Every finding on record at Settlers Ridge Care Center

Based on observations, 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 for kitchen safety. The facility failed to ensure food in the facility's dry storage, and refrigerator areas were labeled and dated according to guidelines. The facility failed to seal lids securely on containers in the refrigerator area and dry storage pantry. These deficient practices could affect residents who received meals or snacks from the kitchen and place them at risk for cross contamination and other food-borne illnesses.Findings Included: 3/31/2026 Dry Pantry area revealed 12 plastic round maroon bowls had plastic lids that were unsealed, exposed to the air, not labeled and not dated. 3/31/2026 Walk-in refrigerator revealed 1 clear plastic container with a red cracked lid unsealed and exposed to the air. 9:12am on 3/31/26-Brief tour of the kitchen and interview with Director of Nutritional Services revealed, the facility has 1 kitchen and 1 main dining room. Conducted a brief walk through the walk-in freezer, walk-in refrigerator, and dry pantry. Surveyor observed a clear hard plastic container with a red cracked lid was on the top wire shelf in the walk-in refrigerator. Surveyor observed 12 unlabeled and undated plastic round maroon bowls with plastic lids that were not securely on the bowls on the shelf in the dry pantry.Interview on 3/31/26 at 9:30am with The Director of Nutritional Services stated the Dietitian comes weekly on Tuesday's and is responsible for the resident assessments, therapeutic menus, and kitchen in-services. Returning visit to the kitchen on 4/1/26 at 11:30am to observe the kitchen The Dietitian and Director of Nutritional Services were present. Surveyor observed walk-in freezer, observed walk-in refrigerator and dry pantry. Surveyor observed the 12 unlabeled and undated plastic round maroon bowls with plastic lids that were not securely on the bowls remained on the shelf in the dry pantry.Interview on 4/1/26 at 11:45am with The Dietitian stated she does periodic kitchen walkthroughs looking for sanitary conditions. Returning visit to the kitchen on 4/2/26 at 10:12am both The Dietitian and Director of Nutritional Services were present. Observed walk-in freezer. Observed walk-in refrigerator and dry pantry with the Dietitian. Interview on 4/2/26 at 10:40am with Director of Nutritional Services stated if there was a case of food poisoning, he would look to see if there were any causes of cross contamination in the kitchen. Record review of the facility's policy, Food Storage effective August 1, 2018, and Revised February 6, 2024: April 8, 2025, revealed, Policy: Sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. Food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination.Storeroom:Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and the date opened.Refrigerator:All foods are covered, labeled, and dated. Defrosting meat, eggs, and milk shakes are labeled with the date pulled for thawing. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 5 of 5 residents (Resident #33, #57, #10, #65, and #16) reviewed for comprehensive care plans.The facility failed to ensure Resident #33, #57, #10, #65 and #16's comprehensive care plan addressed their goals, needs, strengths, medical, nursing, mental, and psychosocial needs.This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.Findings included:Record review of Resident #33's MDS assessment dated [DATE], reflected an [AGE] year-old female, admitted to the facility on [DATE], with a BIMS score of 4 which indicated severe cognitive impairment. Diagnoses included: Chronic Heart Failure (the heart can't pump blood as well as it should, causing fatigue, swelling, and shortness of breath), Type 2 Diabetes (a condition where the body can't properly use sugar for energy, leading to high blood sugar and possible complications), Alzheimer's Disease (a brain disease that slowly destroys memory and thinking skills, making it hard to do everyday tasks), Anxiety Disorder (excessive worry or unease), and Depression (feelings of severe sadness. Inability to initiate activity). Record Review of Resident #33's Order Summary dated 04/01/2026, reflected Resident #33 was admitted to hospice on 02/01/2026. Record Review of Resident #33's comprehensive care plan dated 04/01/2026, reflected Resident #33 had 3 identified goals related to Activities, personal preferences, and Advance Directive preference. Record review of Resident #57's MDS assessment dated [DATE], reflected an [AGE] year-old female, admitted to the facility on [DATE]. The Resident's MDS assessment did not include the BIMS score, as staff selected 0, which indicated the resident was never or rarely understood, which directed the assessment to skip to the staff assessment for mental status. The staff assessment indicated the Resident had short and long-term memory problems and was severely cognitively impaired. The Resident had diagnoses that included: Adult Failure to Thrive (significant decline in physical, cognitive, and emotional health, often leading to weight loss, malnutrition, and reduced functional ability), Dysphagia (difficulty swallowing liquids and/or solid food and drink), Dementia ((severe decrease in memory and intellectual functioning that can occur in the later stages of Parkinson's), and Bipolar Disorder (mood swings between high-manic and low depressive moods). Record Review of Resident #57's MAR dated 03/01/2026 - 03/31/2026, reflected the Resident refused prescribed medication on 3/1/2026, 3/24/2026, 3/26/2026, and 3/28/2026. The MAR also reflected the resident's vitals were not obtained due to resident refusal on 3/4/2026, 3/9/2026, 3/10/2026, 3/13/2026, 3/14/2026, 3/19/2026, 3/20/2026, 3/23/2026, 3/24/2026, 3/28/2026, 3/30/2026, and 3/31/2026. Record Review of Resident #57's Comprehensive Care Plan dated 04/01/2026, reflected the plan did not address the resident's refusal of care and discharge planning or options. Record review of Resident #10's MDS assessment dated [DATE], reflected a [AGE] year-old female, admitted to the facility on [DATE]. The Resident's MDS assessment did not include the BIMS score, as staff selected 0, which indicated the resident was never or rarely understood, which directed the assessment to skip to the staff assessment for mental status. The staff assessment indicated the Resident had short and long-term memory problems and was severely cognitively impaired. The Resident had diagnoses that included: Alzheimer's Disease (a brain disease that slowly destroys memory, thinking, and the ability to carry out daily tasks), Dysphagia (difficulty swallowing liquids and/or solid food and drink), and Moderate protein-calorie malnutrition (a form of undernutrition characterized by insufficient intake of protein and calories). Record Review of Resident #10's MAR dated 03/01/2026 - 03/31/2026, reflected the Resident refused prescribed medication on 03/03/2026, 03/11/2026, 03/12/2026, 03/14/2026, 03/15/2026, 03/16/2026, 03/21/2026, 03/24/2026, 03/26/2026, 03/27/2026, 03/28/2026, 03/29/2026, and 03/30/2026. The MAR also reflected the resident's vitals were not obtained due to resident refusal on 03/06/2026, 03/28/2026, and 03/29/2026. Record Review of Resident #10's Comprehensive Care Plan dated 04/01/2026, reflected the plan did not address the resident's refusal of care and discharge planning or options. Record review of Resident #65's MDS assessment dated [DATE], reflected an [AGE] year-old male, admitted to the facility on [DATE]. The Resident's MDS assessment did not include the BIMS score, as staff selected 0, which indicated the resident was never or rarely understood, which directed the assessment to skip to the staff assessment for mental status. The staff assessment indicated the Resident had short and long-term memory problems and was severely cognitively impaired. The Resident had diagnoses that included: Cerebral infarction (a type of stroke caused by a blocked blood vessel in the brain, leading to brain tissue damage), Vascular Dementia (severe decrease in memory and intellectual functioning that can occur in the later stages of Parkinson's), Major Depressive Disorder (severe, persistent sadness and loss of interest that interferes with daily life), and Anxiety Disorder (excessive worry or unease). Record Review of Resident #65's Physician Orders dated 04/01/2026, reflected the following orders: Consult for Psychiatry to evaluate and treat and Alprazolam .5 MG tablet by mouth twice a day (to treat anxiety). Record Review of Resident #65's Comprehensive Care Plan dated 04/01/2026, reflected the plan did not address mental health needs for depression and anxiety and discharge planning or options. Record review of Resident #16's MDS assessment dated [DATE], reflected a [AGE] year-old male, admitted to the facility on [DATE]. The Resident's BIMS score was 8 which indicated moderate cognitive impairment. The Resident had diagnoses that included: Alzheimer's Disease (a brain disease that slowly destroys memory, thinking, and the ability to carry out daily tasks), Type 2 Diabetes (a condition where the body can't properly use sugar for energy, leading to high blood sugar and possible complications), and Depression (persistent sadness and loss of interest that interferes with daily life). Record Review of Resident #16's Comprehensive Care Plan dated 04/01/2026, reflected the plan did not address discharge planning or options. In an interview on 04/01/2026 at 11:50 AM with the MDS Nurse, she reported she was responsible for completing resident care plans in collaboration with other nursing staff. She stated she got behind on completing resident care plans and was in the process of auditing each resident care plan to ensure they were accurate and complete. She stated she is completing 1-2 resident care plans a day. In an interview on 04/01/2026 at 12:00 PM with the DON, she stated she looked over Resident #33's care plan and acknowledged it was not complete. The DON stated the facility opened a new part-time position that would be responsible for care plans. She stated this position is publicly posted and no applicant had met the requirements. She stated a care plan should include any pertinent information to the resident's care, medications, and treatments. The DON acknowledged that Resident's #57 and #10 both had a history of refusing medications and vital sign readings. She also acknowledged that the refusal of care should be addressed in the care plans. She stated the risk to residents with inaccurate or incomplete care plans was that PRN staff would not be up to date on resident care. Record Review of the Facility Care Plan Process dated March 27, 2023, reflected in part: The interdisciplinary team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process within the required timeframes. The team directs care planning toward attaining and maintaining the highest optimal physical, psychosocial, functional status including Advance Directives, and signs the approved Plan of Care. The Plan of Care identifies the date, problem, goals - measurable and realistic, time frames for achievement, interventions, discipline specific services, and frequency, and discharge options.

Based on observation, interview, and record review the facility failed to maintain essential equipment in operating condition by failing to maintain walk-in refrigerator and walk-in freezer coolant fans for 1 of 1 kitchens reviewed for equipment in operating condition. The facility failed to maintain the coolant fans in the walk-in freezer and in the walk-in refrigerator for operating condition.The facility's failure to maintain coolant fans in operating condition had the potential to place all residents at risk for cross-contamination and increased risk of foodborne illness. Findings Included:Walk-in refrigerator revealed dripping liquid from the coolant fan within the refrigerator. Walk-in freezer revealed ice build up on the coolant fan within the freezer. Observations of the kitchen during the brief initial tour of the kitchen on 03/31/26 at 9:12am revealed the following: 9:12am-Brief tour of the kitchen and interview with Director of Nutritional Services revealed, the facility has 1 kitchen and 1 main dining room. Conducted a brief walk through the walk-in freezer, and walk-in refrigerator. Surveyor observed the coolant fan unit mounted on the ceiling of the refrigerator was actively dripping water onto the shelving below. Drops of water were observed going into a clear container and outside the clear container on food items.Interview on 3/31/26 at 9:30am with The Director of Nutritional Services stated the Dietitian comes weekly on Tuesday's and is responsible for the resident assessments, therapeutic menus, and kitchen in-services.Returning visit to the kitchen on 4/1/26 at 11:30am to observe the kitchen. The Dietitian ran the Low Temperature dishwasher as a periodic test, the dishwasher rose to 120 degrees, within normal range.The coolant fan in the freezer was leaking a clear liquid substance into a rectangular clear durable plastic container sitting on the top shelf just below the coolant fan mechanical motor. Interview on 4/1/26 at 11:45am The Dietitian stated she does periodic kitchen walkthroughs looking for sanitary conditions.Returning visit to the kitchen on 4/2/26 at 10:12am to observe the kitchen, both The Dietitian and Director of Nutritional Services were present observing the walk-in freezer. Frost was observed on the coolant fans in the freezer. The Dietitian stated the frozen ice melts off during the day. Observed walk-in refrigerator still dripping liquid from the coolant fan. The Dietitian stated every 2-3 days the Maintenance Director has to has to drain the coolant fan. Interview on 4/2/26 at 10:45am The Dietitian stated there would be no harm to the residents because the food items are always washed regardless including food like oranges.Interview at 10:40am with Director of Nutritional Services stated if there was a case of food poisoning, he would look to see if there were any causes of cross contamination in the kitchen. Interview at 11:00am with [NAME] B stated 2 days or so the walk-in refrigerator coolant fan has to be drained. [NAME] B stated that not washing hands can cause cross contamination. Interview on 4/2/26 at 12:26pm Maintenance Director said he worked at the facility for 3 years. Maintenance Director on 4/1/2026 said he cleaned the coolant fan drain and blew out the drain on the coolant fan. The Maintenance Director said he will blow out the coolant fan again. Maintenance Director said due to the humidity levels it is hard to keep up with the condensation, causing the reason for the issue with the coolant fans. The Maintenance Director stated he does not call out contract commercial maintenance for repairs with refrigeration and HVAC repairs, but instead he fixes things himself. The Maintenance Director stated the refrigerator door was left open too long on the freezer which caused ice to develop. Record review of the facility's policy, Food Storage effective August 1, 2018, and Revised February 6, 2024: April 8, 2025, revealed, Policy: Sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. Food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination.

Based on observation, interview and record review, the facility failed to provide a therapeutic diet that take into account the resident's clinical condition for one (Resident #86) of six residents reviewed for diet status and maintenance. The facility failed to offer Resident #86 the right diet as indicated in the residents' physician orders. These failures could increase the resident's risk for aspiration and choking. Record Review of Resident #86's admission MDS dated [DATE] reflected Resident #86's admission date of 03/18/26. She was [AGE] year-old female with active diagnoses included: acute respiratory failure with hypoxia, pneumonia, and pleural effusion (buildup of excess fluid between the layers of the pleura outside your lungs), malnutrition (imbalance between the nutrients your body needs to function and the nutrients it gets) and dysphagia (difficult swallowing). Nutrition and swallowing status reflected the resident had loss of liquids/solids from mouth when drinking or eating, holding food in the mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or swallowing medications, and complaints of difficulty or pain with swallowing. Resident #86 was required to eat mechanically altered diet - require change in texture of food or liquids (e.g puree food, thickened liquids). Record Review of Resident #86's physician order revealed an order for puree consistency diet with an order date of 03/31/26 and status as active (current). Record Review of Resident #86's comprehensive plan of care dated, 03/24/26 revealed the following, Problem; [Resident #86] at risk for weight changes due to poor PO intake, malnutrition, failure to thrive, she refused a G-tube (is a medical device inserted through the abdominal wall directly into the stomach to provide nutrition, fluids, and medication when oral intake is insufficient) placement for nutrition at the hospital prior to admitting to the facility. Intervention: provide diet as ordered. In an observation and interview on 03/31/26 at 1:04 PM during lunch meal it was revealed that Resident #86 was in her room up in the wheelchair. The resident was served puree diet meal, but fruit cobbler was not pureed, she was served a regular diet. The resident had not eaten the puree food, and she was observed taking a few bites of the fruit cobbler which was regular consistency. RN E went into the room and witnessed and confirmed the resident was served a regular diet dessert, left the room and she stated she was to confirm with dietary. No choking or coughing was noted with the resident. In an interview on 03/31/26 at 1:12 PM with RN E When RN E reviewed the resident's clinicals record, she stated the resident was supposed to be eating only puree diet. She checked the resident records and stated the resident had a diagnosis of dysphagia and that was the reason why she was on puree diet. RN E stated she was supposed to check the tray before being served to the resident, but she did not because by the time she came to the hall the resident had already been served. RN E stated the resident was at risk of choking if she ate regular diet meal. In an interview on 04/01/26 at 12:28 PM with Regional Dietary Consultant, she stated she was made aware of Resident #86 being served a regular dessert. She stated it was a facility wide responsibility to check the food trays when they were being served, from the kitchen and then when they were being served on halls. Regional Dietary Consultant stated when serving meals the staff were to check to make sure the ticket matched the meals that were served. She stated the resident was at risk of getting pneumonia if she was served the wrong diet. In an interview on 04/01/26 at 01:36 PM with the Dietary Aide revealed he was the one who served the meals from the kitchen to the hall trays. The Dietary Aide stated it was an overlook and he missed to see that the resident had a regular desert. After the incident the dietary aide stated he was in-serviced on making sure the meals being served matched the meal ticket in the tray and making sure they were checked correctly. The dietary aide stated the resident was at risk for choking if she was not served the right meal. In an interview on 04/02/26 at 11:15 AM with Housekeeper revealed he was the one who served Resident #86 the lunch meal tray on 03/31/26 that had the regular diet desert. He stated he normally assisted with serving the trays on the halls. He stated he did not check the ticket with the meals the resident was served to make sure the resident was served the right meal. The housekeeper stated previously he had not been in-serviced on serving meal trays on the hall, but after the incident he had been in-serviced and educated to make sure the nurse checked the meal trays before they meals were served to the residents. In an interview on 04/02/26 at 11:28 AM with the DON she stated she was made aware of Resident #86 being served the regular dessert instead of puree. She stated the staff were expected to check the trays before being served to the residents. The nurses or aides on the halls were to check the tickets and make sure the tickets matched the meals that were served. The DON stated Resident #86 was served by the housekeeper and seemed like the meal trays were not checked by the nurse before being served. The housekeeper was in-serviced on making sure the meal trays were checked by the nurses before being served. The DON stated Resident #86 was at risk for aspiration from being served the wrong diet. Review of the facility policy revised 02/06/24 and titled Nutrition Services reflected, Tray line positions and set up procedures should promote an efficient and accurate meal service. Each tray will be checked for; correct name, room number and diet order.

Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 Residents reviewed for medication administration (Resident #26). The facility failed to ensure Resident #26 swallowed his medication before the staff member left the resident's room. This failure could place Residents at risk for missed doses, ineffective treatment, and potential decline in condition.Findings Included:Record review of Resident #26's Quarterly MDS Assessment, dated 03/23/26, reflected the Resident was a [AGE] year-old male with a BIMs score of 11 indicating he was moderately cognitively impaired. His diagnoses included: Coronary Artery Disease (a condition where the arteries that supply blood to the heart become narrowed or blocked by plaque, a buildup of fatty deposits, cholesterol, and other substances), Hypertension (blood pressure is consistently too high, which can strain the heart and blood vessels), and Peripheral Artery Disease (blood has trouble getting to your legs or arms because the blood vessels or arteries are narrowed or blocked). Record review of Resident #26's Comprehensive Care Plan dated 04/02/2026, reflected the plan did not address any goals or interventions to self-administer medications. Record review of Resident #26's Physician's Orders, dated 04/01/2026 through 04/30/2026, reflected there were no orders for Resident #26 to self-administer medications. During observation and interview with Resident #26 in his room on 03/31/26 at 9:36 AM, resident was observed lying in bed, awake and alert. He stated he needed just a minute to talk as he was finishing up taking his medication. The Resident was observed taking a drink and swallowing an unknown medication. He stated the nurse who gave him the medication just brought it before the surveyor walked in and then the nurse left. He said the nurse did not stay to watch him swallow the medication. He said the nurse usually would stay to watch but sometimes doesn't. The resident reported he did not have any difficulty swallowing his medication. During an interview on 3/31/26 at 9:57 AM with RN F, she reported she was responsible for administering medications to Resident #26. She reported she gave Resident #26 his medication and stepped out of the room because someone was calling for her in the hallway. She stated she did not witness Resident #26 swallow his medication. She stated she usually would stay in the room to visually confirm the Resident swallows his medication. She stated the Resident is cognizant but could not see. RN F stated Resident #26 did not have orders to take medications without supervision. RN F stated the risk to residents if they were not supervised while taking medications was that they might not take all of their medications. During an interview with the on 04/02/2026 at 11:30 AM with the DON, she reported there were no allowances or orders for Resident #26 to take unsupervised medication. The DON stated the facility policy was that a staff administrating medication to a resident was to stay with the resident until the medication was swallowed. She stated staff are to visually confirm the resident swallowed the medication. Review of Facility's Policy/Procedure - Nursing Services titled: Medication Administration General Guidelines dated 01/2024 reflected: The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate.

Based on observation, interview, and record review, the facility failed to store drugs and biologicals in locked compartments based on the needs of one of five residents (Resident #16) reviewed for medication storage.The facility failed to ensure Resident #16 did not have unsecured Glipizide 10 MG tablet (an oral medication used to treat Type 2 Diabetes) in his room.This failure could place residents at risk for compromised medication efficacy, unsafe administration, and increased harm to residents.Findings Included:Record review of Resident #16's MDS assessment dated [DATE], reflected a [AGE] year-old male, admitted to the facility on [DATE]. The Resident's BIMS score was 8 which indicated moderate cognitive impairment. The Resident had diagnoses that included: Alzheimer's Disease (a brain disease that slowly destroys memory, thinking, and the ability to carry out daily tasks), Type 2 Diabetes (a condition where the body can't properly use sugar for energy, leading to high blood sugar and possible complications), and Depression (persistent sadness and loss of interest that interferes with daily life). Record review of Resident #16's Care plan dated 04/01/2026, reflected the plan did not address any goals or interventions related to the medication that was at bedside or orders to self-administer medications.Record review of Resident #16's active Physician's Orders, dated 04/01/2026 through 04/30/2026, reflected an active order for Glipizide 10 MG Tablet to be taken 1 tablet by mouth twice a day at 7AM and 8PM.Record review of Resident #16's Physician's Orders, dated 04/01/2026 through 04/30/2026, reflected there were no orders for Resident #16 to self-administer medications.During observation and interview with Resident #16 in his room on 03/31/26 at 9:37 AM, resident was observed lying in bed, awake and alert. A round, white pill was observed on the floor between his bed and his roommate's bed. Resident #16 reported the pill had been on the floor for several days and was probably his. He stated he took his medication this morning. He reported he was not sure if he had missed a dose of medication recently.During an interview on 3/31/26 at 9:57 AM with RN F, she reported she was responsible for administering medications to Resident #16. She identified the pill in Resident #16's room as Glipizide. She stated the medication was used to treat diabetes and belonged to Resident #16. She stated she knew it was his because his roommate did not have diabetes and Resident #16 did. She stated she was not sure how it ended up on the floor. She stated it could have fallen out of the resident's mouth. She stated she could only assume it fell out because she did not see it happen. She stated she had stayed this morning to make sure the Resident swallowed the medication. RN F destroyed the medication, she stated she would then notify the DON and the resident's physician.During an interview with the on 04/02/2026 at 11:30 AM with the DON, she reported there were no allowances or orders for Resident #16 to have medication unsecured in his room. She stated any missed medication doses are documented and addressed by notifying the MD. She denied Resident #16 having any complications of a missed diabetes medication dose. The DON also denied any other residents having complications of missed medication doses.Review of the facility's policy Storage of Medication Revised January 12, 2020, reflected the following: Staff will store medications in accordance with standard practice guidelines. Refer to the Pharmerica Nursing Care Center Pharmacy Policy & Procedure Manual regarding bedside medication storage.

Based on observations, record review and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents in 2 (Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]) of 5 shower rooms reviewed for environment. 1. The facility failed to properly clean and sanitize the floor, toilet and sink of Shower room [ROOM NUMBER] and failed to empty the trash and soiled linen bins. 2. The facility failed to properly clean and sanitize the floor of one of the showers in Shower room [ROOM NUMBER]. This failure could affect all residents that were showered in the shower rooms by exposing them to bacteria and organisms that could impact their health and diminish their quality of life. The findings include: Record review of a grievances filed on 10/27/25 revealed a resident relative requested a cleaner environment for their relative at the facility. During an observation of Shower room [ROOM NUMBER] on 12/15/25 at 9:55am revealed a strong odor of urine as upon entrance to the shower room. Against the wall were two large see-through bins with plastic bags. The first bin was overflowing with linen, and the top would not close. The second bin was labeled trash; it was closed and trash was full to the top. The toilet bowl was observed to have what looked like feces and urine in it. The floor had two dried red circular spots. The sink counter had a beige dirty shoe insole on the corner of it. During an observation of Shower room [ROOM NUMBER] on 12/15/25 at 10:06am revealed, one shower (the one straight ahead upon entrance to the room), had 5 various sized brown smudges that ranged from quarter size to pencil eraser size on the tiled floor of the shower. During an interview and observation with the Director of Environmental Services on 12/15/25 at 10:17am revealed housekeeping staff was responsible for cleaning the shower rooms once or twice a day and upon request. The Director of Environmental Services and surveyor entered Shower room [ROOM NUMBER] and observed the same 5 brown smudges on the shower floor of the first shower, the Director of Environmental Services stated she could not confirm what the smudges were. She stated housekeeping had not cleaned Shower room [ROOM NUMBER] yet, however the CNAs were responsible for cleaning the shower room after each use. The Director of Environmental Services then observed Shower room [ROOM NUMBER] with the surveyor and stated she could not say what the red drops on the floor were and no one had informed her there were red spots on the floor that needed cleaning. The Director of Environmental Services referred to the bins against the wall in Shower room [ROOM NUMBER] as the bed rolls and explained one side was soiled linens and one was trash. She stated the bed rolls were at the point they needed to be emptied because they were full and stated the strong urine odor in Shower room [ROOM NUMBER] could have been due to the bed rolls not being emptied. She stated the CNAs typically emptied the bed rolls several times per day. She reported Shower room [ROOM NUMBER] was typically cleaned after lunch and after dinner due to its high usage. The Director of Environmental Services reiterated it was the CNAs responsibility to clean the shower rooms after each shower throughout the day as needed. She stated the insole of the shoe observed in Shower room [ROOM NUMBER] should have been thrown away immediately and not left on the sink. The risk to the residents who were showered in a dirty shower was possible exposure to bacteria that could have made them sick. During an anonymous group interview with 8 Residents on 12/15/25 at 10:32am revealed the residents believed the shower rooms were messy and at times when they were taken to the shower rooms the shower rooms had dirty towels on the floor from the previous resident who showered. One of the anonymous residents stated they had observed feces on the floor in the shower on one occasion when staff took them to the shower room. During an interview with CNA A on 12/15/25 at 10:42 am revealed she was responsible for cleaning the showers after showering residents in the shower rooms. If a resident had an accident and there was urine or feces in the shower, she would have picked it up immediately and wiped the shower down. She would have then notified housekeeping about the need to sanitize the shower. CNA A stated the risk to the residents of not cleaning the showers after every use was the resident could have gotten sick, an infection or slipped if there was urine on the floor. During an interview with CNA B on 12/15/25 at 11:34 am revealed she had used the Shower room [ROOM NUMBER] about 8am and had not observed it to be dirty. CNA B stated it was the responsibility of the CNA to clean up any accidents that happened during or after a shower. She stated once they cleaned up any feces or urine, they would call housekeeping to sanitize the shower room. The risk of bringing a resident in the shower room while it was dirty with feces would have been the resident could have gotten contaminated or an infection. During an interview with CNA C on 12/15/25 at 11:44 am revealed she frequently used Shower room [ROOM NUMBER] to shower residents. She stated after every shower she would situate the resident in a safe place and would go back to the shower room and would pick up trash and dirty linens. If she saw poop on the floor, she would clean it up immediately. CNA C stated she also checked the showers before the end of her shift to make sure they were clean because her main goal was infection control. CNA C stated a dirty floor, with poop, in a shower room could have exposed a resident to bacteria. During an interview with CNA D on 12/15/25 12:15pm revealed he worked in the section assigned to Shower room [ROOM NUMBER]. CNA D stated he had not noticed the dirty conditions of Shower room [ROOM NUMBER] because he used another shower room in the area. He stated if he had observed blood on the floor he would have cleaned it up as best as he could and called housekeeping for more in-depth cleaning. If he was showering a resident and there were bodily fluids like urine, feces or blood he would have cleaned it and would have asked housekeeping to disinfect the room. CNA D reported the person who gave the shower to a resident was responsible for cleaning up the shower room after. He stated if he entered a shower room and it had feces or blood he would clean and disinfect it before he brought the new resident into the shower room. CNA D stated there was a high risk to residents if there was feces or blood in the shower room because they could catch something because you never know what is in the stool or blood. During an interview with the DON on 12/15/25 at 4:05pm revealed housekeeping staff had been cleaning the shower rooms daily, but CNAs were responsible for cleaning up after themselves between showering residents. The DON stated housekeeping staff should have been keeping up with the shower rooms and should have been checking them throughout the day. The risk to the residents of not having had clean showers was infection. During an interview with the Administrator on 12/15/25 at 4:51pm revealed the expectation of the CNAs after using the shower rooms would have been they no wait to clean up the shower but cleaned it immediately. The Administrator stated if a CNA saw BM on the floor he would have expected them to clean it up and not leave it there. The CNAs were required to keep the showers sanitary and clean. Housekeeping was expected to do their daily rounds to ensure the shower rooms remain clean, but it was not housekeeping staff's responsibility to keep the showers clean after every shower. The risk to the residents of not having clean showers was infections and negative effect on their sense of dignity. Requested the policy related to the cleanliness of the facility and/or the shower rooms on 12/15/25 at 5:00pm and was informed by the Administrator the facility did not have a policy related to cleanliness. The facility did not submit a policy on cleanliness of the facility or shower rooms by the date and time of exit.

Based on observation, interview, and record review the facility failed to immediately inform the resident, consult with the resident's physician, notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 resident (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's physician when an injury of unknown origin was discovered on 5/06/2025. This deficient practice could place residents at risk of not having their physician informed when there was a change in condition resulting in a delay in medical intervention and decline in health. Findings include: Record review of Resident #1's Face Sheet revealed that the resident was a [AGE] year-old female. She was admitted to the facility on [DATE] and discharged on 5/06/2025. She was a respite care (temporary care services) resident. Diagnoses of Alzheimer's disease (brain condition that progressively damages memory, thinking, and learning skills), Hyperlipidemia (High cholesterol), Dysphagia (Difficulty swallowing), Protein-calorie malnutrition, Anxiety disorder (Mental health conditions characterized by excessive fear, dread, or apprehension that arises without a clear or appropriate cause), History of falling, Dementia (Loss of cognitive function), Adult failure to thrive (Substantial decline in overall health and functional abilities), Parkinson's disease with dyskinesia (Dyskinesia is a term used to describe involuntary, uncontrollable movements), and Pain. Record review of Resident #1's Care Plan revealed that Resident #1 had a fall on 5/03/2025. Goals include that Resident #1 will be free from complications related to falling over the next 3 days and resident at risk for falls resident safety will be maintained over the next 90 days. Resident fall interventions include assess contributing factors related to fall history, assess for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems, etc., Keep call light and most frequently used personal items within reach, remind resident to call when needing assistance. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note on 5/03/2025 at 4:51 PM that was entered by LVN B. The progress note referenced the assessment for Resident #1 and stated that Resident #1 had fallen asleep in her chair slouched over. LVN B repositioned Resident #1 attempting to prevent a fall. Approximately 30 minutes later, CNA C alerted LVN B that Resident #1 had repositioned herself. Resident #1 had fallen back asleep and slouched over causing Resident #1 to fall out of her chair. Resident #1 was assessed with no noticeable injuries. Resident #1 denied pain. Record review of Resident #1's MDS Assessment, dated 5/05/2025, reflected Resident #1 had a BIMS (Brief Interview for Mental Status Test) score of 2 (Severe Cognitive Impairment). Resident #1 was assessed to require assistance with ADLs including the following: transfers, personal hygiene, showers, and dressing. Record review of the facilities Activities of Daily Living care log on 6/18/2025, dated 5/06/2025, reflected that CNA provided ADL care to Resident #1 at 7:51 PM. No injuries or change in condition were noticed at that time. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note on 5/06/2025 at 10:56 PM that was entered by LVN A. The progress note stated that there was a concern made by the family about the resident's care and the family requested to speak with the Director of Nursing. Record review of LVN A's employee statement, not dated, reflected that LVN A was working the night shift on 5/06/2025 when Resident #1 was discharged at 10:56 PM. The resident was discharged because it was the end of her Respite Care. He stated that the family member had concerns about Resident #1's care because there was some bruising that the family was not aware of. He stated that he saw the bruising on Resident #1's face but there was no open wound. He stated Resident #1 was in her wheelchair with her head facing down and not able to voice what happened. Record review of TULIP (Texas Unified Licensure Information Portal) on 6/18/2025 revealed that the facility did not report the injury of unknown origin for the wound that was discovered on 5/06/2025. The facility failed to follow the requirements by not reporting the incident within 24 hours of discovering the incident. Observation of video submitted by Family Member X dated 5/07/2025 at 1:10 pm in Resident #1's room at the nursing facility revealed an injury located on the right side of Resident #1's cheek. The injury appeared as a linear abrasion that was deeper than a scratch. The skin where the injury was located was bright red, clotted, and an irregular shape about 2.5 centimeters in diameter which Physician D claimed was caused by blunt force trauma. Timestamp date is inconsistent with the time of Resident #1's discharge time and date. Observation of photograph submitted by Family Member X dated 5/07/2025 at 1:10 pm in Resident #1's room at the nursing facility revealed Resident #1's injury to the right side of her cheek. The injury appeared as a linear abrasion that was deeper than a scratch. The skin where the injury was located was bright red, clotted, and an irregular shape about 2.5 centimeters in diameter which Physician D claimed was caused by blunt force trauma. Timestamp date is inconsistent with the time of Resident #1's discharge time and date. Interview with Physician D on 6/18/2025 at 9:00 AM confirmed that the wound appeared to be open and recent to the time of the photograph. Interview with Wound Care Nurse H on 6/17/2025 at 2:10 PM revealed that the wound appeared to be open and recent to the time of the photograph. Interview on 6/17/2025 at 9:40 AM with Director of Nursing F revealed that staff are trained to notify the administrator, director of nursing, physician, and responsible party if they find a wound or injury of unknown origin. She stated the reason this wound was not reported was because it was not something that they thought was a new injury because it was assumed to be related to the fall incident that occurred on 5/03/2025. Director of Nursing F stated that the physician and family members were notified of the fall that occurred on 5/03/2025. It was a witnessed fall. Director of Nursing F stated that she had seen Resident #1 on 5/06/2025 during the day shift and the wound was not there at that time. She stated that she did not know that when the family called to complain about Resident #1's injury that they were talking about that specific injury that she was not aware of. She stated that she assumed that Resident #1's family were calling to complain about a bruise on the right side of Resident #1's face that was related to the fall that occurred on 5/03/2025. Interview on 6/17/2025 at 11:00 AM with RN I, revealed that he saw Resident #1 on 5/06/2025. and saw that she had a bruise on the right side of her face above her eye. He stated it was a light purple bruise but there was no open skin. He stated the wound did not have any open areas and that it was right above her eye. Interview on 6/18/2025 at 9:00 AM with Physician D revealed the facility did not notify her of the wound in the video and photograph that was discovered on 5/06/2025 at 10:56 PM. She stated that she was at the facility on 5/06/2025 and observed Resident #1 around 9:00 AM. She stated Resident #1 did not have the injury that can be seen in the video and photographs when she observed her. She stated that the injury had to of happened after she left the facility that day. She stated that the wound appeared to be open and would have met the criteria for someone who should have been seen by the wound care nurse. She stated that had she seen that wound she would have provided wound care by applying ointment and bandaging the wound. She stated that the wound was not significant but that it should still have been treated. She stated that the wound looked like it was caused by blunt trauma possibly from her slouching over in her wheelchair and hitting the wheelchair armrest. She stated that the resident slouches over in her chair a lot and she could have hit her face on her armrest. She stated that she remembered being notified by LVN B of Resident #1 having the fall on 5/03/2025. She stated that she did not think that the fall and the injury to her cheek are related and that they had to of occurred at separate times. She stated that she should be contacted about any new injury of unknown origin, open wound, or injury. Interview on 6/18/2025 at 10:00 AM with Administrator J, revealed that he had spoken to RN I and learned that Resident #1 had light bruising on 6/05/2025. He stated that RN I knew about Resident #1's fall on 5/03/2025 and thought that the bruising was related to the fall. Administrator J stated that all the staff were inserviced on 6/17/2025 on documentation and notifications. Administrator J stated that he had talked to LVN A and learned that the injury was there at the time of discharge on [DATE] at 10:56 PM. He stated that LVN A had talked to the family, and they wanted to know what happened to Resident #1's face. Administrator J stated that everyone that was communicating with the family was communicating with them under the assumption that they were all talking about the injury that was related to the fall that occurred on 5/03/2025 and not about the injury of unknown origin that was discovered on 5/06/2025. He stated that they were communicating with inaccurate information that they didn't know was inaccurate because of the circumstances of the fall occurring a few days prior. Administrator J stated that the staff didn't notice that this was a new injury to Resident #1's face and assumed it was from the fall. He stated that it was unfortunate but that's just what happened. He stated the staff were inserviced to go back and check or compare notes to make sure that they are consistent with any injuries that are discovered. Interview on 6/18/2025 at 10:30 AM with RN I, revealed that the wound to Resident #1's cheek in the photograph and video were not there when he saw the resident during the day shift around 3:00 PM on 5/06/2025. He stated that if there had been an open wound then he would have provided wound care immediately and documented it. He stated if there had been a new wound then he would have notified the family and physician. LVN A was attempted to be interviewed on 6/18/2025 at 1:08 PM. Message was left requesting a call back. Record Review of the Facility Abuse & Neglect Policy dated June 23, 2017, reviewed February 12, 2020, states that The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegation of abuse, neglect, exploitation and misappropriation of resident property. All managed healthcare facilities and all management company staff members or third parties providing services to such facilities and/or their residents.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting. The facility failed to report an injury of unknown origin that was discovered on 5/06/2025, to HHSC. This failure could place residents at risk for not having incidents reported as required. Findings included: Record review of Resident #1's Face Sheet revealed that the resident was a [AGE] year-old female. She was admitted to the facility on [DATE] and discharged on 5/06/2025. She was a respite care (temporary care services) resident. Diagnoses of Alzheimer's disease (brain condition that progressively damages memory, thinking, and learning skills), Hyperlipidemia (High cholesterol), Dysphagia (Difficulty swallowing), Protein-calorie malnutrition, Anxiety disorder (Mental health conditions characterized by excessive fear, dread, or apprehension that arises without a clear or appropriate cause), History of falling, Dementia (Loss of cognitive function), Adult failure to thrive (Substantial decline in overall health and functional abilities), Parkinson's disease with dyskinesia (Dyskinesia is a term used to describe involuntary, uncontrollable movements), and Pain. Record review of Resident #1's Care Plan revealed that Resident #1 had a fall on 5/03/2025. Goals include that Resident #1 will be free from complications related to falling over the next 3 days and resident at risk for falls resident safety will be maintained over the next 90 days. Resident fall interventions include assess contributing factors related to fall history, assess for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems, etc., Keep call light and most frequently used personal items within reach, remind resident to call when needing assistance. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note on 5/03/2025 at 4:51 PM that was entered by LVN B. The progress note referenced the assessment for Resident #1 and stated that Resident #1 had fallen asleep in her chair slouched over. LVN B repositioned Resident #1 attempting to prevent a fall. Approximately 30 minutes later, CNA C alerted LVN B that Resident #1 had repositioned herself. Resident #1 had fallen back asleep and slouched over causing Resident #1 to fall out of her chair. Resident #1 was assessed with no noticeable injuries. Resident #1 denied pain. Record review of Resident #1's MDS Assessment, dated 5/05/2025, reflected Resident #1 had a BIMS (Brief Interview for Mental Status Test) score of 2 (Severe Cognitive Impairment). Resident #1 was assessed to require assistance with ADLs including the following: transfers, personal hygiene, showers, and dressing. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note on 5/06/2025 at 10:56 PM that was entered by LVN A. The progress note stated that there was a concern made by the family about the resident's care and the family requested to speak with the Director of Nursing. Record review of LVN A's employee statement, not dated, reflected that LVN A was working the night shift on 5/06/2025 when Resident #1 was discharged at 10:56 PM. The resident was discharged because it was the end of her Respite Care. He stated that the family member had concerns about Resident #1's care because there was some bruising that the family was not aware of. He stated that he saw the bruising on Resident #1's face but there was no open wound. He stated Resident #1 was in her wheelchair with her head facing down and not able to voice what happened. Record review on 6/18/2025 of TULIP (Texas Unified Licensure Information Portal) revealed that the facility did not report the injury of unknown origin for the wound that was discovered on 5/06/2025. The facility failed to follow the requirements by not reporting the incident within 24 hours of discovering the incident. Observation of video submitted by Family Member X dated 5/07/2025 at 1:10 pm in Resident #1's room at the nursing facility revealed an injury located on the right side of Resident #1's cheek. The injury appeared as a linear abrasion that was deeper than a scratch. The skin where the injury was located was bright red, clotted, and an irregular shape about 2.5 centimeters in diameter which Physician D claimed was caused by blunt force trauma. Timestamp date is inconsistent with the time of Resident #1's discharge time and date. Observation of photograph submitted by Family Member X dated 5/07/2025 at 1:10 pm in Resident #1's room at the nursing facility revealed Resident #1's injury to the right side of her cheek. The injury appeared as a linear abrasion that was deeper than a scratch. The skin where the injury was located was bright red, clotted, and an irregular shape about 2.5 centimeters in diameter which Physician D claimed was caused by blunt force trauma. Timestamp date is inconsistent with the time of Resident #1's discharge time and date. Interview with Physician D on 6/18/2025 at 9:00 AM confirmed that the wound appeared to be open and recent to the time of the photograph. Interview with Wound Care Nurse H on 6/17/2025 at 2:10 PM revealed that the wound appeared to be open and recent to the time of the photograph. Interview on 6/17/2025 at 9:40 AM with Director of Nursing F revealed that staff are trained to notify the administrator, director of nursing, physician, and responsible party if they find a wound or injury of unknown origin. She stated the reason this wound was not reported was because it was not something that they thought was a new injury because it was assumed to be related to the fall incident that occurred on 5/03/2025. Director of Nursing F stated that the physician and family members were notified of the fall that occurred on 5/03/2025. It was a witnessed fall. Director of Nursing F stated that she had seen Resident #1 on 5/06/2025 during the day shift and the wound was not there at that time. She stated that she did not know that when the family called to complain about Resident #1's injury that they were talking about that specific injury that she was not aware of. She stated that she assumed that Resident #1's family were calling to complain about a bruise on the right side of Resident #1's face that was related to the fall that occurred on 5/03/2025. Interview on 6/17/2025 at 10:30 AM with CNA C revealed that Resident #1 was seen falling to the ground in the dining room on 5/03/2025. CNA C alerted LVN B of the fall and LVN B assessed Resident #1. CNA C stated that Resident #1 did not have any signs of injury. CNA C stated that he never saw a wound on Resident #1's face while she was at the facility. Interview on 6/17/2025 at 11:00 AM with RN I, revealed that he saw Resident #1 on 5/06/2025. and saw that she had a bruise on the right side of her face above her eye. He stated it was a light purple bruise but there was no open skin. He stated the wound did not have any open areas and that it was right above her eye. Interview on 6/17/2025 at 2:10 PM with Wound Care Nurse H revealed that she saw a bruise on the upper right side of Resident #1's face over the weekend of Saturday 5/03/2025 and Sunday 5/04/2025. She stated that it was a light bruise on the upper right side of her face. She stated that she was never informed of any open wounds or skin tears. She stated that the wound in the video and photograph appeared to be an open wound with bleeding. She stated that it had to have occurred after she saw the resident on the weekend because it was not there when she saw that resident sitting in her chair over the weekend. She stated that she also does not believe that the resident would have gone 24, 48, or even 72 hours with a with a wound that was visibly bleeding on her face without being notified about it. Interview on 6/17/2025 at 2:20 PM with Assistant Director of Nursing G, revealed that he did see the bruise that was on Resident #1's upper right-hand side of her face on 5/06/2025 that was a result of her fall on 5/03/2025. He stated that there was no cut or skin tear when he saw her, and that Resident #1 was not bleeding. He stated that he never saw the a wound on Resident #1's cheek. He stated that if he had seen a wound on Resident #1 he would have notified the director of nursing, doctor, and family. He would have addressed it with the wound care nurse too. Interview on 6/18/2025 at 9:00 AM with Physician D revealed the facility did not notify her of the wound in the video and photograph that was discovered on 5/06/2025 at 10:56 PM. She stated that she was at the facility on 5/06/2025 and observed Resident #1 around 9:00 AM. She stated Resident #1 did not have the injury that can be seen in the video and photographs when she observed her. She stated that the injury had to of happened after she left the facility that day. She stated that the wound appeared to be open and would have met the criteria for someone who should have been seen by the wound care nurse. She stated that had she seen that wound she would have provided wound care by applying ointment and bandaging the wound. She stated that the wound was not significant but that it should still have been treated. She stated that the wound looked like it was caused by blunt trauma possibly from her slouching over in her wheelchair and hitting the wheelchair armrest. She stated that the resident slouches over in her chair a lot and she could have hit her face on her armrest. She stated that she remembered being notified by LVN B of Resident #1 having the fall on 5/03/2025. She stated that she did not think that the fall and the injury to her cheek are related and that they had to of occurred at separate times. She stated that she should be contacted about any new injury of unknown origin, open wound, or injury. Interview on 6/18/2025 at 10:00 AM with Administrator J, revealed that he had spoken to RN I and learned that Resident #1 had light bruising on 6/05/2025. He stated that RN I knew about Resident #1's fall on 5/03/2025 and thought that the bruising was related to the fall. Administrator J stated that all the staff were inserviced on 6/17/2025 on documentation and notifications. Administrator J stated that he had talked to LVN A and learned that the injury was there at the time of discharge on [DATE] at 10:56 PM. He stated that LVN A had talked to the family, and they wanted to know what happened to Resident #1's face. Administrator J stated that everyone that was communicating with the family was communicating with them under the assumption that they were all talking about the injury that was related to the fall that occurred on 5/03/2025 and not about the injury of unknown origin that was discovered on 5/06/2025. He stated that they were communicating with inaccurate information that they didn't know was inaccurate because of the circumstances of the fall occurring a few days prior. Administrator J stated that the staff didn't notice that this was a new injury to Resident #1's face and assumed it was from the fall. He stated that it was unfortunate but that's just what happened. He stated the staff were inserviced to go back and check or compare notes to make sure that they are consistent with any injuries that are discovered. Interview on 6/18/2025 at 10:30 AM with RN I, revealed that the wound to Resident #1's cheek in the photograph and video were not there when he saw the resident during the day shift around 3:00 PM on 5/06/2025. He stated that if there had been an open wound then he would have provided wound care immediately and documented it. He stated if there had been a new wound then he would have notified the family and physician. LVN A was attempted to be interviewed on 6/18/2025 at 1:08 PM. Message was left requesting a call back. Record Review of the Facility Abuse & Neglect Reporting Policy dated June 23, 2017, reviewed February 12, 2020, states that: (ii) Timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation, and misappropriation of resident property. 3.2 All facility staff members have a duty to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the Administrator of the facility, who serves as the Abuse Coordinator. In the Administrator's absence, the Director of Nursing (DON) or another designee will be appointed to function as the interim Abuse Coordinator. 3.3 Upon receiving an allegation abuse, neglect, exploitation or misappropriation, the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation, c) in conjunction with the Region Director of Operations and Regional Nurse Consultant determine whether the allegation is reportable under federal and state regulations, and d) if the allegation is reportable, report such allegation to the State Regulatory Agency, Adult Protective Services (where state law provides jurisdiction in skilled nursing or assisted living facilities), and in certain cases, local law enforcement, within the following timeframes: A. Not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or B. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 10 residents (Resident #23, Resident #22, Resident #72, and Resident #64) observed for infection control. 1. The facility failed to ensure MA C administered Resident 23's medication without cross contaminating her medications on 02/18/25. 2. The facility failed to ensure MA B prepared Resident 72's medication without cross contaminating her medications on 02/18/25. 3. The facility failed to ensure MA B sanitized the blood pressure cuff between use on Resident #22 and Resident #72 on 02/18/25. 4. The facility failed to ensure that CNA D changed her gloves and performed hand hygiene while providing incontinence care to Resident #64 on 02/18/25. 4. The facility failed to ensure the Treatment Nurse used the required PPE for Resident #64, who was on enhanced barrier precautions due to her venous access device and wounds, while performing wound care on 02/19/25. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. During medication observation on 02/18/25 at 08:50 a.m., MA C was observed at the medication cart. MA C performed hand hygiene and prepared Resident #23's morning medications. MA C placed eight medications in one plastic medication cup and 1 medication (iron supplement) in a second medication cup, stating the resident usually refused her iron supplement. MA C entered the resident's room and asked the resident if she wanted her iron supplement. Resident #23 stated she would take her iron supplement. MA C poured the supplement into the cup containing the 8 other medications and handed the pill cup to the resident. Resident #23 poured the medication into her mouth, dropping one of the pills into the crook of her arm. MA C picked up the fallen pill with her bare hands, and placed it into the palm of her hand for Resident #23 to retrieve from her hand. Resident #23 retrieved the pill from MA C palm and took it with the remainder of her medications. In an interview on 02/20/25 at 09:10 a.m. with MA C she stated she realized she had cross contaminated the medication when she touched it with her hand. She stated she should have disposed of the medication and retrieved a new medication. She stated she had been taught they were not supposed to touch any of the medications with their hands due to the risk of cross contamination. 2. During medication observation on 02/18/25 at 09:15 a.m., MA B was observed at the medication cart in the dining room area on the memory care unit. MA B performed hand hygiene and obtained Resident 22's blood pressure. MA B returned to the medication cart and placed the blood pressure cuff on top of the cart. MA B sanitized her hands and pulled Resident #22's medication and administered his medications to him at the dining room table. MA B returned the medication cart, sanitized her hands and picked up the unsanitized blood pressure cuff and took Resident #72's blood pressure. MA B returned to the medication cart and placed the blood pressure cuff on top of the medication cart. MA B sanitized her hands and opened the medication cart to retrieve Resident #72's medication. MA B pulled keys from her pocket and unlocked the Locked section of the medication cart and retrieved a blister pack containing Resident #72's Xanax (anti-anxiety). MA B punched the blister pack over the plastic medication cup, but the pill remained stuck inside the blister pack. MA B took her finger and pulled the tablet out of the blister pack into the plastic cup. MA B then continued to pull 5 more medications. MA B crushed all the medication except the 1 tablet of potassium (mineral) and then mixed all the pills into yogurt and administered the medications to Resident #72. In an interview with MA B on 02/18/25 at 09:30 a.m., she stated she was supposed to sanitize the blood pressure cuff between resident-use and stated she had forgotten that step. She stated she had been taught they were not supposed to touch any of the medication with bare hands and stated she should have gotten a spoon to retrieve the stuck pill. She stated the reason for not touching the medication and sanitizing the blood pressure cuff was to prevent the spread of germs prevent the spread of infections. In an interview on 02/19/25 at 03:40 p.m. with the DON, she stated the staff were taught to punch the medication directly into the med cup without touching the medication to prevent cross contamination. She stated the staff could have used a spoon to retrieve the medication from the blister pack and should have disposed of the dropped medication and retrieved a new pill. She stated they had all been taught to clean equipment between resident use. She stated they went over and over infection control practice with the staff. 3. In an observation on 02/18/25 at 10:05 a.m., CNA D and CNA E entered Resident #64's room to provide incontinence care. Both staff donned a gown, performed hand hygiene, and put on gloves. CNA D opened the resident's brief and pushed it downward toward the resident's buttocks. CNA D provided peri care from front to back, wiping once and changing wipes with each stroke. Both staff rolled the resident onto her left side. CNA D wiped from front to back, removed her gloves, and performed hand hygiene. CNA D then removed the soiled brief and placed the clean brief under the resident without changing her gloves or performing hand hygiene. Both staff rolled the resident back onto her back and fastened the brief. Both staff removed their gown and gloves and performed hand hygiene. In an interview on 02/18/25 at 10:08 a.m., CNA D stated she should had removed the soiled brief, and then changed her gloves and perform hand hygiene. She stated the way she did it cross contaminated the clean brief and potentially the resident. She stated they had been taught to change their gloves and perform hand hygiene when finished with the dirty and before going to the clean. 4. In an observation on 02/19/25 at 10:05 a.m. revealed the Treatment Nurse at the treatment cart preparing wound care supplies for Resident #64's wound to her left heel. The Treatment Nurse placed her supplies on a piece of wax paper and entered Resident #64's room. The Treatment Nurse placed the supplies on the resident's bed, performed hand hygiene and put on gloves, but did not put on a gown. The Treatment Nurse removed the old dressing off her left heel revealing a moderate amount of blood-tinged drainage, removed her gloves and performed hand hygiene and put on clean gloves. The Treatment Nurse cleaned the wound with Normal Saline and applied hydrogel (gel that increases moisture level in the wound) and covered it with a dry dressing. The Treatment Nurse then removed her gloves and performed hand hygiene. In an interview on 02/20/25 at 10:15 a.m. with the Treatment Nurse, she stated she did not think Resident #64 was on Enhanced Barrier precautions because the wound did not have significant drainage and she thought the Resident had a peripheral line, not a PICC line. She stated she was taught that if the resident had a minor wound and a peripheral line, they did not have to use Enhanced Barrier precautions. She stated since the resident did have a PICC line, she should have worn a gown. She stated she was not sure if the wound alone would require a gown. In an interview on 12/05/24 at 11:10 a.m. with the DON, she stated staff were supposed to wash hands and change gloves before and after completion of cleaning a resident, and after completion of care. She stated they had worked so hard with the staff on skills and stated they were all aware of what they were supposed to be doing. She stated the risk of failing to perform hand hygiene was increased infections and cross contamination. She stated any resident with a central line or PICC line required the staff to wear a gown for high contact care. She stated simple skin tears did not require the use of gown but stated Resident #64's wound would not be described as a simple skin tear. She stated they had done training with all the staff on Enhanced Barrier precautions as well as infection control. She stated the reason the residents were placed in Enhanced Barrier precautions was because they were more susceptible to spread of infection and provided an extra level of protection. She stated they did skills checks and education upon hire and annually on infection control, hand hygiene, and Enhanced Barrier precautions, or as needed when training needs were identified. Record review of the facility's policy titled, Disinfecting and Sterilizing Resident Care Equipment, dated January 2022, reflected, Equipment will be maintained and kept sanitized or disinfected in accord with acceptable policies .Only EPA-approved cleaning products and germicides are utilized for the cleaning, disinfection and sterilization of resident equipment .Non-critical items are those that either do not touch the resident or touch only intact skin. Such items include .blood pressure cuffs .These items rarely transmit disease. However, it is imperative that these items are clean . Record review of the facility's policy titled, Medication Administration, dated January 2024, reflected, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so .hands are washed with soap and water and gloves applied prior to handling tablets . Record review of the facility's policy titled, Hand Hygiene for Staff and Residents, dated January 2022, reflected, .Hand Hygiene is the most important component for preventing the spread of infection .Hand hygiene is done before .resident contact .taking part in a medical or surgical procedure .After contact with soiled or contaminated articles, such as articles that are contaminated body fluids . Record review of the facility policy titled, Enhanced Barrier Precautions, dated April 2024, reflected, Many residents in nursing homes are at increased risk of becoming colonized and developing infections with multi-drug resident organisms .Indications .Wounds and/or indwelling medical devices even if the resident is not known to be infection or colonized with an MDRO .High Contact Resident care Activities .Wound care: any skin opening requiring a dressing .EBP are sued in conjunction with standard precautions and expand ethe use of PPE to donning of gown and gloves during high contact care activities that provide opportunities of r transfer of MDROs to staff hands and clothing .

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 Residents (Resident #64) reviewed for respiratory care. 1. The facility failed to obtain an order for Resident #64's use of supplemental O2 with stated liter amount to be delivered. 2. The facility failed to include rationale for the use of O2 for Resident #64 from 02/16/25 through 02/18/25. These failures could place residents who received oxygen therapy at risk of receiving an incorrect amount of oxygen and the risk of oxygen toxicity. Findings Included: Record review of Resident #64's significant change MDS assessment dated [DATE], reflected an [AGE] year-old female with a re-entry date of 12/06/24 to the facility. She had a BIMS score of 9 which indicated her cognition was moderately impaired. Diagnoses included dementia, fractured hip, and coronary artery disease (damage or disease of the hearts major blood vessels). The resident required substantial to maximum assistance with ADL's. Resident #64 had not experience shortness of breath in the previous 5 days and had not received Oxygen therapy while a resident. Record review of Resident #64's care plan with an onset date of 02/15/25 reflected, Breathing patterns onset 02/15/25. Evidenced by Ipratropium 0.5 mg-albuterol 3 mg (used to open airways) .1 solution for Nebulization (converts liquid medication into a fine mist to be inhaled directly into the lungs) .Goal-Resident will demonstrate effective respiratory rate, depth, and pattern over the next 90 days .Interventions .Administer medications, respiratory treatments, and oxygen as ordered . Record of Resident #64's Physician orders report dated 02/20/25, reflected, Ipratropium 0.5 mg-albuterol 3 mg/3 ml nebulization-1 solution for nebulization inhalation every 6 hours with a start date of 02/17/25. There were no orders for oxygen therapy. Record review of Resident #64's Medication administration record dated February 2025 reflected, . ipratropium 0.5 mg-albuterol 3 mg (2.5 mg base)/3 mL nebulization. (IPRATROPIUM BROMIDE/ALBUTEROL SULFATE) 1 Solution for Nebulization Inhalation every 6 hours NEBULIZATION Dx: Nasal congestion Start Date:02/17/2025. Medication had been administered every 6 hours as ordered. There was no administration recorded for Oxygen therapy from 02/01/25 through 02/18/25. Record review of Resident #64's nurses notes dated 02/16/25 reflected: 05:15 a.m. Resident in bed resting comfortably resp. even and unlabored, crackle lung sound noted on auscultation, breathing treatment administrated as ordered with an effective result. 02 sats 94-96% on 02 @ 2L via NC Signed by LVN G 11:11 a.m. Resident lethargic, alert oriented x 1, sleeping comfortably, no s/sx of respiratory distress or any other discomfort noted, sating at 95% on 2l of oxygen .[NP] On call notified. IV hydration completed. Received orders for midline (IV access) insertion x1, normal saline 0.9% IV X 2 liters, CEFTRIAXONE (antibiotic) 1 GRAM Q 24HRS X 3 DAYS, vital signs q 6 hours x 48 hours Family notified Singed by LVN F. In an observation on 02/18/25 at 10:05 a.m., Resident #64 was observed in bed with O2 via nasal cannula. The O2 concentrator was set to deliver 2 liters per minute. In an interview on 02/20/25 at 11:30 a.m. with LVN F, she stated Resident #64 was having difficulty breathing a few days ago and they had to place her on oxygen. She stated her breathing had improved, but she still had a bad cough and some crackles in her lungs. She stated they had a standing order from the physician that they could apply oxygen at 2 liters and titrate according to the resident's oxygen saturation level and resident's comfort. She stated the order should be in the physician orders. LVN F searched the physician orders and MAR, and stated there were no orders put in. She stated she would add the orders now. In an interview with the DON on 02/20/25 at 11:35 a.m., she stated even though they had a standing order list from the physician, the staff had to place those orders into the electronic physician orders which would then populate to the MAR/TAR. She stated the staff had to have an order for the amount of Oxygen to be administered, if it was continuous or as needed, when it was applied and the necessary assessment that needed to be performed for anyone receiving Oxygen therapy. She stated failing to have the order in place, placed a resident at risk lack of continuity of care and the specific amount of Oxygen to be administered. In an interview on 02/20/25 at 11:40 a.m. with LVN G, he stated he worked the night shift on 02/16/25 and stated Resident #64 was on O2 when he arrived. He stated he assessed her vitals and O2 sats and documented in the nurses' notes, but stated he did not check to see if there was an order for the Oxygen. He stated he assumed the order was in place. He stated they were required to have an order for any oxygen administration and the amount to be administered. Record review of the facility's policy titled, Oxygen Therapy, Concentrator-Initiation, dated January 2020, reflected, The licensed staff will provide the prescribed amount oxygen therapy to the residents as prescribed by physician and according to practice guidelines .Procedure: Review physician's orders .Turn liter flow to the prescribed amount .Document in the eMar/eTar ordered oxygen therapy administration .

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #205) reviewed for intravenous fluids. RN A failed to change Resident #205's Central Venous Catheter line dressing using sterile technique. This failure could affect residents by placing them at risk for infections and cross-contamination. Findings include: Record review of Resident #205's Minimum Data Set Assessment, dated 02/11/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE], his BIMS score was 15/15 indicating intact cognition. His diagnoses included blood stream infection due to central venous catheter, respiratory failure, pneumonia (an infection that inflames the air sacs in one or both lungs). Record review of Resident #205's Order Summary Report, dated January 2023, reflected: PICC LINE (CVC) DRESSING CHANGE every 7 days 1 time per day, Dx: Bloodstream infection due to central venous catheter, subsequent encounter. An observation on 02/19/25 at 2:24 PM with Resident #205 revealed he was awake and lying on the bed. He had a PICC (CVC) line in his right upper chest with a dressing that has a one-inch tear on it. The line entry site was not red or swollen. RN A entered the resident's room with donned gown, clean gloves. She wiped the bed side table, let it to dry, and put the dressing change kit on it. RN A changed gloves performed hands hygiene, opened the sterile kit, got the mask from the kit and put it on the resident; RN A was wearing a mask as well. RN A removed gloves, sanitized hands, donned sterile gloves, and separated the sterile supplies individually for clear view. RN A put a white drape from the sterile kit underneath the line lumens without touching them, then removed the old dressing. RN A, without changing gloves, cleaned the line exit site with chlorhexidine, applied the Bio Patch, and clean dressing without using the skin prep on the sterile kit. RN A removed the white drape and proceeded to dispose of the rest of the sterile kit on the trash. When RN A was asked about the extra sterile gloves in the kit, she replied for a helper in case she needed another person to help her with the dressing change. In an interview on 02/19/25 at 2:47 PM with RN A, she stated supposed to change gloves with hands hygiene going from dirty to clean during the dressing change. RN A stated she received sterile dressing change training as an RN student at school two years ago, in the facility on hire two years ago, and annually. RN A stated the risk, if proper sterile technique was not followed, could be the development of infection for the residents. In an interview on 02/19/25 at 3:12 PM with the DON, she stated her expectation for the staff doing central venous/PICC line dressing change was to follow the proper sterile techniques, and to change gloves with hands hygiene going from dirty to clean tasks. The DON stated the nurse RNs received training with check list on the central venous line care on hire, and annually. The DON stated the risk, if proper sterile technique was not followed, could be the development of infection for the residents. Record review of RN A's annual skill check revealed it was done on 09/20/24. Record review of the facility's policy Titled Infusion Therapy Policy and Procedure Manual-2011 reflected: Midline, PICC and Central catheter dressing changes are performed using strict sterile technique . Removes and disposes of old dressing . Removes gloves and washes hands Sets up the sterile dressing tray .

Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident#1) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #1 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was an [AGE] year-old male with initial admitted to the facility on [DATE]. His diagnoses included fracture of part of neck of left femur (the bone of the thigh), Obstructive uropathy (urine cannot drain through the urinary tract), and Alzheimer's disease. Resident #1 had a BIMS of 99 which indicated Resident #1 was unable to complete brief interview for mental status. Resident #1 required moderate assistance with personal hygiene. Review of Resident #1's Comprehensive Care Plan, revised 07/04/24, reflected the following: Care area: Self-Care Deficit Goal: [Resident #1] Will maintain or improve self-care area of dressing, grooming hygiene and bathing Interventions: . Provide assistance with self-care as needed. An observation on 11/19/24 at 09:47 AM, revealed Resident #1 was laying in his bed. The nails on both hands were approximately 0.3 centimeters in length extending from the tip of his fingers and had black substance underneath the nails and around the nail beds. Resident #1 was unable to answer questions. In an interview on 01/19/24 at 11:00 AM, with CNA A revealed she was assigned to Resident #1. She stated that most ADL's such as hair trimming, nail clipping was completed during shower times. She revealed that since Resident #1 was not a Diabetic resident, CNAs were responsible for clipping and cleaning his nails. CNA A stated that fingernail clipping should be done weekly or as needed and the risk of not cleaning/ trimming fingernails could be increased risk of infection. CNA A stated she did not check Resident #1's nails this morning when she changed him. In an interview with the DON on 11/20/24 at 12:59 PM, revealed her expectation was that nail care should be provided as needed, especially during shower time. She stated that CNAs were responsible for doing nail care unless the resident had a diagnosis of diabetes. She also stated that as the DON, either herself or her designee were responsible to do routine rounds for monitoring. The DON stated that residents having long, and dirty fingernails could be an infection control issue and skin breakdown. Record review of the facility policy titled Bathing revised 02/12/20 reflected: . Perform hand hygiene and perform nail care

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #2) of one resident reviewed for catheter care. The facility failed to ensure LVN B maintained Resident #2's indwelling urinary catheter drainage bag below the bladder level during wound care on 11/19/24. This failure placed residents at risk for not receiving care appropriate to address their incontinence and risk for infection. Findings included: A record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included multiple sclerosis (a disease resulting in nerve damage), stage 4 pressure ulcer, and neuromuscular dysfunction of bladder (the nerves and muscles of the bladder don't communicate properly with the brain, resulting in bladder control issues). Resident #2 had a BIMS of 12 which indicated Resident #2's cognition was moderately impaired. She required extensive assistance of two-person physical assistance with bed mobility. MDS assessment, section bowel and bladder reflected resident had an indwelling urinary catheter. Record review of Resident #2's care plan revised on 01/25/24 reflected, Urinary catheter . Resident will be free of complications of indwelling catheter . Goal: Resident will be free of complication of indwelling catheter . Interventions: Care/changing of urinary catheter as ordered . Review of Resident #2's Order Summary report dated November 2024, reflected, Foley Catheter ( indwelling urinary catheter) every shift to continuous gravity drainage and catheter care. with a start date of 06/19/24. Observation on 11/19/24 at 11:32 AM, revealed LVN B entered Resident #2's room to do wound treatment. CNA C entered Resident #2's room to assist LVN B. Both staff washed hands, donned gowns and gloves. LVN B unhooked the urinary catheter bag from the bed rail and put it flat on the foot of bed, above the resident's bladder. LVN B provided wound care to the sacrum wound. During the procedure urine was observed flowing back toward the resident's bladder. LVN B finished the treatment and then she hooked the urinary catheter bag onto the bed rail. Observation of the urinary catheter bag revealed approximately 300 milliliters of urine in the bag. In an interview with LVN B on 11/19/24 at 11:49 AM, she stated that the urinary catheter bag tubing was short and to prevent pulling on the catheter tubing she put the catheter bag on the bed. She stated the catheter bag and catheter tubing were supposed to be kept below the bladder. She stated failing to do this could cause the urine to back up and might cause an infection. She stated she supposed to empty the catheter bag before putting it on the bed. In an interview with the DON on 11/20/24 at 12:59 PM, she stated any resident with an indwelling urinary catheter should always have the catheter bag and catheter tubing below the bladder. She stated not keeping the urinary catheter bag below the resident's bladder, placed them at risk of urinary tract infection. She stated to ensure staff were knowledgeable in the care of indwelling catheter the facility does skills competency checks. She stated when staff needed to be re-trained, she provided the in-service training. Record review of LVN B's competency check off for catheter care revealed she was proficient in care as of 11/20/24. No other training was provided. Review of the facility's policy titled, Urinary Catheter Infection Prevention reviewed January 2022 reflected, . 8. Gravity drainage bags are positioned below the level of the patient's bladder .

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (600 hall nurses' medication cart and 400 hall nurses' medication cart) of 4 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1- The 600 Hall medication cart had 2 insulin pens for Resident #18 without an opened date. 2- The 400 Hall medication cart had 1 insulin pen for Resident #54 without an opened date. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings include: 1- Record review of Resident #18's Quarterly MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, elevated blood pressure, and hyperlipidemia (too many lipids and fats in the blood). She had a BIMS score of 09 indicating her cognition was cognitively moderately impaired. Record review of Resident #18's physician's orders dated January 2024 revealed an order for Humulin 70/30 U-100 insulin 100 unit/ml subcutaneous suspension. Inject 52 units subcutaneously every morning. Humulin R Regular U-100 insulin 100 unit/ml injection solution units per sliding scale. Subcutaneous before meals and at bedtime 0-149=0 units, 150-199=2 units, 200-249=4 units, 250-299=6 units, 300-349=8 units Observation on 01/23/2024 at 3:05 PM revealed the 600-hall nurse's medication cart had a pen of Humulin 70/30 U-100 insulin 100 unit/ml, and a pen of Humulin R Regular U-100 insulin 100 unit/ml for Resident #18, did not have an opened date. Interview on 01/23/2024 at 3:08 PM, LVN A stated the 2 pens of insulin belong to Resident #18 did not have an open date. LVN A stated she used both pen in the morning. She stated she forgot to check if there was an open date on the pens. LVN A stated the purpose for putting an open date was for expiration purposes because the insulin was only good for 28 days. 2- Record review of Resident #54's Comprehensive MDS, dated [DATE], revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, elevated blood pressure, and hyperlipidemia (too many lipids and fats in the blood). He had a BIMS score of 10 indicating her cognition was cognitively moderately impaired. Record review of Resident #54's physician's orders dated January 2024 revealed an order for Lantus Solostar U-100 insulin 100 unit/ml (3ml) subcutaneous pen (insulin glargine, human recombinant analog) 45 units subcutaneous at bedtime. Observation on 01/23/2024 at 3:15 PM revealed the 400-hall nurse's medication cart had a pen of Lantus Solostar U-100 insulin 100 unit/ml (3ml), did not have an opened date. Interview on 01/23/2024 at 3:17 PM, LVN B stated the pen of insulin belong to Resident #54 did not have an open date. LVN B stated he did not give the insulin yet because it was due at bedtime. LVN B stated he did not know when the pen was opened and he stated the nurse who opened the pen supposed to put the open date, because the insulin was good only for 28 days after it was opened. LVN B stated the risk would be giving ineffective insulin to resident. Interview on 01/24/24 at 12:20 PM, the DON stated the insulin flex pens, once opened, needed to be dated because each insulin pen had a 30 or 40 days shelf life and if not thrown out before that time the insulin could lose its effectiveness. The DON stated the Assisted DON and the DON were supposed to do random check of the medication carts for monitoring. Record review of the facility's policy titled Storage of Medication, dated September 2018, revealed in part .12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used.

Based on observation, interview and record review, the facility failed to provide food with appetizing temperature for one (01/24/24 breakfast) of one meal reviewed for appetizing temperature. The facility failed to serve eggs and oatmeal that had a palatable texture during the breakfast meal on 01/24/24. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: Review of Resident #7's quarterly MDS assessment dated [DATE] reflected Resident #7 was an [AGE] year old female admitted to the facility on [DATE]. Resident #7 had a BIMS of 9 indicating she was moderately cognitively impaired. Interview on 01/23/24 at 9:25 AM with Resident #7 revealed breakfast was late today and her eggs were cold. She stated hall trays get served last if they chose to eat in their rooms. Review of Resident #10's quarterly MDS dated [DATE] reflected Resident #10 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #10 had a BIMS of 11 indicating he was moderately cognitively impaired. Interview on 01/23/24 at 12:17 PM with Resident #10 revealed his food was cold for his meals and eggs were cold at breakfast for his meals. He stated he ate in his room for meals and ate in his room. Observation on 01/24/24 at 8:10 AM reveal breakfast trays for secure unit were brought to secure unit by Dietary Aide. Observation on 01/24/24 at 8:12 AM revealed Resident #86 was sleeping in her room lying down. Observation on 01/24/24 at 9:12 AM revealed Resident #86 was sleeping in her room lying down. Observation on 01/24/24 at 9:15 AM revealed dining room breakfast trays for secure unit were being put on cart after breakfast in dining room and staff assisted residents out of secure unit after breakfast. Observation and Interview on 01/24/24 at 9:16 AM revealed MA M was in Resident #86's room feeding Resident #86 with head of bed elevated. MA A stated she had just started feeding Resident #86 her eggs and was on vegetarian diet. She had eggs and toast on her breakfast plate. MA A stated Resident #86 was sleeping so she waited to assist her after done in dining room with other residents. She stated Resident #86 would grab and eat other residents' food so she feed her in her room. MA M stated the eggs were barely warm. Observation on 01/24/24 at 9:22 AM revealed facility staff passing out hall breakfast trays to residents on 600 hall and test tray was on cart. Observation at 9:31 AM revealed last hall tray was served to resident room [ROOM NUMBER]. Observation on 01/24/24 at 9:33 AM of breakfast test tray revealed plate had cover and oatmeal was covered with plastic lid. Test tray revealed eggs were cold to touch and tasted cold. Test tray revealed oatmeal was covered with plastic lid with no steam and tasted cold. Follow-up interview with Resident #7 on 01/24/24 at 9:46 AM revealed her breakfast was usually cold. She further stated her eggs this morning were cold and would have liked them warmer. She stated she ate her breakfast in her room for meals. Confidential group interview with six of six residents on 01/24/24 at 10:00 AM revealed breakfast was cold. One of the residents in group stated the eggs were cold this morning. Record Review of Resident Council Minutes for the November 2023, December 2023 and January 2024 did not mention about cold food. Interview on 01/24/24 at 9:42 AM with the Dietary Manager revealed he expected breakfast to be served to residents warm. He stated the eggs and oatmeal should not be cold when served. He stated hall trays were the last to be served for meals. He stated secure unit got their meal trays first, then dining room and last were hall trays for the nonsecure unit halls. The Dietary Manager stated he was aware of Resident #10 complaining of cold breakfast food. Review of facility's policy Hot and Cold Food Temperatures dated 08/01/18 reflected The temperatures of the food items will be managed to conserve maximum nutritive value and flavor .All hot food items must be served to the resident at a palatable temperature.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one (Resident #5) of eight residents reviewed for ADLs. The facility failed to ensure Resident #5 had her fingernails cleaned and trimmed. This failure could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings include: Record review of Resident #5's quarterly MDS assessment, dated 01/11/24, reflected a [AGE] year-old female with an admitted [DATE]. Resident # 5 was unable to participate in the brief interview for mental status and staff had assessed her to be severely cognitively impaired. Resident #5 was dependent for all ADLs and had no history of refusing care. Active diagnoses included cerebral vascular accident (stroke), hemiplegia (paralysis), heart failure and dementia. Record review of Resident #5's comprehensive care plan reviewed and continued 12/05/23, reflected, .[Resident #5] has a self-care deficit in all Activities of Daily living. Requires total staff performance of ADLS's due to .Contractures to bilateral hands, knees, and shoulders .Interventions .Total assist with dressing, grooming hygiene, and bathing . Record review if Resident #5's ADL Flow Sheet for 01/01/24 through 01/22/24 reflected resident had received a bath on the evening shift on Mondays, Wednesday, and Fridays. Observed Resident #5 on 01/23/24 at 10:00 a.m. lying in bed. Both hands were drawn up in a fist. Both hands noted with long thumb nails approximately 1/2 inch long. Resident appeared to understand questions but cannot vocalize response. Resident #5 was unable to open hands. In an interview with CNA I on 01/24/24 at 11:00 a.m. she stated they were responsible for trimming residents' nails on bath days. She stated Resident #5 was a 2p.m.-10 p.m. bath on Monday, Wednesday and Friday's. She stated she had not noticed Resident #5's nails. In an interview CNA K and CNA J on 01/24/24 at 2:45 p.m. both staff stated they were not providing nail care to Resident #5 because someone else was assigned to nail care. CNA J stated they did Resident #5's bed bath on Monday, Wednesday, and Friday, but not her nail care. CNA J did not know who was assigned to do the nail care. In an observation and interview with RN H on 01/24/24 at 2:50 p.m. at Resident #5's bedside, she stated Resident #5's nails needed to be trimmed. She stated the facility in the past had assigned one staff member to do nail care unless the resident was diabetic, but stated she was not sure who it was. RN J inspected Resident #5's hands revealing some nails on her left were shorter but were dirty with dark gray substance under them. Both thumb nails were over 1/2 inch in length. She stated with the resident's contractures her nails needed to be kept short and clean to prevent skin breakdown. In an interview with LVN G on 01/24/24 at 03:05 p.m. he stated the CNAs were responsible for trimming residents' nails, unless they were diabetic. He stated Resident #5 was not diabetic, but with her hand contractures it might be difficult for the CNAs to trim her nails. He stated the Medical Records clerk use to trim resident's nails but stated she had not done that since the first of January 2024. In an Interview with the Medical Records clerk on 01/24/24 at 03:10 p.m. she stated nail care was done on the resident's scheduled shower days. She stated she was a floor CNA and recently became the medical records clerk. She stated she used to trim the majority of the residents' nails. She stated she had not done that since the end of December 2023. She stated would highlight a resident list and give it to the nurse on any residents she had trimmed nails. She stated she could see where it got miscommunicated. She stated she had trimmed Resident #5's nails in the past but could not remember when she had trimmed them last. She stated Resident #5's hands were very contracted. Interview with the DON on 01/24/24 at 03:30 p.m. she stated it was the CNAs responsibility to make sure residents nails were trimmed and clean. She stated it was done on the resident's shower days. She stated she would make sure the staff were aware of their responsibility. She stated failing to keep resident's nails trimmed and clean could cause skin scratches, risk of infections, and someone with contractures could cause skin breakdown. Review of facility's policy Bathing, dated January 2023 reflected, Staff will provide bathing services for residents within standard practice guidelines .Perform hand hygiene and perform nail care .

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #5) of three residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #5's contracture to her right and left hands after discharge from occupational therapy on 11/13/23. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record review of Resident #5's quarterly MDS assessment, dated 01/11/24, reflected a [AGE] year-old female with an admitted [DATE]. Resident # 5 was unable to participate in the brief interview for mental status and staff had assessed her to be severely cognitively impaired. The Resident had lower extremity impairment on both sides. Resident #5 was dependent for all ADLs and had no history of refusing care. Resident #5 had not received OT or PT services in the seven days look back period. Resident #5 had not received restorative care, splints, or braces. Active diagnoses included cerebral vascular accident (stroke), hemiplegia (paralysis), heart failure and dementia. Record review of Resident #5's comprehensive care plan reviewed and continued 12/05/23, reflected, .[Resident #5] has limited Range of Motion of all extremities .Interventions included .Assess contracted area/areas with decreased ROM for evidence of skin breakdown: report significant changes to MD .Use devises, appliances, splints, or positioning pillows as indicated. Hand rolls placed to bilateral hands . Record Review of Occupational Therapy Discharge Summary dated 11/14/23 reflected, .Dates of Services: 10/16/23-11/13/23 .Short-Term Goals .Patient will safely wear a hand roll and-or a palmar guard on bilateral hands for up to 4 hours w/minimal signs and symptoms of redness, swelling, discomfort or pain .Previous tolerance 10/28/23 .3 hours Discharge .11/13/23 .5 hours Assessment and Summary of Skilled Services Prognosis to Maintain current level of function- Excellent with consistent staff support . Record review of Resident #5's Electronic Medical Record reflected a nursing restorative plan initiated on 11/16/22 for 6 weeks. No record found indicting restorative continued beyond the initial 6-week period. Record review of Resident #5's Consolidated Physician orders, dated 01/24/23 reflected, .Occupation Therapy services 3-5x/week for 1 week with emphasis on Upper extremity therapeutic exercise. Therapeutic activities, Modalities, and Patient/caregiver education . with a start date of 01/23/24. An observation of Resident #5 on 01/23/24 10:00 a.m. revealed both hands drawn into a fist. Resident #5 was unable to open hands or move fingers. Thumb nails on both hands were approximately 1/2 inches long. Unable to view other nails. No hand splints or hand rolls in place. In an interview with CNA J on 01/23/24 at 12:15 p.m. she stated Resident #5 used to have a ball like splint that therapy placed in her hands but stated she had not seen it for several months. She stated the residents' hands were awfully hard to open. In an interview with LVN G on 01/23/24 at 1:30 p.m. he stated therapy had been placing splints in Resident #5's hands. He stated he had never had an order for nursing to place splints in her hands. He stated they had placed washcloths in her hands in the past. He stated he thought she was under therapy services at this time. In an interview with the DOR on 01/23/24 at 02:10 p.m. she stated they had put Resident #5 on physical therapy for her legs and hips around the first of January. She stated the resident was on their contracture management list and they did quarterly screenings on her. She stated the previous date of service for Resident #5 was 10/16/23 through 11/13/23 with Occupational therapy and that was for the contractures to her hands. She stated she was not sure if the resident was put on restorative after she was discharged in November, she stated the OT would probably know. In an interview with OTR D on 01/23/24 at 02:20 p.m. he stated when he discharged Resident #5 from therapy in November 2023, he met with the MDS nurse, and the restoratives aide about the residents ongoing needs and he thought they were adding her to restorative. He stated he was splinting both hands and was doing stretching when he saw her in October and November last year. In an Interview with MDS F on 01/23/24 at 02:25 p.m. she stated she provided oversight for the restorative program. She stated Resident #5 had not been on restorative since 2022. She stated Resident #5 was currently on Physical therapy services. She stated she did not recall having a conversation with OTR D about placing the resident on restorative in November 2023. She stated they only had one Restorative aide and could only care 9-10 residents at a time. She stated they could assign application of splints and range of motion to the nursing staff. She stated therapy used to send written restorative plans when they were discharging residents and the resident needed restorative, but they had stopped doing that. She stated now they just discussed it during stand-up meetings. She stated failing to provide ongoing range of motion and splinting could cause a decline in the resident's range of motion and worsening of her contractures. In an Interview with PTA C 01/23/24 at 02:35 a.m. he stated he evaluated Resident #5 and picked her up on physical therapy services. He sated he seen her for decreased mobility to her lower extremities but stated due to the progression of her hand contractures her had started splinting her hands. He stated they had rapidly progressed from her previous round of therapy. He stated he had started her on stretches and splinting to get her back to her previous level. In an interview with the Restorative Aide on 01/23/24 at 2:40 p.m. she stated she had worked in the position of Restorative Aide for about 6 months. She stated Resident #5 had never been assigned to her for restorative services. She stated she recalled having a conversation with therapy and the MDS nurse about putting her on restorative but stated she had never been assigned to her. In a follow up interview with the DOR on 01/23/24 at 02:45 p.m., she stated she and the MDS nurse communicate daily and review upcoming quarterly screenings and residents who will be coming off therapy services. She stated they only had one Restorative aide that worked Monday through Friday. She stated if they had a resident who required ongoing splinting or range of motion, she would request nursing to write the order so it could be continued, and they could monitor the resident's skin. She stated she was not sure what happened with Resident #5, and stated they just dropped the ball. She stated by not having her splinting and stretching continued it could cause a decline and worsening of the residents' contractures. In a follow up interview with OTR D on 01/24/24 at 8:45 a.m. her stated he re-evaluated Resident #5 on 01/23/24 and had placed her on occupational therapy for her hand contractures. He stated he had placed hand rolls in both hands yesterday and she was able to tolerate them for 4 hours. He stated they would be educating the nursing staff on her ongoing needs when he discharged her from therapy. Record review of the Occupation Therapy Evaluation and Plan of treatment dated 01/23/24 reflected, .Clinical Impression: Patient was fitted with bilateral hand rolls and was able to tolerate donning orthosis for 4 hours without signs of redness and discomfort. Bilateral palm protector/palm guard will be ordered, and a restorative nursing program will be implemented with emphasis on proper orthotic fitting and schedule .Skilled OT services are warranted to design and implement Restorative Nursing Program . In an interview with the DON on 01/24/24 at 08:50 a.m. she stated Resident #5 should have been picked up by nursing services for range of motion and splinting when she was discontinued from therapy services in November 2023. She stated therapy just needed to let her know what the ongoing needs were going to be. She stated failing to have interventions in place for residents with limited range of motion could lead to worsening of a resident's contractures and decline in function. Review of the facility's policy titled, Screening, Rehabilitation, dated April 2012, reflected, .Any patient/resident identified by the interdisciplinary team, as requiring a rehabilitation scree will have the screening initiate by a Physical, Occupation Therapist or Assistant, or Speech Language Pathologist withing 48 hours of notification of the request and quarterly A patient /resident is referred for a rehabilitation screen in response to any of the following .Contracture risks or splinting needs .Decline in ROM .A rehab screen is a hands-off' process by which the therapist reviews the medical record, observes the patient/resident, and interviews the patient/resident, caregivers, interdisciplinary team, and/or family to identify the patient's /resident's prior level of function, expectations for return of function and discharge plan .The screening process requires no more than 10 to 15 minutes of the therapist time .The outcome of the screen may be to proceed with a request for a physician's order to evaluate . Review of the facility's policy titled, Quality of Life Rounds Procedures,' dated May 7, 2017, reflected, To identify all therapy/restorative appropriate changes in condition of residents and provide medically necessary services as indicate to ensure the highest practical level of care for each resident .The facility will first ensure that current systems are in place for addressing changes in condition .Any residents identified with decline in ADL . will be referred to Therapy for screening .A team including a MDS, Charge Nurse, CNA, Restorative Aide and Therapy Representative assigned to cover each hall of the nursing facility will be established .The teams will make rounds .complete the quarterly joint mobility screens ( Nursing) and screen resident (Therapy). Changes noted on the mobility screen, declines identified by staff, or triggers noted on Quality Measures will be documented (by charge nurse) and resident will be referred for a therapy eval .Residents identified in the morning meeting to have changes in condition . or other related conditions will be referred to therapy via the Nursing to Therapy communication form .It will be the responsibility of the Restorative Aide9s) to maintain restorative plans and CNASs may perform the maintenance programs The DON or MDS Nurse will be designated as a liaison to the restorative program to insure resident's plans are appropriate . Review of the facility's policy titled, Joint Mobility, Splints, and Range of Motion, dated February 2020, reflected, Standard of Practice: The nursing staff will assist the resident with activities of daily living regarding joint mobility, splinting and range of motion using restorative and rehabilitative care techniques .

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for two (Resident #17, Resident #72) of eight Residents reviewed for accidents/hazards/supervision/ devices. The facility failed to properly maintain wheelchairs for Residents #17 and Resident# 72. This failures could affect the resident by placing the residents at risk for discomfort, pain, and injuries. Resident #17 Record review of Resident #17's quarterly MDS assessment dated [DATE] revealed resident was a [AGE] year-old female with an admitted [DATE]. Resident #17 had a BIMS score of 9 indicating moderate cognitive impairment. Resident #17 required 2-person assistance with transfers, and she used a manual wheelchair for mobility. Resident #17 had an active diagnosis of Non-Traumatic Brain Dysfunction (injury to the brain), End-Stage Renal Disease (kidney failure), Muscle weakness, type 2 diabetes mellitus with diabetic nephropathy (Deterioration of kidney function due to high blood sugar). Record review of Resident #17's care plan dated 03/16/2023 revealed Resident #17 had muscular weakness, 03/19/2023 care plan revealed Resident #17 was a fall risk, 12/26/2023 care plan revealed Resident #17 was at risk for skin breakdown. An interview and observation with Resident #17 on 01/23/2024 at 09:56 AM revealed resident was sitting on her wheelchair in her room. Resident complained that the right wheel of her wheelchair was hard to move. Resident stated this was affecting her mobility since it was hard for her to wheel the wheelchair. Resident stated she had reported this issue to a staff member some time back and it was fixed. Resident stated she reported the current problem to a staff (she could not remember the name or title of that staff member) few days ago but nobody came to fix it. It was observed the right arm rest of the wheelchair was touching the right wheel while resident was seated in her wheelchair. Resident #72 Record Review of Resident #72' quarterly MDS assessment dated [DATE] revealed resident was a [AGE] year old male with an admitted [DATE]. Resident #72 had a primary diagnosis of unspecified Dementia, Congestive Heart Failure, diabetes mellitus. Resident has a BIMS score of 9 indicating moderate cognitive impairment. Resident #72 was a one person assist with transfers and bed mobility. Record Review of Resident #72's care plan dated 12/23/23 revealed resident was wheelchair was wheelchair dependent for ambulation. Care Plan dated 12/26/23 revealed resident was a fall risk. An interview and observation of Resident #72 on 12/25/2024 at 02:40 PM revealed Resident #72 was sitting on his wheelchair in his room. Resident #72's stated both arm rests of the wheelchair were torn and exposed. Resident #72 stated the maintenance Director was aware of the issue and he was waiting on parts to arrive to replace the arm rests. Resident #17 stated the maintenance director noticed he issue few weeks ago. The interview with CNA L on 01/24/2024 at 11:27 AM, he stated he was not aware of Resident #17 and Resident #72's wheelchair related problems. CNA L stated every staff member of the facility was expected to report to the charge nurse and enter in the maintenance log located in the nurse's station, when they saw or heard about an issue related to resident's wheelchairs. CNA L stated if a wheelchair was not repaired in a timely manner, it may cause accidents, skin tear to the resident. The interview with CNA M on 01/24/2024 at 11:38 AM, she stated she was not aware of Resident #17 and Resident #72's wheelchair related problems. CNA M stated if she was aware of the problems related to the resident's wheelchair, she would report it to the charge nurse, report it to the maintenance director and in the maintenance log located in the nurses station. The maintenance director checks the maintenance log every day and address any concerns reported to him. CNA M stated a resident can get hurt if a wheelchair was not maintained properly. The interview with ADON E on 01/24/24 11:46, he stated he was not aware the wheelchair issues to Resident #17 and Resident #72. ADON E stated if he learned about a wheelchair issue, he would send a group text via group Me, which could be seen by the maintenance director, DON, Administrator. He would also report it in the maintenance log located in all the nurses' stations. ADON E stated if a wheelchair was not well maintained, it could cause fall risk, affects a resident's free movement and skin tear. The interview with LVN N on 01/24/24 12:21 PM, she stated she was not aware of Resident #17 and Resident #72's issues with their wheelchair. LVN N stated Resident #17 had an issue with her wheelchair around a month ago, her wheelchair arm rest was raised and the issue was resolved. LVN N stated the current wheelchair issues related to Resident #17 and Resident #72 were not reported in the maintenance log. LVN N stated if she knew about the wheelchair issue, she would have reported in the maintenance log, so that the maintenance director would see it when he checked the maintenance log daily. LVN N stated the issues related to resident's wheelchair could cause fall, skin tear, mobility impairment to the residents. The interview with maintenance director on 01/2/2024 at 12:28 PM revealed he was not aware of the current issues with the wheelchairs of Resident #17, he learned about Resident #72's wheelchair arm rest issue few weeks ago when he was doing a routine check and he ordered the parts for it but he could not fix the arm rest since he has not received the parts yet. He stated he had informed the resident the reason for the delay in getting the parts for replacement. Maintenance director stated he checked the maintenance log at the nurses station every day and he did not see any reports about Resident #17's wheelchair issue. He stated a wheelchair which was not maintained could cause fall risk, mobility impairment, skin tear to the resident. Interview with the DON on 01/24/24 at 02:21 PM revealed she was not aware of Resident #17 and Resident #72's wheelchair issues. The DON stated Therapy department and Maintenance department share the responsibility for wheelchairs. The DON stated Maintenance orders parts for the wheelchairs. Therapy department evaluate, repair and order new wheelchairs. The DON stated there was no specific system in place for reporting the issues with wheelchair to therapy. All staff can report to the charge nurse or to therapy if they see or hear a concern about the wheelchair via text message or verbally. The DON stated she was not aware of any maintenance log available at the nurse's station to log wheelchair related issues. The DON stated residents are at risk for fall, skin tear, mobility issues if a wheelchair was not repaired or maintained properly. The interview with the Administrator on 01/25/2024 at 10:55 AM revealed all the staff were responsible to immediately report an issue with a resident's wheelchair in the maintenance log located in the nurses' stations. She stated all the staff had access to the maintenance director's phone number and the staff are expected to report any serious concern regarding a resident's wheelchair to the maintenance director immediately. She stated there were extra wheelchairs available at the facility and if a damage was reported, the resident could get a replacement wheelchair. The Administrator stated the Maintenance director was responsible for repairing and maintaining the wheelchairs. She stated a wheelchair which was not maintained properly could cause fall risk, injury, mobility impairment, skin tear to a resident. Record review of the maintenance log located in nurses' station at the 300 hall and 400 hall revealed Resident #17 and Resident #72's wheelchair related issues were not reported. Record review of the facility's Resident General Equipment Cleaning policy with a review date of 02/20/2023 revealed Resident's general equipment will be cleaned on a routine basis in accordance with manufacturer's specifications and guidelines. Facility will check equipment weekly or as needed, General equipment may include wheelchairs.

Based on observation, interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (Resident #7) of four residents reviewed for behavioral health services. The Social Worker failed to follow up to ensure Resident #7 received a psychiatric service after a referral was made on 11/02/23. This failure could place residents at risk for not receiving behavioral health services and a decline in Quality of life. Findings Included: Record review of Resident #7 quarterly MDS assessment dated [DATE] reflected an [AGE] year-old female with an admitted [DATE]. Resident #7 had a BIMS of 9 which indicated she was moderately cognitively impaired. There were no behaviors, signs of delusions or rejection of care noted on the assessment. Resident #7 had active diagnosis which included Alzheimer's, dementia with unspecified severe psychotic disturbance (suggestive of mental or emotion unsoundness or instability) and depression. Record review of Resident #7's care plan with an onset date of 11/27/23 reflected, .History of Dementia with behaviors .History of being hostile towards roommate at other Long term care facility prior to admitting to this facility .History of Alzheimer's with psychotic disturbance .Behavioral aggression, Anger, Verbally abusive, Socially inappropriate, frustration, poor judgement and history of yanking curtains, cursing at others prior to admitting to the facility .Interventions .Frequent visual checks .Maintain behavior log .Referral to psychiatry/psychology services .remove resident from immediate situation to assure safety . Record Review of Resident #7's Consolidated physician orders dated 01/24/24 reflected resident was taking 75 mg of Seroquel ( antipsychotic) 1 tablet twice a day and Amitriptyline (antidepressant) 50 mg 1 tablet at bedtime. Resident #7 was taking both medications upon admission on 10/31/23. Record review of Resident #7's Behavior Monitoring log from 11/01/23 through 01/23/24 reflected the facility was monitoring for hallucinations. No hallucinations were reported on day of monitoring. Record review of the Social Workers progress noted dated 11/02/23 reflected, SW made a psych referral to [psychiatric services] due to diagnosis of Anxiety, Alzheimer's, Dementia with psychotic disturbance .delusions and being hostile toward her roommate at the previous facility she was at. SW received consent from residents [family member] to receive psych services SW will continue to follow up as needed . Record review of Resident #7's electronic medical record did not reflect a psychiatric assessment or progress notes. In an observation on 01/23/24 at 9:25 a.m. revealed Resident #7 in her room eating her breakfast. No complaints at that time. In an interview with the Social Worker on 01/24/24 at 1:05 p.m. she stated she had made a referral to the facility's psychiatric services. She stated she assumed Resident #7 was receiving psychiatric services. The social worker presented a fax cover sheet to the psychiatric services dated 11/02/23 and it was confirmed as sent. The Social Worker stated she had not followed up with the psychiatric provided and stated she had never followed up after making a referral. She stated she would reach out to them to see when they saw the resident. In an interview with the DON 01/24/24 at 01:23 p.m. she stated Resident #7 was admitted from another facility and was already on Seroquel. She stated the resident had also received services from psychiatric services at her pervious facility and the same psychiatric provider would also be following her here. She stated the Social Worker was responsible for making the referral when the resident admitted to the facility. In a follow up with the Social Worker on 01/24/24 at 01:40 p.m. she stated she contacted the psychiatric provider, and they stated they never received the referral. She stated she had never followed up after making a referral, she just sent them. She stated she was not sure who was responsible for following up when referrals were made. She stated she never spoke with the psychiatric provider and had no idea which resident's they were seeing when they came to the facility. In an interview with the Administrator 01/24/24 at 02:00 p.m. she revealed it was the Social Workers responsibility to follow up on any ancillary service referred. She stated they would put a system in place where referrals made were checked off when the ancillary service came and provided the services. She stated not following up could cause a delay in care and services to the residents. In an interview with the DON 01/24/24 at 02:05 p.m. she stated the Social Worker was responsible for making the referral to the psychiatric provider and following up to ensure the services had been provided. She stated failing to do this causes a delay in the resident receiving necessary services and a possible mental decline and helps determine if the resident is on the proper medications. In an interview with Resident #7's family member on 01/24/23 at 3:54 p.m. she stated the facility had requested her consent for psychiatric services with Resident #7 admitted to the facility. She stated she consented and stated the resident had been on those services at the previous facility. She stated the resident had been treated for depression for several years. She stated she wanted the Resident to have these services if would help with depression and dementia. Record review of the facility's policy titled, Behavior Management- Social Service Referral, dated February 2020, reflected, Standards of Practice: The staff will make social services referrals as deemed appropriate when the resident's behavioral incident and/or accident pattern increases .

Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance to maintain proper hydration and health for one (Resident #1 ) of thirteen residents reviewed for nutritional status. The facility failed to: Ensure Resident #1 maintained proper nutrition and hydration, was assessed by the RD in a timely manner, and interventions were implemented when Resident #1 had significant weight loss and a change in mental status from his admission on [DATE] until he was sent to the hospital on [DATE]. These failures resulted in Resident #1 being hospitalized from [DATE] until [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His labs at the hospital on [DATE] were BUN 62, Creatinine 2.49. These failures places residents at risk of receiving insufficient nutrition and /or hydration which could result in dehydration, malnutrition, hospitalization , and/or death. An IJ was identified on [DATE] at 4:16 PM. The DON and the ADM were notified, the IJ template was provided, and the POR was requested. While the IJ was removed on [DATE] at 4:50 PM, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal (POR). Findings included: Review of Resident #1 ' s face sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 ' s undated hospital records reflected he was hospitalized from [DATE] until [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His dementia was initially diagnosed in theER on [DATE] when he was seen for worsening cognitive function, recent confusion, and wandering from home. His labs on [DATE] showed a BUN of 19 (normal range ,d+[DATE]) and a Creatinine of 1.11 (normal range 0.,d+[DATE].3 for men and 0.,d+[DATE].1 women). In an interview on [DATE] at 2:07 PM, Resident #1 ' s RP stated she was also Resident #1 ' s DPOA and MPOA. She said Resident #1 was admitted to the facility ' s memory care unit on [DATE]. She said Resident #1 was walking and talking when we moved him, and when he declined very fast. She said she kept reporting to the facility Resident #1 ' s decline in his feeding, his memory, [and] his falls. RP #11 said MD I was Resident #1 ' s attending physician initially but stated, we never saw him. RP #11 said when Resident #1 returned from the hospital on [DATE], she was adamant we needed to get off of [MD I ' s] service. [Resident #1] he lost 20 lbs. in 3 weeks. I saw [Resident #1] severely malnourished. I sensed [Resident #1] had a [CONDITION(S)] and it took them 5 days to perform the test and 8 days to get him on antibiotics. RP #11 stated she notified facility staff regarding her concerns about Resident #1 ' s weight loss including: DON A, ADON B, and LVN C. RP #11 said after a second hospitalization after a fall on [DATE] Resident #1 was placed on hospice and expired on [DATE]. RP #11 described the following series of events for Resident #1: [DATE]- RP #11 alerted staff that Resident #1 had lost weight and was still refusing to eat. Resident #1 claimed he ' s going to vomit, took one bite of food and spit it out. [DATE]- Resident #1 lost 8 pounds in 14 days weighing 172 pounds. RP #11 alerted the nursing home about the weight concern. [DATE]- Resident #1 moved from the memory care unit to 400 hall. He was alert, walking on his own, eating some, and seemed pleased with move. [DATE]- Resident #1 fell around 5 am. LVN F called at 6 AM to inform family. Said doctor would be notified and test would be performed to make sure nothing was broke. RP #11 requested a UA be done to evaluate for a [CONDITION(S)]. [DATE]- RP #11 visits and notices Resident #1 was struggling to urinate and refusing to eat. Family again requests status of UA. [DATE]- Nurse said she tried to retrieve specimen and Resident #11 refused. [DATE]- Nurse retrieved UA sample. Resident #1 weighed in at 164 pounds. RP #11 notified the facility of weight loss of 16 pounds in 3 weeks. [DATE] to [DATE]- Resident #1 not eating and refusing food. He was unable to take calls and extremely confused. [DATE]- Resident #1 started on antibiotics for [CONDITION(S)]. [DATE]- RP #11 visited Resident #1 at wound 4PM. She found him slumped over in bed. Very confused and very weak. He was too weak to stand. Tried feeding Resident #1 dinner, after 1 bite, patient begins chocking and vomits. Staff was called in. Resident #1 said food made him sick and has difficulty swallowing. Speech pathologist came in and said she would speak with staff over concerns of not eating and concerns of weight loss. Nurse also mentioned he had been on medication to help with appetite. RP #11 said she shared concerns that Resident #1 was still not eating. Nurse stated she would speak with doctor. Review of Resident #1 ' s nurses ' notes reflected: a. [DATE] 1:17 PM- RN D documented Resident #1 refused to eat, drink fluids, drink medicine and to be changed. NP K and RP #1 were notified. Resident #1 ate 75% of lunch and was seen by NP K. b. [DATE]- RN D documented Resident #1 ate a late breakfast and refused to eat lunch. c. [DATE]- RN D reviewed that Resident #1 had refused breakfast and lunch. d. [DATE] at 2:17, a late entry from [DATE]- RN D documented Resident #1 was still in bed and did not like to get up to eat breakfast. Medication was not given and delegated to incoming nurse. Resident #1 drank fluids given. e. [DATE] 9:12 PM- LVN M documented Resident #1 had nausea and vomiting after eating dinner. NP K was notified and gave a new order for [MEDICATION(S)] and [MEDICATION(S)] PRN and a CBC/CMP on Monday ([DATE]). [MEDICATION(S)] was given and was effective. f. [DATE] at 1:58 PM- RN D documented Resident #1 was alert and verbally responsive. He ate 1 patty for breakfast and a Glucerna brought by family. Resident #1 was not compliant with drinking fluids. NP K was informed and gave a telephone order for [MEDICATION(S)] 7.5mg every night for depression and to stimulate appetite. ADON obtained order from NP K for Boost Glucose Control 1 can three times a day. CBC and BMP results were pending. g. [DATE] at 1:41 PM- RN D documented Resident #1 would be transferred to another unit in the morning ([DATE]). Resident #1 drank fluids and NP K reviewed the labs with no new orders given. h. [DATE] at 1:27 PM- RN D documented Resident #1 are his breakfast at the dining room. Fluids and Boost were given and taken well by Resident #1. Resident #1 was transferred to a room in the 400s hall, walking, with RP #11. i. [DATE] at 6:55 AM- LVN F documented she was notified by a CNA that Resident #1 was on the floor. MD was notified via NP, DON A was notified, and RP #1 was notified via a voicemail. Neurological checks were initiated. j. [DATE] at 10:33 AM- LVN G documented she called the doctor ' s office and left a message on his voicemail to relay RP #11 ' s request for a UA to be done on Resident #1. k. [DATE] at 7:06 AM- LVN F documented she called the doctor to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 refused to have urine collected and this was communicated with the incoming nurse. l. [DATE] at 4:26 AM- LVN F documented a second attempt to collect urine for a UA was unsuccessful as Resident #1 was combative and refused to be catheterized or to void in urine hat. m. [DATE] at 11:37 AM- LVN H documented Resident #1 was in bed all morning, accepted morning medications with a sip of Ensure (nutritional drink), and declined eating or drinking any other beverages. She received preliminary UA results those were called out to NP K who gave orders to wait for culture and sensitivity. n. [DATE] at 1:04 PM- LVN H documented she received Resident #1 ' s urine culture results, notified NP K who gave orders for [MEDICATION(S)] (antibiotic) for 5 days. o. [DATE] at 10:58 AM- LVN H documented Resident #1 continued lying listless in bed, declining all food, hydration, and care. No effect was noted from the [MEDICATION(S)]. MD was notified and gave a new order for [MEDICATION(S)] (appetite stimulant), CBC, and CMP. p. [DATE] at 9:41 AM- LVN H documented Resident #1 was very weak that morning and continued to decline eating and drinking. She tried to offer him Ensure with his medications and he took one sip and started projectile vomiting. MD was notified and gave orders to send Resident #1 to the ER for further evaluation and treatment. Review if Resident #1 ' s labs on [DATE] reflected the following: WBC 7.5 (normal 3.,d+[DATE].2), BUN 33 (normal ,d+[DATE]), Creatinine 2.00 (normal 0.,d+[DATE].30). Review of Resident #1 ' s meal and fluid intake report dated [DATE] reflected: a. [DATE]- refused dinner, [DATE]- nothing documented for dinner, [DATE]- refused lunch, [DATE]- nothing documented for dinner, [DATE]- refused breakfast and lunch, ate 25% of dinner, [DATE]- refused breakfast and lunch, nothing documented for dinner, [DATE]- refused lunch, [DATE]- nothing documented for dinner, [DATE]- refused dinner. Review of Resident #1 ' s meal and fluid intake report dated [DATE] reflected: a. No food or fluid intake was documented on [DATE], [DATE], [DATE], and [DATE] for breakfast, lunch or dinner. b. [DATE]- nothing was documented for breakfast or lunch, refused dinner. 120mL fluid intake for the day documented. c. [DATE]- nothing was documented for breakfast or lunch, ate 75% of dinner. 240mL fluid intake for the day documented. d. [DATE]- nothing was documented for breakfast or lunch, ate 50% of dinner. 240mL fluid intake for the day documented. e. [DATE]- ate 25% of breakfast and lunch, ate 75% of dinner. 5040mL fluid intake for the day documented. f. [DATE]- refused breakfast, ate 50% of lunch, ate 75% of dinner. 1460mL fluid intake for the day documented. g. [DATE]- nothing was documented for breakfast or lunch, ate 100% of dinner. 240mL fluid intake for the day documented. h. [DATE]- ate 100% of breakfast, ate 100% of lunch, refused dinner. 480mL fluid intake for the day documented. i. [DATE]- nothing was documented for breakfast or lunch, ate 25% of dinner. 100mL fluid intake for the day documented. Review if Resident #1 ' s weight record, dated [DATE], reflected the following weights: a. [DATE] at 3:32 PM- 180 lbs. b. [DATE] at 1:13 PM- 172.6 lbs. c. [DATE] at 2:32 PM- 173 lbs. d. [DATE] at 3:51 PM- 164 lbs. Review of Resident #1 hospital report dated [DATE] reflected he was seen at theER on [DATE] for gradual onset of weakness of lower extremities, recent [CONDITION(S)], significantly decreased appetite and weight loss (16 lbs. in one month). The MD in the ER document Resident #1 was ill-appearing. He was diagnosed with failure to thrive (state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity), suspected persistent [CONDITION(S)]/failed outpatient antibiotics, acute [CONDITION(S)] (sudden and reversible alteration of mental status due to systemic factors), dehydration, acute kidney injury (kidneys suddenly stop working properly. It can range from minor loss of kidney function to complete kidney failure), and severe protein calorie malnutrition. His labs at the hospital on [DATE] were WBC 10.7 (normal 3.,d+[DATE].2), BUN 62 (normal ,d+[DATE]), and creatinine 2.49 (normal 0.,d+[DATE].30). Resident #1 was treated with IV fluids and IV antibiotics while in the hospital. On [DATE], Resident #1 ' s labs at the hospital had improved to BUN 26 and Creatinine 1.52. Resident #1 was discharged back to the facility on [DATE]. In an interview on 08 /,d+[DATE] at 3:10 PM, MD J said he was the facility ' s medical director and had worked at the facility for one month. MD J said Resident #1 should have been treated with IV fluids in [DATE] when his labs on [DATE] showed his was BUN increasing and he had oral intake refusals. In an interview on [DATE] at 11:57 AM, MD I said Resident #1 had advanced dementia and initially his appetite was ok, but then it was picked up that he was not eating well. MD I said NP K added [MEDICATION(S)] (appetite stimulant), did labs, added nutritional drinks, consulted psychiatry who increased [MEDICATION(S)], added [MEDICATION(S)] as an appetite stimulate and placed a dietitian consult to make suggestions. MD I said IV fluids should have been considered because Resident #1 ' s labs on [DATE] showed a slightly increased creatinine of 2.0. MD I and NP K put in a note that he ordered labs and would re-check in 1 week. MD I said most of the notes by NP K stated, nurses are to call me with any change or deterioration. MD I said he expected nurses to call him if the interventions for Resident #1 were not effective and his appetite was not increased. MD I said he believed Resident #1 was sent to the hospital on [DATE] because he had a mental status change. MD I said the facility had his contact information and he did not receive any calls from the facility regarding Resident #1 from [DATE] to [DATE]. In an interview on [DATE] at 12:14 PM, NP K said he was he cared for Resident #1 at the facility from [DATE] to [DATE]. He said he did not recall being notified of Resident #1 ' s weight loss but did recall Resident #1 had poor appetite which was believed to be due to a [CONDITION(S)]. NP K said he gave LVN an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP K said he gave the order to send Resident #1 to the hospital on [DATE] and would have send Resident #1 to the hospital if he would have known [Resident #1] had neurological shift. NP K said he did not believe IV fluids were considered for Resident #1 because by the time they need IV fluids [he would] just send them to the hospital. NP K said he asked the nurses if Resident #1 looked sick enough to go to the hospital. In an interview on [DATE] at 3:29 PM, RP #11 said there was never a discussion regarding IV fluids for Resident #1 from [DATE] until [DATE]. She said the facility staff were to offer a Boost (nutritional drink) nut they never offered that. RP #11 said she notified they facility that it did not appear the Boost was effective, and she was told, by LVN F and ADON B, that they would tell the doctor about her concerns. In an interview with RN D, on [DATE] at 12:25 PM, she said she only contact NP K when calling about Resident #1. She stated NP K ordered nutritional supplements, and every time Resident #1 did not eat, she notified NP K and RP #11. RN D said it was the CNAs responsibility to monitor Resident #1 ' s oral intake and documented every shift. She said CNAs were responsible for taking the weights for the residents monthly. RN D said new admission residents and residents with weight loss would be weighed weekly based on the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on [DATE] at 12:31 PM, LVN H said she documented a nursing note for Resident #1 on [DATE] because there was a concern about his weight loss because he was not eating. LVN H said she and the CNAs would have to sit with him and try to get him to eat. LVN H said on [DATE], Resident #1 was weak, not responding to verbal prompts, and would not open his mouth or eyes. LVN H said Resident #1 would say leave me alone with a physical prompt. LVN H said she never spoke with MD I, only NP K. She said when she documented that the MD was notified in her notes for Resident #1, it meant she contacted NP K. LVN H said she made attempts to call MD I, but he would not answer his telephone or return calls with messages. She said only NP K would answer the telephone. LVN H said IV fluids could be and have been done at the facility but there must be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In a follow-up interview [DATE] at 9:28AM, LVN H said it was her expectation for CNAs to document intake in the POC and on the diet slips, and she expected the CNAs to notify her of meals refusals as soon as the resident refuses. LVN H said Resident #1 had poor appetite in [DATE] and she remembered notifying DON A, RP #11, and the doctor. She said Resident #1 was tried on [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] which were appetite stimulant but there was not change in his appetite. LVN H said the aides notified her that Resident #1 was not eating, and she went in, tried to feed him, and he refused, pushed her hand away and closed his eyes. She stated she asked him if he wanted an alternative and he said no. LVN H said Resident #1 ' s family was with him all the time. During interview on [DATE] at 9:28AM, LVN H said when Resident #1 expired he was on hospice, and he was on hospice because of his decline and failure to thrive. In an interview on [DATE] at 2:51 PM, CNA E said he worked at the facility in the memory care unit for over 1 year. He said he was assigned to Resident #1 while he was in the memory care unit. He said Resident #1 was very depressed, and did not want to come out of his room. He was able to feed himself. Sometimes he wouldn't eat, he was very depressed. CNA E said he would know how much Resident #1 ate at each meal when he picked up the meal tray at the end of each mealtime by looking at the amount of food and liquid left on his plate. CNA E said that sometimes his meal intake documentation for residents was not accurate because sometimes he forgot, but he tried to make it as accurate as possible. CNA E said when Resident #1 did not eat, he would notify RN D. CNA A said when a resident had weight loss, first he would re-weigh them and if the loss was 2 to 3 lbs., he would tell the nurse. CNA E said newly admitted residents were weighed weekly for 6 weeks. CNA E said Resident #1 was losing weight when he was in the memory care unit, and he told RN D. CNA E said Resident #1 wanted to go home and did not want to be at the facility. He said Resident #1 would be angry, and sometimes he refused to take a bath. CNA E said he would wait for RP #11 to arrive to the facility to help with Resident #1. He said RP #11 would visit Resident #1 at least 2 times per week. In an interview on [DATE] at 1:55 PM, DON stated documentation gaps in Resident #1 ' s intake records on [DATE], [DATE],[DATE] and [DATE] meant there was no documentation, not necessarily that he was not fed. DON stated the process is for CNA to document all meal intake or refusal in the system. DON stated nurses were supposed to be monitoring to ensure CNA complete task in computer including meal intake. In an interview on [DATE] at 10:52 AM, RD L said she had worked for the facility as a consultant. She said she was at the facility at least once per week. RD L said she was at the facility on [DATE] and completed the nutritional assessment for Resident #1 since a consult was ordered. RD L said she had not previously completed a nutritional assessment for Resident #1. RD L said she observed Resident #1 but did not remember nor did she document what he looked like because that was not her focus at that time. She said Resident #1 had poor intake and her main focus was to review how he was eating and his weight status. She said Resident #1 was not eating very well and she was unable to gather information from Resident #1 because he had dementia and the majority of the information she obtained for her assessment was from the facility ' s nursing staff. RD L said she did not speak with RP #11 as part of her assessment and said she was not responsible for contacting the RPs. RD L said she did not observe Resident #1 eating as part of her nutritional assessment, but it was reported by nursing staff that he needed assistance with eating. RD L said given [Resident #1 ' s] weight at the time ([DATE]) she did not have any weight concerns at that point. RD L said she reviewed Resident #1 ' s weight from [DATE] as 172.6 lbs. and [DATE] as 173 lbs., and Resident #1 ' s weight had been stable for one week. RD L said she reviewed all of Resident #1 ' s weights. She said because Resident #1 had a weight increase from [DATE] to [DATE], he did not trigger on the weekly weights reports for significant weight loss. RD L said when she assessed Resident #1 on [DATE], she ran the weight report for the entire facility for the previous 7 days, so the weight from [DATE] would not have been captured. RD L said she attempted to see Resident #1 on [DATE] based on the weight from [DATE] of 164lbs., but he went to the hospital, and she assessed him when he returned. RD L said she did not know if the weight loss from [DATE] to [DATE] from 180lbs. to 173lbs. would have been considered a significant weight loss. RD L said she did not make any new recommendations for Resident #1 on her assessment because Boost and [MEDICATION(S)] were already ordered. RD L said when a resident had significant weight loss, she normally observed them eating. When asked if she should have observed Resident #1 eating as part of her assessment, she stated, not necessarily, because nursing staff could provide her with the information. RD Stated DON and her, communicate either verbally via text or email about residents losing weight. In a follow-up interview on [DATE] at 3:06 PM, RD L said she could not say for sure if Resident #1 ' s nutrition assessment was started within 72 hours of admission/re-admission per the facility ' s policy. RD L said Resident #1 ' s first nutrition assessment was started on and completed on [DATE] and she did not know why the assessment was not started within 72 hours per the facility ' s policy. In an interview on [DATE] at 2:07 PM, CNA P said he had worked at the facility for 4 years. CNA P said he weighed residents monthly. His co-workers and the staffing coordinator also obtained resident weights. CNA P stated he gave the weights to the staffing coordinator and the nurses, and they documented in the EHR. CNA P said he was not able to see the weights for the residents and it was hard for him to track weights. CNA P said he obtained weights weekly and daily when instructed by a nurse. CNA P said each resident ' s oral intake was documented in the POC and any blank in POC meant the CNA did not document, which would mean the resident did not eat. CNA P stated it was important to document intake so it could be tracked if a resident was not eating well. Review of the facility ' s Matrix for Providers report dated [DATE] reflected Residents #2, #7, and #4 were identified as having Excessive Weight Loss [without] Prescribed Weight Loss Program. Review of the facility form titled, Weight Losses dated [DATE], which was submitted at evidence of the POR implementation reflected the facility identified the following significant weight loss: Review of the facility ' s policy, titled Weight Monitoring, dated [DATE], reflected: Resident weights will be recorded and monitored at a minimum frequency of monthly . Nursing weighs residents within twenty-four (24) hours of admission and re-admission . Newly admitted residents are weighed upon admission and weekly for 4 and then monthly thereafter, unless otherwise indicated by physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The date of such notification is documented in the nurses notes in the EHR The Registered Dietitian reviews the resident ' s nutritional status and makes recommendations for intervention in the nutritional therapy assessment if significant weight change is noted . Significant, unplanned changes in weights are reviewed at the Standards of Care Committee meeting. The Committee will also identify any gradual weight loss trends . Unplanned and undesired weight variance will be evaluated for significance utilizing the Resident Assessment Instrument Guidelines. Suggested guidelines are as followed: 5% in thirty (30) days . 7.5% in ninety (90) days . 10% in one hundred-eighty (180) days . Review of the facility ' s policy on oral hydration dated [DATE] revealed residents would be provided significant fluid intake to maintain proper hydration in accordance with standard guidelines. Residents were to be offered ,d+[DATE] ounces of fluid t during and in between meals and during activities unless contraindicated. Review of the facility ' s policy on oral supplement dated [DATE] revealed resident who needed additional calories or protein as determined through the nutrition plan process, may be served a suitable oral supplement. Review of the facility ' s policy titled Hydration, dated [DATE], revealed residents at risk for dehydration would be identified, assessed and provided with sufficient fluids intake to encourage adequate hydration. Review of the facility ' s policy titled Documentation, dated [DATE], revealed documentation of the clinical assessment of the resident would be recorded in accordance with state specific regulations, other regulatory bodies as indicated and the practice guidelines in EHR. . The DON and the ADM were notified on [DATE] at 4:50 PM an IJ was identified. The IJ template was provided, and the POR was requested. The POR was accepted [DATE] at 4:50 PM and reflected: [Facility Name] [DATE] PLAN OF REMOVAL F692- The facility failed to ensure Resident #1 maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance. [DATE] Facility will assess residents with significant unplanned change in weight, hydration, or nutritional status immediately when identified within 24 hours. Audit of residents with unplanned weight change had no negative outcome and is documented on the weight change notification form by DON. [DATE] Facility reviewed residents that had lab (CMP) drawn since [DATE]-to [DATE] to ensure notification were documented and completed with new interventions if indicated (interventions and outcomes are documented on each lab report reviewed with no negative outcomes and is documented on the lab report by DON). (Interventions will include- Per Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [DATE] (VPCO)-Vice President of Clinical Services educated DON/ADONs-on notifying residents 'physician when there is a significant change in residents ' physical status and requires a need to alter treatment. Also, on importance of documenting refusal of care, meal intake or oral hydration in nurses 'notes. This education will include explaining need for ADL care, meal intake and oral hydration to patient with potential complications of refusal of ADL care, meals, or hydration. Additionally, involve any family members or staff who may assist in getting resident to comply with ADLs care, meal intake and oral hydration. Additionally, on importance of immediate notification of physician & documentation on 24-hour report if patient refuses adl care, meals, or hydration. VPCO educated on the importance of immediate notification of abnormal labs to physician so that the facility can ensure timely interventions per MD order. To monitor resident weights weekly during standards of care meeting by Interdisciplinary Team (IDT) to ensure timely interventions and referrals are immediate initiated with prompt notification to physician. The facility shall coordinate a care conference with resident, responsible party, physician, and IDT to discuss the positive and negative consequences refusal and an alternate treatment or intervention, if indicated- The immediate notification will be completed within 24 hours of facility being notified of a significant change and will be documented in residents Electronic Health Record (EHR). The DON/ADON will monitor for compliance and will document findings on the monitoring tool. The Administrator will ensure that the monitoring is taking place. [DATE] All nurses to be educated by DON/ADON prior to their next shift on the importance of nutrition and hydration assessment and Dietary referral with immediate intervention [DATE]-on going All nurses will be educated verbally by DON / ADON prior to their next shift on importance of documenting refusal of care, meal intake or oral hydration in nurses notes. This education will include explaining need for ADL care, meal intake and oral hydration to patient with potential complications of refusal of ADL care, meals, or hydration. Additionally, involve any family members or staff who may assist in getting resident to comply with adl care, meal intake and oral hydration. [DATE]-on going All nurses will be educated verbally by DON / ADON prior to their next shift on importance of immediate notification of MD & documentation on 24-hour report if patient refuses adl care, meals, or hydration (factors that reflect individuals ' nutritional status is adequate, relative to his or her overall condition and prognosis). The immediate notification will be completed within 24 hours of facility being notified of a significant change and will be documented in residents Electronic Health Record (EHR). The DON/ADON will monitor for compliance and will document findings on the monitoring tool. The Administrator will ensure that the monitoring is taking place. [DATE]-on going In response to questions ,d+[DATE] Vice President of Nutrition Services will education RD on nutrition assessment timeline [DATE]-on going Regional Dietician will observe residents with significant weight loss during weekly scheduled visits. [DATE]-on going The RD will gather subjective data to use during the nutrition assessment and plan of care process. The [NAME] President of Nutrition Services will educate the RD on this process. [DATE]-on going Vice President of Nutrition Services will educate the RD on contacting the RP/DPOA/MPOA if resident is an unreliable source for baseline background information. [DATE]-on going RD will monitor weights on scheduled weekly visits and communicate with the Interdisciplinary Team (IDT) to ensure timely interventions and referrals are promptly initiated. [DATE]-on going RD has assessed all residents timely. RD assess new admission and readmission and as indicated if weight loss occurs and documented in nutrition tab of (EHR). [DATE]-on going Morning meeting will include monitoring of meal percentages per ADL alerts daily during morning meeting to ensure that the meal intake is documented accurately. DON/ADON will monitor meal percentage documentation each shift and will document monitoring on monitoring tool. [DATE]-on going Charge nurse will notify physician upon receipt of lab results and if new order received will document in nursing note and 24-hour report if critical lab values are resulted will complete a change in condition, Charge nurse will notify resident/ RP of lab results and any new orders have received. DON/ADON will monitoring daily during morning meeting and document results on monitoring tool. [DATE]-on going DON/ADON will educate CNAs on the importance of documenting intake and the importance of accurate documentation on intake. DON/ADON will educate CNAs on the impor [TRUNCATED]

Based on interview and record review, the facility failed to immediately consult with the resident 's physician when there was a significant change in the resident 's physical status and a need to alter treatment significantly for one (Resident #1) of thirteen residents reviewed for notification of changes. The facility failed to immediately consult with Resident #1 's physician when he had significant weight loss and a change in mental status from his admission on [DATE] until he was sent to the hospital on [DATE] which resulted in Resident #1 being hospitalized from [DATE] until [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His labs at the hospital on [DATE] were BUN 62, Creatinine 2.49. These failures could place residents at risk for a delay in treament and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An IJ was identified on [DATE] at 7:37 PM. While the IJ was removed on [DATE] at 4:50 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal (POR). Findings included: Review of Resident #1 ' s face sheet reflected he was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 ' s undated hospital records reflected he was hospitalized from [DATE] until [DATE]. Further review reflected his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His dementia was initially diagnosed in theER on [DATE] when he was seen for worsening cognitive function, recent confusion, and wandering from home. His labs on [DATE] showed a BUN of 19 (normal ,d+[DATE]) and a Creatinine of 1.11 (normal 0.,d+[DATE].30). In an interview on [DATE] at 2:07 PM, Resident #1 ' s RP stated she was also Resident #1 ' s DPOA and MPOA. She said Resident #1 was admitted to the facility ' s memory care unit on [DATE] and he was walking and talking when [she] moved him, and when he declined very fast. RP #11 said she reported to the facility Resident #1 ' s decline in his feeding, his memory, [and] his falls. RP #11 said MD I was Resident #1 ' s attending physician initially but stated, we never saw [MD I]. RP #11 said when Resident #1 returned from the hospital on [DATE], she was adamant [they] needed to get off of [MD I ' s] service. [Resident #1] lost 20 lbs. in 3 weeks. I saw [Resident #1] severely malnourished. I sensed [Resident #1] had a [CONDITION(S)] and it took them 5 days to perform the test and 8 days to get him on antibiotics. RP #11 stated she notified facility staff regarding her concerns about Resident #1 ' s weight loss, including notification to DON A, ADON B, and LVN C. RP #11 said after a second hospitalization after a fall on [DATE], Resident #1 was placed on hospice and expired on [DATE]. RP #11 described the following series of events for Resident #1: [DATE]- RP #11 alerted staff that Resident #1 had lost weight and was still refusing to eat. Resident #1 claimed he ' s going to vomit, took one bite of food and spit it out. [DATE]- Resident #1 lost 8 pounds in 14 days weighing 172 pounds. RP #11 alerted the nursing home about the weight concern. [DATE]- Resident #1 moved from the memory care unit to the 400 hall. He was alert, walking on his own, eating some, and seemed pleased with move. [DATE]- Resident #1 fell around 5 AM. LVN F called at 6 AM to inform family and said doctor would be notified and test would be performed to make sure nothing was broken. RP #11 requested a UA be done to evaluate for a [CONDITION(S)]. [DATE]- RP #11 visited and noticed Resident #1 was struggling to urinate and refusing to eat. Family again requested status of UA. [DATE]- LVN F said she tried to retrieve urine specimen and Resident #11 refused. [DATE]- Nurse retrieved UA sample. Resident #1 weighed in at 164 pounds. RP #11 notified the facility of weight loss of 16 pounds in 3 weeks. [DATE] to [DATE]- Resident #1 was not eating and refusing food. He was unable to take calls and extremely confused. [DATE]- Resident #1 was started on antibiotics for [CONDITION(S)]. [DATE]- RP #11 visited Resident #1 at around 4PM. She found him slumped over in bed. Very confused and very weak. He was too weak to stand. She tried feeding Resident #1 dinner, after 1 bite, Resident #1 began choking and vomited. Staff were called in and Resident #1 said food made him sick and had difficulty swallowing. Speech pathologist came in and said she would speak with staff over concerns of Resident #1 not eating and concerns of weight loss. Nurse also mentioned Resident #1 had been on medication to help with appetite. RP #11 said she shared concerns that Resident #1 was still not eating. Nurse stated she would speak with doctor. Review of Resident #1 ' s nurses ' notes reflected: [DATE] 1:17 PM- RN D documented Resident #1 refused to eat, drink fluids, drink medicine and to be changed. NP K and RP #1 were notified. Resident #1 ate 75% of lunch and was seen by NP K. [DATE]- RN D documented Resident #1 ate a late breakfast and refused to eat lunch. [DATE]- RN D documented she reviewed CNA POC charting documenting that Resident #1 had refused breakfast and lunch. [DATE] at 2:17, a late entry from [DATE]- RN D documented Resident #1 was still in bed and did not like to get up to eat breakfast. Medication was not given and delegated to incoming nurse. Resident #1 drank fluids given. [DATE] 9:12 PM- LVN M documented Resident #1 had nausea and vomiting after eating dinner. NP K was notified and gave a new order for [MEDICATION(S)] (anti-nausea medication) and [MEDICATION(S)] (anti-hypertension medication) PRN and a CBC/CMP on Monday ([DATE]). [MEDICATION(S)] was given and was effective. [DATE] at 1:58 PM- RN D documented Resident #1 was alert and verbally responsive. He ate 1 patty for breakfast and a Glucerna (nutritional drink) brought by his family. Resident #1 was not compliant with drinking fluids. NP K was informed and gave a telephone order for [MEDICATION(S)] 7.5mg every night for depression and to stimulate appetite. ADON obtained order from NP K for Boost Glucose Control (nutritional drink) 1 can three times a day. CBC and BMP results were pending. [DATE] at 1:41 PM- RN D documented Resident #1 would be transferred to another unit in the morning ([DATE]). Resident #1 drank fluids and NP K reviewed the labs with no new orders given. [DATE] at 1:27 PM- RN D documented Resident #1 ate his breakfast in the dining room. Fluids and Boost were given and taken well by Resident #1. Resident #1 was transferred to a room on the 400 hall, walking, with RP #11. [DATE] at 6:55 AM- LVN F documented she was notified by a CNA that Resident #1 was on the floor. MD was notified via NP, DON A was notified, and RP #1 was notified via a voicemail. Neurological checks were initiated. [DATE] at 10:33 AM- LVN G documented she called the doctor ' s office and left a message on his voicemail to relay RP #11 ' s request for a UA to be done on Resident #1. [DATE] at 7:06 AM- LVN F documented she called the doctor to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 refused to have urine collected and this was communicated with the incoming nurse. [DATE] at 4:26 AM- LVN F documented a second attempt to collect urine for a UA was unsuccessful as Resident #1 was combative and refused to be straight catheterized or to void in urine hat. [DATE] at 11:37 AM- LVN H documented Resident #1 was in bed all morning, accepted morning medications with a sip of Ensure (nutritional drink), and declined eating or drinking any other beverages. She received preliminary UA results, and those were called out to NP K who gave orders to wait for culture and sensitivity. [DATE] at 1:04 PM- LVN H documented she received Resident #1 ' s urine culture results and notified NP K who gave orders for [MEDICATION(S)] (antibiotic) for 5 days. [DATE] at 10:58 AM- LVN H documented Resident #1 continued lying listless in bed, declining all food, hydration, and care. No effect was noted from the [MEDICATION(S)]. MD was notified and gave a new order for [MEDICATION(S)] (appetite stimulant), CBC, and CMP. [DATE] at 9:41 AM- LVN H documented Resident #1 was very weak that morning and continued to decline eating and drinking. She tried to offer him Ensure with his medications and he took one sip and started projectile vomiting. MD was notified and gave orders to send Resident #1 to the ER for further evaluation and treatment. Review of Resident #1 ' s labs dated [DATE] reflected the following: WBC 7.5 (normal 3.,d+[DATE].2), BUN 33 (normal ,d+[DATE]), Creatinine 2.00 (normal 0.,d+[DATE].30). Review of Resident #1 ' s meal and fluid intake report printed [DATE] reflected: a. [DATE]- refused dinner, [DATE]- nothing documented for dinner, [DATE]- refused lunch, [DATE]- nothing documented for dinner, [DATE]- refused breakfast and lunch, ate 25% of dinner, [DATE]- refused breakfast and lunch, nothing documented for dinner, [DATE]- refused lunch, [DATE]- nothing documented for dinner, [DATE]- refused dinner. Review of Resident #1 ' s meal and fluid intake report printed [DATE] reflected: a. No food or fluid intake was documented on [DATE], [DATE], [DATE], and [DATE] for breakfast, lunch, or dinner. b. [DATE]- nothing was documented for breakfast or lunch, refused dinner. 120mL fluid intake for the day documented. c. [DATE]- nothing was documented for breakfast or lunch, ate 75% of dinner. 240mL fluid intake for the day documented. d. [DATE]- nothing was documented for breakfast or lunch, ate 50% of dinner. 240mL fluid intake for the day documented. e. [DATE]- ate 25% of breakfast and lunch, ate 75% of dinner. 5040mL fluid intake for the day documented. f. [DATE]- refused breakfast, ate 50% of lunch, ate 75% of dinner. 1460mL fluid intake for the day documented. g. [DATE]- nothing was documented for breakfast or lunch, ate 100% of dinner. 240mL fluid intake for the day documented. h. [DATE]- ate 100% of breakfast, ate 100% of lunch, refused dinner. 480mL fluid intake for the day documented. i. [DATE]- nothing was documented for breakfast or lunch, ate 25% of dinner. 100mL fluid intake for the day documented. In an interview on [DATE] at 1:55PM, DON N stated documentation gaps in Resident #1 ' s intake records on [DATE], [DATE],[DATE] and [DATE] meant there was no documentation, not necessarily that he was not fed. Review of Resident #1 ' s weight record, printed [DATE], reflected the following weights: a. [DATE] at 3:32 PM- 180 lbs. b. [DATE] at 1:13 PM- 172.6 lbs. c. [DATE] at 2:32 PM- 173 lbs. d. [DATE] at 3:51 PM- 164 lbs. Review of Resident #1 ' s e-MAR from [DATE] to [DATE] reflected he was given: [MEDICATION(S)] 7.5mg at bedtime from [DATE] until [DATE] [MEDICATION(S)] 15mg at bedtime on [DATE] [MEDICATION(S)] 2.5mg once on [DATE] and [DATE] Boost Glucose control 1 can three times a day: once on [DATE] and three times a day on [DATE] through [DATE]. Resident did not receive the Boost once on [DATE], [DATE], an [DATE] and the reason was not indicated. Review of Resident #1 hospital report dated [DATE] reflected he was seen in theER on [DATE] for gradual onset of weakness of lower extremities, recent [CONDITION(S)], significantly decreased appetite and weight loss (16 lbs. in one month). The MD in the ER document Resident #1 was ill-appearing. He was diagnosed with failure to thrive (state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity), suspected persistent [CONDITION(S)]/failed outpatient antibiotics, acute [CONDITION(S)] (sudden and reversible alteration of mental status due to systemic factors), dehydration, acute kidney injury (kidneys suddenly stop working properly. It can range from minor loss of kidney function to complete kidney failure), and severe protein calorie malnutrition. His labs at the hospital on [DATE] were WBC 10.7 (normal 3.,d+[DATE].2), BUN 62 (normal ,d+[DATE]), and creatinine 2.49 (normal 0.,d+[DATE].30). Resident #1 was treated with IV fluids and IV antibiotics while in the hospital. On [DATE], Resident #1 ' s labs at the hospital had improved to BUN 26 and Creatinine 1.52. Resident #1 was discharged back to the facility on [DATE]. In an interview on 08 /,d+[DATE] at 3:10 PM, MD J said he was the facility ' s medical director and had worked at the facility for one month. MD J said Resident #1 should have been treated with IV fluids when his labs on [DATE] showed his was BUN increasing and he had oral intake refusals. He Stated resident was under the care of his primary provider. In an interview on [DATE] at 11:57 AM, MD I said Resident #1 had advanced dementia and initially his appetite was ok, but then it was picked up that he was not eating well. MD I said NP K added [MEDICATION(S)] (appetite stimulant), did labs, added nutritional drinks, consulted psychiatry who increased [MEDICATION(S)], added [MEDICATION(S)] as an appetite stimulate and placed a dietitian consult to make suggestions. MD I said NP K should have considered IV fluids because Resident #1 ' s labs on [DATE] showed a slightly increased creatinine of 2.0. MD I said NP K put in a note that he ordered labs and would re-check labs in 1 week. MD I said most of the notes by NP K stated, nurses are to call me with any change or deterioration. MD I said he expected NP K to call him if the interventions for Resident #1 were not effective and his appetite was not increased. MD I said he believed Resident #1 was sent to the hospital on [DATE] because he had a mental status change. MD I said the facility had his contact information and he did not receive any calls from the facility regarding Resident #1 from [DATE] to [DATE]. NP K sees residents for MD I In an interview on [DATE] at 12:14 PM, NP K said he provided care services for Resident #1 at the facility from [DATE] to [DATE]. He said he did not recall being notified of Resident #1 ' s weight loss but did recall Resident #1 had poor appetite which was believed to be due to a [CONDITION(S)]. NP K said he gave LVN H an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP K said he gave the order to send Resident #1 to the hospital on [DATE] and would have sent Resident #1 to the hospital if he would have known [Resident #1] had neurological shift. NP K said he did not believe IV fluids were considered for Resident #1 because by the time they need IV fluids [he would] just send them to the hospital. NP K said he asked the nurses if Resident #1 looked sick enough to go to the hospital. In an interview on [DATE] at 3:29 PM, RP #11 said there was never a discussion regarding IV fluids for Resident #1 from [DATE] until [DATE]. She said the facility staff were to offer a Boost (nutritional drink) but they never offered that. RP #11 said she notified they facility that it did not appear the Boost was effective, and she was told, by LVN F and ADON B, that they would tell the doctor about her concerns. In an interview with RN D, on [DATE] at 12:25 PM, she said she only contacted NP K when calling about Resident #1. She stated NP K ordered nutritional supplements, and every time Resident #1 did not eat, she notified NP K and RP #11. RN D said it was the CNAs responsibility to monitor Resident #1 ' s oral intake and documented every shift. She said CNAs were responsible for taking the weights for the residents monthly. RN D said newly admitted residents and residents with weight loss should be weighed weekly or based on the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on [DATE] at 12:31 PM, LVN H said she documented a nursing note for Resident #1 on [DATE] because there was a concern about his weight loss because he was not eating. LVN H said she and the CNAs would have to sit with him and try to get him to eat. LVN H said on [DATE], Resident #1 was weak, not responding to verbal prompts, and would not open his mouth or eyes. LVN H said Resident #1 would say leave me alone with physical prompts. LVN H said she never spoke with MD I, only NP K. LVN H said when she documented the MD was notified in her notes for Resident #1, it meant she contacted NP K. NP K works under MD I and should be notifying MD I, of what is going on with his resident at the facility. LVN H said she made attempts to call MD I, but he would not answer his telephone or return calls with messages. She said only NP K would answer the telephone. LVN H said IV fluids could be done at the facility but there must be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] In a follow-up interview on [DATE] at 9:28AM, LVN H said it was her expectation for CNAs to document intake in the POC and on the diet slips, and she expected the CNAs to notify her of meal refusals as soon as the resident refused. LVN H said Resident #1 had poor appetite in [DATE] and she remembered notifying DON A, RP #11, and the NP K on behalf of MD I. She said Resident #1 was tried on [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] which were appetite stimulant but there was not a change in his appetite. LVN H said the aides notified her that Resident #1 was not eating, and she went in, tried to feed him, and he refused, pushed her hand away and closed his eyes. She stated she asked him if he wanted an alternative and he said no. LVN H said Resident #1 ' s family was with him all the time. LVN H said when Resident #1 expired he was on hospice, and he was on hospice because of his decline and failure to thrive. In an interview on [DATE] at 11:03AM, CNA V said she worked with Resident #1 when he was on the 400 hall prior to his hospitalization on [DATE]. She said on admission to the 400 hall, Resident #1 could walk and stand up. Stated resident condition began to decline when he started refusing to eat. In an interview [DATE] at 3:22 PM, DON A said she worked at the facility form [DATE] to [DATE]. She said she recalled Resident #1 very well. She said she had several conversations with RP #11. DON A said, one of the problems with [Resident #1] was weight loss, [RP #11] told me he had lost a lot of weight. DON A said Resident #1 had dementia and was admitted to the memory care unit. She said he was isolating, shutting his door, refusing to eat and drink. DON A said, We contacted the doctor and they put him on supplements. [Resident #1] was, on his own, refusing food. DON A said she thought Resident #1 was very angry because he would refuse food [RP #11] would bring. He had significant behavioral issues. DON A said Resident #1 was moved out of the memory care unit thinking it would help, but he continued to have care refusals by nurses and CNAs. She said Resident #1 was challenging, he continued to lose weight and refused to eat with everything we tried. DON A said RP #11 was in her office in tears because of [Resident #1 ' s] refusals. She said RP #11 went to her office several times, in tears about she didn ' t know what else to do. DON A said she never personally spoke with Resident #1 ' s attending physician, MD I. DON A said the nurses called MD I and there were issues with him returning calls so they would call [NP K]. DON A said if a nurse had trouble getting ahold of a physician, she expected to be notified and she would reach out to the NP or his office to make sure the message got to him. DON A said the physician should be contacted, instead of a NP, when there was a critical situation, or if she did not think the NP was being appropriate or responding. DON A said she could not recall that NP K did anything that gave her a cause to believe he was not treating the residents accordingly. DON A said she only worked with [NP K] for maybe a month. DON A said the physician was the person that oversaw the residents ' care through the NP or the nurses on the floor. DON A said she thought they did as good a job as [they] could with [Resident #1] that was refusing to eat and drink, and he wouldn ' t accept supplements either. DON A said she did not know if anything else could have been done for Resident #1. DON A said when Resident #1 moved to the 400s hall, his refusals got more frequent. Review of the facility ' s policy titled, Change if Condition (Acute), dated [DATE], reflected: The nurse assigned to the resident or supervising the care of the resident is responsible for notification of and communication with the medical staff regarding significant changes or significant deterioration in the resident ' s condition and for assuring that there is a physician response. The primary goal of identifying Acute Changes of Condition (ACOCs) is to enable staff to evaluate and mange a patient at the community and avoid transfer to a hospital or emergency room (ER). To achieve this goal, the community ' s staff and practitioners must recognize an ACOC and identify its nature, severity, and cause(s). The practitioner needs a detailed description of the patient ' s condition to determine whether a symptom is problematic or simply a normal or expected variant . Care-giving staff should describe and document the nature, extent, and severity of symptoms, abnormalities, and condition changes clearly and in sufficient detail to help practitioners their potential causes and consequences . Immediate Notification: Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: a marked change (i.e. more severe) in relation to usual symptoms or signs, or unrelieved by measures already prescribed . As part of the interdisciplinary team, Certified Nursing Assistants (C.N.A. ' s) . are expected to report findings that might represent ACOC ' s . The nurse notifies the responsible physician utilizing the appropriate channels and chain of command. Notify the physicians in the following order unless otherwise indicated by physician order, by routine service, or as indicated by patient condition: a) Attending Physician b) Advanced Practice Registered Nurse (APRN) or c) As necessary, notify the nursing supervisor . d) The nursing supervisor (in hours) and nursing administrator (on call) will determine the need to initiate the following steps: a. Notification of the Medical Director . Document in the medical record the date, time and name of each physician notified, actions taken and/or patient ' s response to treatment . Review of policy and procedure titled Change of Shift Report dated [DATE] revealed staff would document and communicate necessary information to the oncoming shift in an organized manner in accordance with standard practice guidelines. Effective communication between the clinical staff during the change of shift was vital in order to ensure that safe quality and effective care in delivered. . The DON and the ADM were notified on [DATE] at 7:37 PM that an IJ was identified due to the above failures. The IJ template was provided, and the POR was requested. The POR was accepted [DATE] at 4:50 PM and reflected: [Facility Name] [DATE] PLAN OF REMOVAL F580 -The facility failed to immediately consult with a resident ' s physician when there was a significant change in the resident ' s physical status and a need to alter treatment significantly. DON/ADON will notify residents physician when there is a significant change in residents ' physical status and requires a need to alter treatment. Audit of residents with unplanned weight change had no negative outcome and is documented on the weight change notification form by DON. [DATE] Facility reviewed residents that had lab (CMP) drawn since [DATE]-to [DATE] to ensure notification were documented and completed with new interventions if indicated (interventions and outcomes are documented on each lab report reviewed with no negative outcomes and is documented on the lab report by DON) (Interventions will include- Per Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [DATE] (VPCO)-Vice President of Clinical Services educated DON/ADONs-on notifying residents ' physician when there is a significant change in residents ' physical status and requires a need to alter treatment. Also, on importance of documenting refusal of care, meal intake or oral hydration in nurses ' notes. This education will include explaining need for ADL care, meal intake and oral hydration to patient with potential complications of refusal of ADL care, meals, or hydration. Additionally, involve any family members or staff who may assist in getting resident to comply with ADLs care, meal intake and oral hydration. Additionally, on importance of immediate notification of physician & documentation on 24-hour report if patient refuses ADLs care, meals, or hydration. VPCO educated on the importance of immediate notification of abnormal labs to physician so that the facility can ensure timely interventions per MD order. To monitor resident weights weekly during standards of care meeting by Interdisciplinary Team (IDT) to ensure timely interventions and referrals are immediate initiated with prompt notification to physician. The facility shall coordinate a care conference with resident, responsible party, physician, and IDT to discuss the positive and negative consequences refusal and an alternate treatment or intervention, if indicated- The immediate notification will be completed within 24 hours of facility being notified of a significant change and will be documented in residents Electronic Health Record (EHR). The DON/ADON will monitor for compliance and will document findings on the monitoring tool. The Administrator will ensure that the monitoring is taking place. [DATE] All nurses to be educated by DON/ADON prior to their next shift on the importance of nutrition and hydration assessment and Dietary referral with immediate intervention. [DATE]-on going All nurses will be educated verbally by DON / ADON prior to their next shift on importance of documenting refusal of care, meal intake or oral hydration in nurses notes. This education will include explaining need for ADL care, meal intake and oral hydration to patient with potential complications of refusal of ADL care, meals, or hydration. Additionally, involve any family members or staff who may assist in getting resident to comply with adl care, meal intake and oral hydration. [DATE]-on going All nurses will be educated verbally by DON / ADON prior to their next shift on importance of immediate notification of MD & documentation on 24-hour report if patient refuses adl care, meals, or hydration (factors that reflect individuals ' nutritional status is adequate, relative to his or her overall condition and prognosis). The immediate notification will be completed within 24 hours of facility being notified of a significant change and will be documented in residents Electronic Health Record (EHR). The DON/ADON will monitor for compliance and will document findings on the monitoring tool. The Administrator will ensure that the monitoring is taking place. [DATE]-on going In response to questions ,d+[DATE] Vice President of Nutrition Services will education RD on nutrition assessment timeline [DATE]-on going Regional Dietician will observe residents with significant weight loss during weekly scheduled visits. [DATE]-on going The RD will gather subjective data to use during the nutrition assessment and plan of care process. The [NAME] President of Nutrition Services will educate the RD on this process. [DATE]-on going Vice President of Nutrition Services will educate the RD on contacting the RP/DPOA/MPOA if resident is an unreliable source for baseline background information. [DATE]-on going RD will monitor weights on scheduled weekly visits and communicate with the Interdisciplinary Team (IDT) to ensure timely interventions and referrals are promptly initiated. [DATE]-on going RD has assessed all residents timely. RD assess new admission and readmission and as indicated if weight loss occurs and documented in nutrition tab of (EHR). [DATE]-on going Morning meeting will include monitoring of meal percentages per ADL alerts daily during morning meeting to ensure that the meal intake is documented accurately. DON/ADON will monitor meal percentage documentation each shift and will document monitoring on monitoring tool. [DATE]-on going Charge nurse will notify physician upon receipt of lab results and if new order received will document in nursing note and 24-hour report if critical lab values are resulted will complete a change in condition, Charge nurse will notify resident/ RP of lab results and any new orders have received. DON/ADON will monitoring daily during morning meeting and document results on monitoring tool. [DATE]-on going DON/ADON will educate CNAs on the importance of documenting intake and the importance of accurate documentation on intake. DON/ADON will educate CNAs on the importance of reporting meal/fluid refusals to nurse. DON/ADON will monitor adl documentation during morning meeting daily and will record monitoring on monitoring tool. [DATE]-on going All nurses will be educated verbally by DON/ADON prior to their next shift on the importance of notification of abnormal labs to MD so that the facility can ensure timely interventions per MD order. The immediate notification will be completed within 24 hours of facility being notified of a significant change and will be documented in residents Electronic Health Record (EHR). The DON/ADON will monitor for compliance and will document findings on the monitoring tool. The Administrator will ensure that the monitoring is taking place. [DATE]-on going New nursing staff will be educated on these processes in clinical orientation upon hire and will include usage of agency staff prior to shift worked. [DATE]-on going Morning meeting will include monitoring of 24-hour report and nursing notes for meal percentages, refusals of care, refusal of meals, refusal of oral intake, refusal of lab, and to ensure documentation of timely notification to MD. [DATE]-on going Facility will monitor resident weights weekly during standards of care meeting by Interdisciplinary Team (IDT) to ensure timely interventions and referrals are promptly initiated. The immediate notification will be completed within 24 hours of facility being notified of a significant change and will be documented in residents Electronic Health Record (EHR). The DON/ADON will monitor for compliance and will document findings on the monitoring tool. The Administrator will ensure that the monitoring is taking place. [DATE]-on going Facility staff shall coordinate a care conference with resident, responsible party, physician, and IDT to discuss the positive and negative consequences refusal and an alternate treatment or intervention, if indicated[DATE]-on going DON/ADON/Charge Nurse will monitor compliance during morning meeting to include review of ADL alert (meal intake, beverage, and snacks) nursing notes, and 24-shift report. (Factors that reflect individuals ' nutritional status is adequate, relative to his or her overall condition and prognosis). [DATE]-on going Results will be reported to QAPI monthly x 3 months to ensure on-going compliance ,d+[DATE]/ [TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of 10 residents reviewed for infection control practice. The facility failed to isolate Resident #1 and implement contact isolation precautions when she was readmitted to the facility's memory care unit from the hospital instead of the facility's step-down unit with an unknown COVID-19 status. On 06/02/20 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/04/20, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility was provided with the IJ template on 06/02/20 at 4:35 PM. This failure placed residents at increased risk of exposure to COVID-19, which could result in illness, hospitalization , or even death. Findings included: Review of Resident #1's face sheet, dated 06/02/20, revealed the resident was a [AGE] year-old female readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #1's admission MDS (Minimum Data Set) assessment, dated 05/12/20, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 0 indicating the resident was cognitively impaired. The resident had a history of [REDACTED]. The resident also required extensive assistance with dressing, toileting, and personal hygiene. Review of Resident #1's Physician Orders, dated 06/01/20, revealed the resident was to be on contact isolation precautions for 14 days. Review of Resident #1's Nurse's Notes from LVN A, dated 06/01/20, revealed the resident was on contact isolation, but moved around the hall and was redirected to her room by staff. Review of Resident #1's Care Plan, dated 05/12/20, revealed the resident was at risk of signs/symptoms of COVID-19 and was unable to participate in social distancing or wearing a face mask when out of her room due to cognitive impairment. Interventions included following the facility's protocol for COVID-19 screening/precautions. Interview with the DON on 06/02/20 at 9:45 AM revealed Resident #1 had readmitted to the facility yesterday (06/01/20) in the evening time. She stated the resident was placed on the memory care unit with other residents. She said Resident #1 had not been tested for COVID-19 and was not showing any signs or symptoms at that time. The DON stated the facility's policy was to quarantine newly admitted residents and residents readmitting to the facility for 14 days on the Step-down Unit. She stated they decided not to follow the policy for residents requiring placement on the memory care unit because they were memory care . She said there was not dedicated staff to Resident #1 and that the staff were caring for Resident #1 and others on the memory care unit. Observation on 06/02/20 at 10:30 AM revealed Resident #1 was in her room on the memory care unit asleep. There were no signs posted inside or outside of the room indicating the resident was on isolation. There was no Personal Protective Equipment (PPE) observed near Resident #1's door, either inside or outside the room. Staff were observed wearing surgical masks and taking care of other residents in the memory care unit. Resident #1 did not have a roommate. An interview with LVN A on 06/02/20 at 10:45 AM revealed that she worked on the memory care unit and Resident #1 readmitted yesterday (06/01/20) from the hospital. She stated the resident was placed in a room on the memory care unit because she wandered often. She stated the resident was on isolation precautions, and staff were wearing gloves and a surgical mask while caring for her. She said staff should be wearing a gown and gloves when caring for the resident and there was one gown in the room. She said Resident #1 was up most of the night and needed constant redirection as she was out of her room often. She said they had tried to keep her in the room as much as possible but it was difficult. An interview with RN B on 06/02/20 at 11:00 AM revealed she worked on the memory care unit and Resident #1 readmitted yesterday (06/01/20) from the hospital. She stated the resident wandered a lot and was on the memory care unit for her wandering. She stated the resident was often out of her room and needed constant redirection although she was supposed to stay in her room. She stated that she was not assigned to that resident but knew she was supposed to be on contact isolation precautions. She said staff should have been wearing a gown and gloves when caring for the resident. An interview with CNA C on 06/02/20 at 4:07 PM revealed she worked on the memory care unit and that Resident #1 was readmitted yesterday (06/01/20) to the memory care unit. She said she was never told Resident #1 was supposed to be on isolation precautions. She said she knew Resident #1 was supposed to be placed on the Step-down Unit for 14 days upon readmission, but that was not what the facility was doing. She said that she was wearing a surgical mask and gloves to care for the resident. An interview with CNA D on 06/04/20 at 10:00 AM revealed she worked on the memory care unit and that Resident #1 was readmitted yesterday (06/01/20) to the memory care unit. She said she was not told the resident should have been on isolation precautions. She said she knew Resident #1 should have been on the Step-down Unit for 14 days because she returned from the hospital and could have been exposed to COVID-19. She said that she had spoken to the Administrator and DON about residents on the memory care unit returning and not being quarantined or isolated as they should have been. She said that she was told it was fine and that staff were educated on how to care for the readmitted residents. She said that they wore surgical masks and gloves when caring for the resident. She said that Resident #1 was hard to redirect and was often out of her room. An interview with the Administrator and DON on 06/02/20 at 11:30 AM revealed that Resident #1 was on the memory care unit with the other residents after readmitting yesterday (06/01/20). The Administrator and DON stated their policy was for all readmits and new admits to be quarantined for 14 days on their Step-down Unit. They stated the memory care unit residents were placed on the memory care unit and not on the Step-down unit for 14 days. They stated they did not have a separate area for isolation or dedicated staff for the residents on isolation on the memory care unit. They stated they planned to move Resident #1 from the memory care unit and place her on the Step-down Unit to be quarantined for 14 days with one-on-one care for redirection. The DON said that she knew the hospital where Resident #1 discharged from did not have any positive COVID-19 patients, so she did not think it was an issue. The DON stated that she followed up with the hospital to ensure they did not have any positive patients by calling them. The DON and Administrator said that they put general population admits/readmits and memory care new admits on the Step-down Unit for 14 days but did not use the same practice for memory care readmits. They stated that they had their staff wearing masks and using gloves and gowns to care for isolated residents. They stated that they did not have dedicated staff to the re-admits or new admits on the memory care unit. They stated that they expected staff to wear the items outside of the door for precautions and that staff were to review the orders for isolation. They stated that staff had not told them there was not PPE available, signs posted, or any wandering concerns from the resident. An interview with the Medical Director on 06/02/20 at 3:27 PM revealed that all residents that admitted or readmitted to the facility should be placed in the facility's Step-down Unit which was separated from all other residents and were quarantined for suspected COVID-19. He stated even memory care residents that met the admission/readmission criteria should also be quarantined from other memory care unit residents. Review of the facility's policy Coronavirus Management Plan Phase 2, undated, revealed Develop a 'Step-down Unit' for all new admits. This unit is for asymptomatic new admissions. New residents will stay in this unit for 14 days before being moved to the regular population. Review of the CDC's Guidance on Preparing for COVID-19 in Nursing Homes revealed: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown .placing the resident in a separate observation area so the resident can be monitored for evidence of COVID-19 .residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Accessed from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html titled An IJ was identified on 06/02/20, and the Administrator and DON were notified of the IJ. A plan of removal to remove the immediacy was requested on 06/02/2020 at 5:00 PM. The following plan of removal was accepted on 06/03/20 at 8:47 PM. The following is a plan of removal to the IJ called for the facility's alleged violation of Infection Control failure to create a plan for memory care unit re-admissions. o The Administrator, made the notification of IJ status to the Medical Director, on 06/02/2020 at 6:10 pm. The Medical Director is available to the team as needed. o Quality Assurance / Process Improvement meeting scheduled for 06/03/2020 at 9:00 am. o On 06/02/2020, the DON conducted an audit of re-admissions to (Facility name) for the past 14 days and identified three residents with recent re-admissions. All three of these residents were immediately moved on 06/02/20 to the step-down unit, and their respective representatives notified. The residents were moved, per facility's procedure, that all new and re-admissions are to be admitted to a step-down unit for 14 days of monitoring for signs and symptoms of COVID-19. Additionally, they will be monitored for change of condition, including signs of behavioral and emotional distress. o The findings of the audit noted the COVID-19 status of the three residents as follows: o Resident #1 re-admitted on [DATE] and was not tested in the acute care hospital due to not meeting criteria o Resident #2 re-admitted on [DATE] and tested negative for COVID-19 at the acute care hospital prior to admission to (Facility name) o Resident #3 re-admitted on [DATE] and was not tested in the acute care hospital o On 06/02/2020, the DON audited all physician orders [REDACTED]. The audit found that physician ordered isolation precautions needed to be initiated for the three residents listed above. Isolation precautions were initiated for the three respective residents on 06/02/2020. o The DON or designated nurse manager will audit new orders daily to identify residents with physician ordered transmission-based precautions. o Clinical staff will be trained on the plan created for re-admissions to the facility. The facilities plan is for all new and re-admissions to be admitted to a step-down unit for 14 days of monitoring for signs and symptoms of COVID-19. (DON) or designated nurse manager will review all admissions daily to assure proper placement. o Starting 06/03/2020 and ongoing all memory care re-admissions' COVID-19 status will be monitored, by the DON or designated nurse manager, through review of the Hospital to Post-Acute Care Facility Transfer-COVID-19 Assessment prior to admission to (Facility name). Beginning 06/02/20 and ending on 06/04/20, Clinical Staff, Management Staff, and Nursing Staff will be trained on Memory Care Resident Re-admission Plan. Beginning 06/02/20 and ending on 06/04/20, Licensed Nurses will be trained on Following Physician order [REDACTED].>Staff that have not been trained on the respective topics above, will be trained prior to returning to work. The Administrator will be responsible to monitor and ensure this staff is trained. Monitoring of the plan of removal included the following: Observations made on 06/03/2020 at 10:00 AM revealed that the three re-admits from the memory care unit had been placed on the step-down. Resident #1 was observed in a room on the step-down unit where staff were using gowns, gloves, and N95 masks to care for the residents. Isolation precaution signs were also posted on the door of Resident #1's room to alert staff as to what PPE was required prior to entering. Interviews were conducted on 06/04/20 from 9:00 AM to 3:00 PM with the following staff: the Administrator, the DON, the ADON, LVN A, RN B, CNA C, CNA D, CNA E, LVN F, CNA G, LVN H, LVN I, MA J, CNA K, CNA L, CNA M, LVN N, CNA O, MA P, LVN Q, CNA R, CNA S. These interviews with staff confirmed they had been in-serviced on all readmissions or new admissions to the facility. The staff revealed residents were to be placed on the Step-down Unit for 14 days to be monitored for signs and symptoms of COVID-19 . The staff also stated their understanding of contact precautions for newly admitted or readmitted residents. On 06/02/20 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/04/20, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review, the facility failed to notify the physician and family of a significant change in the resident's physical, mental, or psychosocial status for one (Resident #298) of six residents reviewed for change in condition. 1. LVN A failed to notify Resident #298's physician, DON, and family of a change in condition of respiratory status when the resident experienced an oxygen saturation of 64 percent and altered mental status at 12:00 A.M. on [DATE]. 2. LVN E failed to notify Resident #298's physician or the DON after the resident continued to experience low oxygen saturation on [DATE] until after surveyor intervention. As a result of the failures, Resident #298's physician and DON were unaware of the resident's status. The resident received inadequate treatment over the next seven and one-half hours before being sent to the hospital and ultimately expiring as a result of her acute illness on [DATE]. Resident #298 expired at 4:00p.m on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:13 P.M. While the IJ was removed on [DATE] at 1:42 P.M., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at the scope of isolated because the facility was still monitoring the plan of removal. These failures could affect residents by placing them at risk for delay in appropriate treatment, [MEDICAL CONDITION], and death. Findings included: Review of Resident #298's MDS assessment dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The resident was alert, with cognitive impairment, but able to comprehend and make her needs known. Review of Resident #298's baseline care plan dated [DATE] revealed: Resident #298 was at risk for altered breathing pattern related to ineffective respiratory status. Interventions included: Notify MD and family of any changes of conditions. Monitor lung sounds, pallor, cough, and character of sputum. Observation on [DATE] at 9:15 A.M. revealed Resident #298 in bed, lying on her back with the head of bed elevated and family member at the bedside. The resident was awake, alert, and conversing with her family member. The resident stated, yes, she was a painter and had painted the picture on her wall. The resident was observed without respiratory distress and no oxygen in use. The family member said the resident had a history of [REDACTED]. Review of Resident #298's physician's orders [REDACTED]. physician's orders [REDACTED]. Review of Resident #298's Medication Administration Record [REDACTED]. oxygen saturation check with a start date of [DATE]. [DATE]- day- oxygen saturation-97 percent. [DATE]- evening- oxygen saturation- 92 percent. [DATE]- day- oxygen saturation-94 percent. [DATE]- evening- oxygen saturation- 94 percent. Review of Resident #298's nurse's notes written by LVN A dated [DATE] at 12:00 A.M. revealed resident very congested with increased secretion suctioned several times, and oxygen saturation 64 percent, lips cyanosis, oxygen via nasal canula at 3liters started . There was no documentation of notification of the physician, DON, or the family. Acceptable range of oxygen saturation for adults is ninety five percent or greater as listed in Fundamentals of Nursing by Potter and Perry. Review of Resident #298's nurses notes dated [DATE] at 1:34 P.M. revealed LVN A documented, will continue to monitor. No other entries of the resident's respiratory condition being monitored were made for the next five-and one-half hours. At approximately 7:00 A.M, LVN E noted the resident was lethargic, opened eyes with verbal stimuli but closed them right back, with audible congestion, shallow breathing and an oxygen saturation of 88 percent with oxygen infusing at 3 liters. There was no documentation of notification of the physician, DON, or family. An interview with LVN A on [DATE] at 12:27 P.M. revealed on [DATE] at midnight, Resident #298 was confused, had shallow breathing, and her lips were blue with an oxygen saturation of 64 percent. She had a lot of secretions, and she was suctioned a couple of times. LVN A stated she did not notify the physician, DON, or family of the change of condition. She stated her reason for not calling the physician was because it was midnight, when asked why she did not notify the family, she stated, I don't do that, call the family. Observation on [DATE] at 7:10 AM revealed LVN E entered Resident #298's room to administer her morning medication through her [DEVICE] (a tube inserted through the abdominal wall that delivers nutrition directly to the stomach). LVN E called the resident by name and the resident opened her eyes but did not verbally respond. LVN E continued to explain she was going to give her some medication. The resident was observed to be lethargic, with difficulty breathing and using her abdominal accessory muscles to aid with breathing, and cyanosis was noted to her upper lip with oxygen infusion at 3 liters per nasal canula. At 7:12 AM, LVN E proceeded to administer medications through the [DEVICE]. At approximately 7:15 AM, Resident #298's family member entered the room and called out to the resident. Resident #298 opened her eyes but was unable to converse. The family member asked the LVN what happened to the resident and why she had not been contacted since the resident had been fine when the family member left the day prior. The family member again attempted to get the resident to respond to verbal stimuli, but the resident did not respond. The family member said there had been a major change in the resident as she had been alert yesterday ([DATE]). LVN E explained at around midnight, the night nurse had to put the resident on oxygen because her oxygen saturation dropped down to 64 percent, and the nurse suctioned her several times. LVN E completed giving the resident her medication and left the room. LVN E did not assess Resident #298's respiratory status per the baseline care plan or mental status. At 7:25 AM, LVN E proceeded down the hallway with the medication cart. At approximately 7:26 AM, the surveyor inquired about Resident #298's condition and if the DON and Physician had been called. LVN E did not respond. At approximately 7:28 AM, LVN E picked up her cellular phone from the top of the cart, dialed a number, then stated, Where are you at, ok, look me up when you get here. LVN E was asked who she had spoken to, and LVN E replied, the DON. At approximately 7:30 AM after the surveyor asked LVN E to obtain the resident's oxygen saturation, LVN E re-entered the room and obtained the resident's oxygen saturation with results of 89 percent. LVN E walked to the nurse's station, picked up the phone, dialed a number, and stated, (Dr. F), (Resident #298's) O2 (oxygen) saturation is 89 and is on oxygen at 3 liters by nasal cannula. Ok, thank you. LVN E did not tell the DON or physician about the change in condition at 12:00 AM. In an interview on [DATE] at 7:32 A.M., Resident #298's family member stated, I was not notified of the change in mother's condition. An observation of Resident #298 on [DATE] at 7:35 A.M. revealed the resident to be lethargic and unable to respond verbally. The resident's family member repeatedly tried to rouse the resident utilizing verbal stimuli. The resident opened eyes with no verbal response. The family member requested nurses' notes from prior night from LVN E. The DON who had arrived at the resident's door assured the family member access to the notes before leaving. LVN E obtained the resident's oxygen saturation of 89 percent, and at this time LVN E replaced the nasal canula with a facemask. Review of the Resident/Patient Transfer Form to hospital dated [DATE] at 8:53 A.M. revealed Resident #298 was a full code, with increased congestion, fever, altered mental status, hypoxic (an absence of enough oxygen in the tissues to sustain bodily functions), on oxygen at 5 liters per mask, suctioned three times with minimal results and auditory gurgling. Paramedics transported resident to the hospital at approximately 9:00 A.M. An interview with Dr. F on [DATE] at 8:55 A.M. revealed he was not notified on [DATE] at 12 midnight when Resident #298 had a change in her respiratory status. He stated he would have expected to be notified when her oxygen saturation had dropped to 64 percent, and he instructed the facility to transport resident to the hospital. A second interview with Dr. F on [DATE] at 12:20 PM revealed if he had been notified on [DATE] at midnight, his orders would have depended on the clinical condition of the resident. With an oxygen saturation of 64 percent on ,[DATE]liters of oxygen, he would have increased the oxygen to 5 liters, given [MEDICATION NAME], ordered a chest x-ray, and if no response, sent resident to the hospital. An interview with LVN E on [DATE] at 8:58 A.M. revealed Resident's #298's oxygen saturation was 83 percent, the resident was suctioned, and the last oxygen saturation taken was 81 percent with oxygen mask on. The physician was notified, and an order was received to transport to the hospital. Record review revealed no documentation of oxygen saturation being eighty one percent prior to transport to the hospital. An interview on [DATE] at 10:50 A.M. with the DON revealed she had called the facility at 2:51 A.M., talked with LVN A about an unrelated matter, and Resident #298's change of condition with the need for oxygen at 12:00 A.M. was not mentioned. The DON stated she was not notified of the change of condition of this resident. The DON's expectation was to be notified of all changes of condition with any resident, and the physician and family should also be notified. During a second interview with the DON on [DATE] at 5:15 P.M., the DON said she had spoken with LVN A one on one regarding lack of notification, but no in-services had been done with other staff. Interview on [DATE] at 12:45 P.M. revealed LVN E stated Resident #298 was admitted to the hospital with [REDACTED]. Review of resident #298's hospital record revealed she was admitted to the ER (emergency room ) on [DATE] at 9:25 A.M. with [DIAGNOSES REDACTED].) Her ER nurse notes stated [DATE] at 9:32 A.M. appears ill, behavior is confused . respiratory effort is labored . breath sounds are coarse with rales (crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation) on both sides . oxygen saturation 77 percent on room air. On [DATE] at 9:53 the ER physician documented, The patient is hypoxic (an absence of enough oxygen in the tissues to sustain bodily functions). Review of the discharge summary dated [DATE] at 8:27 P.M. revealed date of admission [DATE] at 10:54 A.M., reason for hospitalization , found to have pleural effusion and will be admitted . Hospital course summary revealed, patient found to have pneumonia with acute [MEDICAL CONDITION] . significant shortness of breath. Date of Discharge: Patient pronounced dead on [DATE] at 4:00 P.M. Review of facility's policy Change in Resident's Condition or Status with a revised date of (MONTH) 2001 revealed; 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: . d. A significant change in the resident's physical/emotional/mental condition; i. Instructions to notify the physician of changes in the resident's condition. 2. Unless otherwise instructed .the nurse will notify the next-of-kin or representative when: b. There is a significant change in the resident's physical, mental, or psychosocial status. 6. If a significant change in the resident's current mental or physical condition occurs, a comprehensive assessment of the resident's condition will be conducted . The Administrator, DON and Corporate Nurse were notified on [DATE] at 5:15 P.M. that an Immediate Jeopardy situation was identified, and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 5:56 P.M. and included: .4. Starting [DATE], utilizing the 24-hour report, residents will be reviewed daily by nursing leadership and/or DON for changes of condition, assessments/reassessments and residents discharged to hospital will be reviewed in clinical meeting and during shift to shift report to validate notification of physician and nursing leadership per policy. 5. Documented walking rounds will occur each shift for an observational view of the resident to identify any changes in resident's baseline health condition and to validate changes in conditions that may or may not have been mentioned on the 24-hour report by the staff nurses and nursing leadership working at that time starting on the night shift on [DATE]. 6. The following is an immediate education implementation plan completed by [DATE]. No employee will be allowed to work until education complete. Nursing leadership (DON, ADON and nurse manager), Facility Administrator, and staff nurses (RNs and LVNs) were included in the following training: 7. On [DATE] the RNC and RDO conducted Nursing and Facility leadership training with the DON and Facility Administrator. The DON and Facility Administrator conducted nursing leadership training with licensed nurses with an in-service regarding timely physician and nursing leadership and/or DON notification for change in condition, and assessments/reassessments. 8. Education on following the baseline care plan completed [DATE]. 9. On [DATE], LVN assigned to Resident #298 has received 1:1 education regarding timely notification of changes of condition to the physician and charge nurse, and assessment/reassessment by the DON and RNC. Her competency was validated by test. The DON also discussed timely documentation. The LVN remains on suspension pending investigation as of [DATE]. An in-service dated [DATE] of Notification of Changes, Resident Rights, and Baseline Care Plans revealed twelve licensed nurses (ADON I, ADON G, MDS coordinator, LVNs E, J, K, L, M, N, O, P, and RN Q) representing all three shifts, management, and weekend staff all had training on identifying a change of condition, who to notify of the change of condition as per the initial Baseline Care Plan, nurses will note the change of condition and promptly notify the family, physician and nursing leadership/DON. Interviews on [DATE] from 5:30 A.M. to 1:25 P.M. revealed twelve licensed nurses (ADON I, ADON G, MDS coordinator, LVNs E, J, K, L, M, N, O, P, and RN Q) representing all three shifts, management, and weekend staff all had training on identifying a change of condition, who to notify of the change of condition, nurses will note the change of condition and promptly notify the family, physician and nursing leadership/DON. Areas of notification include: a. An accident or incident involving the resident; b. A discovery of injuries of unknown source; c. A reaction to medication; d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications (i.e. two (2) or more consecutive times); g. A need to transfer the resident to a hospital/treatment center; h. A discharge without proper medical authority; and/or i. Instructions to notify the physician of changes in the resident's condition. As for the initial Baseline Care Plans, nurses will note the change in condition and promptly notify the family, physician, and nursing leadership/DON. Areas of notification include: a. An accident or incident involving the resident; b. A discovery of injuries of unknown source; c. A reaction to medication; d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications (i.e. two (2) or more consecutive times); g. A need to transfer the resident to a hospital/treatment center; h. A discharge without proper medical authority; and/or i. Instructions to notify the physician of changes in the resident's condition. Review of Statement of Resident Rights includes: Pursuant to 40 TAC 19.401(c) . You have a right to: (1) all care necessary for you to have the highest possible level of health . An interview with the DON on [DATE] at 5:20 P.M. revealed LVN A assigned to Resident #298 on [DATE] from 10:00 P.M. to 6:00 A.M received 1:1 education regarding timely notification of changes of condition to the physician and charge nurse, and assessment/reassessment by the DON and RNC. The DON also discussed timely documentation. The LVN remains on suspension with possible termination pending facility's investigation. A review of document titled Notice of Warning dated [DATE] revealed an investigatory suspension was issued to LVN A for violation of company policies/procedures and failure to report to MD and RN for changes in condition and was signed by LVN A, DON, and a witness. Review of twenty-four-hour report on [DATE] from 5:30 A.M. to 3:25 P.M. revealed night shift, day shift, and evening shift nurses had documented all resident's conditions. ADON I and the DON had printed and reviewed the twenty-four-hour reports per the plan of removal. Observation on [DATE] at 5:45 A.M. revealed in memory care and the main floor, room rounds between the night shift staff and the day shift staff, going room to room with the 24hr report sheet, discussing the condition of each resident listed.