10/24/2025 at 12:47PM the local area advocate ([NAME]) stated she was notified by a family member regarding a complaint that Resident #5 had a dressing on his arm for roughly 8 days without any clinical staff member assessing underneath the dressing. The [NAME] stated when she arrived in the facility on either 9/24/2025 or 9/25/2025, she entered Resident #5's room and saw Resident #5 with a neutral color dressing to elbow, with red discoloration to the very same area. The [NAME] stated while she spoke to Resident #5, he never exhibited any sign or symptom of distress and was very pleasant. The [NAME] stated she conversed with Resident #5 and found no immediate concerns for Resident #5 and left the facility.During an interview on 10/24/2025 at 1:43PM, LVN E stated, while the administrator was present, that she requested the administrator to be present during the interview. LVN E stated she did not document her observation of Resident #5's right arm bandage/dressing on 09/17/2025 because she did not think that it warranted documentation. LVN E stated in hindsight she should have documented her observation as an effort to ensure Resident #5's well-being. LVN E stated as part of her professional scope of practice documentation would aid in monitoring any irregularities but reiterated there were no negative outcomes due to her lack of documentation of Resident #5's bandage on 09/17/2025. LVN E stated there was no negative outcome due to her actions, however stated going forward she will document all her observations when she conducts her head-to-toe assessments. LVN E stated she attended a facility in-service on 09/25/2025 regarding documentation, refusals, measurement, and description of skin integrities. During an interview on 10/25/2025 at 11:07AM LVN F interviewed with ADON A present. LVN F stated she recalled Resident #5's right forearm discoloration on 09/25/2025. LVN F stated Resident #5 had some redness to his right arm, and within the general antecubital area, there appeared a straight line, roughly 2-3 inches in diameter. LVN F stated she did not observe any other discoloration to Resident #5 extremities. LVN F stated she did not place the details of what she saw in the note as she did not think to document it in a note. LVN F stated details like measurements, would help her assessment to ensure skin irregularities were not getting worse. LVN F stated by documenting her assessment findings, this documentation would aid in avoiding infections and ensure the safety and well-being of all her residents. LVN F stated she is more vigilant now, and thoroughly intentional with her observation documentation. LVN F stated there was no negative outcome to her lack of documentation for Resident #5.During an interview on 10/25/2025 at 4:00PM the DON stated, LVN E should have documented her observation of Resident #5's bandage on 09/17/2025, and furthermore LVN F should have documented her 09/25/2025 detailed assessment regarding Resident #5 skin impairment. THE DON stated the expectation of the facility was to document and detail all observational findings with as much detail including measurement and descriptive verbiage. The DON stated documentation should include measurements, description of injury, any odors, color, and if skin is blanchable. The DON stated documentation is an effort to ensure the safety of all residents and a way to monitor any irregularities. The DON stated the clinical staff, in no way, compromised the wellbeing of Resident #5, but going forward the staff have been in-serviced on the facility's expectation to document all observational findings.Record review of the facility's documentation, refusals, measurements, and description of skin integrity in-service dated 09/25/2025 was reviewed.Record review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol revised April 2018 documented, 2. In addition, the nurse/physician shall describe and document/report the following: a. Full data collection of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue.

Based on observation, interview and record review the facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access for 1 of 2 wound treatment carts on hall 100 reviewed for storage.The 100 hall wound care treatment cart was found unlocked.This failure could place residents at risk of access and ingestion of medications or supplies not intended for them and/or misappropriation. Findings were:Observation on 10/21/2025, at 11:24 a.m., a wound care treatment cart was found unlocked in front of the 100 hall nursing station. The observation of items inside the wound care cart included: betadine solution, hydrogen peroxide, triple antibiotic ointment, nystatin cream, diclofenac sodium gel, iodoform packing strips, lidocaine cream, and a variety of bandages used for wound care treatment.During an interview on 10/21/2025 at 11:30 a.m., LVN A verbalized the treatment cart was an extra cart and was not assigned to any staff member. LVN A verbalized she was unsure who used the cart last, but it is policy for the cart to be locked. LVN A stated if a resident accessed the items in the cart they could ingest or use the items in the cart. During an interview on 10/27/2025 at 9:50 a.m., the Director of Nursing (DON) stated it is the expectation of the facility for all staff to lock all carts including the wound care carts. The DON stated depending on the items in the cart the residents could have ingested or utilized the items in the cart. The DON stated the cart was not assigned to any staff member(s) as the cart was an extra wound care treatment cart.During an interview on 10/27/2025 at 9:55 a.m., the Administrator stated all carts should be locked and all items on the cart should be put away. The Administrator stated, depending on what is in the cart it would depend on what happens to a resident if they access a cart, but a resident could open an item and ingest it. The Administrator also stated it is not necessarily neglect or abuse, but it is against the policy and procedure to leave any carts unlocked.A review of the medication policy dated 2001 Medpass (revised November 2020) revealed #1 Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity control. Only persons authorized to prepare, and administer medications have access to locked medication, #2 The nursing staff is responsible for maintaining medication storage, and preparation areas in a clean, safe and sanitary manner, and #6 Compartments, including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biologicals are locked when not in use.

Based on observation, interviews, and record reviews the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards as possible for 1 of 5 residents (Resident #1) reviewed for supervision, accidents, and hazards. The facility failed to keep Resident #1 free from accident and/or hazards when she fell on [DATE] which caused her to sustain a left hip fracture by not providing the necessary monitoring and supervision for Resident #1 with known history of behaviors of wandering into other resident rooms. The three staff assigned to supervise the secure unit were at the nurse's station distracted and engaged in personal conversation when Resident #1 wandered out of her room and into another resident's room. An IJ was identified on 08/20/25. The IJ template was provided to the facility on [DATE] at 3:22 PM. While the IJ was removed on 08/21/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because new procedures implemented to prevent future errors were still in process. This failure could place residents at risk for injuries and a decline in health.The findings included: Record review of Resident #1's face sheet dated 07/31/25 revealed an [AGE] year-old female with an original admission date of 01/12/23 and a current admission date of 06/05/25. Pertinent diagnoses included Displaced Intertrochanteric Fracture of Left Femur (a common hip fracture which occurs in the upper part of the femur which typically required surgical intervention); Other Abnormalities of Gait and Mobility, Dementia (a decline in cognitive function which affects daily life, memory, reasoning, and language skills), Alzheimer's Disease (the most common form of dementia, characterized by problems with memory, thinking, and behavior), and Blindness to the Left Eye. Record review of Resident #1's care plan initiated 06/15/2023 and revised 07/25/25 revealed Resident #1 was at risk for falls related to gait and balance problems. Interventions included anticipate and meet the resident's needs, follow facility fall protocol, and evaluate and treat as ordered. Resident #1's care plan initiated 01/16/2023 and revised 01/03/2025 revealed Resident #1 was an elopement risk as evidenced by wandering; interventions included distracting Resident #1 from wandering by offering diversions, structured activities, food, conversation, television, books, and/or listening to the radio in her room. Other interventions included Resident #1 would be redirected when wandering into other residents' rooms or as needed, and Resident #1 would reside in the memory care unit for safety. Resident #1's care plan also included the actual fall on 06/01/25 with serious injury. It was initiated on 06/03/25. Interventions included determine and address causative factors of the fall. Record review of Resident #1's Quarterly MDS assessment dated [DATE], section C, cognitive patterns, revealed a BIMS score of 00 (severe cognitive impairment). This MDS revealed no falls since admission, entry, reentry, or prior assessment. Record review of Resident #1's Quarterly MDS assessment dated [DATE], section C, cognitive patterns, revealed a BIMS score of 00 (severe cognitive impairment). This MDS revealed fall with major injury requiring surgical intervention. There was no provider investigation or internal investigation for the fall of the unsupervised Resident #1 done by the facility, so there was no review done of a provider or facility investigation. Record review of Resident #1's Fall Risk Evaluation dated 03/04/25 revealed Resident #1 wanders; no falls in the past 3 months; regularly incontinent; balance problem while standing/walking. Resident was considered a high risk for falls. Record review of Resident #1's progress note dated 06/01/25, written by LVN-I, revealed a male resident came out of his room and said there was a woman in his room on the floor. Resident #1 was found on her left side, and two CNAs were called to the room for assistance. The skin check was done, and there was a small hematoma to the left brow. Resident #1 was in severe pain to left thigh. Staff assisted Resident #1 into the wheelchair and then assisted her to bed. Left leg was noted to be shorter than the right leg. Record review of Resident #1's Hospital Summary - Orthopedic Discharge Instructions dated 06/05/25 revealed Resident #1 underwent open reduction with internal fixation (surgical procedure to repair broken bones) on 06/02/25. Pertinent information included per family member, [Resident #1] was found in another resident's room and had fallen. The Assessment and Plan portion of the hospital summary revealed unwitnessed fall. The Hospital Diagnoses portion of the hospital summary revealed unwitnessed fall. Record review of the Staffing Schedule for the locked unit revealed a census of 26 and the following staff: 05/31/25 revealed 6AM - 6PM had 2 CNAs and an LVN (from 6AM-1:30PM) and another LVN (from 1:30PM-12AM). 6Pm - 6AM had 2 CNAs and an LVN (from 12AM-6AM).06/01/25 revealed 6AM - 6PM had 2 CNAs and an LVN (from 6AM-1:30PM) and another LVN (from 1:30PM-6PM). 6PM - 6AM had 2 CNAs and an LVN.06/02/25 revealed 6AM - 6PM had 2 CNAs and 2 LVNs. 6PM - 6AM had 2 CNAs and an LVN. In an observation on 08/19/25 at 9:40 AM revealed Resident #1 lying in bed. She smiled and nodded her head to every question asked. Attempted to interview Resident #1, but she was pleasantly confused. In an observation on 08/19/25 at 9:45 AM the locked unit revealed 5 residents walking down the hallway assisted by 1 CNA. LVN was off the unit (had stepped away) and 2nd CNA was providing patient care. In an observation on 08/20/25 at 1:05 PM the locked unit revealed some residents sitting in the television room, some residents sitting in the activities/dining room, while multiple other residents were wandering up and down the hall. Three residents were noted to have gone into rooms which did not belong to them, and staff did redirect these residents. In an observation on 08/20/25 at 1:30 PM the locked unit revealed 8 camera monitors located at the nurses' station to be able to view all angles of the hallway. In an interview on 07/30/25 at 3:35 PM LVN-I stated she had not seen Resident #1 fall as she was sitting at the nurses' station at the time. She stated it was an unwitnessed fall, and Resident #2 had found her on the floor in his room. Resident #2 came out of his room and notified staff there was a woman on the floor in his room. She stated Resident #1 had severe pain with facial grimacing and moaning. LVN-I stated she assessed Resident #1, and she was noted to have had some bruising, as well as a deformity in which one leg was noted to be longer than the other leg as a result of the fall. She stated two CNAs assisted her with getting Resident #1 up and to the wheelchair, then to the bed in her room, and LVN-I notified the provider and Emergency Medical Services. In an interview on 07/30/25 at 3:48 PM ADON-A stated Resident #1 had not had any other recent falls since 09/04/24 in which she had wandered into another resident's room and had a fall. She also stated she only knew what she had read about the fall from LVN-I's progress note as an investigation had not been done. In an interview on 07/30/25 at 4:21 PM the DON stated Resident #1's fall was reported to him during the morning meeting the next morning. The DON stated he did not further investigate the incident after he was made aware. DON also stated he did not investigate the staffing supervision at the time of the incident. In an interview on 07/30/25 at 4:45 PM the Administrator stated he remembered an incident report was done, and Resident #1 had a fracture from the fall. He stated another resident reported there was a lady on the floor. The Administrator stated he did not conduct an investigation regarding the supervision of the staff or how the fall occurred. The Administrator stated he had not done any further interviews or investigations into this incident because he had not thought it was necessary or a reportable incident at the time, but he stated now looking back, he felt like this incident should have been investigated further, and if he would have realized it was an unwitnessed fall with a major injury, he would have reported it within 2 hours. In an interview on 07/31/25 at 11:05 AM CNA-J stated she heard Resident #2 say there was a woman on the floor in his room. She stated no one questioned Resident #2 as to what happened to Resident#1 or how she ended up on the floor. CNA-J stated she did not remember exactly what she was doing at the time she was notified of the fall, but she believed she was either assisting or watching another resident. In an interview on 07/31/25 at 11:20 AM CNA-K stated she was could not remember what she was doing at the time, but believed she was at the nurses' station with the nurse because she remembered Resident #2 came out and told them at the same time Resident #1 had fallen in his floor. She stated she remembered seeing Resident #2 go in his room, but did not recall seeing Resident #1 go in Resident #2's room. She stated Resident #2 was in his room a minute or two before he came out to notify staff about Resident #1. In an interview on 08/19/25 at 10:09 AM ADON-A stated all residents in the locked unit have wandering behaviors, and this was why they were located on the locked unit, so they are monitored more closely and cannot exit the facility unattended. In an interview on 08/19/25 at 1:45 PM the DON stated he was not here when the fall occurred, but the facility called him to tell him Resident #1 had fallen and he called the Administrator to report there was a fall. He stated not all the residents in the locked unit wander, and if one CNA was off the floor doing patient care the other CNA or nurse was monitoring the hall. He also stated the staff monitor residents, if they attempt to go into the wrong room, staff would redirect them with things such as the tv room or activities to keep them entertained. The DON stated he was not sure how Resident #1 got missed by staff when she wandered into another resident's room on the night of 06/01/25. The DON stated he felt like 2 CNAs and one LVN were enough staff to monitor the locked unit, but he felt like it was more manageable at night because not as many residents wandered. He stated he did not remember interviewing the staff about where they were or what they were doing when Resident #1 entered Resident #2's room and had the fall. He also stated he felt like he should have interviewed and investigated this incident further. In an interview on 08/19/25 at 1:55 PM the Administrator stated he got a call and was told Resident #1 had fallen. He stated he was not sure where the CNAs or nurse were when the fall occurred because he never asked or interviewed the staff. The Administrator stated there were always 2 CNAs and a nurse on the locked unit, and the residents were free to move around the locked unit as they pleased. The Administrator stated if one of the CNAs was performing patient care, the other CNA was watching the hall, and if both the CNAs were busy, then the LVN steps forward to watch the hall. He stated he did have cameras back there, but he never went back and looked at the footage because at the time he was not investigating the fall, and he stated you cannot go back more than 72 hours, so he would not be able to review it now. The Administrator stated the staff get training upon hire on monitoring and handling dementia patients, as well as routine in-services, so they understand the concerns and needs of dementia patients. He also stated staff redirect the residents as needed, but he was unsure what redirection techniques were used. The Administrator stated he felt like 2 CNAs and 1 LVN were enough staff for the locked unit. In an interview on 08/19/25 at 6:09 PM CNA-K stated she remembered she was standing in the hallway talking to the nurse when Resident #2 stated a lady had fallen. She was not sure if CNA-J was standing with her and the nurse, or if she was doing something else. CNA-K stated she saw Resident #1 approximately 3 minutes prior to Resident #2 coming out of his room to notify them Resident #1 had fallen. She stated she was not sure how she missed seeing Resident #1 walk into Resident #2's room since they were standing in the hallway observing. CNA-K stated if she saw residents wandering around she would guide them back to the activities room or living room. CNA-K stated she felt like 2 CNAs and 1 LVN were enough staff to take care of the residents, and if one of the CNAs was doing patient care, the other was observing the residents in the hall, but if both CNAs were busy, the nurse would sit outside of the nurses desk in the hall so she was able to observe both ends of the hall. She also stated she recalled being in-serviced regarding monitoring and redirecting residents that wander. In an interview on 08/19/25 at 6:30 PM CNA-J stated she was at the nurses' station with CNA-K and LVN-I on the night of 06/01/2025 just chatting and talking about life in general. She stated she could see down both halls, so she was unsure how she missed Resident #1 walking into Resident #2's room. CNA-J stated it had only been a matter of minutes since she had last seen Resident #1 in the hallway, but she was unsure of how many minutes it had been. CNA-J stated Resident #1 was a quick walker and hard to keep up with sometimes, and she would redirect her often to keep her occupied or sometimes sit Resident #1 close to the nurses' station so as to keep a closer eye on her. CNA-J stated hanging out at the nurses' station and chatting maybe was not the best idea because they weren't as focused as they should have been on the residents. She also stated she recalled being in-serviced regarding monitoring and redirecting residents that wander. 08/20/25 at 1:05 PM Requested policy regarding staffing the locked unit, as well as a policy regarding monitoring and redirecting on the locked unit. Regional personnel and Administrator both stated there were no such policies, so this surveyor requested any general policies regarding staffing/adequate staffing, as well as any general policies regarding monitoring and redirecting residents. Both stated they would look for something. 08/20/25 at 2:00 PM the Administrator brought a policy regarding behavioral assessment, intervention and monitoring and stated this was all they had in regard to monitoring a resident. They did not have any other policy outlining staffing, monitoring, redirecting, or the locked unit in general. Record review of the facility's Wandering and Elopements policy, revised March 2019, revealed The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. IJ template and notification of immediacy was provided to both the Administrator and the DON on 08/20/2025 at 3:21 PM. Plan of Removal 08/20/2025Issue identified by surveyor: The facility failed to ensure the safety of Resident #1 by not providing consistent supervision to prevent Resident #1 from entering another resident's room on the secure unit, resulting in a fall with left femur fracture. Corrective Actions: **On 7/30/2025 LVN-I was terminated.**On 7/30/2025 the DON, ADON-A, and ADON-B in-serviced all direct care staff on the Fall Policy with focus on assessment after incident and including monitoring specific to the secure unit. Any new employee would be educated prior to start of shift.- One person conducts peri care while another was sitting in the hall monitoring the other residents.- Redirect residents back into activities room or living area when trying to enter other residents' rooms, and occupy them with a distraction (TV, coloring, games.)- Nurse should be positioned at the end of the nurse's station where she could visibly see down the hall when/if the CNAs were providing care.**On 7/30/2025, safe surveys were completed with residents by the DON and ADON. **On 7/30/2025, the Administrator and Director of Nursing were in-serviced on Reportable Guidelines, to include investigating all unwitnessed falls.**On 7/31/2025, all falls within the last 3 months were reviewed for documentation and assessment accuracy with no other issues noted.**On 7/31/2025, Ad Hoc QAPI was conducted with the Medical Director to review the plan of action and monitoring results will be reviewed monthly X 3 months in monthly QAPI.**On 7/31/2025 and going forward, all falls will be reviewed after morning meeting by the DON, the Administrator, ADON-A, and ADON-B to ensure a thorough assessment had been completed.**On 8/19/2025, 8 cameras were installed on the secure unit with a screen for viewing all angles of the hall at the nurse's station in the event the nurse was unable to position themselves at the end of the station.**On 8/20/2025, the IDT determined which residents were at highest risk of wandering into other rooms and care plans were updated to indicate on the Kardex for staff communication. Assessments would be conducted by DON/ADON/MDS nurses on admission, quarterly, and with a change of condition.**On 8/20/2025, the IDT in coordination with secure unit staff determined 4 residents required additional supervision due to daily redirection from other residents' room. Care Plan updated for supervision to hourly while awake and CNAs to document in the plan of care. **Starting 8/20/2025 the Administrator, the DON, or the ADON will round 3x a week for 3 months, and monthly thereafter, to ensure staff were effectively supervising residents.This plan of removal was developed, implemented, and completed as designed in this document. It was requested the Plan of Removal be accepted. Record review and verification of Plan of Removal implemented action performed 08/21/25: -On 07/30/25 LVN-I was terminated; verified by record review. -On 07/30/25 the DON and ADON in-serviced all direct care staff on the fall policy with a focus on assessment after incident and including monitoring specific to the secured unit; verified by record review of the in-service and staff signature page. -On 07/30/25 safe surveys were completed; verified by record review of the safe surveys completed. -On 07/30/25 the Administrator and the DON were in-serviced on Reportable Guidelines, to include investigating all unwitnessed falls; verified by record review of the e-mail containing the in-service. -On 07/31/25 a three-month review of all falls was reviewed for documentation and assessment accuracy. No tool was utilized. It was a discussion between the Administrator and the DON. -On 07/31/25 an Ad Hoc QAPI was conducted to review the plan of action; verified by record review of the QAPI signature page. -On 07/31/25 and moving forward, all falls are being reviewed after the morning meeting by the DON, the Administrator, and ADONs; no tool was being utilized to verify this process. It was being discussed after morning meetings. No fall assessments available at this time for review. -0n 08/19/25 8 cameras were installed on the secured unit with a monitor at the nurse's station for viewing all angles of the hall; surveyor verified by visually inspecting and observing all cameras and the monitor at the nurse's station. -On 08/20/25 the IDT determined 4 residents at highest risk for wandering and required additional supervision due to daily redirection; verified by reviewing the care plans for Residents #6, #7, #8, and #9 were updated to reflect hourly supervision while awake. -On 08/20/25 and moving forward, the Administrator, DON, or ADON will round three times per week for three months and monthly thereafter to ensure staff were effectively supervising residents; there was no tool being utilized to verify this, so unable to observe or verify. In an interview on 08/19/2025 at 10:09 AM, ADON-A stated all staff have been in-serviced regarding monitoring residents, fall policies and procedures, abuse and neglect, as well as procedures on providing appropriate supervision In an interview on 08/19/25 at 10:25 AM, CNA-O stated there were always two CNAs on the unit, and most of the residents on the locked unit wander. The CNAs and nurse watch up and down the halls to see who was wandering and tried to redirect them to either their room, the dining area, or the activity area. If one CNA was in a room providing assistance, the other CNA was in the hall monitoring the other residents. If they had to assist the other CNA with care, they inform the nurse to keep an eye on the residents in hall. If a resident had a fall or was found on the floor, the CNA would notify the charge nurse to assess them. Do not move the resident unless the nurse stated they were okay. CNA-L stated the staff try different things to keep the residents from wandering such as sit and do puzzles, read books, eat snacks, or watch television to occupy their mind and time. CNA-L stated she had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. In an interview 08/19/125 at 10:45 AM, CNA-P stated there was always someone monitoring the halls when the other staff were doing patient care, as well as the person from activities was there a lot during the daytime hours to do activities with many of the residents on the locked unit. CNA-M stated they do a lot of redirection while monitoring residents who wander, which could include sitting them in the tv area, or giving them a magazine or book, sometimes providing an activity such as a puzzle works as well, and many of them would sit to have a snack. CNA-M stated she had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. In an interview 08/19/125 at 10:55 AM, LVN-Q stated she had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. She stated most of the residents were easily redirected with things such as activities, snacks, television, radio, etc. She stated there was always someone watching the halls. If both CNAs had to be in a room providing care, the nurse was monitoring the halls, and if the nurse had to step away from the locked unit, the ADON or another nurse would monitor the unit until the nurse returns. In an observation on 08/19/25 at 1:30 PM it was revealed many of the residents on the locked unit were in the dining/common room doing activities with 1 staff from activities. There were 5 residents noted to be wandering in the hallways, but CNA's were monitoring and redirecting them as needed, and the charge nurse was seated at the nurse's station across from the living area where some residents were seated watching television. In an interview on 08/19/25 at 1:45 PM the DON stated there were always 2 CNAs and a nurse on the locked unit, and there was always at least one of the CNAs or nurses in the hallways observing at all times. If the two CNAs were busy providing patient care, the LVN steps forward, and if the LVN had to step off the locked unit, the ADON or another nurse would cover until they return. The DON stated most of the residents on the locked unit only needed one staff to assist with incontinent or patient care, so it rarely required both CNA's to be in a room together and off the hall at the same time, but if it did, they just notify the charge nurse, and the charge nurse monitored the halls until the CNAs returned. The DON stated staff had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. In an interview on 08/19/25 at 1:45 PM the Administrator stated there was always 2 CNAs and a nurse on the locked unit, and the residents were free to move around the locked unit as they pleased. He stated he would perform random spot checks which would always reveal one of the CNAs or nurses in the hallways observing any residents who may be wandering. The Administrator stated if both CNAs were busy performing patient care, then the charge nurse steps forward to monitor the halls. In an interview on 08/20/25 at 10:55 AM, LVN-R stated there were always at least two CNAs and the charge nurse on the locked unit, and many times during the day there were others such as the person from activities, or the DON or ADON rounding. He stated someone was always watching the hall, and if both CNAs must be in a room providing care, he was the one on the hall monitoring for residents who wander. He stated he had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. The Administrator was informed the Immediate Jeopardy was removed on 08/21/25 at 4:35 PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place.

Based on observations, interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to enforce the post-fall assessment policy leading to Resident #1 being moved from the floor to her wheelchair, and from her wheelchair to her bed after a fall while having severe pain and an obvious hip and leg deformity. The failure could affect residents currently residing in the facility, resulting in them not receiving the needed care to maintain optimal health and placing them at risk for injury or deterioration in their condition. The findings included: Record review of Resident #1's face sheet dated 07/31/25 revealed an [AGE] year-old female with an original admission date of 01/12/23 and a current admission date of 06/05/25. Pertinent diagnoses included Displaced Intertrochanteric Fracture of Left Femur (a common hip fracture which occurs in the upper part of the femur which typically requires surgical intervention); Other Abnormalities of Gait and Mobility, Dementia (a decline in cognitive function which affects daily life, memory, reasoning, and language skills), Alzheimer's Disease (the most common form of dementia, characterized by problems with memory, thinking, and behavior), and Blindness to the Left Eye. Record review of Resident #1's Fall Risk Evaluation dated 06/05/25 revealed a history of 1-2 falls in the past 3 months, regularly incontinent, requires use of assistive devices, and Resident #1 was considered high risk for potential falls. Record review of Resident #1's Quarterly MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 0 (severe cognitive impairment). Record review of Resident #1's care plan initiated 06/15/2023 and revised 07/25/25 revealed resident was at risk for falls related to gait and balance problems. Interventions included anticipate and meet the resident's needs, be sure call light was within reach, follow facility fall protocol, and evaluate and treat as ordered. Record review of Resident #1's care plan initiated 01/16/23 and revised 01/03/25 revealed resident was an elopement risk related to dementia, as evidenced by wandering around unit and into other residents' rooms. Interventions include distract resident from wandering, evaluate and screen quarterly for memory unit, redirect when wandering into other residents' rooms, and Resident #1 would reside in memory care unit for safety. Record review of Resident #1's care plan initiated 06/03/2025 revealed resident had an actual fall on 06/01/25. Interventions included continue post fall follow up x 72 hours, determined and addressed causative factors, and physical therapy to consult for strength and mobility. Record review of Resident #1's fall risk dated 03/04/25 revealed Resident #1 had a balance problem while standing and/or walking. Record review of Resident #1's progress noted dated 06/01/25, written by LVN-I, revealed a male resident came out of his room and said there was a woman in his room on the floor. Resident #1 was found on her left side, and two CNAs were called to room for assistance. The skin check was done, and there was a small hematoma to left brow. Resident #1 was in severe pain to left thigh. Staff assisted Resident #1 into wheelchair and assisted her to bed. Left leg was shorter than right leg. Record review of Resident #1's progress noted dated 06/01/25 revealed Resident #1's family member called to let the facility know Resident #1 had a hip fracture, and they were waiting to speak with Orthopedic Doctor regarding options. Record review of Resident #1's Hospital Summary - Orthopedic Discharge Instructions dated 06/05/25 revealed Resident #1 underwent open reduction with internal fixation (surgical procedure to repair broken bones) on 06/02/25. Pertinent information included per [daughter], [Resident #1] was found in another resident's room and had fallen. The Assessment and Plan portion of the hospital summary revealed unwitnessed fall. The Hospital Diagnoses portion of the hospital summary revealed unwitnessed fall. In an interview on 07/30/25 at 3:35 PM LVN-I stated she had not seen Resident #1 fall. She stated it was an unwitnessed fall, and another (male) resident had found her on the floor in his room. The male resident came out of his room and notified staff there was a woman on the floor in his room. She stated Resident #1 was having severe pain with facial grimacing and moaning. LVN-I stated she assessed Resident #1, and she was noted to have had some bruising, as well as a deformity in which one leg was noted to be longer than the other leg. She then had two CNAs assist her with getting Resident #1 up and to the wheelchair, then to the bed in her room, and notified provider and EMS. LVN-I stated severe pain and a deformity with the hip and leg could mean an injury or possible fracture, and the resident should not have been moved because movement could possibly have made the injury worse. In an interview on 07/30/25 at 3:48 PM ADON-A stated Resident #1's fall on 06/01/25 with a hip fracture was the most recent fall, and she had not had any other recent falls. ADON-A stated she was informed another resident walked in and found Resident #1 on the floor in his room. She stated she only knew what she had read about the fall from LVN-I's progress note, and Resident #1 had severe pain, the left leg was shorter than the right leg, and the staff moved Resident #1 to the wheelchair and then to the bed. ADON-A stated Resident #1 should not have been moved, but assessed for injuries, vital signs checked, neuro checks started, and the nurse should have checked to see if she had anything for pain. The nurse should have kept her there on the floor and not moved her until EMS arrived to evaluate and stabilize her. LVN-I should have notified the on-call for the facility, the DON, the Administrator, and the family. She stated if the resident was moved while having severe pain and a leg deformity, indicating a major injury, this could cause further injury to the resident. In an interview on 07/30/25 at 4:21 PM the DON stated Resident #1's fall was reported to him during the morning meeting the next morning. He stated LVN-I reported to whomever was on-call the night of the fall, then it was discussed at the morning meeting the next morning. The DON stated he went over clinical needs and reviewed the incidents and accidents in the morning meetings. He stated what he knew about the fall was Resident #1 entered another resident's room, and the other resident reported Resident #1 had fallen. He also stated LVN-I assessed Resident #1 for pain. He stated if Resident #1 was identified to have had an injury, then moving her might have exacerbated the injury. He stated the protocol for falls included body and skin assessment, vital sign assessment, neuro checks, and if any abnormalities were noted, she should not have been moved until EMS arrived to evaluate. If a fall was unwitnessed the administrator should have been notified, and he would have then determined the next step. The DON stated Resident #1's fall was reported to the administrator in the morning meeting as well, but he and the administrator both assumed it was a witnessed fall because they interpreted the note as there was a resident in the room with Resident #1 when she fell, and they did not feel it needed to be investigated any further or reported to the state. In an interview on 07/30/25 at 4:45 PM the Administrator stated he remembered an incident report was done, and Resident #1 had a fracture from the fall. He stated another resident reported there was a lady on the floor. The other resident had found her on the floor and she had a fall. The Administrator stated he did not recall who reported it to him, but it would have been reported and discussed in the morning clinical meeting. He also stated he did not consider this a reportable type of incident as he did not believe it was an unwitnessed fall, but he did state unwitnessed falls with major injuries would be reported. The Administrator stated he had not done any further interviews or investigations into this incident because he had not thought it was necessary at the time. He also stated it was probably questionable as to whether or not the resident who reported the fall was competent enough to answer questions with a BIMS of 3, which indicated severely impaired cognition. The Administrator stated now looking back he felt like this incident should have been investigated further, and if he would have realized it was an unwitnessed fall with a major injury, he would have reported it within 2 hours. In an interview on 07/31/25 at 8:32 AM ADON-S stated she was the one who did fall trending and tracking as well as fall investigations. She stated Resident #1 had only had 1 fall this year, and it was this unwitnessed fall with a major injury. ADON-A stated she completed her report based on the note written by the nurse, and according to the documentation, the nurse called the DON and reported fall. ADON-A state she followed up with the resident and nurse post fall, and LVN-I told her Resident #1 was found in floor, and after assessing Resident #1, LVN-I asked the CNAs to transport Resident #1 to the wheelchair and then to her bed. ADON-A stated LVN-I should not have moved Resident #1 while in severe pain or after noting one leg was longer than the other because it could have meant there was a fracture or major injury, and movement could have caused further injury. In an interview on 07/31/25 at 11:05 AM, CNA-J stated she heard the male resident say there was a woman on the floor in his room. She stated no one questioned the male resident as to what happened Resident#1 and how she ended up on the floor. CNA-J stated LVN-I went and assessed the Resident #1 while she was lying on the floor, and Resident #1 kept moaning and groaning in pain as well as making faces like she was in severe pain. She stated the LVN-I never said anything to about one leg being longer than the other, so both CNAs assumed it was okay to move Resident #1. CNA-J stated she realized moving a resident with an injury could make it worse. Record review of an all-staff in-service dated 04/30/25 revealed a fall is signified as any break in plane regardless of where the patient lands. If a resident fall occurred it must be immediately reported to the charge nurse so they can assess resident and situation and determine if resident is safe to move or transfer, then incident report must be completed by charge nurse. Record review of the facility's Fall, and Fall Risk, Managing Policy, revised March 2018, revealed Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The staff will implement a fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the appropriate State Agency, but no later than 2 hours after the allegation was made, for 1 of 5 Residents (Resident #1) reviewed for reporting allegations of abuse and/or neglect. The facility failed to report Resident #1's fall with a major injury on 06/01/25 in which Resident #1 sustained a left hip fracture. State Agency was not notified of the fall with injury. This failure could result in placing residents at increased risk for not receiving a proper or thorough investigation. The findings included: Record review of Resident #1's face sheet dated 07/31/25 revealed an [AGE] year-old female with an original admission date of 01/12/23 and a current admission date of 06/05/25. Pertinent diagnoses included Displaced Intertrochanteric Fracture of Left Femur (a common hip fracture which occurs in the upper part of the femur which typically required surgical intervention); Other Abnormalities of Gait and Mobility, Dementia (a decline in cognitive function which affects daily life, memory, reasoning, and language skills), Alzheimer's Disease (the most common form of dementia, characterized by problems with memory, thinking, and behavior), and Blindness to the Left Eye. Record review of Resident #1's care plan initiated 06/15/2023 and revised 07/25/25 revealed resident was at risk for falls related to gait and balance problems. Interventions included anticipate and meet the resident's needs, follow facility fall protocol, and evaluate and treat as ordered. Resident #1's care plan initiated 01/16/2023 and revised 01/03/2025 revealed Resident was an elopement risk as evidenced by wandering; interventions included distracting Resident #1 from wandering by offering diversions, structured activities, food, conversation, television, books, and/or listening to the radio in her room. Other interventions included Resident #1 would be redirected when wandering into other residents' rooms or as needed, and Resident #1 would reside in memory care unit for safety. Resident #1's care plan also included the actual fall on 06/01/25 with serious injury. It was initiated on 06/03/25. Interventions included determine and address causative factors of the fall. Record review of Resident #1's Quarterly MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 00 (severe cognitive impairment). This MDS revealed no falls since admission, entry, reentry, or prior assessment. Record review of Resident #1's Quarterly MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 0 (severe cognitive impairment). This MDS revealed fall with major injury requiring surgical intervention. There was no provider investigation or internal investigation for the fall of the unsupervised Resident #1 done by the facility, so there was no review done of a provider or facility investigation. Record review of Resident #1's Fall Risk Evaluation dated 03/04/25 revealed Resident #1 wanders; no falls in past 3 months; regularly incontinent; balance problem while standing/walking. Resident was considered High Risk for falls. Record review of Resident #1's progress note dated 06/01/25, written by LVN-I, revealed a male resident came out of his room and said there was a woman in his room on the floor. Resident #1 was found on her left side, and two CNAs were called to room for assistance. There was a small hematoma to left brow. Resident #1 was in severe pain to left thigh. Staff assisted Resident #1 into wheelchair and assisted her to bed. Left leg was shorter than right leg. Record review of Resident #1's Hospital Summary - Orthopedic Discharge Instructions dated 06/05/25 revealed Resident #1 underwent open reduction with internal fixation (surgical procedure to repair broken bones) on 06/02/25. Pertinent information included per [family member], [Resident #1] was found in another resident's room and had fallen. The Assessment and Plan portion of the hospital summary revealed unwitnessed fall. The Hospital Diagnoses portion of the hospital summary revealed unwitnessed fall. In an interview on 07/30/25 at 3:35 PM LVN-I stated she had not seen Resident #1 fall. She stated it was an unwitnessed fall, and Resident #2 had found Resident #1 on the floor in his room. LVN-I stated Resident #1 had severe pain with facial grimacing and moaning, and when she assessed Resident #1 she was noted to have had some bruising as well as a deformity in which one leg was noted to be longer than the other leg. She stated two CNAs assisted her with getting Resident #1 up and to the wheelchair, then to the bed in her room, then notified provider and EMS. LVN-I stated she notified the facility on-call number (the afterhours number to be notified) of the fall like she was supposed to, as well as documented the fall in Resident #1's chart. In an interview on 07/30/25 at 3:48 PM ADON-A stated Resident #1 had not had any other recent falls since 09/04/24 in which she had wandered into another resident's room and had a fall. She also stated she only knew what she had read about the fall from LVN-I's progress note as an investigation had not been done. ADON-A stated she had discussed Resident #1's fall with the DON, and an incident report had been done, but an investigation was not done. She stated the DON and Administrator determine if an investigation should be completed and if an incident was considered a reportable incident. In an interview on 07/30/25 at 4:21 PM the DON stated Resident #1's fall was reported to him during the morning meeting the next morning. The DON stated he did not further investigate the incident after he was made aware. The DON also stated he did not investigate the staffing supervision at the time of the incident. He also stated LVN-I reported to whomever was on-call the night of the fall, then it was discussed at the morning meeting the next morning, in which he went over clinical needs and reviewed the incidents and accidents. The DON stated Resident #1's fall was reported to the administrator in the morning meeting as well, but he and the administrator both assumed it was a witnessed fall because they interpreted LVN-I's progress note as there was a resident in the room with Resident #1 when she fell, and they did not feel it needed to be investigated any further or reported to the state. In an interview on 07/30/25 at 4:45 PM the Administrator stated he remembered an incident report was done, and Resident #1 had a fracture from the fall. He stated Resident #2 had reported there was a lady on his floor, and Resident #2 had found her on the floor. The Administrator stated he did not conduct an investigation regarding the supervision of the staff or how the fall occurred, and he had not done any further interviews or investigations into this incident because he had not thought it was necessary or a reportable at the time, but he stated now looking back he felt like this incident should have been investigated further, and if he would have realized it was an unwitnessed fall with a major injury, he would have reported it within 2 hours. The administrator stated unwitnessed falls with major injuries should always be reported, and he was the person who should have, and typically did, report incidents to the state. The Administrator stated there was no specific policy on how or what to report, but he followed the stated and CMS guidelines on how and what to report. Record Review of the Long-Term Care Regulation Provider Letter, issued 08/29/2024, revealed 2.1 Incidents that a NF must report to HHSC: A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect, Suspicious injuries of unknown source, and/or Emergency situations that pose a threat to resident health and safety. When to report: Immediately, but not later than two hours after the incident occurs or is suspected.

Based on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and measures were taken to prevent further potential abuse, neglect, exploitation or mistreatment in accordance with State law, and if the alleged violation was verified appropriate, corrective action must have been taken for 1 (Resident #1) of 5 residents reviewed for abuse, neglect, and/or misappropriation. The facility failed to do a thorough investigation to include interviewing Resident #1, as well as other residents or staff which may have been involved in or witnessed the incident. This failure placed residents at risk of not having their allegations investigated thoroughly or timely. The findings included: Record review of Resident #1's face sheet dated 07/31/25 revealed an [AGE] year-old female with an original admission date of 01/12/23 and a current admission date of 06/05/25. Pertinent diagnoses included Displaced Intertrochanteric Fracture of Left Femur (a common hip fracture which occurs in the upper part of the femur which typically requires surgical intervention); Other Abnormalities of Gait and Mobility, Dementia (a decline in cognitive function which affects daily life, memory, reasoning, and language skills), Alzheimer's Disease (the most common form of dementia, characterized by problems with memory, thinking, and behavior), and Blindness to the Left Eye. Record review of Resident #1's Quarterly MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 0 (severe impairment). Record review of Resident #1's care plan initiated 06/15/2023 and revised 07/25/25 revealed resident was at risk for falls related to gait and balance problems. Interventions included anticipate and meet the resident's needs, be sure call light was within reach, follow facility fall protocol, and evaluate and treat as ordered. Record review of Resident #1's care plan initiated 01/16/23 and revised 01/03/25 revealed resident was an elopement risk related to dementia, as evidenced by wandering around unit and into other residents' rooms. Interventions included distract resident from wandering, evaluate and screen quarterly for memory unit, redirect when wandering into other residents' rooms, and Resident #1 would reside in memory care unit for safety. Record review of Resident #1's care plan initiated 06/03/2025 revealed resident had an actual fall on 06/01/25. Interventions included continue post fall follow up x 72 hours, determined and addressed causative factors, and physical therapy to consult for strength and mobility. Record review of Resident #1's fall risk dated 03/04/25 revealed Resident #1 had a balance problem while standing and/or walking. Record review of Resident #1's progress noted dated 06/01/25, written by LVN-I, revealed a male resident came out of his room and said there was a woman in his room on the floor. Resident #1 was found on her left side, and two CNAs were called to room for assistance. The skin check was done, and there was a small hematoma to left brow. Resident #1 was in severe pain to left thigh. Staff assisted Resident #1 into wheelchair and assisted her to bed. Left leg was shorter than right leg. Record review of Resident #1's progress noted dated 06/01/25 revealed Resident #1's family member called to let the facility know Resident #1 had a hip fracture, and they were waiting to speak with Orthopedic Doctor regarding options. Record review of Resident #1's Hospital Summary - Orthopedic Discharge Instructions dated 06/05/25 revealed Resident #1 underwent open reduction with internal fixation (surgical procedure to repair broken bones) on 06/02/25. Pertinent information included per [family member], [Resident #1] was found in another resident's room and had fallen. The Assessment and Plan portion of the hospital summary revealed unwitnessed fall. The Hospital Diagnoses portion of the hospital summary revealed unwitnessed fall. In an interview on 07/30/25 at 3:35 PM LVN-I stated she had not seen Resident #1 fall. She stated it was an unwitnessed fall, and another (male) resident had found her on the floor in his room. The male resident came out of his room and notified staff there was a woman in the floor in his room. She stated Resident #1 was having severe pain with facial grimacing and moaning. LVN-I stated she assessed Resident #1, and she was noted to have had some bruising, as well as a deformity in which one leg was noted to be longer than the other leg. She then had two CNAs assist her with getting Resident #1 up and to the wheelchair, then to the bed in her room, and notified provider and EMS. LVN-I stated severe pain and a deformity with the hip and leg could mean an injury or possible fracture, and the resident should not have been moved because movement could possibly have made the injury worse. She stated she notified the facility on-call of the fall, as well as documented it. In an interview on 07/30/25 at 3:48 PM ADON-A stated Resident #1's fall on 06/01/25 with a hip fracture was the most recent fall, and she had not had any other recent falls. ADON-A stated she was informed another resident walked in and found Resident #1 on the floor in his room. She stated she only knew what she had read about the fall from LVN-I's progress note, and Resident #1 had severe pain, the left leg was shorter than the right leg, and the staff moved Resident #1 to the wheelchair and then to the bed. ADON-A stated Resident #1 should not have been moved, but assessed for injuries, vital signs checked, neuro checks started, and the nurse should have checked to see if she had anything for pain. The nurse should have kept her there on the floor and not moved her until EMS arrived to evaluate and stabilize her. LVN-I should have notified the on-call for the facility, the DON, the administrator, and the family. She stated if the resident was moved while having severe pain and a leg deformity, indicating a major injury, this could cause further injury to the resident. In an interview on 07/30/25 at 4:21 PM the DON stated Resident #1's fall was reported to him during the morning meeting the next morning. He stated LVN-I reported to whomever was on-call the night of the fall, then it was discussed at the morning meeting the next morning. The DON stated he went over clinical needs and reviewed the incidents and accidents in the morning meetings. He stated what he knew about the fall was Resident #1 entered another resident's room, and the other resident reported Resident #1 had fallen. He also stated LVN-I assessed Resident #1 for pain. He stated if Resident #1 was identified to have had an injury, then moving her might have exacerbated the injury. He stated the protocol for falls included body and skin assessment, vital sign assessment, neuro checks, and if any abnormalities were noted, she should not have been moved until EMS arrived to evaluate. If a fall was unwitnessed the administrator should have been notified, and he would have then determined the next step. The DON stated Resident #1's fall was reported to the administrator in the morning meeting as well, but he and the administrator both assumed it was a witnessed fall because they interpreted the note as there was a resident in the room with Resident #1 when she fell, and they did not feel it needed to be investigated any further or reported to the state. In an interview on 07/30/25 at 4:45 PM the Administrator stated he remembered an incident report was done, and Resident #1 had a fracture from the fall. He stated another resident reported there was a lady on the floor. The other resident had found her on the floor and she had a fall. The Administrator stated he did not recall who reported it to him, but it would have been reported and discussed in the morning clinical meeting. He also stated he did not consider this a reportable type of incident as he did not believe it was an unwitnessed fall, but he did state unwitnessed falls with major injuries would be reported. The Administrator stated he had not done any further interviews or investigations into this incident because he had not thought it was necessary at the time. He also stated it was probably questionable as to whether or not the resident who reported the fall was competent enough to answer questions with a BIMS of 3, which indicated severely impaired cognition. The Administrator stated now looking back he felt like this incident should have been investigated further, and if he would have realized it was an unwitnessed fall with a major injury, he would have reported it within 2 hours. The Administrator stated there was no specific policy on how or what to report, but he followed the stated and CMS guidelines on how and what to report. In an interview on 07/31/25 at 8:32 AM ADON-S stated she was the one who did fall trending and tracking as well as fall investigations. She stated Resident #1 had only had 1 fall this year, and it was this unwitnessed fall with a major injury. ADON-A stated she completed her report based on the note written by the nurse, and according to the documentation, the nurse called the DON and reported the fall. ADON-A stated she followed up with the resident regarding post-fall questions and the reporting nurse, and LVN-I told her Resident #1 was found in floor, and after assessing Resident #1, LVN-I asked the CNAs to transport Resident #1 to the wheelchair and then to her bed. ADON-A stated LVN-I should not have moved Resident #1 while in severe pain or after noting one leg was longer than the other because it could have meant there was a fracture or major injury, and movement could have caused further injury. In an interview on 07/31/25 at 11:05 AM, CNA-J stated she heard the male resident say there was a woman on the floor in his room. She stated no one questioned the male resident as to what happened to Resident#1 and how she ended up on the floor. CNA-J stated LVN-I went and assessed the Resident #1 while she was lying on the floor, and Resident #1 kept moaning and groaning in pain as well as making faces like she was in severe pain. She stated the LVN-I never said anything to about one leg being longer than the other, so both CNAs assumed it was okay to move Resident #1. CNA-J stated she realized moving a resident with an injury could make it worse.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 2 of 2 nutrition rooms for storage, preparation, and sanitation. The facility failed to use internal thermometers in 2 freezers. The facility failed to maintain cleanliness of shelves, the ice machine, coffee cups, and microwave oven throughout the kitchen. The facility failed to follow a proper cleaning schedule. The facility failed to ensure kitchen utensils were in good working order. The facility failed to ensure dented holding pans were not in use and on the clean rack. The facility failed to ensure the dumpster side doors were kept closed. The facility failed to ensure all containers of food in the refrigerator was labeled. The facility failed to ensure boxes of food were not stacked too close to the ceiling in the walk-in refrigerator. The facility failed to ensure personal items were not on the shelves with dry storage items and canned goods. The facility failed to ensure male staff members with beards and mustaches were wearing their beard guards correctly. The facility failed to ensure a kitchen staff member washed his hands after touching his phone and beard guard before returning to prep in the kitchen. The facility failed to ensure the items in the resident nutrition refrigerators in the 100-hall and 200-hall medication rooms were labeled and dated. The facility failed to maintain one oven door in good working order. The facility failed to maintain proper water temperatures for the dishwashing machine, 3-compartment sink, sanitizer sink, and hand washing sink. These failures could place residents who received meals and/or snacks from the kitchen at risk for food contamination, weight loss, and food borne illness. Findings included: Observation and initial tour of the kitchen on 03/04/25 at 8:35 am revealed no internal thermometers in the 3-door freezer or the chest type supplement freezer. The microwave oven a had thick baked on dark brown substance in a splattered pattern on the inside. There was large a wooden handled spatula that had multiple splinters chaffing off the handle. There was a large rubber spatula with pieces missing around the edges. There were 4 heavily dented holding pans in use. The underside of the shelf directly over the stove had a flaking dark red and brown substance. The ice machine had a removable brownish substance on the ice chute. There were dirty cups on a cart used for serving. 2 of 2 dumpsters had the side doors open. The handle on the right side of the oven was loose. There were roaches in the upper mechanical part of the ice machine. The dishwashing machine, 3-compartment sink, sanitizer sink, and hand washing sink were below temperature at 90-100 degrees. Observation and re-visit to the kitchen on 03/05/25 at 9:15 am revealed 1 of 3 containers of food in the refrigerator was dated but not labeled. 5 dented pans remained on a clean rack. 2 large boxes of food were approximately 8 inches from the ceiling in the walk-in refrigerator. There were multiple personal items on the shelves with dry storage items and canned goods: 1 purse, 1 backpack, 3 used aprons, 3 hoodies, a partially full and opened 16-ounce bottle of water, and a thin, tin box of colored pencils. 2 male staff members with beards and mustaches were wearing their beard guards under their chins, exposing their facial hair. 1 staff member did not wash his hands after touching his phone and beard guard before returning to prep in the kitchen. 2 of 2 dumpsters had the side doors open. Observation of the resident nutrition refrigerator in the 100-hall medication room on 03/06/25 at 8:40 am revealed a large partial tray of store-bought sandwiches that was unlabeled and undated. Observation of the resident nutrition refrigerator in the 200-hall medication room on 03/06/25 at 8:44 am revealed two large disposable boxes of food from a local restaurant that were unlabeled and undated. In an interview with the DM on 03/04/25 at 8:45 am, she said she did not know where the thermometers for the freezers were. She said she knew the thermometers were in there, but a shipment was coming today and the staff must have taken them out. She said staff was using the external digital thermometers on the 3-door freezer. She said she was not aware of the dirty microwave or spatulas. She said the microwave should have been cleaned as soon as whoever saw it that way. She said the wood on the spatula was coming off, could get in the food and make residents sick or get stuck in their teeth. She said the rubber spatula had pieces missing from the edges and probably got in the food because the rubber spatula was only used for the pureed foods in the puree machine. She said the holding pans had a lot of dents in them. She said the crevasses could harbor bacteria, which would get in the food and could make residents sick. She said the shelf above the stove was pretty dirty. She ran her fingers on the underside of the shelf and had bits of dark red and black flakes on her fingers. She said the substances were probably rust, could get into the food, and make residents sick or get in their teeth. She said she had cleaned the ice machine not too long ago but could not say when. She said the removable brownish substance on the ice chute was mold. She said the dirty cups were on the serving tray. She said the process for reporting equipment that needed to be repaired or replaced was for her to place the request in the facility's electronic reporting system, the MS received a text, and all requests were discussed in the daily morning meetings. She said staff were following a cleaning schedule, but did not have one posted and said my cleaning schedules are a mess. The DM said she had been trying to get the handle on the oven door fixed for several weeks. She said the water in the kitchen had not been hot enough since they caught it Sunday 03/02/25. Temperature logs for the last 2 weeks were requested at this time. She said they would start using disposable dishes today. In an interview and re-visit to the kitchen with the DM on 03/05/25 at 9:40 am, she identified a container of egg salad in the refrigerator that was not labeled and the use by date was today. She said the dented pans were not supposed to be in use because they were identified yesterday. She said she would have an in-service including dented pans. She said the boxes in the walk-in refrigerator were supposed to be 18 inches from the ceiling because they could block the sprinklers and become a fire hazard. She said personal items were not allowed in the dry storage area she identified as the emergency food closet. She said staff were supposed to use the hangers behind the door of the closet that was easier to get to than the shelves. She said she had told staff Over and over about this (personal items on the shelves). She said she had in serviced and trained staff about proper use of hair nets and beard guards, handwashing, and personal items. Cleaning schedules, facility policies for safe equipment, Proper disposal of trash, food storage and temperatures, in-services/training, and electronic request logs, were requested at this time. In an interview with DA 1 on 03/05/25 at 9:50 am, she said the purse and one of the hoodies in the emergency food closet belonged to her. She said personal items were not supposed to be stored on the shelves of the emergency food closet or any dry storage area because of cross contamination and make other staff and resident's sick. She said the food she and others touched would have to be thrown away. She said she had been trained on where to store personal items, which was behind the door approximately 2 feet away from the shelves. In an interview with DA 2 on 03/05/25 at 9:55 am, he said the backpack, water, and one of the hoodies belonged to him. He said personal items were not supposed to be stored on the shelves of the emergency food closet because outside items mixed with kitchen items could cause cross contamination and make other staff and resident's sick. He said he had been trained on where to store personal items, which was on the door approximately 2 feet away from the shelves. He said he washed his hands before and after he entered the area where his personal items were kept. In an interview and observation with DA 3 on 03/05/25 at 10:00 am revealed his beard guard was under his chin, exposing his facial hair. He was standing over the main prep table in the kitchen and using his phone with bare hands. He said he forgot to put his beard and mustache guard up because it did not fit properly over his nose. He said exposed hair of any kind could cause cross contamination and make other staff and resident's sick. He said he had been trained on where to store personal items, which was on the door approximately 2 feet away from the shelves in the emergency food closet. He was observed returning to the prep table without washing his hands after touching his face and his phone. In an interview with the MS on 03/05/25 at 3:30 pm, he said the process for reporting kitchen repairs or problems was the problem would be entered into the facility electronic reporting system. He said the ADM, himself, and corporate got a text alert from the electronic reporting system. He said he followed weekly and monthly tasks to stay prioritized. He said it was a collective effort to keep the dumpster doors closed and pick up trash around the dumpster. He said the side doors were to be closed at all times when not in use. The MS said the process for reporting kitchen repairs or problems was the problem would be entered into the facility electronic reporting system. He said the ADM, himself, and corporate got a text alert from the electronic reporting system. He said he followed weekly and monthly tasks to stay prioritized. He said he had work orders for the AC returns. He said one of the 4 water heaters was dedicated to the kitchen, 2 were dedicated to the halls. He said the 4th one was out of commission, and they were trying to source one or get a new one. In an interview with ADON F on 03/06/25 at 8:48 am, she said all items in the resident refrigerators should be dated and labeled with the resident's names. She said she did not know how long the tray of store-bought sandwiches had been in the 100-hall resident refrigerator or who might have put it there. She said the food containers in the 200-hall resident refrigerator should not have been in there if it belonged to a staff member. She said cross contamination of outside unlabeled and undated food items could occur with resident items, and potentially make the residents sick. In an interview with the ADM on 03/06/25 at 4:00 pm, he said he was notified Sunday (03/02/25) regarding the water temperature in the kitchen. He said one of the water heaters had a leak. He said the plumber came out Monday (03/03/25) and said the water heater was fine. The ADM said he checked the water heater after the plumber and that was when he found the water heater was not heating. The ADM said he called the plumber to the facility to check the water heater. The ADM said he did not check the water temperature in the kitchen on Monday (03/03/25). He said paper dishes were used on Monday because the water had not been hot enough to sanitize dishware and could make the residents sick. Record review of the facility's undated Competency Checklist- Dishwasher revealed each dietary personnel received the training and were deemed competent in the following areas: Sanitation, meal service, dishroom, and kitchen safety. Record review of the facility's undated Competency Checklist- [NAME] revealed each dietary personnel received the training and were deemed competent in the following areas: Sanitation, meal service, menus, food orders, and kitchen safety. Record review of the facility's undated Competency Checklist- Dietary Aide revealed each dietary personnel received the training and were deemed competent in the following areas: Sanitation, meal service, menus, food preparation/service, and kitchen safety. Record review of the facility's In-Service Log revealed all dietary personnel received the following in-service and each staff person signed the in-service that indicated receiving the in-service and understanding: 01/03/25 - Topic: Sanitation, uniforms, eating in kitchen 02/05/25 - Fire extinguisher and fire safety 02/07/25 - Cleaning and sanitation, state readiness 02/18/25 - Timeliness and attendance Record review of the undated facility's Orientation/Pre-Survey In-service Checklist revealed all dietary personnel were provided the in-service regarding the following topics: Review menu, Tray line sanitation/Tray line Service, Pot and pan sink, Dishwasher, Food storage, Food preparation, and Meal service. Record review of the facility's Daily and weekly cleaning schedules dated 01/01/25-01/31/25 included a 25-task list including can opener, food processsor, cutting boards, prep tables/countertops, beverage table, coffee ursn, pots and pans, stovetop/grill, floor, microwave, handwashing sink, and pot and pan sink. All tasks for all days of the month were checked off as having been done. Record review of the facility's Daily and Weekly cleaning schedules dated 02/03/25-03/01/25 included a 26-task list including for mornings: dining room tables, juice dispenser, tea dispenser, coffee dispenser, thickened beverage dispenser, condiment/silverware bins, ice machine/scoop, 200-hall nutrition refrigerator, ice chest, service doors, and condiment holders. The morning schedule indicated no tasks were done on 02/03, 02/04, 02/06, 02/07, 02/08, or 02/09. For evenings: service carts and trays, dishroom, garbage cans and lids, hand sinks/soap/papertowels, service hall/back dock area, dishroom sinks, floors, mop bucket, mops, dry storage area, storeroom floor, water pitchers, drains, and dishmachine filters. The schedule indicated no tasks were done for 02/03, 02/07, and 02/08. Partial tasks were done the other days of the week for mornings and evenings. Record review of the undated facility kitchen document titled, Policy and Procedure Manual-General HACCP (Hazard Analysis Critical Control Point) Guidelines for Food Safety Ch. 3:Food Production and Safety pg. 3-18 revealed under 9.Refrigerator/Freezer Temperatures a. Take the internal temperatures of each unit. 10. A. Be sure the wash and rinse temperatures are appropriate for the dish machine (Low Temp Type). Under Food Storage pg. 3-22 9. Food will be stored a minimum of 6 inches above the floor, 18 inches from the ceiling, and 2 inches from the wall with adequate space on all sides of stored items to permit ventilation. Racks and other storage surfaces will be clean and protected from splashes, overhead pipes, or other contamination (ceiling sprinklers .etc.) pg. 3-23 11. Leftover food will be stored in covered containers. Each item will be clearly labeled and dated before being refrigerated. 12. Refrigerated food storage: c. Every refrigerator must be equipped with an internal thermometer. F. All foods should be covered, labeled, and dated. Ch. 4 pg. 4-1:Food Safety and Sanitation 2. Employees a. All staff will be in good health, will have clean personal habits and will use safe food handling practices. C. Hair restraints are required and should cover all hair on the head. [NAME] nets are required when facial hair is visible. D. Employees will wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom, handling dirty dishes, touching face, hair, other people or surfaces or items with potential for contamination. Pg. 4-2 Food Storage a. stored food is handled to prevent contamination and growth of pathogenic organisms. Food is protected from contamination (dust, flies, rodents, and other vermin). Pg. 4-29 Pest Control under policy: .Appropriate action will be taken to eliminate any reported pest situation in the department. Pg. 4-21 Dry Storage areas under Policy: Dry storage areas will be maintained to keep food safe and free of infestation or contamination. 4. Ceilings must be free from water .to protect the food from leaking pipes, heat, or contamination. Pg. 4-4 Employee Sanitary Practices under Policy: All food and nutrition services employees will practice good personal hygiene and safe food handling procedures. 1. Wear hair restraints (hairnet, hat, and/or beard restraint to prevent hair from contacting exposed food. 2. Wash hands before handling food .6. Avoid touching mouth or face while preparing food and wash hands if contaminated. food storage, personal items, nutrition rooms under section 10. Dishwashing a. Be sure the wash and rinse temperatures are appropriate for the dish machine. Record review of facility kitchen policy revised 09/16/16, titled, Food-Related Garbage and Rubbish Disposal 7. Outside dumpsters provided by garbage pick up services will be kept closed . Record review of the facility's undated Competency Checklist- Diet Aide/Wait Staff/Hostess revealed each dietary personnel received the training and were deemed competent in the following areas: sanitation, meal service, specific approved and corporate menus, food preparation/service, and kitchen safety. Record review of the facility's Personal Hygiene and Health Reporting Chapter 4: Sanitation and Infection Control 4-7 policy and procedure dated 03/05/25 reflected Policy: All food and nutrition services employees will be trained on appropriate personal hygiene and health reporting 5. Hair should be neat and clean. Hair restraints must be worn around exposed foods, in the kitchen or food service areas and dining areas. 6. [NAME] and mustaches should be closely cropped and neatly trimmed. When around exposed foods, beards must be restrained using beard covers .9. Hands should be washed in the designated hand washing sinks . References: FDA Food Code 2022 Ch. 2-4 Hygienic Practices 2-401 Food Contamination Prevention 2-401.11 Eating, Drinking, or Using TOBACCO PRODUCTS an EMPLOYEE shall eat, drink, or use any form of TOBACCO PRODUCTS only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES; or other items needing protection cannot result. (B) A FOOD EMPLOYEE may drink from a closed BEVERAGE container if the container is handled to prevent contamination of: (1) The EMPLOYEE'S hands; (2) The container; and (3) Exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Ch. 3-305 Preventing contamination from the premises 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Ch. 4-202 Cleanability 4-202.11 Food-Contact Surfaces. (A)Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; 501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. (C) Except as specified in (D) of this section, if used with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned throughout the day at least every 4 hours.

Based on interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 eloped from the facility at night. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. The noncompliance was identified as Past Non-Compliance. The IJ began on 12/18/23 and ended on 12/18/2023. Verifcation of corrections ended on 12/22/2023. The facility had corrected the noncompliance before the investigation began. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Alzheimer's Disease (brain condition that causes a progressive decline in memory, thinking, learning, and organizing skills), Dementia (cognitive decline in a person's ability to perform everyday activities), bipolar disorder (periods of depression and periods of abnormally elevated mood), personality disorder (disruptive patterns of thinking, behavior, and mood), Chronic Obstructive Pulmonary Disease, and heart disease. Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 4 (Severe Impairment) and required Partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting, transfers dressing, bathing and Resident #1 utilized a manual wheelchair. Record review of Resident #1's quarterly Wandering assessment dated [DATE] reflected Resident #1 was not a wandering risk. Care Plan dated 12/21/2021 reflected Resident #1 was at risk for falls related to poor safety awareness, and history of falls. Resident # 1 had impaired cognitive function and impaired thought processes related to alzheimers, dementia, and CVA (cerecrocascular Accident/ Stroke). Record review of Resident #1's nursing documentation dated 12/18/2023 at 4:17AM by LVN A reflected: SN received a call from local hospital in regards of resident (Resident #1) being at the ER due to resident being spotted by law enforcement and picked up by the ambulance at an unknown location away from the facility. The ER physician informed SN that the resident was not in any distress and no injuries were noted to the resident's body upon arrival, and the resident was to be sent back to facility shortly. When asked how the incident occurred, the resident stated I don't remember as he smiled and laughed. The DON and Administrator were immediately notified. The staff were instructed to check all rooms in the facility to account for all residents and to ensure that all doors were locked, and alarms were set and working correctly, and for the resident to be transferred to 300-hall (secured unit) as an extra precaution upon the resident's return to facility. The resident returned to facility 2:20 AM on this day, 12/18/2023. A head to toe assessment performed by the SN. No s/s of distress noted. Vitals WNL. The resident resumed to original function and mobility. No visible injuries were noted. No new or abnormal markings noted to the resident's body. Resident denies any pain/discomfort. The resident assisted into clean clothes, clean and dry incontinent brief without any difficulties. The resident was compliant with the room change and safely transferred to 300-hall. The Administrator aware resident's return. Resident #1's RP, physician, social worker, and Ombudsman were notified of incident. Interview on 12/22/2023 at 10:51AM the Administrator stated the elopement of Resident #1 occurred sometime right before or after midnight on 12/18/2023 and the Administrator believed Resident #1 eloped from the front lobby doors but the door alarm either did not go off or had turned off as staff was not aware the front lobby doors had been opened. The Administrator stated staff at the local hospital notified the facility after noticing Resident #1 had his name written in his shirt/sweater and the hospital assumed he was a resident at a nursing facility. The Administrator stated staff were unaware that Resident #1 had eloped until the call from the local hospital came in. The Administrator stated the resident was transported back to the facility that night as the resident had no injuries and was placed in the 300-hall secured unit for closer observation. The Administrator stated staff-initiated elopement protocols immediately once learning of Resident #1's elopement. The Administrator stated there was weekly checks of all the doors and alarms but stated there was nothing wrong with the front lobby doors on the day of the elopement of Resident #1. According to the Administrator, the door alarms, after trying to be pushed open without the code, but will open after 15 seconds of pushing on the handlebar but the alarm should [NAME] sounding off until a staff member enters the code to turn alarm off. The Administrator stated front lobby doors are always locked, alarmed, and required a code to enter and exitd through the front lobby doors. Interview on 12/22/2023 at 10:58AM the Administrator stated he contracted an alarm company on 11/14/2023, 11/19/2023, and 12/4/2023 as the front lobby doors were having some issues after the contracted alarm company stated the issue was corrected. The Administrator stated on 12/18/2023, a new technician from the alarm company was requested and the front lobby doors were fixed and alarm was in working order. The Administrator stated that recently, the doors were given a new motherboard and had to be reprogramed and the Administrator believed that is what caused the alarm to stop alarming after Resident #1 had eloped. Record review on 12/22/2023 at 2:00PM of contracted alarm company statements reflected a new technician was sent to the facility on [DATE] and was able to correct the door alarms by reprogramming. Obsereved second lock were installed an in working order by this surveyor on 12/22/2023 at 4:00PM. Observed door alarms by this surveyor on 12/22/2023 at 11:35AM and by Life Safety on 12/23/2023 at 1:10PM and were in working order. Interview on 12/22/2023 at 10:58AM the Administrator stated an additional second lock was placed on the front lobby doors and double doors leading to the front lobby that will alarm and could only be turned off with a key after Resident #1 eloped. The Administrator stated Resident #1 did not show signs of exit seeking behaviors prior to this incident but has since been transferred to a memory care facility on 12/18/2023 at 4:50PM with consent from the RP. The Administrator stated staff completed a wandering assessment on all residents beginning on 12/18/2023 and a head count was conducted for all residents when the elopement was identified, and procedures were followed as per protocols. Interview on 12/22/23 at 12:48PM the Social Worker stated the front lobby door has always had ongoing issues, but they were addressed by the Administrator and the contracted alarm company had been coming out to correct the issue. Interview on 12/22/2023 with ADON B at 3:13PM revealed he was notified Resident #1 had eloped around midnight on 12/18/2023 but did not see the notification until later that morning. ADON B stated the resident did return to the facility uninjured and was placed in the 300-hall secured unit and wandering assessment conducted and changed to high risk by the Social Worker. Attempted to contact Charge Nurse (LVN A) on 12/23/2023 at 9:43AM, 12/23/2023 at 11:08AM, 12/23/2023 at 1:28PM and on 12/23/2023 at 1:49PM, with no answer and messages left. LVN A was the Charge Nurse for Resident #1 during the night of the eloepement. The Administrator attempted to call LVN A on 12/23/2023 at 1:39PM, with no answer. Phone interview on 12/23/2023 at 1:20PM CNA A stated the last time she saw Resident #1 was at 10:00PM on 12/17/2023, rolling around in his wheelchair as Resident #1 usually did and was not displaying exit seeking behaviors at that time. CNA A stated she did not hear any door alarms go off or she would have followed protocol and went to front lobby doors to turn off the alarm. CNA A stated the night of 12/17/2023 and early morning of 12/18/2023 the facility was shorthanded of CNA's due to a CNA calling in which made it very difficult to round every two hours as she was busy with other residents and was not aware Resident #1 left the facility until the hospital had called. CNA A stated once staff learned of the elopement, a head count of all residents was conducted, and elopement protocols were initiated. CNA A was the CNA providing care for Resident #1 at the time of the elopement. Beginning on 12/22/2023 at 10:00AM this surveyor verified through record review, observation, and interviews of in-services and corrective action implemented by the facility beginning on 12/18/2023 which included; This surveyor verified through interviews, observation and record review beginning on 12/22/2023 at 10:00AM. -Outside contractor, worked on door, new mother board installed, set door alarm to remain on indefinitely until the code is entered and staff have determined why the alarm is sounding. -Second alarm added to Lobby door. Second alarm is 100 decibels and will sound when someone attempts an unauthorized exit. This second alarm will be active from 5:00 PM to 8:00 AM Monday through Friday and from 5:00 PM Friday to 8:00 AM Monday. The front lobby door will not be used except in case of an emergency during the above hours. (observed) -Lobby smoke doors to be closed and alarm turned on from 5:00 PM to 8:00 AM Monday - Friday and from 5:00 PM Friday through 8:00 AM Monday. Staff are not to enter the lobby or use the lobby restroom during these times. -All residents have a current wandering evaluation. (verified) -Re-educated and in-serviced staff (all shifts) beginning on 12/20-21/23 regarding elopment procedures and verified through interviews beginning on 12/22/2023 at 10:00AM. -This portion of the plan of correction will be ongoing. -Elopement -What to do if a resident is seen trying to get out. -Out on pass procedure, nurse is only one allowed to let patient out once (OOP) book signature has been verified and counter-signed by nurse. -Door code not to be provided to anyone who is not a current employee. -Staff need to let visitors in and out, do not give anyone the code to the doors. -What to do when door alarm sounds, locate cause of alarm, locate person who went out or in the door. Do not reset alarm without determining who entered or exited. -If unable to determine who went in or out the door to cause the alarm to sound, a complete resident head count must be completed to determine is any residents are unaccounted for. If a resident is missing, activate the missing resident emergency procedures. -Additional Alarm on lobby (reception desk) door to be activated from 5:00 PM to 8:00 AM Monday - Friday and from 5:00 PM Friday through 8:00 AM Monday. -Smoke doors to be closed and alarm turned on from 5:00 PM to 8:00 AM Monday - Friday and from 5:00 PM Friday through 8:00 AM Monday. Staff are not to enter the lobby or use the lobby restroom during these times. -Location of residents at risk for elopement binders. (observed) -All new admissions will sign and acknowledge out on pass procedures. -All new admissions will have wandering assessment completed within 12 hours. -All residents who are determined to be at risk of wandering will have care plan updated. -Weekly door checks by maintenance, notify administrator and maintenance immediately if any of the doors appear to malfunction. All residents have updated wandering assessments. Any resident who is designated at risk - which will be determined by the IDT Team and will be moved to the secure unit. -All staff will know which residents are at risk of elopement by accessing the elopement binder which includes a picture, face sheet, elopement care plan, and wandering assessment. -DON, ADON A and ADON B will be responsible for updating elopement binders with change of condition or new admission. -All new admissions will have a wandering assessment completed within 12 hours. -All staff have been in-serviced that only a nurse can let a resident out the exit door once it has been confirmed a resident has signed out on pass. This should eliminate the risk of residents who have been deemed incompetent from going outside unsupervised. 1.All residents who are determined to be at risk of wandering have an updated care plan and was verified by this surveyor on 12/22/2023 at 4:36PM. 2.All residents have an updated wandering assessment and was verified by this surveyor on 12/22/2023 at 5:02PM. 3.Maintenance personnel, a nurse, or the administrator, will conduct an inspection of all exit doors to confirm the doors are locked and the alarm sounds after 15 seconds. An audit log for each door is kept at the corresponding nurse's station and was verified by this surveyor on 12/22/2023 at 4:33PM. -This portion of the plan of correction will be ongoing. 4.All staff have been educated on the definition of elopement, if an employee observes a resident leaving the premises, he/she should: (verified by this surveyor through in-services and interviews) -Attempt to prevent the resident from leaving in a courteous manner. -Get help from other staff members in the immediate vicinity if necessary. -Stay with the patient at all times. -Instruct another staff member to inform the charge nurse or DON services that a resident is attempting to leave or has left the premises. Call if necessary. -This portion of the plan of correction will be ongoing. 5.If door alarm sounds, but no resident is found outside the premises a complete resident head count must be completed to determine if any residents are unaccounted for. If a resident is missing, initiate the elopement/missing resident emergency procedure. -Determine if the resident is out on an authorized Leave or Pass. -If the resident was not authorized to leave, initiate a search of the building and premises. All staff members will conduct a thorough search for the resident in the facility, including areas such as kitchen, closets, and bathroom to ensure all residents are accounted for. -If the resident is not located, notify the Administrator and DON services, the legal representative, the attending physician, law enforcement officials, and if needed volunteer agencies. When the resident returns to the facility the DON and/or charge nurse shall -Examine the resident for injuries. -Contact the physician, report finding and condition of resident. -Notify resident's legal representative (RP) -Notify everyone in search that the resident has been located. -Complete incident report -Document relevant information in PCC (point click care) 6.Residents will utilize the binder located at each nurse's station to sign out on pass and binder was observed at nurse's station by this surveyor on 12/23/2023 at 11:03AM. -This portion of the plan of correction will be ongoing. 7.A nurse will escort resident out of facility that have properly signed out and/or leaving Against Medical Advice All door codes are changed periodically to ensure no resident or visitor is aware of the code. Staff have been informed not to share the code with residents and/or visitors. -This portion of the plan of correction will be ongoing. 8.All residents who are cognitively intact, not in the secure unit or bed ridden have received a behavioral contract regarding the requirement to sign out on pass prior to leaving the facility. -This portion of the plan of correction will be ongoing. 9.Administrator, DON, and ADON will monitor by randomly questioning 5 staff members per week for 30 days to ensure comprehension of what an elopement is, what he/she should do if they observe a resident trying to elope, escorting residents out who have properly signed out, and not providing the door code to residents or visitors. The random checks will be documented on a log that is kept in the Administrator's office. -This portion of the plan of correction will be ongoing. 10.The process to ensure residents will not follow visitors when exiting the building will be to not provide visitors with the door code and require staff to enter code for visitors. -This portion of the plan of correction will be ongoing. 11.The nurse will countersign when the resident signs out on pass to ensure he/she is aware that the resident has left the building. Interviews beginning on 12/22/2023 at 10:10am with RN A, LVN A, LVN B, LVN C, CNA A, CNA B, and Social Worker about the elopement process and protocols. All staff were able to identify the policy and procedures implemented and what actions to take during an elopement.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, sanitary, comfortable, and homelike environment for 5 of 86 resident rooms (room [ROOM NUMBER], 132, 133, 233, and 306) 1of 2 resident common areas in hall 100 and 1 of 1 resident common areas in 300 hall and 1 of 3 hallway (hall 100) reviewed for environment, in that: The facility failed to ensure resident rooms and the facility maintained a temperature of 71-81 degrees. These residents were not being screened for signs and symptoms of dehydration or heat related illness. The temperature in the residents' rooms reached 88.5 degrees on 07/11/23, the temperature outside reached 100 degrees on 07/11/23. These failures placed residents at risk of, and a diminished quality of life. An IJ was identified on 07/12/23. The IJ template was provided to the facility on [DATE] at 5:40pm. While the IJ was removed on 07/14/23, the facility remained out of compliance at a scope of widespread and a severity level of No actual harm with potential for more than minimal harm because all staff had not been trained over Inservice covering heat exhaustion, S/S (signs and symptoms) med pass, policy on recognizing dehydration, protecting from workers the effects of heat, nutrition and hydration care, emergency procedure staff severe hot weather procedures and vent temp checks, room temp checks, temp log. Findings included: Review of Resident #1's face sheet dated 07/15/23 reflected a [AGE] year-old male who resided in room [ROOM NUMBER]-B and was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (an autoimmune and inflammatory disease), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems. ), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS of 11, indicating a moderate cognitive impairment. It further reflected he was able to ambulate in room and corridor with supervision. Review of Resident #2's face sheet dated 07/15/23 reflected a [AGE] year-old female who resided in room [ROOM NUMBER]-A and was admitted to the facility on [DATE] with diagnoses including, hypothyroidism (underactive thyroid gland), dementia(impaired ability to remember, think, or make decisions that interferes with doing everyday activities) in other diseases classified elsewhere, mild with agitation, senile degeneration of brain (a decrease in cognitive abilities or mental decline), essential hypertension(high blood pressure) Review of Resident #2's admission MDS, dated [DATE], reflected a BIMS of 05, indicating severe cognitive impairment. It further reflected she required extensive assistance for bed mobility and transfers. Review of Resident #3's face sheet dated 07/15/23 reflected a [AGE] year-old male who resided in room [ROOM NUMBER]-A and was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), stage 5, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar ), and essential (primary) hypertension (high blood pressure) Review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS of 13, indicating no cognitive impairment. It further reflected he required limited assistance for transfers and required use of a wheelchair. Review of Resident #4's face sheet dated 07/15/23 reflected a [AGE] year-old female who resided in room [ROOM NUMBER]-B and was admitted to the facility on [DATE] with diagnoses including, Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), squamous cell carcinoma of skin (the second most common form of skin cancer, characterized by abnormal, accelerated growth of squamous cells.), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar ), end stage renal disease (occurs when the kidneys are no longer able to work at a level needed for day-to-day life). Review of Resident #4's quarterly MDS, dated [DATE], reflected a BIMS of 11, indicating moderate cognitive impairment. It further reflected she required limited assistance for transfers and bed mobility. Review of Resident #5's face sheet dated 07/15/23 reflected a [AGE] year-old female who resided in room [ROOM NUMBER]-A and was admitted to the facility on [DATE] with diagnoses including, rhabdomyolysis (breakdown of muscle tissue that releases a damaging protein into the blood), hepatic failure (Loss of liver function), unspecified without coma, unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and rheumatoid arthritis (an autoimmune and inflammatory disease). Review of Resident #5's quarterly MDS, dated [DATE], reflected a BIMS of 12, indicating moderate cognitive impairment. It further reflected she required extensive assistance bed mobility and was total dependent for transfers. Review of Resident #6's face sheet dated 07/15/23 reflected an [AGE] year-old female who resided in room [ROOM NUMBER]-A and was admitted to the facility on [DATE] with diagnoses including, Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), unspecified combined systolic (congestive) and diastolic (congestive) heart failure (In systolic heart failure, the heart muscle is weak, and the ventricle can't contract normally. With diastolic heart failure, the heart muscle is stiff, and the left ventricle can't relax normally), dysphagia (swallowing difficulties), type 1 diabetes mellitus without complications (A chronic condition in which the pancreas produces little or no insulin), essential (primary) hypertension (high blood pressure), and hyperlipidemia (high levels of fat in the blood). Review of Resident #6's quarterly MDS, dated [DATE], reflected a BIMS of 00, indicating severe cognitive impairment. It further reflected she required extensive assistance bed mobility and transfers. Record review of facility documents revealed HVAC service order invoices for the following dates: 07/05/23, 07/06/23, 07/09/23, 07/10/23, 07/11/23 and 07/12/23. Record review of HVAC service order dated 07/05/23 by HVAC Company revealed a section titled, DESCRIPTION OF WORK PERFORMED had the following verbiage written, Work on chiller and solenoid valves for the dining room. Section titled; recommendations was blank. Record review of HVAC service order dated 07/06/23 by HVAC Company revealed a section titled, DESCRIPTION OF WORK PERFORMED had the following verbiage written, Raise temp. for water coming out of chiller to 40 degrees to 45 degrees. Manually open 2 solenoid valves for dining room Section titled; recommendations was blank. Record review of HVAC service order dated 07/09/23 by HVAC Company revealed a section titled, DESCRIPTION OF WORK PERFORMED had the following verbiage written, Reset the chiller. Checked and watched it make sure it runs properly and doesn't shut off Section titled; recommendations was blank. Record review of HVAC service order dated 07/10/23 by HVAC Company revealed a section titled, DESCRIPTION OF WORK PERFORMED had the following verbiage written, Checked out chiller found unit tripping out on high load pressure. Raised out condenser coil. Waited for coil to dry. Checked head pressure. Unit staying online. Chiller back to normal operation. Section titled; recommendations was blank. Record review of HVAC service order dated 07/11/23 and 7/12/23 by HVAC Company revealed a section titled, DESCRIPTION OF WORK PERFORMED had the following verbiage written, Found unit down new on low oil circuit A alarm. Got with carrier tech support to find type of oil and low much. Unable to valve off oil separator refrost pressure continue to pass threw. Had to recover 13 1/9 from chiller to add oil. Needed 3 out of 5 gallons ordered thermistor for water inlet and outlet. Had code for freeze also due to bad temp thermistor. 3 to 5days. Added oil pulled vacuum system recharged chiller online. Day 2 checked several Section titled; recommendations was blank. Record review of outside temperature on 07/05/23 was a high of 95 degrees. Record review of outside temperature on 07/06/23 was a high of 85 degrees. Record review of outside temperature on 07/09/23 was a high of 98 degrees. Record review of outside temperature on 07/10/23 was a high of 98 degrees. Record review of outside temperature on 07/11/23 was a high of 100 degrees. Record review of outside temperature on 07/12/23 was a high of 99 degrees. Record review of facility temperature logs dated 07/10/23 provided by the Maintenance Director revealed all rooms in the facility were checked at 8:00am and 9:00am with all documented temperatures over 81 degrees, reaching as high as 85 degrees. Observation of the temperature in Resident #3's room, room [ROOM NUMBER] on 07/11/23 at 7:17pm revealed Resident #3 present in his room while the ambient room air reached 85 degrees, temperature of ambient room air was taken by this surveyor with use of a wireless thermometer. Observation of temperature in Resident #4's and Resident #5's room, room [ROOM NUMBER], on 07/11/23 at 7:55pm revealed Residents #4 and #5 were present in room when the ambient room air was 82 degrees. Temperature of ambient room air was taken by this surveyor with use of a wireless thermometer. Observation of Resident #4's and Resident #5's room, room [ROOM NUMBER] on 07/11/23 at 8:55PM revealed an oscillating fan was present and in use in room [ROOM NUMBER]. Observation of Resident #1's room, room [ROOM NUMBER]on 07/11/23 at 9:36PM revealed no fan or portable air conditioner present in room [ROOM NUMBER]. Observation of temperature in Resident #1's room, room [ROOM NUMBER], on 07/11/23 at 9:46pm revealed Resident #1 was present in his room while the ambient room air was 84 degrees and the temperature coming out of the air vent in room [ROOM NUMBER] was 88.5 degrees. Temperature of ambient room air was taken by this surveyor with use of a wireless thermometer. Temperature of air coming out of air vent was taken by this surveyor with use of an infrared thermometer Observation of temperature in Resident #2's room, room [ROOM NUMBER], on 07/11/23 at 10:04pm revealed Resident #2 was present in the room while the ambient room air was 83 degrees. Temperature of ambient room air was taken by this surveyor with use of a wireless thermometer. Observation of temperature in Resident #6's room, room [ROOM NUMBER], on 07/11/23 at 11:40pm revealed the resident was in her room while the ambient room air was 84 degrees. Temperature of ambient room air was taken by this surveyor with use of a wireless thermometer. Observation of hall 100 common area located in front of the physical therapy gym (room [ROOM NUMBER]) on 07/11/23 at 7:31pm revealed no residents present in common area while the ambient air temperature was 84. Temperature of ambient room air was taken by this surveyor with use of a wireless thermometer. Observation of air vent in hall 100 about 3 feet away from hall 100 common area located in front of room [ROOM NUMBER]/128 on 07/11/23 at 7:39pm revealed the air vent temperature to be at 85.5 degrees. Temperature of air coming out of air vent was taken by this surveyor with use of an infrared thermometer Observation of temperature of air vent in front of room [ROOM NUMBER] and 132 in 100 hall on 7/11/23 at 10:05pm revealed the temperature to be 83 degrees. Temperature of air coming out of air vent was taken by this surveyor with use of an infrared thermometer Observation of temperature of hall 100 taken outside of room [ROOM NUMBER] on 7/11/23 at 10:06pm revealed the ambient temperature in the hall to be 84 degrees. Temperature of ambient room air was taken by this surveyor with use of a wireless thermometer. Observation of temperature of air vent in front of room [ROOM NUMBER] in 100 hall on 7/11/23 at 10:07pm revealed the temperature to be 84 degrees. Temperature of air coming out of air vent was taken by this surveyor with use of an infrared thermometer Observation of temperature of hall 300 nurse station/common area taken 7/11/23 at 11:23pm revealed the ambient temperature in the hall to be 83 degrees. Temperature of ambient room air was taken by this surveyor with use of a wireless thermometer. Record Review of TULIP (HHSC online incident reporting application) on 07/11/23 at 11:25pm revealed the facility had not made a self-report regarding air conditioning issues or temperatures in building. During an interview with Resident #3 on 07/11/23 at 7:17pm, Resident #3 stated it had been warm, with temperature issues starting a couple weeks prior. Resident #3 stated it had been hard to sleep with no circulation of air. During an interview with CNA A on 07/11/23 at 7:45pm she stated the temperature has been worse the days before and stated she was sweating because of the temperature. During an interview with the Administrator on 07/11/23 at 8:00pm he stated the problems with the temperature stated on 07/01/23 when their chiller(system that uses a method of producing chilled water and sending water to the chilled water coil of the air conditioner shut itself off. The Administrator stated since then the air conditioning company they use had come out multiple times and had finally identified and fixed the issue with their chiller on 07/11/23. The Administrator stated he had some residents complain and stated they were moved to cooler rooms. The Administrator stated staff had been monitoring temperatures throughout the facility and stated the highest temperature gathered was 82. The Administrator did not state who was responsible for doing temperature checks, stating water temps are taken but not necessarily air temps. The Administrator was asked what the policy stated in regard to what to do when heating/cooling go out, and he stated he would follow CMS guidelines. The Administrator stated he had not seen a specific policy he had regarding heating and cooling. The Administrator stated his backup plan was to evacuate if they were not able to take care of the situation and temperatures got out of hand. The Administrator stated temperatures would have to be at 85-90 degrees to be out of hand. The Administrator stated he had 10 portable air conditioners in use and stated staff is checking temperatures throughout the facility but not necessarily logging them. During an interview with Resident #4 on 07/11/23 at 8:55pm she stated the facility had been hot the previous days and had just gotten better the evening of 07/11/23. During an interview on 07/11/23 at 9:36pm Resident #1 stated its hot, way too hot. Resident #1 continued to say that the entire building had been this way for the last 3 days. Resident #1 stated he had complained about the heat the day before on 07/10/23 and the day of our interview on 07/11/23. When asked if the facility had offered him anything to combat the heat he stated, the entire building was this way. During an interview with the Administrator on 07/11/25 at 10:15PM, the Administrator stated he was not aware and had not been told about Resident #1's complaint about the temperature in his room. The Administrator stated complaints were talked about during morning meetings and stated he had not been made aware. During an interview on 07/11/23 at 9:19pm with Resident #7 who's room was in hall 100 stated her room had been hot and she had to scream and holler for a fan to be placed in her room. She stated she was sweating and uncomfortable. During an interview on 07/11/23 at 9:30pm with Resident #8 who's room was in hall 100 stated, it was hotter than hell stating the air conditioner at the facility had gone out a month ago. He stated he had to buy a fan because he could not stand it anymore. During an interview with Resident #5 on 07/12/23 at 10:38 AM she stated a family member of Resident #4 had provided them a fan due to the heat in the building. Resident #5 stated it had been hot for 2 weeks and stated she had been sweating. She stated staff was helpful, but it was hot. During a telephone interview with CNA B on 07/12/23 at 2:32pm CNA B stated she worked the evening of 07/11/23 and stated that was the first night it started to feel better in the facility. She stated it had been hot before and she would be sweating at work. During an interview with the Maintenance Director on 07/12/23 at 9:35pm he stated the facility started having issues with their air conditioner on 07/01/23. The Maintenance Director stated he started taking room temperatures on 07/01/23 for certain rooms. The Maintenance Director stated he did not remember which rooms he had checked the temperature in, stating he had logs but did not know where they were and had misplaced them. The Maintenance Director stated he knew he should have written down the temperatures he took. The Maintenance Director stated he only had temperature logs for 07/09/23 and 07/10/23 and 2 other papers that had hand written numbers without any other details or times or dates documented. While reviewing the temperature log dated 07/10/23 the Maintenance Director stated the highest temperature he identified was 85. The Maintenance Director stated he only used a temperature laser gun and averaged the temperature in the room by getting the temp of the air vent, wall and floor. The Maintenance Director stated he did not have a thermometer to capture the ambient room temperature. When asked what should be done when temperature that high are identified the Maintenance Director stated he would call an air conditioning company and move residents to a cooler place with fans added for residents who refused to move rooms. The Maintenance Director stated he had called and had an air conditioning company come to the facility multiple times in the previous week to fix the air conditioner. The Maintenance Director stated it took the air conditioning company multiple visits to fix the issue, stating on 07/11/23 the chiller was found to be low on oil. The Maintenance Director stated the facility had provided 10 or 12 portable air conditioners, and 4 commercial fans throughout the facility. The Maintenance Director stated they have provided fans to residents, but he was unsure the exact number During an interview with the DON on 07/12/23 at 11:56am she stated staff was going in and checking on every resident and making sure they were comfortable during the rounds the CNAs completed. The DON stated if any complaints were verbalized they would get fans in the room or move the resident to a cooler area. The DON stated it had been a challenge. The DON stated she did not know if they were documenting room changes but stated she had nursing staff scan everybody's body temp for fever and stated everyone had been okay so far. The DON stated staff did their normal rounds, the DON stated if concerns such as dehydration came up or had been reported that nursing would have documented it, further stating she checked in with nurses in the mornings to see if these concerns had come up. The DON stated residents who are relocated to cooler rooms are assessed the same as all other residents by taking temperatures, checking for signs of dehydration, and asking them if they are okay. The DON stated they had not had to send anybody out. The DON stated if a resident did not wish to relocate and the building was above 81 degrees they would check for skin tenting, urinary output and stated a decrease in urinary output is a sign of dehydration. The DON stated they would also assess for dry mouth, elevated temperature and stated that would be completed by the hall nurse and the aides reporting urinary output. The DON stated a body temperature over 99 would be when she would encourage ice cold water and relocation to a cooler area. During an interview with Resident #5 on 7/13/23 at 2:12pm she stated she did not think the facility would ever fix the air conditioner, stating it had not worked for a couple of weeks. Resident #5 stated it was unbearable and she thought she was going to faint. Resident #5 stated she was sweating so much that her clothes and bed were wet. Resident #5 stated there were 2 nights in row that she could not sleep because of the heat. During an interview on 07/23/23 at 4:30pm with Resident #9 in hall 300 she stated it was hot and it had been hot for weeks. Resident #9 stated the staff did not offer anything and stated they did not have any rooms. Resident #9 stated she had felt sick with the heat stating she has felt nauseous sine the heat has been going on. Resident #9 stated she sweats from the heat and stated the temperature had not improved today During a telephone interview with the Maintenance Director on 07/16/23 at 7:40am he stated he was not sure what the temperatures should have been but stated he had been told by the facility that temperatures should have been between 70-72. The Maintenance Director stated he had identified rooms over 81 degrees on 07/10/23 and 07/11/23. The Maintenance Director was read the temperatures he documented on the temperature log on 07/10/23 with the highest documented as 85, the Maintenance Director stated that was hot and stated the temperatures should have been less than 85. The Maintenance Director stated temperatures over 81 are uncomfortable and stated its important to keep temperatures within the appropriate range to keep the residents comfortable. The Maintenance Director stated temperatures over 81 could negatively affect the residents by making them sweaty and uncomfortable in the bed or could lead to them being hospitalized . During an interview with the Administrator on 07/16/23 at 3:23pm he stated the temperature in the facility should be between 71 and 80 degrees. The Administrator stated 1 or 2 rooms had been identified to be at 81-82 degrees. The Administrator stated the problem was not having the right air conditioning company to come out to the facility. The Administrator stated the temperatures should have been lower, stating temperatures over 81 are not okay. The Administrator stated if resident would complain they would move their rooms and stated the facility did not find any indication of anyone getting dehydrated or any heat related illness. The Administrator stated its important to keep temperatures within range because it's a safety situation, stating some residents are fragile and could dehydrate very easily. The Administrator stated dehydration could lead to heat related situations were some ways temperatures over 81 could negatively impact residents. The Administrator was notified on 07/12/23 at 5:09pm, that an Immediate Jeopardy (IJ) had been identified due to the above failures. The IJ template was provided to the Administrator on 07/12/23 at 5:32 PM. A Plan of Removal (POR) was first submitted by the Administrator on 07/12/23 at 9:47 PM and the 4th revision POR was accepted on 07/14/23 at 1:01 PM and read as follows: PLAN OF REMOVAL 7/14/2023 On 7/11/2023, an off-cycle survey was initiated at (facility). On 7/12/2023, the facility was notified by the surveyor that an immediate jeopardy had been called and needed to submit a plan of removal. The Facility respectfully submits this plan of removal pursuant to Federal and State regulatory requirements. Submission of the plan of removal does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. Issue identified by surveyor: The facility did not maintain comfortable and safe temperatures. All residents have the potential to be affected by the alleged deficient practice. Corrective Actions: 1. Temporary portable A/C units were placed throughout the facility while air conditioning vendor performed troubleshooting and repairs. 2. (HVAC Company) completed final repair to chiller 7/11/2023 at 5:45 p.m. 3. New Maintenance Director (Maintenance Director C) verified all resident rooms and common area temperatures were below 81 degrees as of 7/12/2023. 4. (Maintenance Director C)- Maintenance Director to continue monitoring and recording temperature logs on morning and evening shift for 24 hours from 7/12/2023 to ensure sustained compliance. Temperatures will be logged on to the audit sheet to include vent temperature and room temperature. Vent temperature will be performed with an infrared thermometer used to measure surface temperature without contact. Vent temperature will be used to identify any malfunctioning air conditioners. This reading is instantaneous. Room temperatures will be performed with digital thermometer that takes ambient reading. The thermometer should be allowed to stabilize for a minimum of 30 seconds prior to recording the reading. This reading will be used to determine if immediate action (which is outlined below in #6) is required for the comfort of the resident. 5. An extra infrared thermometer and digital thermometer will be kept in 100 hall medication cart to ensure nurses have the ability to check vent/room temperature as needed. Charge nurses have been educated on the proper method of taking room temperatures. 6. All resident rooms and common areas have been verified to be below 81 degrees: 7/12/2023 4:57 pm, 8:43pm, 7/13/2023 9:55 am, and 6:46pm. 7. If any resident room exceeds 81 F moving forward, room temperature checks will be performed on every resident room on that hall every 4 hours by that hall's Charge Nurse. These temperature checks will be documented on the Temperature Log template and stored in a binder at each respective nurse's station. Should any resident refuse to relocate from a room with an out of specification temperature, room temperature and resident dehydration checks will be performed hourly. The Administrator, Director of Nursing, and Maintenance Supervisor shall be notified within 1 hour if a resident refuses to move and will be exposed, albeit willingly, to temperatures in excess of 81 F. During normal working hours, the Administrator or Director of Nursing may assign an alternate, qualified individual to perform these checks and documentation if prudent. 8. Any resident whose room exceed 81 F, will be monitored for indications of dehydration and said indications will be documented in the resident's medical record by the Charge Nurse. The Charge Nurse for the hall is responsible for ensuring the resident heat stress and dehydration checks are performed and documented in the medical record. The Administrator and Director of Nursing will be notified within 1 hour of any signs of dehydration or heat stress when a resident is exposed to temperatures in excess of 81 F. The Charge Nurse on each hall is responsible for performing and documenting these checks. Once temperature is restored in the resident's room, Charge Nurses will monitor vital signs and record resident BP, pulse, Respiration, and temperatures once per shift for 24hrs. If any abnormal vital signs are identified, the Director of Nursing and the Medical Director will be notified with 1 hour. 9. Should any resident complain of uncomfortable temperatures, or a member of the staff notice a room or area feels warm, the air temperature of said area shall be measured with a thermometer. If the air temperature exceeds 81 F, the actions specified above shall be taken. 10. If internal air temperatures exceed 81 degrees in the future, Certified Nursing Assistants, Certified Medication Aides, Charge Nurses (LVN/RN), and Activities will offer fresh cool fluids/popsicles every two hours while resident is awake. Documentation will be kept on a Log at the nurse's station. 11. Previous Maintenance Director (Maintenance Director) terminated 7/13/2023. 12. Maintenance Director, (Maintenance Director C) sealed side entrance and smoking exit doors with weather stripping and air curtain to improve insulation on 7/13/2023. 13. Administrator (Administrator) LNFA, DON (DON), RN, ADON- (ADON D), LVN and (ADON E) and (Social Worker), LMSW interviewed all residents to confirm they are comfortable with current room temperature completed 7/13/2023. If any resident expressed discomfort, alternate room options will be made available. 14. All residents are currently being monitored by charge nurses once per shift for 24 hrs, and vital signs will be documented in the MAR. 15. DON- (DON), RN, ADON- (ADON D), LVN and (ADON E), LVN developed training to in- service all Registered Nurses, Licensed Vocation Nurses, Certified Medication Aides, and Certified Aides on recognizing and taking appropriate immediate actions for signs and symptoms of dehydration and heat exhaustion. Training is complete for all scheduled staff as of 7/13/2023 and all current staff are required to complete said in-services prior to their first shift. Signs and symptoms according to OSHA: Heat Exhaustion Headache Nausea Dizziness Weakness Irritability Confusion Thirst Heavy sweating Body Temperature greater than 100.4F Med Pass Policy on recognizing Dehydration Drinks less than 6 cups of liquid per day Has more of the following: -Dry mouth -Cracked lips -Sunken eyes -Dark urine Needs help drinking from a cup of glass Has trouble swallowing liquids Frequent vomiting, diarrhea, or fever Is easily confused/tired Report and Take Action Report observations and warning signs to nurse Offer 2-4 ounces of water or liquids frequently. Offer ice water or chips frequently (unless the resident has a swallowing problem) Check swallowing precautions, then if appropriate, offer sips of liquid between bites of food at meals and snacks. Offer appropriate assistance as needed if resident cannot drink without help Policy/Procedure Severe Hot Weather Procedures if loss of cooler - Move residents to an air- conditioned part of the facility, if available. - Encourage the residents to drink fluids. - Provide cold washcloths as needed. - (If outside temperature is cooler than inside) open windows to let cooler outside air in and utilize fans to move air around. - Monitor body temperature of the residents and notify attending physicians if necessary. - Notify 911 if resident/Staff member appears to be in danger of heat related stress. - Evacuate residents if necessary. - Monitor environmental thermometers. - Notify Medical Director. 16. Should building A/C failure occur again, the portable A/C units be utilized immediately to maintain temperatures. Additional portable A/C units have been purchased since this occurrence and appear adequate to maintain temperature with a failed chiller. Should existing portable A/C capacity fail to maintain temperature less than 81 F, the CFO and COO shall be notified, and additional units purchased immediately. If temperatures exceed 81 F for more than 4 hours, the COO, Administrator, Director of Nurses, and Medical Director shall conference and evaluate the risk to resident health and safety from the heat versus the risk from evacuation. Should the Medical Director determine it clinically appropriate, the building will be evacuated following the disaster plan and residents transferred to alternate facilities. The Medical Director, Dr. [NAME], has received training o [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 20 residents (Resident #10, Resident #11 Resident #3) reviewed for accidents and hazards: 1. The facility failed to ensure Resident #10 did not elope from facility. Resident #10 eloped on 07/01/23 at around 5:30pm and was found on 07/01/23 at around 10:30pm. 2. The facility failed to ensure Resident #11 did not elope from the facility after he was identified as a moderate elopement risk. Resident #11 eloped from the facility on 07/15/23 at around 6:30pm. 3. The facility failed to ensure Resident #3 did not have a vape pen in his possession. Resident #3 was observed to have a vape pen in his possession while in the building on 07/14/23 at 11:39AM. The facility failed to implement measures to prevent elopements for Resident #10 and #11 and to maintain the environment free of hazards for Resident #3. An IJ was identified on 07/16/23. The IJ template was provided to the facility on [DATE] at 8:08pm. While the IJ was removed on 07/17/23, the facility remained out of compliance at a scope of pattern and a severity level No actual harm with potential for more than minimal harm because all staff had not been trained over elopement procedures. This deficient practice could place the residents at risk for harm, serious injury or death. The findings were: 1. Review of Resident #10's face sheet dated 07/15/23 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including, Parkinson's disease (A disorder that affects a person's ability to think, feel, and behave clearly.), schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly.), peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), vascular dementia ( problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and essential (primary) hypertension (high blood pressure). Resident #10 was not identified as his own responsible party. Review of Resident #10's quarterly MDS, dated [DATE], reflected a BIMS of 10, indicating moderate cognitive impairment. It further reflected that Resident #10 did not require a cane, crutch or walker and when walking was not steady, but able to stabilize without staff assistance. Record review of Resident #10's wandering assessment dated [DATE] revealed he was categorized as low risk with a score of 4, with no history of wandering/elopement noted on assessment. Record review of Resident #10's wandering assessment dated [DATE] revealed he was categorized as low risk with a score of 3, with no history of wandering/elopement noted on assessment. Record review of Resident #10's wandering assessment dated [DATE] revealed he was categorized as low risk with a score of 3, with no history of wandering/elopement noted on assessment. Record review of Resident #10's comprehensive care plan with a start date of 06/13/23 revealed Resident #10 had impaired cognitive function/dementia or impaired though processes due to Dementia Record review of Resident #10's nursing notes dated 07/01/23 at 5:30pm by LVN H revealed staff were unable to find Resident #10 in the facility and had to initiate a code silver (missing person). Record review of Resident #10's nursing noted dated 07/01/23 at 10:30pm by ADON D revealed Resident #10 had been found by ADON D. Resident was found approximately 2.5 miles away from the facility (high temp for that day 98 degrees Fahrenheit). ADON D assessed Resident #10 when found and was alert and oriented x4, with no signs or symptoms of distress, Resident #10 denied pain or discomfort, even and unlabored respirations, Resident #10 was able to recognize ADON D and other family member who had also found Resident #10 at the same time. RP for Resident #10 requested Resident #10 be taken to her house by family member and then she would drop him off at the facility later. Record Review of TULIP (HHSC online incident reporting application) on 07/15/23 at 9:00AM revealed the facility made a self-reported incident on 07/02/23 Record review of resident sign out binder revealed Resident #10 did not sign out of facility on 07/01/23. During an interview on 07/15/23 at 11:20AM the Administrator stated he was no longer able to access video clip of Resident #10 leaving the facility stating their video surveillance systems do not save recordings for that much time. The Administrator stated on the video Resident #10 was seen pushing and tugging at the door and stated the door will open after pushing it for a while and pointed to written notice on door of 15 seconds. The Administrator stated the video did not have sound and was unable to determine if the alarm had gone off and state he did check to see if anyone had come up to keypad to enter code to turn off alarm. The Administrator stated the facility began a search and then started a perimeter search and continued to widen the area, stating an ADON found the resident. During an interview on 07/15/23 at 11:30AM with Resident #10's responsible party (RP) she stated Resident #10 was going the right way to her house and was only a couple of blocks off. Resident #10's responsible party stated Resident #10 was found by a staff member and s family member and stated Resident #10 chose to not go back to the facility right then and instead went to his responsible parties home and was later returned to the facility by his RP. Interview with CNA J on 7/15/23 at 1:10pm revealed she last saw Resident #10 by the vending machines at 5:15pm on the day he eloped. During on 07/15/23 at 1:15pm with ADON D she stated Resident #10 had no history of elopement, ambulated on his own, was independent, cognitively aware and never identified as an elopement risk. ADON D stated she found Resident #10 at around 10:30pm the night he left the facility further stating Resident #10's brother-in-law was there with the resident. ADON D stated she assessed Resident #10 and stated he was fine and safe. During an interview with Resident #10 on 07/15/23 at 1:30pm he stated he recalled when he left the facility, stating he did not tell anybody and did not sign out. Resident #10 stated he busted down the door and kicked it to get out of the facility. Resident #10 stated he wanted to go for an outing and wanted to go to his RP's house. Resident #10 stated he walked far, got lost and was picked up by a friend who dropped him off at his RP's home and later was [NAME] back to the facility by his daughter. Resident #10 stated that was the first time he had done anything like that and was told that now his RP had to sign him out. Interview on 07/15/23 with LVN H at 11:20 am revealed she was working on 07/01/23 when Resident #10 eloped from the facility and stated she had not heard any alarm go off around 5PM-6PM on 07/01/23, stating she was not near the door at that time. Interview on 07/15/23 with LVN R at 11:25am revealed she was working on 07/01/23 when Resident #10 eloped from the facility and stated she had not heard any alarm go off around 5PM-6PM on 07/01/23, stating she was not near the door at that time. Interview on 07/15/23 with CNA F, G and AF at 12:58pm revealed all 3 staff members were working on 07/01/23 when Resident #10 eloped from the facility and stated none of them had heard any alarm go off around 5PM-6PM on 07/01/23, stating none of them were near the door at that time. Interview with CNA F on 07/16/23 at 5:49pm revealed the magnet on the side entrance had fallen off on 07/01/23. CNA F stated Maintenance E had fixed it about 3 hours before Resident #10 eloped from facility. CNA F stated he checked if the door was working correctly at 3:30pm or 4:00pm on the day Resident #10 eloped and stated it was working. Maintenance E was attempted to be reached via telephone on 07/15/23 at 1:50pm and 2:00pm. No phone call was returned by Maintenance E. During an interview with CNA B on 07/17/23 at 6:58am she stated Resident #10 was not allowed to leave the facility on his own and could only leave with his RP. CNA B stated Resident #10 had no history of elopement or wandering and have never heard of him doing something like that. CNA B stated she worked on 07/01/23 and noticed Resident #10 was not in his room when she was doing meal tray rounds. CNA B stated she asked LVN H who stated she had not seen Resident #10 since passing out medications, CNA B stated she did not think Resident #10 signed himself out and sated they searched rom by room and all areas. CNA B stated it was identified around 5:30pm that Resident #10 was missing and stated he returned around 9 or 10pm that night. CNA B stated the facility elopement policy said for a CNA to get in touch with nurses and administrator right away. CNA B stated she followed the facility policy. CNA B stated Resident #10 had not mentioned wanting to leave the facility and stated he was independent, able to ambulate on his own and was not cognitively impaired. CNA B stated when Resident #10 returned an Inservice was provided to everyone. CNA B stated Resident #10 was appropriate to be outside of the locked unit. During an interview with LVN H on 07/17/23 at 8:36am she stated Resident #10 was not allowed to leave the facility on his own and had never asked to leave the facility on his own and would only leave with his RP. LVN H stated she last saw the resident at around 4:30 when she gave him meds. LVN H stated an aide notified asked her where Resident #10 was at about 5:30pm and that's when she went to check Resident #10's room, restroom, dining area and other areas he visits around the facility. LVN H stated when she could not find Resident #10 she called his RP and checked the sign out book to see if Resident #10 had been signed out, which she stated he had not been. LVN H stated she initiated code silver around 5:50pm. LVN H stated the facility elopement policy was to take a head count, search around the building and then call out a code silver and notify everyone. LVN H stated she followed the facility policy. LVN H stated Resident #10 had no history of elopement or wandering and had not stated he wanted to leave. LVN H stated Resident #10 was independent, able to ambulate on his own and was not cognitively impaired. LVN H stated she had been in serviced afterwards over code silver, and procedures to follow such as who to notify, head counts and doing walking rounds. LVN H stated when she asked Resident #10 why he left he stated he wanted to go for a walk. LVN H stated Resident #10 was appropriate to be outside of the locked unit. LVN H stated if a resident elopes without the facility being aware it can cause a negative impact on the resident such as stress, anxiety, or they can fall, hit their heads or head up hospitalized . During an interview with the DON on 07/17/23 at 1:08pm she stated the facility policy on elopement stated if a resident wanted to go out they needed to sign out properly and if they don't then it would be considered elopement, further clarifying that staff should escort the resident out of the building. The DON stated if a resident is not found the first thing staff should do is check if they signed out. The DON stated the level of supervision for residents is determined by their assessments like BIMS, fall risk and elopement assessment. The DON stated those assessment will determine if the resident required to be moved closer to the nurse's station or be placed in the locked unit. The DON stated she used quarterly assessments to monitor residents for any changes that may require a change in supervision levels. The DON stated getting hurt, having a negative impact from the heat, something happening on the road with all the vehicles or residents seeking drugs are some of the negative impacts a resident by experience if eloping from the facility. 2. Review of Resident #11's face sheet dated 07/16/23 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including, dementia (A group of thinking and social symptoms that interferes with daily functioning)in order diseases classified elsewhere, unspecified severity, with agitation, senile degeneration of brain (a decrease in cognitive abilities or mental decline), not elsewhere classified, encephalopathy ( a decrease in blood flow or oxygen to the brain), atherosclerotic heart disease (caused by buildup of plaque) of native coronary artery without angina pectoris (chest pain), chronic embolism (occurs when a piece of a blood clot, foreign object, or other bodily substance becomes stuck in a blood vessel and largely obstructs the flow of blood) and thrombosis (occurs when a thrombus, or blood clot, develops in a blood vessel and reduces the flow of blood through the vessel) of other specified veins, and essential (primary) hypertension (high blood pressure). Resident #11 was not identified as his own responsible party. Review of Resident #11's quarterly MDS, dated [DATE], reflected a BIMS of 12, indicating moderate cognitive impairment. It further reflected that Resident #10 did not require a cane, crutch, walker or wheelchair and when walking was not steady, but able to stabilize without staff assistance. Record review of Resident #11's elopement risk assessment dated [DATE] revealed resident was categorized as a moderate risk with a score of 8. Based on elopement risk assessment Resident #11 was not a known wanderer or had a history of wandering. Record review of Resident #11's elopement risk assessment dated [DATE] revealed resident was categorized as a moderate risk with a score of 10. Based on elopement risk assessment Resident #11 was a known wanderer or had a history of wandering. Record review of Resident #11's elopement risk assessment dated [DATE] revealed resident was categorized as a moderate risk with a score of 10. Based on elopement risk assessment Resident#11 was a known wanderer or had a history of wandering. Record review of Resident #11's elopement risk assessment dated [DATE] revealed resident was categorized as a low risk with a score of 5. Based on elopement risk assessment Resident #11 was not a known wanderer or had a history of wandering. Record review of Resident #11's nursing note dated 02/03/23 at 3:31pm by the Social Worker revealed Resident #11 had previously walked out of building and sat on a chair outside and refused to reenter the facility. Record review of Resident #11's comprehensive care plan with a start date of 05/03/23 revealed Resident #11 had impaired cognitive function/dementia or impaired though processes due to Dementia. Resident #11's care plan had no documentation related to resident previously leaving facility and refusing to come back in on 02/03/23. Resident #11's care plan had no documentation of his moderate elopement risk identified through his elope risk assessments. Record review of staff Inservice dated 07/01/23 covering topics of elopement, code silver and attending to the door when the alarm is on revealed CNA K had received the in service. Observation of video footage caught on facility recording system from camera facing the side entrance door from the inside of building revealed Resident #11 eloped from the facility on 07/15/23. At 6:29:05 PM, Resident #11 was seen standing less than approximately 5 feet away from the locked side door. At 6:29:26 PM, a visitor approached the side door area waiting for someone to unlock the door. At 6:29:49-52 PM, Resident #11 was seen pushing and pulling the door in attempt to open the door. At 6:30:02 PM, CNA K was seen approaching and deactivating the keypad to unlock the door and watched Resident #11 exit the building. At 6:30:10 PM, Resident #11 quickly walks out the door towards the facility parking lot while CNA K walked back towards the 100 hall. At 6:30:56 PM CNA K and CNA B were seen running toward and out the side door of the facility towards the parking lot. At 6:31:03 PM, LVN L was seen running towards and exiting the facility side door towards the parking lot. On 07/15/23 at 6:32pm Resident #11 was observed by this surveyor in the parking lot on his knees with multiple staff members around him. During an interview with LVN L on 07/15/23 at 7:09pm she stated CNA K was at the entrance door and asked LVN K if a man she described as Resident #11 was supposed to go out. LVN L stated she said no and ran out to catch Resident #11. LVN L stated she caught Resident #11 before he reached the street. LVN K stated she required to get a wheelchair for Resident #11 because Resident #11 had placed himself on the ground. She stated Resident #11 had a history of this before but was not sure how many times. During an interview with CNA K on 07/15/23 at 7:37pm she stated she saw Resident #11 standing right at the door and stated she did not know anybody from that hall, stating she only worked the 300 hall. She stated she was putting in the code for the door for a visitor while Resident #11 was at the door. CNA K stated Resident #11 pushed the door open after she put in the code and walked out of the building. CNA K stated she went back to the hallway and yelled for additional staff to ask if Resident #11 was allowed to leave, to which staff members, LVN L and CNA B responded no. CNA K stated, something told her Resident #11 was not allowed to leave. During an interview on 07/16/23 at 9:34am LVN L stated she was working on 07/15/23 when Resident #11 eloped from the building. She stated she was asked by CNA K if a man described as Resident #11 was allowed to leave the building. LVN L stated when notified she locked her med cart and proceeded to run outside to Resident #11. LVN L stated Resident #11 did not want to go back inside the facility and was stating he was leaving and was going to kill himself. LVN L stated she notified the Administrator and the DON who assisted her outside with Resident #11. LVN L stated Resident #11 placed himself on the ground and she went to retrieve a gait belt and a wheelchair. LVN L stated Resident #11 became aggressive and combative and she notified his nurse practitioner who gave new orders to send Resident #11 to the hospital. LVN L stated she called 911 and police and ambulance arrived. LVN L stated all staff is responsible for supervising residents. LVN L stated Resident #11 had not verbalized wanting to leave the facility but stated he has done this before, stating he had gone outside on the front porch before and stated the Social Worker was involved and stated during that incident they were able to calm him down and get him to sit in a chair. LVN L stated Resident #11 was not able to sign himself out. LVN L stated Resident #11 was confused and an elopement risk, and stated was appropriately placed outside of the locked unit. (a secured unit) During an interview with the Social Worker on 07/16/23 at 9:59AM she stated Resident #11 had done this previously, stating one time Resident #11 was sitting outside the side door and did not want to go back into facility when being redirected During an interview with the DON on 07/16/23 at 10:49am she stated usually the aides, and the nurses are responsible for supervising residents. The DON stated Resident #11 had not verbalized that he wanted to leave the facility since she had been working there since 07/03/23. The DON stated she was not aware of Resident #11 attempting to elope. The DON stated she did not think Resident #11 was allowed to sign himself out, stating he is not his own responsible party. The DON stated the day before on 07/15/23 she was pulling into the parking lot of the facility where she saw Resident #11 on his knees with his hands down and his head on his hands. The DON stated he said, I don't want to live anymore I just want to die. The DON stated Resident #11 was with LVN L, and CNA B and K. The DON stated Resident #11 was making himself heavy and stated they retrieved a wheelchair and her, LVN L, CNA B and CNA K got Resident #11 up off the floor and onto the wheelchair. The DON stated Resident #11's knees, hands and face had no scrapes, marks or indentations. The DON stated Resident #11 was appropriately placed outside of the locked unit. The DON was asked if Resident #11 was cognitively aware and stated he does have dementia and stated that behavior was not his regular behavior stating she did think there was some issues there. The DON did not know what caused Resident #11's elopement assessment score increases or decrease. The DON she stated the facility policy on elopement stated if a resident wanted to go out they needed to sign out properly and if they don't then it would be considered elopement, further clarifying that staff should escort the resident out of building. The DON stated if a resident is not found the first thing staff should do is check if they signed out. The DON stated the policy was followed in regard to Resident #11 eloping from facility and stated nothing else should have been done. The DON stated level of supervision for residents is determined by their assessments like BIMS, fall risk and elopement assessment. The DON stated those assessment will determine if the resident required to be moved closer to the nurse's station or be placed in the locked unit. The DON stated she used quarterly assessments to monitor residents for any changes that may require a change in supervision levels. The DON stated getting hurt, having a negative impact from the heat, something happening on the road with all the vehicles or residents seeking drugs are some of the negative impacts a resident by experience if eloping from the facility. During an interview with CNA K on 07/16/23 at 1:46pm she stated on 07/15/23 at around 6:30pm she saw Resident #11 standing at the door, she stated she did not know who he was and did not know if he was a resident or a visitor. She stated by the time she put in the code to unlock the door Resident #11 pushed the door open and went out. CNA K stated she walked backwards to keep an eye on Resident #11 and asked LVN L and CNA B if a person described as Resident #11 was allowed to leave. CNA K stated her, and CNA B ran out of facility towards Resident #11 in parking park where CNA B held on to Resident #11's left elbow and CNA K held on to the left part of Resident #11's sweater. CNA K stated LVN L came out and stood in front of Resident #11. CNA K stated she went back inside the facility to retrieve and wheelchair and did not observe Resident #11 placing himself on the ground. CNA K stated all staff members were responsible for supervising resident and stated Resident #11 had not previously verbalized he wanted to leave the facility stating he had not done this before, and she did not think Resident #11 was an elopement risk. CNA K stated she did not know if she should have gone after Resident #11 stating she did not know who could and could not leave the facility. During an interview with CNA B on 07/17/23 at 6:58am she stated on 07/15/23 CNA K from 300 hall had asked her if Resident #11 was allowed to go outside. CNA B stated she heard LVN L state no and she proceeded to run outside to get Resident #11 stating he walks real fast. CNA B stated he was walking towards the highway, and she was able to reach him and attempted to encourage him to go back to facility. CNA B stated Resident #11 did not want return, stating he wanted to die. CNA B stated Resident #11 started to go down because he did not want staff to hold him up. CNA B stated everyone including hall nurses, aides, the Administrator and DON are all responsible for supervision of the resident. CNA B stated Resident #11 was not allowed to leave the facility on his own and stated she had previously been trained on elopement. Record review of facility's wandering and elopements policy revised on March 2019 revealed 1. If residents are identified as at risk for wandering, elopement or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. Get help from other staff member in the immediate vicinity, if necessary and c. Instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. 3. Review of Resident #3's face sheet dated 07/15/23 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), stage 5, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar ), and essential (primary) hypertension (high blood pressure) Review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS of 13, indicating no cognitive impairment. It further reflected he required limited assistance for transfers and required use of a wheelchair. Record review of Resident #3's care plan reviewed on 07/14/23 at 11:42AM did not identify him as a smoker. Record review of Resident #3's assessments reviewed on 07/14/23 at 11:42AM did not reveal any smoking evaluations in Resident #3's electronic medical record. Observation and interview with Resident #3 on 07/14/23 at 11:39am Resident #3 stated he had a vape pen in his possession and proceeded to take it out of his pocket and show it to this surveyor. Observation of Resident #3 on 07/14/23 at 1:04pm revealed Resident #3 smoking his vape pen in front of the facility without supervision. During an interview with the Administrator on 07/14/23 at 4:55pm he stated residents could not have contraband on them, further clarifying contraband to include, cigarettes, lighters and vape pens. The Administrator stated the facility had high level residents who would go out and buy items that have to be confiscated by the facility. The Administrator stated nobody should have vape pens or cigarettes on them and stated residents should be supervised when smoking. The Administrator stated when he had to confiscate items from residents he would go over the rules and the regulation that have to be followed with the resident. The Administrator stated he tried to utilize he ombudsman as a 3rd party to speak to the resident. During an interview with CNA F on 07/15/23 at 2:48pm he stated he was aware Resident #3 had a vape, stating Resident #3 has the vape pen about a year and a half. CNA F stated he wasn't aware if Resident # 3 was allowed to have a vape pen in his possession he stated he did not know. CNA F stated Resident #3 got the vape pen in the mail. During a interview with CNA G on 07/15/23 at 2:50pm she stated she had seen Resident #3 with a vape pen and cigarettes twice, stating she was not sure if Resident #3 was allowed to have those items in his possession but stated the facility was allowing him to have them now. Record review of Resident #3's electronic medical record reviewed on 07/15/23 revealed an updated care plan to identify Resident #3 as a smoker and a smoking safety screen was identified as created on 07/15/23. Facility made these changes to Resident #3's electronic medical record after this surveyor made the Administrator aware of Resident #3 having a vape pen in his possession on 07/14/23 at 4:55pm. During an interview with the Administrator on 07/15/23 at 5:30pm he stated he had spoken to the activities department who did not have Resident #3 identified as a smoker and stated he was not aware that Resident #3 was a smoker until it was brought to his attention by this surveyor and stated Resident #3 had not been seen with a vape pen. The Administrator stated he spoke to Resident #3 about him having his vape pen and stated it was picked up by the Activities Director. The Administrator stated a new smoking policy was put in place on 07/14/23 because the old one was outdated. The Administrator stated the new policy put in place stated if a resident was deemed a safe smoker after staff completed a smoking safety evaluation, then they would be allowed to have their cigarettes or vape pens in their possession. The Administrator stated nursing would now be doing smoking safety evaluations, stating Resident #3 had one done earlier that morning. When asked if this should have been completed before the Administrator was made aware by this surveyor he stated, when things came up and they needed to be reevaluated this was the process they are doing, further stating, are we perfect? No. The Administrator stated the smoking safety evaluations would be completed quarterly. The Administrator was asked if the facility policy was followed, the Administrator stated based on the facility old policy residents were not allowed to have contraband on him because when a resident would smoke they required supervision, stating that based on old smoking policy Resident #3 should not have had his vape pen in his possession. The Administrator stated Resident #3 did not have a previous smoking evaluation completed because the facility was unaware he was a smoker, stating if smoking evaluations are not complete residents can burn themselves or cause harm to other people. Record review of initial smoking policy provided on 07/14/23 with a revision date of 06/12/19 included a section titled, Policy statement that stated, This facility shall establish and maintain safe resident smoking practices. Section titled, Policy Interpretation and Implementation stated, 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: a. current level of tobacco consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. desire to quit smoking, if a current smoker; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 7. The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited.13. Residents are not permitted to give smoking articles to other residents. 14. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. Record review of updated smoking policy provided on 07/15/23 with no revision date included a section titled, Process that stated, 1. For Centers that allow smoking: 1.1 Smoking (including electronic cigarettes) will only be allowed in designated areas. 1.3 The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke. This is for safety during smoking and for use of smoking apron. 1.4 The patient will be allowed to smoke only with direct supervision. 1.5 All patients who smoke will have a smoking status of supervised and will be noted in their care plan. 1.6 Smoking supplies (including, but not limited to, tobacco, matches, lighters, lig [TRUNCATED]

Based on interviews, and record reviews, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 of 7 residents (Resident #1) reviewed for basic life support, including CPR, in that: 1. LVN A, CNA B, and CNA J failed to check the code status of Resident #1 when Resident #1 was found unresponsive on [DATE]. 2. LVN A, CNA B, and CNA J failed to provide resuscitative measures after assessing Resident #1 and finding him in a state of deterioration with shallow, rapid respirations, pulse 42, blood pressure ,d+[DATE], and no verbal response. 3. The facility staff failed to call 911 when Resident #1 was found to have a change in condition and was deteriorating. 4. LVN R did not have a CPR card on file and LVN S's CPR card was expired. Resident #1 received hospice services but remained a full code status (indicating he wished to receive resuscitative measures). Resident #1 expired in the facility on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:00 PM. While the IJ was removed on [DATE] at 4:16 p.m., the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place all residents who requested a full code status at risk of not receiving necessary life-saving measures, declining health and death. Findings included: Record review of Resident #1's Face Sheet/Admission Record dated [DATE] documented a [AGE] year-old male initially admitted on [DATE] and readmitted from the hospital on [DATE] with the diagnoses of Asthma, heart failure, muscle wasting, abnormality of gait and mobility, diabetes mellitus (high blood sugar), chronic kidney disease, stage 3, and old myocardial infarction (heart attack). Resident #1 expired in the facility on [DATE]. The record indicated Resident #1 had an advance directive of full code status. A record review of Resident #1's Minimum Data Set (MDS) revealed he did not have a complete MDS available due to recent admission. A record review of Resident #1's Brief Interview of Mental Status (BIMS) assessment dated [DATE] documented a score of 9 - moderate cognitive impairment. A record review of Resident #1's Admit/Readmit Screener dated [DATE] indicated Resident #1 was admitted from the hospital with vital signs of blood pressure: ,d+[DATE], pulse: 55 and regular, respiration: 17. Resident #1 verbalized/demonstrated use of call bell, bed controls, side rails, and television. Resident #1 required extensive assistance with bed mobility, dressing, and personal hygiene. Resident #1 was alert, oriented to person, place, time, and situation, and was verbally appropriate. A record review of the hospice admission packet dated [DATE] documented I do not have an advanced directive signed by HN M and Resident #1. A record review of Resident #1's initial baseline/advanced care plan dated [DATE] documented: Resident #1's representative relationship was himself, Resident #1 had no advanced directives, and his code status was full code. A record review of Resident #1's [DATE] Physician Orders documented [DATE] - Admit to hospice services effective [DATE] for diagnoses of end-stage heart failure. For any questions, concerns, or change in condition, do not call 911, call hospice triage . Record review of Resident #1's care plan detail dated [DATE] documented in the focus, I chose to have Full Code. In goals, status will be maintained through the next review date. Interventions were Inform staff of code status. Monitor for decreases in a change of condition-report to MD and responsible party. Record review of Resident #1's [DATE] Physician Orders documented [DATE]- Discontinue service for MD Q to MD L. Record review of Resident #1's [DATE] Physician Orders documented [DATE]-**Code Status ***FULL CODE*** There was no order for oxygen. Record review of Resident #1's [DATE] vital signs dated [DATE] at 1:30 AM documented a normal heart rate of 74 beats per minute. His blood pressure was normal at ,d+[DATE]. His respirations were normal at 18 breaths per minute. His oxygen saturation was normal at 98% (out of 100%). Record review of daily staffing sheets dated [DATE] and [DATE] revealed full staff on duty, on all shifts; 3 CNAs and 2 nurses. Record review of Resident #1's Nursing Progress Notes documented: -[DATE] 6:10 AM - written by LVN A, Note Text: called by CNA to resident's room. resident presented with shallow rapid respirations, on 4 liters of oxygen via nasal cannula, pulse 42, blood pressure ,d+[DATE], no verbal response. CNA posted to monitor resident until hospice arrives hospice contacted at this time for change of condition. answering service stated RN would be here asap. will continue to monitor for changes. [DATE] 6:12 AM - written by: LVN A Note Text: addendum to previous note: CNA in room with this nurse. mouth care given, skin care given, brief changed hob up 30 degrees. foley intact and patent draining dark urine to bedside drainage. no swelling noted. skin warm and dry. resp 22 shallow and rapid O2 increased to 5 liters resp (respirations) appeared to deepen and slow. spo2 (oxygen saturation) 94 at this time. will continue to monitor. -[DATE] 6:39 AM -written by: LVN A Data Entry Error -?Note Text: upon entering the floor for my shift, I was informed by the CNA that this resident was altered. upon examination, resident (Resident #1) appears to have declined to the point of actively dying. Hospice was contacted. Unable to get a reading for bp or pulse ox. resp 12 o2 in place at 4 l per min. mouth breathing eyes fixed non-responsive to verbal stimuli will continue to monitor for changes. -[DATE] 6:57 AM - written by: LVN A Data Entry Error -Note Text: called to resident's room by CNA. Resident #1 has eyes fixed upward, unable to obtain vital signs. Hospice RN on the way to pronounce. -[DATE] 7:29 AM - written by: LVN A Note Text: Hospice nurse arrived. came to this nurse stating that the resident had passed. stated he had pronounced resident and would handle all further arrangements and contact family. [DATE] 9:02 AM - written by: LVN A Note text: SW P spoke with facility nurse who stated she notified hospice of Resident #1's decline in condition. Additionally, SW P spoke with HN M who denied initiating any attempts of CPR and/or calling EMS however he stated he pronounced Resident #1 as deceased . Record review of the hospice call center transcription dated [DATE]: 06:35 AM received a call from LVN A at nursing facility- Resident #1 is not doing so well. He is unresponsive, (I) can't get a pulse or pressure. Respirations are shallow around 10. Caller requesting nurse visit for decline in status/imminent death. Escalated to [HN M. 6:49 AM]. Please acknowledge message receipt. 07:01 Received message by HN M. 07:45 AM Patient expired. During an interview with LVN A on [DATE] at 5:33 PM revealed her shift started at 6:00 AM on [DATE]. She said she assessed Resident #1 around 6:15 AM on [DATE], and he was not doing so well. LVN A stated his breathing was shallow and rapid, he was unresponsive, his heart rate was in the low 40s, and his blood pressure was low. LVN A said he was breathing when she left his room about five minutes later. LVN A said she did not assign anyone to stay with Resident #1. LVN A said she called the hospice call center and left a message for the hospice nurse. She said she did not know whom she talked to. LVN A said she knew of Resident #1's full code status. LVN A said there was an order that read, . do not call 911, call hospice. LVN A stated she did not initiate CPR and she did not call Resident #1's doctor. LVN A said after she called hospice, she passed meds to her other residents. LVN A said around 7:10 AM, the hospice nurse walked up to her and told her Resident #1 was dead. LVN A said the hospice nurse did not say anything else to her. LVN A said she was unaware that the hospice nurse was in the building until he approached her. LVN A said she did not check on Resident #1 after the initial assessment at 6:15 AM, nor did she assign anyone to monitor him Because I only had one CNA for 24 residents, and I was busy. During an interview with the DON on [DATE] at 5:46 PM revealed he was off on [DATE] and just noticed LVN A had texted him at 7:46 AM. The DON said the text read, please come to 200 (hall). He said he was asleep and did not see the text for hours. The DON said the ADM was supposed to have been there. The DON said he received a phone call at 8:56 AM from the MDS coordinator to inform him the hospice nurse was there and had pronounced Resident #1 dead. The DON said the MDS coordinator told him she was concerned because she discovered Resident #1 was a full code. The DON said he was told no one initiated CPR on Resident #1. During an interview with the ADM on [DATE] at 5:55 PM revealed Resident #1 was his own responsible party. The ADM said LVN A should have known Resident #1 was a full code. The ADM said he was unaware of the situation with Resident #1 as it was happening and LVN A made no attempt to contact him. During an interview with LVN A on [DATE] at 6:07 PM revealed she knew Resident #1 was a full code before he went south but didn't check to make sure. LVN A said she did not assign anyone to sit with Resident #1 because everybody was too busy. LVN A said when she went back to check on him (an hour later), that was when she ran into HN M and he told her about Resident #1's death. LVN A said she had another hospice patient declining, she was very busy passing meds, and there was only her and one CNA caring for 24 residents. LVN A said she would have checked on Resident #1 sooner, but she could not leave the CNA because she only had one CNA. She said there was not anyone else she could have asked for help. During an interview with the BOM on [DATE] at 6:24 PM she said Resident #1 was cognitive when he was admitted on [DATE] and he was his own representative. During an interview with LVN A on [DATE] at 7:19 PM revealed she said Resident #1 was breathing and moaning and she could not do CPR on someone who was still breathing. Regarding Resident #1's pulse in the 40's, she said she did not take any manual vital signs, they were all done by the machine. She said she did not ask for help. LVN A said Resident #1 was bradycardic (slower than expected heart rate, generally beating less than 60 beats per minute) since he was admitted on [DATE]. She said she did not administer any breathing treatments and could not recall if Resident #1 was on oxygen. A record review of Resident #1's vital sign log dated ,d+[DATE] revealed there was no documented pulse rate lower than 55 beats per minute. During an interview with CNA D on [DATE] at 8:10 PM revealed she looked at every resident's profile she was assigned to every shift for their code status. CNA D said the code status was found on the 1st page, of the profile, in the electronic chart. CNA D said CPR should be started when there was no pulse and the resident unconscious. During an interview with LVN E on [DATE] at 8:12 PM revealed she would start CPR when the resident was unresponsive and/or had no pulse. She said the code status could be found on the resident's profile. During an interview with CNA C on [DATE] at 8:14 PM revealed CPR should be started when a resident was not breathing or did not have a pulse. She said we (CNAs) don't look at code status because the nurse should know. During an interview with CNA F on [DATE] at 8:16 PM revealed CPR should be started when someone stops breathing and she would call the nurse. During an interview with LVN G on [DATE] at 8:18 PM revealed she would start CPR when she knew their (a resident) code status. She said she looks every shift for her resident's code status because she never knew when it could change. So even if she took care of the same residents on consecutive shifts, she would look at each shift. During an interview with the DON on [DATE] at 8:20 PM revealed he said CPR should be started for cardiac or respiratory arrest, when there was no pulse or when breathing stopped; If someone did not know the code status, CPR should be done until the code status was determined. During a phone interview with NP K on [DATE] at 8:21 AM revealed he had been running into some issues trying to change the culture at the facility and was afraid something like this would eventually happen. He said as soon as Resident #1 was discovered to be in distress, and LVN A knew his code status, she should have started resuscitative measures immediately once he stopped breathing or no longer had a heartbeat. [LVN A] should have called the doctor, she should have put oxygen on [Resident #1], and she should have contacted the family while he was still breathing. During a phone interview with MD L on [DATE] at 8:50 AM revealed he was unaware of any resident's death, as he had not seen any of the residents at the facility since taking over for the previous doctor on [DATE] and was surprised to learn his name was on the full code order dated [DATE]. He also said that it was ok for full-code residents to be in hospice to get the benefits that hospice offered. MD L said the resident had to go to the hospital if they were not doing well. MD L said CPR was not necessarily helpful for nursing home patients, and that it did not matter if they were full code. He informed this surveyor that only 1% of nursing home residents who receive CPR survive. During a phone interview with HN N and HN O on [DATE] at 10:42 AM revealed all calls made to the hospice call center were transcribed. HN O said that while the order HN M had written was confusing, Resident #1 should have been sent to the hospital regardless-that was what normally happened, and/or follow the facility's protocol. HN N said Resident #1 was a full code, they should have initiated CPR. HN O said do not call 911 was not a common thing to write as part of an order-the facility should have modified the order or sent him (Resident #1) out to the hospital. During an interview with the DON on [DATE] at 2:38 PM, he said he and the Administrator were responsible for initiating an internal investigation. The DON said he began an internal investigation regarding Resident #1's death approximately on the afternoon of [DATE]. The DON said he interviewed LVN A and conducted in-service training. The DON said LVN A- stated to him that LVN A was informed by CNA B that Resident #1 Was not looking good. The DON said LVN A assessed Resident #1, retrieved vitals, and decided to call hospice to inform hospice of Resident #1's condition. The DON said LVN A told him that she was aware of Resident #1 being a full code. The DON said LVN A said she was not informed upon the hospice nurse's arrival but was approached by the male hospice nurse who told LVN A that Resident #1 had expired and that he pronounced Resident #1. The DON said LVN A said she had not re-entered Resident #1's room from the time she first assessed Resident #1 and made the decision to call hospice until she was approached by the hospice nurse. During an interview with CNA B on [DATE] at 2:48 PM revealed she was the CNA assigned to care for Resident #1 on [DATE] from 6:00 AM to 6:00 PM. CNA B said at approximately 6:00 AM she noticed Resident #1 was going downhill. Around 6:15 AM on [DATE], she saw Resident #1 not breathing right. CNA B said Resident #1 had oxygen on, and he was just lying there. CNA B said she informed LVN A which LVN A assessed Resident #1 and said she was going to notify hospice of his change in condition. CNA B said she went in and out of Resident #1's room several times to check on Resident #1 because she knew Resident #1 was not doing good however she was also checking on other residents she was assigned to. CNA B said she was not instructed by LVN A to stay at Resident #1's bedside for monitoring. CNA B said at 6:57 AM, she entered Resident #1's room and saw that he was no longer breathing. CNA B said she looked at her phone which indicated the time of 6:57 AM. CNA B said she called out for LVN A, who was sitting at the nursing station, and yelled He's not breathing, come on. CNA B said she did not know what Resident #1's code status was and was waiting for the direction of LVN A. CNA B said LVN A entered the room and confirmed Resident #1 was not breathing but did not initiate any CPR measures. CNA B said she left the room after the nurse confirmed Resident #1 was not breathing. CNA B said her practice was that if she saw that a resident showed a change in condition, she would immediately call the nurse to assess the resident. CNA B said she would get to the kiosk to review the resident's care plan to check the code status. When asked if she checked Resident #1's code status, she said she did not. CNA B said since the nurse was calling hospice and going through his records, the nurse should have informed all the staff of Resident #1 being a full code so everyone could intervene by initiating CPR, calling 911, and the doctor. CNA B said since Resident #1 was a full code, CPR should have been initiated as soon as he was found not breathing or had no heart rate. CNA B said she was not there when HN M got there because her shift had ended. During a phone interview with HN M on [DATE] at 4:09 PM revealed that around 6:40 AM on [DATE], a nurse (LVN A) called the hospice triage line and reported: [Resident #1] had no pulse, no blood pressure, low respirations, and she thought [Resident #1] was declining. HN M said he called the facility around 6:50 AM and the SW told him Resident #1 was a full code. He said he showed up at the facility around 7:,d+[DATE]:20 AM and saw LVN A standing at a med cart, and LVN A said to him he (Resident #1) checked out at 6:30 (AM). HN M said he assumed LVN A called 911 and that she should have followed facility protocol of when to initiate CPR. HN M said he could understand why the order he wrote that read, .do not call 911. Call hospice . could have been misconstrued and why she could have been confused, but nothing in the orders said not to start CPR. HN M said after he pronounced Resident #1's death, LVN A asked him if he started any CPR measures for Resident #1 when he assessed Resident #1 however, HN M said he had not since Resident #1 had already been deceased since 6:30 AM as reported to him by LVN A. HN M said he found it odd that LVN A asked him if he had the DNR papers for Resident #1 to which he replied, I understand he's a full code and she responded, Oh f**k and then walked away. During an interview with CNA J on [DATE] at 8:55 AM revealed she worked for the facility for one year and a half. CNA J said she worked on [DATE] 6:00 AM - 6:00 PM. CNA J said she worked the 200 hall, rooms ,d+[DATE], and, CNA B had rooms ,d+[DATE]. CNA J said she arrived on shift at 6:10 AM. She said she got a shift report from the night shift CNA, and she told CNA B and CNA J to look after Resident #1 because his breathing was irregular, and they had to turn up the oxygen overnight. The night shift CNA said he (Resident #1) could go anytime today either later or in a matter of minutes. CNA J said at approximately 6:30, AM she and CNA B cleaned Resident #1 up, saw his lips were chapped, and his skin was ashy (dry). CNA J said Resident #1 was nodding his head to answer questions appropriately. CNA J said she did not think LVN A got a shift report from the night nurse because she would have made them aware of his condition and she didn't; she just sat at the desk and did not get up at all. CNA B came out of Resident #1's room and said, come here I don't think he is breathing anymore. CNA J said she looked for Resident #1's chest which was not going up and down, then touched him and he was not breathing. CNA B went to tell LVN A that Resident #1 was not breathing. LVN A went to the room, asked CNA B what time it was - 6:57 AM, and LVN A stood by the door, looked at Resident #1, and said, yes he's dead. Then LVN A walked up to Resident #1, put her hand on his chest, and again said Yes, he's dead. LVN A never checked Resident #1's pulse. CNA J said she saw HN M sitting on the living room couch but at the time she did not know who he was. CNA J said she did not see LVN A tell HN M what was happening with Resident #1. I do not think he knew what was happening. When we were trying to figure out who HN M was, Resident #1 was still alive. There was a lot of screaming, SW P saw Resident #1 in the body bag and stopped the morticians and asked who it was. They told her, and SW P said he was a full code, what are you doing? CNA J said LVN A was asking us (CNA C and CNA J) to lie for her; LVN A told us If state comes out to talk to you tell them that you went to Resident #1's room to change him and then you went to change another resident and we did not know Resident #1 was dead. She told us 4 or 5 times about telling you all (state) that. CNA J said she did not know Resident #1's code status. CNA J said the facility had the code status book on the kiosk and Kardex. CNA J said she did not think to check it at the time. CNA J said she did not have a current CPR card and said she put her name on the facility sign-up list a while ago but no class was offered yet. When asked what the procedure was to check a resident's code status, CNA J said she would check the DNR list located at the nurse's station and would ask the nurse for his code status. CNA J said the nurses should be aware of their resident's code status. CNA J said she did not think LVN A knew Resident #1 was a full code because she would have immediately done CPR, which she did not. CNA J said the nurse is the one that calls a CODE BLUE. She said she had been in a code before. She said LVN H, the other nurse, and HN M were in the building when all this was going on with Resident #1 before he passed away, So she had help but she didn't call for any help. Several attempts were made to contact HN M on [DATE] from 09:36 AM-11:30 AM for clarification as to his whereabouts alluded to in the above statement. Messages were left but no return call was received During an interview with the DON on [DATE] at 11:32 AM revealed the facility had two AEDs in the building. The DON said a vast majority of staff had been trained on AED usage. The DON said the AED should be used when the resident stops breathing or has no pulse. The DON said AED pads would be put on as CPR is initiated. The DON said no one attempted to use any AED on Resident #1 on [DATE]. During an interview with LVN H on [DATE] at 12:29 PM revealed he said he was working on [DATE]. He said he did not know what was happening with Resident #1, and that he only found out when HN M showed up at approximately 7:00 AM. He said HN M asked him when the last time he saw Resident #1 and LVN H told him he was not his nurse, (he was working on the opposite end of the hallway) and that LVN A was his nurse. LVN H said he did not know why LVN A did not inform him of Resident #1's change in condition or death. LVN H said if he had a resident declining too fast, he would monitor vitals, initiate CPR and call 911, and notify supervisors. LVN H said he would get assistance or get a CNA to notify another nurse on duty to assist him. LVN H said a Code Blue and another nurse should have been called. LVN H said if the CNAs were CPR certified, they could have initiated CPR. He said AEDs were available but not used for Resident #1. LVN H said he would have started CPR because Resident #1 was full code. Attempts to contact HN M on [DATE] at 01:54 PM, and at 5:45 PM- messages were left. No return call was received for the rest of the day or the following day. A record review of LVN R's personnel file documented a hire date of [DATE]. Her nursing license was due for renewal on [DATE]. As of [DATE], her license had not been renewed. LVN R's CPR card had an expiration date of ,d+[DATE]. A record review of LVN S's personnel file documented a hire date of [DATE] and documented a CPR card with an expiration date of ,d+[DATE]. An interview with the DON on [DATE] at 9:41 AM revealed licenses and certifications including a Covid card, were verified during the hiring process. When asked if he was aware of LVN R's expired license and CPR cards, and LVN S's expired CPR card, he said he did not know, that they just fell through the cracks. An interview with the DON on [DATE] at 9:44 AM revealed LVN R had taken a 1-hour online CPR class and presented this surveyor with her new CPR card dated [DATE]. When asked how LVN R could have taken a full-day course and completed the hands-on skills portion, as required by the AHA guidelines when a CPR card lapsed, he said nothing. In addition, the CPR card documented eligible for skills session within 90 days indicating the required skills portion was not complete. An interview with HR on [DATE] at 2:40 PM revealed potential new employees required a background check and an application that contained license information, education, employer history, certifications, and references. She said the DON and the ADM approve applications for all licensed personnel and other department heads handle their respective areas. HR said she did not know of any policies or guidelines for the hiring process other than the background check and application. An interview with the CCO on [DATE] at 3:55 PM revealed the HR process was supposed to be checking the credentialing. He said the DON and/or the ADM were also supposed to be checking the credentialing before hiring. The CCO said he did not know who dropped the ball. LVN R and LVN S were unavailable for interviews. Record review of In-services:[DATE]: .resident change of condition ., [DATE]: automated external defibrillator, use and care of, [DATE]: how and when to call a code, advanced directives, what to do if unsure about code status, not leaving resident during a crisis situation, getting help, [DATE]: code status binder/DNR binder in the nurse's station, cardiopulmonary resuscitation, code review, verification of all orders (admission and hospice), cardiopulmonary resuscitation, code procedure, how to verify a resident's code status, (DNR vs FULL), change in a resident's condition or status, resident code status binder location, (for nursing and non-nursing), [DATE]: Policies read verbatim-change in a resident's condition or status, code procedure, emergency procedure-cardiopulmonary resuscitation, location of DNR binders for clinical and non-clinical. A record review of all licensed personnel and their CPR cards revealed 2 expired CPR cards and 1 expired license. A record review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation policy and procedure dated February 2018 documented Personnel has completed training on initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest: General Guidelines: .5. Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (rigor mortis) 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR . Emergency Procedure -Cardiopulmonary Resuscitation: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing . 6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. 7. When AED arrives, assess for need and follow AED protocol as indicated. 8. Continue with CPR/BLS until emergency medical personnel arrive. A record review of the facility's Change in Condition or Status policy and procedure dated February 2021 documented Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status: 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): .d. significant change in the resident's physical/emotional/mental condition . 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form . A record review of the facility's Advance Directives policy and procedure dated [DATE] documented Advance directives will be respected in accordance with state law and facility policy: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. A record review of the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care documents in Part 3, page 1, top 10 take-home messages for adult cardiovascular life support 1) On recognition of a cardiac arrest, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation. On [DATE] at 1:12 PM, the facility Administrator, DON, and Chief Compliance Officer (CCO) were notified that an Immediate Jeopardy situation had been identified due to the above failures. The Administrator was provided with the Immediate Jeopardy Templates via e-mail on [DATE] at 1:14 PM. On [DATE] at 2:44 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: PLAN OF REMOVAL [DATE] On [DATE], an off-cycle survey was initiated at San [NAME] Nursing and Rehabilitation Center. On [DATE], the facility was notified by the surveyor that an immediate jeopardy had been called and needed to submit a letter of credible allegation. The Facility respectfully submits this Letter of Credible Allegation pursuant to Federal and State regulatory requirements. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. Issue identified by the surveyor: The facility failed to ensure staff was knowledgeable of when to initiate basic life support and ensure staff was familiar with Resident #l's Full Code status. All 7 hospice residents who have been designated to be a Full Code have the potential to be affected by the alleged deficient practice. Corrective Actions: 1. Upon identification of the fa [TRUNCATED]

Based on record review and interview, the facility failed to ensure each resident received adequate supervision to prevent accidents, for one Resident (R#1) of six residents reviewed for falls and accident hazards. CNA A did not provide the amount of supervision necessary to prevent R#1 from falling and sustaining multiple right side rib fractures, right humeral fracture, and a contusion to the resident's head which led to hospitalization . This failure could affect all residents and place them at risk for falls and injuries. The findings included: Review of R#1's Face sheet, dated January 12, 2021, documented a [AGE] year-old female admitted [DATE], with the [DIAGNOSES REDACTED]. R#1 was discharged on [DATE]. Review of R#1's Minimum Data Set (MDS) assessment, dated 12/19/20, documented she: -had severe cognitive impairment, -required extensive assistance for all activities of daily living, -required two-person assistance with bed mobility and transfers, -was frequently incontinent of urine and bowel. Review of R#1s Individual Resident Care Plan, initiated 04/26/19 (revised 12/12/20) documented: Locomotion/Transfer/Positioning; Assist 2 assist w/mobility . Comments/Special Needs; Risk for falling (describe) Poor safety awareness Review of R#1's Care Plan, dated 01/11/21, which was revised on 1/12/21, documented: The resident has an ADL self-care performance deficit related to Dementia. Goal The resident will maintain current level of function in ADL's through the review date. Interventions documented . -BED MOBILITY: The resident requires (extensive assistance) by (2) staff to turn and reposition in bed. -TOILET USE: The resident requires (extensive assistance) by (2) staff for toileting. Review of R#1's Care Plan, dated 01/11/21, which was revised on 01/12/21, documented: The resident is at risk for falls related to [MEDICAL CONDITION]. Goal The resident will be free of falls through the review date. Dated initiated: 01/11/21. Revision on: 01/12/21. Target date: 12/08/20. Interventions documented . -Anticipate and meet The resident's needs. (date initiated 01/11/21) -Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. (date initiated 01/11/2021) -Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. (date initiated 01/11/21) -The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position personal items within reach. (date initiated 01/11/21). Hospital Radiology report of x-ray to right shoulder dated 01/09/2021 documented Impression: suspected acute fracture through the humeral neck. -x-ray to right Humerus on 01/09/21 documented Impression: comminuted mildly impacted right humeral head neck fracture. -x-ray to chest dated 01/09/2021 documented Impression: multiple right-sided rib fractures at least 2 of which are indeterminate and may be acute. Correlate with point of tenderness. -CAT (Computed tomography) scan report dated 01/09/2021 documented impression: Right 6th through 9th rib fracture. -CAT (Computed tomography) scan report dated 01/09/2021 documented impression: prominent soft tissue contusion along the forehead. Review of R#1's Nurse's Note, dated 01/09/21 at 4:17 p.m,. documented CNA A notified nurse of resident on the floor after a fall. Nurse entered room and found resident laying on the floor face down with her left arm under her. Nurse assessed resident and found her bleeding profusely from her nose and complaining of right arm pain. CNA A applied pressure while nurse went to call 911. This nurse then called 911 and stayed with resident until EMS arrived. Resident left the facility accompanied by five EMS and was escorted to Doctors regional hospital. Review of R#1's Incident report, dated 01/09/21, documented: Nursing description: CNA notified nurse of resident on the floor after a fall. Nurse entered room and found resident laying on the floor face down with her left arm under her. Nurse assessed resident and found her bleeding profusely from her nose. This nurse then called 911 and stayed with resident until EMS arrived. Residents description: I fell out the bed when she turned me. An interview with ADON B on 01/12/21 at 1:26 p.m. revealed that CNA A was currently suspended pending investigation. She was able to interview CNA A over the phone briefly, but CNA A had not answered any phone calls since 1/10/2021. ADON B revealed that during the interview with CNA A, CNA A revealed she was providing incontinent care for R#1 and while turning R#1 to change her, R#1 continued to turn and rolled off the bed. R#1 had fallen off the bed to the ground. CNA A immediately called LVN D. ADON B revealed that she believed that CNA A was the only one in the room to witness the fall but was unsure because she didn't get to ask any in depth questions during interview. ADON B confirmed that the resident was a 2 person assist while changing because it said it on the facility's Kardex and care tracker. The Kardex/ Care tracker was what CNAs documented on and informed the staff what care to provide to the resident and how the care should be provided. ADON B revealed on the kardex/care tracker it specified that R#1 was a 2 person assist with bed mobility. This meant that during the care that was provided by CNA A there should have been 2 staff in the room to assist R#1. ADON B stated that If there was only one staff member in the room while changing (R#1), that would be considered negligence on the CNA's part. Record review of interview with CNA A by ADON B on 01/10/21 at approximately 12:30 p.m. revealed: This nurse calls (CNA A) to inform her of her suspension pending further investigation of fall sustained by (R#1) on 01/09/21 at approximately 3:15 pm. This CNA states to this nurse that while providing incontinent care to (R#1) in her room, in her bed, she attempted to turn (R#1) onto her side and resident continued to roll over off of the bed and onto the floor. (R#1) was noted by (CNA A) lying on the floor by her bed in the prone position, (CNA A) immediately notified (LVN D) for further assessment. Interview with ADON B on 01/13/21 at 10 a.m., revealed that she still could not get ahold of CNA A. ADON B revealed that all staff was supposed to learn about the kardex/care tracker during orientation. The staff was supposed to have a CNA competency form that they followed but she was unsure who was in charge of following that tracking. The facility was unable to provide CNA competency tracking upon orientation. An interview with RN C on 01/13/21 at 11:29 p.m. revealed that CNAs knew how to care for residents because they had access to the care chart that told them how the care should be provided. The CNAs used the care charts daily to sign off on the care provided daily. An interview with RN C on 01/13/21 at 10:30 a.m revealed that if a resident required extensive and 2 persons assist with bed mobility, there should be two staff members in the room and they need to use muscles. RN C stated the staff should be following the Kardex/ Care chart and the care plan stated there should have been two staff members in the room to provide care for R#1. In a phone interview with CNA A on 01/14/21 at 12:59 p.m., revealed that, on 01/09/21, she went into R#1's room to provide incontinent care. She left the room to look for assistance and couldn't find anyone to help her. She returned to R#1's room alone. She began to provide incontinent care and, while turning R#1 away from her to place a sheet under her back, R#1 continued to roll and fell off the bed. After the fall occurred, she called LVN D and R#1 was sent to the hospital. CNA A revealed that she didn't know how many staff members it took to change R #1. She stated that the care tracker has a kardex that will tell the staff how many staff mebers it takes to care for a resident, but she did not looked at R #1's kardex prior to providing care. She stated she documents any resident care into the care tracker after it is complete. In multiple interviews with six CNA's conducted on 1/14/21 and 2/04/21 it was revealed, they were introduced to the care tracker and kardex upon orientation and were able to demonstrate on the care tracker how to find the kardex and where to locate the information which described to staff how to care for the residents and how many staff it takes to perform different activities of daily living. Facility was unable to provide the Kardex of R#1.

Based on observation, interview, and record review, the facility failed to implement their written policy and procedure that prohibits neglect for one Resident (R #1) of five Residents reviewed for injuries. R #6 was identified at risk for inadequate nutrition and dehydration. The facility did not evaluate the results of their interventions (food/fluid intake data) or revise interventions when R #6's food/fluid intake declined. R #6 was sent to the hospital with altered mental status and low oxygen saturation. R #6 was diagnosed with [REDACTED]. R #6 remained in the hospital during this investigation. This failure affected one resident (R #6) and placed 79 residents who needed assistance with meals at risk for inadequate nutrition/hydration issues and neglect. Findings included: The facility's Abuse Prevention Program Policy Revised and dated 07/31/14 revealed "Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Comprehensive policies and procedures have been developed to aid out facility in preventing abuse, neglect or mistreatment of [REDACTED]. R #6's Face Sheet, dated 05/22/14, indicated R #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnoses: [REDACTED]. of pressure inside the eye), [MEDICAL CONDITION] (too little [MEDICAL CONDITION] hormone), and Senile Cataract (age related vision impairing disease). R #6 was [AGE] years old. R #6's Admission Minimum Data Set ((MDS) dated [DATE] indicated R #6 had short-term and long- term memory problems; cognition was moderately impaired (decisions poor; cues/supervision required). R #6 was independent with eating but may require one person physical assist. R #6 had no signs or symptoms of possible swallowing disorders; his height was 70 inches and his weight was 161 pounds. R #6 had no weight loss in the last 6 months. R #6 had no natural teeth or tooth fragments. R #6 was always incontinent of bowel and bladder. The MDS indicated R #6's active [DIAGNOSES REDACTED]. R #6's Nutritional Data Set and Progress Note, dated 10/01/14, revealed R #6's weight was 164 pounds (lbs.) and he was 70 inches in height. The Consultant Dietitian documented "no significant change." Estimated Nutritional Needs for R #6 were: "2250 kcal, 75-83 g (grams) pro (protein), 1875-2250 mi (milliliter) fluid d/t (due to) [MEDICAL CONDITIONS]. Current diet Order: Mechanical Soft. Goal/Intervention: Resident with Dx (diagnosis) of CKD ([MEDICAL CONDITION]) stage 3. Recommend: Provide 120 ml [MEDICATION NAME] (nutritional supplement for [MEDICAL CONDITION] patients) four times daily with medication pass D/T high BUN (Blood Urea Nitrogen- a laboratory blood test that reveals information on how the kidneys and liver are functioning)." R #6's physician's orders [REDACTED]. PO (orally) QID with med (medication) pass for supplement and increased BUN." R #6's Care Plan dated 10/15/14, revealed R #6 was at "risk for alteration in nutrition related to impaired cognition, rejects care, functional impairment, sensory impairment; has no teeth (refuses pureed diet)." The goal of the Care Plan was to "administer iron supplements as ordered; [MEDICATION NAME] as ordered; [MEDICATION NAME] (nutritional shake) as ordered; [MEDICATION NAME] (for [MEDICAL CONDITION] reflux) as ordered; Multivitamins as ordered; set-up, cue, assist as needed with meal consumption; Diet as ordered- Regular mechanical soft large portions; encourage greater than 75% offered fluids and meals daily; Record % of meal and fluid intake, report changes as needed..." R #6's Care Plan dated 10/31/14, revealed R #6 was at "risk for dehydration. Related Diagnoses: [REDACTED]. Approaches: R/O (rule out) UTI with changes in continence, promote adequate hydration, report changes to characteristics of urine such as color, odor, sediment, incontinence care PRN (as needed), monitor for bladder distension, c/o (complaints of) pain, decreased urine output and report, continue to encourage resident to drink fluids/ more water and less soda's. Resident does refuse water/juices in preference to soda's." R #6's Telephone Order dated 10/31/14 revealed an order for [REDACTED]." R #6's Medication Administration Record [REDACTED] 1. [MEDICATION NAME] (treats fluid retention in people with [MEDICAL CONDITION]; excretes fluid) 40 mg (milligrams) PO (orally) daily at 8:00 a.m. from 10/01/14-10/31/14; 2. [MEDICATION NAME] 250 mg IM on 10/31/14; and 3.[MEDICATION NAME] mg PO BID on 10/31/14 at 4:00 p.m. R #6's Physician order [REDACTED].#6 did not have an order for [REDACTED]. R #6's Consolidated Physician order [REDACTED]. 1. [MEDICATION NAME] (treats fluid retention in people with [MEDICAL CONDITION]; excretes fluid) 40 mg (milligrams) PO daily; 2. Folic Acid (a B vitamin) 1 mg PO daily; 3. [MEDICATION NAME] (iron supplement) 325 mg PO daily at noon; 4. Multiple Vitamin with Minerals one tab (tablet) for supplement; 5. [MEDICATION NAME] (a replacement for a hormone normally produced by the [MEDICAL CONDITION]); 6. Diet: Regular, Mechanical Soft, larger portions; 7. [MEDICATION NAME] 120 ml PO QID with med pass for supplement and increased BUN. Additional Diagnoses: [REDACTED]., and thoughts), [MEDICAL CONDITION] Stage III (deteriorating renal function; eGFR is approximately 30-60%; eGFR is estimated Glomerular Filtration Rate, usually based on serum Creatinine level, age, sex, and race. http://www.renal.org/information-resources/the-uk-eckd-guide/about-egfr#sthash.OT2uBJIh.dpuf). R #6's Fluid Intake Flowsheet dated 10/2014 and 11/2014 revealed: 10/21/14- Brk (breakfast)- 360 ml (milliliters); Lun (lunch)- 9 ml; Din (dinner)-240 ml; other- nothing documented; Total- 609 ml. 10/22/14- Brk- 360 ml; Lun- 480 ml; Din- 240 ml; other- nothing documented; Total- 1080 ml. 10/23/14- Brk- 316 ml; Lun- 480 ml; Din- 0 ml; other- 160; Total- 956 ml. 10/24/14- Brk- 360 ml; Lun- 480 ml; Din- 200 ml; other- nothing documented; Total- 1040 ml. 10/25/14- Brk- 300 ml; Lun- 240 ml; Din- 0 ml; other- nothing documented; Total- 540 ml. 10/26/14- Brk- 200 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 640 ml. 10/27/14- Brk- 360 ml; Lun- 200 ml; Din- 0 ml; other- nothing documented; Total- 560 ml. 10/28/14- Brk- 600 ml; Lun- 200 ml; Din- 80 ml; other- nothing documented; Total- 880 ml. 10/29/14- Brk- 360 ml; Lun- 2 ml; Din- 0 ml; other- 120 ml; Total- 482 ml. 10/30/14- Brk- 600 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 1040 ml. R #6's Nurses Note dated 10/30/14 at 1:35 p.m. documented "Notified NP (Nurse Practitioner) resident has a foul odor in urine, fair skin tugor (a sign used by healthcare workers to assess fluid loss or dehydration). NP stated to encourage fluids. Resident drinks fluids, refuses to drink water, states he doesn't like it. NP aware of this, NP states it can be any type of fluids." 10/30/14 8:52 p.m.- "Res (resident) drinks fluids, refuses to drink water, states he doesn't like it. Staff continue to offer water to resident." 10/31/14- Brk- 240 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 680 ml. R #6's Nurses Note dated 10/31/14 at 11:43 a.m. documented "Dr (doctor) here notified him of res foul odor in urine, dr went into room and assessed res. Obtained [MEDICATION NAME] (antibiotic) IM (intramuscularly) [MEDICATION NAME](antibiotic) PO (orally) for dx (diagnosis) UTI. Continuing to offer fluids, taken well, poor skin tugor...10/31/14 1:49 p.m.- "Staff continues to encourage resident to drink more water and other fluids other than soda d/t (due to) urine having a foul odor.." 11/01/14- Brk- 200 ml; Lun- 200 ml; Din- 0 ml; other- 120 ml; Total- 520 ml. R #6's Nurses Note dated 11/01/14 at 9:08 p.m. documented "Continues on ABT (antibiotic therapy) for UTI, increase water fluids and continue to monitor. Continues with foul smelling urine..." 11/02/14- Brk- 0 ml; Lun- 120 ml; Din- 240 ml; other- nothing documented; Total- 360 ml. R #6's Nurses Note dated 11/02/14 at 3:06 a.m. documented "Res continues on ABX (antibiotic) for UTI. Continues with foul odor to urine..." 11/03/14- Brk- 0 ml; Lun- 120 ml; Din- 120 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Note dated 11/03/14 at 9:50 a.m. documented "Res continue on abx for uti, refused breakfast, continue to encourage fluids, refused offered fluids per nurse.." 11/04/14- Brk- 600 ml; Lun- 240 ml; Din- 240 ml; other- 140 ml; Total- 1220 ml. R #6's Nurses Notes dated 11/04/14 at 11:48 a.m. documented "Continue on antibiotic for UTI, encourage fluids...11/04/14 1:22 p.m.- "Resident refused lunch only ate few bites, fluids tolerated..." 11/05/14- Brk- 120 ml; Lun- 120 ml; Din- 0 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Note dated 11/05/14 at 1:27 p.m. documented "Ate only bites for lunch, fluids taken well..." 11/06/14- Brk- 120 ml; Lun- 246 ml; Din- 0 ml; other- 120 ml; Total- 486 ml. R #6's Nurses Note dated 11/06/14 at 3:29 a.m. documented "Accepts small amounts of hydration only.." 11/07/14- Brk- 240 ml; Lun- 0 ml; Din- 0 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Noted dated 11/07/14 at 12:14 p.m. documented "Fluids encouraged, requires a lot of encouragement, fluids tolerated in small amounts. Fair appetite noted." 11/08/14- Brk- 0 ml; Lun- 0 ml; Din- 240 ml; other- 120 ml; Total- 360 ml. R #6's Nurses Note dated 11/08/14 at 10:20 a.m. documented "Continue on abx for UTI; fluids not taken well, skin tugor poor, poor appetite noted..." 11/09/14- Brk- 0 ml; Lun- 0 ml; Din- 240 ml; other- 120 ml; Total- 360 ml. R #6's Nurses Note dated 11/09/14 at 9:33 p.m. documented "Continue to assist resident with fluids and offered fluids; resident accepted small amount..." 11/10/14- Brk- 480 ml; Lun- 0 ml; Din- 0 ml; other- nothing documented; Total- 480 ml. R #6's Nurses Not dated 11/10/14 at 3:34 a.m. documented "Refusing to drink water at times..." 11/11/14- Brk- 120 ml, no other fluid was documented this day; R #6 was sent to the hospital at 12:00 p.m. The facility began to treat R #6 for "UTI" on 10/31/14; Even after knowledge of the [DIAGNOSES REDACTED].#6 consumed, at least, his daily recommended fluid intake after 10/31/14 and continued to administer his daily dose of [MEDICATION NAME], which assisted in depleting his fluids. R #6's Nurses Note dated 11/11/14 at 11:40 a.m. documented "Skin warm and dry to touch, appears very lethargic. SPO2 (oxygen saturation) at 80%, O2 (oxygen) at 3 liters via nasal cannula, resident refused to leave in place, continues to take it off. V/S (vital signs) obtained 86/46, pulse- 103, respirations-16 temperature- 96.8. Change in mental status. Fluids encouraged takes only sips at times. Refuses to eat breakfast. Voids very little, incontinent care given. Informed by CNA (Certified Nursing Assistant) noted to have small amount of drainage from penis thick cloudy mucus, with foul odor noted. Notified Dr's (doctor) nurse and obtained transfer to (local hospital)." There was no documentation in the Nurse's Notes to estimate how much fluids R #6 received nor if other fluids, besides water, were provided." R #6's Activities of Daily Living Flowsheet dated 10/2014 and 11/2014 revealed "Diet Intake Key- E=100%, G= 75%, P= 25%, F=50%, O= 0%, B= bites, and R= Refusal: "10/29/14- Brk (breakfast)- P; Lun (lunch)- F; Din (dinner)- R; 10/30/14- Brk- G, Lun- 0, Din- (no entry); 10/31/14- Brk- P, Lun- R, Din- F; 11/01/14- Brk- F, Lun- P, Din- R; R #6's Nurses Note dated 11/02/14 at 1:10 p.m. documented "Res continues on ABX (antibiotic) for UTI. Poor appetite eating bites for meals." 11/02/14- Brk- R, Lun- B, Din- O; 11/03/14- Brk- R, Lun- B, Din- P; 11/04/14- Brk- P, Lun- B, Din- P; R #6's Nurses Note dated 11/04/14 at 1:22 p.m. documented "resident refused lunch only ate few bites, fluids tolerated..." 11/05/14- Brk- 0, Lun- B, Din- R; R #6's Nurses Note dated 11/05/14 at 1:27 p.m. documented "Ate only bites for lunch, fluids taken well..." 11/06/14- Brk- 0, Lun- P, Din- (no entry); R #6's Nurses Note dated 11/06/14 at 3:29 a.m. documented "Accepts small amounts of hydration only..." 11/07/14- Brk- 0, Lun- R, Din- R; R #6's Nurses Note dated 11/07/14 at 12:14 p.m. documented "Fluids encouraged, requires a lot of encouragement, fluids tolerated in small amounts. Fair appetite noted..." 11/08/14- Brk- R, Lun- R, Din- P; R #6's Nurses Note dated 11/08/14 at 10:20 a.m. documented "Continue on abx for UTI; fluids not taken well, skin tugor poor, poor appetite noted..." 11/09/14- Brk- R, Lun- R, Din- (no entry); R #6's Nurses Note dated 11/09/14 at 9:33 p.m. documented "Continue to assist resident with fluids and offered fluids; resident accepted small amount. Only took bites of dinner meal this shift...4:06 p.m.- assist resident with dinner monitored by nurse this shift, continue appetite poor..." 11/10/14- Brk- B, Lun- R, Din- R." R #6's Nurses Note dated 11/10/14 at 3:34 a.m.documented "Refusing to drink water at times, resident ate few bites states not hungry, continue appetite poor..." R #6's Nurses Note dated 11/11/14 at 11:40 a.m. documented "Skin warm and dry to touch, appears very lethargic. SPO2 (oxygen saturation) at 80%, O2 (oxygen) at 3 liters via nasal cannula, resident refused to leave in place, continues to take it off. V/S (vital signs) obtained 86/46, pulse- 103, respirations-16 temperature- 96.8. Change in mental status. Fluids encouraged takes only sips at times. Refuses to eat breakfast. Voids very little, incontinent care given. Informed by CNA (Certified Nursing Assistant) noted to have small amount of drainage from penis thick cloudy mucus, with foul odor noted. Notified Dr's (doctor) nurse and obtained transfer to (local hospital)." R #6's Weight Change History dated 11/05/14 revealed: 05/21/14- 160 lbs (pounds). 06/09/14- 160 lbs. 06/18/14- 160 lbs. 07/07/14- 163 lbs. 08/08/14- 165 lbs. 09/09/14- 164 lbs. 10/07/14- 161 lbs. 11/05/14- 151 lbs. R #6's Physician order [REDACTED]." R #6's MAR indicated [REDACTED] 1. [MEDICATION NAME] 40 mg PO daily at 8:00 a.m. from 11/01/14-11/11/14. The facility continued to provide R #6 with [MEDICATION NAME] even after R #6 was identified to be drinking small amounts of fluids. 2.[MEDICATION NAME] mg PO BID from 11/01/14 to 11/10/14 at 8:00 a.m. and 4:00 p.m. As well, on 11/11/14 at 8:00 a.m. R #6's Telephone Order dated 11/11/14 revealed an order to send R #6 to the (local hospital). R #6's Emergency Provider Record dated 11/11/14 1:03 p.m. revealed "Altered Mental Status: decreased responsiveness. V/S at 12:58 p.m.= Pulse ox (pulse oximetry) 80%, B/P (blood pressure)- 87/49, pulse- 63, respirations- 16. Purulent (bacteria that causes pus) urine output when a (urinary catheter- a tube placed in the bladder to drain urine) was placed. Laboratory: BUN=223 (Blood Urea Nitrogen- a laboratory blood test that reveals information on how the kidneys and liver are functioning), normal range was 6-20; Creatinine= 7.8 (a blood test that measures kidney function), normal range was 0.6-1.0; Estimated GFR (deteriorating renal function; eGFR is approximately 30-60%; eGFR is estimated Glomerular Filtration Rate, usually based on serum Creatinine level, age, sex, and race. - See more at: http://www.renal.org/information-resources/the-uk-eckd-guide/about-egfr#sthash.OT2uBJIh.dpuf), normal range was 35-81; Potassium (K) Level= 7.7, normal range was 3.5-6.1. R #6's last documented weight was 151 lbs. on 11/05/14; from 11/05/14 to 11/11/14 R #6 had lost a total of 14.32 pounds, in 6 days. Disposition: Dehydration, Acute [MEDICAL CONDITIONS] (high potassium level), and lower UTI. Will gently hydrate and monitor I/O (input and output). Counseled patient/family:Discussed his poor condition with son; he doesn't desire [MEDICAL TREATMENT] or PEG (Percutaneous Endoscopic Gastrostomy- an endoscopic procedure in which a tube is placed in the stomach through the abdominal wall)." R #6's Hospitalist Progress Note dated 11/13/14 revealed "lethargic. Diagnosis/Assessment/Plan- continue monitor, [MEDICAL CONDITION] resolved. Discussed pt's (patient's) condition and poor prognosis with pt's daughter and son. They decided to pursue hospice." R #6's Weight Change Alert Report dated 11/14/14 documented "10/07/14 161 lbs- 11/05/14 151 lbs. 29 Days; -10 lbs; -6.21% change." Observation and interview with R #6 at the local hospital on [DATE] at 3:10 p.m. revealed R #6 layed face up with his eyes closed and mouth open. R #6 had an intravenous (IV) access to his right neck with IV fluids infusing. R #6's lips were dry and cracked with peeling skin; his bottom left lip had a black pinpoint spot covering a piece of detaching peeling skin. R #6's upper palate (roof) of his mouth was dry and had a quarter size black scab looking patch on it. R #6's tongue was also dry with approximately half a dime sized black patch. R #6's hands, arms, feet, and legs had dry flaky skin. R #6 did not provide any verbal or gestured feedback from verbal and tactile (touch) stimuli. Interview with the hospital Registered Nurse/Charge Nurse "A" for R #6 on 11/13/14 at 5:05 p.m. revealed R #6 was admitted to the hospital on [DATE] for dehydration, [MEDICAL CONDITION], urinary tract infection, and Acute [MEDICAL CONDITION]. Registered Nurse/Charge Nurse "A" stated R #6 was receiving IV fluids for hydration due to dehydration. Registered Nurse/Charge Nurse "A" stated R #6 had "eschar (slough or piece of dead tissue) to his upper oral palate, tongue, and lower lip due to prolonged dehydration and him being a mouth-breather." Registered Nurse/Charge Nurse "A" stated R #6 failed his swallow study therefore, he was not allowed to eat or drink anything. Interview with Director of Nurses (DON) "G" on 11/14/14 at 10:53 a.m. revealed the facility procedure was for the nursing staff to document intake and output at the end of each meal via the computerized head-set system daily. DON "G" stated the charge nurses were responsible for reviewing each flowsheet at the end of their shift, daily, "I guess they were not doing that." DON "G" reviewed R #6's fluid intake flowsheet and stated she was not aware of R #6's trend of decreased fluid intake. DON "G" stated she was aware that the nursing staff had to provide R #6 with a lot of encouragement to drink fluids because "he doesn't like water." DON "G" confirmed R #6 had a history of [REDACTED].#6's fluid intakes, even after the facility was aware R #6's would occasionally refuse fluids and made it known he did not like water. In addition, DON "G" stated the facility had not implemented any new procedures to address R #6's fluid intake, as of 11/14/14. DON "G" reviewed R #6's meal intake flowsheet and stated she was not aware of R #6's trend of decreased meal consumption. DON "G" stated the facility noticed R #6 lost 10 pounds after he was weighed on 11/05/14. DON "G" explained the facility called the physician on 10/06/14 and informed him of R #6's weight loss. DON "G" verified the facility's interdisciplinary team had not reviewed or addressed R #6's meal intakes, even after the facility was aware of R #6's 10 pound weight loss in less than one month. DON "G" stated her nursing staff should have been reviewing R #6's meal intakes and notified the physician of continued decreased intake. DON "G" stated the facility had not implemented any new procedures to address resident's with weight loss or decreased documented meal intakes as of 11/14/14. DON "G" stated the facility did not have a policy that corresponded to the facility's meal monitoring procedure. At this time, DON "G" was asked for the facility's hydration policy and procedure. DON "G" did not provide any policy and procedure regarding hydaration or additional information that pertained to R #6's meal/fluid intake. Interview with Licensed Vocational Nurse (LVN)/Unit Manager "B" on 11/14/14 at 11:15 a.m. revealed the facility's practice to monitoring intake was the CNA documented the intake using the computerized head-set system immediately after meals. LVN "B" stated the charge nurses were to review the meal and fluid intake documentation at the end of each shift. LVN "B" said she did not know exactly how much food and fluid R #6 was consuming. LVN "B" confirmed she had worked as a charge nurse for R #6 and did not review the intake flowsheets for any resident. LVN "B" stated "I couldn't tell you when was the last time I reviewed this flowsheet." LVN "B" confirmed R #6 had a history of [REDACTED]. Interview with LVN/Charge Nurse "C" on 11/14/14 at 11:23 a.m. revealed she was R #6's nurse on multiple occasions including on 11/11/14, the day he was transferred to the hospital. LVN "C" stated she transferred R #6 to the hospital for altered mental status and decreased oxygen saturation of 80%. LVN "C" stated she did not know nor was made aware of how much food or fluid R #6 was consuming. LVN "C" confirmed she knew R #6 refused to drink water because "he did not like it." LVN "C" said she had not reviewed any residents' intake flowsheet in "I don't know how long." LVN "C" stated she had not noticed or been made aware of R #6 having any problems with his meals or eating. LVN "C" confirmed R #6 had a history of [REDACTED]. Interview with LVN/Unit Manager "D" on 11/14/14 at 12:26 p.m. revealed she had taken care of R #6 on multiple occasions. LVN "D" stated she was not aware of R #6's approximate food or fluid intake. LVN "D" stated she had not reviewed any residents' intake flowsheet. LVN "D" stated staff had to encourage R #6 to drink fluids due to "he did not like water and required assistence to eat." LVN "D" confirmed R #6 had a history of [REDACTED]. Interview with CNA "E" on 11/14/14 at 1:08 p.m. revealed she would periodically encourage R #6 to drink water. CNA "E" said R #6 would frequently refuse to drink water because "he did not like water." CNA "E" stated R #6 would drink "little sips at a time." CNA "E" stated she could not calculate the total amount of "sips" R #6 would drink on a daily basis on her shift. CNA "E" stated she documented residents' food and fluid intake via the head-set computerized system and did not verbally report to a supervisor. Interview with CNA "F" on 11/14/14 at 1:14 p.m. revealed she would periodically encourage R #6 to drink water. CNA "F" said R #6 would frequently refuse to drink water because "he did not like water." CNA "F" stated R #6 would drink "small sips at a time." CNA "F" stated she could not calculate the total amount of "sips" R #6 would drink on a daily basis on her shift. CNA "F" stated she documented residents' food and fluid intake via the head-set computerized system and did not verbally report to a supervisor. None of the staff interviewed stated they offered R #6 a fluid other than water or a food substitute and could not present any additional documented evidence that revealed R #6 consumed any other foods or fluids. On 11/14/14 at 3:15 p.m., DON "G" was asked to present a copy of the facility's Hydration policy and procedure. None was provided prior to surveyor exiting the facility. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 11/14/14 revealed 79 residents who needed assistance with meals at risk for inadequate nutrition and hydration issues. At the exit conference on 11/14/14 at 4:45 p.m., the facility was provided an opportunity to provide additional information related to abuse and neglect prohibition. The facility provided no further information.

Based on observation, record review, and interview, the facility failed to provide necessary care and services to attain the highest practicable physical, mental, and psychological well-being for one resident (R #6) of five residents reviewed for care and services. R #6 was identified at risk for inadequate nutrition and dehydration. The facility did not evaluate the results of their interventions (food/fluid intake data) or revise interventions when R #6's food/fluid intake declined. R #6 was sent to the hospital with altered mental status and low oxygen saturation. R #6 was diagnosed with [REDACTED]. R #6 remained in the hospital during this investigation. This failure affected one resident (R #6) and placed 79 residents who needed assistance with meals at risk for inadequate nutrition and hydration issues. Findings included: R #6's Face Sheet, dated 05/22/14, indicated R #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnoses: [REDACTED]. of pressure inside the eye), [MEDICAL CONDITION] (too little [MEDICAL CONDITION] hormone), and Senile Cataract (age related vision impairing disease). R #6 was [AGE] years old. R #6's Admission Minimum Data Set ((MDS) dated [DATE] indicated R #6 had short-term and long- term memory problems; cognition was moderately impaired (decisions poor; cues/supervision required). R #6 was independent with eating but may require one person physical assist. R #6 had no signs or symptoms of possible swallowing disorders; his height was 70 inches and his weight was 161 pounds. R #6 had no weight loss in the last 6 months. R #6 had no natural teeth or tooth fragments. R #6 was always incontinent of bowel and bladder. The MDS indicated R #6's active [DIAGNOSES REDACTED]. R #6's Nutritional Data Set and Progress Note, dated 10/01/14, revealed R #6's weight was 164 pounds (lbs.) and he was 70 inches in height. The Consultant Dietitian documented "no significant change." Estimated Nutritional Needs for R #6 were: "2250 kcal, 75-83 g (grams) pro (protein), 1875-2250 mi (milliliter) fluid d/t (due to) [MEDICAL CONDITIONS]. Current diet Order: Mechanical Soft. Goal/Intervention: Resident with Dx (diagnosis) of CKD ([MEDICAL CONDITION]) stage 3. Recommend: Provide 120 ml [MEDICATION NAME] (nutritional supplement for [MEDICAL CONDITION] patients) four times daily with medication pass D/T high BUN (Blood Urea Nitrogen- a laboratory blood test that reveals information on how the kidneys and liver are functioning)." R #6's physician's orders [REDACTED]. PO (orally) QID with med (medication) pass for supplement and increased BUN." R #6's Care Plan dated 10/15/14, revealed R #6 was at "risk for alteration in nutrition related to impaired cognition, rejects care, functional impairment, sensory impairment; has no teeth (refuses pureed diet)." The goal of the Care Plan was to "administer iron supplements as ordered; [MEDICATION NAME] as ordered; [MEDICATION NAME] (nutritional shake) as ordered; [MEDICATION NAME] (for [MEDICAL CONDITION] reflux) as ordered; Multivitamins as ordered; set-up, cue, assist as needed with meal consumption; Diet as ordered- Regular mechanical soft large portions; encourage greater than 75% offered fluids and meals daily; Record % of meal and fluid intake, report changes as needed..." R #6's Care Plan dated 10/31/14, revealed R #6 was at "risk for dehydration. Related Diagnoses: [REDACTED]. Approaches: R/O (rule out) UTI with changes in continence, promote adequate hydration, report changes to characteristics of urine such as color, odor, sediment, incontinence care PRN (as needed), monitor for bladder distension, c/o (complaints of) pain, decreased urine output and report, continue to encourage resident to drink fluids/ more water and less soda's. Resident does refuse water/juices in preference to soda's." R #6's Telephone Order dated 10/31/14 revealed an order for [REDACTED]." R #6's Medication Administration Record [REDACTED] 1. [MEDICATION NAME] (treats fluid retention in people with [MEDICAL CONDITION]; excretes fluid) 40 mg (milligrams) PO (orally) daily at 8:00 a.m. from 10/01/14-10/31/14; 2. [MEDICATION NAME] 250 mg IM on 10/31/14; and 3.[MEDICATION NAME] mg PO BID on 10/31/14 at 4:00 p.m. R #6's Physician order [REDACTED].#6 did not have an order for [REDACTED]. R #6's Consolidated Physician order [REDACTED]. 1. [MEDICATION NAME] (treats fluid retention in people with [MEDICAL CONDITION]; excretes fluid) 40 mg (milligrams) PO daily; 2. Folic Acid (a B vitamin) 1 mg PO daily; 3. [MEDICATION NAME] (iron supplement) 325 mg PO daily at noon; 4. Multiple Vitamin with Minerals one tab (tablet) for supplement; 5. [MEDICATION NAME] (a replacement for a hormone normally produced by the [MEDICAL CONDITION]); 6. Diet: Regular, Mechanical Soft, larger portions; 7. [MEDICATION NAME] 120 ml PO QID with med pass for supplement and increased BUN. Additional Diagnoses: [REDACTED]., and thoughts), [MEDICAL CONDITION] Stage III (deteriorating renal function; eGFR is approximately 30-60%; eGFR is estimated Glomerular Filtration Rate, usually based on serum Creatinine level, age, sex, and race. http://www.renal.org/information-resources/the-uk-eckd-guide/about-egfr#sthash.OT2uBJIh.dpuf). R #6's Fluid Intake Flowsheet dated 10/2014 and 11/2014 revealed: 10/21/14- Brk (breakfast)- 360 ml (milliliters); Lun (lunch)- 9 ml; Din (dinner)-240 ml; other- nothing documented; Total- 609 ml. 10/22/14- Brk- 360 ml; Lun- 480 ml; Din- 240 ml; other- nothing documented; Total- 1080 ml. 10/23/14- Brk- 316 ml; Lun- 480 ml; Din- 0 ml; other- 160; Total- 956 ml. 10/24/14- Brk- 360 ml; Lun- 480 ml; Din- 200 ml; other- nothing documented; Total- 1040 ml. 10/25/14- Brk- 300 ml; Lun- 240 ml; Din- 0 ml; other- nothing documented; Total- 540 ml. 10/26/14- Brk- 200 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 640 ml. 10/27/14- Brk- 360 ml; Lun- 200 ml; Din- 0 ml; other- nothing documented; Total- 560 ml. 10/28/14- Brk- 600 ml; Lun- 200 ml; Din- 80 ml; other- nothing documented; Total- 880 ml. 10/29/14- Brk- 360 ml; Lun- 2 ml; Din- 0 ml; other- 120 ml; Total- 482 ml. 10/30/14- Brk- 600 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 1040 ml. R #6's Nurses Note dated 10/30/14 at 1:35 p.m. documented "Notified NP (Nurse Practitioner) resident has a foul odor in urine, fair skin tugor (a sign used by healthcare workers to assess fluid loss or dehydration). NP stated to encourage fluids. Resident drinks fluids, refuses to drink water, states he doesn't like it. NP aware of this, NP states it can be any type of fluids." 10/30/14 8:52 p.m.- "Res (resident) drinks fluids, refuses to drink water, states he doesn't like it. Staff continue to offer water to resident." 10/31/14- Brk- 240 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 680 ml. R #6's Nurses Note dated 10/31/14 at 11:43 a.m. documented "Dr (doctor) here notified him of res foul odor in urine, dr went into room and assessed res. Obtained [MEDICATION NAME] (antibiotic) IM (intramuscularly) [MEDICATION NAME](antibiotic) PO (orally) for dx (diagnosis) UTI. Continuing to offer fluids, taken well, poor skin tugor...10/31/14 1:49 p.m.- "Staff continues to encourage resident to drink more water and other fluids other than soda d/t (due to) urine having a foul odor.." 11/01/14- Brk- 200 ml; Lun- 200 ml; Din- 0 ml; other- 120 ml; Total- 520 ml. R #6's Nurses Note dated 11/01/14 at 9:08 p.m. documented "Continues on ABT (antibiotic therapy) for UTI, increase water fluids and continue to monitor. Continues with foul smelling urine..." 11/02/14- Brk- 0 ml; Lun- 120 ml; Din- 240 ml; other- nothing documented; Total- 360 ml. R #6's Nurses Note dated 11/02/14 at 3:06 a.m. documented "Res continues on ABX (antibiotic) for UTI. Continues with foul odor to urine..." 11/03/14- Brk- 0 ml; Lun- 120 ml; Din- 120 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Note dated 11/03/14 at 9:50 a.m. documented "Res continue on abx for uti, refused breakfast, continue to encourage fluids, refused offered fluids per nurse.." 11/04/14- Brk- 600 ml; Lun- 240 ml; Din- 240 ml; other- 140 ml; Total- 1220 ml. R #6's Nurses Notes dated 11/04/14 at 11:48 a.m. documented "Continue on antibiotic for UTI, encourage fluids...11/04/14 1:22 p.m.- "Resident refused lunch only ate few bites, fluids tolerated..." 11/05/14- Brk- 120 ml; Lun- 120 ml; Din- 0 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Note dated 11/05/14 at 1:27 p.m. documented "Ate only bites for lunch, fluids taken well..." 11/06/14- Brk- 120 ml; Lun- 246 ml; Din- 0 ml; other- 120 ml; Total- 486 ml. R #6's Nurses Note dated 11/06/14 at 3:29 a.m. documented "Accepts small amounts of hydration only.." 11/07/14- Brk- 240 ml; Lun- 0 ml; Din- 0 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Noted dated 11/07/14 at 12:14 p.m. documented "Fluids encouraged, requires a lot of encouragement, fluids tolerated in small amounts. Fair appetite noted." 11/08/14- Brk- 0 ml; Lun- 0 ml; Din- 240 ml; other- 120 ml; Total- 360 ml. R #6's Nurses Note dated 11/08/14 at 10:20 a.m. documented "Continue on abx for UTI; fluids not taken well, skin tugor poor, poor appetite noted..." 11/09/14- Brk- 0 ml; Lun- 0 ml; Din- 240 ml; other- 120 ml; Total- 360 ml. R #6's Nurses Note dated 11/09/14 at 9:33 p.m. documented "Continue to assist resident with fluids and offered fluids; resident accepted small amount..." 11/10/14- Brk- 480 ml; Lun- 0 ml; Din- 0 ml; other- nothing documented; Total- 480 ml. R #6's Nurses Not dated 11/10/14 at 3:34 a.m. documented "Refusing to drink water at times..." 11/11/14- Brk- 120 ml, no other fluid was documented this day; R #6 was sent to the hospital at 12:00 p.m. The facility began to treat R #6 for "UTI" on 10/31/14; Even after knowledge of the [DIAGNOSES REDACTED].#6 consumed, at least, his daily recommended fluid intake after 10/31/14 and continued to administer his daily dose of [MEDICATION NAME], which assisted in depleting his fluids. R #6's Nurses Note dated 11/11/14 at 11:40 a.m. documented "Skin warm and dry to touch, appears very lethargic. SPO2 (oxygen saturation) at 80%, O2 (oxygen) at 3 liters via nasal cannula, resident refused to leave in place, continues to take it off. V/S (vital signs) obtained 86/46, pulse- 103, respirations-16 temperature- 96.8. Change in mental status. Fluids encouraged takes only sips at times. Refuses to eat breakfast. Voids very little, incontinent care given. Informed by CNA (Certified Nursing Assistant) noted to have small amount of drainage from penis thick cloudy mucus, with foul odor noted. Notified Dr's (doctor) nurse and obtained transfer to (local hospital)." There was no documentation in the Nurse's Notes to estimate how much fluids R #6 received nor if other fluids, besides water, were provided." R #6's Activities of Daily Living Flowsheet dated 10/2014 and 11/2014 revealed "Diet Intake Key- E=100%, G= 75%, P= 25%, F=50%, O= 0%, B= bites, and R= Refusal: "10/29/14- Brk (breakfast)- P; Lun (lunch)- F; Din (dinner)- R; 10/30/14- Brk- G, Lun- 0, Din- (no entry); 10/31/14- Brk- P, Lun- R, Din- F; 11/01/14- Brk- F, Lun- P, Din- R; R #6's Nurses Note dated 11/02/14 at 1:10 p.m. documented "Res continues on ABX (antibiotic) for UTI. Poor appetite eating bites for meals." 11/02/14- Brk- R, Lun- B, Din- O; 11/03/14- Brk- R, Lun- B, Din- P; 11/04/14- Brk- P, Lun- B, Din- P; R #6's Nurses Note dated 11/04/14 at 1:22 p.m. documented "resident refused lunch only ate few bites, fluids tolerated..." 11/05/14- Brk- 0, Lun- B, Din- R; R #6's Nurses Note dated 11/05/14 at 1:27 p.m. documented "Ate only bites for lunch, fluids taken well..." 11/06/14- Brk- 0, Lun- P, Din- (no entry); R #6's Nurses Note dated 11/06/14 at 3:29 a.m. documented "Accepts small amounts of hydration only..." 11/07/14- Brk- 0, Lun- R, Din- R; R #6's Nurses Note dated 11/07/14 at 12:14 p.m. documented "Fluids encouraged, requires a lot of encouragement, fluids tolerated in small amounts. Fair appetite noted..." 11/08/14- Brk- R, Lun- R, Din- P; R #6's Nurses Note dated 11/08/14 at 10:20 a.m. documented "Continue on abx for UTI; fluids not taken well, skin tugor poor, poor appetite noted..." 11/09/14- Brk- R, Lun- R, Din- (no entry); R #6's Nurses Note dated 11/09/14 at 9:33 p.m. documented "Continue to assist resident with fluids and offered fluids; resident accepted small amount. Only took bites of dinner meal this shift...4:06 p.m.- assist resident with dinner monitored by nurse this shift, continue appetite poor..." 11/10/14- Brk- B, Lun- R, Din- R." R #6's Nurses Note dated 11/10/14 at 3:34 a.m.documented "Refusing to drink water at times, resident ate few bites states not hungry, continue appetite poor..." R #6's Nurses Note dated 11/11/14 at 11:40 a.m. documented "Skin warm and dry to touch, appears very lethargic. SPO2 (oxygen saturation) at 80%, O2 (oxygen) at 3 liters via nasal cannula, resident refused to leave in place, continues to take it off. V/S (vital signs) obtained 86/46, pulse- 103, respirations-16 temperature- 96.8. Change in mental status. Fluids encouraged takes only sips at times. Refuses to eat breakfast. Voids very little, incontinent care given. Informed by CNA (Certified Nursing Assistant) noted to have small amount of drainage from penis thick cloudy mucus, with foul odor noted. Notified Dr's (doctor) nurse and obtained transfer to (local hospital)." R #6's Weight Change History dated 11/05/14 revealed: 05/21/14- 160 lbs (pounds). 06/09/14- 160 lbs. 06/18/14- 160 lbs. 07/07/14- 163 lbs. 08/08/14- 165 lbs. 09/09/14- 164 lbs. 10/07/14- 161 lbs. 11/05/14- 151 lbs. R #6's Physician order [REDACTED]." R #6's MAR indicated [REDACTED] 1. [MEDICATION NAME] 40 mg PO daily at 8:00 a.m. from 11/01/14-11/11/14. The facility continued to provide R #6 with [MEDICATION NAME] even after R #6 was identified to be drinking small amounts of fluids. 2.[MEDICATION NAME] mg PO BID from 11/01/14 to 11/10/14 at 8:00 a.m. and 4:00 p.m. As well, on 11/11/14 at 8:00 a.m. R #6's Telephone Order dated 11/11/14 revealed an order to send R #6 to the (local hospital). R #6's Emergency Provider Record dated 11/11/14 1:03 p.m. revealed "Altered Mental Status: decreased responsiveness. V/S at 12:58 p.m.= Pulse ox (pulse oximetry) 80%, B/P (blood pressure)- 87/49, pulse- 63, respirations- 16. Purulent (bacteria that causes pus) urine output when a (urinary catheter- a tube placed in the bladder to drain urine) was placed. Laboratory: BUN=223 (Blood Urea Nitrogen- a laboratory blood test that reveals information on how the kidneys and liver are functioning), normal range was 6-20; Creatinine= 7.8 (a blood test that measures kidney function), normal range was 0.6-1.0; Estimated GFR (deteriorating renal function; eGFR is approximately 30-60%; eGFR is estimated Glomerular Filtration Rate, usually based on serum Creatinine level, age, sex, and race. - See more at: http://www.renal.org/information-resources/the-uk-eckd-guide/about-egfr#sthash.OT2uBJIh.dpuf), normal range was 35-81; Potassium (K) Level= 7.7, normal range was 3.5-6.1. R #6's last documented weight was 151 lbs. on 11/05/14; from 11/05/14 to 11/11/14 R #6 had lost a total of 14.32 pounds, in 6 days. Disposition: Dehydration, Acute [MEDICAL CONDITIONS] (high potassium level), and lower UTI. Will gently hydrate and monitor I/O (input and output). Counseled patient/family:Discussed his poor condition with son; he doesn't desire [MEDICAL TREATMENT] or PEG (Percutaneous Endoscopic Gastrostomy- an endoscopic procedure in which a tube is placed in the stomach through the abdominal wall)." R #6's Hospitalist Progress Note dated 11/13/14 revealed "lethargic. Diagnosis/Assessment/Plan- continue monitor, [MEDICAL CONDITION] resolved. Discussed pt's (patient's) condition and poor prognosis with pt's daughter and son. They decided to pursue hospice." R #6's Weight Change Alert Report dated 11/14/14 documented "10/07/14 161 lbs- 11/05/14 151 lbs. 29 Days; -10 lbs; -6.21% change." Observation and interview with R #6 at the local hospital on [DATE] at 3:10 p.m. revealed R #6 layed face up with his eyes closed and mouth open. R #6 had an intravenous (IV) access to his right neck with IV fluids infusing. R #6's lips were dry and cracked with peeling skin; his bottom left lip had a black pinpoint spot covering a piece of detaching peeling skin. R #6's upper palate (roof) of his mouth was dry and had a quarter size black scab looking patch on it. R #6's tongue was also dry with approximately half a dime sized black patch. R #6's hands, arms, feet, and legs had dry flaky skin. R #6 did not provide any verbal or gestured feedback from verbal and tactile (touch) stimuli. Interview with the hospital Registered Nurse/Charge Nurse "A" for R #6 on 11/13/14 at 5:05 p.m. revealed R #6 was admitted to the hospital on [DATE] for dehydration, [MEDICAL CONDITION], urinary tract infection, and Acute [MEDICAL CONDITION]. Registered Nurse/Charge Nurse "A" stated R #6 was receiving IV fluids for hydration due to dehydration. Registered Nurse/Charge Nurse "A" stated R #6 had "eschar (slough or piece of dead tissue) to his upper oral palate, tongue, and lower lip due to prolonged dehydration and him being a mouth-breather." Registered Nurse/Charge Nurse "A" stated R #6 failed his swallow study therefore, he was not allowed to eat or drink anything. Interview with Director of Nurses (DON) "G" on 11/14/14 at 10:53 a.m. revealed the facility procedure was for the nursing staff to document intake and output at the end of each meal via the computerized head-set system daily. DON "G" stated the charge nurses were responsible for reviewing each flowsheet at the end of their shift, daily, "I guess they were not doing that." DON "G" reviewed R #6's fluid intake flowsheet and stated she was not aware of R #6's trend of decreased fluid intake. DON "G" stated she was aware that the nursing staff had to provide R #6 with a lot of encouragement to drink fluids because "he doesn't like water." DON "G" confirmed R #6 had a history of [REDACTED].#6's fluid intakes, even after the facility was aware R #6's would occasionally refuse fluids and made it known he did not like water. In addition, DON "G" stated the facility had not implemented any new procedures to address R #6's fluid intake, as of 11/14/14. DON "G" reviewed R #6's meal intake flowsheet and stated she was not aware of R #6's trend of decreased meal consumption. DON "G" stated the facility noticed R #6 lost 10 pounds after he was weighed on 11/05/14. DON "G" explained the facility called the physician on 10/06/14 and informed him of R #6's weight loss. DON "G" verified the facility's interdisciplinary team had not reviewed or addressed R #6's meal intakes, even after the facility was aware of R #6's 10 pound weight loss in less than one month. DON "G" stated her nursing staff should have been reviewing R #6's meal intakes and notified the physician of continued decreased intake. DON "G" stated the facility had not implemented any new procedures to address resident's with weight loss or decreased documented meal intakes as of 11/14/14. DON "G" stated the facility did not have a policy that corresponded to the facility's meal monitoring procedure. At this time, DON "G" was asked for the facility's hydration policy and procedure. DON "G" did not provide any policy and procedure regarding hydaration or additional information that pertained to R #6's meal/fluid intake. Interview with Licensed Vocational Nurse (LVN)/Unit Manager "B" on 11/14/14 at 11:15 a.m. revealed the facility's practice to monitoring intake was the CNA documented the intake using the computerized head-set system immediately after meals. LVN "B" stated the charge nurses were to review the meal and fluid intake documentation at the end of each shift. LVN "B" said she did not know exactly how much food and fluid R #6 was consuming. LVN "B" confirmed she had worked as a charge nurse for R #6 and did not review the intake flowsheets for any resident. LVN "B" stated "I couldn't tell you when was the last time I reviewed this flowsheet." LVN "B" confirmed R #6 had a history of [REDACTED]. Interview with LVN/Charge Nurse "C" on 11/14/14 at 11:23 a.m. revealed she was R #6's nurse on multiple occasions including on 11/11/14, the day he was transferred to the hospital. LVN "C" stated she transferred R #6 to the hospital for altered mental status and decreased oxygen saturation of 80%. LVN "C" stated she did not know nor was made aware of how much food or fluid R #6 was consuming. LVN "C" confirmed she knew R #6 refused to drink water because "he did not like it." LVN "C" said she had not reviewed any residents' intake flowsheet in "I don't know how long." LVN "C" stated she had not noticed or been made aware of R #6 having any problems with his meals or eating. LVN "C" confirmed R #6 had a history of [REDACTED]. Interview with LVN/Unit Manager "D" on 11/14/14 at 12:26 p.m. revealed she had taken care of R #6 on multiple occasions. LVN "D" stated she was not aware of R #6's approximate food or fluid intake. LVN "D" stated she had not reviewed any residents' intake flowsheet. LVN "D" stated staff had to encourage R #6 to drink fluids due to "he did not like water and required assistence to eat." LVN "D" confirmed R #6 had a history of [REDACTED]. Interview with CNA "E" on 11/14/14 at 1:08 p.m. revealed she would periodically encourage R #6 to drink water. CNA "E" said R #6 would frequently refuse to drink water because "he did not like water." CNA "E" stated R #6 would drink "little sips at a time." CNA "E" stated she could not calculate the total amount of "sips" R #6 would drink on a daily basis on her shift. CNA "E" stated she documented residents' food and fluid intake via the head-set computerized system and did not verbally report to a supervisor. Interview with CNA "F" on 11/14/14 at 1:14 p.m. revealed she would periodically encourage R #6 to drink water. CNA "F" said R #6 would frequently refuse to drink water because "he did not like water." CNA "F" stated R #6 would drink "small sips at a time." CNA "F" stated she could not calculate the total amount of "sips" R #6 would drink on a daily basis on her shift. CNA "F" stated she documented residents' food and fluid intake via the head-set computerized system and did not verbally report to a supervisor. None of the staff interviewed stated they offered R #6 a fluid other than water or a food substitute and could not present any additional documented evidence that revealed R #6 consumed any other foods or fluids. On 11/14/14 at 3:15 p.m., DON "G" was asked to present a copy of the facility's Hydration policy and procedure. None was provided prior to surveyor exiting the facility. "Urinary Tract Infection" [MEDICAL CONDITION] is a clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract, including the urethra (urethritis), bladder ([MEDICATION NAME]), ureters (ureteritis), and/or kidney ([MEDICAL CONDITION]). An infection of the urethra or bladder is classified as a lower tract UTI & infection involving the ureter or kidney is classified as an upper tract UTI. Drink plenty of fluids, especially water: to ensure proper amounts of fluid were consumed to help dilute the urine and ensure adequate urination allowing bacteria to be flushed from the urinary tract before an infection can begin (www.mayoclinic.org/diseasescondition/urinarytractinfection/prevention/ 89)." This information was retrieved on 11/24/14. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 11/14/14 revealed 79 residents who needed assistance with meals at risk for inadequate nutrition and hydration issues. At the exit conference on 11/14/14 at 4:45 p.m., the facility was provided an opportunity to provide additional information related to the reviewing and addressing the needs of each resident, especially the residents whom were identified with nutrition and hydration issues. The facility provided no further information.

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for one Resident (R #6) of three Residents reviewed for Urinary Tract Infections [MEDICAL CONDITION]. R #6 had a history of [REDACTED].#6's fluid intake before and after his most current UTI. R #6 was sent to the hospital with altered mental status and low oxygen saturation. R #6 was diagnosed with [REDACTED]. R #6 remained in the hospital during this investigation. This failure placed all three residents diagnosed with [REDACTED]. Findings were: R #6's Face Sheet, dated 05/22/14, indicated R #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnoses: [REDACTED]. of pressure inside the eye), [MEDICAL CONDITION] (too little [MEDICAL CONDITION] hormone), and Senile Cataract (age related vision impairing disease). R #6 was [AGE] years old. R #6's Admission Minimum Data Set ((MDS) dated [DATE] indicated R #6 had short-term and long- term memory problems; cognition was moderately impaired (decisions poor; cues/supervision required). R #6 was independent with eating but may require one person physical assist. R #6 had no signs or symptoms of possible swallowing disorders; his height was 70 inches and his weight was 161 pounds. R #6 had no weight loss in the last 6 months. R #6 had no natural teeth or tooth fragments. R #6 was always incontinent of bowel and bladder. The MDS indicated R #6's active [DIAGNOSES REDACTED]. R #6's Nutritional Data Set and Progress Note, dated 10/01/14, revealed R #6's weight was 164 pounds (lbs.) and he was 70 inches in height. The Consultant Dietitian documented "no significant change." Estimated Nutritional Needs for R #6 were: "2250 kcal, 75-83 g (grams) pro (protein), 1875-2250 mi (milliliter) fluid d/t (due to) [MEDICAL CONDITIONS]. Current diet Order: Mechanical Soft. Goal/Intervention: Resident with Dx (diagnosis) of CKD ([MEDICAL CONDITION]) stage 3. Recommend: Provide 120 ml [MEDICATION NAME] (nutritional supplement for [MEDICAL CONDITION] patients) four times daily with medication pass D/T high BUN (Blood Urea Nitrogen- a laboratory blood test that reveals information on how the kidneys and liver are functioning)." R #6's Care Plan dated 10/31/14, revealed R #6 was at "risk for dehydration. Related Diagnoses: [REDACTED]. Approaches: R/O (rule out) UTI with changes in continence, promote adequate hydration, report changes to characteristics of urine such as color, odor, sediment, incontinence care PRN (as needed), monitor for bladder distension, c/o (complaints of) pain, decreased urine output and report, continue to encourage resident to drink fluids/ more water and less soda's. Resident does refuse water/juices in preference to soda's." R #6's Telephone Order dated 10/31/14 revealed an order for [REDACTED]." R #6's Medication Administration Record [REDACTED] 1. [MEDICATION NAME] (treats fluid retention in people with [MEDICAL CONDITION]; excretes fluid) 40 mg (milligrams) PO (orally) daily at 8:00 a.m. from 10/01/14-10/31/14; 2. [MEDICATION NAME] 250 mg IM on 10/31/14; and 3.[MEDICATION NAME] mg PO BID on 10/31/14 at 4:00 p.m. R #6's Physician order [REDACTED].#6 did not have an order for [REDACTED]. R #6's Consolidated Physician order [REDACTED]. 1. [MEDICATION NAME] (treats fluid retention in people with [MEDICAL CONDITION]; excretes fluid) 40 mg (milligrams) PO daily; 2. Folic Acid (a B vitamin) 1 mg PO daily; 3. [MEDICATION NAME] (iron supplement) 325 mg PO daily at noon; 4. Multiple Vitamin with Minerals one tab (tablet) for supplement; 5. [MEDICATION NAME] (a replacement for a hormone normally produced by the [MEDICAL CONDITION]); 6. Diet: Regular, Mechanical Soft, larger portions; 7. [MEDICATION NAME] 120 ml PO QID with med pass for supplement and increased BUN. Additional Diagnoses: [REDACTED]., and thoughts), [MEDICAL CONDITION] Stage III (deteriorating renal function; eGFR is approximately 30-60%; eGFR is estimated Glomerular Filtration Rate, usually based on serum Creatinine level, age, sex, and race. http://www.renal.org/information-resources/the-uk-eckd-guide/about-egfr#sthash.OT2uBJIh.dpuf). R #6's Fluid Intake Flowsheet dated 10/2014 and 11/2014 revealed: 10/21/14- Brk (breakfast)- 360 ml (milliliters); Lun (lunch)- 9 ml; Din (dinner)-240 ml; other- nothing documented; Total- 609 ml. 10/22/14- Brk- 360 ml; Lun- 480 ml; Din- 240 ml; other- nothing documented; Total- 1080 ml. 10/23/14- Brk- 316 ml; Lun- 480 ml; Din- 0 ml; other- 160; Total- 956 ml. 10/24/14- Brk- 360 ml; Lun- 480 ml; Din- 200 ml; other- nothing documented; Total- 1040 ml. 10/25/14- Brk- 300 ml; Lun- 240 ml; Din- 0 ml; other- nothing documented; Total- 540 ml. 10/26/14- Brk- 200 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 640 ml. 10/27/14- Brk- 360 ml; Lun- 200 ml; Din- 0 ml; other- nothing documented; Total- 560 ml. 10/28/14- Brk- 600 ml; Lun- 200 ml; Din- 80 ml; other- nothing documented; Total- 880 ml. 10/29/14- Brk- 360 ml; Lun- 2 ml; Din- 0 ml; other- 120 ml; Total- 482 ml. 10/30/14- Brk- 600 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 1040 ml. R #6's Nurses Note dated 10/30/14 at 1:35 p.m. documented "Notified NP (Nurse Practitioner) resident has a foul odor in urine, fair skin tugor (a sign used by healthcare workers to assess fluid loss or dehydration). NP stated to encourage fluids. Resident drinks fluids, refuses to drink water, states he doesn't like it. NP aware of this, NP states it can be any type of fluids." 10/30/14 8:52 p.m.- "Res (resident) drinks fluids, refuses to drink water, states he doesn't like it. Staff continue to offer water to resident." 10/31/14- Brk- 240 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 680 ml. R #6's Nurses Note dated 10/31/14 at 11:43 a.m. documented "Dr (doctor) here notified him of res foul odor in urine, dr went into room and assessed res. Obtained [MEDICATION NAME] (antibiotic) IM (intramuscularly) [MEDICATION NAME](antibiotic) PO (orally) for dx (diagnosis) UTI. Continuing to offer fluids, taken well, poor skin tugor...10/31/14 1:49 p.m.- "Staff continues to encourage resident to drink more water and other fluids other than soda d/t (due to) urine having a foul odor.." 11/01/14- Brk- 200 ml; Lun- 200 ml; Din- 0 ml; other- 120 ml; Total- 520 ml. R #6's Nurses Note dated 11/01/14 at 9:08 p.m. documented "Continues on ABT (antibiotic therapy) for UTI, increase water fluids and continue to monitor. Continues with foul smelling urine..." 11/02/14- Brk- 0 ml; Lun- 120 ml; Din- 240 ml; other- nothing documented; Total- 360 ml. R #6's Nurses Note dated 11/02/14 at 3:06 a.m. documented "Res continues on ABX (antibiotic) for UTI. Continues with foul odor to urine..." 11/03/14- Brk- 0 ml; Lun- 120 ml; Din- 120 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Note dated 11/03/14 at 9:50 a.m. documented "Res continue on abx for uti, refused breakfast, continue to encourage fluids, refused offered fluids per nurse.." 11/04/14- Brk- 600 ml; Lun- 240 ml; Din- 240 ml; other- 140 ml; Total- 1220 ml. R #6's Nurses Notes dated 11/04/14 at 11:48 a.m. documented "Continue on antibiotic for UTI, encourage fluids...11/04/14 1:22 p.m.- "Resident refused lunch only ate few bites, fluids tolerated..." 11/05/14- Brk- 120 ml; Lun- 120 ml; Din- 0 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Note dated 11/05/14 at 1:27 p.m. documented "Ate only bites for lunch, fluids taken well..." 11/06/14- Brk- 120 ml; Lun- 246 ml; Din- 0 ml; other- 120 ml; Total- 486 ml. R #6's Nurses Note dated 11/06/14 at 3:29 a.m. documented "Accepts small amounts of hydration only.." 11/07/14- Brk- 240 ml; Lun- 0 ml; Din- 0 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Noted dated 11/07/14 at 12:14 p.m. documented "Fluids encouraged, requires a lot of encouragement, fluids tolerated in small amounts. Fair appetite noted." 11/08/14- Brk- 0 ml; Lun- 0 ml; Din- 240 ml; other- 120 ml; Total- 360 ml. R #6's Nurses Note dated 11/08/14 at 10:20 a.m. documented "Continue on abx for UTI; fluids not taken well, skin tugor poor, poor appetite noted..." 11/09/14- Brk- 0 ml; Lun- 0 ml; Din- 240 ml; other- 120 ml; Total- 360 ml. R #6's Nurses Note dated 11/09/14 at 9:33 p.m. documented "Continue to assist resident with fluids and offered fluids; resident accepted small amount..." 11/10/14- Brk- 480 ml; Lun- 0 ml; Din- 0 ml; other- nothing documented; Total- 480 ml. R #6's Nurses Not dated 11/10/14 at 3:34 a.m. documented "Refusing to drink water at times..." 11/11/14- Brk- 120 ml, no other fluid was documented this day; R #6 was sent to the hospital at 12:00 p.m. The facility began to treat R #6 for "UTI" on 10/31/14; Even after knowledge of the [DIAGNOSES REDACTED].#6 consumed, at least, his daily recommended fluid intake after 10/31/14 and continued to administer his daily dose of [MEDICATION NAME], which assisted in depleting his fluids. R #6's Nurses Note dated 11/11/14 at 11:40 a.m. documented "Skin warm and dry to touch, appears very lethargic. SPO2 (oxygen saturation) at 80%, O2 (oxygen) at 3 liters via nasal cannula, resident refused to leave in place, continues to take it off. V/S (vital signs) obtained 86/46, pulse- 103, respirations-16 temperature- 96.8. Change in mental status. Fluids encouraged takes only sips at times. Refuses to eat breakfast. Voids very little, incontinent care given. Informed by CNA (Certified Nursing Assistant) noted to have small amount of drainage from penis thick cloudy mucus, with foul odor noted. Notified Dr's (doctor) nurse and obtained transfer to (local hospital)." There was no documentation in the Nurse's Notes to estimate how much fluids R #6 received nor if other fluids, besides water, were provided." R #6's MAR indicated [REDACTED] 1. [MEDICATION NAME] 40 mg PO daily at 8:00 a.m. from 11/01/14-11/11/14. The facility continued to provide R #6 with [MEDICATION NAME] even after R #6 was identified to be drinking small amounts of fluids. 2.[MEDICATION NAME] mg PO BID from 11/01/14 to 11/10/14 at 8:00 a.m. and 4:00 p.m. As well, on 11/11/14 at 8:00 a.m. R #6's Telephone Order dated 11/11/14 revealed an order to send R #6 to the (local hospital). R #6's Emergency Provider Record dated 11/11/14 1:03 p.m. revealed "Altered Mental Status: decreased responsiveness. V/S at 12:58 p.m.= Pulse ox (pulse oximetry) 80%, B/P (blood pressure)- 87/49, pulse- 63, respirations- 16. Purulent (bacteria that causes pus) urine output when a (urinary catheter- a tube placed in the bladder to drain urine) was placed. Laboratory: BUN=223 (Blood Urea Nitrogen- a laboratory blood test that reveals information on how the kidneys and liver are functioning), normal range was 6-20; Creatinine= 7.8 (a blood test that measures kidney function), normal range was 0.6-1.0; Estimated GFR (deteriorating renal function; eGFR is approximately 30-60%; eGFR is estimated Glomerular Filtration Rate, usually based on serum Creatinine level, age, sex, and race. - See more at: http://www.renal.org/information-resources/the-uk-eckd-guide/about-egfr#sthash.OT2uBJIh.dpuf), normal range was 35-81; Potassium (K) Level= 7.7, normal range was 3.5-6.1. Disposition: Dehydration, Acute [MEDICAL CONDITIONS] (high potassium level), and lower UTI. Will gently hydrate and monitor I/O (input and output). Counseled patient/family:Discussed his poor condition with son; he doesn't desire [MEDICAL TREATMENT] or PEG (Percutaneous Endoscopic Gastrostomy- an endoscopic procedure in which a tube is placed in the stomach through the abdominal wall)." R #6's Hospitalist Progress Note dated 11/13/14 revealed "lethargic. Diagnosis/Assessment/Plan- continue monitor, [MEDICAL CONDITION] resolved. Discussed pt's (patient's) condition and poor prognosis with pt's daughter and son. They decided to pursue hospice." Observation and interview with R #6 at the local hospital on [DATE] at 3:10 p.m. revealed R #6 layed face up with his eyes closed and mouth open. R #6 had an intravenous (IV) access to his right neck with IV fluids infusing. R #6's lips were dry and cracked with peeling skin; his bottom left lip had a black pinpoint spot covering a piece of detaching peeling skin. R #6's upper palate (roof) of his mouth was dry and had a quarter size black scab looking patch on it. R #6's tongue was also dry with approximately half a dime sized black patch. R #6's hands, arms, feet, and legs had dry flaky skin. R #6 did not provide any verbal or gestured feedback from verbal and tactile (touch) stimuli. Interview with the hospital Registered Nurse/Charge Nurse "A" for R #6 on 11/13/14 at 5:05 p.m. revealed R #6 was admitted to the hospital on [DATE] for dehydration, [MEDICAL CONDITION], urinary tract infection, and Acute [MEDICAL CONDITION]. Registered Nurse/Charge Nurse "A" stated R #6 was receiving IV fluids for hydration due to dehydration. Registered Nurse/Charge Nurse "A" stated R #6 had "eschar (slough or piece of dead tissue) to his upper oral palate, tongue, and lower lip due to prolonged dehydration and him being a mouth-breather." Registered Nurse/Charge Nurse "A" stated R #6 failed his swallow study therefore, he was not allowed to eat or drink anything. Interview with Director of Nurses (DON) "G" on 11/14/14 at 10:53 a.m. revealed the facility procedure was for the nursing staff to document intake and output at the end of each meal via the computerized head-set system daily. DON "G" reviewed R #6's fluid intake flowsheet and stated she was not aware of R #6's trend of decreased fluid intake. DON "G" stated she was aware that the nursing staff had to provide R #6 with a lot of encouragement to drink fluids because "he doesn't like water." DON "G" confirmed R #6 had a history of [REDACTED].#6's fluid intakes, even after the facility was aware R #6's would occasionally refuse fluids and made it known he did not like water. In addition, DON "G" stated the facility had not implemented any new procedures to address R #6's fluid intake, as of 11/14/14. At this time, DON "G" was asked for the facility's hydration policy and procedure. Interview with Licensed Vocational Nurse (LVN)/Unit Manager "B" on 11/14/14 at 11:15 a.m. revealed the facility's practice to monitoring intake was the CNA documented the intake using the computerized head-set system immediately after meals. LVN "B" stated the charge nurses were to review the intake documentation at the end of each shift. LVN "B" said she did not know exactly how much fluid R #6 was consuming. LVN "B" confirmed she had worked as a charge nurse for R #6 and did not review the intake flowsheet for any resident. LVN "B" stated "I couldn't tell you when was the last time I reviewed this flowsheet." LVN "B" confirmed R #6 had a history of [REDACTED]. Interview with LVN/Charge Nurse "C" on 11/14/14 at 11:23 a.m. revealed she was R #6's nurse on multiple occasions including on 11/11/14, the day he was transferred to the hospital. LVN "C" stated she transferred R #6 to the hospital for altered mental status and decreased oxygen saturation of 80%. LVN "C" stated she did not know nor was made aware of how much fluid R #6 was consuming. LVN "C" confirmed she knew R #6 refused to drink water because "he did not like it." LVN "C" said she had not reviewed any residents' intake flowsheet in "I don't know how long." LVN "C" stated she had not noticed or been made aware of R #6 having any problems with his meals or eating. LVN "C" confirmed R #6 had a history of [REDACTED]. Interview with LVN/Unit Manager "D" on 11/14/14 at 12:26 p.m. revealed she had taken care of R #6 on multiple occasions. LVN "D" stated she was not aware of R #6's approximate fluid intake. LVN "D" stated she had not reviewed any residents' fluid intake flowsheet. LVN "D" stated staff had to encourage R #6 to drink fluids due to "he did not like water." LVN "D" confirmed R #6 had a history of [REDACTED]. Interview with CNA "E" on 11/14/14 at 1:08 p.m. revealed she would periodically encourage R #6 to drink water. CNA "E" said R #6 would frequently refuse to drink water because "he did not like water." CNA "E" stated R #6 would drink "little sips at a time." CNA "E" stated she could not calculate the total amount of "sips" R #6 would drink on a daily basis on her shift. CNA "E" stated she documented residents' fluid intake via the head-set computerized system and did not verbally report to a supervisor. Interview with CNA "F" on 11/14/14 at 1:14 p.m. revealed she would periodically encourage R #6 to drink water. CNA "F" said R #6 would frequently refuse to drink water because "he did not like water." CNA "F" stated R #6 would drink "small sips at a time." CNA "F" stated she could not calculate the total amount of "sips" R #6 would drink on a daily basis on her shift. CNA "F" stated she documented residents' fluid intake via the head-set computerized system and did not verbally report to a supervisor. None of the staff interviewed stated they offered R #6 a fluid other than water and could not present any additional documented evidence that revealed R #6 consumed any other fluids. On 11/14/14 at 3:15 p.m., DON "G" was asked to present a copy of the facility's Hydration policy and procedure. None was provided prior to surveyor exiting the facility. "Urinary Tract Infection" [MEDICAL CONDITION] is a clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract, including the urethra (urethritis), bladder ([MEDICATION NAME]), ureters (ureteritis), and/or kidney ([MEDICAL CONDITION]). An infection of the urethra or bladder is classified as a lower tract UTI & infection involving the ureter or kidney is classified as an upper tract UTI. Drink plenty of fluids, especially water: to ensure proper amounts of fluid were consumed to help dilute the urine and ensure adequate urination allowing bacteria to be flushed from the urinary tract before an infection can begin (www.mayoclinic.org/diseasescondition/urinarytractinfection/prevention/ 89)." This information was retrieved on 11/24/14. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 11/14/14 revealed 53 residents with hydration issues and three residents diagnosed with [REDACTED]. At the exit conference on 11/14/14 at 4:45 p.m., the facility was provided an opportunity to provide additional information related to the reviewing and addressing the needs of each resident, especially the residents whom were identified with hydration issues. The facility provided no further information.

Based on observation, interview and record review the facility failed to ensure sufficient fluid intake to maintain proper hydration for one Resident (R #6) of six Residents reviewed for hydration. The facility was aware R #6 was at risk for dehydration but did not consistently monitor or address R #6's reduced fluid consumption. R #6 was sent to the hospital with altered mental status and low oxygen saturation and was diagnosed with [REDACTED]. R #6 remained in the hospital during this investigation. These deficient practices placed 53 residents with hydration issues at risk of not receiving proper hydration assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: R #6's Face Sheet, dated 05/22/14, indicated R #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnoses: [REDACTED]. of pressure inside the eye), [MEDICAL CONDITION] (too little [MEDICAL CONDITION] hormone), and Senile Cataract (age related vision impairing disease). R #6 was [AGE] years old. R #6's Admission Minimum Data Set ((MDS) dated [DATE] indicated R #6 had short-term and long- term memory problems; cognition was moderately impaired (decisions poor; cues/supervision required). R #6 was independent with eating but may require one person physical assist. R #6 had no signs or symptoms of possible swallowing disorders; his height was 70 inches and his weight was 161 pounds. R #6 had no weight loss in the last 6 months. R #6 had no natural teeth or tooth fragments. R #6 was always incontinent of bowel and bladder. The MDS indicated R #6's active [DIAGNOSES REDACTED]. R #6's Nutritional Data Set and Progress Note, dated 10/01/14, revealed R #6's weight was 164 pounds (lbs.) and he was 70 inches in height. The Consultant Dietitian documented "no significant change." Estimated Nutritional Needs for R #6 were: "2250 kcal, 75-83 g (grams) pro (protein), 1875-2250 mi (milliliter) fluid d/t (due to) [MEDICAL CONDITIONS]. Current diet Order: Mechanical Soft. Goal/Intervention: Resident with Dx (diagnosis) of CKD ([MEDICAL CONDITION]) stage 3. Recommend: Provide 120 ml [MEDICATION NAME] (nutritional supplement for [MEDICAL CONDITION] patients) four times daily with medication pass D/T high BUN (Blood Urea Nitrogen- a laboratory blood test that reveals information on how the kidneys and liver are functioning)." R #6's Care Plan dated 10/31/14, revealed R #6 was at "risk for dehydration. Related Diagnoses: [REDACTED]. Approaches: R/O (rule out) UTI with changes in continence, promote adequate hydration, report changes to characteristics of urine such as color, odor, sediment, incontinence care PRN (as needed), monitor for bladder distension, c/o (complaints of) pain, decreased urine output and report, continue to encourage resident to drink fluids/ more water and less soda's. Resident does refuse water/juices in preference to soda's." R #6's Telephone Order dated 10/31/14 revealed an order for [REDACTED]." R #6's Medication Administration Record [REDACTED] 1. [MEDICATION NAME] (treats fluid retention in people with [MEDICAL CONDITION]; excretes fluid) 40 mg (milligrams) PO (orally) daily at 8:00 a.m. from 10/01/14-10/31/14; 2. [MEDICATION NAME] 250 mg IM on 10/31/14; and 3.[MEDICATION NAME] mg PO BID on 10/31/14 at 4:00 p.m. R #6's Physician order [REDACTED].#6 did not have an order for [REDACTED]. R #6's Consolidated Physician order [REDACTED]. 1. [MEDICATION NAME] (treats fluid retention in people with [MEDICAL CONDITION]; excretes fluid) 40 mg (milligrams) PO daily; 2. Folic Acid (a B vitamin) 1 mg PO daily; 3. [MEDICATION NAME] (iron supplement) 325 mg PO daily at noon; 4. Multiple Vitamin with Minerals one tab (tablet) for supplement; 5. [MEDICATION NAME] (a replacement for a hormone normally produced by the [MEDICAL CONDITION]); 6. Diet: Regular, Mechanical Soft, larger portions; 7. [MEDICATION NAME] 120 ml PO QID with med pass for supplement and increased BUN. Additional Diagnoses: [REDACTED]., and thoughts), [MEDICAL CONDITION] Stage III (deteriorating renal function; eGFR is approximately 30-60%; eGFR is estimated Glomerular Filtration Rate, usually based on serum Creatinine level, age, sex, and race. http://www.renal.org/information-resources/the-uk-eckd-guide/about-egfr#sthash.OT2uBJIh.dpuf). R #6's Fluid Intake Flowsheet dated 10/2014 and 11/2014 revealed: 10/21/14- Brk (breakfast)- 360 ml (milliliters); Lun (lunch)- 9 ml; Din (dinner)-240 ml; other- nothing documented; Total- 609 ml. 10/22/14- Brk- 360 ml; Lun- 480 ml; Din- 240 ml; other- nothing documented; Total- 1080 ml. 10/23/14- Brk- 316 ml; Lun- 480 ml; Din- 0 ml; other- 160; Total- 956 ml. 10/24/14- Brk- 360 ml; Lun- 480 ml; Din- 200 ml; other- nothing documented; Total- 1040 ml. 10/25/14- Brk- 300 ml; Lun- 240 ml; Din- 0 ml; other- nothing documented; Total- 540 ml. 10/26/14- Brk- 200 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 640 ml. 10/27/14- Brk- 360 ml; Lun- 200 ml; Din- 0 ml; other- nothing documented; Total- 560 ml. 10/28/14- Brk- 600 ml; Lun- 200 ml; Din- 80 ml; other- nothing documented; Total- 880 ml. 10/29/14- Brk- 360 ml; Lun- 2 ml; Din- 0 ml; other- 120 ml; Total- 482 ml. 10/30/14- Brk- 600 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 1040 ml. R #6's Nurses Note dated 10/30/14 at 1:35 p.m. documented "Notified NP (Nurse Practitioner) resident has a foul odor in urine, fair skin tugor (a sign used by healthcare workers to assess fluid loss or dehydration). NP stated to encourage fluids. Resident drinks fluids, refuses to drink water, states he doesn't like it. NP aware of this, NP states it can be any type of fluids." 10/30/14 8:52 p.m.- "Res (resident) drinks fluids, refuses to drink water, states he doesn't like it. Staff continue to offer water to resident." 10/31/14- Brk- 240 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 680 ml. R #6's Nurses Note dated 10/31/14 at 11:43 a.m. documented "Dr (doctor) here notified him of res foul odor in urine, dr went into room and assessed res. Obtained [MEDICATION NAME] (antibiotic) IM (intramuscularly) [MEDICATION NAME](antibiotic) PO (orally) for dx (diagnosis) UTI. Continuing to offer fluids, taken well, poor skin tugor...10/31/14 1:49 p.m.- "Staff continues to encourage resident to drink more water and other fluids other than soda d/t (due to) urine having a foul odor.." 11/01/14- Brk- 200 ml; Lun- 200 ml; Din- 0 ml; other- 120 ml; Total- 520 ml. R #6's Nurses Note dated 11/01/14 at 9:08 p.m. documented "Continues on ABT (antibiotic therapy) for UTI, increase water fluids and continue to monitor. Continues with foul smelling urine..." 11/02/14- Brk- 0 ml; Lun- 120 ml; Din- 240 ml; other- nothing documented; Total- 360 ml. R #6's Nurses Note dated 11/02/14 at 3:06 a.m. documented "Res continues on ABX (antibiotic) for UTI. Continues with foul odor to urine..." 11/03/14- Brk- 0 ml; Lun- 120 ml; Din- 120 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Note dated 11/03/14 at 9:50 a.m. documented "Res continue on abx for uti, refused breakfast, continue to encourage fluids, refused offered fluids per nurse.." 11/04/14- Brk- 600 ml; Lun- 240 ml; Din- 240 ml; other- 140 ml; Total- 1220 ml. R #6's Nurses Notes dated 11/04/14 at 11:48 a.m. documented "Continue on antibiotic for UTI, encourage fluids...11/04/14 1:22 p.m.- "Resident refused lunch only ate few bites, fluids tolerated..." 11/05/14- Brk- 120 ml; Lun- 120 ml; Din- 0 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Note dated 11/05/14 at 1:27 p.m. documented "Ate only bites for lunch, fluids taken well..." 11/06/14- Brk- 120 ml; Lun- 246 ml; Din- 0 ml; other- 120 ml; Total- 486 ml. R #6's Nurses Note dated 11/06/14 at 3:29 a.m. documented "Accepts small amounts of hydration only.." 11/07/14- Brk- 240 ml; Lun- 0 ml; Din- 0 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Noted dated 11/07/14 at 12:14 p.m. documented "Fluids encouraged, requires a lot of encouragement, fluids tolerated in small amounts. Fair appetite noted." 11/08/14- Brk- 0 ml; Lun- 0 ml; Din- 240 ml; other- 120 ml; Total- 360 ml. R #6's Nurses Note dated 11/08/14 at 10:20 a.m. documented "Continue on abx for UTI; fluids not taken well, skin tugor poor, poor appetite noted..." 11/09/14- Brk- 0 ml; Lun- 0 ml; Din- 240 ml; other- 120 ml; Total- 360 ml. R #6's Nurses Note dated 11/09/14 at 9:33 p.m. documented "Continue to assist resident with fluids and offered fluids; resident accepted small amount..." 11/10/14- Brk- 480 ml; Lun- 0 ml; Din- 0 ml; other- nothing documented; Total- 480 ml. R #6's Nurses Not dated 11/10/14 at 3:34 a.m. documented "Refusing to drink water at times..." 11/11/14- Brk- 120 ml, no other fluid was documented this day; R #6 was sent to the hospital at 12:00 p.m. The facility began to treat R #6 for "UTI" on 10/31/14; Even after knowledge of the [DIAGNOSES REDACTED].#6 consumed, at least, his daily recommended fluid intake after 10/31/14 and continued to administer his daily dose of [MEDICATION NAME], which assisted in depleting his fluids. R #6's Nurses Note dated 11/11/14 at 11:40 a.m. documented "Skin warm and dry to touch, appears very lethargic. SPO2 (oxygen saturation) at 80%, O2 (oxygen) at 3 liters via nasal cannula, resident refused to leave in place, continues to take it off. V/S (vital signs) obtained 86/46, pulse- 103, respirations-16 temperature- 96.8. Change in mental status. Fluids encouraged takes only sips at times. Refuses to eat breakfast. Voids very little, incontinent care given. Informed by CNA (Certified Nursing Assistant) noted to have small amount of drainage from penis thick cloudy mucus, with foul odor noted. Notified Dr's (doctor) nurse and obtained transfer to (local hospital)." There was no documentation in the Nurse's Notes to estimate how much fluids R #6 received nor if other fluids, besides water, were provided." R #6's MAR indicated [REDACTED] 1. [MEDICATION NAME] 40 mg PO daily at 8:00 a.m. from 11/01/14-11/11/14. The facility continued to provide R #6 with [MEDICATION NAME] even after R #6 was identified to be drinking small amounts of fluids. 2.[MEDICATION NAME] mg PO BID from 11/01/14 to 11/10/14 at 8:00 a.m. and 4:00 p.m. As well, on 11/11/14 at 8:00 a.m. R #6's Telephone Order dated 11/11/14 revealed an order to send R #6 to the (local hospital). R #6's Emergency Provider Record dated 11/11/14 1:03 p.m. revealed "Altered Mental Status: decreased responsiveness. V/S at 12:58 p.m.= Pulse ox (pulse oximetry) 80%, B/P (blood pressure)- 87/49, pulse- 63, respirations- 16. Purulent (bacteria that causes pus) urine output when a (urinary catheter- a tube placed in the bladder to drain urine) was placed. Laboratory: BUN=223 (Blood Urea Nitrogen- a laboratory blood test that reveals information on how the kidneys and liver are functioning), normal range was 6-20; Creatinine= 7.8 (a blood test that measures kidney function), normal range was 0.6-1.0; Estimated GFR (deteriorating renal function; eGFR is approximately 30-60%; eGFR is estimated Glomerular Filtration Rate, usually based on serum Creatinine level, age, sex, and race. - See more at: http://www.renal.org/information-resources/the-uk-eckd-guide/about-egfr#sthash.OT2uBJIh.dpuf), normal range was 35-81; Potassium (K) Level= 7.7, normal range was 3.5-6.1. Disposition: Dehydration, Acute [MEDICAL CONDITIONS] (high potassium level), and lower UTI. Will gently hydrate and monitor I/O (input and output). Counseled patient/family:Discussed his poor condition with son; he doesn't desire [MEDICAL TREATMENT] or PEG (Percutaneous Endoscopic Gastrostomy- an endoscopic procedure in which a tube is placed in the stomach through the abdominal wall)." R #6's Hospitalist Progress Note dated 11/13/14 revealed "lethargic. Diagnosis/Assessment/Plan- continue monitor, [MEDICAL CONDITION] resolved. Discussed pt's (patient's) condition and poor prognosis with pt's daughter and son. They decided to pursue hospice." Observation and interview with R #6 at the local hospital on [DATE] at 3:10 p.m. revealed R #6 layed face up with his eyes closed and mouth open. R #6 had an intravenous (IV) access to his right neck with IV fluids infusing. R #6's lips were dry and cracked with peeling skin; his bottom left lip had a black pinpoint spot covering a piece of detaching peeling skin. R #6's upper palate (roof) of his mouth was dry and had a quarter size black scab looking patch on it. R #6's tongue was also dry with approximately half a dime sized black patch. R #6's hands, arms, feet, and legs had dry flaky skin. R #6 did not provide any verbal or gestured feedback from verbal and tactile (touch) stimuli. Interview with the hospital Registered Nurse/Charge Nurse "A" for R #6 on 11/13/14 at 5:05 p.m. revealed R #6 was admitted to the hospital on [DATE] for dehydration, [MEDICAL CONDITION], urinary tract infection, and Acute [MEDICAL CONDITION]. Registered Nurse/Charge Nurse "A" stated R #6 was receiving IV fluids for hydration due to dehydration. Registered Nurse/Charge Nurse "A" stated R #6 had "eschar (slough or piece of dead tissue) to his upper oral palate, tongue, and lower lip due to prolonged dehydration and him being a mouth-breather." Registered Nurse/Charge Nurse "A" stated R #6 failed his swallow study therefore, he was not allowed to eat or drink anything. Interview with Director of Nurses (DON) "G" on 11/14/14 at 10:53 a.m. revealed the facility procedure was for the nursing staff to document intake and output at the end of each meal via the computerized head-set system daily. DON "G" reviewed R #6's fluid intake flowsheet and stated she was not aware of R #6's trend of decreased fluid intake. DON "G" stated she was aware that the nursing staff had to provide R #6 with a lot of encouragement to drink fluids because "he doesn't like water." DON "G" confirmed R #6 had a history of [REDACTED].#6's fluid intakes, even after the facility was aware R #6's would occasionally refuse fluids and made it known he did not like water. In addition, DON "G" stated the facility had not implemented any new procedures to address R #6's fluid intake, as of 11/14/14. At this time, DON "G" was asked for the facility's hydration policy and procedure. Interview with Licensed Vocational Nurse (LVN)/Unit Manager "B" on 11/14/14 at 11:15 a.m. revealed the facility's practice to monitoring intake was the CNA documented the intake using the computerized head-set system immediately after meals. LVN "B" stated the charge nurses were to review the intake documentation at the end of each shift. LVN "B" said she did not know exactly how much fluid R #6 was consuming. LVN "B" confirmed she had worked as a charge nurse for R #6 and did not review the intake flowsheet for any resident. LVN "B" stated "I couldn't tell you when was the last time I reviewed this flowsheet." LVN "B" confirmed R #6 had a history of [REDACTED]. Interview with LVN/Charge Nurse "C" on 11/14/14 at 11:23 a.m. revealed she was R #6's nurse on multiple occasions including on 11/11/14, the day he was transferred to the hospital. LVN "C" stated she transferred R #6 to the hospital for altered mental status and decreased oxygen saturation of 80%. LVN "C" stated she did not know nor was made aware of how much fluid R #6 was consuming. LVN "C" confirmed she knew R #6 refused to drink water because "he did not like it." LVN "C" said she had not reviewed any residents' intake flowsheet in "I don't know how long." LVN "C" stated she had not noticed or been made aware of R #6 having any problems with his meals or eating. LVN "C" confirmed R #6 had a history of [REDACTED]. Interview with LVN/Unit Manager "D" on 11/14/14 at 12:26 p.m. revealed she had taken care of R #6 on multiple occasions. LVN "D" stated she was not aware of R #6's approximate fluid intake. LVN "D" stated she had not reviewed any residents' fluid intake flowsheet. LVN "D" stated staff had to encourage R #6 to drink fluids due to "he did not like water." LVN "D" confirmed R #6 had a history of [REDACTED]. Interview with CNA "E" on 11/14/14 at 1:08 p.m. revealed she would periodically encourage R #6 to drink water. CNA "E" said R #6 would frequently refuse to drink water because "he did not like water." CNA "E" stated R #6 would drink "little sips at a time." CNA "E" stated she could not calculate the total amount of "sips" R #6 would drink on a daily basis on her shift. CNA "E" stated she documented residents' fluid intake via the head-set computerized system and did not verbally report to a supervisor. Interview with CNA "F" on 11/14/14 at 1:14 p.m. revealed she would periodically encourage R #6 to drink water. CNA "F" said R #6 would frequently refuse to drink water because "he did not like water." CNA "F" stated R #6 would drink "small sips at a time." CNA "F" stated she could not calculate the total amount of "sips" R #6 would drink on a daily basis on her shift. CNA "F" stated she documented residents' fluid intake via the head-set computerized system and did not verbally report to a supervisor. None of the staff interviewed stated they offered R #6 a fluid other than water and could not present any additional documented evidence that revealed R #6 consumed any other fluids. On 11/14/14 at 3:15 p.m., DON "G" was asked to present a copy of the facility's Hydration policy and procedure. None was provided prior to surveyor exiting the facility. "Urinary Tract Infection" [MEDICAL CONDITION] is a clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract, including the urethra (urethritis), bladder ([MEDICATION NAME]), ureters (ureteritis), and/or kidney ([MEDICAL CONDITION]). An infection of the urethra or bladder is classified as a lower tract UTI & infection involving the ureter or kidney is classified as an upper tract UTI. Drink plenty of fluids, especially water: to ensure proper amounts of fluid were consumed to help dilute the urine and ensure adequate urination allowing bacteria to be flushed from the urinary tract before an infection can begin (www.mayoclinic.org/diseasescondition/urinarytractinfection/prevention/ 89)." This information was retrieved on 11/24/14. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 11/14/14 revealed 53 residents with hydration issues. At the exit conference on 11/14/14 at 4:45 p.m., the facility was provided an opportunity to provide additional information related to the reviewing and addressing the needs of each resident, especially the residents whom were identified with hydration issues. The facility provided no further information.

Based on observation, interview, and record review, the facility failed to implement their policy and procedure that prohibits neglect for one Resident (R #6) of five Residents reviewed for neglect. R #6 was identified at risk for inadequate nutrition and dehydration. The facility did not evaluate the results of their interventions (food/fluid intake data) or revise interventions when R #6's food/fluid intake declined. R #6 was sent to the hospital on with altered mental status and low oxygen saturation. R #6 was diagnosed with [REDACTED]. R #6 remained in the hospital during this investigation. This failure affected one resident (R #6) and placed 79 residents who needed assistance with meals at risk for inadequate nutrition/hydration issues and neglect. Findings included: R #6's Face Sheet, dated 05/22/14, indicated R #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnoses: [REDACTED]. of pressure inside the eye), [MEDICAL CONDITION] (too little [MEDICAL CONDITION] hormone), and Senile Cataract (age related vision impairing disease). R #6 was [AGE] years old. R #6's Admission Minimum Data Set ((MDS) dated [DATE] indicated R #6 had short-term and long- term memory problems; cognition was moderately impaired (decisions poor; cues/supervision required). R #6 was independent with eating but may require one person physical assist. R #6 had no signs or symptoms of possible swallowing disorders; his height was 70 inches and his weight was 161 pounds. R #6 had no weight loss in the last 6 months. R #6 had no natural teeth or tooth fragments. R #6 was always incontinent of bowel and bladder. The MDS indicated R #6's active [DIAGNOSES REDACTED]. R #6's Nutritional Data Set and Progress Note, dated 10/01/14, revealed R #6's weight was 164 pounds (lbs.) and he was 70 inches in height. The Consultant Dietitian documented "no significant change." Estimated Nutritional Needs for R #6 were: "2250 kcal, 75-83 g (grams) pro (protein), 1875-2250 mi (milliliter) fluid d/t (due to) [MEDICAL CONDITIONS]. Current diet Order: Mechanical Soft. Goal/Intervention: Resident with Dx (diagnosis) of CKD ([MEDICAL CONDITION]) stage 3. Recommend: Provide 120 ml [MEDICATION NAME] (nutritional supplement for [MEDICAL CONDITION] patients) four times daily with medication pass D/T high BUN (Blood Urea Nitrogen-a laboratory blood test that reveals information on how the kidneys and liver are functioning)." R #6's physician's orders [REDACTED]. PO (orally) QID with med (medication) pass for supplement and increased BUN." R #6's Care Plan dated 10/15/14, revealed R #6 was at "risk for alteration in nutrition related to impaired cognition, rejects care, functional impairment, sensory impairment; has no teeth (refuses pureed diet)." The goal of the Care Plan was to "administer iron supplements as ordered; [MEDICATION NAME] as ordered; [MEDICATION NAME] (nutritional shake) as ordered; [MEDICATION NAME] (for [MEDICAL CONDITION] reflux) as ordered; Multivitamins as ordered; set-up, cue, assist as needed with meal consumption; Diet as ordered- Regular mechanical soft large portions; encourage greater than 75% offered fluids and meals daily; Record % of meal and fluid intake, report changes as needed..." R #6's Care Plan dated 10/31/14, revealed R #6 was at "risk for dehydration. Related Diagnoses: [REDACTED]. Approaches: R/O (rule out) UTI with changes in continence, promote adequate hydration, report changes to characteristics of urine such as color, odor, sediment, incontinence care PRN (as needed), monitor for bladder distension, c/o (complaints of) pain, decreased urine output and report, continue to encourage resident to drink fluids/ more water and less soda's. Resident does refuse water/juices in preference to soda's." R #6's Telephone Order dated 10/31/14 revealed an order for [REDACTED]." R #6's Medication Administration Record [REDACTED] 1. [MEDICATION NAME] (treats fluid retention in people with [MEDICAL CONDITION]; excretes fluid) 40 mg (milligrams) PO (orally) daily at 8:00 a.m. from 10/01/14-10/31/14; 2. [MEDICATION NAME] 250 mg IM on 10/31/14; and 3.[MEDICATION NAME] mg PO BID on 10/31/14 at 4:00 p.m. R #6's Physician order [REDACTED].#6 did not have an order for [REDACTED]. R #6's Consolidated Physician order [REDACTED]. 1. [MEDICATION NAME] (treats fluid retention in people with [MEDICAL CONDITION]; excretes fluid) 40 mg (milligrams) PO daily; 2. Folic Acid (a B vitamin) 1 mg PO daily; 3. [MEDICATION NAME] (iron supplement) 325 mg PO daily at noon; 4. Multiple Vitamin with Minerals one tab (tablet) for supplement; 5. [MEDICATION NAME] (a replacement for a hormone normally produced by the [MEDICAL CONDITION]); 6. Diet: Regular, Mechanical Soft, larger portions; 7. [MEDICATION NAME] 120 ml PO QID with med pass for supplement and increased BUN. Additional Diagnoses: [REDACTED]. R #6's Fluid Intake Flowsheet dated 10/2014 and 11/2014 revealed: 10/21/14- Brk (breakfast)- 360 ml (milliliters); Lun (lunch)- 9 ml; Din (dinner)-240 ml; other- nothing documented; Total- 609 ml. 10/22/14- Brk- 360 ml; Lun- 480 ml; Din- 240 ml; other- nothing documented; Total- 1080 ml. 10/23/14- Brk- 316 ml; Lun- 480 ml; Din- 0 ml; other- 160; Total- 956 ml. 10/24/14- Brk- 360 ml; Lun- 480 ml; Din- 200 ml; other- nothing documented; Total- 1040 ml. 10/25/14- Brk- 300 ml; Lun- 240 ml; Din- 0 ml; other- nothing documented; Total- 540 ml. 10/26/14- Brk- 200 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 640 ml. 10/27/14- Brk- 360 ml; Lun- 200 ml; Din- 0 ml; other- nothing documented; Total- 560 ml. 10/28/14- Brk- 600 ml; Lun- 200 ml; Din- 80 ml; other- nothing documented; Total- 880 ml. 10/29/14- Brk- 360 ml; Lun- 2 ml; Din- 0 ml; other- 120 ml; Total- 482 ml. 10/30/14- Brk- 600 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 1040 ml. R #6's Nurses Note dated 10/30/14 at 1:35 p.m. documented "Notified NP (Nurse Practitioner) resident has a foul odor in urine, fair skin tugor (a sign used by healthcare workers to assess fluid loss or dehydration). NP stated to encourage fluids. Resident drinks fluids, refuses to drink water, states he doesn't like it. NP aware of this, NP states it can be any type of fluids." 10/30/14 8:52 p.m.- "Res (resident) drinks fluids, refuses to drink water, states he doesn't like it. Staff continue to offer water to resident." 10/31/14- Brk- 240 ml; Lun- 240 ml; Din- 200 ml; other- nothing documented; Total- 680 ml. R #6's Nurses Note dated 10/31/14 at 11:43 a.m. documented "Dr (doctor) here notified him of res foul odor in urine, dr went into room and assessed res. Obtained [MEDICATION NAME] (antibiotic) IM (intramuscularly) [MEDICATION NAME](antibiotic) PO (orally) for dx (diagnosis) UTI. Continuing to offer fluids, taken well, poor skin tugor...10/31/14 1:49 p.m.- "Staff continues to encourage resident to drink more water and other fluids other than soda d/t (due to) urine having a foul odor.." 11/01/14- Brk- 200 ml; Lun- 200 ml; Din- 0 ml; other- 120 ml; Total- 520 ml. R #6's Nurses Note dated 11/01/14 at 9:08 p.m. documented "Continues on ABT (antibiotic therapy) for UTI, increase water fluids and continue to monitor. Continues with foul smelling urine..." 11/02/14- Brk- 0 ml; Lun- 120 ml; Din- 240 ml; other- nothing documented; Total- 360 ml. R #6's Nurses Note dated 11/02/14 at 3:06 a.m. documented "Res continues on ABX (antibiotic) for UTI. Continues with foul odor to urine..." 11/03/14- Brk- 0 ml; Lun- 120 ml; Din- 120 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Note dated 11/03/14 at 9:50 a.m. documented "Res continue on abx for uti, refused breakfast, continue to encourage fluids, refused offered fluids per nurse.." 11/04/14- Brk- 600 ml; Lun- 240 ml; Din- 240 ml; other- 140 ml; Total- 1220 ml. R #6's Nurses Notes dated 11/04/14 at 11:48 a.m. documented "Continue on antibiotic for UTI, encourage fluids...11/04/14 1:22 p.m.- "Resident refused lunch only ate few bites, fluids tolerated..." 11/05/14- Brk- 120 ml; Lun- 120 ml; Din- 0 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Note dated 11/05/14 at 1:27 p.m. documented "Ate only bites for lunch, fluids taken well..." 11/06/14- Brk- 120 ml; Lun- 246 ml; Din- 0 ml; other- 120 ml; Total- 486 ml. R #6's Nurses Note dated 11/06/14 at 3:29 a.m. documented "Accepts small amounts of hydration only.." 11/07/14- Brk- 240 ml; Lun- 0 ml; Din- 0 ml; other- nothing documented; Total- 240 ml. R #6's Nurses Noted dated 11/07/14 at 12:14 p.m. documented "Fluids encouraged, requires a lot of encouragement, fluids tolerated in small amounts. Fair appetite noted." 11/08/14- Brk- 0 ml; Lun- 0 ml; Din- 240 ml; other- 120 ml; Total- 360 ml. R #6's Nurses Note dated 11/08/14 at 10:20 a.m. documented "Continue on abx for UTI; fluids not taken well, skin tugor poor, poor appetite noted..." 11/09/14- Brk- 0 ml; Lun- 0 ml; Din- 240 ml; other- 120 ml; Total- 360 ml. R #6's Nurses Note dated 11/09/14 at 9:33 p.m. documented "Continue to assist resident with fluids and offered fluids; resident accepted small amount..." 11/10/14- Brk- 480 ml; Lun- 0 ml; Din- 0 ml; other- nothing documented; Total- 480 ml. R #6's Nurses Not dated 11/10/14 at 3:34 a.m. documented "Refusing to drink water at times..." 11/11/14- Brk- 120 ml, no other fluid was documented this day; R #6 was sent to the hospital at 12:00 p.m. The facility began to treat R #6 for "UTI" on 10/31/14; Even after knowledge of the [DIAGNOSES REDACTED].#6 consumed, at least, his daily recommended fluid intake after 10/31/14 and continued to administer his daily dose of [MEDICATION NAME], which assisted in depleting his fluids. R #6's Nurses Note dated 11/11/14 at 11:40 a.m. documented "Skin warm and dry to touch, appears very lethargic. SPO2 (oxygen saturation) at 80%, O2 (oxygen) at 3 liters via nasal cannula, resident refused to leave in place, continues to take it off. V/S (vital signs) obtained 86/46, pulse- 103, respirations-16 temperature- 96.8. Change in mental status. Fluids encouraged takes only sips at times. Refuses to eat breakfast. Voids very little, incontinent care given. Informed by CNA (Certified Nursing Assistant) noted to have small amount of drainage from penis thick cloudy mucus, with foul odor noted. Notified Dr's (doctor) nurse and obtained transfer to (local hospital)." There was no documentation in the Nurse's Notes to estimate how much fluids R #6 received nor if other fluids, besides water, were provided." R #6's Activities of Daily Living Flowsheet dated 10/2014 and 11/2014 revealed "Diet Intake Key- E=100%, G= 75%, P= 25%, F=50%, O= 0%, B= bites, and R= Refusal: "10/29/14- Brk (breakfast)- P; Lun (lunch)- F; Din (dinner)- R; 10/30/14- Brk- G, Lun- 0, Din- (no entry); 10/31/14- Brk- P, Lun- R, Din- F; 11/01/14- Brk- F, Lun- P, Din- R; R #6's Nurses Note dated 11/02/14 at 1:10 p.m. documented "Res continues on ABX (antibiotic) for UTI. Poor appetite eating bites for meals." 11/02/14- Brk- R, Lun- B, Din- O; 11/03/14- Brk- R, Lun- B, Din- P; 11/04/14- Brk- P, Lun- B, Din- P; R #6's Nurses Note dated 11/04/14 at 1:22 p.m. documented "resident refused lunch only ate few bites, fluids tolerated..." 11/05/14- Brk- 0, Lun- B, Din- R; R #6's Nurses Note dated 11/05/14 at 1:27 p.m. documented "Ate only bites for lunch, fluids taken well..." 11/06/14- Brk- 0, Lun- P, Din- (no entry); R #6's Nurses Note dated 11/06/14 at 3:29 a.m. documented "Accepts small amounts of hydration only..." 11/07/14- Brk- 0, Lun- R, Din- R; R #6's Nurses Note dated 11/07/14 at 12:14 p.m. documented "Fluids encouraged, requires a lot of encouragement, fluids tolerated in small amounts. Fair appetite noted..." 11/08/14- Brk- R, Lun- R, Din- P; R #6's Nurses Note dated 11/08/14 at 10:20 a.m. documented "Continue on abx for UTI; fluids not taken well, skin tugor poor, poor appetite noted..." 11/09/14- Brk- R, Lun- R, Din- (no entry); R #6's Nurses Note dated 11/09/14 at 9:33 p.m. documented "Continue to assist resident with fluids and offered fluids; resident accepted small amount. Only took bites of dinner meal this shift...4:06 p.m.- assist resident with dinner monitored by nurse this shift, continue appetite poor..." 11/10/14- Brk- B, Lun- R, Din- R." R #6's Nurses Note dated 11/10/14 at 3:34 a.m.documented "Refusing to drink water at times, resident ate few bites states not hungry, continue appetite poor..." R #6's Nurses Note dated 11/11/14 at 11:40 a.m. documented "Skin warm and dry to touch, appears very lethargic. SPO2 (oxygen saturation) at 80%, O2 (oxygen) at 3 liters via nasal cannula, resident refused to leave in place, continues to take it off. V/S (vital signs) obtained 86/46, pulse- 103, respirations-16 temperature- 96.8. Change in mental status. Fluids encouraged takes only sips at times. Refuses to eat breakfast. Voids very little, incontinent care given. Informed by CNA (Certified Nursing Assistant) noted to have small amount of drainage from penis thick cloudy mucus, with foul odor noted. Notified Dr's (doctor) nurse and obtained transfer to (local hospital)." R #6's Weight Change History dated 11/05/14 revealed: 05/21/14- 160 lbs (pounds). 06/09/14- 160 lbs. 06/18/14- 160 lbs. 07/07/14- 163 lbs. 08/08/14- 165 lbs. 09/09/14- 164 lbs. 10/07/14- 161 lbs. 11/05/14- 151 lbs. R #6's Physician order [REDACTED]." R #6's MAR indicated [REDACTED] 1. [MEDICATION NAME] 40 mg PO daily at 8:00 a.m. from 11/01/14-11/11/14. The facility continued to provide R #6 with [MEDICATION NAME] even after R #6 was identified to be drinking small amounts of fluids. 2.[MEDICATION NAME] mg PO BID from 11/01/14 to 11/10/14 at 8:00 a.m. and 4:00 p.m. As well, on 11/11/14 at 8:00 a.m. R #6's Telephone Order dated 11/11/14 revealed an order to send R #6 to the (local hospital). R #6's Emergency Provider Record dated 11/11/14 1:03 p.m. revealed "Altered Mental Status: decreased responsiveness. V/S at 12:58 p.m.= Pulse ox (pulse oximetry) 80%, B/P (blood pressure)- 87/49, pulse- 63, respirations- 16. Purulent (bacteria that causes pus) urine output when a (urinary catheter- a tube placed in the bladder to drain urine) was placed. Laboratory: BUN=223 (Blood Urea Nitrogen- a laboratory blood test that reveals information on how the kidneys and liver are functioning), normal range was 6-20; Creatinine= 7.8 (a blood test that measures kidney function), normal range was 0.6-1.0; Estimated GFR (deteriorating renal function; eGFR is approximately 30-60%; eGFR is estimated Glomerular Filtration Rate, usually based on serum Creatinine level, age, sex, and race. - See more at: http://www.renal.org/information-resources/the-uk-eckd-guide/about-egfr#sthash.OT2uBJIh.dpuf), normal range was 35-81; Potassium (K) Level= 7.7, normal range was 3.5-6.1. R #6's last documented weight was 151 lbs. on 11/05/14; from 11/05/14 to 11/11/14 R #6 had lost a total of 14.32 pounds, in 6 days. Disposition: Dehydration, Acute [MEDICAL CONDITIONS] (high potassium level), and lower UTI. Will gently hydrate and monitor I/O (input and output). Counseled patient/family:Discussed his poor condition with son; he doesn't desire [MEDICAL TREATMENT] or PEG (Percutaneous Endoscopic Gastrostomy- an endoscopic procedure in which a tube is placed in the stomach through the abdominal wall)." R #6's Hospitalist Progress Note dated 11/13/14 revealed "lethargic. Diagnosis/Assessment/Plan- continue monitor, [MEDICAL CONDITION] resolved. Discussed pt's (patient's) condition and poor prognosis with pt's daughter and son. They decided to pursue hospice." R #6's Weight Change Alert Report dated 11/14/14 documented "10/07/14 161 lbs- 11/05/14 151 lbs. 29 Days; -10 lbs; -6.21% change." Observation and interview with R #6 at the local hospital on [DATE] at 3:10 p.m. revealed R #6 layed face up with his eyes closed and mouth open. R #6 had an intravenous (IV) access to his right neck with IV fluids infusing. R #6's lips were dry and cracked with peeling skin; his bottom left lip had a black pinpoint spot covering a piece of detaching peeling skin. R #6's upper palate (roof) of his mouth was dry and had a quarter size black scab looking patch on it. R #6's tongue was also dry with approximately half a dime sized black patch. R #6's hands, arms, feet, and legs had dry flaky skin. R #6 did not provide any verbal or gestured feedback from verbal and tactile (touch) stimuli. Interview with the hospital Registered Nurse/Charge Nurse "A" for R #6 on 11/13/14 at 5:05 p.m. revealed R #6 was admitted to the hospital on [DATE] for dehydration, [MEDICAL CONDITION], urinary tract infection, and Acute [MEDICAL CONDITION]. Registered Nurse/Charge Nurse "A" stated R #6 was receiving IV fluids for hydration due to dehydration. Registered Nurse/Charge Nurse "A" stated R #6 had "eschar (slough or piece of dead tissue) to his upper oral palate, tongue, and lower lip due to prolonged dehydration and him being a mouth-breather." Registered Nurse/Charge Nurse "A" stated R #6 failed his swallow study therefore, he was not allowed to eat or drink anything. Interview with Director of Nurses (DON) "G" on 11/14/14 at 10:53 a.m. revealed the facility procedure was for the nursing staff to document intake and output at the end of each meal via the computerized head-set system daily. DON "G" stated the charge nurses were responsible for reviewing each flowsheet at the end of their shift, daily, "I guess they were not doing that." DON "G" reviewed R #6's fluid intake flowsheet and stated she was not aware of R #6's trend of decreased fluid intake. DON "G" stated she was aware that the nursing staff had to provide R #6 with a lot of encouragement to drink fluids because "he doesn't like water." DON "G" confirmed R #6 had a history of [REDACTED].#6's fluid intakes, even after the facility was aware R #6's would occasionally refuse fluids and made it known he did not like water. In addition, DON "G" stated the facility had not implemented any new procedures to address R #6's fluid intake, as of 11/14/14. DON "G" reviewed R #6's meal intake flowsheet and stated she was not aware of R #6's trend of decreased meal consumption. DON "G" stated the facility noticed R #6 lost 10 pounds after he was weighed on 11/05/14. DON "G" explained the facility called the physician on 10/06/14 and informed him of R #6's weight loss. DON "G" verified the facility's interdisciplinary team had not reviewed or addressed R #6's meal intakes, even after the facility was aware of R #6's 10 pound weight loss in less than one month. DON "G" stated her nursing staff should have been reviewing R #6's meal intakes and notified the physician of continued decreased intake. DON "G" stated the facility had not implemented any new procedures to address resident's with weight loss or decreased documented meal intakes as of 11/14/14. DON "G" stated the facility did not have a policy that corresponded to the facility's meal monitoring procedure. At this time, DON "G" was asked for the facility's hydration policy and procedure. DON "G" did not provide any policy and procedure regarding hydaration or additional information that pertained to R #6's meal/fluid intake. Interview with Licensed Vocational Nurse (LVN)/Unit Manager "B" on 11/14/14 at 11:15 a.m. revealed the facility's practice to monitoring intake was the CNA documented the intake using the computerized head-set system immediately after meals. LVN "B" stated the charge nurses were to review the meal and fluid intake documentation at the end of each shift. LVN "B" said she did not know exactly how much food and fluid R #6 was consuming. LVN "B" confirmed she had worked as a charge nurse for R #6 and did not review the intake flowsheets for any resident. LVN "B" stated "I couldn't tell you when was the last time I reviewed this flowsheet." LVN "B" confirmed R #6 had a history of [REDACTED]. Interview with LVN/Charge Nurse "C" on 11/14/14 at 11:23 a.m. revealed she was R #6's nurse on multiple occasions including on 11/11/14, the day he was transferred to the hospital. LVN "C" stated she transferred R #6 to the hospital for altered mental status and decreased oxygen saturation of 80%. LVN "C" stated she did not know nor was made aware of how much food or fluid R #6 was consuming. LVN "C" confirmed she knew R #6 refused to drink water because "he did not like it." LVN "C" said she had not reviewed any residents' intake flowsheet in "I don't know how long." LVN "C" stated she had not noticed or been made aware of R #6 having any problems with his meals or eating. LVN "C" confirmed R #6 had a history of [REDACTED]. Interview with LVN/Unit Manager "D" on 11/14/14 at 12:26 p.m. revealed she had taken care of R #6 on multiple occasions. LVN "D" stated she was not aware of R #6's approximate food or fluid intake. LVN "D" stated she had not reviewed any residents' intake flowsheet. LVN "D" stated staff had to encourage R #6 to drink fluids due to "he did not like water and required assistence to eat." LVN "D" confirmed R #6 had a history of [REDACTED]. Interview with CNA "E" on 11/14/14 at 1:08 p.m. revealed she would periodically encourage R #6 to drink water. CNA "E" said R #6 would frequently refuse to drink water because "he did not like water." CNA "E" stated R #6 would drink "little sips at a time." CNA "E" stated she could not calculate the total amount of "sips" R #6 would drink on a daily basis on her shift. CNA "E" stated she documented residents' food and fluid intake via the head-set computerized system and did not verbally report to a supervisor. Interview with CNA "F" on 11/14/14 at 1:14 p.m. revealed she would periodically encourage R #6 to drink water. CNA "F" said R #6 would frequently refuse to drink water because "he did not like water." CNA "F" stated R #6 would drink "small sips at a time." CNA "F" stated she could not calculate the total amount of "sips" R #6 would drink on a daily basis on her shift. CNA "F" stated she documented residents' food and fluid intake via the head-set computerized system and did not verbally report to a supervisor. None of the staff interviewed stated they offered R #6 a fluid other than water or a food substitute and could not present any additional documented evidence that revealed R #6 consumed any other foods or fluids. On 11/14/14 at 3:15 p.m., DON "G" was asked a second to present a copy of the facility's Hydration policy and procedure. None was provided prior to surveyor exiting the facility. The facility's Abuse Prevention Program Policy Revised and dated 07/31/14 revealed "Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Comprehensive policies and procedures have been developed to aid out facility in preventing abuse, neglect or mistreatment of [REDACTED]. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 11/14/14 revealed 79 residents who needed assistance with meals at risk for inadequate nutrition and hydration issues. At the exit conference on 11/14/14 at 4:45 p.m., the facility was provided an opportunity to provide additional information related to abuse and neglect prohibition. The facility provided no further information.

Based on observation, interview and record review the facility failed to ensure one Resident (R #6) of six residents reviewed for nutritional status maintained acceptable nutrition to prevent significant weight loss. R #6 experienced significant weight loss in less than one month. The facility did not consistently review or address R #6's reduced nutritional intake. R #6 was sent to the hospital with altered mental status and low oxygen saturation. R #6 was diagnosed with [REDACTED]. R #6 remained in the hospital during this investigation. This failure could place the 79 residents who needed assistance to eat, at risk of inadequate nutrition and unplanned weight loss. The findings were: R #6's Face Sheet, dated 05/22/14, indicated R #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnoses: [REDACTED]. of pressure inside the eye), [MEDICAL CONDITION] (too little [MEDICAL CONDITION] hormone), and Senile Cataract (age related vision impairing disease). R #6 was [AGE] years old. R #6's Admission Minimum Data Set ((MDS) dated [DATE] indicated R #6 had short-term and long- term memory problems; cognition was moderately impaired (decisions poor; cues/supervision required). R #6 was independent with eating but may require one person physical assist. R #6 had no signs or symptoms of possible swallowing disorders; his height was 70 inches and his weight was 161 pounds. R #6 had no weight loss in the last 6 months. R #6 had no natural teeth or tooth fragments. R #6 was always incontinent of bowel and bladder. The MDS indicated R #6's active [DIAGNOSES REDACTED]. R #6's Nutritional Data Set and Progress Note, dated 10/01/14, revealed R #6's weight was 164 pounds (lbs.) and he was 70 inches in height. The Consultant Dietitian documented "no significant change." Estimated Nutritional Needs for R #6 were: "2250 kcal, 75-83 g (grams) pro (protein), 1875-2250 mi (milliliter) fluid d/t (due to) [MEDICAL CONDITIONS]. Current diet Order: Mechanical Soft. Goal/Intervention: Resident with Dx (diagnosis) of CKD ([MEDICAL CONDITION]) stage 3. Recommend: Provide 120 ml [MEDICATION NAME] (nutritional supplement for [MEDICAL CONDITION] patients) four times daily (QID) with medication pass D/T high BUN (Blood Urea Nitrogen- a laboratory blood test that reveals information on how the kidneys and liver are functioning)." There was no other dietary note after 10/01/14. R #6's physician's orders [REDACTED]. PO (orally) QID with med (medication) pass for supplement and increased BUN." R #6's Care Plan dated 10/15/14, revealed R #6 was at "risk for alteration in nutrition related to impaired cognition, rejects care, functional impairment, sensory impairment; has no teeth (refuses pureed diet)." The goal of the Care Plan was to "administer iron supplements as ordered; [MEDICATION NAME] as ordered; [MEDICATION NAME] (nutritional shake) as ordered; [MEDICATION NAME] (for [MEDICAL CONDITION] reflux) as ordered; Multivitamins as ordered; set-up, cue, assist as needed with meal consumption; Diet as ordered- Regular mechanical soft large portions; encourage greater than 75% offered fluids and meals daily; Record % of meal and fluid intake, report changes as needed..." R #6's Consolidated Physician order [REDACTED]. 1. [MEDICATION NAME] (treats fluid retention in people with [MEDICAL CONDITION]; excretes fluid) 40 mg (milligrams) PO daily; 2. Folic Acid (a B vitamin) 1 mg PO daily; 3. [MEDICATION NAME] (iron supplement) 325 mg PO daily at noon; 4. Multiple Vitamin with Minerals one tab (tablet) for supplement; 5. [MEDICATION NAME] (a replacement for a hormone normally produced by the [MEDICAL CONDITION]); 6. Diet: Regular, Mechanical Soft, larger portions; 7. [MEDICATION NAME] 120 ml PO QID with med pass for supplement and increased BUN. Additional Diagnoses: [REDACTED]., and thoughts), [MEDICAL CONDITION] Stage III (deteriorating renal function; eGFR is approximately 30-60%; eGFR is estimated Glomerular Filtration Rate, usually based on serum Creatinine level, age, sex, and race. http://www.renal.org/information-resources/the-uk-eckd-guide/about-egfr#sthash.OT2uBJIh.dpuf). 8. Monthly weights. R #6's Activities of Daily Living Flowsheet dated 10/2014 and 11/2014 revealed "Diet Intake Key- E=100%, G= 75%, P= 25%, F=50%, O= 0%, B= bites, and R= Refusal: "10/29/14- Brk (breakfast)- P; Lun (lunch)- F; Din (dinner)- R; 10/30/14- Brk- G, Lun- 0, Din- (no entry); 10/31/14- Brk- P, Lun- R, Din- F; 11/01/14- Brk- F, Lun- P, Din- R; R #6's Nurses Note dated 11/02/14 at 1:10 p.m. documented "Res continues on ABX (antibiotic) for UTI. Poor appetite eating bites for meals." 11/02/14- Brk- R, Lun- B, Din- O; 11/03/14- Brk- R, Lun- B, Din- P; 11/04/14- Brk- P, Lun- B, Din- P; R #6's Nurses Note dated 11/04/14 at 1:22 p.m. documented "resident refused lunch only ate few bites, fluids tolerated..." 11/05/14- Brk- 0, Lun- B, Din- R; R #6's Nurses Note dated 11/05/14 at 1:27 p.m. documented "Ate only bites for lunch, fluids taken well..." 11/06/14- Brk- 0, Lun- P, Din- (no entry); R #6's Nurses Note dated 11/06/14 at 3:29 a.m. documented "Accepts small amounts of hydration only..." 11/07/14- Brk- 0, Lun- R, Din- R; R #6's Nurses Note dated 11/07/14 at 12:14 p.m. documented "Fluids encouraged, requires a lot of encouragement, fluids tolerated in small amounts. Fair appetite noted..." 11/08/14- Brk- R, Lun- R, Din- P; R #6's Nurses Note dated 11/08/14 at 10:20 a.m. documented "Continue on abx for UTI; fluids not taken well, skin tugor poor, poor appetite noted..." 11/09/14- Brk- R, Lun- R, Din- (no entry); R #6's Nurses Note dated 11/09/14 at 9:33 p.m. documented "Continue to assist resident with fluids and offered fluids; resident accepted small amount. Only took bites of dinner meal this shift...4:06 p.m.- assist resident with dinner monitored by nurse this shift, continue appetite poor..." 11/10/14- Brk- B, Lun- R, Din- R." R #6's Nurses Note dated 11/10/14 at 3:34 a.m.documented "Refusing to drink water at times, resident ate few bites states not hungry, continue appetite poor..." R #6's Nurses Note dated 11/11/14 at 11:40 a.m. documented "Skin warm and dry to touch, appears very lethargic. SPO2 (oxygen saturation) at 80%, O2 (oxygen) at 3 liters via nasal cannula, resident refused to leave in place, continues to take it off. V/S (vital signs) obtained 86/46, pulse- 103, respirations-16 temperature- 96.8. Change in mental status. Fluids encouraged takes only sips at times. Refuses to eat breakfast. Voids very little, incontinent care given. Informed by CNA (Certified Nursing Assistant) noted to have small amount of drainage from penis thick cloudy mucus, with foul odor noted. Notified Dr's (doctor) nurse and obtained transfer to (local hospital)." R #6's Weight Change History dated 11/05/14 revealed: 05/21/14- 160 lbs (pounds). 06/09/14- 160 lbs. 06/18/14- 160 lbs. 07/07/14- 163 lbs. 08/08/14- 165 lbs. 09/09/14- 164 lbs. 10/07/14- 161 lbs. 11/05/14- 151 lbs. R #6's Physician order [REDACTED]." R #6's Telephone Order dated 11/11/14 revealed an order to send R #6 to the (local hospital). R #6's Emergency Provider Record dated 11/11/14 1:03 p.m. revealed "Altered Mental Status: decreased responsiveness. V/S at 12:58 p.m.= Pulse ox (pulse oximetry) 80%, B/P (blood pressure)- 87/49, pulse- 63, respirations- 16. Purulent (bacteria that causes pus) urine output when a (urinary catheter- a tube placed in the bladder to drain urine) was placed. Laboratory: BUN=223 (Blood Urea Nitrogen- a laboratory blood test that reveals information on how the kidneys and liver are functioning), normal range was 6-20; Creatinine= 7.8 (a blood test that measures kidney function), normal range was 0.6-1.0; Estimated GFR (deteriorating renal function; eGFR is approximately 30-60%; eGFR is estimated Glomerular Filtration Rate, usually based on serum Creatinine level, age, sex, and race. - See more at: http://www.renal.org/information-resources/the-uk-eckd-guide/about-egfr#sthash.OT2uBJIh.dpuf), normal range was 35-81; Potassium (K) Level= 7.7, normal range was 3.5-6.1. Pt (patient) wt. (weight) 62 kg (62 kg is equivelant to 136.68 pounds). Disposition: Dehydration, Acute [MEDICAL CONDITIONS] (high potassium level), and lower UTI. Will gently hydrate and monitor I/O (input and output). Counseled patient/family:Discussed his poor condition with son; he doesn't desire [MEDICAL TREATMENT] or PEG (Percutaneous Endoscopic Gastrostomy- an endoscopic procedure in which a tube is placed in the stomach through the abdominal wall)." R #6's last documented weight was 151 lbs. on 11/05/14; from 11/05/14 to 11/11/14 R #6 had lost a total of 14.32 pounds, in 6 days. R #6's Hospitalist Progress Note dated 11/13/14 revealed "lethargic. Diagnosis/Assessment/Plan- continue monitor, [MEDICAL CONDITION] resolved. Discussed pt's (patient's) condition and poor prognosis with pt's daughter and son. They decided to pursue hospice. R #6's Weight Change Alert Report dated 11/14/14 documented "10/07/14 161 lbs- 11/05/14 151 lbs. 29 Days; -10 lbs; -6.21% change." Observation and interview with R #6 at the local hospital on [DATE] at 3:10 p.m., revealed R #6 layed face up with his eyes closed and mouth open. R #6 had an intravenous (IV) access to his right neck with IV fluids infusing. R #6's lips were dry and cracked with peeling skin; his bottom left lip had a black pinpoint spot covering a piece of detaching peeling skin. R #6's upper palate (roof) of his mouth was dry and had a quarter size black scab looking patch on it. R #6's tongue was also dry with approximately half a dime sized black patch. R #6's hands, arms, feet, and legs had dry flaky skin. R #6 did not provide any verbal or gestured feedback from verbal and tactile (touch) stimuli. Interview with the hospital Registered Nurse/Charge Nurse "A" for R #6 on 11/13/14 at 5:05 p.m., revealed R #6 was admitted to the hospital on [DATE] for dehydration, [MEDICAL CONDITION] (high potassium levels), urinary tract infection, and Acute [MEDICAL CONDITION]. Registered Nurse/Charge Nurse "A" stated R #6 was receiving IV fluids for hydration due to dehydration. Registered Nurse/Charge Nurse "A" stated R #6 had "eschar (slough or piece of dead tissue) to his upper oral palate, tongue, and lower lip due to prolonged dehydration and him being a mouth-breather." Registered Nurse/Charge Nurse "A" stated R #6 failed his swallow study therefore, he was not allowed to eat or drink anything. Interview with Director of Nurses (DON) "G" on 11/14/14 at 10:53 a.m., revealed the facility procedure was for the nursing staff to document intake and output at the end of each meal via the computerized head-set system daily. DON "G" reviewed R #6's meal intake flowsheet and stated she was not aware of R #6's trend of decreased consumption. DON "G" stated the charge nurses were responsible for reviewing each flowsheet at the end of their shift, daily, "I guess they were not doing that." DON "G" stated the facility noticed R #6 lost 10 pounds after he was weighed on 11/05/14. DON "G" explained the facility called the physician on 10/06/14 and informed him of R #6's weight loss. DON "G" verified the facility's interdisciplinary team had not reviewed or addressed R #6's meal intakes, even after the facility was aware of R #6's 10 pound weight loss in less than one month. DON "G" stated her nursing staff should have been reviewing R #6's meal intakes and notified the physician of continued decreased intake. DON "G" stated the facility had not implemented any new procedures to address resident's with weight loss or decreased documented meal intakes as of 11/14/14. DON "G" stated the facility did not have a policy that corresponded to the facility's meal monitoring procedure. At this time, DON "G" was not able to provide any other additional information that pertained to R #6's meal intake. Interview with Licensed Vocational Nurse (LVN)/Unit Manager "B" on 11/14/14 at 11:15 a.m., revealed the facility's practice to monitoring intake was the CNA documented the intake using the computerized head-set system immediately after meals. LVN "B" stated the charge nurses were to review the intake documentation at the end of each shift. LVN "B" said she did not know how much food R #6 was consuming. LVN "B" confirmed she had worked as a charge nurse for R #6 and did not review the intake flowsheet for R #6 or any other resident. LVN "B" stated "I couldn't tell you when was the last time I reviewed this flowsheet." Interview with LVN/Charge Nurse "C" on 11/14/14 at 11:23 a.m., revealed she was R #6's nurse on multiple occasions including on 11/11/14, the day he was transferred to the hospital. LVN "C" stated she transferred R #6 to the hospital for altered mental status and decreased oxygen saturation of 86%. LVN "C" stated she did not know nor was made aware of how much food R #6 was consuming. LVN "C" said she had not reviewed R #6's or any other resident's intake flowsheet in "I don't know how long." LVN "C" stated she had not noticed or been made aware of R #6 having any problems with his meals or eating. Interview with LVN/Unit Manager "D" on 11/14/14 at 12:26 p.m., revealed she had taken care of R #6 on multiple occasions. LVN "D" stated she was not aware of R #6's approximate meal intake. LVN "D" stated she had not reviewed R #6's or any other resident's meal intake flowsheet, in a "long time." LVN "D" stated on 11/11/14 "just before lunch time", she visited R #6 and was told by Certified Nursing Assistant (CNA) "F" that R #6 had not eaten anything that day. LVN "D" said she found it abnormal that R #6 did not eat and appeared to not recognize her. LVN "D" stated R #6 was transferred to the hospital for evaluation on 11/11/14 at "lunch time." Interview with CNA "E" on 11/14/14 at 1:08 p.m., revealed on 11/11/14, R #6 refused to eat any breakfast. CNA "E" said she documented R #6's meal intake through the computerized head-set system. CNA "E" said she had noticed R #6 not "eating much" several days prior to 11/11/14. CNA "E" said she did not report R #6's decreased meal intake but did document the meal intakes through the computerized head-set system." Interview with CNA "F" on 11/14/14 at 1:14 p.m., revealed on 11/11/14, she saw that R #6 did not eat his breakfast. CNA "F" said when she picked up R #6's breakfast tray she attempted to feed R #6 some oatmeal and he refused so she removed the breakfast tray from bedside. CNA "F" stated she did not inform anyone that R #6 did not eat but did document the meals intake through the computerized head-set system. The facility's Centers for Medicare and Medicaid Services (CMS) Form 672- Resident Census and Conditions of Residents dated 11/13/14 revealed there were 79 residents needing the assistance of one or two staff with eating. At the exit conference on 11/14/14 at 4:45 p.m., the facility was provided an opportunity to provide additional information related to the reviewing and addressing the needs of each resident, especially the residents who were identified with altered nutritional status. The facility provided no further information.

Based on observation, interview and record review, the facility failed to ensure a resident who entered the facility without pressure sores did not develop pressure sores, and after having them, the resident did not receive the necessary care and treatment to promote healing and prevent worsening of the pressure sores for one Resident (R#3) of five residents reviewed for pressure sores. 1. When admitted R#3 did not have any pressure sores and developed two avoidable stage II pressure sores/ulcers. 2. R#3 had two facility acquired stage II pressure sores to her buttocks. The facility failed to implement interventions after developing pressure sores. R#3 did not receive care and treatment in a timely manner to prevent the stage II pressure sores from worsening to Stage III pressure sores and later unstageable. These failures could place the six residents with pressure sores at risk for development of new pressure sores, infection and worsening of current pressure sores. The findings were: R#3's Face Sheet dated 07/30/14 indicated R#3 was admitted to the facility on [DATE] with a readmitted d of 07/30/14. R#3 was [AGE] years old. R#3's Consolidated physician's orders [REDACTED].#3's [DIAGNOSES REDACTED]. R#3's Annual Minimum Data Set ((MDS) dated [DATE] revealed R#3 had unclear speech, usually understood others and usually made herself understood to others. R#3's cognition was intact. R#3 required extensive assistance from two staff persons for bed mobility, and had only transferred to and from bed once or twice during the seven day assessment period. Resident was non-ambulatory. R#3 required extensive assistance from one staff person for dressing, incontinent care and personal hygiene. R#3 was incontinent of bowel and bladder. R#3 had not had one or more unhealed pressure sores at Stage I (sores that were not open wounds. The skin may be painful, but it had no breaks or tears. The skin appeared reddened and did not blanch, lose color briefly when you press your finger on it and then remove your finger). R#3's Impaired Skin Care Plan dated 10/18/13 indicated R#3 was at risk for impaired skin integrity due to impaired mobility, impaired cognition, rejected care at times, pain due to a history of a femur fracture. The goal of the Care Plan was for R#3's skin to remain intact. Approaches to be utilized by nursing and Certified Nurse Aides (CNAs) were: -pressure redistributing mattress and/or wheelchair cushion, -use draw sheet for bed mobility to prevent friction and shearing, -weekly skin checks, -skin assessments quarterly and as needed (PRN), -notify medical doctor, family, and responsible party of changes as needed, -turn and reposition every two hours and PRN. R#3's Skin Inspection Report dated 01/24/14 through 07/07/14 indicated "skin intact." R#3's Braden Risk Assessment Report (Weekly Update) dated 06/23/14 indicated R#3 scored a 15 (mild risk) on the Braden Risk Assessment. A score of 15 to 18 indicated a mild risk for sustaining pressure sores. R#3's mobility was slightly limited. R#3 was able to make frequent, though slight changes in body or extremity position independently. R#3 had a potential for friction or shear due to R#3 moved feebly or required minimum assistance. R#3's Quarterly MDS dated [DATE] revealed R#3 had unclear speech, sometimes understood, and usually understood others. R#3's cognition was moderately impaired (decisions poor) and she required cues and supervision for decision making. R#3 required extensive assistance from two staff persons for bed mobility, transfer, dressing, incontinent care and personal hygiene. R#3 was incontinent of bowel and bladder. R#3 had not had one or more unhealed pressure sores at Stage I or higher. R#3's Braden Risk Assessment Report (Weekly Update) dated 07/07/14 indicated R#3 scored a 16 (mild risk) on the Braden Risk Assessment. A score of 15 to 18 indicated a mild risk for sustaining pressure sores. R#3's mobility was slightly limited. R#3 was able to make frequent though slight changes in body or extremity position independently. R#3 had a potential for friction or shear due to R#3 moved feebly or required minimum assistance. R#3's Wound Healing Progress Report dated 08/07/14 revealed R #3's pressure sore on her left buttock was assessed and staged on: 07/07/14 -3.00 centimeters (cm) x 0.40 (cm) x 0.00 -Stage II (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape/abrasion, blister, or a shallow crater in the skin). This was the date the pressure sore was identified. Wound Healing Progress Report dated 08/07/14 revealed R#3's Pressure Sore on her right buttock was assessed and staged on: 07/07/14-4.00cm x 2.00cm x 0.00 (Stage II) -date Pressure Sore identified. R#3's Impaired Skin Care Plan dated 07/07/14 indicated R#3 had a Stage II pressure sore to her right and left buttock. The plan indicated R#3 would show signs of healing in 30days. The approaches to be utilized by CNAs and nursing were: -pressure redistributing mattress and/or wheelchair cushion, -use draw sheet for bed mobility to prevent friction and shearing, -weekly skin checks, -skin assessments quarterly and as needed (PRN), -notify medical doctor, family responsible party of changes as needed, -turn and reposition every two hours and PRN. On 08/25/14 at 10:25 a.m. Licensed Vocational Nurse (LVN)/Unit Manager (UM) "A" stated all the facility mattresses were pressure redistributing mattresses. LVN/UM "A" stated she had been employed with the facility approximately six months and R#3 had utilized the same mattress. R#3's Itemized Activities of Daily Living Coding Report (report from Accunurse CNAs utilized to document positioning in bed) dated July 07/07/14 revealed R#3 was repositioned in bed at the following times: 2:15 a.m. 1:00 p.m. 6:00 p.m. 11:15 p.m. R#3's Impaired Skin Care Plan dated 07/08/14 indicated R#3 was prescribed Stress Tablet with Zinc (to promote wound healing) and Prostat (liquid protein designed to assist with wound healing) as ordered. R#3's Physician's Telephone Order dated 07/08/14 indicated to discontinue previous wound care order. Cleanse Stage II to right and left sacrum with normal saline/wc (wound care), pat dry with 4 X 4 gauze, apply [MEDICATION NAME], cover with a broad gauze every day times 14 days then reassess. R#3's Impaired Skin Care Plan dated 07/09/14 indicated R#3 had a "New Wound Treatment to right and left buttock." R#3's Braden Risk Assessment Report (Weekly Update) dated 07/14/14 indicated R#3 scored a 15 (mild risk) on the Braden Risk Assessment. A score of 15 to 18 indicated a mild risk for sustaining pressure sores. R#3's mobility was slightly limited. R#3 was able to make frequent though slight changes in body or extremity position independently. R#3 had a potential for friction or shear due to R#3 moved feebly or required minimum assistance. R#3's Wound Healing Progress Report dated 08/07/14 revealed R#3's pressure sore on her left buttock was assessed and staged on: 07/09/14- 4.00cm x 1.70cm x 0.10cm (Stage II). Wound Healing Progress Report dated 08/07/14 revealed R#3's pressure sore on her right buttock was assessed and staged on: 07/09/14- 3.50cm x 0.70cm x 0.10cm (Stage II). Wound Healing Progress Report dated 08/07/14 revealed R#3's pressure sore on her left buttock was assessed and staged on: 07/16/14-documented an increase in size-4.10cm x 7.00cm x 0.20cm (Stage II). Wound Healing Progress Report dated 08/07/14 revealed R#3's pressure sore on her right buttock was assessed and staged on: 07/16/14- 3.00cm x 7.00cm x 0.20cm (Stage II). R#3's Skin Inspection Report dated 07/14/14 through 07/21/14 indicated "skin not intact-existing." R#3's undated Quality Improvement Tool for Review of Acute Care Transfers indicated R#3 was transferred to the hospital on [DATE] due to uncontrollable body movements and a 13 pound weight loss. On 08/08/14 at 9:30 a.m., LVN/UM "A" stated R#3 was admitted to the hospital on [DATE] for uncontrolled spasms and R#3 returned to the facility on [DATE]. R#3's Wound Assessment Report dated 07/30/14 revealed R#3 was readmitted to the facility with the same two pressure sores to her buttocks as before she was sent to the hospital. The plan was to continue to treat wounds as ordered. Assessment occasion was a weekly update. -Left buttock-length 3.00 cm; width-1.40 cm and depth-0.00 cm. -Right buttock-length 3.50 cm; width 1.00cm and depth 0.00 cm. The right and left buttock pressure sores were defined as: Border definition well defined wound bed-100% granulation. R#3's Braden Risk Assessment Report (Admission) dated 07/30/14 indicated R#3 scored a 14 (moderate risk) on the Braden Risk Assessment. A score of 13 to 14 indicated a moderate risk for sustaining pressure sores. R#3's mobility was very limited. R#3 was able to make occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently. R#3 had a "problem" for friction or shear due to R#3 required moderate to maximum assistance in moving. R#3's Physician's Telephone Order dated 07/31/14 revealed R#3 had a Stage II pressure sore to her right and left sacrum. The order for treatment to R#3's pressure sores, start date of 07/31/14 was to clean with normal saline or wound cleanser, pat dry, apply Xeroform and cover with dry dressing every day for 14 days and then reassess. R#3's Impaired Skin Care Plan dated 07/31/14 indicated R#3 was readmitted to the facility; wound care to right and left buttock per medical doctor; will show signs of healing in 30 days. R#3's Nurse's Notes dated 07/31/14 at 10:20a.m., indicated follow up, readmit from the hospital. The note indicated R#3 was lying in bed, awake; heel protectors in place; Stage II to right and left coccyx. Turned and repositioned every two hours. R#3's Consolidated physician's orders [REDACTED]. The undated Panacea Mattress Specifications indicated the Panacea Mattress had super-soft foam in the heel area that provided excellent protection against skin breakdown, high-density top layer in the head and torso for comfortable pressure redistribution and shear force reduction, built in firm foam perimeters to ease resident transfers, reduce risk of falls and reduce risk of entrapment, raised one piece side perimeters to reduce risk of resident falls from bed and help reduce need for bed rails. R#3's Nurse's Notes dated 08/01/14 at 2:19 a.m. revealed R#3 had a pressure sore to her left buttock...R#3 had two pressure sores to her buttock before she was sent out to the hospital and came back with the same two pressure sores to her buttocks. The note stated will continue to treat wounds as ordered. R#3's Nurse's Notes dated 08/01/14 at 11:12 a.m., indicated R#3 continued on follow-up for readmission and was on antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION]. The note also stated a dressing was intact to buttocks area Stage II's. Turned and repositioned as needed. R#3's Nurse's Notes dated 08/01/14 at 2:24 p.m. indicated pressure sores right buttock. R#3 had two pressure sores to right and left buttocks. Returned with the same two pressure sores to buttocks. Will treat as per ordered. R#3's Braden Risk Assessment Report (Weekly Update) dated 08/04/14 indicated R #3 scored a 15 (mild risk) on the Braden Risk Assessment. A score of 15 to 18 indicated a mild risk for sustaining pressure sores. R#3's mobility was slightly limited. R#3 was able to make frequent though slight changes in body or extremity position independently. R#3 had a potential for friction or shear due to R#3 moved feebly or required minimum assistance. R#3's Itemized Activities of Daily Living Coding Report (report from the Accunurse CNAs utilized to document positioning in bed) dated 08/04/14 revealed R#3 was repositioned in bed at 4:30 p.m., only once in a 24 hour period. On 08/04/14 at 7:43 a.m., during initial tour with LVN/UM (Licensed Vocational Nurse/Unit Manager) "A," R#3 was observed lying on a low bed with a scooped mattress (mattress with raised sides to prevent falls). On 08/04/14 at 12:00 p.m., R#3 was observed lying on a scooped mattress. On 08/04/14 at 1:40 p.m., R#3 was observed sitting up in bed on a scooped mattress. Review of R#3's Resident Incident Reports indicated R#3 had fallen on: -12/23/14 at 2:45 a.m. from bed and was on her back on the floor mat next to her bed. Bed was in a low position and side rails up times two. No injuries noted. -12/20/13 from her bed and was found on the floor mat next to the bed. No injuries noted. On 08/25/14 at 10:35 a.m., LVN/UM "A" stated she was not able to find a physician's orders [REDACTED]. LVN/UM "A" stated the scooped mattress was used to prevent falls and injuries from involuntary movements. LVN/UM "A" stated she was not aware of R#3 having any recent falls. During observation of R#3's wound care on 08/05/14 at 4:50 p.m., LVN "ZZ" removed the dressing from R#3's buttocks to provide wound care (physician orders [REDACTED]. LVN "ZZ" said, "I would say it's a stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling), she came back from the hospital this way. I want to make sure Dr. "YY" (wound care specialist doctor) sees her. Last week she was in the hospital and I think he needs to see this to probably change her treatment." On 08/22/14 at 4:20 p.m., LVN "ZZ" stated she had not notified Dr. "YY" of R#3's wound change from a stage II to a stage III on 08/05/14. R#3's Daily Skilled Nurses' Notes dated 08/05/14 at 6:00 p.m. documented by LVN "ZZ" revealed R#3 "continues under medicare skilled services for dx (diagnosis) UTI, [MEDICAL CONDITION], Type 2 Diabetes Mellitus/Sepsis, [MEDICAL CONDITION], resident alert/sleepy, responds to verbal/tactile stimuli, oriented to self, denied pain when asked, continuing on antibiotic therapy Amoxicillan Suspension for urinary tract infection without any adverse drugs reactions, afebrile PO (by mouth) fluids offered, taking well, resident presently on finger sticks blood glucose BID (twice daily)...no evidence of any blood observed in stool during incontinent care, resident incontinent of B/B (bowel and bladder), repositioning every 2 hours and PRN (as needed)." R#3's Daily Skilled Nurses' Notes dated 08/05/14 at 7:50 p.m. documented by LVN "ZZ" revealed, "air mattress applied to resident bed as requested d/t (due to) pressure ulcers both buttocks." R#3's Daily Skilled Nurses' Notes dated 08/05/14, documented by LVN "ZZ" revealed, "Nurse Practitioner notified stage two decubitis to (unreadable handwriting) buttock changed to stage three (unreadable handwriting) drainage-no new order rec'd (received) except stated to inform Doctor (Dr. "YY") on round in a.m. (morning)." R#3's Impaired Skin Care Plan dated 08/05/14 indicated R#3 was ordered an air mattress. The facility provided a printed copy dated 08/25/14 indicating a low air loss mattress was used to treat moderate to severe pressure ulcers. Clinical Considerations for the use of the low air loss mattress were multiple stage II, III, or IV pressure ulcers. During observation on 08/06/14 at 3:22 p.m., LVN/UM "A" accompanied the wound care specialist, Dr. "YY" to assess R#3's pressure sores. Dr. "YY" stated that previously R#3 had two stage II pressure sores to her right and left sacrum and now it is unstageable. Dr. "YY" said, "it's gotten worse, it (pressure sore) measures 7.5 (centimeter) by 8.0 (centimeter). Change treatment orders ...that I might need to debride (remove dead or damaged tissue from a wound) last time I saw it was left and right. I need to see it again; if it's combined it will stay as the one big measurement." Dr. "YY" said (to LVN/UM "A"), "was she always on an air loss mattress?" LVN/UM "A" stated, "no, we just got that last night (08/05/14)." On 08/06/14 at 3:22 p.m. Dr. "YY" said to R#3, "your wound has gotten bigger." R#3 nodded and did not say anything. Outside R#3's room, Dr. "YY" stated, "mine are just recommendations; the PCP (primary care physician) is the one who writes the orders. I'm available for the facility (staff) and the PCP if they have concerns, if the wound is getting worse, they can call me anytime." Skin Inspection Report dated 08/07/14 indicated "skin not intact-existing." R#3's Braden Risk Assessment Report (Weekly Update) dated 08/08/14 indicated R#3 scored a 13 (moderate risk) on the Braden Risk Assessment. A score of 13 to 14 indicated a moderate risk for sustaining pressure sores. R#3's mobility was very limited. R#3 was able to make occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently. R #3 had a "problem" for friction or shear due to R#3 required moderate to maximum assistance in moving. R#3's Braden Risk Assessment Report (Weekly Update) dated 08/11/14 indicated R#3 scored an 11 (high risk) on the Braden Risk Assessment. A score of 10 to 12 indicated a high risk for sustaining pressure sores. R#3's mobility was very limited. R#3 was able to make occasional slight changes in body extremity position but was unable to make frequent or significant changes independently. R#3 had a "problem" for friction or shear due to R#3 required moderate to maximum assistance in moving. R#3's Braden Risk Assessment Report (Weekly Update) dated 08/18/14 indicated R#3 scored a 12 (high risk) on the Braden Risk Assessment. A score of 10 to 12 indicated a high risk for sustaining pressure sores. R#3's mobility was very limited. R#3 was able to make occasional slight changes in body extremity position but was unable to make frequent or significant changes independently. R#3 had a "problem" for friction or shear due to R#3 required moderate to maximum assistance in moving. On 08/08/14 at 9:23 a.m., LVN/UM "A" stated that when R#3 was readmitted from the hospital back to the facility there was no change in orders for her wound care. LVN/UM "A" said, "charge nurses on the floor do assessments when they (residents) come back. I do rounds with the doctor ...we measure weekly, and if we notice it's getting worse, we call the doctor to get the treatment changed. There's only a place in the TAR (treatment administration record) that we check off that the treatment was done. If it looks worse, we call (Dr."YY"). We may need to do some teaching on staging." LVN/UM "A" stated when R#3 returned to the facility from the hospital, Dr. "YY" had already made weekly rounds and R#3 had not been assessed on 07/30/14. On 08/22/14 at 1:50 p.m., R#3 was able to state yes and/or no to surveyor's questions. R#3 stated "no" CNAs did not turn her every two hours. R#3 stated "no" she did not know if her pressure sores were getting better or worse. R#3 stated "no" she did not have the pressure sores when she was admitted . On 08/22/14 at 2:05 p.m., CNA "EE" stated R#3 was turned every two hours when the facility was fully staffed. CNA "EE" stated R#3 was turned at least three times if the facility was short staffed. CNA "EE" stated there was not a turning schedule for residents who needed to be assisted with turning. CNA "EE" said, "it is just something you get used to doing." CNA "EE" stated her turning schedule was the following: 8:00 a.m.-facing the door, 10:00 a.m.-lying on back, 12:00 p.m.-facing the window, 2:00 p.m.-lying on back. CNA "EE" stated if she was "pulled" to work on another hall she would remind the other CNAs on the hall to reposition R#3. CNA "EE" stated when her shift started she asked the Charge Nurse on which side to turn R#3. CNA "EE" stated R#3 went to the hospital with two pressure sores on her buttocks. CNA "EE" stated she worked on 07/31/14, the day after R#3 returned from the hospital and when she provided incontinent care, R #3 "had one large sore" on her buttocks. On 08/22/14 at 2:10 p.m., CNA "U" stated she turned residents who needed assistance every two hours. CNA "U" turned residents on the following schedule: 8:00 a.m.-facing window, 10:00 a.m.-facing door, 12:00 p.m.-facing window, 2:00 p.m.-facing door. CNA "U" stated "this is my routine. I'm not sure of other CNAs' routine." CNA "U" stated if she was pulled to assist on another hall she would communicate to the other CNAs which way to turn R#3 and when to turn R#3. On 08/22/14 at 2:20 p.m., CNA "FF" stated she turned R#3 every two hours. CNA "FF" stated when she arrived at work if R#3 was facing the door she would turn R#3 to the window, if facing window to her back, and if R#3 was on her back, she would face her to the door. CNA "FF" stated if another CNA had repositioned R#3, she would not have a way of knowing R#3 had recently been repositioned. CNA "FF" stated if she was pulled to work on another floor, the other CNAs working on the hall with R#3 would not know when to turn R#3 or which way to turn R#3. On 08/22/14 at 2:25 p.m., CNA "GG" stated at the beginning of the shift, the Charge Nurse told the CNAs which position to place R#3. CNA "GG" stated, "it depends on nurses which way they want." CNA "GG" stated the normal schedule was: 8:00 a.m.-back-for breakfast, 10:00 a.m. to 11:30-CNAs had their breaks and as they returned from breaks, residents who were bedfast were put on their backs to get ready for lunch, 12:30 p.m. to 1:00 p.m.-facing door, 2:00 p.m.-facing window. On 08/22/14 at 2:35 p.m., CNA "HH" stated, she "tried to turn residents every two hours, to be honest it is usually three times a day." CNA "HH" stated the turning schedule she used was: 7:00 a.m.-lying on back, 10:00 a.m.-lying on right side, 12:00-lying on back for lunch, 2:00 p.m.-lying on left side. CNA "HH" showed the surveyor a turning schedule on the inside of R#3's closet. CNA "HH" stated the turning schedule was no longer used because the Accunurse (headset that reminds CNAs when to provide care for residents) tells the CNAs when to turn a resident. On 08/22/14 at 3:20 p.m., CNA "BB" stated she worked the 3:00 p.m. to 11:00 p.m. shift on Hall 200. CNA "BB" stated the Accunurse headset beeped every two hours and would state to the CNA turn resident so and so. The CNA answered into the headset which position the resident was turned: right, left or back. CNA "BB" stated when she arrived on her shift she knew which way to turn a resident by the position the resident was lying. If a resident was on their right side it was time to turn the resident to their left side, next she would turn the resident to their back. CNA "BB" stated R#3 was discharged to the hospital with a dime sized pressure sore on each buttock. CNA "BB" stated she saw R#3 two or three days after #3 returned from the hospital and the pressure sores "were all one, larger." On 08/22/14 at 3:35 p.m., CNA "CC" stated she worked the 3:00 p.m. to 11:00 p.m. shift on Hall 200. CNA "CC" stated residents who needed assistance with positioning were to be turned every two hours. CNA "CC" stated there was not a turning schedule to follow. CNA "CC" stated when she arrived on her shift and walked into a resident's room that needed assistance with positioning, she would know what position to turn the resident by the following: -resident was facing the window or on their left side, the resident would be turned toward the door and from that point CNA "CC" repositioned every two hours. CNA "CC" stated R#3 had two small pressure sores on each buttock and now the pressure sores merged together. On 08/22/14 at 4:20 p.m., LVN "ZZ" stated when she was "doing rounds" if she noticed a resident needed to be repositioned, she would tell a CNA. LVN "ZZ" stated R#3 needed to be repositioned/turned every two hours. LVN "ZZ" stated, "I at least make sure residents are turned three times during in an eight hour shift." LVN "ZZ" stated the 3:00 p.m. to 11:00 p.m. had three CNAs to 22 residents. "We have inadequate staffing to be turning residents every two hours." On 08/25/14 at 10:25 a.m., LVN/UM "A" stated prior to R#3 obtaining two stage II pressure sores on her right and left buttocks, R#3 was able to move around in her bed, due to the involuntary spasms. LVN/UM "AA" stated she was not able to locate a physician's orders [REDACTED]. LVN/UM "A" stated LVN "ZZ" had not notified Dr. "YY" on 08/05/14 after the stage II pressure sore had worsened to a stage III. LVN/UM "A" stated LVN "ZZ" notified the Physician Assistant (PA) of R#3's Primary Care Physician. The PA stated to inform Dr. "YY" when he arrived the morning of 08/06/14. LVN/UM "A" stated Dr. "YY" did not arrive at the facility to complete skin assessments until the afternoon of 08/05/14. LVN/UM "A" stated a low air loss mattress was ordered from the durable medical company on 08/05/14 after R#3's pressure sore had worsened from a stage II to a stage III. The low loss air mattress was delivered the evening of 08/05/14. LVN/UM "A" stated low air loss mattresses were only ordered for residents ' with stage III or higher pressure sores or based on nursing judgment. LVN/UM "A" stated Dr. "YY" was notified of R#3's stage III pressure sore when he arrived on the 3:00 p.m. to 11:00 p.m. shift to make rounds. LVN/UM "A" stated when a pressure sore was discovered or a pressure sore worsened the Physician was to be notified immediately of the pressure sore. LVN/UM "A" stated the floor Charge Nurse for each shift was responsible for ensuring the Physician was notified of pressure sores and the Unit Manager was responsible for ensuring the Charge Nurse notified the Physician. LVN/UM "A" stated after Dr. "YY" made rounds he entered his information (stages) into his computer and the facility Director of Nurses (DON) was able to print the information from a computer program. The DON printed out the information and gave it to the Unit Managers, who entered the information into the facility's computer program. LVN/UM "A" stated after R#3 obtained the stage II pressure sores on her buttocks, the same Care Plan was followed as was initiated on 10/18/13. LVN/UM " A " stated the protocol utilized by nursing staff after a resident was discovered with a pressure sore was the same protocol used to prevent pressure sores. Wound Healing Progress Report dated 08/07/14 revealed R#3's pressure sore on her left buttock was assessed and staged on the following dates: 07/07/14-3.00 x 0.40 x 0.00-stage II 07/09/14-4.00 x 1.70 x 0.10-stage II 07/16/14-4.10 x 7.00 x 0.20-stage II documented an increase in size on 07/16/14- 4.10 x 7.00 x 0.20 (Stage II) documented a decrease in size on 07/30/14- 3.00 x 1.40 x 0.00 (Stage II)-(date readmitted to the facility from the hospital). Wound Healing Progress Report dated 08/07/14 revealed R#3's pressure sore on her right buttock was assessed and staged on the following dates: 07/07/14- 4.00 x 2.00 x 0.00 (Stage II) (-date pressure sore identified) 07/09/14- 3.50 x 0.70 x 0.10 (Stage II) 07/16/14- 3.00 x 7.00 x 0.20 (Stage II) 07/30/14- 3.50 x 1.00 x 0.00 (Stage II) (date readmitted to the facility from the hospital) Wound Healing Progress Report dated 08/22/14 revealed R#3's two Stage II pressure sore on her right buttock was assessed and staged as one pressure sore on the following dates: 08/06/14-7.50 x 8.00 x 0.00-unstageable due to slough/eschar (dead tissue) 08/13/14-7.50 x 6.00 x 0.00-unstageable due to slough/eschar 08/20/14-4.00 x 6.00 x 0.00-unstageable due to slough/eschar The facility's Policy and Procedures for the Prevention of Pressure Ulcers dated October 2010 revealed the "purpose of the procedure was to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. -Preparation-1) Review the resident's care plan to assess for any special needs of the resident. -General Guidelines-1) Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time cause increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue...5) Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. 6) The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed... -Interventions and Preventive Measures: General-2) For a person in bed: a. Change position at least every two hours or more frequently if needed; b. Determine if resident needs a special mattress; c. if a special mattress is needed, use one that contains foam, air, gel, or water, as indicated... 9) Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. 10) Immediately report any signs of a developing pressure ulcer to the supervisor. Interventions and Preventive Measures: Residents with Risk Factors: 3) Risk Factor-Bed-Fast- a. Change position at least every two hours and more frequently as needed... Documentation: The following information should be recorded in the resident's medical record: 1. The type of skin care given. 2. The date and time skin care was given. 3. The position in which the resident was placed. 4. The name and title of the individual who gave the care. 5. Any change in the resident's condition. 6. The condition of the resident's skin (i.e., the size and location of any red or tender areas)." The facility's Policy and Procedures for Pressure Ulcers/Skin Breakdown-Clinical Protocol dated October 2010 revealed Assessment and Recognition; "1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example immobility, recent weight loss, and a history of pressure ulcers(s). 2. In addition, the nurse shall assess and comment/report the following: a. Vital signs, b. Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue, c. Pain assessment, d. Resident's age and sex, e. Resident's mobility status, f. Current treatments, including support surfaces, g. All active diagnoses." According to Center for Medicare and Medicaid (CMS) form 672 dated 08/04/14 there were six residents identified with pressure sores. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to pressure sores. As of exit on 08/25/14 at 4:30 p.m., the facility provided no further information.

Based on Observation, Interview and Record Review the facility failed to implement policies and procedures that prohibit neglect for one Resident (R#1) of five residents reviewed for neglect. -The facility failed to provide adequate supervision for R #1. CNA "K" turned around to close the shower room door and R #1 was in the process of falling. R #1 fell from the shower bed and sustained a 16 cm (centimeter) scalp laceration all the way to the bone. -The facility failed to remove a broken shower bed from use. These failures placed R #1 and seven additional totally dependent residents that required the use of a shower bed at risk for neglect . The findings were: (R #1 was in the hospital at the time of the investigation.) R #1's Face Sheet dated 08/21/13 revealed an [AGE] year old female admitted [DATE] with the following Diagnoses: [REDACTED]. R #1's Diagnosis/History dated 02/24/14 revealed the [DIAGNOSES REDACTED]. R #1's quarterly MDS (Minimum Data Set) dated 04/08/14 revealed R #1 was rarely/never understood and rarely/never understood *had severely impaired vision *had minimum difficulty hearing *had BIMS (Brief Interview for Mental Status) was not conducted * had severely impaired cognition-never/rarely made decisions *was totally dependent requiring two person assistance with bed mobility and dressing *was totally dependent with bathing requiring one person assistance *Height=61 inches, Weight=123 pounds R #1's Care Plan dated 10/23/13 revealed: "Self-Care Deficit: Total Assist with all ADL's ...Approaches ...Bed Mobility: Total assist x 2 staff. Transfers: Total assist x 2 staff with (Mechanical Lift) ..." R #1's Care Plan dated 10/23/13 revealed: "Risk for Injury r/t (related to) Falls ....Approaches ...Side rails up x 2 while in bed for security and enable turning in bed ...Shower Bed for baths ...Transfer with assist of 2 people with (Mechanical Lift) ..." R #1's Interdisciplinary Care Plan dated 04/17/14 "areas reviewed " revealed R #1 was total care with all ADL's (Activities of Daily Living), and had no history of falls. R #1's consolidated Physician order [REDACTED].) R #1's discharge MDS dated [DATE] revealed R #1 was totally dependent with: *transfers *bathing *bed mobility *Dressing *Bathing *Height=61 inches, Weight=123 pounds * Had one fall with injury R# 1's Resident Incident Report dated 06/30/14 revealed R #1 was bedfast and had no independent movement. R #1 was on the shower bed in the shower room when CNA turned around to shut the door and when she turned back around the R #1 "was actively falling from shower bench." R #1 sustained a large laceration on top of R #1's head..."Immediate-Post Incident Action: replace shower bed, teachable moments on safe equipment, teachable moments not to turn your back on a (resident) when in the shower chair or shower bed and have two cna's when using the shower bed to bath." Nursing Home To Hospital Transfer Form revealed on 06/30/14 at 9:35 a.m., R #1 was transferred to hospital due to fall with a laceration to the top of R #1's head. Telephone Order dated 06/30/14 at 10:00 a.m. revealed a Physician order [REDACTED]." Emergency Physician Record dated 06/30/14 at 10:40 a.m., revealed R #1 had a 16 centimeter (cm) stellate (irregular tear-like wound caused by [MEDICATION NAME] trauma) scalp laceration all the way to the bone. The repair of the laceration required staples and suture with a two layer closure. According to the ER diagram (frontal) revealed the laceration was midline and extended to the left side of the cranium (skull). Hospital Discharge Summary dated 07/12/14 revealed R #1 was hospitalized from [DATE] until 07/10/14. "The Patient is an [AGE] year old woman coming to the hospital from the nursing home after being dropped during a transfer. This resulted in a large laceration of the forehead along with bruising of the right foot." R #1's Hospital [DIAGNOSES REDACTED]. Resident was discharged to another facility. On 07/04/14 at 3:15 p.m., interview with Licensed Vocational Nurse (LVN) "P" said the shower bed that R #1 was using at the time of the fall was in the dumpster outside of the facility. During this same interview Surveyor, accompanied by LVN "P", observed a shower bed with a broken rail outside at the back of the facility. It was located to the right of the back door, against the building. The left broken rail had jagged edges. The observation revealed the raised rail on the shower bed measured approximately seven and one half inches from the non-compressed cushion on the shower bed to the top of the rail. On 07/04/14 at 4:10 p.m., the Director of Nurses (DON) said the facility plan was to throw away the broken bed and the 200 unit would share the shower bed from the 100 unit with the residents that require the use of a shower bed. On 07/04/14 at 4:35 p.m., the Maintenance Director (MD) said the staff notified him 10 minutes after R #1 fell from the broken rail of the shower bed. The MD said he was told that a Certified Nurse Aide (CNA) had left R #1 unattended and R #1 fell . The MD said the Administrator then instructed the MD to move the broken bed outside. The MD said the staff should not have used that shower bed because the rail had been broken for over two weeks. MD said the rail had been fixed once before however, the second time the rail broke the MD could not repair the broken rail, because the break in the rail had jagged edges. The MD said he notified the Administrator that the shower bed could not be repaired and that another shower bed would have to be purchased. MD was unable to provide a work order request for the either repair request and said it was a verbal request made both times. MD said the staff should write any requests for repairs in the Maintenance Log Book but many times the staff will just verbally bring requests to his attention. Review of order form emailed to facility dated 07/01/14 revealed purchase order for a "PVC Patient Transport or Shower Gurney" On 07/04/14 at 4:35 p.m., LVN "L" (200 Unit Manager) said it was the responsibility of the Unit Manager to ensure the residents had a safe environment and equipment to use. LVN "L" said she was not aware the shower bed was broken on her unit. LVN "L" said that one of the CNAs told LVN "L", R #1 fell out of the shower bed from the right side, which was not broken, and the rail was raised. LVN "L" said, "if the rail on the shower bed was broken someone should have written it the maintenance log request book." On 07/18/14 at 12:50 p.m., LVN "J" said R #1 was not able to move and required total assistance for any mobility. LVN "J" said R #1 had bilateral lower and upper extremity contractures and the only movement R #1 was able to perform was slight movement in her hands. LVN "J" said if R #1 was on her back without support and there was any movement of the shower bed then R #1 "could have" passively rolled to her side. LVN "J" said that in her "professional opinion it was not possible" for R #1 to roll over the rails and off the shower bed. LVN "J" said now there must be two CNAs in the shower room when providing shower bed showers. On 07/18/14 at 1:10 p.m., CNA "K" said, "I was in the room when (R #1) fell , I turned around to close the shower room door and (R #1) was in the process of falling." CNA "K" said R #1 was dependent with all mobility and the day R #1 fell ; R #1 was positioned on her back. CNA "K" said that if R #1 was positioned on her back R #1 would "go" either to her right or left side. CNA "K" said the side rails were up and were not broken. CNA "K" said, "I really do not know how (R# 1) fell over the rail, I have never seen that happen before." CNA "K" said now there must be two CNAs in the shower room when providing shower bed showers. She said all showers that require a shower bed would be provided in the 100 hall shower room so two CNAs could fit in the room. On 07/18/14 at 2:15 p.m., the Administrator said he was made aware of R #1's fall at approximately 9:15 a.m. the day the incident occurred. Administrator said the staff was inserviced after the fall, to never turn their back on a resident while providing care. The facility now required two CNAs to be present in the shower room at all times when providing showers to residents who required a shower bed, and all shower bed showers were to be provided in the 100 hall shower room. The Administrator said, "(CNA "K") told me the entire bed tipped over." The Administrator said, "There was no malfunction in the bed, the bed was not broken. The left rail was a little loose, it had been broken before and (MD) placed new pins in the bed, and it was fixed. There was no malfunction in the bed, that I am aware of. Besides that would have nothing to do with the resident falling, (R #1) fell off the right side, over the top of the rail. The rails were up." The Administrator said he and the DON conducted a demonstration and he was able to roll over to the right side and tip the bed over. According to Texas Nurse Aide Training and Competency Evaluation Programs 2013 revealed: "UNIT VII-PERSONAL CARE PROCEDURAL GUIDELINE #18-TUB OR SHOWER BATH... B. Precautions... 2. NEVER leave the resident unattended in the tub or shower... C. Procedural Guidelines... 3. Assist resident to the bathing area as appropriate, providing needed support to prevent accidents... 6. a. Provide adequate support to avoid falls and injuries... 7. Stay with the resident assist with or supervise with bating as appropriate..." On 07/21/14 at 1:37 p.m., CNA "N" said, "In my opinion there is no way a resident could roll out of a shower bed with the rails raised." CNA "N" said that the rail on the shower bed in the 200 unit had been broken for over two weeks. CNA "N" said, all the Nurses on the 200 unit were told about the broken rail numerous times by the CNAs that used the shower bed. CNA "N" said that the DON, Administrator and the "Maintenance man" were also aware of the broken rail but nothing was done to correct the problem. CNA "N" said she would use the broken shower bed but turn the cushion around so the head of the bed was away from the broken piece of rail to prevent any resident from rolling out onto the floor. CNA "N" said R #1 was able to roll to either side if positioned on her back without support pillows but was unable to turn independently in the bed. On 07/21/14 at 1:44 p.m. CNA "I" said R #1 was completely dependent with all mobility, "(R #1) could not move." CNA "I" said the Administrator, Unit Manager and the DON were aware of the broken rail on the 200 unit shower bed, and said they would "fix it but never did." one of the aides took the broken piece of rail to the Nurse's Station and placed it on the desk to show the nurses the rail was broken. CNA "I" said, "We continued to use the broken bed because the nurses told us that we could not give bed baths." CNA "I" said, "There is no way (R #1) could have fallen out of that shower bed with the rails up." On 07/21/14 at 2:08 p.m., CNA "H" said, "(R #1) could not move by herself. (R #1) was totally dependent with turning, and required a (mechanical lift) with two people to assist for transfers. The Administrator, DON and all the Nurses knew about the broken shower bed, because we placed the broken piece of plastic on the Nurse's Station to show the Nurses it was broken. There is no way (R #1) could have rolled out of the shower bed with the rails up. Sometimes if (R #1) was positioned on her back, (R #1's) arms and legs were contracted, and if you didn't place a pillow on either side of her legs she would flop over to one side or the other just from her weight shift, but (R #1) could not voluntarily turn to either side." On 07/21/14 at 2:46 p.m., CNA "V" said CNA "H" knew the 200 unit shower bed was broken for at least two weeks because both CNAs "V" and "H" saw the piece of broken pipe from the shower bed rail at the nurse's station for several days, and commented to each other that the bed had not been repaired. CNA "V" said she told MD but MD said the shower bed could not be repaired. CNA "V" said, "I do not think it would be possible for a resident to roll out of a shower bed, over the rails, with the rails up." Review of "Teachable Moment" form dated 07/01/14 revealed, "(1) 2 CNAs when using the shower bed to bath/shower must shower in the large shower room (2) Never turn back on the resident, Do not leave resident alone in the shower room" Facility inservice dated 07/01/14 was titled: "Reporting Damaged/Malfunctioning Equipment" was signed as attended by 37 facility staff. Review of "Staff Meeting Agenda" dated 07/03/14, 2:00 p.m.-2:45 p.m., included * "Abuse and Neglect *What to do with damaged or broken equipment ..." Review of Facility Policy and Procedure(revised August 2006) titled "Equipment-General Use for All Residents" dated 06/30/14 revealed, "...4. All broken/faulty equipment needs to be labeled and removed immediately-Notify maintenance and then administrator..." Review of facility "Abuse Prevention Program Policy Statement" (revised August 2006) revealed; "Our residents have the right to be free from abuse, neglect, misappropriation of a resident property, corporal punishment and involuntary seclusion ...3.Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect or mistreatment of [REDACTED]. "Texas Department of Aging and Disability ServicesNursing Facility Requirements for Licensure and Medicaid Certification HandbookRevision: 13-3 Subchapter B ?19.101 Definitions The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise... (81) Neglect - The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness." The facility's hand written list (no date), identified seven residents requiring the use of a shower bed for baths/showers. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to R #1's neglect. As of exit on 07/21/13 at 3:00 p.m., the facility provided no further information.

Based on observation, interview and record review. The facility failed to implement written policies and procedures that prohibit neglect for one Resident (R#1) of five residents reviewed for neglect. -The facility failed to provide adequate supervision for R #1. CNA "K" turned around to close the shower room door and R #1 was in the process of falling. R #1 fell from the shower bed and sustained a 16 cm (centimeter) scalp laceration all the way to the bone. -The facility failed to remove a broken shower bed from use. These failures placed R #1 and seven additional totally dependent residents that required the use of a shower bed at risk for neglect . The findings were: (R #1 was in the hospital at the time of the investigation.) Review of facility "Abuse Prevention Program Policy Statement" (revised August 2006) revealed; "Our residents have the right to be free from abuse, neglect, misappropriation of a resident property, corporal punishment and involuntary seclusion ...3.Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect or mistreatment of [REDACTED]. Review of Facility Policy and Procedure(revised August 2006) titled "Equipment-General Use for All Residents" dated 06/30/14 revealed, "...4. All broken/faulty equipment needs to be labeled and removed immediately-Notify maintenance and then administrator..." "Texas Department of Aging and Disability ServicesNursing Facility Requirements for Licensure and Medicaid Certification HandbookRevision: 13-3 Subchapter B ?19.101 Definitions The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise... (81) Neglect - The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness." R #1's Face Sheet dated 08/21/13 revealed an [AGE] year old female admitted [DATE] with the following Diagnoses: [REDACTED]. R #1's Diagnosis/History dated 02/24/14 revealed the [DIAGNOSES REDACTED]. R #1's quarterly MDS (Minimum Data Set) dated 04/08/14 revealed R #1 was rarely/never understood and rarely/never understood *had severely impaired vision *had minimum difficulty hearing *had BIMS (Brief Interview for Mental Status) was not conducted * had severely impaired cognition-never/rarely made decisions *was totally dependent requiring two person assistance with bed mobility and dressing *was totally dependent with bathing requiring one person assistance *Height=61 inches, Weight=123 pounds R #1's Care Plan dated 10/23/13 revealed: "Self-Care Deficit: Total Assist with all ADL's ...Approaches ...Bed Mobility: Total assist x 2 staff. Transfers: Total assist x 2 staff with (Mechanical Lift) ..." R #1's Care Plan dated 10/23/13 revealed: "Risk for Injury r/t (related to) Falls ....Approaches ...Side rails up x 2 while in bed for security and enable turning in bed ...Shower Bed for baths ...Transfer with assist of 2 people with (Mechanical Lift) ..." R #1's Interdisciplinary Care Plan dated 04/17/14 "areas reviewed " revealed R #1 was total care with all ADL's (Activities of Daily Living), and had no history of falls. R #1's consolidated Physician order [REDACTED].) R #1's discharge MDS dated [DATE] revealed R #1 was totally dependent with: *transfers *bathing *bed mobility *Dressing *Bathing *Height=61 inches, Weight=123 pounds * Had one fall with injury R# 1's Resident Incident Report dated 06/30/14 revealed R #1 was bedfast and had no independent movement. R #1 was on the shower bed in the shower room when CNA turned around to shut the door and when she turned back around the R #1 "was actively falling from shower bench." R #1 sustained a large laceration on top of R #1's head..."Immediate-Post Incident Action: replace shower bed, teachable moments on safe equipment, teachable moments not to turn your back on a (resident) when in the shower chair or shower bed and have two cna's when using the shower bed to bath." Nursing Home To Hospital Transfer Form revealed on 06/30/14 at 9:35 a.m., R #1 was transferred to hospital due to fall with a laceration to the top of R #1's head. Telephone Order dated 06/30/14 at 10:00 a.m. revealed a Physician order [REDACTED]." Emergency Physician Record dated 06/30/14 at 10:40 a.m., revealed R #1 had a 16 centimeter (cm) stellate (irregular tear-like wound caused by [MEDICATION NAME] trauma) scalp laceration all the way to the bone. The repair of the laceration required staples and suture with a two layer closure. According to the ER diagram (frontal) revealed the laceration was midline and extended to the left side of the cranium (skull). Hospital Discharge Summary dated 07/12/14 revealed R #1 was hospitalized from [DATE] until 07/10/14. "The Patient is an [AGE] year old woman coming to the hospital from the nursing home after being dropped during a transfer. This resulted in a large laceration of the forehead along with bruising of the right foot." R #1's Hospital [DIAGNOSES REDACTED]. Resident was discharged to another facility. On 07/04/14 at 3:15 p.m., interview with Licensed Vocational Nurse (LVN) "P" said the shower bed that R #1 was using at the time of the fall was in the dumpster outside of the facility. During this same interview Surveyor, accompanied by LVN "P", observed a shower bed with a broken rail outside at the back of the facility. It was located to the right of the back door, against the building. The left broken rail had jagged edges. The observation revealed the raised rail on the shower bed measured approximately seven and one half inches from the non-compressed cushion on the shower bed to the top of the rail. On 07/04/14 at 4:10 p.m., the Director of Nurses (DON) said the facility plan was to throw away the broken bed and the 200 unit would share the shower bed from the 100 unit with the residents that require the use of a shower bed. On 07/04/14 at 4:35 p.m., the Maintenance Director (MD) said the staff notified him 10 minutes after R #1 fell from the broken rail of the shower bed. The MD said he was told that a Certified Nurse Aide (CNA) had left R #1 unattended and R #1 fell . The MD said the Administrator then instructed the MD to move the broken bed outside. The MD said the staff should not have used that shower bed because the rail had been broken for over two weeks. MD said the rail had been fixed once before however, the second time the rail broke the MD could not repair the broken rail, because the break in the rail had jagged edges. The MD said he notified the Administrator that the shower bed could not be repaired and that another shower bed would have to be purchased. MD was unable to provide a work order request for the either repair request and said it was a verbal request made both times. MD said the staff should write any requests for repairs in the Maintenance Log Book but many times the staff will just verbally bring requests to his attention. Review of order form emailed to facility dated 07/01/14 revealed purchase order for a "PVC Patient Transport or Shower Gurney" On 07/04/14 at 4:35 p.m., LVN "L" (200 Unit Manager) said it was the responsibility of the Unit Manager to ensure the residents had a safe environment and equipment to use. LVN "L" said she was not aware the shower bed was broken on her unit. LVN "L" said that one of the CNAs told LVN "L", R #1 fell out of the shower bed from the right side, which was not broken, and the rail was raised. LVN "L" said, "if the rail on the shower bed was broken someone should have written it the maintenance log request book." On 07/18/14 at 12:50 p.m., LVN "J" said R #1 was not able to move and required total assistance for any mobility. LVN "J" said R #1 had bilateral lower and upper extremity contractures and the only movement R #1 was able to perform was slight movement in her hands. LVN "J" said if R #1 was on her back without support and there was any movement of the shower bed then R #1 "could have" passively rolled to her side. LVN "J" said that in her "professional opinion it was not possible" for R #1 to roll over the rails and off the shower bed. LVN "J" said now there must be two CNAs in the shower room when providing shower bed showers. On 07/18/14 at 1:10 p.m., CNA "K" said, "I was in the room when (R #1) fell , I turned around to close the shower room door and (R #1) was in the process of falling." CNA "K" said R #1 was dependent with all mobility and the day R #1 fell ; R #1 was positioned on her back. CNA "K" said that if R #1 was positioned on her back R #1 would "go" either to her right or left side. CNA "K" said the side rails were up and were not broken. CNA "K" said, "I really do not know how (R# 1) fell over the rail, I have never seen that happen before." CNA "K" said now there must be two CNAs in the shower room when providing shower bed showers. She said all showers that require a shower bed would be provided in the 100 hall shower room so two CNAs could fit in the room. On 07/18/14 at 2:15 p.m., the Administrator said he was made aware of R #1's fall at approximately 9:15 a.m. the day the incident occurred. Administrator said the staff was inserviced after the fall, to never turn their back on a resident while providing care. The facility now required two CNAs to be present in the shower room at all times when providing showers to residents who required a shower bed, and all shower bed showers were to be provided in the 100 hall shower room. The Administrator said, "(CNA "K") told me the entire bed tipped over." The Administrator said, "There was no malfunction in the bed, the bed was not broken. The left rail was a little loose, it had been broken before and (MD) placed new pins in the bed, and it was fixed. There was no malfunction in the bed, that I am aware of. Besides that would have nothing to do with the resident falling, (R #1) fell off the right side, over the top of the rail. The rails were up." The Administrator said he and the DON conducted a demonstration and he was able to roll over to the right side and tip the bed over. According to Texas Nurse Aide Training and Competency Evaluation Programs 2013 revealed: "UNIT VII-PERSONAL CARE PROCEDURAL GUIDELINE #18-TUB OR SHOWER BATH... B. Precautions... 2. NEVER leave the resident unattended in the tub or shower... C. Procedural Guidelines... 3. Assist resident to the bathing area as appropriate, providing needed support to prevent accidents... 6. a. Provide adequate support to avoid falls and injuries... 7. Stay with the resident assist with or supervise with bating as appropriate..." On 07/21/14 at 1:37 p.m., CNA "N" said, "In my opinion there is no way a resident could roll out of a shower bed with the rails raised." CNA "N" said that the rail on the shower bed in the 200 unit had been broken for over two weeks. CNA "N" said, all the Nurses on the 200 unit were told about the broken rail numerous times by the CNAs that used the shower bed. CNA "N" said that the DON, Administrator and the "Maintenance man" were also aware of the broken rail but nothing was done to correct the problem. CNA "N" said she would use the broken shower bed but turn the cushion around so the head of the bed was away from the broken piece of rail to prevent any resident from rolling out onto the floor. CNA "N" said R #1 was able to roll to either side if positioned on her back without support pillows but was unable to turn independently in the bed. On 07/21/14 at 1:44 p.m. CNA "I" said R #1 was completely dependent with all mobility, "(R #1) could not move." CNA "I" said the Administrator, Unit Manager and the DON were aware of the broken rail on the 200 unit shower bed, and said they would "fix it but never did." one of the aides took the broken piece of rail to the Nurse's Station and placed it on the desk to show the nurses the rail was broken. CNA "I" said, "We continued to use the broken bed because the nurses told us that we could not give bed baths." CNA "I" said, "There is no way (R #1) could have fallen out of that shower bed with the rails up." On 07/21/14 at 2:08 p.m., CNA "H" said, "(R #1) could not move by herself. (R #1) was totally dependent with turning, and required a (mechanical lift) with two people to assist for transfers. The Administrator, DON and all the Nurses knew about the broken shower bed, because we placed the broken piece of plastic on the Nurse's Station to show the Nurses it was broken. There is no way (R #1) could have rolled out of the shower bed with the rails up. Sometimes if (R #1) was positioned on her back, (R #1's) arms and legs were contracted, and if you didn't place a pillow on either side of her legs she would flop over to one side or the other just from her weight shift, but (R #1) could not voluntarily turn to either side." On 07/21/14 at 2:46 p.m., CNA "V" said CNA "H" knew the 200 unit shower bed was broken for at least two weeks because both CNAs "V" and "H" saw the piece of broken pipe from the shower bed rail at the nurse's station for several days, and commented to each other that the bed had not been repaired. CNA "V" said she told MD but MD said the shower bed could not be repaired. CNA "V" said, "I do not think it would be possible for a resident to roll out of a shower bed, over the rails, with the rails up." Review of "Teachable Moment" form dated 07/01/14 revealed, "(1) 2 CNAs when using the shower bed to bath/shower must shower in the large shower room (2) Never turn back on the resident, Do not leave resident alone in the shower room" Facility inservice dated 07/01/14 was titled: "Reporting Damaged/Malfunctioning Equipment" was signed as attended by 37 facility staff. Review of "Staff Meeting Agenda" dated 07/03/14, 2:00 p.m.-2:45 p.m., included * "Abuse and Neglect *What to do with damaged or broken equipment ..." The facility's hand written list (no date), identified seven residents requiring the use of a shower bed for baths/showers. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to R #1's neglect. As of exit on 07/21/13 at 3:00 p.m., the facility provided no further information.

The facility failed to ensure that the resident environment/equipment was free from accident hazards and each resident receives adequate supervision to prevent accidents for one resident (R #1) of five residents reviewed for environment/equipment hazards and adequate supervision. -The facility failed to remove a broken shower bed from use. -The facility failed to provide adequate supervision for R #1. CNA "K" turned around to close the shower room door and R #1 was in the process of falling. R #1 fell from the shower bed and sustained a 16 cm (centimeter) scalp laceration all the way to the bone. These failures placed R #1 and seven additional totally dependent residents that required the use of a shower bed at risk for neglect . The findings were: (R #1 was in the hospital at the time of the investigation.) R #1's Face Sheet dated 08/21/13 revealed an [AGE] year old female admitted [DATE] with the following Diagnoses: [REDACTED]. R #1's Diagnosis/History dated 02/24/14 revealed the [DIAGNOSES REDACTED]. R #1's quarterly MDS (Minimum Data Set) dated 04/08/14 revealed R #1 was rarely/never understood and rarely/never understood *had severely impaired vision *had minimum difficulty hearing *had BIMS (Brief Interview for Mental Status) was not conducted * had severely impaired cognition-never/rarely made decisions *was totally dependent requiring two person assistance with bed mobility and dressing *was totally dependent with bathing requiring one person assistance *Height=61 inches, Weight=123 pounds R #1's Care Plan dated 10/23/13 revealed: "Self-Care Deficit: Total Assist with all ADL's ...Approaches ...Bed Mobility: Total assist x 2 staff. Transfers: Total assist x 2 staff with (Mechanical Lift) ..." R #1's Care Plan dated 10/23/13 revealed: "Risk for Injury r/t (related to) Falls ....Approaches ...Side rails up x 2 while in bed for security and enable turning in bed ...Shower Bed for baths ...Transfer with assist of 2 people with (Mechanical Lift) ..." R #1's Interdisciplinary Care Plan dated 04/17/14 "areas reviewed " revealed R #1 was total care with all ADL's (Activities of Daily Living), and had no history of falls. R #1's consolidated Physician order [REDACTED].) R #1's discharge MDS dated [DATE] revealed R #1 was totally dependent with: *transfers *bathing *bed mobility *Dressing *Bathing *Height=61 inches, Weight=123 pounds * Had one fall with injury R# 1's Resident Incident Report dated 06/30/14 revealed R #1 was bedfast and had no independent movement. R #1 was on the shower bed in the shower room when CNA turned around to shut the door and when she turned back around the R #1 "was actively falling from shower bench." R #1 sustained a large laceration on top of R #1's head..."Immediate-Post Incident Action: replace shower bed, teachable moments on safe equipment, teachable moments not to turn your back on a (resident) when in the shower chair or shower bed and have two cna's when using the shower bed to bath." Nursing Home To Hospital Transfer Form revealed on 06/30/14 at 9:35 a.m., R #1 was transferred to hospital due to fall with a laceration to the top of R #1's head. Telephone Order dated 06/30/14 at 10:00 a.m. revealed a Physician order [REDACTED]." Emergency Physician Record dated 06/30/14 at 10:40 a.m., revealed R #1 had a 16 centimeter (cm) stellate (irregular tear-like wound caused by blunt trauma) scalp laceration all the way to the bone. The repair of the laceration required staples and suture with a two layer closure. According to the ER diagram (frontal) revealed the laceration was midline and extended to the left side of the cranium (skull). Hospital Discharge Summary dated 07/12/14 revealed R #1 was hospitalized from [DATE] until 07/10/14. "The Patient is an [AGE] year old woman coming to the hospital from the nursing home after being dropped during a transfer. This resulted in a large laceration of the forehead along with bruising of the right foot." R #1's Hospital [DIAGNOSES REDACTED]. Resident was discharged to another facility. On 07/04/14 at 3:15 p.m., interview with Licensed Vocational Nurse (LVN) "P" said the shower bed that R #1 was using at the time of the fall was in the dumpster outside of the facility. During this same interview Surveyor, accompanied by LVN "P", observed a shower bed with a broken rail outside at the back of the facility. It was located to the right of the back door, against the building. The left broken rail had jagged edges. The observation revealed the raised rail on the shower bed measured approximately seven and one half inches from the non-compressed cushion on the shower bed to the top of the rail. On 07/04/14 at 4:10 p.m., the Director of Nurses (DON) said the facility plan was to throw away the broken bed and the 200 unit would share the shower bed from the 100 unit with the residents that require the use of a shower bed. On 07/04/14 at 4:35 p.m., the Maintenance Director (MD) said the staff notified him 10 minutes after R #1 fell from the broken rail of the shower bed. The MD said he was told that a Certified Nurse Aide (CNA) had left R #1 unattended and R #1 fell . The MD said the Administrator then instructed the MD to move the broken bed outside. The MD said the staff should not have used that shower bed because the rail had been broken for over two weeks. MD said the rail had been fixed once before however, the second time the rail broke the MD could not repair the broken rail, because the break in the rail had jagged edges. The MD said he notified the Administrator that the shower bed could not be repaired and that another shower bed would have to be purchased. MD was unable to provide a work order request for the either repair request and said it was a verbal request made both times. MD said the staff should write any requests for repairs in the Maintenance Log Book but many times the staff will just verbally bring requests to his attention. Review of order form emailed to facility dated 07/01/14 revealed purchase order for a "PVC Patient Transport or Shower Gurney" On 07/04/14 at 4:35 p.m., LVN "L" (200 Unit Manager) said it was the responsibility of the Unit Manager to ensure the residents had a safe environment and equipment to use. LVN "L" said she was not aware the shower bed was broken on her unit. LVN "L" said that one of the CNAs told LVN "L", R #1 fell out of the shower bed from the right side, which was not broken, and the rail was raised. LVN "L" said, "if the rail on the shower bed was broken someone should have written it the maintenance log request book." On 07/18/14 at 12:50 p.m., LVN "J" said R #1 was not able to move and required total assistance for any mobility. LVN "J" said R #1 had bilateral lower and upper extremity contractures and the only movement R #1 was able to perform was slight movement in her hands. LVN "J" said if R #1 was on her back without support and there was any movement of the shower bed then R #1 "could have" passively rolled to her side. LVN "J" said that in her "professional opinion it was not possible" for R #1 to roll over the rails and off the shower bed. LVN "J" said now there must be two CNAs in the shower room when providing shower bed showers. On 07/18/14 at 1:10 p.m., CNA "K" said, "I was in the room when (R #1) fell , I turned around to close the shower room door and (R #1) was in the process of falling." CNA "K" said R #1 was dependent with all mobility and the day R #1 fell ; R #1 was positioned on her back. CNA "K" said that if R #1 was positioned on her back R #1 would "go" either to her right or left side. CNA "K" said the side rails were up and were not broken. CNA "K" said, "I really do not know how (R# 1) fell over the rail, I have never seen that happen before." CNA "K" said now there must be two CNAs in the shower room when providing shower bed showers. She said all showers that require a shower bed would be provided in the 100 hall shower room so two CNAs could fit in the room. On 07/18/14 at 2:15 p.m., the Administrator said he was made aware of R #1's fall at approximately 9:15 a.m. the day the incident occurred. Administrator said the staff was inserviced after the fall, to never turn their back on a resident while providing care. The facility now required two CNAs to be present in the shower room at all times when providing showers to residents who required a shower bed, and all shower bed showers were to be provided in the 100 hall shower room. The Administrator said, "(CNA "K") told me the entire bed tipped over." The Administrator said, "There was no malfunction in the bed, the bed was not broken. The left rail was a little loose, it had been broken before and (MD) placed new pins in the bed, and it was fixed. There was no malfunction in the bed, that I am aware of. Besides that would have nothing to do with the resident falling, (R #1) fell off the right side, over the top of the rail. The rails were up." The Administrator said he and the DON conducted a demonstration and he was able to roll over to the right side and tip the bed over. According to Texas Nurse Aide Training and Competency Evaluation Programs 2013 revealed: "UNIT VII-PERSONAL CARE PROCEDURAL GUIDELINE #18-TUB OR SHOWER BATH... B. Precautions... 2. NEVER leave the resident unattended in the tub or shower... C. Procedural Guidelines... 3. Assist resident to the bathing area as appropriate, providing needed support to prevent accidents... 6. a. Provide adequate support to avoid falls and injuries... 7. Stay with the resident assist with or supervise with bating as appropriate..." On 07/21/14 at 1:37 p.m., CNA "N" said, "In my opinion there is no way a resident could roll out of a shower bed with the rails raised." CNA "N" said that the rail on the shower bed in the 200 unit had been broken for over two weeks. CNA "N" said, all the Nurses on the 200 unit were told about the broken rail numerous times by the CNAs that used the shower bed. CNA "N" said that the DON, Administrator and the "Maintenance man" were also aware of the broken rail but nothing was done to correct the problem. CNA "N" said she would use the broken shower bed but turn the cushion around so the head of the bed was away from the broken piece of rail to prevent any resident from rolling out onto the floor. CNA "N" said R #1 was able to roll to either side if positioned on her back without support pillows but was unable to turn independently in the bed. On 07/21/14 at 1:44 p.m. CNA "I" said R #1 was completely dependent with all mobility, "(R #1) could not move." CNA "I" said the Administrator, Unit Manager and the DON were aware of the broken rail on the 200 unit shower bed, and said they would "fix it but never did." one of the aides took the broken piece of rail to the Nurse's Station and placed it on the desk to show the nurses the rail was broken. CNA "I" said, "We continued to use the broken bed because the nurses told us that we could not give bed baths." CNA "I" said, "There is no way (R #1) could have fallen out of that shower bed with the rails up." On 07/21/14 at 2:08 p.m., CNA "H" said, "(R #1) could not move by herself. (R #1) was totally dependent with turning, and required a (mechanical lift) with two people to assist for transfers. The Administrator, DON and all the Nurses knew about the broken shower bed, because we placed the broken piece of plastic on the Nurse's Station to show the Nurses it was broken. There is no way (R #1) could have rolled out of the shower bed with the rails up. Sometimes if (R #1) was positioned on her back, (R #1's) arms and legs were contracted, and if you didn't place a pillow on either side of her legs she would flop over to one side or the other just from her weight shift, but (R #1) could not voluntarily turn to either side." On 07/21/14 at 2:46 p.m., CNA "V" said CNA "H" knew the 200 unit shower bed was broken for at least two weeks because both CNAs "V" and "H" saw the piece of broken pipe from the shower bed rail at the nurse's station for several days, and commented to each other that the bed had not been repaired. CNA "V" said she told MD but MD said the shower bed could not be repaired. CNA "V" said, "I do not think it would be possible for a resident to roll out of a shower bed, over the rails, with the rails up." Review of "Teachable Moment" form dated 07/01/14 revealed, "(1) 2 CNAs when using the shower bed to bath/shower must shower in the large shower room (2) Never turn back on the resident, Do not leave resident alone in the shower room" Facility inservice dated 07/01/14 was titled: "Reporting Damaged/Malfunctioning Equipment" was signed as attended by 37 facility staff. Review of "Staff Meeting Agenda" dated 07/03/14, 2:00 p.m.-2:45 p.m., included * "Abuse and Neglect *What to do with damaged or broken equipment ..." Review of Facility Policy and Procedure(revised August 2006) titled "Equipment-General Use for All Residents" dated 06/30/14 revealed, "...4. All broken/faulty equipment needs to be labeled and removed immediately-Notify maintenance and then administrator..." Review of facility "Abuse Prevention Program Policy Statement" (revised August 2006) revealed; "Our residents have the right to be free from abuse, neglect, misappropriation of a resident property, corporal punishment and involuntary seclusion ...3.Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect or mistreatment of [REDACTED]. "Texas Department of Aging and Disability ServicesNursing Facility Requirements for Licensure and Medicaid Certification HandbookRevision: 13-3 Subchapter B ?19.101 Definitions The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise... (81) Neglect - The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness." The facility's hand written list (no date), identified seven residents requiring the use of a shower bed for baths/showers. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to R #1's neglect. As of exit on 07/21/13 at 3:00 p.m., the facility provided no further information.