Every finding on record at Sonterra Health Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to ensure the ice scoop was stored outside of the kitchen's ice machine.2. The facility failed to write a correct temperature for the reach-in refrigerator next to the food preparation areas for 07/01/2026 evening temperature.3. The facility failed to throw out cabbage that had black substance on 07/07/2026.4. The facility failed to keep a personal beverage away from storage of disposable plates.5. The facility failed to ensure Dietary Aide F was not wearing a necklace and small hoop earrings while preparing food for 07/08/2026 lunch. These failures could place residents at risk for food borne illness.The findings were: During an interview, record review, and kitchen observation on 07/07/2026 at 08:58 AM, there was an ice scoop hanging on a hook on the right-hand side of the interior of the ice machine. The CDM stated that this was okay because the ice machine was made with the hook inside for hanging the ice scoop. Record review of the Refrigerator Temperature Log for July 2026 for the reach-in refrigerator next to a food preparation area reflected 42 degrees Fahrenheit for 07/01/2026 evening temperature, signed by the CDM. The CDM revealed she wrote that temperature and did corrective action because 42 degrees was not a safe temperature for the refrigerator. She revealed that the plug had been out, unsure of how long, but the morning temperature for 07/01/2026 was at 34 degrees Fahrenheit so she did not have to throw the food out because the temperature went below 41 degrees Fahrenheit after corrective action was taken. She revealed she forgot to document the new temperature or the action taken on the refrigerator temperature log. She revealed it was important to document the new temperature that was within range, so the kitchen staff knew the refrigerator was staying at temperature, and the foods did not spoil. There was one cabbage with black substance on it stored in a cardboard box, on a shelf beneath a food preparation tabletop and about 6 inches above the floor. There was a personal beverage in front of a stack of disposable plates. The CDM revealed this beverage should not be in this area, and she threw away the disposable plates that were exposed to the personal beverage. During an interview and observation on 07/08/2026 at 11:26 AM, Dietary Aide F was wearing a chained necklace that was laying on top of her shirt and small hoop earrings while preparing food for 07/08/2026 lunch. The CDM revealed this was okay as long as the jewelry was not long. During an interview and observation on 07/09/2026 at 04:25 PM, Dishwasher D revealed he worked as a dietary aide, cook, or wherever he was needed in the kitchen. He revealed it was important to label food products with their discard dates to prevent sickness from bacteria or contamination. The CDM revealed she did not know what black substance was on the cabbage, but she threw it out so that no resident could get sick. During an interview on 07/10/2026 at 03:52 PM, Dietary Aide E revealed the kitchen staff was not allowed to store personal beverages in the kitchen or in the storage area because it could cause contamination. He revealed if a food had black substance on it, he would throw it out because the food may have mold or be bad. During an interview on 07/10/2026 at 02:13PM, the ADM revealed his expectation was for the kitchen to follow the best practice. Record review of the facility's policy Infection Control Policy/Procedure for Dietary Services reflected It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness .1.Director of Food Service Responsibilities . B, Keep adequate records of temperature of refrigeration . G. Maintain storage of perishable foods at 41 degrees Fahrenheit or below3. Personnel, A. Employee Health, 1) Personnel will comply with all health policies, 4. Personal Hygiene . B. No long/drooping jewely (sp)5. Food Storage . E. Fruits, vegetables, dairy products, meat, and poultry must be stored at temperatures between 33 degrees to 45 degrees Fahrenheit .6. Proper Food Handling . X. Ice machines must be of a type that eliminates contamination during ice manufacture, storage and dispensing Record review of the FDA Food Code 2022, U.S. Department of H&HS, reflected, 2-303 Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 Guide 3-B .43. IN-use utensils; properly stored . Ice scoops may be stored handles up in an ice bin except for an ice machine.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for two (2) of two (2) residents (Resident #23 and Resident # 116) reviewed for hospice services. 1. The facility failed to maintain the current hospice plan of care to ensure Resident #23 received adequate end-of-life care. 2. The facility failed to maintain the current hospice plan of care to ensure Resident #116 received adequate end-of-life care. These failures could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs.The findings included: 1. Record review of Resident #23's Face Sheet, dated 07/09/2026, revealed Resident #23 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #23 was noted to be a 90-years-old male. Record review of Resident #23's Medical Diagnosis, undated and accessed 07/09/2026 at 10:19 a.m., revealed diagnoses included acute and chronic respiratory failure with hypoxia (a condition in which the lungs cannot adequately oxygenate the blood leading to low oxygen levels), tinea unguium (a fungal infection of the nails), and bronchiectasis (a persistent lung condition in which the airways become permanently widened, thickened, and damaged, impairing mucus clearance and leading to frequent infections). Record review of Resident #23's Quarterly MDS assessment, dated 04/30/2026, revealed Resident #23 had a BIMS of 07, which indicated severe cognitive impairment. He had an active diagnosis of respiratory failure. Record review of Resident #23's Care Plan Report, undated and accessed 07/09/2026 at 12:38 p.m., revealed Resident #23 had a focus of [Resident #23] has a terminal prognosis r/t bronchiectasis **Resident admitted to [Hospice N name and telephone number] under dx: Bronchiectasis, date initiated 12/17/2024, and created and revised on 12/23/2024. Record review of Resident #23's Order Summary Report, dated 07/09/2026 with active orders as of 07/09/2026, revealed the following order:- Admit to [Hospice N] Phone: [Hospice N phone number] Dx: Bronchiectasis No Lab, x-rays [a photographic image made by electromagnetic radiation to look at bones and joints] without hospice approval. Notify for ER send outs., noted as active with order date of 06/17/2025. No end date noted. Record review of Resident #23's physical hospice binder on 07/10/2025 at 10:55 a.m., revealed:- Out-Of-Hospital Do-Not Resuscitate order, signed 12/16/2024, - a binder checklist including 3071 Form, 3074 Form- For Current Cert, Plan of Care with Dates/Frequency, and DNR signed 06/18/2025 and 08/12/2025 with all four items checked off for each date, - a second binder checklist including 3071 Form, 3074 Form, Care Plan- From Hospice, Recert Forms, First 60 days- Recert, and 30 Days- Recert Cont with 3071 Form, Care Plan- From Hospice, and Recert Forms checked off and note 3074- updated (6/13/25) Texted Rep VA- per hospice 3074 to not be updated after admissions exp 8/12/25 with signature, - Form 3071 Texas Medicaid Hospice Program Individual Election/Cancellation/Update form, signed on 12/16/2024,- Form 3074 Texas Medicaid Hospice Program Physician Certification of Terminal Illness form, signed on 12/16/2024,- Hospice Plan of Care for certification period from 06/14/2025 to 08/12/2025,- Nursing Facility Record Documentation with ii. Certification/Plan of Care .2. Hospice care plan,- Communicating with [Hospice N] document, with regular business hours and phone numbers,- a second copy of Out-Of-Hospital Do-Not Resuscitate order, signed 12/16/2024,- Hospice Plan of Care for certification period from 03/16/2025 to 06/13/2025,- Hospice Plan of Care for certification period from 12/16/2024 to 03/15/2025,- Hospice Certification of Terminal Illness [Hospice N] for certification period 12/16/2024- 03/15/2025, - Patient Face Sheet [Hospice N], dated 12/16/2024,- Medication Profile [Hospice N], printed on 12/18/2024, - Chaplain Care Plan, printed on 12/18/2024, - Aide Care Plan, printed on 12/18/2024, - Interdisciplinary Team Care Plan, printed on 12/18/2024, - Medical Social Worker Care Plan, printed on 12/18/2024, and- Skilled Nursing Care Plan, printed on 12/18/2024. The binder did not include a plan of care for the current certification period. Record review of Resident #23's electronic medical record on 07/10/2026 at 12:22 p.m., revealed two (2) hospice visit notes (both dated as effective 06/10/2026) and two (2) hospice orders (one dated as effective 05/12/2026 and the second on 07/07/2026) uploaded to the record within the last three months. The documents did not include a hospice plan of care. During an observation and interview on 04/07/2026 at 10:50 a.m., Resident #23 was observed lying in bed. Resident #23 stated he had not had any concerns with communicating with his hospice team. During an interview on 07/10/2026 at 11:19 a.m., RN O stated she was Resident #23's hospice nurse. She stated she had only recently taken over as his nurse and did not usually provide hospice care to residents in nursing facilities. She stated she was unsure who was responsible for bringing the hospice's current care plan documentation. She stated she or the other members of the hospice team were possibly responsible. She stated she had not been contacted by the facility that the hospice plan of care was out of date. She stated she could bring a current hospice care plan document when she came to see Resident #23 later that day. During an observation and record review on 07/10/2026 at 02:20 p.m., RN O provided a current hospice care plan document. The document was dated 07/10/2026 with the benefit period noted to be from 06/09/2026 to 08/07/2026. Record review of facility Hospice Services Agreement, dated as agreement effective date and signed on 03/22/2017, for Hospice N, revealed:- 1. Definitions, 1.2. Clinical Record means an individual, comprehensive compilation of information established and maintained by Hospice for each patient receiving Services from Hospice. The Clinical Record contains (i) the initial and subsequent assessment; (ii) the Plan of Care;. - 3. Coordination of Responsibilities .Hospice and Facility shall develop a process to exchange information between the IDG and Facility staff regarding development and updating of the POC and evaluation of care outcomes to ensure that each Hospice patient receives necessary and appropriate care and services. Each Party will designate one or more liaisons to facilitate cooperation and communication between the Parties to assure that individual and family needs are met .3.1. Development, Implementation and Modification of Plan of Care. When a Facility patient is admitted to the Hospice program, Hospice shall develop a POC. Hospice shall retain responsibility for directing the implementation of each POC. Hospice shall modify the POC at intervals required by federal and state regulation, taking into account changes in Hospice patient's condition and the effectiveness of pain management and symptom control. Facility and Hospice each shall designate a Registered Nurse responsible for coordinating the implementation of the POC for each Hospice patient.- 4. Provision of Hospice Services .4.1.3. For those Hospice patients receiving Hospice Inpatient Services from Facility as arranged by Hospice, Hospice shall provide Facility with a copy of each Hospice patient's POC and shall specify the Hospice Inpatient Services to be provided. 2. Record review of Resident #116's Face Sheet, dated 07/09/2026, revealed Resident #116 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #116 was noted to be a 78-years-old male. Record review of Resident #116's Medical Diagnosis, undated and accessed 07/09/2026 at 02:30 p.m., revealed diagnoses included encephalopathy (a disease in which the function or structure of the brain is affected, typically caused by infection, tumor, or stroke), acute bronchitis (inflammation of the bronchial tubes in the lungs), and Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors) without dyskinesia (uncontrollable and involuntary movements). Record review of Resident #116's Quarterly MDS assessment, dated 05/25/2026, revealed Resident #116 had a BIMS of 11, which indicated moderate cognitive impairment. He had an active diagnosis of Parkinson's Disease. Record review of Resident #116's Care Plan Report, undated and accessed 07/09/2026 at 12:38 p.m., revealed Resident #116 had a focus of [Resident #116] is on hospice services r/t parkinsons [sic], date initiated, created, and revised 07/03/2026. Record review of Resident #116's Order Summary Report, dated 07/09/2026 with active orders as of 07/09/2026, revealed the following order:- Admit to [Hospice P] with DX of Parkinsons Disease ., noted as active with order date of 07/02/2026. No end date noted. Record review of Resident #116's physical hospice folder on 07/10/2025 at 10:55 a.m., revealed:- a document titled Facility and Hospice Delineation of Duties, dated 07/02/2026. The document included under Hospice Responsibilities, 3. The Hospice RN will coordinate and discuss changes in patient's POC with the Facility at least every 15 days. Under Facility Responsibilities, 1. The Facility will communicate with the Hospice: .b) clinical complications that suggest need to alter the POC;. - a document titled Palliative Care Form with the resident's diagnosis and areas marked where the attending physician should identify where the patent's response to the disease process or the end-of-life process may be unavoidable for the resident.- a document titled [Hospice P] INFORMATION FOR MEDICAL EXAMINER. - a document titled Facility Notification, signed 07/02/2026.- a sign-in sheet for [Hospice P] staff- an Out-Of-Hospital Do-Not Resuscitate order, signed 07/02/2026. - a Facility admission Contents document- a blank Volunteer Request Form. - a blank Medication Disposal form. - a blank Testimonial Authorization and Release form. - a blank Photograph Authorization and Release form.- a How does Immediate Advocacy help people with Medicare? document. The folder did not include a plan of care for the current certification period. Record review of Resident #116's electronic medical record on 07/10/2026 at 12:24 p.m., revealed two (2) hospice orders (one dated as effective 07/07/2026 and the second on 07/09/2026) and one [Hospice P] admission Orders (dated as effective 07/03/2026). The documents did not include a hospice plan of care. During an observation and resident representative interview on 04/08/2026 at 09:21 a.m., Resident #116 was observed sitting up in a wheelchair with his resident representative present. Resident #116's resident representative stated Resident #116 had just elected to be on hospice services. She denied having any concerns or problems with the facility communicating with the hospice. During an interview on 07/10/2026 at 11:19 a.m., RN Q stated she was Resident #116's hospice nurse. She stated she felt the facility had been very collaborative with the hospice team on his recent hospice admission. She stated Resident #116's family and his nurse were great at notifying her of any changes in Resident # 116's condition. She stated she was unsure if the facility had a copy of Resident #116's hospice care plan but stated the facility would typically have a copy. She stated she was unsure on who was responsible for providing the hospice care plan and did not know if it had been requested by the facility. Record review of facility Hospice Services Agreement, dated as agreement effective date 05/31/2019 and signed on 06/03/2019, for Hospice P, revealed:- 1. Definitions, 1.2. Clinical Record means an individual, comprehensive compilation of information established and maintained by Hospice for each patient receiving Services from Hospice. The Clinical Record contains (i) the initial and subsequent assessment; (ii) the Plan of Care;. - 3. Coordination of Responsibilities .Hospice and Facility shall develop a process to exchange information between the IDG and Facility staff regarding development and updating of the POC and evaluation of care outcomes to ensure that each Hospice patient receives necessary and appropriate care and services. Each Party will designate one or more liaisons to facilitate cooperation and communication between the Parties to assure that individual and family needs are met .3.1. Development, Implementation and Modification of Plan of Care. When a Facility patient is admitted to the Hospice program, Hospice shall develop a POC. Hospice shall retain responsibility for directing the implementation of each POC. Hospice shall modify the POC at intervals required by federal and state regulation, taking into account changes in Hospice patient's condition and the effectiveness of pain management and symptom control. Facility and Hospice each shall designate a Registered Nurse responsible for coordinating the implementation of the POC for each Hospice patient.- 4. Provision of Hospice Services .4.1.3. For those Hospice patients receiving Hospice Inpatient Services from Facility as arranged by Hospice, Hospice shall provide Facility with a copy of each Hospice patient's POC and shall specify the Hospice Inpatient Services to be provided. During an interview on 04/10/2026 at 04:40 p.m., the DON stated she believed Staff R checked the hospice documentation regularly to ensure that the required documentation was present. She stated she did not believe there would have been an impact of not having a current hospice care plan for Resident # 23 and Resident #116 because the staff maintain communication with the hospice care teams for order and treatment updates. During an interview on 07/10/2026 at 03:30 p.m., Staff R stated she reviewed the hospice documentation quarterly and would contact the hospice companies for hospice visit notes and orders. She stated she had not ever requested or reviewed the hospice documentation for hospice care plans. She stated for Resident #116, she contacted Hospice P on 07/03/2026, but due to the holiday, the office staff were not available. She stated she had not yet recontacted them. During an interview on 04/10/2026 at 04:05 p.m., the ADM stated the facility staff had not reported any concerns with communicating with the hospice staff. He stated that due to the frequent visits of the hospice staff to the facility, the facility staff were able to stay updated to the hospices' current orders and plans of care. He stated he did not believe the residents would have been impacted by not having a current hospice plan of care due to the frequent and ease of communication between facility and hospice staff. Record review of facility policy End of Life Care; Hospice and/or Palliative Care, date revised 12/2023, revealed: Procedure .4. Hospice services will be offered as appropriate and as ordered by the physician. These services will be integrated into the overall individualized, interdisciplinary care plan. Collaboration with Hospice will include processes for orienting staff to facility policies and procedures which may include: resident's rights, documentation and record keeping requirements.

Based on observation, interview 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 3 of 8 residents (Resident #3, #4, and #14) reviewed for care plans.1. The facility failed to ensure Resident #4's comprehensive care plan was updated to reflect that resident was no longer taking cephalexin. 2. The facility failed to ensure Resident #3's comprehensive care plan was updated with his current ADLs. 3. The facility failed to ensure Resident #14's comprehensive care plan included that she had contractures in her legs.These failures could place residents at risk for not having their needs and preferences met.The findings were: 1. Record review of Resident #4's face sheet reflected an [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE]. Her diagnoses included: urinary tract infection. Record review of Resident #4's quarterly MDS assessment, dated 06/19/2026 revealed a BIMS score of 6 out of 15, which indicated a severe cognitive impairment. Record review of Resident #4's care plan, undated, reflected a focus [Resident #4] is at risk for infection r/t reoccurring UTI, revised 08/07/2025, with an intervention Cephalexin Oral Tablet 250 MG, dated 08/07/2025. Record review of Resident #4's order summary report, dated 07/07/2026, did not reflect an order for Cephalexin Oral Tablet 250 MG. During an interview on 07/08/2026 at 08:32 AM, Resident #4 revealed she received her medications on time and had no concerns with her care at this time. She revealed she was currently fine. 2. Record review of Resident #3's face sheet, dated 07/08/2026, reflected a [AGE] year-old male initially admitted on [DATE] and re-admitted [DATE]. His diagnoses included: cognitive communication deficit (condition when an individual struggles with the mental processes that support communication), unsteadiness on feet, lack of coordination, hemiplegia and hemiparesis following cerebral infarction (blood flow to part of the brain is blocked) affecting left dominant side (complete paralysis of one side of the body). Record review of Resident #3's (type not selected) MDS assessment, dated 06/18/2026 revealed a BIMS score of 12 out of 15, which indicated a moderate cognitive impairment. It further reflected Resident #3 required substantial/maximal assistance for toileting hygiene, substantial/maximal assistance for upper body dressing, and substantial/maximal assistance for putting on/taking off footwear. Record review of Resident #3's care plan, undated, reflected a focus [Resident #3] ADL Self Care Performance Deficit r/t CEREBRAL INFARCTION DUE TO THROMBOSIS OF UNSPECIFIED MIDDLE CEREBRAL ARTERY (type of cerebral infarction in which a blood clot has formed inside the middle cerebral artery), HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING LEFT DOMINANT SIDE, revised 06/08/2026, with intervention Toileting Hygiene: supervision or touching assist, Upper Body Dressing: supervision, Putting on/taking off footwear: supervision., revised 06/09/2026. During an interview on 07/08/2026 at 12:41 PM, Resident #3 revealed he needed help with using the restroom and basic care and the facility was helping him with his needs. 3. Record review of Resident #14's face sheet, dated 07/07/2026, reflected a [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE]. Her diagnoses included: urinary tract infection. Record review of Resident #14's admission MDS assessment, dated 06/10/2026 revealed a BIMS score of 15 out of 15, which indicated intact cognition. Record review of Resident #14's care plan, undated, did not reflect that Resident #14 had contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility) of the legs. During an interview and observation on 07/10/2026 at 08:40AM, Resident #14 was lying in bed under the covers (unable to assess her body that was covered). She revealed she was not in pain, and the facility managed her pain appropriately. She revealed she received her medications in a timely manner and had no complaints about her care at the facility. During an interview on 07/10/2026 at 12:27PM, CNA A and LVN B revealed Resident #14 had contractures of her legs, so they had to make sure she was comfortable. LVN B further revealed that because of Resident #14's contractures, Resident #14's pain medications had to be administered before they helped assist Resident #14 to minimize her pain. They revealed this should be care planned, but they did not have to refer to the care plan because they were given information about resident care verbally.LVN B revealed Resident #4 was on cephalexin multiple times, but she was recently taken off her antibiotic, date unknown. LVN B further revealed the nurses administered medication per doctor's orders and not per Resident #4's care plan. CNA A revealed Resident #3 needed maximal assist with upper body dressing, toileting, and putting on his shoes. CNA A revealed it was important for Resident #3 to get the assistance he needed because it would be neglectful behavior if the nursing staff was not giving residents the assistance they needed. During an interview on 07/10/2026 at 12:55 PM, LPN C revealed she was an MDS nurse and oversaw care plans being updated. She revealed Resident #14 had contractures, it was not in her care plan, and it should be updated in the care plan, so the staff knew how to turn her, reposition her, and give her appropriate care. LPN C revealed Resident #4 was not taking Cephalexin anymore per doctor's orders and it should be deleted from Resident #4's care plan. She revealed when Resident #4 was re-admitted , she was no longer taking Cephalexin. LPN C revealed Resident #3's ADLs were not updated to reflect how much assistance he needed for some of his ADLs. She revealed it was important to have his ADLs updated so the staff provided proper care. She revealed if proper care was not provided, then Resident #3 would not have his needs met. During an interview on 07/10/2026 at 01:39 PM, the DON revealed Resident #14's contractures should be care planned because it affected the care that the facility was giving the resident. The DON revealed if Resident #4's doctor's orders did not reflect Cephalexin, then it should not be reflected in her care plan because it would not accurately reflect her care. She further revealed Resident #3's ADLs should be updated to reflect the care that the facility was giving to the resident. She further revealed that the staff knew how to care for Resident #3 but the care plan should be updated to refer to If any new staff member was working or if anyone had questions about residents' care. During an interview on 07/10/2026 at 02:13PM, the ADM revealed his expectations for residents' care plans were that they should be updated to reflect resident care. Record review of the facility's policy Comprehensive Person-Centered Care Planning, last revised 4.2025, reflected It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure at the time each resident is admitted , the facility had physician orders for the resident's immediate care for 1 of 8 residents (Resident #29) reviewed for new admissions. The facility failed to ensure Resident #29 had an order in place to provide catheter care for an indwelling urinary catheter. This failure could lead to residents not receiving necessary care. The findings included: Record review of Resident #29's face sheet, dated 07/07/2026, revealed that the resident was a [AGE] year-old male and initially admitted to the facility on [DATE] with diagnosis of reflex neuropathic bladder (when spinal cord damage blocks brain signals to the bladder affecting the sensation of bladder fullness and voluntary control). Record review of Resident #29's MDS assessment dated [DATE] revealed in section H0100 that Resident #29 has an indwelling catheter. Record review of Resident #29's physician orders revealed an order with a start date of 07/02/2026 for: Catheter Type 16Fr #30ml to closed urinary drainage system. Diagnosis for use: neurogenic bladder. No order was present for catheter care. Record review of Resident #29's baseline care plan, dated 07/02/2026 revealed Resident #29 has, an indwelling catheter: neurogenic bladder, with intervention, provide catheter care every shift and as needed. Interview on 07/07/2026 at 9:15a.m. with Resident #29 stated he has a urinary catheter and staff have been providing care for it. Observation on 07/08/2026 at 2:32p.m. revealed Resident #29 had an indwelling urinary catheter. Interview with DON on 07/09/2026 at 1:30p.m. DON stated Resident #29 has an indwelling urinary catheter and should be receiving catheter care every shift. DON stated the CNA staff is documenting incontinence care in the medical chart however, there was not an order. DON explained that urinary catheter orders are done upon admission and this order was missed for unknown reasons. DON stated the importance of having catheter care orders is to ensure care is provided while monitoring the catheter and preventing infection. Interview on 07/10/2026 at 9:25a.m. with MDS C nurse stated the interdisciplinary team reviews orders each day after their morning meeting and should have caught the missing order for catheter care for Resident #29 and she does not know why it was not caught. Interview on 7/10/2026 at 9:40a.m. with LVN H stated Resident #29 has an indwelling urinary catheter and she has witnessed Resident #29 receiving catheter care. LVN H stated it is a group effort to ensure physician orders are accurate and nursing staff is responsible for providing care. LVN H was not aware Resident #29 did not have an active order to provide catheter care. Interview on 07/10/2026 at 10:10a.m. with CNA J stated Resident #29 has a urinary catheter and she has been providing catheter care since his admission.

Based on observation, interviews, and record review the facility failed to ensure the assessment accurately reflected the resident's status for two (2) of eight (8) residents (Resident #126 and Resident #64) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #126 was coded on her Discharge Return Anticipated MDS assessment, dated 04/13/2026, for having received tube feeding while a resident and at discharge. 2. The facility failed to ensure Resident #64 was coded on her Quarterly MDS assessment, dated 05/11/2026, for having received a therapeutic diet while a resident. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #126's Face Sheet, dated 07/08/2026, revealed a [AGE] year-old female. She was admitted on [DATE] and discharged on 04/13/2026. Record review of Resident #126's Medical Diagnosis, undated and accessed 07/08/2026 at 01:52 p.m., revealed diagnoses included chronic obstructive pulmonary disease (a type of progressive lung disease), acute respiratory failure with hypoxia (a sudden condition when the lungs cannot deliver enough oxygen to the blood), and dysphagia (difficulty swallowing). Record review of Resident #126's Discharge Return Anticipated MDS Assessment, dated 04/13/2026, revealed the assessment reference and observation end date was 04/13/2026. The resident had a memory problem and was severely impaired for daily decision making. Under Section K - Swallowing/Nutritional Status of the MDS Assessment, Resident #126 was noted to have received a mechanically altered diet, defined as a diet that required a change in texture of foods or liquids, while a resident. She was not documented as having received feeding tube while a resident as a nutritional approach. LPN C was noted to have completed Section K on 04/15/2026. RN M was noted to have signed the assessment as complete on 04/27/2026. Record review of Resident #126's Order Summary Report, dated 07/08/2026 with active orders as of 04/13/2026, revealed the following orders:- REGULAR diet MECHANICAL SOFT- Ground texture, THIN LIQUIDS consistency, for diet, noted as active with order and start date of 04/09/2026. No end date noted.- Enteral Feed [any method of supplying nutrients through the gastrointestinal tract [mouth, stomach, and intestines] either by mouth, the use of liquid supplements, or the use of a feeding tube [a tube that supplies nutrients directly into the stomach or small intestine]] Order every shift CONTINUOUS TUBE FEEDING VIA:PEG [sic; a type of feeding tube] formula: ., noted as active with order and start date of 04/09/2026. No end date noted. - Enteral Feed Order every shift TYPE OF FEEDING TUBE: PEG DX: DYSPHAGIA, noted as active with order date of 04/08/2026 and start date of 04/09/2026. No end date noted. Attempted interview with Resident #126 and her resident representative on 07/10/2026 at 09:11 a.m. and 12:13 p.m. No return call was received. 2. Record review of Resident #64's Face Sheet, dated 07/09/2026, revealed a [AGE] year-old female. She was admitted on [DATE]. Record review of Resident #64's Medical Diagnosis, undated and accessed 07/09/2026 at 01:43 p.m., revealed diagnoses included dementia (a general term for impaired ability to remember, think, or make decisions), type 2 diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), and dysphagia. Record review of Resident #64's Quarterly MDS Assessment, dated 05/11/2026, revealed the assessment reference date and observation end date was 05/11/2026. The resident had a BIMS Summary Score of 14, indicating she was cognitively intact. Under Section K - Swallowing/Nutritional Status of the MDS Assessment, Resident #64 was noted to have received None of the above while a resident for nutritional approaches. Therapeutic diet was not selected. LPN L was noted to have completed Section K on 05/22/2026. RN M was noted to have signed the assessment as complete on 05/22/2026. Record review of Resident #64's Order Summary Report, dated 07/08/2026 with active orders as of 07/08/2026, revealed the following order:- LCS diet REGULAR texture, THIN LIQUIDS consistency, scoop dish with meals, noted as active with order and start date of 02/05/2024. No end date noted. During an observation and interview with Resident #64 on 07/07/2026 at 11:35 a.m., Resident #64 was observed lying in bed. She denied unintentional weight loss. She did not report receiving food inappropriate for her diet. During an interview on 07/10/2026 at 10:38 a.m., LPN C stated when completing Section K for nutritional approaches, she would review the resident's order listing report for active and discontinued orders. She stated if there was an error in how Resident #126 and Resident #64's nutritional approaches were coded; it would not have affected the residents' care but might impact the facility's reimbursement for that care. She stated for Resident #126 having not had been coded as received tube feeding on her discharge MDS, she would have to review the MDS Assessment. She stated for Resident #64, the LCS diet should be considered a therapeutic diet, but the missed coding of a therapeutic diet would not have impacted Resident #64's care. She stated LPN L, who completed Resident #64's MDS Assessment was a staff member from a different facility assisting with MDS Assessments and RN M, who signed both MDS Assessments as complete, worked offsite and reviewed the assessments. During an interview on 07/10/2026 at 10:53 p.m., LPN K stated she worked on MDS assessments and reviewed the two MDS Assessments discussed with LPN C, Resident #126's Discharge Return Not Anticipated MDS Assessment, dated 04/13/2026, and Resident #64's Quarterly MDS Assessment, dated 05/11/2026. She stated it appeared the nutritional approaches were missed. She stated she felt the missed coding could have an impact on the facility's reimbursement for the care provided and might impact the plan of care when it was next updated. She stated what was coded on the MDS would trigger care planning, and in that way, it could impact the resident's care. During an interview on 07/10/2026 at 11:01 a.m., LPN C stated she reviewed Resident #126's Discharge Return Not Anticipated MDS Assessment, dated 04/13/2026, and feeding tube should have been checked. During an interview on 07/10/2026 at 02:25 p.m., the DON stated she did not believe an error in coding Resident #126's feeding tube and Resident #64's therapeutic diet had impacted either resident's care. She stated the errors might have an impact on the facility's reimbursement and future care plan triggers. She stated the nursing staff were familiar with the residents' orders and care needs, and therefore the care the nursing staff provided would have been appropriate. The DON stated the facility's Comprehensive Person-Centered Care Planning policy was provided upon request for a policy to address MDS Accuracy. During an interview on 07/10/2026 at 03:15 p.m., LPN L stated she would review resident orders when completing Section K for nutritional approaches. She stated she did not recall completing Resident #64's Quarterly MDS Assessment but stated the LCS diet should have been coded as a therapeutic diet. She stated the order must have been missed when she reviewed the orders or she had an error when she completed the assessment. She stated she did not believe miscoding a therapeutic diet would have impacted Resident #64's care because the physician order would have been what the nurses and nutritional staff referred to for Resident #64's diet. Attempted interview on 07/10/2026 at 03:17 p.m. with RN M. Unable to contact via telephone and telephone did not allow a message to be recorded. During an interview on 07/10/2026 at 04:05 p.m., the ADM stated he did not believe an error in either residents' MDS Assessment for nutritional approaches would have impacted either resident's care but stated it might impact the facility's reimbursement for care. Record review of facility policy Comprehensive Person-Centered Care Planning, date revised 04/2025, revealed: PolicyIt is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment Procedure .4. The facility IDT will develop and implement a comprehensive person-centered, culturally competent, and trauma-informed care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, .6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.

Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 8 Residents (Resident #133) whose care plan records were reviewed. The facility failed to ensure Resident #133's baseline care plan included the resident's indwelling urinary catheter. This deficient practice could contribute to residents not having their needs met based on their assessment. The findings included: Record review of Resident #133's face sheet, dated 07/07/2026, revealed that the resident was a 73-years-old male and admitted to the facility on [DATE] with diagnosis of retention of urine (the inability to completely empty the bladder). Record review of Resident #133's 5-day MDS assessment revealed the assessment was in progress on 07/07/2026 because the resident was admitted to the facility on [DATE]. Record review of Resident #133's physician orders revealed an order with a start date of 07/03/2026 for: Catheter Type 16Fr #30ml to closed urinary drainage system. Diagnosis for use: retention. Record review of Resident #133's baseline care plan, dated 07/04/2026 revealed the resident did not have a baseline care plan for indwelling urinary catheter. Observation on 07/08/2026 at 2:03p.m. revealed Resident #133 had an indwelling urinary catheter. Interview on 07/08/2026 at 2:05p.m. with Resident #133, stated he has a urinary catheter and staff have been providing care for it. Interview with DON on 07/09/2026 at 1:30pm. DON stated Resident #133 has an indwelling urinary catheter but it was not identified in the initial care plan. DON stated the MDS nurse along with the interdisciplinary team review new admissions daily and she is responsible for entering the initial care plan. DON stated the importance of accurate care plans is so the staff knows what kind of care the patient requires. Interview on 07/10/2026 at 9:25a.m. with MDS C nurse stated Resident #133's care plan did not reflect the indwelling urinary catheter. MDS C nurse stated the DON is responsible for completing the initial care plan and the team meets daily to discuss newly admitted residents and MDS nurse will personalize the care plan. MDS C nurse stated Resident #133's urinary catheter should have been included in the initial care plan and does not know why it was not. Interview on 07/10/2026 at 9:40a.m. with LVN H stated Resident #133 has a urinary catheter and the importance of an accurate care plan is to ensure care and interventions are being followed. LVN H stated Resident #133 has been receiving catheter care and monitoring since he was admitted . Record review of the facility policy, titled Comprehensive Person-Centered Care Planning, dated 04/2025, revealed 1. Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care.

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 disease and infection for 1 of 3 residents (Resident #21) reviewed for infection control, in that: The facility failed to ensure signage was posted to alert staff that the resident was on Enhanced Barrier Precautions. The facility failed to ensure there was an active order for the use of Enhanced Barrier Precautions. This failure could place residents at risk of infection due to improper care practices. The findings included: Record review of Resident #21's face sheet, dated 07/09/2026, revealed that the resident was a [AGE] year-old female and initially admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus (the body cannot use insulin correctly and sugar builds up in the blood), generalized muscle weakness, and chronic pain syndrome. Record review of Resident #21's MDS assessment dated [DATE] revealed the resident has a BIMS score of 8 indicating moderately impaired cognition. Record review of Resident #21's skin assessment dated [DATE] indicated a new stage II pressure wound to resident's coccyx (tailbone). Record review of Resident #21's physician orders revealed: Tx to coccyx: cleanse with NS/ Wound cleanser, pat dry, apply medi-honey to wound bed, apply calcium alginate, cover with dry dressing one time a day every Mon, Wed, Fri for Stage 2 pressure injury. There was no order for Enhanced Barrier Precautions. Record review of Resident #21's care plan, dated 06/09/2026 revealed Resident #21 had, stage 2 pressure ulcer to coccyx r/t immobility, with intervention, Use Enhanced Barrier Precautions. Observation of wound care on 07/09/2026 at 9:00 a.m., revealed Resident #21 had an open wound to the coccyx area. Wound care nurse donned PPE when entering room to provide care. There was no signage outside or inside the resident's room indicating the need for PPE. Interview with LVN G on 7/9/26 at 12:00 p.m., stated EBP is put in place for residents with urinary catheters, peg tubes, wounds, or any openings into the body and are put in place to protect the resident and the staff from blood or bodily fluid exposures and consist of the staff donning PPE when providing care. LVN G stated Resident #21 has a pressure wound and should have an order for EBP,there should be a sign on the door. LVN G stated the ADON/Infection nurse is responsible for placing the signs. Interview with DON on 7/9/26 at 1:30 p.m., the DON stated Resident #21 had a stage 2 pressure wound and was made aware that there was not an order for EBP or a sign posted outside the resident's room. The DON stated EBP are necessary for any opening in the resident's body including IV's, catheters, and wounds. She stated the purpose of EBP is to prevent infection in the site. Interview on 07/10/2026 at 9:45 a.m., wound care LVN I stated Resident #21 developed a stage 2 pressure wound on 06/05/2026. LVN I stated EBP is a communication system to prevent infection and no one person is responsible for placing signs outside of resident rooms to indicate EBP is needed. LVN I stated she does not know why Resident #21 did not have an order for EBP or signage outside her room and the consequences could be possible infection to the resident. Interview on 7/10/2026 at 9:55 a.m., the Infection Preventionist ADON stated Resident #21 has an open pressure wound. The ADON stated all nurses have been educated to place EBP signs as needed and she runs audits to ensure EBP orders and signs are in place and does not know why the order and signage were missing. The ADON stated she learns of new wounds by obtaining a list from the wound care nurse. The ADON stated the purpose of EBP is to prevent infection. Record review of the facility policy, titled IPCP Standard and Transmission Based Precautions dated 10/2022, revealed 3. Enhanced Barrier Protection (EBP): expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident -to-resident. (e.g., residents with wounds and indwelling medical devises are at especially high risk of both acquisition of and colonization with MDROs.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 1 of 5 Residents (Resident #1) reviewed for medication storage:The facility failed to ensure Resident #1 did not have a medication cup with pills and a medication cup with a medication in powder form at the bedside.These failures could affect residents who received medications in the facility and place them at risk for not receiving the correct medications, medication misuse or drug diversion.The findings included:Record review of Resident #1's face sheet date 6/17/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes (condition in which the body does not use insulin properly), muscle weakness, dementia (decline in memory, thinking, and reasoning abilities that is severe enough to interfere with daily life), prostatic hyperplasia (a noncancerous enlargement of the prostate gland) with lower urinary tract symptoms, hypertension (high blood pressure), depression (a mental health disorder characterized by persistent feelings of sadness, hopelessness, loss of interest in activities that were once enjoyable), and pain in joints of right hand, right shoulder, and left shoulder.Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills.Record review of Resident #1's Order Summary Report reflected the following:- Aricept 5 mg, give 1 tablet by mouth one time a day for dementia with order date 3/23/26 and no end date- Aspirin 81 mg tablet, give 1 tablet by mouth one time a day for heart health with order date 11/6/25 and no end date-Docusate Calcium Oral Capsule 240 mg, give 1 capsule by mouth one time a day for daily chronic constipation with order date 12/11/25 and no end date- Flomax capsule 0.4 mg, give 1 capsule by mouth one time day for benign prostatic hyperplasia with order date 11/6/25 and no end date- Losartan Potassium oral tablet 100 mg, give 1 tablet by mouth one time a day for hypertension hold if systolic blood pressure is less than 100 with order date 11/6/25 and no end date- Metamucil Oral Powder 48.57%, give 30 ml by mouth one time a day for constipation with order date 3/19/26 and no end date- Multiple Vitamin Tablet, give 1 tablet by mouth one time a day for supplementation with order date 11/6/25 and no end date- Myrbetriq Oral Tablet Extended Release 24-hour 50 mg, give 1 tablet by mouth one time a day for bladder spasms with order date 2/1/26 and no end date- Venlafaxine Oral Capsule Extended Release 24-hour 150 mg, give 1 capsule by mouth one time a day for depression to be taken with Venlafaxine 37.5 mg daily with order date 2/11/26 and no end date- Venlafaxine Oral Capsule Extended release 24-hour 37.5 mg, give 1 tablet by mouth one time a day for depression to be taken with Venlafaxine 150 mg daily with order date 11/25/26 and no end date- Lyrica Capsule 200 mg, give 1 capsule by mouth two times a day for pain with order date 11/6/25 and no end dateRecord review of Resident #1's Medication Administration Record for June 2026 reflected Aricept, Aspirin, Docusate Calcium, Flomax, Metamucil, Multiple Vitamin, Myrbetriq, Venlafaxine, and Lyrica were scheduled for administration at 7:00 a.m.During an observation and interview on 6/17/26 at 11:20 a.m., Resident #1 was sitting up in a regular chair in his room and was observed with one medication cup with several pills in it and one medication cup with a tan color powder placed on top of the bedside table placed in front of the resident. Resident #1 stated the nursing staff provided medications to him and was not allowed to keep medications at the bedside I might misuse them. Resident #1 stated the tan color powder in the medication cup was for constipation and the pills in the other medication cup were his morning medications. Resident #1 stated his morning medication times varied and were usually administered at 10:00 a.m. or so. Resident #1 stated the nurse did not provide him with his morning medications and stated he received the morning medication from the medication aide. Resident #1 stated the medication aide was female but did not know her name. Resident #1 stated, when the medication aide provided him with the morning medications, he told the medication aide he wanted to sleep. Resident #1 stated, the medication aide told him, That's fine, I'll leave them and you can take them later.During an interview on 6/17/26 at 11:33 a.m., LVN A stated she had administered insulin to Resident #1 earlier in the morning and the medication aides administered other scheduled medications. LVN A stated, residents in the facility were not allowed to keep medications at the bedside and was not sure if Resident #1 was allowed to self-administer medications. LVN A stated residents who were allowed to self-administer medications required a physician's order and it also needed to be care-planned.During an observation and interview on 6/17/26 at 11:38 a.m., LVN A observed the medication cup with pills and the medication cup with the tan powder left on Resident #1's bedside table and asked Resident #1 if he was going to consume them. Resident #1 stated, she (the Medication Aide) left the medications at around 10:30 a.m. and I went back to sleep and wanted to take the medications now. LVN A stated she would discard the medications left at the bedside and would dispense a new set of medications. LVN A stated she would make the DON aware of the medications left at Resident #1's bedside and would notify the physician.During an interview on 6/17/26 at 11:44 a.m., the DON stated that medications cannot be left at the resident's bedside, and the nursing staff were supposed to stay and watch the resident consume their medications. The DON stated there were no residents in the facility that could self-administer medications. The DON stated that if a resident wanted to self-administer medications, they would need to be assessed to ensure safety and then the doctor would have to be notified to obtain an order, and it would have to be care-planned. The DON stated once a resident was assessed and cleared to safely self-administer medications, a re-assessment to self-administer was done quarterly.During an interview on 6/17/26 at 11:55 a.m., Medication Aide B stated she was assigned to administer medications to Resident #1 and tried to wake him up, and the resident did get up and while he got up in my head I'm thinking he's (Resident #1) gonna take them (the medications) right now, so I went to his roommate in the next bed and started to prepare the roommates medications. Medication Aide B stated she did not recall the actual time she left Resident #1's medications on the bedside table, and stated the resident was allowed to consume his morning medications between 7:00 a.m. and 10:00 a.m. Medication Aide B stated she believed she left Resident #1's medications on the bedside table around 8:00 a.m. Medication Aide B stated, Resident #1 would take his medications when he is ready and she was going to report to LVN A about the resident not willing to take the medications but got busy and didn't report to LVN A. Medication Aide B stated, by that time State was here and it was a blow out. Medication Aide B stated she was not supposed to leave medications at the beside because other residents who wandered could consume them and they could die and she was supposed to make sure she observed Resident #1 consumed his medications. Record review of the facility document titled Medication Administration - Oral with revision date 5/2007 reflected in part, .It is the policy of this facility to accurately prepare. Administer and document oral medications.Procedures.Essential Points.The nurse or med aide preparing the drug administers it.The person administering medication must remain with the resident until all medication has been swallowed.Record review of the facility document titled Medication Access and Storage with revision date 5/2007 reflected in part, .It is the policy of this facility to store all drugs and biological(s) in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with State and Federal Laws for 1 of 4 medication carts (300 hall medication cart) reviewed for storage of drugs and biologicals.The facility failed to ensure the medication cart for 300 hall was locked and secured when it was unattended.This failure could place residents at risk of medication misuse or drug diversion.Findings included:During an observation on 06/07/2026 from 8:58 a.m. to 9:01 a.m. on 300 hall there was an unlocked medication cart by the workstation, with the lock sticking out in the fullest position. Observation revealed the drawers to the medication cart were towards the hallway and anyone who walked by could open the drawers. There was no nurse within sight of the unlocked medication cart and 2 residents were sitting in wheel chairs about 6 feet away from the unlocked medication cart. CNA B walked by the unattended, unlocked medication cart as he pushed a meal cart down the hallway.During an observation and interview on 06/07/2026 at 9:02 a.m., RN A walked down the 300 hallway over to the unlocked medication cart. As RN A approached the unlocked medication cart, the surveyor opened the top drawer of the medication cart and asked the nurse if it was locked, and she stated No.During an interview on 06/07/2026 at 9:07 a.m., RN A stated she had removed a medication from the 300 hall medication cart, went to a resident's room and forgot to lock it before she walked away; and stated I know better, I have been doing this long enough to know it needed to be locked.During an interview on 06/07/2026 at 4:25 p.m., the DON said, If it [the medication cart] is out of site, it needs to be locked. The DON said anyone could get into the medication cart if it was unlocked and unattended, so it needed to be always locked. The DON stated as she walked by medications carts, she would look at the cart locks to see if they were pushed in to monitor them to determine if they were locked.During an interview on 06/07/2026 at 4:40 p.m., the Executive Director stated the medication carts should be locked when they were unattended, and the harm that could result was theft of medications by an employee, visitor, or by a resident. The Executive Director stated if a resident took medication from the unlocked cart, it could be dangerous to them. The Executive Director stated staff received training on ensuring the medication cart was locked when it was unattended; and Every time you find one [unlocked medication cart], you lock it, emphasize it has to be locked [to the staff], but never how much you in-service them, they are human and make mistakes at times.Record review of the facility's undated policy titled Medication Access and Storage, revealed, It is the policy of this facility to store all drugs.in locked compartments.The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications:.2. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview and record review the facility failed to ensure the right for a resident to refuse or discontinue treatment for 1 of 6 Residents (Resident #155) whose records were reviewed for resident rights. LVN H/Treatment Nurse, failed to stop wound treatment after Resident #155 yelled out in pain multiple times for her to stop on 5/13/25. This deficient practice could affect any resident and could result in residents believing their right to say stop does not matter. The findings were: Review of Resident #155's face sheet, dated 5/14/25, revealed she was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy (according to Cleveland Clinic: it is a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness) and Heart Failure. Review of Resident #155's, initial admission record, dated 5/8/25, revealed she was alert, but confused, oriented to person and able to follow simple commands. Review of Resident #155's Care Plan, initiated 5/9/25, included several risk factors: Resident #155 is at risk for impaired cognitive function/dementia or impaired thought processes r/t Metabolic Encephalopathy, anemia, CKD 3, CHF, OSA. Interventions included Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions Provide with necessary cues- stop and return if agitated. Social Services to provide psychosocial support as needed. Resident #155 has acute/chronic pain r/t metabolic encephalopathy, anemia, CKD 3, CHF, OSA. Interventions included Administer analgesia medication as per orders. Follow pain scale to medicate as ordered. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Monitor/record pain characteristics: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal, or resistance to care. Further review of Resident #155's Care Plan revealed she had an actual fall with no Injury, on 5/12/25 related to poor communication/comprehension. Interventions included Floor mats, Neuro-checks as ordered. Therapy consult for strength and mobility and Vital signs as ordered. Review of Resident #155's physician orders for May 2025 revealed the following orders: Acetaminophen-Codeine Tablet 300-30 MG Give 1 tablet by mouth every 8 hours as needed for Severe Pain DNE 4 gm/24 hrs; and Gabapentin Oral Tablet 100 MG (Gabapentin) Give 1 capsule by mouth three times a day for neuropathy. Cefdinir Oral Capsule 300 MG (Cefdinir) Give 300 mg by mouth two times a day for increased wbc for 7 Days; and Monitor & Assess level of pain using the 0-10 scale: 0=No Pain, 1-3=Mild Pain, 4- 6=Moderate Pain, 7-10=Severe Pain every shift -Order Date-05/08/2025 at 1815 (6:15 PM). Review of Resident #155's medication administration record and treatment administration record for May 2025 revealed she received Gabapentin the morning of 5/13/25; she refused the Cefdinir at 9:00 A< and the Acetaminophen-Codeine Tablet 300-30 MG at 10:35 AM. Further review revealed Resident #155's pain level on 05/13/25 was 5 of 10 in the morning. Review of a progress note dated 05/13/25 written by LVN H at 12:25 read Note Text: Treatment nurse followed up with patient for skin assessment. Upon attempting to remove the blanket, patient began yelling, stop, hurts. Explained to patient the need for a skin assessment. Noted DTI to left lateral heel. Patient continued to yell stop, hurts Upon initial touch. Was able to complete assessment, obtain measurements, and apply a skin barrier to the affected area. Offloading boots were also applied to relieve pressure. Review of facility document, Nursing Home to Hospital Transfer Form, dated 5/13/25 revealed LVN A sent Resident #155 to the hospital. Observation and interview on 05/13/25 at 10:05 AM revealed yelling coming from Resident #155's room. Resident #155 cried and yelled out loudly stop, it hurts, stop,several times. Upon entering her room, Resident #155 was lying in bed. LVN H/Treatment nurse was in the room with Resident #155. She introduced herself as the treatment nurse and stated rehabilitation staff noted a DTI on Resident #155's left heel. She stated she was trying to get measurements and apply skin prep. She stated she tried to assess Resident #155 yesterday but the Resident would stiffen up and told her, leave me alone. LVN H stated she left Resident #155 alone. LVN H stated she managed to get the measurement and apply skin prep. She then pointed to a scratch Resident #155 had on the back of her right ear. LVN H was not addressing Resident #155 during this discussion. LVN H pulled Resident #155's blanket back and Resident #155 quickly grabbed the blanket and covered herself back up and made a noise indicating she was agitated. LVN H let go of the blanket and put her hands up. Resident #155 never opened her eyes or engaged in conversation. LVN H stated she was barely touching her. Interview on 5/14/25 at 11 AM with LVN H/Treatment Nurse revealed the DOR texted her that one of the rehab staff noted Resident #155 had a DTI on her left lateral heel. She stated she went in to assess Resident #155 and as soon as she approached Resident #155 even before touching her,Resident #155 started yelling out. LVN H stated she tried to assess Resident #155 the day before and the Resident told her don't touch me so she left the Resident alone. LVN H stated she wanted to assess Resident #155's heel so that she could obtain an order and Resident #155 would receive treatment. LVN H stated she understood Resident #155 had the right to refuse treatment and she should have stopped when the Resident told her to stop. LVN H stated Resident #155 yelled out several times that it hurt and to stop. LVN H stated she was aware Resident #155 had a fall the weekend prior to the assessment and stated maybe Resident #155 was in pain. She stated during the assessment she noted bruising to Resident #155's upper extremities. LVN H stated she was not sure but guessed they were from the fall. She stated the DOR was supposed to assist during the assessment but the DOR was delayed with helping another resident. She stated she did not talk with LVN A about whether or not Resident #155 had received any PRN pain medications before she assessed Resident #155. She stated protocol required a resident receive pain medication prior to treatment as needed. Interview on 5/15/25 at 9:30 AM with the DON revealed he was made aware that Resident #155 was yelling out when LVN H/Treatment Nurse was assessing her left heel. He stated LVN H should have checked with the nurse to ensure Resident #155 received a PRN pain medication before assessing Resident #155. He stated LVN H should have also stopped when Resident #155 told her to stop. He stated Resident #155 had a right to refuse treatment. The DON further stated LVN H should have stopped and engaged other staff to help and could have attempted the assessment at a later time when Resident #155 was calmer. The DON stated LVN A attempted to give Resident #155 pain medication after LVN H assessed her but Resident #155 refused it. Interview on 05/15/25 at 03:13 PM with LVN A revealed therapy sent her a text message they found a reddened area on Resident #155's left heel. LVN A stated she heard Resident #155 yelling down the hallway the morning of 5/13/25 and went to her room to find out what was going on. She stated she heard Resident #155 say she hurt and to stop. LVN A stated after LVN H assessed Resident #155 she tried to give the Resident a Tylenol 3 PRN and a schedule antibiotic. She stated Resident #155 refused all medications. LVN A stated she found that as odd behavior. It appeared to her that Resident #155 was experiencing AMS, combination of anxiety and change in behavior from when she last worked with Resident #155 which was on Friday, 5/9/25. LVN A stated Resident #155 also did not want to eat her breakfast and was not wanting to wake up that morning either. LVN A stated she sent Resident #155 out to the hospital on 5/13/25. Telephone interview on 05/15/25 at 03:38 PM with Resident #155's RP revealed staff called to tell her Resident #155 had a fall early morning on 05/12/25 but did not sustain any injuries. The RP stated Resident #155 was still at the hospital with a UTI and that hospital staff took X-rays of her left and right side and a took a CT of her head. All findings were negative. The RP stated Resident #155 was supposed to have a left hip replacement months prior but was delayed due to other health complications. She stated Resident #155 often complained about pain around her left hip and would yell out when she did not want to be bothered usually related to having pain. Review of facility policy, Resident Rights, undated, read in relevant part POLICY: It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The Resident has the right: 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality. 14. To refuse medical treatment and to participate in experimental research.

Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 Residents (Resident #155) whose records were reviewed for pain management. LVN H/Treatment Nurse, failed to ensure Resident #155 received a PRN pain medication prior to assessment Resident #155 and then failed to stop wound treatment when Resident #155 yelled out in pain multiple times for her to stop on 5/13/25. This deficient practice could affect any resident experiencing pain and undue pain and mental distress. The findings were: Review of Resident #155's face sheet, dated 5/14/25, revealed she was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy (according to Cleveland Clinic: it is a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness) and Heart Failure. Review of Resident #155's, initial admission record, dated 5/8/25, revealed she was alert, but confused, oriented to person and able to follow simple commands. Review of Resident #155's Care Plan, initiated 5/9/25, included several risk factors: Resident #155 is at risk for impaired cognitive function/dementia or impaired thought processes r/t Metabolic Encephalopathy, anemia, CKD 3, CHF, OSA. Interventions included Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions Provide with necessary cues- stop and return if agitated. Social Services to provide psychosocial support as needed. Resident #155 has acute/chronic pain r/t metabolic encephalopathy, anemia, CKD 3, CHF, OSA. Interventions included Administer analgesia medication as per orders. Follow pain scale to medicate as ordered. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria (according to microsoft [NAME]: a state of unease or generalized dissatisfaction with life); nausea; vomiting; dizziness and falls. Report occurrences to the physician. Monitor/record pain characteristics: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal, or resistance to care. Further review of Resident #155's Care Plan revealed she had an actual fall with no Injury, on 5/12/25 related to poor communication/comprehension. Interventions included Floor mats, Neuro-checks as ordered. Therapy consult for strength and mobility and Vital signs as ordered. Review of Resident #155's physician orders for May 2025 revealed the following orders: Acetaminophen-Codeine Tablet 300-30 MG Give 1 tablet by mouth every 8 hours as needed for Severe Pain DNE 4 gm/24 hrs; and Gabapentin Oral Tablet 100 MG (Gabapentin) Give 1 capsule by mouth three times a day for neuropathy (according to the center for Bone and Joint Surgery). Cefdinir Oral Capsule 300 MG (Cefdinir) Give 300 mg by mouth two times a day for increased wbc for 7 Days; and Monitor & Assess level of pain using the 0-10 scale: 0=No Pain, 1-3=Mild Pain, 4- 6=Moderate Pain, 7-10=Severe Pain every shift -Order Date-05/08/2025 at 1815 (6:15 PM). Review of Resident #155's medication administration record and treatment administration record for May 2025 revealed she received Gabapentin the morning of 5/13/25; she refused the Cefdinir at 9:00 AM. Review of administration of the Acetaminophen-Codeine Tablet 300-30 MG revealed Resident #155 recieved Acetaminophen-Codine tablet 300-30mg on 05/09/2025 at 06:24 AM, 05/10/2025 at 09:56 AM, 05/10/2025 at 11:46 PM, 05/12/025 at 04:05 AM, 05/12/2025 at 11:33 PM. Further review of medication administration record shows Resident #155 refused Acetaminoph-Codeine Tablet 300-30MG on 05/13/2025 at 10:35 AM. Further review revealed Resident #155's pain level on 05/13/25 was 5 of 10 in the morning. Review of a progress note dated 05/13/25 written by LVN H at 12:25 read Note Text: Treatment nurse followed up with patient for skin assessment. Upon attempting to remove the blanket, patient began yelling, stop, hurts. Explained to patient the need for a skin assessment. Noted DTI to left lateral heel. Patient continued to yell stop, hurts Upon initial touch. Was able to complete assessment, obtain measurements, and apply a skin barrier to the affected area. Offloading boots were also applied to relieve pressure. Observation and interview on 05/13/25 at 10:05 AM revealed yelling coming from Resident #155's room. Resident #155 cried and yelled out loudly stop, it hurts, stop, several times. Upon entering her room, Resident #155 was lying in bed. LVN H/Treatment nurse was in the room with Resident #155. She introduced herself as the treatment nurse and stated rehabilitation staff noted a DTI on Resident #155's left heel. She stated she was trying to get measurements and apply skin prep. She stated she tried to assess Resident #155 yesterday (5/12/25) but the Resident would stiffen up and told her, leave me alone. LVN H stated she left Resident #155 alone. LVN H stated she managed to get the measurement and apply skin prep. She then pointed to a scratch Resident #155 had on the back of her right ear. LVN H was not addressing Resident #155 during this discussion. LVN H pulled Resident #155's blanket back and Resident #155 quickly grabbed the blanket and covered herself back up and made a noise indicating she was agitated. LVN H let go of the blanket and put her hands up. Resident #155 never opened her eyes or engaged in conversation. LVN H stated she was barely touching her. Interview on 5/14/25 at 11 AM with LVN H/Treatment Nurse revealed the DOR texted her that one of the rehab staff noted Resident #155 had a DTI on her left lateral heel. She stated she went in to assess Resident #155 and as soon as she approached Resident #155 even before touching her, Resident #155 started yelling out. LVN H stated she tried to assess Resident #155 the day before (5/12/25) and the Resident told her don't touch me so she left the Resident alone. LVN H stated she wanted to assess Resident #155's heel so that she could obtain an order and Resident #155 would receive treatment. LVN H stated she understood Resident #155 had the right to refuse treatment and she should have stopped when the Resident told her to stop. LVN H stated Resident #155 yelled out several times that it hurt and to stop. LVN H stated she was aware Resident #155 had a fall the weekend prior to the assessment and stated maybe Resident #155 was in pain. She stated during the assessment she noted bruising to Resident #155's upper extremities. LVN H stated she was not sure but guessed they were from the fall. She stated the DOR was supposed to assist during the assessment but the DOR was delayed with helping another resident. She stated she did not talk with LVN A about whether or not Resident #155 had received any PRN pain medications before she assessed Resident #155. She stated protocol required a resident receive pain medication prior to treatment as needed. Interview on 5/15/25 at 9:30 AM with the DON revealed he was made aware that Resident #155 was yelling out when LVN H/Treatment Nurse was assessing her left heel. He stated LVN H should have checked with the nurse to ensure Resident #155 received a PRN pain medication before assessing Resident #155. He stated LVN H should have also stopped when Resident #155 told her to stop. He stated Resident #155 had a right to refuse treatment. The DON further stated LVN H should have stopped and engaged other staff to help and could have attempted the assessment at a later time when Resident #155 was calmer. The DON stated LVN A attempted to give Resident #155 pain medication after LVN H assessed her but Resident #155 refused it. Interview on 05/15/25 at 03:13 PM with LVN A revealed therapy sent her a text message they found a reddened area on Resident #155's left heel. LVN A stated she heard Resident #155 yelling down the hallway the morning of 5/13/25 and went to her room to find out what was going on. She stated she heard Resident #155 say she hurt and to stop. LVN A stated after LVN H assessed Resident #155 she tried to give the Resident a Tylenol 3 PRN and a schedule antibiotic. She stated Resident #155 refused all medications. Telephone interview on 05/15/25 at 03:38 PM with Resident #155's RP revealed staff called to tell her Resident #155 had a fall early morning on 05/12/25 but did not sustain any injuries. The RP stated Resident #155 was supposed to have a left hip replacement months prior but was delayed due to other health complications. She stated Resident #155 often complained about pain around her left hip and would yell out when she did not want to be bothered usually related to having pain. Review of facility policy, Pain Recognition and Management, undated read Policy It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Purpose The facility assists each resident with pain management to maintain or achieve the highest practicable level of well-being and functioning by: Interviewing or observing the resident to determine if pain is present; Identifying circumstances when pain can be anticipated; Evaluating pain and working with the resident to develop a plan of care that considers their needs preferences and goals; Developing and implementing a plan, using non-pharmacologic and/or pharmacologic interventions to manage and/or prevent pain. Procedure 1. The resident will be evaluated for pain upon admission, quarterly, and with any change in their status. 2. Pain will be documented in the electronic health record (EHR) using a scale of 1 - 10. 3. For the resident who is unable to communicate verbally or understand abstract concepts, the PAINAD scale for the cognitively impaired will be used and documented in the resident's EHR. 4. Management: a. The Care Plan will include preventative or care interventions (pharmacological and non-pharmacological) for any resident admitted with pain. b. Medication(s) received, refused and response to medication will be documented on the Electronic Medication Administration Record (e-MAR). c. If the pain management program is not effective, the licensed nurse will contact the resident's physician. 5. Monitoring: a. Monitor pain status every shift using either the numerical pain rating (1-10) or PAINAD scale. (Pain Advanced Dementia scoring guide) b. Consult physician for additional interventions if pain is not relieved by current orders. c. The Interdisciplinary Care Plan will reflect the location and type of pain, pharmacological, and non-pharmacological interventions, with evaluation and revision as indicated.

Based on observations , interviews and record reviews the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated, for 1 of 8 residents (Resident #259 reviewed for investigating alleged verbal abuse. On Monday 5/12/2025 Resident #259 reported to the assistant food service manager (AFSM) that on Saturday 5/10/2025 the cook was rude and yelled while in his room reviewing the lunch meal served. The AFSM did not report the alleged verbal abuse and or mistreatment. The facility did not investigate the allegation of verbal abuse. The failure could place residents at risk for verbal abuse. The findings included: A record review of Resident #259's admission record dated 5/15/2025 revealed Resident #259 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included major depressive disorder, anxiety, and post-traumatic stress disorder (PTSD). A record review of Resident #259's care plan dated 5/8/2025 revealed, [sic(Resident #259)] is at risk for re traumatization related to history of trauma PTSD related to disasters . caregivers to provide opportunity for positive interaction, attention. Stop and talk with him as passing by. document behaviors and resident response to interventions. [sic(Resident #259)] has history of major depressive disorder encouraged to express feelings. monitor document report to nurse doctor signs and symptoms of depression . as potential nutritional problem . honor resident rights to make personal dietary choices A record review of the facility's grievance records for the month of May 2025 revealed no evidence of any grievance report for Resident #259 for the complaints made on 5/10/2025. A record review of the Texas Unified Licensure Information Portal website accessed 5/14/2025 revealed no evidence for a facility related incident report on behalf of Resident #259. During an observation and interview on 5/12/2025 at 11:59 AM revealed Resident #259 was in his room seated in his wheelchair. Resident #259 stated, that earlier in the day, he reported to the assistant food service manager (AFSM) that he was served raw chicken for lunch on 5/10/2025 and the [NAME] was rude and yelled. Resident #259 stated the Food Service Manager had come to speak with him that morning and heard his complaints. Resident #259 stated, I took a picture of the pink in the middle chicken breast and went to the kitchen and complained to the cook. he then came to my room and took the chicken in his hand and shredded the chicken and yelled 'I cooked the f***ing chicken myself and this is not raw,' . CNA E saw and heard him. During interview on 5/14/2025 at 1:44 PM the AFSM stated she was approached by Resident #259 on the morning of Monday 5/12/2025 and was told Resident #259 was served raw chicken for lunch on Saturday 5/10/2025. The AFSM stated Resident #259 was upset and claimed the cook came to his room and shredded the chicken breast and was rude and yelled. The AFSM stated she spoke with the [NAME] and the FSM and the cook stated he had not yelled and shredded the chicken to demonstrate the chicken was cooked thoroughly. The AFSM stated she had not reported to anyone that Resident #1 alleged he was yelled at by the [NAME] because, I know the [sic(Cook)] and he is not the kind of person to cuss or yell. During an interview on 5/15/2025 at 11:00 AM the Administrator stated the expectation was for any staff member who heard an allegation of abuse, neglect, and or exploitation (ANE) to immediately report the allegation to himself the Administrator. The Administrator stated he was not aware of the allegation until the surveyor's investigation. The Administrator stated he had not begun his investigation until 5/14/2025 and has not yet completed his report to the state regulatory agency. The Administrator stated the potential for harm to residents would be their allegations of ANE would go unheard, undocumented, and uninvestigated. A record review of the facility's undated Abuse: Prevention of and Prohibition Against revealed, Policy: it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. investigation: all identified events are reported to the administrator immediately. all allegations of abuse, neglect, this appropriation of resident property, end exploitation will be promptly and thoroughly investigated by the administrator for his her designee

Based on observation, interview and record review the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible for 1 of 7 Residents (Resident #80) whose environment was reviewed for safety hazards. Nursing staff failed to remove 3 razors from Resident #80's bathroom. This deficient practice could affect residents exposed to the razors and could contribute to avoidable accidents. The findings were: Review of Resident #80's face sheet, dated 5/15/25, revealed he was admitted to the facility on [DATE] with diagnoses including Vascular Dementia and Visual Hallucinations. Review of Resident #80's MDS assessment, dated 3/27/25, revealed his BIMS was 8 of 15 reflective of moderate cognitive impairment. Review of Resident #80's Care Plan, revised on 1/2/25 revealed he was at risk for impaired cognitive function/dementia or impaired thought processes r/t Dementia. Interventions included COMMUNICATION: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. Use simple, directive sentences. Provide with necessary cues- stop and return if agitated. Observation on 05/12/25 at 11:41 revealed 3 razors in a cup on top of the sink in Resident #80's bathroom. Interview on 05/12/25 at 11:50 AM with RN I revealed Resident #80 went OOP this past weekend and his family probably provided him with the razors. She stated staff should ensure Resident #80 did not have any sharps in his possession upon returning from being OOP. She stated nursing staff should also be on the look out during rounding. RN I stated she was the floor nurse on duty on this date, 05/12/25, and did not notice the razors because she had not been in the bathroom. She stated she was not sure if the residents were allowed to have razors in their possession but would check. She stated Resident #80 and his roommate were fairly independent but questioned their level of cognition. Follow up interview on 05/12/25 at 12:30 PM with RN I revealed residents were not able to have razors in their possession according to facility policy. She stated there were residents on the hallway that had Dementia, were confused and who wandered. She stated it would be a safety hazard for the residents so it was up to nursing staff to ensure the environment was safe. Interview on 05/14/25 at 11:50 AM with the DON revealed it was facility policy that residents were not allowed to have sharps in their possession or in their room to prevent accidents and to keep the residents environment safe. The DON stated he was not sure if there were residents who wandered who lived on the same hall as Resident #80. However, he stated there were Residents who were confused and who had Dementia. Review of facility policy, Accident Intervention, undated, read in relevant part, POLICY: It is the policy of this facility that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents PURPOSE: The purpose is to ensure that the facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident to prevent avoidable accidents. This includes systems and processes designed to: Identify hazard(s) and risk(s); Evaluate and analyze hazard(s) and risk(s); Implement interventions to reduce hazard(s) and risk(s); and Monitor for effectiveness and modify approaches as indicated

Based on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 24 residents (Resident #84) reviewed for MDS transmission. Resident #84's discharge MDS assessment was completed but not transmitted within 14 days of completion. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings were: Review of Resident #84's face sheet, dated 05/15/2025, revealed an admitted [DATE] and a discharge date of [DATE], with diagnoses that included: Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Post-traumatic stress disorder ( psychiatric condition that may occur in people who have experienced or witnessed a traumatic event or series of traumatic events). Review of Resident #84's Discharge MDS Assessment, dated 12/20/2024, revealed the assessment had been completed but not transmitted to CMS. During an interview on 05/15/2025 at 1:37 p.m. MDS Nurse B revealed the Discharge MDS assessment was completed for Resident #84, but it was not transmitted. MDS Nurse B further stated the Discharge MDS assessment should have been transmitted within 14 days after completion. MDS nurse B stated she did not really know how it was overlooked. MDS Nurse B stated it was the MDS Nurses' responsibility to complete and transmit the Discharge MDS assessment. During an interview on 05/15/2025 at 2:30 p.m. the DON stated the MDS Nurses were responsible for the accuracy and completion of MDS assessments. The DON was not sure why Resident #84's Discharge MDS assessment would have been missed. MDS Nurse B revealed she used the RAI as resource and could electronically access it on her laptop. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual Version 1.19.1, dated October 2024, revealed 09. Discharge Assessment Return Not Anticipated (A0310F = 10) [ .] Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days).

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 Residents (Resident #150) who were reviewed for dignity. The facility failed to ensure Resident #150 had clothes to wear while providing physical therapy out in the hallway. This deficient practice could affect any resident and contribute to feelings of dissatisfaction or poor self-esteem. The findings were: Review of Resident #150's face sheet, dated 5/15/25, revealed he was admitted to the facility on [DATE] with diagnoses including Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, subsequent encounter and Cognitive communication deficit. Review of Resident #150's initial admission record, dated 5/4/25, revealed he was alert, oriented to time able to follow simple commands. Review of Resident #150's Care Plan, initiated 5/5/25, revealed he was At risk for impaired cognitive function/dementia or impaired thought processes r/t infection of cardiac device, liver cirrhosis, HTN, CKD 3. Interventions included Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions, Social Services to provide psychosocial support as needed. During an interview on 5/12/2025 at 9:34 AM with OTA F revealed she showered Resident #150 on the morning of 5/12/2025. She stated she tried to dress him afterwards and discovered he had no clean clothes so she went to the laundry and could not find any clothes to fit him he is tall. OTA F stated she dressed him in a double gown after she conferred with LVN A. During an interview on 5/12/2025 at 10:00 AM with the ADM revealed the morning of 5/12/2025 he was alerted that Resident #150 had been dressed in a double gown because he had no clean clothes at the time and was in the rehabilitation gym. The ADM stated he gave a peer administrator in training some money to purchase clothing for Resident #150. The ADM stated it was his expectation to have Residents treated with dignity and thus provided clothing for Resident #150. During an observation and interview on 5/12/2025 at 11:00 AM revealed Resident # 150 was dressed in a cloth double gown and was ambulating with a gait belt and wheelchair with PT G. PT G stated OTA F showered Resident #150 and dressed him in double gowns. During an interview on 5/12/2025 at 11:05 AM, LVN A stated she knew why Resident #150 had no clothes because his wife had not brought him any. Observation and interview on 05/12/25 11:18 AM revealed Resident #150 was lying in bed with gown on. Resident #150 presented as being anxious and irritable. During an interview on 5/12/2025 at 11:20 AM revealed Housekeeper Supervisor stated and demonstrated the laundry had lost and found clothes available for residents who needed clothes. She stated the laundry had a turnaround from 1 day to the next. Observation and interview on 05/14/25 at 03:20 PM revealed Resident #150 was in the therapy gym. Resident #150 was wearing a pair of faded sweat pants and shirt that appeared small for his height. During an interview on 5/15/2025 at 09:30 AM with the DOR revealed OTA F showered Resident #150 and dressed him in a double gown due to not having clothes that morning, on 5/12/2025. The DOR stated Resident #150 received treatment in his gown, in public hallway and therapy gym. Observation and interview on 05/15/25 at 11:02 AM with Resident #150 revealed he was sitting in a wheelchair by the bed. He was wearing a pair of sweat pants and a t-shirt. Resident was talkative during this visit. Asked him about his preference r/t wearing gowns vs. regular clothes. Resident #150 commented Well, I don't even know what I was wearing yesterday, but I hate those things. Asked what he meant and he stated the gowns, Hate those things. I would rather wear clothes. Interview on 05/15/25 at 03:01 PM with LVN A revealed she called Resident #150's family member the first day back on duty after Resident #150's admission. She let the family member know Resident #150 would need more clothes. She stated he only had 2 outfits. She was not sure if they were his own or if staff obtained them from lost and found. She stated the CNA's knew to look in the laundry for clothes for residents who needed clothes. She stated she did not give them instructions to get him some clothes and did not talk to the ADON about the fact Resident #150 had no clothes or limited clothes. However, she stated it came up during a morning meeting and the SW became involved. LVN A stated obtaining clothes for residents was not a priority once she made initial contact with a family member. She stated she had too many other residents and duties to perform. LVN A stated nursing staff worked together to obtain clothes as needed. She stated based on a reasonable person concept most people would want to wear clothes while receiving therapy out in public in a hallway. She stated it was a matter of preserving the resident's dignity. Interview on 05/15/25 at 3:31 PM with the DOR revealed Resident #150's rehabilitation was initiated on 5/5/25. Initially, rehabilitation staff met with him in his room because he was not able to tolerate getting out of bed because he had surgery prior to admission. She stated this was the first week Resident #150 started receiving therapy out of his room, in the hallway and in the gym. She stated rehabilitation staff got involved in looking for clothes that fit him but were not able to find any because he was such a big/tall man. Interview on 5/15/25 at 3:46 PM with the SSS revealed she learned about Resident #150 not having clothes during the morning meeting on 5/14/25. She stated Resident #150's family member was in the facility on the same date, 5/14/25, and she talked with the family member about providing clothes. The family member commented she thought the facility would provide gowns. The SSS told her the facility preferred residents wore clothes during therapy. She stated the family member told her she would bring some clothes in a couple of days. Interview on 05/16/25 at 3:00 PM with the DON revealed he did not know Resident #150 did not have any clothes until the survey team entered on 5/12/25. He stated it was their policy residents wear clothes while receiving therapy especially out in public to preserve their dignity. He stated even though some residents might not have a problem with it, they would want the residents to wear clothes. The DON stated Resident #150 was cognitively impaired and might not be able to tell someone his preference but again it was their policy to maintain the dignity of the residents. Review of facility policy, Resident Rights, undated, read in relevant part POLICY: It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The Resident has the right: 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality.

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #8) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #8. This deficient practice could place residents at risk of keeping them from calling for help as needed. The findings were: Record review of Resident #8's face sheet, dated 05/15/2025, revealed she was admitted to the facility on [DATE] with diagnoses which included: unspecified dementia (a general term for a progressive decline in mental abilities, impacting memory, thinking, and reasoning to the point of interfering with daily life), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified lack of coordination, unsteadiness on feet, unspecified diastolic (congestive) heart failure (occurs when the left ventricle, the heart's main pumping chamber, struggles to relax and fill with blood during the diastole phase of the heartbeat), heart failure, unspecified, pain in joints of right hand, pain in joints of left hand, and other abnormalities of gait and mobility. Record review of Resident #8's Annual MDS assessment, dated 03/31/2025, revealed the resident's BIMS score was 8, which indicated moderate cognitive impairment. The Annual MDS assessment further revealed Resident #8 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to lying, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tube/shower transfer. Record review of Resident #8's care plan, target date of 06/30/2025, revealed Resident #8 did not reflect the use of the call light. Observation and interview on 05/12/2025 at 11:36 a.m. revealed Resident #8 sitting in her wheelchair next to her bed with over bed table in front of her and call light hanging down from the grab bar at the top of her bed resting on the floor behind Resident #8's wheelchair. Resident #8 stated she did not use her call light much, but if the staff do not get to her fast enough, she would use her call light. Resident #8 attempted to maneuver her wheelchair and reach her call light. Resident #8 stated she was not able to get to it. Observation and interview on 05/12/2025 at 11:45 a.m. revealed MA B and LVN D in Resident #8's room with MA B picking up the call light off the floor and discussed with LVN D the call light did not have a clip. MA B placed the call light on the side of the bed next Resident #8 near her wheelchair. LVN D stated resident did use her call light. LVN D further stated the call light should be placed right next to residents. LVN D stated the purpose of the call light was if residents needed anything it would notify the staff. LVN D stated it was everyone's responsibility to ensure the call lights were within reach of residents. MA B stated Resident #8's call light was on the floor behind her wheelchair when she entered the room and Resident #8 would not have been able to use the call light. MA B further stated the call light was for in case a resident needed anything, and Resident #8 was able to use her call light. During an interview on 05/15/2025 at 2:28 p.m. the DON stated the call lights were to alert the staff residents needed help. The DON stated anyone who was to go into the rooms was responsible for call light placement. The DON further stated by not having a call light could cause a delay in care. The DON stated as far as he was aware Resident #8 did typically use her call light and theoretically it could have dropped behind her chair. The DON stated a clip could be used to prevent the call light from falling. During an interview on 05/15/2025 at 2:55 p.m. the Administrator stated call lights needed to be within reach or they needed to be able to demonstrate they could get to the call light. The Administrator stated the purpose of the call lights were to alert staff of any needs that may arise with a resident. The Administrator state a resident could potentially attempt to perform the care themselves and fall or prolong them from receiving the care they needed. The Administrator further stated everyone was responsible for the placement of the call light. Record review of facility's Routine Procedures Call Light/Bell policy, revised 05/2007, read Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff. Procedures: #5. Leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor.

Based on observations, interviews and record reviews the facility failed to ensure the residents had the right to voice grievances to include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 8 residents (Residents #259) reviewed for grievances. On 5/10/2025 Resident #259 made a grievance to the cook to which he did not document and/or report the grievance. This failure could place residents at risk for harm by leaving residents with frustration and demoralization. The findings included: A record review of Resident #259's admission record dated 5/15/2025 revealed Resident #259 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included major depressive disorder, anxiety, and post-traumatic stress disorder (PTSD). A record review of Resident #259's care plan dated 5/8/2025 revealed, [sic(Resident #259)] is at risk for re traumatization related to history of trauma PTSD related to disasters . caregivers to provide opportunity for positive interaction, attention. Stop and talk with him as passing by. document behaviors and resident response to interventions. [sic(Resident #259)] has history of major depressive disorder encouraged to express feelings. monitor document report to nurse doctor signs and symptoms of depression . as potential nutritional problem . honor resident rights to make personal dietary choices A record review of the facility's grievance records for the month of May 2025 revealed no evidence of any grievance report for Resident #259 for the complaints made on 5/10/2025. During an observation and interview on 5/12/2025 at 11:59 AM revealed Resident #259 was in his room seated in his wheelchair. Resident #259 stated, that earlier in the day, he reported to the assistant food service manager (AFSM) that he was served raw chicken for lunch on 5/10/2025 and the [NAME] was rude and yelled. Resident #259 stated the Food Service Manager had come to speak with him that morning and heard his complaints. Resident #259 stated, I took a picture of the pink in the middle chicken breast and went to the kitchen and complained to the cook. he then came to my room and took the chicken in his hand and shredded the chicken and yelled 'I cooked the f***ing chicken myself and this is not raw,' . CNA E saw and heard him . During interview on 5/14/2025 at 1:38 PM the FSM stated the AFSM had reported to him on Monday 5/12/2025 that Resident #259 had complained he was served undercooked chicken on Saturday 5/10/2025. The FSM stated he spoke with Resident #259 and heard the report that the cook had served Resident #259 undercooked chicken. The FSM stated he began an in-service for his team to reinforce training for checking temperatures of meals served and had reviewed the temperature logs for Saturday's lunch and the temperatures were safe. The FSM stated he had not documented a grievance report and was not aware if anyone had documented a grievance report. During interview on 5/14/2025 at 1:44 PM the AFSM stated she was approached by Resident #259 on the morning of Monday 5/12/2025 and was told Resident #259 was served raw chicken for lunch on Saturday 5/10/2025. The AFSM stated Resident #259 was upset and claimed the cook came to his room and shredded the chicken breast and was rude and yelled. The AFSM stated she spoke with the [NAME] and the FSM, and the cook stated he had not yelled and shredded the chicken to demonstrate the chicken was cooked thoroughly. The AFSM stated she had not documented the complaint on a grievance form and stated she was not aware of where the forms were kept nor how to use the form. During an interview on 5/14/2025 at 1:52 PM the [NAME] stated on Saturday during the lunch service Resident #259 came to the kitchen to complain the chicken was undercooked. The [NAME] stated he went with Resident #259 to his room to see the meal. The [NAME] stated he took the chicken and pulled it apart to reveal the chicken was fully cooked. The [NAME] stated he was accompanied by CNA E. The [NAME] stated he was not rude, nor did he raise his voice. The [NAME] stated he did not document a grievance report because he did not know about the form. During an interview on 5/15/2025 at 10:42 AM CNA E stated she was a witness to the Saturday 5/10/2025 incident where Resident #259 was in his room with the [NAME] and they were reviewing the lunch meal served. CNA E stated the [NAME] was not rude nor did he raise his voice. CNA E stated Resident #259 was upset and believed the chicken lunch was undercooked. CNA E stated she had not documented a grievance form and in retrospect she could have alerted the nurse to document a grievance form. During an interview on 5/15/2025 at 11:00 AM the Administrator stated the expectation was for any staff member who heard a complaint to document the complaint on a grievance form which would then be submitted to himself for review. The Administrator stated he was not aware of the complaint until the surveyor's investigation. The administrator stated the potential for harm to residents would be their grievances would go unheard, undocumented, and unreviewed for resolution. A record review of the facility's Grievances policy dated 12/2023, revealed, It is the policy of this facility to establish a grievance process that allows the resident(s) a way to execute their right to voice concerns or grievances to the facility or other agency/entity without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the resident may have

Based on observations , interviews and record reviews the facility failed to ensure alleged violations involving abuse or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or not later than 24 hours if the events that cause the allegation do not involve abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 8 residents (Resident #259 ) reviewed for reporting alleged verbal abuse. On Monday 5/12/2025 Resident #259 reported to the assistant food service manager (AFSM) that on Saturday 5/10/2025 the cook was rude and yelled while in his room reviewing the lunch meal served. The AFSM did not report the alleged verbal abuse and or mistreatment. The failure could place residents at risk for verbal abuse. The findings included: A record review of Resident #259's admission record dated 5/15/2025 revealed Resident #259 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included major depressive disorder, anxiety, and post-traumatic stress disorder (PTSD). A record review of Resident #259's care plan dated 5/8/2025 revealed, [sic(Resident #259)] is at risk for re traumatization related to history of trauma PTSD related to disasters . caregivers to provide opportunity for positive interaction, attention. Stop and talk with him as passing by. document behaviors and resident response to interventions. [sic(Resident #259)] has history of major depressive disorder encouraged to express feelings. monitor document report to nurse doctor signs and symptoms of depression . as potential nutritional problem . honor resident rights to make personal dietary choices A record review of the facility's grievance records for the month of May 2025 revealed no evidence of any grievance report for Resident #259 for the complaints made on 5/10/2025. A record review of the Texas Unified Licensure Information Portal website accessed 5/14/2025 revealed no evidence for a facility related incident report on behalf of Resident #259. During an observation and interview on 5/12/2025 at 11:59 AM revealed Resident #259 was in his room seated in his wheelchair. Resident #259 stated, that earlier in the day, he reported to the assistant food service manager (AFSM) that he was served raw chicken for lunch on 5/10/2025 and the [NAME] was rude and yelled. Resident #259 stated the Food Service Manager had come to speak with him that morning and heard his complaints. Resident #259 stated, I took a picture of the pink in the middle chicken breast and went to the kitchen and complained to the cook. he then came to my room and took the chicken in his hand and shredded the chicken and yelled 'I cooked the f***ing chicken myself and this is not raw,' . CNA E saw and heard him. During interview on 5/14/2025 at 1:44 PM the AFSM stated she was approached by Resident #259 on the morning of Monday 5/12/2025 and was told Resident #259 was served raw chicken for lunch on Saturday 5/10/2025. The AFSM stated Resident #259 was upset and claimed the cook came to his room and shredded the chicken breast and was rude and yelled. The AFSM stated she spoke with the [NAME] and the FSM and the [NAME] stated he had not yelled and shredded the chicken to demonstrate the chicken was cooked thoroughly. The AFSM stated she had not reported to anyone that Resident #259 alleged he was yelled at by the [NAME] because, I know the [sic(Cook)] and he is not the kind of person to cuss or yell. During an interview on 5/15/2025 at 11:00 AM the Administrator stated the expectation was for any staff member who heard an allegation of abuse, neglect, and or exploitation (ANE) to immediately report the allegation to himself the Administrator. The Administrator stated he was not aware of the allegation until the surveyor's investigation. The Administrator stated the potential for harm to residents would be their allegations of ANE would go unheard, undocumented, and uninvestigated. A record review of the facility's undated Abuse: Prevention of and Prohibition Against revealed, Policy: it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. all allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the administrator

Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 4 Residents (Resident 150 and Resident #155) whose records were reviewed. 1. The facility failed to ensure Resident #150's baseline CP included the use of side rails. 2. The facility failed to ensure Resident #155's baseline CP included the use of side rails. This deficient practice could affect any resident and contribute to residents not having their needs met based on their assessment. The findings were: 1. Review of Resident #150's face sheet, dated 5/15/25, revealed he was admitted to the facility on [DATE] with diagnoses including Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, subsequent encounter and Cognitive communication deficit. Review of Resident #150's initial admission record, dated 5/4/25, revealed he was alert, oriented to time and able to follow simple commands. Review of Resident #150's Care Plan, initiated 5/5/25, revealed there was no indication he used side rails for bed mobility. Observation on 05/12/25 at 11:18 AM revealed Resident #150 was lying in bed with 1/4 SR's up on both sides of his bed. Resident #150 presented as being alert but confused. Interview on 05/15/25 at 04:13 PM with the DON revealed he wrote Resident #150's Care Plan. He stated Resident #150's Care Plan did not reflect he used side rails for bed mobility, but stated it should to ensure nursing staff understood Resident #150's needs. He stated nursing staff had access to the residents care plans and were supposed to follow them when providing assistance with ADL's. 2. Review of Resident 155's face sheet, dated 5/14/25, revealed she was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy (according to Cleveland Clinic: it is a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness and Heart Failure. Review of Resident #155's, initial admission record, dated 5/8/25, revealed she was alert, but confused, oriented to person and able to follow simple commands. Review of Resident #155's Care Plan, initiated 5/9/25, revealed there was no indication she used side rails for bed mobility. Interview on 05/15/25 at 04:20 PM with the DON revealed he wrote Resident #155's CP. He stated the CP did not reflect the use of side rails for mobility. He stated it was important so staff could know how to care for Resident #155. He stated the CP provided instructions on how Resident #155 used the side rails and would ensure nursing staff was using them appropriately. Review of facility policy, Comprehensive Person-Centered Care Planning, revised 08/2017, read in relevant part The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. PROCEDURES: 1. Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person- centered care. 2. The baseline care plan will include minimum healthcare information necessary to properly care for a resident including, but not limited to: a) Initial goals based on admission orders, b) Physician orders, c) Dietary orders, d) Therapy services, e) Social services; and f) PASARR recommendations, if applicable. 3. The facility team will provide a written summary of the baseline care plan to the resident or resident representative by completion of the comprehensive care plan.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframe's to meet a resident's medical and nursing needs for 1 of 6 Residents #Resident #21 whose records were reviewed. The facility failed to include the use of 1/2 side rails on Resident #21's Care Plan since his admission, 3/28/25. This deficient practice could affect any resident and contribute to residents not having their needs met according to their assessment. The findings were: Review of Resident #21's face sheet, dated 5/15/25, revealed he was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy (according to Cleveland Clinic: it is a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness}, Muscle weakness (generalized), Other lack of coordination and Other abnormalities of gait and mobility. Review of Resident #21's quarterly MDS assessment revealed his BIMS score was 14 of 15 reflective of minimal cognitive impairment; he required partial to moderate assistance with rolling left and right and required substantial to maximal assistance with from sitting to lying and from lying to sitting on side of bed. Review of Resident #21's Care Plan, initiated on 3/30/25 revealed there was no indication Resident #21 used SR's. Observation and interview on 05/13/25 at 09:45 AM revealed Resident #21 lying in bed with 1/2 SR's up on both sides of the bed. Interview with Resident #21 revealed he used the SR's for bed mobility. He stated the SR's were on the bed upon admission. Interview on 05/15/25 04:24 PM with the DON revealed he wrote Resident #21's Care Plan and stated he identified on this date, 5/15/25, the use of SR's was not on the CP. He stated it should be on the CP prior to implementing the use of side rails to ensure staff was aware Resident #21 was using side rails and the reason he was using them. This would ensure nursing staff provided the help needed when providing Resident #21 with ADL assistance. Review of facility policy, Comprehensive Person-Centered Care Planning, revised 08/2017, read in relevant part POLICY: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. PROCEDURES: 4. The comprehensive care plan will be developed by the IDT within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plans. 7. The facility IDT includes, but is not limited to the following professionals: A. Attending Physician or Non-Physician Practitioner (NPP) designee involvd in resident's care; B. Registered Nurse responsible for the resident; C. Nurse Aide responsible for the resident; D. Member of the Food and Nutrition services staff; E. To the extent practicable, resident and/or resident representative; F. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. 8. The facility will provide the resident and resident representative, if applicable, advance notice of care planning conference to encourage resident and/or resident representative participation. Care conference may be in the form of face to face meeting, conference calls or video conferencing. If not practicable, reason will be documented in the medical record.

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #1) reviewed for significant medication errors, in that: The facility failed to ensure that Resident #1 was administered Touch U-200 (long-acting insulin) and Novo Log (rapid-acting insulin) for 2 days from 3/12/25 to 3/14/25. The resident was sent to the hospital, admitted and diagnosed with Diabetic [NAME] Acidosis. The non-compliance was identified as IJ past non-compliance. The noncompliance began on 3/12/2025 and ended on 3/17/25. The facility had corrected the non-compliance before the survey began. This failure placed resident at risk for adverse side effects, and life-threatening complications . Findings include: Record review of resident #1's face sheet dated 3/20/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis (an illness where kidneys don't function, and a machine is required to filter blood through an artificial kidney), diabetes type 1 ( Illness where the pancreas does not produce insulin) and Hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). Record review of Resident # 1's hospital discharge instructions, reviewed 3/20/25 at 9:30 AM, dated 3/12/25, revealed an order for insulin Flex Touch U-200 administer 18 units subcutaneously daily, and Novo Log to be administered per sliding scale. Record review of Resident # 1's care plan dated 3/13/25 revealed [resident's name] has diabetes; interventions include administering diabetes medication as ordered. Record review of Resident # 1 Admission MDS dated [DATE] revealed BIMS assessment was left blank, indicating resident # 1 was unable to complete the interview. Record review of Resident #1's 3/14/25 blood sugar readings were as follows: at 12:45 PM 600 mg/dl, @ 230 PM 600 mg/dl Record review of Resident # 1 progress note 3/14/25 at 2 PM revealed Resident # 1 was returned to the facility early from dialysis due to hyperglycemia ( high blood sugar ) and sent to ER for evaluation. Record review of Resident # 1 hospital records revealed he was admitted to [local hospital] on 3/14/25 at 3:45 PM and diagnosed with Diabetic [NAME] Acidosis (a complication of diabetes in which acids build up in the blood to levels that can be life-threatening.) Review of hospital records reveled Resident # 1 remained in the hospital as of 03/21/2025. A record review of Resident #1's medication administration record conducted on March 19, 2025, revealed no orders for Novo Log per the sliding scale and no orders for Flex Touch U-200 for the dates March 13, 2025, to March 14, 2025. Interview with LVN (A ) on 3/20/25 at 3:50 PM, revealed that on 3/14/25 1235 PM, she was taking vital signs for Resident # 1, when he stated, I don't feel well. This is when resident # 1's family member asked LVN (A), Have you given him his Insulin ? LVN (A ) went to check the hospital admission orders for Resident #1 and discovered that the hospital orders for insulin had not been transcribed. LVN (A ) contacted ADON. Interview with ADON on 3/20/25 at 4:15 PM revealed that LVN (A ) contacted him on 3/14/25, estimated time of 12:45 PM, that orders for insulin for resident # 1 had not been transcribed. ADON advised LVN (A) to call the Nurse Practitioner for orders. Interview with NP B was attempted on 3/20/25, 3:00 PM but unsuccessful Interview with LVN (B), admitting nurse on 3/18/25 at 1:10 PM, revealed she entered orders for Resident # 1 on Electronic Medical Record (EMR) system when he was admitted on [DATE], she does not know if she possibly missed a page of the admission orders, LVN (B) stated that if a nurse does not transcribe MD orders upon admission, medication errors by omission may occur, leading to the unknown. In an interview with ADON on 03/18/25 at 11:45 PM, the ADON stated he was informed by LVN (A) of the missed order for Touch U-200 (long-acting insulin) 18 units subcutaneously daily and Novo Log (rapid-acting insulin) for Resident # 1 from 3/12/25 to 3/14/25. The ADON confirmed Resident # 1 had not received insulin for 2 days from 03/12/25-03/14/25, putting Resident # 1 at risk for hyperglycemia (elevated blood sugar levels). The ADON stated he expected all nursing staff to confirm discharge instructions and transcribe them to the EMR to ensure the administration of medications. Interview with DON on 3/19/25 at 10:25 A.M. revealed that on 3/14/24, he could not recall a time, ADON notified him that orders for insulin for Resident # 1 had not been transcribed, The DON stated that he expected all Licensed Nurses to follow policy and procedure regarding medication administration as failure to do so could negatively impact residents. DON had the ADON review all new admission orders, and the ADON audited all diabetic residents to ensure their orders were correct. In an interview with the Administrator on 03/19/25 at 1:00 PM, the Administrator stated the facility failed to provide necessary medication to Resident #1 per the Physician's order. The Administrator stated he expected nursing staff to follow Physicians' orders. In an interview with the Medical Director on 3/19/25 at 3:15 PM, he stated he did not recall exactly what Resident #1's admitting orders were, but recalled he did ask the facility to continue hospital orders, and he was not concerned when they told him about the missed long acting and short acting insulin because long-acting insulin continues to work for 36-40 hours. Prior to survey entrance, the facility provided in-service to 100 % of Nursing staff on 3/14/24 - 3/17/24 regarding transcribing MD orders and entering orders on to the Electronic Medical Record (Orders), audit of all new admission and Residents with diagnosis of Diabetes for order accuracy. Record review of the facility policy named Nursing Administration, revised May 2007, revealed, note and initiate physician orders . This was verified by the following : Interview with LVN (A) on 3/20/25 at 6:10 AM, confirmed completion of in-services regarding transcribing MD orders, entering orders on EMR system, admission checklist / Procedure: LVN ( A ) was able to verbalize understanding and the information provided in the in-service/training. Interview with LVN (C) on 3/20/25 at 6:20 AM, confirmed completion of in-services regarding transcribing MD orders, entering orders on EMR system, admission checklist / Procedure: LVN ( C ) was able to verbalize understanding and the information provided in the in-service/training. Interview with LVN (D) on 3/20/25 at 6:30 AM, confirmed completion of in-services regarding transcribing MD orders, entering orders on EMR system, admission checklist / Procedure: LVN (D ) was able to verbalize understanding and the information provided in the in-service/training. Interview with LVN (E) on 3/20/25 at 7:05 AM, confirmed completion of in-services regarding transcribing MD orders, entering orders on EMR system, admission checklist / Procedure: LVN ( E ) was able to verbalize understanding and the information provided in the in-service/training. Interview with LVN (F) on 3/20/25 at 8:15 AM, confirmed completion of in-services regarding transcribing MD orders, entering orders on EMR system, admission checklist / Procedure: LVN ( F ) was able to verbalize understanding and the information provided in the in-service/training. Interview with LVN (G) on 3/20/25 at 8:30 AM, confirmed completion of in-services regarding transcribing MD orders, entering orders on EMR system, admission checklist / Procedure: LVN ( G ) was able to verbalize understanding and the information provided in the in-service/training. Interview with LVN (H) on 3/20/25 at 9:20 AM, confirmed completion of in-services regarding transcribing MD orders, entering orders on EMR system, admission checklist / Procedure: LVN ( H ) was able to verbalize understanding and the information provided in the in-service/training. Interview with LVN (I) on 3/20/25 at 9:30 AM, confirmed completion of in-services regarding transcribing MD orders, entering orders on EMR system, admission checklist / Procedure: LVN ( I ) was able to verbalize understanding and the information provided in the in-service/training. Interview with LVN (J) on 3/20/25 at 9:45 AM, confirmed completion of in-services regarding transcribing MD orders, entering orders on EMR system, admission checklist / Procedure: LVN ( J ) was able to verbalize understanding and the information provided in the in-service/training. Interview with LVN (K) on 3/20/25 at 10:00 AM, confirmed completion of in-services regarding transcribing MD orders, entering orders on EMR system, admission checklist / Procedure: LVN ( K ) was able to verbalize understanding and the information provided in the in-service/training. Interview with LVN (L) on 3/20/25 at 10:15 AM, confirmed completion of in-services regarding transcribing MD orders, entering orders on EMR system, admission checklist / Procedure: LVN ( L ) was able to verbalize understanding and the information provided in the in-service/training. Interview with RN (M) on 3/20/25 at 11:00 AM, confirmed completion of in-services regarding transcribing MD orders, entering orders on EMR system, admission checklist / Procedure: RN ( M ) was able to verbalize understanding and the information provided in the in-service/training. Record review on 03/19/2025 of audit performed by ADON revealed admissions from 03/14/2025, to 03/16/2025, new admissions and all diabetic residents electronic medical record was reviewed for accuracy and completion. Observation on 3/19/25 at 1230 PM revealed LVN (B) and RN (M) transcribing and entering MD orders on EMR system . Observation on 3/19/25 at 2:30 P.M. revealed DON randomly checking new admission orders, ensuring MD orders were transcribed and entered on EMR system. The non-compliance was identified as past non-compliance. The noncompliance IJ began on 3/12/25 and ended on 3/17/25. The facility had corrected the non-compliance before the survey began.

Based on observations, interviews, and record review the facility failed to implement a comprehensive person-centered care plan for 2 of 8 residents (Resident #1 and Resident #2) reviewed for Care Plans. 1. The facility failed to ensure Resident #1 was receiving assistance with eating as detailed in his Care Plan and was left unsupervised in his room during the evening meal on [DATE]. Resident #1 was pronounced deceased at the facility on [DATE]. 2. The facility failed to ensure Resident #2 was receiving assistance with eating as detailed in her Care Plan. On [DATE] at 12:13 pm an Immediate Jeopardy (IJ) was identified. While the immediacy was removed on [DATE] at 7:42 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed all residents at risk for weight loss, malnutrition, and/or dehydration due to lack of proper assistance. Findings included: 1. Record review of Resident #1's Admission Record, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), dysphagia (difficulty swallowing), lack of coordination, depression (low mood), anxiety (feeling of dread, fear, or uneasiness), PTSD, and cognitive communication dysfunction (difficulty with thinking and language). Record review of Resident #1's imaging report, dated [DATE], revealed: .Swallowing Function .HISTORY: s/s of aspiration at bedside, dysphagia [difficulty swallowing]. Feeding difficulties .Difficulty swallowing . Record review of Resident #1's Care Plan, dated [DATE], revealed: [Resident #1] has elected DNR status .ADL Self Care Performance Deficit .Will safely perform ADLs .EATING: requires staff assistance . Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 14, suggesting intact cognition. Further review of this assessment revealed Resident #1 required partial/moderate assistance with eating. Record review of Resident #1's Speech Therapy Notes, dated: [DATE], revealed: .Required verbal cues to complete mastication and swallow bolus .Patient at risk of aspiration of food, liquids, and secretions due to delayed movements and delayed swallow reflex . [DATE], revealed: Patient protruding tongue from oral cavity when trying to consume food requiring tactile cues to move tongue posteriorly to allow for intake . [DATE], revealed: Requires verbal cues to swallow secretions to reduce anterior leakage or episodes of coughing .Patient requiring increase time to facilitate A-P propulsion [second step in the oral phase of swallowing] in order to manage secretions. Frequently exhibits coughing when attempting to swallow built up saliva . Record review of Resident #1's Progress Note, dated [DATE], revealed, .ADLs .Eating: Limited assistance .One-person physical assist . Record review of facility's 24-hour log, dated [DATE], revealed: . [Resident #1] .Assist with feedings . Record review of Resident #1's Progress Notes revealed, Effective Date: [DATE] [11:19 pm] . While in another residents [sic] room assisting CNA's, another staff member called me into another residents [sic] room d/t resident choking. This nurse entered residents' [sic] room approx. [6:57 pm] resident was occasionally coughing and choking. Large amounts of secretions noted expelling from resident's mouth, this nurse wiping secretions from mouth. This nurse instructed staff member to call another nurse for assistance at [6:58 pm]. Resident coughed up dime size piece of broccoli. Other nurse came to render aide immediately, while other and [sic] staff members remained with resident, this nurse called 911 at [7:01 pm]. While on the phone with 911, other nurse and CNA's were performing the Heimlich maneuver. Once this nurse ended call with 911, applied O2 nasal cannula @,d+[DATE] LPM while suctioning secretions from residents [sic] mouth. Resident noted with occasional breath and cough. [Fire Department] arrived approximately [7:11 pm], who then attempted to obtain o2 sat via pulse ox, and applied EKG leads to resident. On call [Physician] called at [8:00 pm] left message for on call physician, and wife [Resident #1's wife] after to inform of incident. Medic [ .] stated resident with asystole, [Fire Department] ME pronounced TOD @ [7:16 pm]. ME investigator [sic] notified [ .], instructed this nurse to call [Police Department] .Author: [LVN A] . During telephone interview on [DATE] at 10:34 am, LVN A said she was called by MA A and told Resident #1 was choking. When she arrived in Resident #1's room, she found Resident #1 sitting up in the wheelchair with his tray in front of him. LVN A stated due to Resident #1's condition he was unable to make the universal sign for choking, adding average person would wail or put their hands on their throat LVN A Resident #1 was tense and was holding the seat of the chair tight and we instructed him to let go and sat him up a little more, he had a lot of secretions in his mouth she saw a piece of broccoli come out of his mouth. LVN A said she instructed MA A to get RN A and RN A came immediately. RN A said 911 should be called because Resident #1 was not making the traditional choking signs, LVN A said she was unable to explain the noise Resident #1 was making. LVN A said she called 911 at 7:01 pm and then retrieved the crash cart to give oxygen and suctioning. LVN A said Resident #1 had a lot of secretions, and he took occasional breaths. LVN A stated when EMS arrived, they connected Resident #1 to the pulse oximeter and the EKG leads and EMS stated that he was asystole (absence of heartbeat). LVN A said Resident #1 required assistance with eating but was not sure if it was in his care plan. LVN A said she was not familiar with resident care plans and was not sure if staff were required to review care plans. LVN A added she had not been told resident care plans needed to be reviewed. LVN A said the Kardex did not sound familiar to her. During telephone interview on [DATE] at 12:18 pm, CNA A said on [DATE] she was feeding Resident #1 dinner when a coworker asked for help with a lift transfer, adding she left Resident #1's room and went to help with the other resident. CNA A said while they were in the other resident's room, she heard someone yell out for the nurse and followed the nurse into Resident #1's room. She noticed Resident #1 was having a hard time breathing, adding the resident had some saliva coming out of his mouth. CNA A said she and CNA N attempted to open Resident #1's mouth using a tongue depressor, adding she patted the resident's back and noticed he was having a hard time breathing. CNA A further stated MA A and CNA N stood Resident #1 up and CNA started the Heimlich for a few seconds, no more than 5 she believed, because it was hard to hold him up. CNA A said the nurse instructed someone to get the crash cart and LVN A started suctioning. CNA A and LVN A began to pat Resident #1 on the back. CNA A said when RN A arrived, she told LVN A to call 911. CNA A said she did not know if Resident #1 lost consciousness because she left the resident's room before EMS arrived to assist other residents. CNA A said staff initiated the Heimlich Maneuver because they were not sure if he was choking or if it was saliva. She said she figured if Resident #1 was choking it would make the obstruction come out, but she did not see any food just saliva. CNA A said CNAs did not have individual cards printed for the residents, so she just went by what she was told, adding the only ones that have information regarding the residents' level of assistance required were the nurses. During telephone interview on [DATE] at 2:01 pm, RN A said she was called by MA A and was told they needed help because Resident #1 was making weird noises. When she arrived in Resident #1's room, he was making weird noises and LVN A and MA A were in the room when she arrived. RN A said she tried to assess Resident #1 and noted he had a lot of secretions coming out of his mouth and he was coughing. She provided Resident #1 with back thrusts. RN A said she told LVN A to call 911. She said CNA N and CNA A entered Resident #1's room and while RN A was thrusting the resident's back the CNAs attempted finger sweeps. RN A said she told LVN A to get the crash cart for the suction. In the meantime, CNA A started the Heimlich, but he did not cough anything up. RN A said LVN A arrived with the suction to see if there was anything in his mouth. RN A said she got secretions and the tiniest piece of broccoli, like half the size of her thumb nail, less than dime size. RN A said she stood behind Resident #1 while he was seated in his wheelchair and tried the Heimlich. RN A said Resident #1's lips were getting cyanotic (blue discoloration) but did not think the resident lost consciousness because his eyes were open and moving around and he was trying to breath and cough the whole time. RN A said she was called to help with Resident #1 but was not familiar with his care plan because she was assigned to another hall. During interview on [DATE] at 3:17 pm, CNA A said every resident had a Kardex in POC where information regarding ADLs was found. CNA A said the Kardex would have said the level of assistance Resident #1 required but did not remember what his Kardex said on [DATE]. 2. Record review of Resident #2's Admission Record, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Encephalopathy (conditions that cause brain dysfunction), dysphagia (difficulty swallowing), dementia (group of thinking and social symptoms that interferes with daily functioning), and cognitive communication deficit (difficulty with thinking and language). Record review of Resident #2's Care Plan, dated [DATE], revealed: [Resident #2] ADL Self Care Performance Deficit r/t ENCEPHALOPATHY .EATING: requires x1 staff assistance with feeding . Record review of Resident #2's Comprehensive MDS assessment, dated [DATE], revealed a BIMS score of 5, suggesting severe cognitive impairment. Record review of Resident #2's Kardex, dated [DATE], revealed: EATING: level of assistance ranges from substantial/maximal assistance to complete dependence on staff . Record review of Resident #2's Progress Notes, dated [DATE] and [DATE], revealed, .ADLs .Eating: Extensive assistance .One-person physical assist . During observation and interview on [DATE] at 8:34 am, Resident #2 was sitting in the hallway with another resident eating breakfast on her own. LVN D said Resident #2 and the other resident enjoyed eating in the hallway together and added Resident #2 did not require assistance during meals. Further observation at 8:55 am revealed Resident #2 was still eating her breakfast in the hallway unassisted. During an interview on [DATE] at 12:22 pm, CNA B said Resident #2 was not assigned to her but to her knowledge Resident #2 was required to be fed all three meals. Observation on [DATE], beginning at 12:40 pm and ending at 12:53 pm, revealed Resident #2 sitting at a table in the dining room eating without staff assistance. Resident #2 was observed eating very slowly, taking her second bite at 12:43 pm. At 12:46 pm, Resident #2 attempted to take a third bite but brought the empty spoon to her mouth. Resident #2 took a third bite of food at 12:47 pm, followed by 2 empty spoons at 12:50 pm and 12:51 pm. During an interview on [DATE] at 1:35 pm, LVN C said he had not heard nurses were required to review care plans. LVN C further stated he did know where resident care plans were found and reviewed care plans when there was additional information, he needed to learn about a particular resident. LVN C said he felt care plans should always be reviewed prior to providing care. LVN C further stated, as a nurse, reviewing care plans would probably be expected to learn what the residents' needs were. LVNC further stated it was important to review care plans so that care was provided according to the residents' needs. During an interview on [DATE] at 2:13 pm, LVN D said if a care plan said a resident required staff assistance for eating it could be for set up or encouragement, cuing, or actual feeding and if a resident required assistance x1, staff fed the resident. During interview on [DATE] at 2:29 pm, (translated from Spanish) Resident #2 nodded her head when asked by the state investigator if she needed help eating and shook head, as in no when asked if she received help. Another resident which sat next to Resident #2 in the hallway said Resident #2 did not receive assistance with meals and so she did not eat unless she received encouragement. During an interview on [DATE] at 2:38 pm LVN O said nurses were shown how to find resident care plans but did not know if they were required to review care plans. LVN O further stated care plans were where all the information about the residents' care was found. During interview on [DATE] at 2:52 pm, CNA C said she told the nurse Resident #2 seemed to be declining, sometimes the resident ate and others she sat in a daze. CNA C further stated she chose to start assisting Resident #2 with dinner because she did not want her to lose weight. CNA C said she did not know what Resident #2's Kardex said regarding eating, adding she fed the resident due to decline and not due to what the Kardex said. During observation and interview on [DATE] at 5:46 pm, CNA C was assisting Resident #2 with her evening meal. CNA C said Resident #2 required assistance with eating because otherwise she would not eat or brought the spoon to her mouth empty. During interview on [DATE] at 6:17 pm, LVN C said he did pass out the lunch trays to the residents in the dining room on [DATE] but was not familiar with the residents and was not aware Resident #2 required assistance with eating. During interview on [DATE] at 12:12 pm, CNA E said she did not know how to access the residents' Kardex prior to [DATE] and had just learned because she only worked on the weekends. CNA E said if she was not familiar with a resident, she asked the nurse about the residents' level of care. CNA E further stated she fed Resident #2 because the family said that she would not eat. CNA E said Resident #2's plan said assisted feeder but that she fed Resident#2 because she wanted to make sure she ate. CNA E said assisted feeder meant that the resident was able to eat independently but needed cues. She stated it was required that someone sit with Resident #2 through all her meals. CNA E demonstrated how to access POC, Resident #2's POC notes on [DATE] in the eating tab said Resident #2 was dependent on staff for eating. Record review of facility's policy, titled Policy/Procedure - Nursing Administration .Care and Treatment .ADL's & Staffing, undated, revealed: .4. Assist with care as required based off resident needs that include but not limited to .feeding . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 12:13 pm. The DON was notified and was provided with the IJ template on [DATE] at 1:05 pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 4:47 pm and included the following: [Facility] Plan of Removal [DATE] Per the information provided in the IJ Template given on [DATE], the facility failed to keep Resident #1 safe from Accident Hazards by not providing the proper supervision during evening meal on [DATE]. Immediate Action o Medical Director notified of Immediate Jeopardy on [DATE] at 8 :26pm. o Resident #1 is no longer in the facility. o Resident# 2 was assessed for signs of aspiration. o Resident's# 2 Primary Care Physician will be notified resident wasn't assisted for 12min with feeding, o 100 % audit was completed on care plans to ensure care plan is resident specific to residents [sic] need of assistance with eating. Audit was started on [DATE] and will be completed by [DATE] at noon. The MDS nurse will be responsible for completing the care plan audit by [DATE] at 12 (noon). o The MDS nurse will revise the care plan [sic] and Kardex to ensure all needs are being meet [sic]. This process started on [DATE] and will be ongoing. o CNA C received a one-on-one in-service [sic] on [DATE], on remaining with the resident through the whole entire meal when assisting a resident with eating. o All licensed staff and CNAS were in-serviced [sic] on accessing the Kardex. Ln-services [sic] started on [DATE] at 12 (noon) and will be completed [DATE] By 12 (noon). Any staff not receiving in-service [sic] will be removed from the schedule until the in-service [sic] has been completed. o 100 % of Licensed Nurses were in-serviced [sic] on how to access the care plans and review the plan of care. In-service [sic] started on [DATE] and will be completed by [DATE]. Any staff not receiving in-service will be removed from the schedule until the in-service [sic] has been completed. o Ln-service [sic] on verification of meal trays was completed with 100 % Licensed and registered nurses. In-service [sic] started on ,d+[DATE] /24 and completed on [DATE]. Any staff not receiving in-service [sic] will be removed from the schedule until the in-service [sic] has been completed. o ln-service [sic] on assisting a resident with feeding was done 100 % with licensed staff and CNAS. ln-service [sic] started on [DATE] at 12 (noon) and will be completed [DATE] By 12 (noon). o ln-service [sic] on ADL coding for Licensed staff and CNAs' for [sic] eating was started [DATE] and will be completed by [DATE]. Any staff not receiving in-service [sic] will be removed from the schedule until the in-service [sic] has been completed. o The assistant director of nursing will be responsible to ensure that PRN staff, agency staff, and any new hires receive all training related to the IJ. Any staff not receiving in-service [sic] will not be on the schedule until all in-services [sic] have been completed. The DON and the Administrator will monitor this process starting [DATE]. o Any resident who requires assisted dining and choses to stay in the room will have a CNA assigned to assist with dinning [sic] in their room and will be logged in a log with the name of the CNA assigned to feed. Process started on [DATE]. This will be monitored by the nurse managers daily and charge nurses will assign CNAs to residents who need assisted dining and want to dine in their room. o LVN C received one on one in-serviced [sic] regarding Kardex and care plans to learn levels of assistance for resident cares and ADL's, completed [DATE]. Identification of Others Affected All residents have the potential to be affected by this alleged deficient practice. Systemic Change to Prevent Re-occurrence. 1. The dietary manager will update meal ticket to reflect resident need for assisted dinning [sic]. This will begin on [DATE]. Meal tickets will be audited weekly by the ADON and the dietary manager to ensure residents needs are reflected. 2. Charge Nurses will initial meal ticket to ensure proper meal is served and will document by checking residents name and signing log once meal has been verified. This process started on [DATE]. 3. Kardex have been updated to reflect ADL specific assistance for eating. Kardex update was started on [DATE] and will be completed by [DATE] at noon. 4. Any resident who requires assisted dining and choses [sic] to stay in the room will have a CNA assigned to assist with dining [sic] in their room and will be logged in a log with the name of the CNA assigned to feed. Process started on [DATE]. 5. An off cycle QAPI was conducted on [DATE] to review Plan of removal. 6. A log was created that contains the date/start/end of shift, Kardex, care plan, any changes, if any and nurse manager signature, this process started on [DATE]. 7. The DON created a mandated schedule for a nurse manager to hold huddles at start and end of shift in order to review and ensure staff know of any changes/updates to the care plan and to ensure current interventions in place, this process was started [DATE]. 8. Nurse managers at that time will be responsible to updating care plans and flagging care plans for the next shift to review, this process started on [DATE]. 9. Any agency/contract, new hired staff is required to see nurse manager prior to start of shift for care plan and Kardex review, this process started on [DATE]. 10. Kardex to be used for shift change report, this process started on [DATE]. 11. All nursing staff was in-serviced [sic] on how to refer to Kardex in POC and care plan in PCC, in addition to the care plan binder printed out and stored at the nurse's station, this process started on [DATE] and will be at 100% by [DATE] at 3:00PM. Monitoring 1. Nurse manager will be present for every meal to ensure residents that require assisted dining [sic] are assisted. This process was started on [DATE]. 2. MDS nurse and Nurse Managers will monitor Kardex daily to ensure any changes needed if any, have been updated to Kardex. This was process started on [DATE]. 3. Nurse Manager and MDS nurse would review care plan/Kardex binder daily to ensure if any changes needed and if any will be updated. This process started on [DATE] at 6pm. 4. Nurse managers will review log daily for residents eating in room to ensure they are being assisted by a staff member. This Process was started on [DATE]. 5. Nurse Manager will monitor Kardex to ensure it is being used for shift change report, this process started on [DATE] at 10:00PM. 6. Nurse Managers will be monitoring staff to ensure care plans and Kardex are being reviewed by staff. 7. Nurse Managers will ensure Kardex binders are at each nurse's station daily with Kardex report, which pulls directly from the care plans, this process started on [DATE]. 9. Summary of IJ and corrective action to be reviewed by QAPI monthly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance, process started [DATE]. Verification of POR: Record review of facility's In-service Training Report sign-in sheets dated [DATE]-[DATE], revealed 87 out of 87 active nursing/therapy staff were in-serviced in-person and via telephone regarding the following topics: Kardex, Care Plans, feeding residents, assisting residents with meals, and ADL coding. During interviews between [DATE] and [DATE], with 6 nursing staff and 2 therapy staff on the 6 am - 2 pm shift (4 LVNs, 2 CNAs, 1 ST, and 1 PT), 7 nursing staff on the 2 pm - 10 pm shift (1 RNs, 2 LVNs, 3 CNAs, and 1 CMA), and 3 CNAs on the 10 pm - 6 am shift, staff said they had been in-serviced regarding how to access the residents' Kardex and Care Plans in PCC, ADL coding, and feeding residents. During an interview on [DATE] at 1:49 pm, LVN E said she had received in-services on [DATE] regarding how to find care plans and Kardex, and everything on how to take care of the residents. LVN E said she was expected to review care plans at the beginning of the shift, after report and prior to care. LVN E further stated changes to the care plans should be communication during shift change. LVN E said the nurse must assign a CNA to each resident that required assistance with meals and ensure that residents were not left alone during meals and that they are positioned correctly. During an interview on [DATE] at 2:02 pm, LVN F said she had received in-services during the last three days (starting Thursday or Friday). LVN F further stated the in-services were about care plans, ADL coding, and the Kardex. She said the in-services also included where the care plans and Kardex were located. LVN F said they were expected to review care plans and Kardex every day for changes at the beginning at the shift. During an interview on [DATE] at 2:06 pm, LVN G said he had received in-service yesterday [DATE] regarding how to access the care plans, the Kardex, and how mealtimes would operate. During an interview on [DATE] at 11:12 pm, CNA J said she received in-service over the past 4 days regarding the Kardex and how to access it. CNA J further stated ADL terms were reviewed, adding if a resident required assistance with eating, staff assisted as needed and if a resident required one-person assist staff were to assist them to eat and were required to stay with the resident during the meal. During meal observation on [DATE], beginning at 1:15 pm, Residents #2, 3, and 4 were fed their meals by staff. Residents' meal tickets read assisted dining. During an interview on [DATE] at 5:09 pm, RN B said she assisted in the dining room and remained in the dining room through the entirety of the meal service to ensure CNAs were feeding appropriately and for safety (choking, etc.). RN B said the floor nurses were responsible for the residents eating in their rooms and assignments for the CNAs assisting residents eating in their rooms. During an interview on [DATE] at 6:29 am, CNA L said he received in-services regarding where to find resident information in POC and added staff were not allowed to leave the resident unattended during meals if they required assistance. During an interview on [DATE] at 11:58 am, CNA H said she was in-serviced regarding ADLs, Kardex, and determining how much assistance the residents required during meals. CNA H further stated the in-services included assisting residents with feeding, communicating with residents, and providing cues during meals. CNA H said staff were not allowed to leave residents unattended when assisting with eating because the resident could choke or put something in their mouth that they should not be eating. CNA H said she was able to check the Kardex at any time and during shift report and was expected to review the Kardex during shift change to familiarize herself with resident care required. CNA H said staff were now expected to review the Kardex with the oncoming shift prior to providing care. During interview on [DATE] at 12:39, pm CNA H said she received several in-services on [DATE] and [DATE] regarding the Kardex and care plans, adding they were available in a binder at the nurses' station. CNA H further stated the in-services included ADL coding and said the definitions of each term was located on the wall by the nurses' station. CNA H said the Kardex included how residents transferred, hygiene (showers), and if they needed assistance with eating. CNA H said supervision while eating meant staff watched while the resident ate (they might have swallowed issues) and staff had to stay with the resident for the whole meal. CNA H said if a resident required assistance, it could be just for cues and reminders (like if they had dementia, they might need reminders) or if they needed help using utensils. CNA H said when a resident was assisted with meals they should not be left alone; you should finish the meal with them. CNA H said extensive/dependent meant the resident needed to be fed small bites, making sure they were clearing their mouth (not pocketing) and giving sips in between every few bites (like 3 or 4). CNA H said the residents' Kardex needed to be reviewed every day during report because it could change every day, and staff needed to ensure there were not any changes to resident care. During interview on [DATE] on 1:38 pm, LVN L said she did receive in-services regarding shift report, Kardex and care plans, including changes. LVN L further stated staff were to review care plans and Kardex, including changes, with the oncoming shift during report. LVN L said care plans were expected to be reviewed before care was provided to residents, adding this was always the expectation. LVN L said she assigned CNAs to assist residents that required assistance with eating. LVN L said supervision during meals meant residents needed to be overseen while they ate. LVN L further stated if a resident required assistance, it meant the resident was taken to the dining room or assigned a CNA to help them eat, adding the staff was required to stay with the resident during the entire meal. During interview on [DATE] at 1:46 pm, the ST said she received in-services regarding ADL coding, Kardex, and care plans. The ST said the care plans and Kardex were found in PCC under the resident's tab. The ST further stated the care plans/Kardex contained information regarding the residents' level of care, such as, transfers, eating, and bed mobility. During an interview on [DATE] at 1:52 pm, the PT said he received in-service regarding ADL coding (defined the functional levels) and making sure they had a list of residents that required assistance with eating. During an interview on [DATE] at 2:56 pm, LVN J said each nurse manager was assigned a shift and were to observe shift change report, provide education, and answer questions. During joint interview on [DATE] at 3:34 pm, LVN D said he received in-services regarding the Kardex and care plans. LVN B said the in-services included ADL coding, updating the Kardex and care plans, nurse rounds, and observing huddles (shift change report) for CNAs and nurses. LVN B said if a resident required assistance with feedings, staff were not allowed to leave the resident unattended during the meal. LVN B said she and LVN D were responsible for updates to the care plans and communication with the therapy team and nursing staff regarding any changes. LVN B said the audits of the care plans and Kardex were completed, and no discrepancies were found. LVN D said care plans were made more specific and resident driven. During interview on [DATE] at 3:53 pm, MA A said she did receive in-services on [DATE] and [DATE] regarding the Kardex, where to find them in the POC, and if she was unable to locate it, it was at each nurses' station in a binder. MA A demonstrated how to access the Kardex in POC and where to find binder at the nurses' station with each resident's care plan and Kardex. During interview on [DATE] at 4:00 pm, LVN A said she did receive in-services regarding the Kardex and care plans, how to access them, and what they each included. LVN A said the care plans were more detailed, for nursing, and the Kardex were for CNAs. LVN A further stated it was her responsibility, as the nurse, to ensure CNAs assisted residents that required assistance with meals and ensured that they stood with the residents until the meal was completed. LVN A said she was expected to review care plans during shift change report for each resident she was assigned to and notified management if there were any changes that needed to be made. During interview on [DATE] at 4:08 pm, CNA B said she did receive in-services over the last few days regarding the Kardex and how to access them, and definitions of ADL terms. CNA B demonstrated how to access the Kardex and said she was expected to review it during shift change report and as needed. During interview on [DATE] at 4:14 pm, CNA A said she did receive in-services regarding using the Kardex during rounds and shift change report. CNA A said if a resident required assistance with eating staff were not supposed to leave their side, were required to be attentive to the resident, and not talk on the phone or other people. During interview on [DATE] at 4:25 pm, LVN N said did receive in-services regarding the Kardex, ADLs and coding, feeding assistance. LVN N said her responsibility was to identify which residents required assistance with eating, which wanted to eat in the dining room, and which wanted to eat in their rooms prior to beginning her shift. LVN N further stated the residents that required assistance with eating and chose to stay in their room, staff were required to always stay in the r[TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 8 residents (Residents #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was not left unsupervised in his room during the evening meal on [DATE]. Resident #1 was pronounced deceased at the facility on [DATE]. On [DATE] at 4:21 pm an Immediate Jeopardy (IJ) was identified. While the immediacy was removed on [DATE] at 7:42 pm, the facility remained out of compliance at scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed all residents at risk for serious injury, harm, and/or death due to lack of appropriate supervision. Findings included: Record review of Resident #1's Admission Record, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Dysphagia (difficulty swallowing), lack of coordination, Depression (low mood), Anxiety (feeling of dread, fear, or uneasiness), PTSD, and cognitive communication dysfunction (difficulty with thinking and language). Record review of Resident #1's imaging report, dated [DATE], revealed: .Swallowing Function .HISTORY: s/s of aspiration at bedside dysphagia. Feeding difficulties .Difficulty swallowing . Record review of Resident #1's Care Plan, dated [DATE], revealed: [Resident #1] has elected DNR status .ADL Self Care Performance Deficit .Will safely perform ADLs .EATING: requires staff assistance . Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 14, suggesting intact cognition. Further review of this assessment revealed Resident #1 required partial/moderate assistance with eating. Record review of Resident #1's Speech Therapy Notes, dated: [DATE], revealed: .Required verbal cues to complete mastication and swallow bolus .Patient at risk of aspiration of food, liquids and secretions due to delayed movements and delayed swallow reflex . [DATE], revealed: Patient protruding tongue from oral cavity when trying to consume food requiring tactile cues to move tongue posteriorly to allow for intake . [DATE], revealed: Requires verbal cues to swallow secretions to reduce anterior leakage or episodes of coughing .Patient requiring increase time to facilitate A-P propulsion in order to manage secretions. Frequently exhibits coughing when attempting to swallow built up saliva . Record review of Resident #1's Progress Note, dated [DATE], revealed, .ADLs .Eating: Limited assistance .One person physical assist . Record review of facility's 24-hour log, dated [DATE], revealed: . [Resident #1] .Assist with feedings . Record review of Resident #1's Progress Notes revealed, Effective Date: [DATE] [11:19 pm] . While in another residents [sic] room assisting CNA's, another staff member called me into another residents [sic] room d/t resident choking. This nurse entered residents' [sic] room approx. [6:57 pm] resident was occasionally coughing and choking. Large amounts of secretions noted expelling from resident's mouth, this nurse wiping secretions from mouth. This nurse instructed staff member to call another nurse for assistance at [6:58 pm]. Resident coughed up dime size piece of broccoli. Other nurse came to render aide immediately, while other and [sic] staff members remained with resident, this nurse called 911 at [7:01 pm]. While on the phone with 911, other nurse and cna's were performing the Heimlich maneuver. Once this nurse ended call with 911, I applied O2 nasal cannula @,d+[DATE] LPM while suctioning secretions from residents [sic] mouth. Resident noted with occasional breath and cough. [Fire Department] arrived approximately [7:11 pm], who then attempted to obtain o2 sat via pulse ox, and applied EKG leads to resident. On call [Physician] called at [8:00 pm] left message for on call physician, and wife [Resident #1's wife] after to inform of incident. Medic [ .] stated resident with asystole, [Fire Department] ME pronounced TOD @ [7:16 pm]. ME investigator [sic] notified [ .], instructed this nurse to call [Police Department] .Author: [LVN A] . During an interview on [DATE] at 3:36 pm, RN D said Resident #1 required staff assistance with meals because he ate very slow. RN D further stated if a resident required assistance with meals staff were expected to be with the resident throughout the entire meal. During a telephone interview on [DATE] at 10:34 am, LVN A said she was called by MA A and told Resident #1 was choking. When she arrived in Resident #1's room, she found Resident #1 sitting up in the wheelchair with his tray in front of him, LVN A further stated due to Resident #1's condition he was unable to make the universal sign for choking, he was tense, average person would wail or put their hands on their throat, but Resident #1 was holding the seat of the chair tight and we instructed him to let go and sat him up a little more, he had a lot of secretions in his mouth she saw a piece of broccoli come out of his mouth. LVN A said she instructed MA A to get RN A she came immediately and said we should call 911 because he was not making the traditional choking signs, LVN A said she was unable to explain the noise Resident #1 was making. LVN A said she called 911 at 7:01 pm and then retrieved the crash cart to give oxygen and suctioning. LVN A said Resident #1 had a lot of secretions, and he took occasional breaths. LVN A when EMS arrived, they connected Resident #1 to the pulse oximeter and the EKG leads and EMS stated that he was asystole (absence of heartbeat). LVN A said Resident #1 needed some assistance with meals but was able to feed himself, he moved very slow due to his condition, he opened his mouth really slow, and he chewed very slow, and drooling was normal for him, so he did have a lot of secretions. LVN A said Resident #1 did require assistance with eating. LVN A further stated Resident #1 was on a mechanical soft diet and received mechanical soft diet on [DATE]. LVN A said if a resident required assistance with eating the staff were required to sit with the resident for the entire meal but did not know if they were able to leave the room or not. LVN A said she was not specifically told Resident #1 required assistance with eating, but it was in the reports that he needed assistance. LVN A further stated she was not sure why Resident #1 required assistance with eating but said it might have been for safety. During a telephone interview on [DATE] at 12:18 pm, CNA A said on [DATE] she was feeding Resident #1 dinner when a coworker asked for help with a lift transfer, adding she left Resident #1's room and went to help with the other resident. CNA A said while they were in the other resident's room, she heard someone yell out for the nurse and followed the nurse into Resident #1's room and noticed Resident #1 was having a hard time breathing, adding the resident had some saliva coming out of his mouth. CNA A said she and CNA N attempted to open Resident #1's mouth using a tongue depressor, adding she patted the resident's back and noticed he was having a hard time breathing, CNA A further stated MA A and CNA N stood Resident #1 up and CNA started the Heimlich for a few seconds, no more than 5 she believed because it was hard to hold him up. CAN A the nurse instructed someone to get the crash cart and LVN A started suctioning and CNA A and LVN A began to pat Resident #1 the back. CNA A said when RN A arrived, she told LVN A to call 911. CNA A said she did not know if Resident #1 lost conscience because she left the resident's room before EMS arrived to assist other residents. CNA A said Resident #1 was assisted with meals because he was a slow eater and required assistance guiding the spoon or cup to his mouth. CNA A said she was told to assist Resident #1 and she did, she added that as far as she knew she was not expected to stay with Resident #1 while she assisted him with his meal. CNA said she did not know what the facility's protocol was regarding assisted dining and no one had told her what the procedures were for assisting residents with meals. CNA A further stated she was not specifically told to stay in the room, just to assist Resident #1 with meals. CNA A said staff initiated the Heimlich Maneuver because they were not sure if he were choking or if it were saliva, so said figured if Resident #1 were choking it would make the obstruction come out, but she did not see any food just saliva. CNA A said CNAs did not have individual cards printed for the residents, so she just went by what she was told, adding the only ones that have information regarding the residents' level of assistance required were the nurses. During a telephone interview on [DATE] at 2:01 pm, RN A said she was called by MA A and was told they needed help because Resident #1 was making weird noises, adding when she arrived in Resident #1's room he was making weird noises and LVN A and MA A were in the room when she arrived. RN A said she tried to assess Resident #1 and noted he had a lot of secretions coming out of his mouth and he was coughing, adding she provided Resident #1 with back thrusts. RN A said she told LVN A to call 911 and CNA N and CNA A entered Resident #1's room and while RN A was thrusting the resident's back the CNAs attempted finger sweeps. RN a said she told LVN A to get the crash cart for the suction and in the meantime CNA A started the Heimlich, but he did not cough anything up. RN A said LVN A arrived with the suction to see if there was anything in his mouth. RN A said she got secretions and the tiniest piece of broccoli, like half the size of her thumb nail, less than dime size. RN A said she stood behind Resident #1 while he was seared in his wheelchair and also tried the Heimlich. RN A said Resident #1's lips were getting cyanotic (blue discoloration) but did not think the resident lost consciousness because his eyes were open and moving around and he was trying to breath and cough the whole time. RN A said she was called to help with Resident #1 but was not familiar with him because she was assigned to another hall. During an interview on [DATE] at 2:45 pm, CNA B said when assisting residents with eating staff were not allowed to leave the resident's room for any reason because they can choke or aspirate. During an interview on [DATE] at 3:17 pm, CNA A said she did know that staff were required to stay with the residents for the entire meal if the resident was dependent on staff for eating. but if the resident just needed assistance with eating, the staff monitored the resident in case the resident needed help; in which case the staff were allowed to leave the room if needed. CNA A further stated Resident #1 was not dependent on staff for eating and just needed assistance with eating. CNA A said on [DATE], before she left the room, she left the table in front of Resident #1 in case he needed a drink but moved the plate back where he was unable to reach it. During an interview on [DATE] at 11:03 am, LVN B said if a resident required assistance with eating it meant they required staff assistance, and some residents needed to be fed. LVN B further stated this information was found in the residents' Kardex. LVN B said when a resident required assistance with eating it meant staff just helped the resident with setting up their tray or if the resident needed water, adding staff were not required to stay in room with the resident. LVN B said Resident #1 required assistance with eating, but he ate by himself or was sometimes fed by the family. LVN B said staff were not required to stay with Resident #1 during meals and as far as she knew he did not require supervision while eating. During an interview on [DATE] at 2:13 pm, LVN D said if a resident required staff assistance for eating staff were required to be in the room with the resident throughout the entire meal. LVN D further stated if they had to leave the resident's room during a meal, the staff needed to get someone to relieve them, adding the resident should not be left alone at any time during the meal. During an interview on [DATE] at 2:38 pm, LVN O said if a resident required assistance with eating and staff were required to stay with the resident for the entire meal and were not allowed to leave the room unless there was an emergency. LVN O further stated this was important because staff were to monitor the resident for choking, signs of aspiration, and how much he ate. LVN O said nurses were responsible for ensuring staff stayed in the room when assisting residents with eating. LVN O said she did not believe Resident #1 was able to feed himself. LVN O further stated if the staff were feeding Resident #1 on [DATE], her expectation was for the staff to stay in room with him for the entire meal, adding this was important in case anything happened, such as aspiration or the incident on [DATE]. LVN O said the nurses on the floor were responsible for ensuring staff were with the resident's during meals if they required assistance. During interview on [DATE] at 4:06 pm, the DM said Resident #1 was supervised when he ate in the dining room because he was a very slow eater but did not know if he required assistance or supervision. The DM said Resident #1 received a mechanical soft diet on [DATE] which he ate in his room. During interview on [DATE] at 5:11 pm, the DOR said she was not very familiar with Resident #1, but the ST worked with him during his stay and was told by the ST Resident #1 fluctuated, sometimes he ate independently and sometimes he needed assistance. The DOR further stated he needed supervision for verbal cues and assistance with eating. The DOR said supervision with eating meant someone should be sitting with the resident throughout the entire meal and the expectation was that staff was to remain in the room with Resident #1 while he ate, adding staff should not have left the room. The DOR further stated it was important that staff remained with Resident #1 to monitor his eating, to ensure he swallowed his food, was drinking between bites, safety, and to ensure he tolerated the diet he was ordered without any risks, such as aspiration. During a telephone interview on [DATE] at 9:58 am, the ST said Resident #1 was very slow to move due to his disease process and she worked with him on communication and eating. The ST said Resident #1 did require some cueing to swallow his saliva. The ST said Resident #1 he did not require someone with him while he ate. The ST further stated Resident #1 did not have issues with mastication or aspiration and her only requirement was that he be up in his wheelchair. The ST said there was always a risk for choking due to of Resident #1's disease process. During a telephone interview on [DATE] at 11:49 am, the ST said the details of her [DATE] progress note was communicated to nursing, adding CNAs on the floor were very good with Resident #1 and went into his room several times to check on him. The ST further stated Resident #1 had a lot of saliva and needed cues to swallow throughout the day. The ST said in her opinion Resident #1 did not require constant supervision during meals, but staff always checked on him because he was slow to eat and spent more time with him when he was having a hard day. The ST said Resident #1 aspirated on his own secretions but there is nothing that could done about that. Record review of facility's policy, titled Policy/Procedure - Nursing Administration .Care and Treatment .ADL's & Staffing, undated, revealed: It is the policy of this facility to ensure the safety and comfort of the resident .2. Observe resident for .safety .4. Assist with care as required based off resident needs that include but not limited to .feeding . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:21 pm. The DON was notified and was provided with the IJ template on [DATE] at 7:45 pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 11:04 am and included the following: [Facility] Plan of Removal [DATE] Per the information provided in the IJ Template given on [DATE], the facility failed to keep Resident #1 safe from Accident Hazards by not providing the proper supervision during evening meal on [DATE]. Immediate Action o Medical Director notified of Immediate Jeopardy on [DATE] at 8 :26pm. o Resident #1 is no longer in the facility. o Resident# 2 was assessed for signs of aspiration. o Resident's# 2 Primary Care Physician will be notified resident wasn't assisted for 12 min with feeding, o 100 % audit was completed on care plans to ensure care plan is resident specific to residents 'need of assistance with eating. Audit was started on [DATE] and will be completed by [DATE] at noon. The MDS nurse will be responsible for completing the care plan audit by [DATE] 12 noon. o The MDS nurse will revise the care plan and Kardex to ensure all needs are being met. This process started on [DATE] and will be ongoing. o CNA A received a one-on-one in-service on [DATE], on remaining with the resident through the whole entire meal when assisting a resident with eating. o All licensed staff and CNAS were in-serviced on accessing the Kardex. In-service started on [DATE] at 12 noon and will be completed [DATE] By 12 NOON. Any staff not receiving in-service will be removed from the schedule until in-service has been completed. o 100 % of Licensed Nurses were in-serviced on how to access the care plans and review the plan of care. In-service started on [DATE] and will be completed by [DATE]. Any staff not receiving in-service will be removed from the schedule until in-service has been completed. o in-service on verification of meal trays was completed with 100 % Licensed and registered nurses. in-service started on ,d+[DATE] /24 and completed on [DATE]. Any staff not receiving in-service] will be removed from the schedule until in-service has been completed. o in-service on assisting a resident with feeding was done 100 % with licensed staff and CNAS. in-service started on ,d+[DATE] /24 at 12 noon and will be completed [DATE] By 12 (noon). o in-service on ADL coding for Licensed staff and CNAs for eating was started [DATE] and will be completed by [DATE]. Any staff not receiving in-service will be removed from the schedule until in-service has been completed. o The assistant director of nursing will be responsible to ensure that PRN staff, agency staff, and any new hires receive all training related to the IJ. Any staff not receiving in-service will not be on the schedule until all in-services have been completed. The DON and Administrator will monitor this process starting [DATE]. o Any resident who requires assisted dining and choses to stay in the room will have a CNA assigned to assist with dining in their room and will be logged in a log with the name of the CNA assigned to feed. Process started on [DATE]. This will be monitored by the nurse managers daily and charge nurses will assign CNAs to residents who need assisted dining and want to dine in their room. Identification of Others Affected All residents have the potential to be affected by this alleged deficient practice. Systemic Change to Prevent Re-occurrence. 1. Dietary manager will update meal ticket to reflect resident need for assisted dining. This will begin on [DATE]. Meal tickets will be audited weekly by the ADON and the dietary manager to ensure residents needs are reflected. 2. Charge Nurses will initial meal ticket to ensure proper meal is served and will document by checking residents name and signing log once meal has been verified. This process started on [DATE]. 3. Kardex have been updated to reflect ADL specific assistance for eating. Kardex update-was started on [DATE] and will be completed by [DATE] at noon. 4. The Nurse Managers will monitor staff to ensure the Kardex and care plan are followed this will occur every shift, they will sign a log once they have observed staff this will be started on [DATE] at 2:00PM. 5. Any resident who requires assisted dining and chooses to stay in the room will have a CNA assigned to assist with dining in their room and will be logged in a log with the name of the CNA assigned to feed. Process started on [DATE]. 6. An off cycle QAPI was conducted on [DATE] to review Plan of removal. Monitoring 1. Nurse manager will be present for every meal to ensure residents that require assisted dining are assisted. This process was started on [DATE]. 2. MDS nurse and Nurse Managers will monitor Kardex daily to ensure any changes needed if any, have been updated to Kardex. This was process started on [DATE]. 3. Nurse managers will review log daily for residents eating in room to ensure they are being assisted by a staff member. This process was started on [DATE]. 4. Nurse Managers will be monitoring staff to ensure care plans and Kardex are being reviewed by staff. 5. Any issues identified with residents dining needs will be corrected immediately on the meal ticket Kardex and care plan. This process will start [DATE] and will be on going. Any issues identified will be reviewed in the QAPI monthly meeting. 6. Summary of IJ and corrective action to be reviewed by QAPI monthly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Verification of POR: Record review of facility's In-service Training Report sign-in sheets dated [DATE]-[DATE], revealed 87 out of 87 active nursing/therapy staff were in-serviced in-person and via telephone regarding the following topics: feeding residents, assisting residents with meals, abuse/neglect, and ADL coding. During interviews between [DATE] and [DATE], with 6 nursing staff and 2 therapy staff on the 6 am - 2 pm shift (4 LVNs, 2 CNAs, 1 ST, and 1 PT), 7 nursing staff on the 2 pm - 10 pm shift (1 RNs, 2 LVNs, 3 CNAs, and 1 CMA), and 3 CNAs on the 10 pm - 6 am shift, staff said they had been in-serviced regarding ADL coding, and feeding residents. During interview on [DATE] at 1:49 pm, LVN E said she had received in-services on [DATE] regarding resident diets, and reviewing care plans. LVN E said she must assign a CNA to each resident that required assistance with meals and ensure that residents was not left alone during meals and they are positioned correctly. During interview on [DATE] at 2:02 pm, LVN F said she had received in-services during the last three days (starting Thursday or Friday) regarding feeding residents and ADL coding. LVN F further state she was expected to review care plans every day for changes at the beginning at the shift. During interview on [DATE] at 2:06 pm, LVN G said he had received in-service on [DATE] regarding how mealtimes would operate, the duties of the nurses and CNAs during meals, and protocols regarding feeding residents. LVN G further stated staff were instructed on how to feed residents and staff were expected to stay with the resident for the entire meal. During interview on [DATE] at 11:03 pm, CNA F said when staff were feeding residents they were not allowed to leave a resident alone and must stay with the resident throughout the entire meal. During interview on [DATE] at 11:12 pm, CNA J said she received in-service regarding taking care of the resident and feeding if the resident needed help eating. CNA J further stated she staff were not allowed to leave a resident unattended while assisting them with eating. CNA J said ADL terms were reviewed during the in-service. CNA J said if a resident required supervision it meant the staff just watched because the resident was able to eat independently (monitoring for choking of if help was needed) . CNA J further stated a if a resident required 1-person assist then one staff was required to be with that resident assisting them to eat and was required to stay with the resident during the entire meal. During meal observation on [DATE], beginning at 1:15 pm, Residents #2, 3, and 4 were fed their meals by staff. Residents' meal tickets read assisted dining. During interview on [DATE] at 5:09 pm, RN B said she assisted in the dining room and I remained in the dining room through the entirety of the meal service to ensure the CNAs were feeding appropriately and for safety (choking, etc.). RN B said the floor nurses were responsible for the residents eating in their rooms. RN B further stated the charge nurses made assignments for the CNAs assisting residents eating in their rooms. During interview on [DATE] at 6:29 am, CNA L said he received in-service regarding feeding residents, adding staff were not allowed to leave residents unattended during meals if they required assistance. During interview on [DATE] at 11:58 am, CNA H said she was in-serviced regarding ADLs, determining how much assistance the resident requires during meals and assisting the residents with feeding. CNA H said staff were not allowed to leave residents when assisting with eating because they can choke or put something in their mouth that they should not be eating. During interview on [DATE] at 12:39, pm CNA H said she received several in-services on [DATE] and [DATE] regarding ADL coding, that was located by the nurses station, posted on the wall. CNA H said if a resident required supervision when eating staff watched while they ate because they might have issues with swallowing and were required to stay with the resident the whole time. CNA H further stated if a resident required assistance with eating it could mean the resident needed cues or reminders (like if they had dementia) or if they needed help using utensils. CNA H said when assisting resident with eating, the resident must not be left alone; you should finish the meal with them. CNA H said if a resident required extensive/dependent assistance, it meant staff fed the resident small bites and made sure the resident was clearing their mouth (not pocketing food) and was required to stay with the resident throughout the meal. During an interview on [DATE] on 1:38 pm, LVN L said she received in-service . LVN L said her responsibility was to ensure a can was assigned to assist residents that require assistance with eating. LVN L further stated if a resident required supervision during meals they needed to be overseen when eating. LVN L said if a resident required assistance when eating she took the resident to the dining room or assigned a CNA to assist them with their meal. LVN L further stated if a resident required assistance when eating staff were required to stay with the resident for the entirety of the meal. During an interview on [DATE] at 1:46 pm, the ST said she received in-service regarding ADL coding and feeding residents. The SR said the facility added the level of assistance each resident needed to the meal tickets. The different types of abuse and who we report it to, the administrator/abuse coordinator. The ST said the definitions for the ADL coding was on the wall by the kiosks and the nurses' station. During an interview on [DATE] at 1:52 pm, the PT said he received in-service regarding ADL coding (defined the functional levels) and received a list of residents that required assistance with eating. During joint interview on [DATE] at 3:34 pm, LVN D said he received in-services regarding ADL coding,. LVN B said if a resident required assistance with feedings staff were not allowed to leave the resident unattended during the meal. LVN D said care plans were made more specific and resident driven. During interview on [DATE] at 4:00 pm, LVN A said she did receive in-services. LVN A said CNAs were assigned to the residents that required assistance with eating and the nurses ensured the CNAs stood with the resident until the meal was complete. During interview on [DATE] at 4:08 pm, CNA B said she did receive in-service over the last few days regarding feeding residents and definitions of ADL terms. CNA B demonstrated how to access the Kardex, said she was expected to review it during shift change report and as needed. During interview on [DATE] at 4:14 pm, CNA A said she did receive in-service regarding feeding residents. CNA A said if a resident required assistance with eating staff we are not supposed to leave their side and had to stay attentive to the resident. During interview on [DATE] at 4:25 pm, LVN N said she did receive in-service regarding ADLs coding and feeding assistance. LVN N said she was now required to identify which residents required assistance with eating, who wanted to stay in their room and who wanted to go to the dining room. LVN N further stated those residents that chose to eat in their room and required assistance was assigned a staff to stay in the room whole they ate. During interview on [DATE] at 4:35 pm, RN A said she did receive in-service regarding resident that eat in the dining room, documenting residents eating in their rooms and assigning CNAs to assist with eating. RN A said if a resident was not eating independently, she assigned a CNA to assist that resident. RN A further stated she was required to keep a log of each resident that required assistance with eating and the CNA assigned to assist with the meal. During interview on [DATE] at 4:44 pm, CNA M said she received in-service regarding how to feed residents and ADL coding, which describes how to assist the resident and how to feed them. CNA M said staff could not leave a resident alone when they assisted them with their meals. During a joint interview on [DATE] at 5:17 pm with the nurse managers, LVN K said the charge nurse logged each residents who chose to eat in their room and required assistance with eating. LVN K further stated the charge ensured staff stayed in the room with the resident throughout the entire meal. LVN J said they had to sign the log after the meal verifying the nurse managers checked to ensure the residents were assisted and the staff remained with them in the room for the entity of the meal. During a joint interview on [DATE] at 5:23 pm, the DON said an audit of all of the care plans was completed to ensure that all the Kardex had clear verbiage of the ADL coding and in-serviced the staff as well so that they are more familiar with the functional level meanings. The DON further stated he would be auditing the logs and conducting meal observations (making sure that the staff are staying with the residents and not leaving the residents unattended. The DON said there will be a nurse manager in the dining room for all meals to ensure the CNAs assisted residents without distractions and ensured safety. During an interview on [DATE] at 5:34 pm, the DM said management made sure residents were not left alone if they required assistance with dining. The DM further stated the meal tickets now said if the resident required assistance with eating, adding, it said assisted dining. During an interview on [DATE] at 5:43 pm, the Administrator said he and the DON created a daily checklist to make sure all agency and PRN completed in-services prior to their next shift and to ensure that shift change has been completed with a nurse manager and ensuring that in the dining services were conducted appropriately. The DON and Administrator were informed the Immediate Jeopardy (IJ) was removed on [DATE] at 7:42 pm. The facility remained out of compliance at scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.