Every finding on record at The Eden of Las Colinas

Based on observation, interview and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for four of ten residents (Resident #1, #2, #3, and #4) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #1, #2, #3 and #4's room were in a position that was accessible to the residents on 08/18/2026.This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: 1. Record review of Resident #1's Face Sheet, dated 08/18/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included lack of coordination and muscle wasting. Record review of Resident #1's Quarterly MDS Assessment, dated 06/17/26, reflected the resident had a BIMS of 1, which indicated severe cognitive impairment. The resident was a fall risk. Record review of Resident #1's Comprehensive Care Plan, dated 06/16/26, reflected the resident was a fall risk and an intervention was to ensure the resident's call light was within reach and to encourage the resident to use the call light. During an observation on 08/18/26 at 8:54 a.m., Resident #1 was observed lying in bed and his call light was located on the floor, under a bedside table, and out of the resident's reach. 2. Record review of Resident #2's Face Sheet, dated 08/18/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included seizures and impaired usage of the left arm and leg. Record review of Resident #2's Quarterly MDS Assessment, dated 07/01/26, reflected the resident had a BIMS of 14, which indicated, intact cognitive response. The resident had active diagnoses which included a stroke and seizure disorder. Record review of Resident #2's Comprehensive Care Plan, dated 05/20/26, reflected the resident was a fall risk and an intervention was to ensure the resident's call light was within reach and to encourage the resident to use the call light.During an observation on 08/18/26 at 8:55 a.m., Resident #2 was observed lying in bed and his call light was located on the floor, under the bed, and out of the resident's reach.3. Record review of Resident #3's Face Sheet, dated 08/18/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included stroke and amputation of left leg, below the knee. Record review of Resident #3's Quarterly MDS Assessment, dated 05/26/26, reflected the resident had a BIMS of 99, which indicated the resident was unable to complete the interview. The resident had an active diagnosis of a stroke. Record review of Resident #3's Comprehensive Care Plan, dated 07/13/26, reflected the resident was a fall risk and an intervention was to ensure the resident's call light was within reach and to encourage the resident to use the call light.During an observation on 08/18/26 at 8:57 a.m., Resident #3 was observed lying in bed and his call light was located on the floor and near his roommate's bed.4. Record review of Resident #4's Face Sheet, dated 08/18/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included history of falls and lack of coordination. Record review of Resident #4's Quarterly MDS Assessment, dated 06/17/26, reflected the resident had a BIMS of 99, which indicated the resident was unable to complete the interview. The resident had active diagnoses which included history of falls and lack of coordination. Record review of Resident #4's Comprehensive Care Plan, dated 05/06/26, reflected the resident was a fall risk and an intervention was to be sure the call light was within reach and encourage the resident to use the call light.During an observation on 08/18/26 at 8:58 a.m., Resident #4 was observed lying in bed and her call light was located on the floor, under the bed, and near the foot of her bed.During an interview on 08/18/26 at 9:27 a.m., the DON stated call lights should always be within reach of the resident. She stated the nursing staff made rounds and one expectation was to ensure the call lights were within reach. She was informed of Residents #1, #2, #3 and #4 not having their call lights within their reach and the DON stated Resident #1 always threw his call light on the floor, Resident #2 did not use his call light, but was capable of using his call light, and Residents #3 and #4 were incapable of using their call light due to their cognitive abilities. She stated she was unsure if Residents #3 and #4 were care planned for being unable to utilize their call light, but they were care planned to anticipate the residents' needs. She stated if the call lights were not within reach of the resident, they would be unable to contact staff if they needed immediate assistance.During an interview on 08/18/26 at 12:24 p.m., LVN P stated the call lights needed to be within the resident's reach so they could contact staff if they needed anything. She stated she was the nurse for the 300 hall. She was informed of Residents #1, #2, #3 and #4 not having their call light within reach and she stated when making their rounds, they were to check for call lights being placed within the resident's reach. She stated Resident #4 had a habit of throwing her call light on the ground, however, it was not care planned.During an interview on 08/18/26 at 12:44 p.m., LVN E stated she was the nurse for the 200 hall. She stated the call lights needed to be within the resident's reach so they could contact staff if they needed anything. She stated staff checked to ensure call lights were within the residents' reach when making rounds.Record review of the facility's policy on Call Light/Bell (08/03/21) reflected It is the policy of this facility to provide the resident a means of communication with nursing staff. 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 interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Residents #5 and #6) reviewed for ADL care provided to dependent residents. The facility failed to ensure Residents #5 and #6 received their scheduled showers for July and August 2026. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.Findings include: 1. Record review of Resident #5's Face Sheet, dated 08/18/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had a diagnosis which included need for assistance with personal care. Record review of Resident #5's Quarterly MDS Assessment, dated 07/02/26, reflected the resident had a BIMS of 7, which indicated severe cognitive impairment. The resident required substantial assistance with shower and bathing. Record review of Resident #5's Quarterly Comprehensive Care Plan, dated 06/30/26, reflected the resident had an ADL self-care deficit. The care plan revealed the resident preferred bed baths and an intervention included bathing the resident three times a week. There was no mentioning of the resident refusing showers or bed baths. Record review of Resident #5's Progress notes for the month of July and August 2026, reflected no documentation of the resident refusing showers/bed baths.Record review of the facility's shower sheet book for July and August 2026 revealed the following shower sheets for Resident #5: 07/03/26 (bed bath); 07/08/26 (bed bath); 07/13/26 (bed bath); 07/17/26 (bed bath); 08/12/26 (bed bath); 08/14/26 (bed bath).During an interview on 08/18/26 at 10:40 a.m., Resident #5 stated she had not been receiving her bed baths as scheduled. She stated she was scheduled to receive her bed baths on Mondays, Wednesdays and Fridays, but it was inconsistent. She stated she could not recall how many bed baths she received in July 2026 and August 2026, but they were not many. She stated she wanted her bed baths and not getting them made her feel terrible. She stated she preferred bed baths. She stated she complained about not getting her bed bath on 08/15/26 and was told it was the day CNA's responsibility. She stated she complained to a night CNA that night and was given a bed bath. She stated she had not had bed sores because of it but was worried about getting them. During an interview on 08/18/26 at 12:17 p.m., CNA C stated she was the CNA for the 300 hall. She stated they were required to complete a shower/bed bath sheet every time residents were scheduled for their showers. She stated she only provided Resident #5 bed baths, and the last time she gave the resident a bed bath was on 08/17/26. She stated she did not work the same hall every week so she could not explain why the resident may not be getting her bed baths. She stated if the residents were not receiving scheduled showers or bed baths they could get bed sores.During an interview on 08/18/26 at 12:24 p.m., LVN P stated she was the nurse for the 300 hall. She stated the CNAs were required to complete shower sheets every time residents were scheduled for showers, and they would still have to complete the form even if the resident refused. She stated the nurses were required to sign all shower sheets because they had to ensure there were no skin issues for the resident. She stated they were to check daily to ensure showers were being completed. She stated Resident #5 was scheduled for her showers on Mondays, Wednesdays, and Fridays on the day shift. She stated if the resident was not receiving their scheduled showers or bed baths, she could have skin breakdown. She was informed Resident #5 only had shower sheets for the dates referenced previously. She stated she was unsure why the resident only had limited shower sheets on file.2. Record review of Resident #6's Face Sheet, dated 08/18/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included reduced mobility and repeated falls. Record review of Resident #6's Quarterly MDS Assessment, dated 06/01/26, reflected the resident had a BIMS of 7, which indicated severe cognitive impairment. The MDS Assessment reflected the resident was totally dependent on staff providing showers and baths. Record review of Resident #6's Quarterly Comprehensive Care Plan, dated 06/24/26, reflected the resident required assistance with showering/baths. Record review of Resident #6's Progress notes for the month of July and August 2026, reflected no documentation of the resident refusing showers/bed baths.Record review of the facility's shower sheet book for July and August 2026 revealed no shower sheets for Resident #6.During an interview on 08/18/26 at 11:35 a.m., Resident #6 stated she was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays, but she had not been getting them when scheduled, and it made her feel dirty when she did not get them. She stated she wanted her showers and her hair washed. She stated she asked the CNAs for her shower, and they told her they were busy and would have to get with her later, but they never did. She stated she could not recall how many showers she received in July and August 2026, but they were not many. She stated her last shower was last Tuesday, 08/11/26. During an interview on 08/18/26 at 12:44 p.m., LVN E stated she was the nurse for the 200 hall. She stated the CNAs were required to complete shower sheets for all residents when they were scheduled to receive showers. She stated the nurses were required to sign off on all shower sheets. She stated she checked shower sheets and followed up with residents who refused a shower and attempted to persuade them to take a shower and notified the family. She stated she was unsure when Resident #6 was scheduled for her showers, but the resident rarely refused showers. She was informed Resident #6 had no shower sheets on file for the month of July and August 2026. She reviewed the shower sheet book for the 200 hall and stated there were no shower sheets in the book for the resident. She stated the resident was a B bed, so she received her showers in the afternoon and she could not confirm the resident received her showers. She stated if the resident was not receiving her scheduled showers, she could have wounds that could go unnoticed and it impacted their dignity. During an interview and record review on 08/18/26 at 12:44 p.m., the DON was informed of Resident #5 only having shower/bed bath sheets on file for the dates referenced previously, and Resident #6 not having any shower/bed bath sheets on file for the month of July and August 2026. She stated the CNAs were not using the shower sheets for residents. She was informed RN A at the nurses' station, CNA C, LVN P and LVN E all stated they completed shower sheets for all residents. She stated the CNAs were required to update the system of records when the residents were scheduled for their showers and the shower/bed bath sheets were more of a way for CNAs to cover themselves to show they completed the shower or bed baths. The system of records for Resident #6 was checked for August and there was no indication a shower was given to the resident. The system of records for Resident #5 showed the resident had only received bed baths on 8/12/2026, 8/14/2026, and 8/17/2026 for the month of August. She stated if the residents did not receive their scheduled showers, it was a dignity concern, and they could have skin issues. She stated the nurses were responsible for ensuring the residents received their scheduled showers. During an interview and record review on 08/18/26 at 1:30 p.m., the DON provided a third source, stating the CNAs were placing the information in another area she was not aware of. The records reports for both residents indicated the residents were receiving baths on consecutive days. The report for Resident #5 revealed shower/bathes self on 08/05/26, 08/06/26, 08/07/26, 08/11/26, 08/12/26, 08/13/26, 08/14/26, 08/14/26, and 08/17/26. The report for Resident #6 revealed shower/bathes self on 08/03/26, 08/04/26, 08/05/26, 08/06/26, 08/07/26, 08/08/26, 08/09/26, 08/11/26, and 08/12/26. She stated it was possible for the residents to receive bed baths on consecutive days. She stated Resident #5 had a history of lying and Resident #6 had dementia so she could forget she received her showers. Resident #6 had no records which indicated a diagnosis of dementia.During an interview on 08/18/26 at 02:50 p.m., Resident #5 was asked if she had received any bed baths on the dates provided by the facility and she stated no. She stated she received at least one bed bath a week and there were times when she had not received any bed baths for the week. She stated she never received bed baths on back-to-back days. She stated she contacted the Ombudsman on 08/14/26 because she was not receiving her bed baths. During an interview on 08/18/26 at 02:55 p.m., Resident #6 was asked if she had received any showers on the dates provided by the facility and she stated absolutely not and it was incorrect. She stated she never received any showers at any time on back-to-back days, and she stated she had a hard time getting at least one shower a week. She stated the last time she received a shower was last week Tuesday (08/11/26). Record review of the facility's policy, Quality of Care, dated 05/2020, reflected It is the policy of this facility that residents were given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. 4. Bathing will be offered at least twice weekly, and PRN per resident request.

Based on observations, interviews, and record review, the facility failed to ensure that the residents' environment remained free of hazards as was possible for three of eight residents (Residents #2, #3 and #6) reviewed for accident hazards. The facility failed to ensure that Resident #2 did not have a container of Sani-wipes germicidal wipes on her shelf and a Hoyer-lift stored in her room on 07/15/2026. The facility failed to ensure that Resident #3 did not have Febreze aerosol spray can, Sani-wipes germicidal wipes and Febreze fabric freshener spray bottle in her room on 07/15/26. The facility failed to ensure that Resident #6 did not have disinfectant spray can in her room on 07/15/26. These deficient practices placed the residents at risk for accidental injury, exposure to hazardous chemicals and misuse of facility equipment.Findings included: Record review of Resident #2's Face Sheet, dated 07/15/2026, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Cerebral palsy (non-progressive neurological disorders caused by brain damage which permanently affects body movement, posture, and muscle coordination) and Seizures (sudden, uncontrolled surge of electrical activity in the brain). Record review of Resident #2's Quarterly MDS Assessment, dated 06/20/26 revealed a BIMS score of 12 (Moderate cognitive impairment). The Quarterly MDS Assessment indicated that the resident is Dependent to require Substantial / Maximal assistance with most ADLs. Record review of Resident #2's Comprehensive Care Plan, dated 01/06/26 last revised 05/25/26 revealed the resident is at risk for impaired cognitive function and thought processes related to paranoid schizophrenia (condition where a person has trouble knowing what is real and what is not), bipolar (extreme, cyclical shifts in mood, energy, and activity levels). During an observation and interview on 07/15/26 at 10:17 a.m., Resident #2 had a can of Sani-cloth germicidal disposable wipes on her nightstand and a Hoyer-lift parked in her room. She stated that she did not bring in the Sani-wipe in her room, she stated that she does not remember who brought it into her room, but it was a staff. She stated that she thought they used it to clean her bed and left it on her nightstand. She stated that the Hoyer-lift was used to transfer her from her chair to her bed last night and they left it in the room. She stated she prefers that they did not store the Hoyer-lift in her room. Record review of Resident #3's Face Sheet, dated 07/15/2026, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Stimulant use, in remission and Personal History of other mental behavioral Disorder. Record review of Resident #3's Quarterly MDS Assessment, dated 07/08/26 revealed a BIMS score of 14 (no cognitive impairment). The Quarterly MDS Assessment indicated that the resident is Independent to require setup clean-up assistance with most ADLs. Record review of Resident #3's Comprehensive Care Plan, dated 04/08/26 revealed the resident is at risk for Delirium or an acuteconfusional episode r/t fluctuations in ammonia levels due to cirrhosis of the liver. During an observation and interview on 07/15/26 at 10:45 a.m., Resident #3had a can of Sani-wipes germicidal wipes, a can of Febreze aerosol spray and a bottle of Febreze fabric freshener spray. She stated that she brought the Sani-wipes with her from the hospital, she stated that the staff in the facility were aware she had the Febreze aerosol and fabric softener, she stated that she bought them from the store when she went out on pass. She stated that no one had told her she should not have them, she stated that she will be ok for the facility to take the items away if they were not allowed in the facility. During an interview on 07/15/26 at 11:52 a.m., LVN B and RN M stated that the Sani-wipes, Febreze aerosol spray and Febreze fabric freshener spray are not allowed in the residents' room, we round and take them away, some of them get annoyed when it is removed. We educate them about why they should not have hazardous items. The hazardous items could cause allergies and harm other residents if any resident comes in contact with them. They stated that they have not noticed any of the items in Resident #2 and Resident #3's rooms in the past. They stated anything with chemicals can harm the residents. They stated that they need to have better monitoring in place to prevent hazardous items in the rooms. They stated that everyone in the facility is responsible when they make rounds to report and remove any hazards in the room. During an interview on 06/23/26 at 10:34 a.m., CNA R stated that the Sani wipes should not be in the residents' rooms. She stated that every staff member is responsible for making sure those items are not in the residents' rooms. She stated that it will endanger residents who are confused, they could have an allergic reaction to the items and cause serious harm to themselves or others.CNA R stated that Hoyer lifts are stored in the shower room or an empty room in the facility. The Hoyer-lift should always be supervised. CNA R stated that the Hoyer-lift should be stored and secured out of reach of the residents for safety and trip hazards, so the residents don't try to use it. CNA R stated that the residents having access to the Hoyer-lift unsupervised could lead to injuries. Hoyer-lifts are usually operated by 2 staff for safety reasons. CNA R stated that the resident is unable to get out of bed by herself and likely will not use it, CNA R stated that another resident might use it inappropriately and cause themselves harm. Record review of Resident #6's Face Sheet, dated 07/15/2026, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Type 2 Diabetes (high blood sugar). Record review of Resident #6's Quarterly MDS Assessment, dated 05/06/26 revealed a BIMS score of 7 (severe cognitive impairment). The Quarterly MDS Assessment indicated that the resident is dependent on requiring substantial/maximal assistance with most ADLs. Record review of Resident #6's Comprehensive Care Plan, dated 04/09/26 revealed the resident is at risk for impaired cognitivefunction/dementia or impaired thought processes with intervention Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. During an observation and interview on 07/15/26 at 2:25 p.m. with CNA S, a can of Disinfectant spray was observed on Resident #6 nightstand on the opposite side of her bed. CNA S proceeded to remove the Disinfectant spray from the room. She stated residents are not allowed to have disinfectant/aerosol cans in their rooms and the policy is to dispose of it if they see it. She stated it can cause breathing problems for residents if left in the rooms During an interview on 07/15/26 at 2:45 p.m., the social worker stated that residents are not allowed to have aerosol sprays and Sani-wipes in the rooms. She stated that when she makes rounds, she makes sure to remove any hazards and educates residents. She stated that some residents will get these items again after we removed them, she stated that an example is Resident #1 and #7. She stated that she had not noticed any of these items in any resident's room other than Resident #1 and #7. She stated that it is a safety hazard and can cause harm. She stated that it can cause inhalation injury/respiratory issues, it could be flammable and a fire hazard. During an interview on 07/15/26 at 3:15 p.m., the Housekeeping/Maintenance supervisor stated that Sani-wipes and Aerosol sprays are not allowed in the residents rooms, he stated that they are fire hazards, they can spray themselves or someone else who might be allergic. He stated that it could affect their breathing which could result in hospitalization. He stated that maintenance and nursing are responsible for making sure no hazardous items are in the rooms. He stated he is not sure of any resident family that brings in such items but has not noticed them himself. During an interview on 07/15/26 at 3:39 p.m., CNA A stated that that no aerosol sprays and Sani-wipes should be in any resident room as per the facility policy. She stated that the chemicals in the aerosol sprays and Sani-wipes can be strong for the residents and cause them to react with respiratory issues. She stated that they use the Sani-wipes to disinfect the rooms and put it back in a locked closet on the hallway that is accessible only to the nurses and CNAs. She stated that everyone is responsible for making sure the residents don't have aerosols or Sani-wipes in resident rooms. She stated that she has not noticed these items in any rooms before now. During an interview on 07/15/26 at 4:09 p.m., CNA P stated the policy is to have 2 people when using the Hoyer lift. She stated it shouldn't be left in a resident's room unattended and should be stored in the shower room. She stated that you need 2 people to use it for resident safety and per policy. She stated the resident could fall and have an injury if you don't have 2 people. During an interview on 07/15/26 at 5:12 p.m., the DON stated that the residents should not have aerosol sprays or Sani-wipes in their rooms. She stated that due to some of the residents being able to go out on pass they are unable to stop them from buying those items and bringing them in. She stated that they monitor hazardous items when they make rounds and remove them. She stated that Resident #3 usually goes out with her Responsible Party and gets them and brings them back to the facility. She stated that her main concern is not the residents that have them but those who are confused and wander room to room. She stated there is a potential for misuse and that can cause respiratory distress and eye irritation. She stated that the Sani-wipes could be confused for personal care wipes as well. She stated that all staff are responsible for collecting any hazardous items and bring them to myself or the administrator. She stated that her expectations are that the Hoyer lifts are stored in the shower rooms and not in the residents' rooms. She stated that if there is an emergency they will not be able to get in and out of the room with ease and if it is needed for another resident, it will not be found since it was not stored at its designated storage location. She stated that if the Hoyer lift is not easily assessable it could cause a momentary delay in other residents' care. During an interview on 07/15/26 at 6:10 p.m., the Administrator stated that the policy is that Aerosol sprays and Sani-wipes should not be in the resident's room and they do their best to make sure of that. She stated it is a safety hazard. She stated that hazardous items like the aerosol spray could cause respiratory injuries, she stated that the residents could confuse the Sani-wipes for a regular perineal wipe and could use it causing skin irritation. She stated that the Hoyer lifts should be stored in an empty room and be locked. She stated that it is safety and fall risk issue. She stated that whoever utilizes the Hoyer lift is responsible for making sure it is stored properly. She stated that the residents could injure themselves if the Hoyer is not stored out of reach. Record review of the facility provided SOM F Resident Rights revealed: The facility must provide- S483.10(i)(1) A safe, clean, comfortable, andhomelike environment, allowing the resident to use his or her personalbelongings to the extent possible.S483.10(i)(2) Housekeeping and maintenance services necessary tomaintain a sanitary, orderly, and comfortable interior; Environment refers to any environment in the facility that is frequented byresidents, including (but not limited to) the residents' rooms, bathrooms,hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. Orderly is defined as an uncluttered physical environment that is neat and wellkept. Sanitary includes, but is not limited to, preventing the spread of disease-causingorganisms by keeping resident care equipment clean and properly stored. Residentcare equipment includes, but is not limited to, equipment used in the completion ofthe activities of daily living

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary comfortable environment for residents' staff and the public for 1 of 4 hall shower rooms (300 Hall shower room) and 2 of 8 (Residents #1 and #4) reviewed for environment. The facility failed to ensure that the shower room in 300 hall was clean and in sanitary condition on 07/15/26. The facility failed to ensure that the trash can in Resident #1's room had trash liners 07/15/26. The facility failed to ensure that the trash can in Resident #4's room had trash liners 07/15/26. This failure could place residents at risk for diminished quality of life.Findings included: Record review of Resident #1's Face Sheet, dated 07/15/26, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Need for Assistance with personal care. Record review of Resident #1's Quarterly MDS Assessment, dated 04/22/2026, revealed a BIMS score of 07 (severe cognitive impairment). It revealed she needs substantial / maximal assistance with Toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. During an observation on 07/15/26 at 9:33 a.m. it was observed that the trash can in Resident #1's room had no liner in it. Record review of Resident #4's Face Sheet, dated 07/15/26, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening). Record review of Resident #4's Quarterly MDS Assessment, dated 04/22/2026, revealed that the resident had two unstageable pressure injuries and one stage 4 pressure ulcer which was present on admission and was coded for risk of developing pressure ulcers/injuries. During an observation on 07/15/26 at 9:40 a.m., it was observed that the trash can in Resident #4's room had no liner in it. During an observation on 07/15/26 at 10:17 a.m., it was observed that the shower room in the 300 hall had Molded/rusted shower seat, shower seat peeling off at the bottom, used gloves, wash clothes, plastic bottles, pillows, broken bedside table frame, old shower head, used tissue paper and plastic wrappings were scattered on the shower room floor. It was observed that the trash can had trash in it but had no liner in it. The toilet seat was observed with a stain on it. Personal belongings and drinks were observed on a bedside table and chair in the shower room. During an interview on 07/15/26 at 3:15 p.m., the Maintenance/housekeeping director stated that Housekeeping makes sure that the shower rooms are cleaned; he stated that CNAs make sure they pick up and put things in the trash when they shower residents. Housekeeping check the shower rooms daily in the morning, the showers in the residents' rooms are cleaned daily as well when they do rounds. She stated the housekeeping did not pay attention to the shower room on the 300 hall. He stated that the old shower head that was left there was changed 07/13/26, that the maintenance helper got distracted and forgot about it. He stated that they will do a deep clean today, he stated that they deep clean the shower rooms weekly and probably missed a few things. He stated that there is no log to track the cleaning of the shower rooms, but he can make one. He stated that it is important to have a log to keep a record of whether the shower room is deep cleaned or not. He stated that not deep cleaning the shower room can be a cause of cross-contamination and can spread disease to every resident who uses the shower. He stated that no personal items should be left in the shower room, he stated that they should be stored in the staff break room. During an interview on 07/15/26 at 3:49 p.m., CNA A stated that the housekeeping normally cleans the showers and the CNAs also clean after every shower. She stated that Housekeeping cleans daily. She stated that the shower rooms could be better cleaned. She stated that no drinks or personal items should be stored in the shower room because of contamination. She stated that a dirty shower room is not safe for the residents and is an infection control issue. She stated that the resident could get infected in a dirty bathroom, touching dirty surfaces is not good for the residents. She stated that no one wants to be in a dirty environment. During an interview on 07/15/26 at 5:12 p.m., the DON stated that her expectation is that the shower room should always be clean, the CNAs should pick up after each shower and that housekeeping sanitizes at the end of each day and that no personal items should be in the shower. She stated that each staff is able to log a maintenance concern to maintenance personnel. She stated that on the daily roosters each department head has a section of rooms including the showers and trash liners are inspected and any issues the residents are having are addressed daily. She stated that a dirty environment could make the facility not feel like a homelike environment and pose an infection control issue. She stated that not having a homelike environment could affect the residents' psychosocial health. During an interview on 07/15/26 at 6:10 p.m., the Administrator stated that her expectation is that the shower room should be clean and clear of debris. She stated that the CNAs who give showers and housekeeping are responsible for making sure the showers are cleaned. She stated that she is not sure of specifics of cleaning the shower, but that daily cleaning is done in the entire facility. She stated that no personal items should be stored in the shower but should be stored in the staff break room. She stated that this could cause cross contamination. She stated that for safety the showers should be clean since it's the resident's home. She stated that if the shower is not clean it puts the resident at risk for injury and infection and contamination. She stated that the trash can should be always lined up for proper disposal of items. She stated that if the trash is not line it could cause an unsanitary environment. She stated that an unsanitary environment could produce unpleasant smells, cause bacterial growth. Record review of the facility's Undated SOM F Resident Rights revealed: The facility must provide- S483.10(i)(1) A safe, clean, comfortable, andhomelike environment, allowing the resident to use his or her personalbelongings to the extent possible.S483.10(i)(2) Housekeeping and maintenance services necessary tomaintain a sanitary, orderly, and comfortable interior; Environment refers to any environment in the facility that is frequented byresidents, including (but not limited to) the residents' rooms, bathrooms,hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. Orderly is defined as an uncluttered physical environment that is neat and wellkept. Sanitary includes, but is not limited to, preventing the spread of disease-causingorganisms by keeping resident care equipment clean and properly stored. Residentcare equipment includes, but is not limited to, equipment used in the completion ofthe activities of daily living

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for one of eight residents (Resident #4) reviewed for quality of care. The facility failed to ensure that Resident #4's non-pressure wound left buttock and stage 4 pressure wound of right lateral ankle were cleansed in accord with best practice on 07/15/26. These failures could place the residents at risk of worsening pressure and non-pressure injuries and could result in a decline in health.Findings included: Record review of Resident #4's Face Sheet, dated 07/15/26, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening). Record review of Resident #4's Quarterly MDS Assessment, dated 04/22/2026, revealed that the resident had two unstageable pressure injuries and one stage 4 pressure ulcer which was present on admission and was coded for risk of developing pressure ulcers/injuries. Record review of Resident #4's most recent Comprehensive Care Plan dated 06/23/26, revealed the resident had the potential for pressure ulcer development related to immobility incontinence of bowel and blader; Has MASD TO LEFT BUTTOCK, right buttock AND SACRUM with intervention to CLEANSE WITH wound cleaner, PAT DRY, APPLY calcium alginate with silver COVER WITHDRY DSG. CHANGE DAILY AND PRN SOILAGE/DISLODGEMENT; Has pressure ulcer related to decreased mobility, fragile skin stage 4 right ankle with intervention to Administer treatments as ordered and monitor for effectiveness. Record review of Resident #4's Physician Order, dated 06/26/2026, revealed MASD TO LEFT BUTTOCK, CLEANSE WITH W/C,PAT DRY, APPLY sodium hypochlorite gel (anasept) WITH DRY DSG. CHANGE DAILY AND PRN SOILAGE/DISLODGEMENT. Every day shift; order dated 05/20/26 revealed PRESSURE INJURY STAGE 4 TO RIGHT LATERAL ANKLE: CLEANSE WITH WOUND CLEANSER, PAT DRY, APPLY MOISTENED HYDROFERA BLUE TOWOUND BED, COVER WITH DRY DSG. CHANGE 3X/WK (M,W,F) AND PRN SOILAGE/DISLODGEMENT every day shift every Mon, Wed, Fri CHANGE DRESSING IF SOILED OR DISLODGED During an observation and interview on 07/15/2026 at 11:03 a.m. - 11:52 a.m., LVN B and RN M were observed during wound care for Resident #4. LVN B cleaned Resident #4's non-pressure wound on the left buttocks (most contaminated area) to the inside of the wound (least contaminated area) using the same gauze and pressure wound to the right from the outside of the wound (most contaminated area) to the inside of the wound (least contaminated area) using the same gauze.They stated that using the same gauze to clean from outside the wound (dirty area) to inside the wound clean area will cross contaminate the wound. They stated the expectation for wound care is to clean from the inside to the outside. They stated that using proper wound cleaning techniques prevents wound contamination and infection. They stated that if the proper technique is not used it could prolong the healing process of the wound which will lead to increased chances of infection. They stated that DON is the one that makes sure that all wound care is provided as directed and a wound care team comes out to provide education on wound care. They stated that the sacral wound will be reported to the wound care provider. During an observation and interview on 07/15/26 at 11:03 a.m. A non-pressure wound of sacrum was observed and treated but was not documented as a wound site in the residents wound provider assessment. They stated Resident #4 had 3 wounds and not 4 that they know of, they stated that they have a wound doctor that comes in to assess the wounds. LVN B stated that the left buttock wound and the wound on the sacrum were the same wound but is healing and now had healed skin separating the sites. During an interview on 07/15/26 at 5:12 p.m. with the DON, she stated that she expects that the wound care should be performed in accordance with all infection control practices for wound cleaning patterns. She stated that this should be done to prevent infection. She stated that the wound should be cleaned from the cleanest to the dirtiest area. She stated that if the proper wound cleaning procedure is not followed, there could be a risk of cross contamination from the outer tissues (dirtiest area) to the inside tissue (cleanest area) which would prolong wound healing. During an interview on 07/24/26 at 1:40 p.m. with the wound care Nurse Practitioner, she stated that the wound on the left buttocks and the sacrum was one big wound that had healed skin separating the wound sites. She stated that it was one big wound initially and will be considered as one site the left buttocks and not 2 sites. Record review of the facility's policy and procedure 483.25 Quality of Care dated 03/2015, latest revision 4/2025, revealed: A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing.Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible)Facility nursing staff will identify and document in the resident's clinical records, the condition and pressure injury risk factors related to the development of unavoidable pressure injury. This identification and implementation of a plan of care will begin at admission with the initial care plan and be completed throughout assessment process for developing a comprehensive plan of care.Ongoing Skin and Wound Assessments: A licensed nurse will assess/evaluate a resident's skin at least weekly.Areas of breakdown, excoriation, or discoloration, or other unusual findings (either initially identified at the time of admission or as new findings) must be documented in the nursing notes or on the appropriate weekly assessment form. (Skin Pressure Ulcer Weekly, Skin Ulcer Non-Pressure Weekly, or Skin Evaluation - PRN/Weekly)A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to: i. Once an area of alteration in skin integrity has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's Order.j. Treatments per physician order, should be documented in the resident's clinical record at the time they are administered.a. Pressure Ulcer, Non-pressure Ulcer, and PRN/Weekly skin assessment/evaluation forms: If the clinical assessment/evaluation indicates a change in condition or decline in the wound, the assessing/evaluating nurse will notify the physician and create a narrative note documenting that notification.b. Weekly Skin Check Licensed nurse should document skin evaluations in accordance with this policy and document on the appropriate skin assessment/evaluation weekly/PRN form.

Based on observations, interviews and record reviews, the facility failed to ensure parental fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive care plan and the resident's goals and preferences for 1 (Resident #5) of 4 residents reviewed for PICC lines (Peripherally Inserted Central Catheter). The facility failed to change the PICC line intravenous catheter (an intravenous catheter that is suitable for long term infusion therapy) dressing on Resident #5 for more than 7 days. These failures placed the residents at risk of infection or dislodgement.Findings included: Record review of Resident # 5's face sheet dated 07/15/26 revealed he was a [AGE] year-old-male admitted on [DATE] he was diagnosed with Infection and Inflammatory Reaction Due To Internal Right Knee Prosthesis (prosthetic joint infection). Record review of Resident #5's physician order dated 06/08/26 revealed an order for PICC Line Care: Change PICC Line Dressing Q 7 Days If Site Is Visible for Assessment. Change Dressing PRN If Wet, Soiled, Saturated or Loose. every day shift every Tue. Record review of Resident # 5's Care Plan dated 06/04/26 revealed the resident's Is on IV Antibiotic Therapy r/t Right kneeprosthesis infection (06/04/26 to 07/30/26) with intervention to Administer medication as ordered and PICC line care per facility protocol. Record review Resident # 5's Medication Administration Record under Schedule for July 2026 revealed, PICC Line Care: Change PICC Line Dressing Q 7 Days If Site Is Visible for Assessment. Change Dressing PRN If Wet, Soiled, Saturated or Loose. every day shift every Tue. The MAR revealed an entry made for a PICC line dressing change on 07/07/26 and 07/17/26. Observation and interview on 07/15/26 at 2:13 p.m., revealed Resident #5 had a single lumen PICC line to the left arm with a dressing dated 07/06/26. The resident stated he is not sure how often the dressing on the PICC line is changed. During an interview on 07/15/26 at 5:12 p.m., the DON stated that the dressing is scheduled to be changed on the PICC line every seven days and as needed if soiled as it was ordered. She stated that this is done to prevent and decrease the risk of an infection. She stated that if the dressing is not changed as ordered it could lead to another infection. She stated that the nurse is responsible for making sure the dressing is changed and she is ultimately responsible for making sure they do so. Review of the facility's current Guidelines Central venous Devices revealed A transparent film dressing is the preferred type of central line dressing for ease of site assessment. This transparent film dressing is changed weekly and PRN soiling, contamination and non-occlusiveness (non-adherent).

Based on observation, interview and record review the facility failed to ensure that a resident receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 2 out of 8 residents (Resident #2 and #3) reviewed for enteral feeding. The facility failed to ensure that Resident #3 was provided with her G-Tube (a medical device inserted through the abdominal wall directly into the stomach. It provides a direct route to deliver nutrition (fluids) feeding on 06/02/26 as ordered by her physician. The facility failed to ensure that Resident #2 had continuous feeding via G-Tube from 12:00 A.M to 10:00 P.M. as ordered on 06/02/26 as ordered by his physician. This failure could place 14 residents who had feeding tubes at risk for dehydration, weight loss, and/or metabolic abnormalities. Findings included: 1.Record review of Resident #3's face sheet dated 06/02/26 revealed a [AGE] year-old female admitted to the facility initially on 02/27/26 muscle wasting and atrophy, severe protein-calorie malnutrition, pressure ulcer of sacral region, stage 4. Record review of Resident #3's care plan dated 02/28/26 revealed the resident has a required tube feeding related to Dysphagia, Resident is non-compliant with NPO diet. Family brings in outside food. Intervention noted on care plan was: 1) Is dependent with tube feeding and water flushes. See MD orders for current feeding orders. 2) Encourage responsible parties to follow NPO diet status. Record review of Resident #3's physician order dated 05/21/26 revealed an order for: Jevity 1.5 cal at 60ml/hr between 6 :00 A.M.-6:00 P.M. flush 20ml/hr of h2o. up at 6PM DOWN AND 6AM. one time a day. Record review of Resident #3's progress note dated 05/29/26 revealed that Resident #3s alert and oriented x3, communicated verbally with clear speech and is able to understand and be understood when speaking. 2. Record review of Resident #2's face sheet dated 06/02/26 revealed a [AGE] year-old male admitted to the facility initially on 03/27/26 with the following diagnoses: protein calorie malnutrition (a serious condition caused by not eating or absorbing enough calories and protein, leading to severe weight loss, muscle wasting, and weakness), muscle wasting and atrophy (the wasting or loss of muscle tissue, which causes the muscles to shrink and weaken) Record review of Resident #2's MDS dated [DATE] revealed all his nutrition via a feeding tube. Record review of Resident #2's care plan dated 03/27/26 revealed the resident has potential nutritional problem r/t NPOstatus, dependence on tube feedings with intervention: Diet as ordered by the physician. Record review of Resident #2's physician order dated 04/23/26 revealed an order for: Enteral Feed Order every shift related toUnspecified Severe Protein-Calorie Malnutrition (E43) Formula: Jevity 1.5 At 40 Ml/Hr X 22 Hrs to Provide Cc/Cal./Day with H2o Free Water Flushes Of 200 Mls Q 4 Hrs. Feeding Pump to Run From 0000 TO 2200 (12:00 A.M. to 10:00 P.M.). During observation on 06/02/23 at 12:53 P.M. It was observed that Resident #2's feeding bag was empty while the feeding pump was still running at 40 ML/HR. During an interview and observation on 06/02/26 at 1:36 P.M it was noted that Resident #2's feeding bag was still empty. LVN M was notified. LVN M, stated that the CNA should let her know when the feeding was running low. She stated the Feeding should be continuous; she stated that it was his only means of nutrition. She stated if he does not get enough nutrition, he could lose weight. Could lead to skin breakdown and other health issues. She proceeded to change the feeding bag and turn on the pump. During an observation and interview on 06/02/26 at 12:11 P.M. with Resident #3. It was observed that her feeding bag dated 06/01/26 time 8:00 P.M was full and not connected to her Feeding tube. When asked if she receives feeding by G-Tube she stated yes and stated that it was supposed to be run last night but the nurse likely forgot. During an interview on 06/02/26 at 12:37 P.M. with RN M. She stated that the nurses are responsible for the feeding, that night shift gives the GT feeding to Resident #4. Facility policy was for the feeding to be given as ordered by the physician. If the feeding was not done as ordered, Resident will not get the amount of feeding to maintain her wellbeing. She stated as a nurse on the floor she should have noticed that the feeding was not done last night and find out why it was not done and report to the DON. During an interview on 06/02/26 at 1;20 P.M. with CNA S. She stated that when she notices a Feeding bag empty or any issues with the feeding pump, she calls the nurse and does not touch it at all. She stated that it is important for residents to have their food since it's the only way for them to have their nutrition. She stated that if the feeding is not given as ordered, the resident could get malnourished and dehydrated and wounds would not heal. During an interview on 06/02/26 at 3:50 P.M. the DON stated the expectation was that the Tube feeding should be done as ordered and if an issue comes up why the feeding could not be done it should be documented. She stated that residents with continuous feeding should be monitored every 8-hour shift, check orders for the Tube feeding and carry out any task due during the shift. She stated that the nurses are responsible for the care provided and I am ultimately responsible for making sure of care given.She stated that Resident #3 refused the feeding during the shift, but it was not documented. She stated the risk of not following the orders for Tube feedings could be a risk for malnutrition.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 2 of 8 residents reviewed for pressure injuries. (Residents #2 and #4) The Facility failed to ensure that Resident #2 buttocks and sacral were covered with dressing as ordered on 06/02/26. The facility failed to ensure that an order for wound care was in place for Resident #2 who had a non-pressure ulcer to the left buttocks and sacrum (triangular area at base of spine). The facility failed to ensure that Resident #4's sacral wound was covered with dressing as ordered on 06/03/26. These failure can place the residents at risk for worsening or pressure and non-pressure injuries and could result in a decline in health. Findings included: 1.Record review of Resident #2's face sheet dated 06/02/26 revealed a [AGE] year-old male admitted to the facility initially on 03/27/26 with the following diagnoses: protein calorie malnutrition (a serious condition caused by not eating or absorbing enough calories and protein, leading to severe weight loss, muscle wasting, and weakness), and muscle wasting and atrophy (the wasting or loss of muscle tissue, which causes the muscles to shrink and weaken), Record review of Resident #2's MDS dated [DATE] revealed that the resident that stage 4 pressure ulcer which was present on admission and was coded for risk of developing pressure ulcers/injuries. Record review of Resident #2's care plan dated 03/27/26 revealed the resident has potential for pressure ulcer development related to immobility incontinence of bowel and blader and listed MASD to left buttocks with the following interventions: Daily body checks, monitor nutritional status, weekly head to toe skin at risk assessment, notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bath or daily care. * Record review of Resident #2's TAR dated for May 2026 revealed an order dated 04/23/26 for: non-pressure left buttock: cleanse area with normal saline or wound cleanser. apply hydrogel and a dry dressing. every day shift, that was discontinued on 05/20/26. No new orders were recorded for continued wound care for the present wound Record review of Resident #2's TAR for June 2026 did not reveal any orders for the wound care to the non-pressure ulcer of the left buttock. Record Review of Resident #2's progress note dated 05/07/26 revealed #009: Skin issue has been evaluated. Location: Buttocks - generalized. Laterality / Orientation: Left. Issue type: Other skin issue. Other skin issue description: Non Pressure Wound Partial Thickness Progress: Improving: overall wound characteristics improved. Wound was present on admission. Length (cm): 4 Width (cm): 4.7 Depth (cm): 0.2 Undermining: No. Tunneling: No. Skin Issue: #010: Skin issue has not been evaluated. Location: Buttocks - generalized. Laterality / Orientation: Circumferential. Issue type: Pressure ulcer / injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence). Wound was present on admission. It is unknown how long the wound has been present Record review or Resident #2's progress noted dated 05/20/26 revealed Issue: #003: Skin issue is resolved. Location: Buttocks - generalized. Laterality / Orientation: Circumferential. Issue type: Pressure ulcer / injury. Progress: Resolved: Wound healed and / or closed. Wound was present on admission. It is unknown how long the wound has been present. Length (cm): 0 Width (cm): 0 Depth (cm): 0 Undermining: No. Tunneling: No. Epithelial: 100%. Peri wound: Epithelialization. Frequency of treatment. Wound care Observation on 06/02/26 at 12:53 P.M, revealed Resident #2 had no wound dressing in place for the wound on his left buttocks and sacrum (Skin issue #009). No sign and symptom of infection noted. Interview on 06/02/26 at 1:15 P.M RN J stated that the dressing must have come off during care by the CNA. She stated that the expectation was that if the CNA observes a wound without dressing or that wound dressing needs to be changed while performing incontinent care, they need to notify the nurse right away. She stated due to the Resident #2 and #4 being incontinent the wound must be covered at all times to prevent the wound from getting infected. She stated that it was expected that all wound care must be ordered by the Resident physician, she stated that having an order and following it is important for the wound to heal. She stated that if there was no order, the wound care could be inconsistent and missed, wound could get worse and systemic infection possibly. She stated that she and the nursing staff are responsible for making sure there was an order for all wound care provided. She stated she updated the order with the wound care provider to make sure the wound care was consistent. Interview on 06/02/26 at 1:20 P.M. CNA S stated that if the wound dressing was soiled or not in place, she would inform the nurse to come put a new dressing on. She stated that not having the wound dressing in place could cause fecal matter to get in the wound and cause an infection and make the wound not heal. Record review of Resident #4's MDS dated [DATE] revealed that the resident that stage 4 pressure ulcer was present on admission and was coded for risk of developing pressure ulcers/injuries. MDS revealed the a BIMS of 7 (indicates severe cognitive impairment) and Resident is always incontinent of bowel. Record review of Resident #4's care plan dated 04/09/26 revealed the resident Has stage 4 pressure ulcer to sacrum andpotential for pressure ulcer development r/t impaired mobility, impaired sensation, with the following interventions: Administer treatments as ordered and monitor for effectiveness. Record Review of Resident #4's physicians' orders dated 05/21/26 revealed: pressure injury stage 4: cleanse withwound cleanser, pat dry, apply collagen to wound bed, followed by alginate, and cover with dry dsg. change daily and prn soilage/dislodgement every day shift. Record review of Resident #4's face sheet dated 06/02/26 revealed a [AGE] year-old female admitted to the facility initially on 04/09/26 with the following diagnoses: Pressure ulcer of sacral region stage 4 (full thickness skin and tissue loss), muscle wasting, and weakness), muscle wasting and atrophy (the wasting or loss of muscle tissue, which causes the muscles to shrink and weaken) Wound care observation on 06/03/26 at 1:23 P.M. revealed Resident #4 had no wound dressing to the stage 4 pressure ulcer on her sacral area. Interview on 06/03/26 at 2:56 P.M. NP M stated wound care orders need to be followed, she stated that when new residents are admitted the facility sends new consultation for her to evaluate the resident and they should also be reporting any worsening of wounds to her for further evaluation. She stated she is satisfied with wound care by wound nurse. She stated the standard is there should always be an order for any wound care provided to any resident in the facility. She stated sometimes with Residents going in and out of the hospital, we need to keep up with any new orders. She stated the orders for Resident #2's wound care orders were in her notes and expected to be put in the resident's treatment orders, she stated she is not sure why it was not in place. She stated that the wound care orders for Resident #2 were accidentally discontinued on 05/20/26 and have now been reinstated on 06/02/26.She stated that not having a wound order could result in wound care not being done, which could result in the wound getting infected and not healing. She stated that the CNA's will be educated to notify the wound nurse if wound dressings need to be changed during care. Interview on 06/02/26 at 3:50 P.M with DON. She stated that the wound dressing should always be in place, she stated the CNA's are responsible to report to the nurse if a dressing was dislodged. The nurses are ultimately responsible for making sure the wound dressing was in place. She stated the wound care nurse was responsible to transcribe the wound care orders into the resident's medical record. She stated that if there was no order the dressing change would not be done. She stated that if there was no order and the dressing was not done it will lead to a deterioration in the wound condition. Review of the facility's Policy and Procedure for quality for Skin and Wound monitoring and management dated 03.2015 Revision/Review Date(s) 12.2019; 1.2022; 12.2023; 4.2025. revealed: It is the policy of this facility that:.2. A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing.i. Once an area of alteration in skin integrity has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's Order.j. Treatments per physician order, should be documented in the resident's clinical record at the time they are administered.

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 8 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's Humidifier bottle was not empty when Oxygen concentrator was in use by Resident #1. The facility failed to ensure Resident #1's nasal cannula storage bag was changed weekly as ordered. These failures could place the residents at risk of respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #1's Face Sheet, dated 06/02/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnosis included Shortness of Breath and Asthma (Lungs become swollen and Narrowed making it hard to breath) Record review of Resident #1's Quarterly MDS assessment, dated 04/01/26, revealed the resident was coded for oxygen therapy. MDS assessment indicated a BIMS of 7 (indicates severe cognitive impairment) Record review of Resident #1's active care plan dated 02/19/24 revealed the resident: Has Oxygen Therapy r/t shortness of breathsecondary to asthma with interventions to: provide oxygen per physician's orders. Record review of Resident #1's active physician's orders date 10/10/2025 revealed active orders for: O2 at 2-6l/min continuous &prn via Nasal Cannula to maintain O2 sats, may titrate to maintain Greater/equal to 90% every shift for SOB related to other asthma; shortness of breath. And change tubing, clean filter and change o2 water bottle weekly every night shifts every Saturday. During an observation and interview on 06/02/26 at 9:44 A.M., the humidified bottle connected to the oxygen concentrator was empty while it was in use by Resident #1 and the nasal canula storage bag was dated 04/25/26. The resident stated she was not aware if the bag should be changed or not. During an interview on 06/02/26 at 10:03 A.M. with LVN M. She stated she does not know the facility policy for oxygen management, but in general the bag and nasal canula should be changed every 7 days, since it's a part of infection control. Water bottle should be changed when empty or every 7 days. She stated that if the bag and nasal canula are not changed every 7 days it could cause infection to the residents and if the humidifier bottle is empty, it could cause dryness to the nostrils which can lead to discomfort. LVN M stated she will go ahead to change the bag and nasal canula and let the DON know. During an interview on 06/02/26 at 10:29 A.M. the DON stated that the Expectation was to have the bag and nasal canula (lightweight, flexible plastic tubing that hooks over the ears and features two small tips that sit inside the nostrils to deliver supplemental oxygen) changed every Saturday as ordered. She stated the evening nurse and ultimately, I will be responsible for doing that. She stated the humidifier bottle should be changed weekly or when it runs out of water. She stated changing the bag and nasal canula prevents risk of infection to the resident, the humidifier bottle should be changed when empty to prevent risk of irritation to the nostrils and changing weekly also prevents infection to the resident. Record review of the facility undated Oxygen equipment policy and procedures revealed: It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use disposable pre-filled humidifiers, tubing, masks and cannulas for residents receiving oxygen. This equipment is to be discarded after use. The facility will maintain clean tanks, connectors and concentrators.PROCEDURES:1. Oxygen Tanks, Connectors and ConcentratorsOxygen tanks, connectors and concentrators must be cleaned after useOxygen masks, nasal cannulas, and tubing will be used for one resident only. When used continuously or intermittently, tubing will be routinely changed to prevent the build-up of respiratory secretions, mucous, and bacterial growth.When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly.

Based on interview and record review the facility failed to ensure and maintain medical records on each resident that are complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for wound care. The facility failed to enter a verbal provider order for a Negative Pressure Wound Treatment device (NPWT) ordered during her rounds at the facility on 03/19/2026. Subsequently, no consistent documentation of care, monitoring, or treatment was documented on Resident #1's EMR between 03/19/2026 - 03/24/2026. This failure could affect residents that require a change in their treatments to ensure they receive accurate orders from providers which could lead to lack of care, infection, and not following provider orders.Findings Included: Review of Resident #1's re-admission MDS dated [DATE] revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] from an acute care facility. Relevant diagnoses included paraplegia (decreased function of lower body,) cancer (cellular malfunction,) aplastic anemia (bone marrow dysfunction,) diabetes (glucose dysfunction,) osteomyelitis to vertebra, sacral, and sacrococcygeal (back and hip area) region (infection to the bone.) He was admitted with stage IV pressure ulcers of the sacral and coccyx (hip area) region. He was cognitively intact with a BIMS score of 14. No documentation of behaviors or rejection of care. Resident #1 required a wheelchair for mobility and substantial assistance from staff with toileting, shower/baths, and other personal hygiene care. Review of Resident #1's Provider Orders on 05/06/2026 at 2:30 PM revealed:Stage 4 Pressure Wound. Negative Pressure Wound Therapy apply three times a week continuous -125 mmhg. If NPWT is unavailable or malfunction cleanse wound with NS, pat dry and apply calcium alginate, cover with foam silicone dressing daily. ordered 03/24/2026 at 8:34 PM. Review of Resident #1's Comprehensive Care Plan, dated 02/27/2026, revealed: Focus: Stage 4 pressure injury to sacrum. initiated 04/10/2026Goal: Management of Pressure Ulcer Interventions/Tasks: [NPWT] to sacral pressure injury per orders. Provide wound care per treatment order. In interview with the Wound Care NP on 05/06/2026 at 1:04 PM revealed she rounded with the facility's ADON and provided her with a verbal order for a NPWT for Resident #1 on 03/19/2026. She then applied Resident #1's NPWT device to his sacrum and ischial area (hip) on 03/19/2026. She stated she expected the facility's ADON to have received the order and have entered it in Resident #1's EMR, and further implemented by the facility nursing staff. She stated during her rounds of Resident #1, the device was appropriately functioning and she had no reason to suspect the facility did not manage the device appropriately. She further stated that his decline in condition was more closely related to his co-morbidities in her professional opinion. She denied any suspicion of abuse or neglect related to Resident #1's care and NPWT device management. She stated it was important for provider orders to be entered in the EMR in a timely manner so their care can be documented accurately. In an interview with nursing staff in charge of Resident #1's care between 03/19/2026 - 03/24/2026, LPN F, she stated she recalled working with Resident #1, he had a NPWT device and it was functioning as expected during her shift working with him. She did not recall any concerns related to his care and did not recall why she did not document that in the EMR. She stated it was important to document in a resident's EMR accurately for safety reasons. In an interview with nursing staff in charge of Resident #1's care between 03/19/2026 - 03/24/2026, LPN A, she stated she recalled working with Resident #1, he had a NPWT device and it was functioning as expected during her shift working with him. She stated she did not recall any concerns related to his care and did not know why she did not document his device management in the EMR. She stated it was important to document any resident care in the EMR for safety reasons. Attempts to interview Resident #1 via telephone on 05/06/2026 at 1:12 PM and 05/08/2026 at 11:53 AM were unsuccessful; and he was no longer at the facility during the time of the investigation. In interview with the facility's nursing leadership representative, RN C, on 05/08/2026 at 10:20 AM she stated the facility's acting DON was currently on leave and the facility's ADON during the time of this incident was no longer employed at the facility. Her expectations were for the ADON to input the provider's order and be completed, and for staff to provide the proper care needed to the residents as stated in their provider orders. She further stated she was not sure why it was not completed at the time, but based on her understanding assessment, care, treatment, and monitoring of the device was completed by the nursing staff during the days in question. She stated it was important orders were put in a timely manner to ensure the best care was provided for the residents. She stated the ADON was suspended pending investigation and then later terminated based on the findings due to her lack of urgency to put in the provider order. She stated this would have been the ADON's responsibility, but ultimately the DON's role to ensure completion and she was not available for interview. She stated in response to the incident she completed a facility-wide audit on documentation with her nursing staff between 04/15/2026 - 05/04/2026 to ensure all residents' documentation was completed to facility policy. Additionally, she stated she conducted skills checkoffs for the nurses related to wound care and device management; and nursing staff in-services related to accurate documentation. In interview with the facility's Administrator on 05/08/2026 on 1:42 PM revealed her understanding was the ADON rounded with the Wound Care NP and received a verbal order for Resident #1's NPWT but did not put in the order until 03/24/2026. She stated sufficient assessment, care, treatment, and monitoring of the device was completed by the nursing staff but she was not sure why the ADON did not put in the order in a timely manner. She stated this did not meet her expectations and a full investigation of her conduct was conducted, the ADON was suspended pending investigation and was later terminated as a result of the findings including the delay in documentation. She stated it was important her nursing staff enter provider orders in a timely manner to ensure the best care can be provided for her residents. Attempts to interview facility's DON (at the time of the incident) on 05/06/2026, 05/07/2026, and 05/08/2026 at approximately 11:30 AM were unsuccessful. Attempts to interview facility's ADON (at the time of the incident) 05/06/2026, 05/07/2026, and 05/08/2026 at approximately 11:45 AM were unsuccessful. Review of facility's Ad Hoc QAPI meeting revealed on 04/14/2026, RN C led a meeting reviewing the incident with facility's Administrator, Executive Director, and Medical Director in attendance. Review of facility wide audit documentation, dated between 04/15/2026 - 05/04/2026 revealed documentation that the charge nurse on that shift reviewed each resident's MAR/TAR and was signed off by the supervisor on that shift. Review of facility In-Service Training Report Medication Administration Documentation, dated 04/14/2026 revealed facility nursing staff training conducted by Clinical Resource Nurse detailing facility policy, procedures, and expectations related to Medication/Treatment Administration Documentation. Nursing staff. are expected to order/reorder medications in a timely manner. When you receive an order from a provider, please update the order to be given from the provider it was received. Review of facility's Counseling/Disciplinary Notice for the ADON, dated 04/01/2026, revealed she was suspended due to lack of adequate and appropriate documentation. Review of facility's Termination Form for the ADON, dated 04/14/2026, revealed she was terminated for failing to carry out general and/or specific instructions promptly or to perform job responsibilities. Review of Facility Policy Physician Services rev. 05/2025 revealed It is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the date and time of the order. Orders for medications must include: Name and strength of the drug; Quantity or specific duration of therapy; Dosage and frequency of administration; Route of administration if other than oral; and Reason or problem for which given.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan to include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for each resident for (Resident #1) of 6 residents reviewed for Comprehensive Care Plans. The facility failed to ensure Resident #1 had sufficient comprehensive care plan to reflect his negative pressure wound treatment device and monitoring care needs. This failure could place residents at risk of their needs not being met. Findings included: Review of Resident #1's re-admission MDS dated [DATE] revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] from an acute care facility. Relevant diagnoses included paraplegia (decreased function of lower body,) cancer (cellular malfunction,) aplastic anemia (bone marrow dysfunction,) diabetes (glucose dysfunction,) osteomyelitis to vertebra, sacral, and sacrococcygeal (back and hip area) region (infection to the bone.) He was admitted with stage IV pressure ulcers of the sacral and coccyx (hip area) region. He was cognitively intact with a BIMS score of 14. No documentation of behaviors or rejection of care. Resident #1 required a wheelchair for mobility and substantial assistance from staff with toileting, shower/baths, and other personal hygiene care. Review of Resident #1's Provider Orders on 05/06/2026 at 2:30 PM revealed:Stage 4 Pressure Wound. Negative Pressure Wound Therapy apply three times a week continuous -125 mmhg. If NPWT is unavailable or malfunction cleanse wound with NS, pat dry and apply calcium alginate, cover with foam silicone dressing daily. ordered 03/24/2026 at 8:34 PM. Review of Resident #1's Comprehensive Care Plan, dated 02/27/2026, revealed: Focus: Stage 4 pressure injury to sacrum. initiated 04/10/2026. Goal: Management of Pressure Ulcer. Interventions/Tasks: [NPWT] to sacral pressure injury per orders. Provide wound care per treatment order. In interview with the Wound Care NP on 05/06/2026 at 1:04 PM revealed she applied Resident #1's NPWT device to his wounds and expected his comprehensive care plan to detail specific care concerns customized to the resident. She stated this could include specific care, monitoring, maintenance, and signs and symptoms to notify her in the event of a change of condition should be included in the care plan. She stated facility care plans were important to guide facility staff on Resident #1's individualized care needs. In interview with facility's nursing leadership representative, RN C, on 05/08/2026 at 10:20 AM she stated the facility's acting DON was currently on leave and the facility's ADON during 03/19/2026 was no longer employed at the facility. She stated that while Resident #1's NPWT was mentioned on his comprehensive care plan, the interventions were not sufficient and did not include care, monitoring, and care requirements customized for the resident's specific care needs. She stated that would have been the ADON's responsibility, but ultimately the DON's role to ensure completion and she was not available for interview. She further stated it's important for care plans to be centered to residents' care needs for safety and to ensure their goals can be met. In interview with the facility's Administrator on 05/08/2026 at 1:42 PM, she stated she expected Resident #1's care plan be personalized with specific care interventions for his care needs. She stated it was nursing leadership's responsibility to ensure that resident care plans were completed to be centered to resident's individual care needs for safety reasons and to ensure their care goals can be met. Attempts to interview Resident #1 via telephone on 05/06/2026 at 1:12 PM and 05/08/2026 at 11:53 AM were unsuccessful; and he was no longer at the facility during the time of the investigation. Attempts to interview facility's DON (at the time of the incident) on 05/06/2026, 05/07/2026, and 05/08/2026 at approximately 11:30 AM were unsuccessful. Attempts to interview facility's ADON (at the time of the incident) 05/06/2026, 05/07/2026, and 05/08/2026 at approximately 11:45 AM were unsuccessful. Review of the facility's Counseling/Disciplinary Notice for ADON, dated 04/01/2026, revealed she was suspended due to lack of adequate and appropriate documentation. Review of facility's Termination Form for ADON, dated 04/14/2026, revealed she was terminated for failing to carry out general and/or specific instructions promptly or to perform job responsibilities. Review of Facility Policy Comprehensive Person-Centered Care Planning rev. 04/2026 revealed the facility 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. which 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.

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systemically organized in accordance with accepted professional standards for 1 of 3 residents (Resident #1) reviewed for clinical records regarding wound care.The facility failed to ensure nursing staff documented that physician ordered wound care was provided to Resident #1 for 2 pressure ulcers on 03/03/26, 03/06/26, 03/07/26, 03/08/26, 03/09/26, 03/10/26, 03/11/26, 03/31/26, 04/01/26, 04/03/26, 04/06/26, 04/07/26, and 04/11/26.This failure could place residents at risk for incomplete and inaccurately documented medical records that included their progress treatment, services, and interventions.Findings included: Record review of Resident #1's Face Sheet, dated 04/14/26, reflected that the resident was a [AGE] year-old female who admitted to the facility on [DATE].Record review of Resident #1's MDS dated [DATE] reflected that the resident had the following diagnoses: Chronic Pulmonary Edema (Gradual buildup of fluid in the lungs), COPD (Ongoing lung condition caused by damage to the lungs), need for assistance with personal care, and pressure ulcer of sacral region. The MDS reflected that Resident #1 had a BIMS of 7 , indicating severe cognitive impairment and was incontinent of bowel and bladder. The MDS further reflected that the resident was at risk of developing pressure ulcers/injuries. Record review of Resident #1's Care plan, revised 01/26/26, reflected the resident was admitted to hospice services on 01/19/26. The care plan reflected that the resident admitted with a stage 4 (wound with full-thickness skin loss, exposing underlying muscle, tendon, or bone) pressure wound to coccyx (tailbone) and a stage 4 pressure wound to the left sacrum (bone at the base of the spine), with interventions to provide wound care per physician orders. Record review of Resident #1's physician orders, dated 04/14/26, reflected the following: .Wound care stage 4 pressure ulcer to the coccyx: Cleanse, apply calcium alginate [a highly absorbent, biodegradable fiber commonly used as a specialized wound dressing that aides in healing chronic or heavily draining wounds] daily cover with a dry dressing. Once time a day for wound care. Stage 4 pressure wound of the left sacrum, cleanse with normal saline [an isotonic solution that does not interfere with normal wound repair], pat dry, apply calcium alginate daily and as needed if saturate, soiled, or dislodge one time a day for wound care.Record review of Resident #1's March and April 2026 Wound Administration Record reflected that there was no documentation showing that the resident was provided with wound care for both pressure ulcers on 03/03/26, 03/06/26, 03/07/26, 03/08/26, 03/09/26, 03/10/26, 03/11/26, 03/31/26, 04/01/26, 04/03/26, 04/06/26, 04/07/26, and 04/11/26. Record review of Resident #1's wound care report by the Wound Care Physician for March and April 2026 reflected the resident was being seen and treated weekly with no evidence the wound deteriorated.During an interview and observation on 04/14/26 at 11:10 AM, Resident #1's Hospice Nurse stated she was at the facility to perform wound care on Resident #1. She stated Resident #1's RP called her on 04/13/26 to report that Resident #1's pressure ulcers did not have any bandages on them. The Hospice Nurse stated the facility staff should be performing wound care daily according to the order. She stated she was coming to do the wound care once or twice a week but stopped due to the facility not doing it in between her visits. She stated she would visit the resident, and it would still be the same wound bandage from the previous week. She stated she was unable to confirm dates that it occurred. She stated when the wound care nurse was at the facility it started getting completed daily again. The Hospice Nurse stated she planned to start again due to inconsistent wound care since the wound care nurse no longer worked at the facility. Observed Resident #1's bandage to sacral area contained no date or initial with a small amount of circular drainage noted to bandage. The Hospice Nurse was observed to remove the old bandage, and 2 pressure wounds were observed. Both wounds were pink in color with intact periwound skin (tissue surrounding a wound). No signs or symptoms of infection observed. The Hospice Nurse stated the wounds have improved and were smaller with less drainage. During an interview on 04/14/26 at 12:43 PM, LVN A stated she was an agency nurse, and it was her first day working at the facility. She stated she was not doing any wound care today. LVN A stated she thought there was a wound care nurse that did that and it was not told to her during report. LVN A stated she would follow up with the supervisor. During an interview on 04/14/26 at 3:09 PM, Resident #1 revealed staff were not doing wound care for her on a regular basis. She stated the hospice nurse stopped doing the wound care because then the facility would not do it at all. Resident #1 stated she had not seen the wound care nurse recently and does not believe she worked at the facility any longer. Resident #1 stated her hospice nurse was going to start to do the wound care again because it had not been cared for daily. During an interview on 04/14/26 at 3:14 PM, Resident #1's RP revealed on 04/13/26 when he visited the facility, Resident #1 did not have any bandages on her wounds. He stated he was concerned about an infection because she was incontinent and stool could get into the wound. The RP stated a nurse did put on a dressing after he asked numerous times but was unable to recall what time or what nurse had performed the care. The RP stated he knew the wound care was not being performed daily because he watched the cameras. During an interview on 04/14/26 at 4:00 PM, LVN B revealed she worked as a wound care nurse at a sister facility but was helping to train the new wound care nurse. LVN B stated she had assisted with skin assessments but was not performing routine wound care. LVN B stated she was not aware when the previous wound care nurse left the facility. LVN B stated she thought the nurses that worked in the hallways were responsible for wound care. LVN B stated the facility was responsible for wound care, but the hospice nurse could assist. LVN B stated wound care should be charted in the wound administration record/TAR. She stated if there were blanks in the TAR and no progress notes, the wound care did not get done or was not charted. She stated failure to document could cause missed care and the wounds getting infected. During an interview on 04/14/26 at 5:03 PM, RN C stated she was covering for the DON while she was out. RN C stated the facility was responsible for wound care. She stated if there were blanks in the TAR then wound care did not get done or the staff did not sign it off. She stated the previous wound care nurse left in March of 2026. RN C stated the DON was covering for wound care but was currently on leave. RN C stated they were training a new wound care nurse, but that the floor nurses had been responsible for wound care. RN C stated they had been informing the agency nurses of the responsibility, and it was on the TAR. RN C stated the risk of not documenting the TAR could cause wound care to not get completed and the wounds worsening. During an interview on 04/14/26 at 5:23 PM, the Administrator stated if there were blanks in the TAR it was possible wound care did not get completed or was not documented. She stated the floor nurses were responsible for wound care. The Administrator stated the risk of not charting wound care was the care may not be completed. Record review of the facility's policy, Skin and Wound Monitoring and Management, revised 04/25 reflected the following: .Once an area of alteration in skin integrity has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's Order. Treatments per physician order, should be documented in the resident's clinical record at the time they are administered.

Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for seven of twelve Resident rooms (room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7), and two of four halls (300 and 400) observed for cleanliness. The facility failed to ensure Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7 on the 300 and 400 halls were thoroughly cleaned and sanitized.The facility failed to ensure the handrails on the 300 and 400 halls were thoroughly cleaned and sanitized.These failures could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings included:During an observation on 03/31/26 at 12:05 p.m., a portion of the handrail on the 300 hall reflected a piece of tissue with a red and brownish substance on it wedged between the rails. During an observation on 03/31/26 at 12:05 p.m., room [ROOM NUMBER] reflected the bathroom floor had brownish and grayish stains in the corners of the floor, around the toilet, and under the sink. During an observation on 03/31/26 at 12:05 p.m., room [ROOM NUMBER] reflected the bathroom floor had grayish stains in the corners of the floor, and around the toilet. Further observation reflected the air conditioning unit vents had black grime between the vents. During an observation on 03/31/26 at 12:09 p.m., room [ROOM NUMBER] reflected the bathroom floor had brownish stains in the corners of the floor, and around the toilet. A section of the wall near the entrance of the room and near a trash can had brownish stains. The air conditioning unit filters had thick dust. A container for disposing needles in the room had used dirty gloves on top of it. During an observation on 03/31/26 at 12:11 p.m., room [ROOM NUMBER] reflected the bathroom floor had brownish stains in the corners of the floor, and around the toilet. The air conditioning unit vents had black dirt between the vents. A container for disposing needles in the room used dirty gloves on top of it. During an observation on 03/31/26 at 12:11 p.m., room [ROOM NUMBER] reflected the room floor had built up dirt near a closet door and edges of the floor. The floor near a bed had brownish stains near a fall mat and closet door. The air conditioning unit vents had black dirt between the vents. During an observation on 03/31/26 at 12:17 p.m., a portion of the handrail on the 400 hall reflected a pieces of candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails.During an observation on 03/31/26 at 12:20 p.m., room [ROOM NUMBER] reflected the room floor had built up dirt in the corners of the door frame and edges of the floor. The bathroom floor had dark stains along the edges of the floor, in the corners, and around the toilet. A container for disposing needles in the room had used disposable gloves and pieces of trash sitting on top of it. During an observation on 03/31/26 at 12:22 p.m., room [ROOM NUMBER] reflected the bathroom floor had dark stains along the edges of the floor, in the corners, and stains around the toilet. The shower floor had grayish stains all over the floor. The room floor had dark stains near the walls. During an interview on 03/31/26 at 12:42 p.m., the Administrator was informed of the concern observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7, and the handrails on the 300 and 400 halls. She stated they had housekeeping performed 7 days a week and cleaning in the morning and evening. She stated the expected housekeeping to thoroughly clean the resident rooms and the facility areas because this was their home.During an interview on 03/31/26 at 2:06 p.m., Housekeeper H stated he was at the facility for four months. He stated he cleaned the 300 and 400 halls. He stated he was responsible for cleaning the entire rooms and the bathrooms. He stated he was responsible for sweeping and mopping the floors and wiping down the handrails in the hall. He stated they wipe the rails down at least once a week. He was informed by the Surveyor of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7, and the handrails on the 300 and 400 halls. He stated the concerns observed were a health hazard to the residents.During an interview on 03/31/26 at 2:06 p.m., the Housekeeping Supervisor was informed by the Surveyor of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7, and the handrails on the 300 and 400 halls. He stated housekeeping and floor technician cleaned the hallways and floors. He stated housekeeping and floor techs were responsible for cleaning the handrails. He stated Housekeeping was responsible for cleaning the entire room, including the floor, bathroom, and air condition unit. He stated he would in-service the staff on proper cleaning. He stated not thoroughly cleaning the rooms and handrails could cause an infection.Record review of the facility's policy titled, Resident Rights, dated 11/2021, revealed, The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 10 of 10 residents (Residents #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17) reviewed for pharmacy services. 1. The Facility failed to administered Residents #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17's medications greater than one hour after the scheduled administration time. 2. The Facility failed to check Resident #10's blood pressure before dispensing medication for administered. 3.The Facility failed to keep Med pass nutritional supplement refrigerated or on ice before serving as directed by manufacture and facility protocol. 4.The facility failed to date 12 out of 14 insulin vials on 100, 200 and 400 Halls. This deficient practice residents on the 100 and 200 Hall at risk for receiving less than therapeutic benefits from medications.Findings included: During a Record Review of Resident #8's face sheet on [DATE] reflected a [AGE] year old male admitted on [DATE] with diagnoses of Type 2 Diabetes (high blood sugar). During a Record review on [DATE] of Resident #8's physicians order, dated [DATE], reflected an order for Metformin HCL tablet 500 mg, give 1 tablet by mouth two times a day for blood sugar control. During a Record review of Resident #9's face sheet on [DATE], dated [DATE], reflected an [AGE] year-old male admitted on [DATE] with diagnoses of Dementia (A progressive loss of memory, reasoning and communication skills), Type 2 Diabetes Mellitus, end stage renal disease (final permanent stage of kidney failure), Hypertension (high blood pressure) During a Record review on [DATE] of Resident #9's active physicians' orders as of[DATE], reflected active order as of [DATE] for Carvedilol tablet 3.125 mg, give 1 tablet by mouth 2 times a day, Eliquis oral tablet 2.5 mg, give one tablet two times a day, Sevelamer HCL oral tablet 800 mg, give 2 tablets by mouth with meals. During a Record review on [DATE] of Resident #10's face sheet, dated [DATE] reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Type 2 Diabetes, Seizures (uncontrolled surge of electric activity in the brain that disrupts normal brain function), Hypertension, Hypothyroidism (low thyroid hormone). During a Record review of Resident #10's active physicians' orders as of [DATE] reflected active orders as for Amlodipine besylate tablet 10 mg, give 1 tablet daily for hypertension, Levetiracetam oral tablet 750 mg 2 times daily for seizures, levothyroxine sodium tablet 100 MCG daily for low thyroid. During a record Review of Resident #11's face sheet dated [DATE] reflected a [AGE] year-old male admitted on [DATE] with diagnoses of Heart Failure (when heart is too stiff to pump blood), Hypertension. During a record Review of Resident #11's active physicians' orders as of [DATE], reflected active order for Eliquis oral tablet 2.5 mg 2 times daily, Furosemide 40 MG tablet 1 time daily, Hydralazine tablet 10 MG give 3 times daily, metoprolol 25 MG tablet 2 times daily. During a record Review of Resident #12's face sheet, dated [DATE], reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Schizophrenia (severe brain disorder that causes people to interpret reality abnormally), Bipolar (condition where depressive episodes alternate with periods of abnormally high energy or mania), Hypothyroidism. During a Record review of Resident #12's active physicians orders as of [DATE] reflected active order for Levothyroxine 25 MCG 1 tablet in the morning for hypothyroidism, Olanzapine tablet 5 MG 2 times daily for Bipolar and schizoaffective disorder. During a record Review of Resident #13's face sheet dated [DATE] reflected an [AGE] year-old female admitted on [DATE] with diagnoses of hypertension. During a Review of Resident #13's active physicians' orders as of [DATE], reflected active order for Carvedilol tablet 25 MG, give 1 tablet by mouth 2 times a day, hydralazine tablet 25 MG 3 times daily, Gabapentin oral capsules 300 MG 3 times daily. During a record Review of Resident #14's face sheet dated [DATE] reflected a [AGE] year-old male admitted on [DATE] with diagnoses of: hypertension, Dementia. During a record Review of Resident #14's active physicians' orders as of [DATE], reflected active order for Benazepril HCL oral tablet 40 MG, 1 tablet by mouth daily for hypertension. During a record Review of Resident #15's face sheet dated [DATE] reflected a [AGE] year-old female admitted on [DATE] with diagnosis of hypertension and dementia. During a record Review of Resident #15's active physicians' orders as of [DATE] reflected active order for Memantine 10 MG tablet 2 times daily, Nifedipine ER osmotic release tablet 60 MG in the morning, Quetiapine Fumarate 25 MG tablet 2 times daily. During a record Review of Resident #16's face sheet dated [DATE] reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Dementia, Pain in unspecified shoulder. During a record Review of Resident #16's active physicians' orders as of [DATE] reflected active order for Baclofen 10 MG and 5 MG tablets 2 times daily for muscle relaxant, Gabapentin tablet 400 MG every 8 hours for Neuropathy, Galantamine Hydrobromide tablet 8 MG 2 times daily for Dementia, Lidoderm patch 5%, apply to left shoulder topically in the morning, may wear for 12 hours and remove per schedule, Metoprolol Tartrate 25 MG 2 times daily. During a record Review of Resident #17's face sheet dated [DATE] reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Congestive Heart Failure, Hypertension. Review of Resident #17's active physicians orders as of [DATE] reflected active order for Carvedilol 12.5 MG tablet 2 times daily, Hydralazine 100 MG tablet 3 times daily, Isosorbide Dinitrate 20 MG tablet 3 times daily, Furosemide 80 MG tablet daily for Congestive heart Failure. During an Observation on [DATE] at 10:15 am to 11:14 a.m. revealed Med Tech F was not done passing morning medications on Hallway 100 and 200, which were scheduled for 8:00 a.m. and 9:00 a.m. During an interview on [DATE] at 11:25 a.m., Med Tech F stated the med pass (Liquid nutritional supplement) should be refrigerated as the direction on the container states to prevent bacterial growth. She stated the risk of not serving the Med pass as directed could cause bacterial infection which could cause diarrhea to residents who received it. She stated the meds should be given as scheduled or one hour before or after schedule. She stated giving the meds in time preserves the window of effectiveness to remain active in the residents' body. She stated the risk of not giving the medications on time could make the medication not work as it was supposed to; she stated with antibiotics it could cause antibiotic resistance if not given when it was scheduled. She stated that any medication that directs blood pressure should be checked first before dispensing medication into cup. She stated the risk of dispensing the medication before checking blood pressure before dispensing medication could result in an overdose and would be difficult to take out the medication If there are several medications that look alike. She stated if the blood pressure is low and medications are given; it could drop the residents' blood pressure and lead to hospitalization. In an interview on [DATE] at 12:35 p.m., LVN A stated the Med pass supplement should be on ice as the direction stated, if not refrigerated or put on ice it could go bad since it is a milk-based product. She stated that if it goes bad giving it to any resident could make them sick and even cause diarrhea or other gastrointestinal issues. She stated that meds should be given for the times it was ordered for or not more than one hour before or after the ordered time. She stated it is important to give meds at ordered times to maintain the effectiveness of the medication. The risk of not giving the medication on time could result in doses being given too close together and may cause toxicity, overdose, especially for pain pills or medications like digoxin. She stated that for all medication with blood pressure check parameters, the blood pressure should be checked first before medication wasdispensed into cup. She stated it could be difficult to remove the medication if there are medications that look alike and can result in an overdose or not giving the right medication if they forget to remove the pill if the blood pressure is low. She stated that all insulin vials should be dated with the date of first use and discarded after 28-30 days. She stated that the risk of not dating when it is first opened for use can result in not knowing when to discard the vial. She stated that expired insulin could lose its effectiveness and cause the residents receiving it to not have proper control of their blood sugars and can lead to high blood sugars and even hospitalization. In an interview on [DATE] at 2:20 pm with LVN B, he stated the facility policy is that insulin vials should be dated when they are opened and discarded after 30 days. He stated all the nurses in each hall are responsible for making sure the insulin vials are dated. He stated that if the vials are not dated and are used if they are open for over 30 days, it could become ineffective or even cause a reaction if expired. In an interview on [DATE] at 2:50 PM with DON, she stated the med pass on ice should be on Ice during med pass or refrigerated before it is administered. Not having it on Ice or refrigerated could cause it to go bad and could make the resident who receive it sick with issues like nausea vomiting. She stated each nurse or CMA was responsible for making sure they put the Med pass on ice as part of their setup for medication administration. She stated the medication administration window was hour before or after, of the ordered time on physicians' orders. She stated that the ADON monitors to make sure meds are given on time.She stated the risk of not giving medications at scheduled times could cause interaction with order meds, and other possible adverse effects. She stated Insulin should be dated, some have a discard date of 14 days or 28 days after opening. She stated that nurses are responsible to date the vial when they open them. She stated that if they are not dated, the expiration date will be unknown. She stated that expired insulin loses its potency. She stated the risk of giving expired insulin could result in adverse effects like Hyperglycemia (too much sugar in the blood) or Hypoglycemia (very little sugar in the blood). During a record review of the facilities medication administration policy and procedures Policy Number 7C on [DATE] it revealed: POLICY: It is the policy of this Facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. PROCEDURE:1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record medication administration.2. Medications must be given in accordance with the resident's service plan.3. Medications must be administered in accordance with the written orders of the attending physician.4. All current drugs and dosage schedules must be recorded on the resident's medication administration record (MAR).5. Topical medications used in treatments should be recorded on the resident's medication administration record (MAR).6. Identification of the resident must be made prior to administering medication to the resident.7. Unless otherwise specified by the resident's attending physician, routine medications will be administered per the facility time ranges. This is to promote the continuance of a home- like environment for our residents.8. The nurse or medication technician administering the medication must record such information on the resident's MAR before administering the next resident's medication.9. When PRN medications are administered, the nurse or medication technician must record the date and time administered, and later the results achieved from the PRN medication as appropriate.10. Should a drug be withheld, refused, or given other than at the scheduled time, the staff administering must indicate the reason on the MAR. For those utilizing eMARs, the appropriate code must be entered with any follow up documentation as appropriate for the situation.11. Prior to administering the resident's medication, the nurse or medication technician should compare the drug and dosage schedule on the resident's MAR with the drug label. NOTE: If there is any reason to question the dosage or the schedule, the nurse or med tech should check the physician's orders.12. An adequate supply of disposable containers (e.g., cups, straws, etc.) should be available at all times.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #1, #2, #3, and #4) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, #2, #3, and #4's room was in a position accessible to the resident on 03/31/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #1's Face Sheet, dated 03/31/26, reflected a [AGE] year-old male, admitted [DATE]. Resident #1 had diagnosis of a fractured skull. Record review of Resident #1's Baseline MDS Assessment, dated 03/30/26, reflected the resident had a BIMS of 99 (unable to complete the interview). The Assessment reflected the resident was a fall risk. Record review of Resident #1's Comprehensive Care Plan, dated 03/27/26, reflected the resident was a fall risk and required assistance with ADL care.During an observation on 03/31/26 at 9:00 a.m., Resident #1 was lying in bed and his call light was located at the head of the bed out of the resident's reach. Record review of Resident #2's Face Sheet, dated 03/31/26, reflected a [AGE] year-old male, admitted [DATE]. Resident #2 had diagnosis of a need for assistance of personal care. Record review of Resident #2's Quarterly MDS Assessment, dated 02/09/26, reflected the resident had a BIMS of 99 (unable to complete the interview). The resident had active diagnoses of a stroke and difficulty swallowing. Record review of Resident #2's Comprehensive Care Plan, dated 02/03/26, reflected the resident was a fall risk and an intervention was to ensure his call light was within his reach.During an observation on 03/31/26 at 9:05 a.m., Resident #2 was lying in bed and his call light was located on the floor out of the resident's reach.Record review of Resident #3's Face Sheet, dated 03/31/26, reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #3 had diagnoses of a lack of coordination and unsteadiness on feet. Record review of Resident #3's Quarterly MDS Assessment, dated 02/25/26, reflected the resident had a BIMS of 1 (severe cognitive impairment). The resident had active diagnoses repeated falls and unsteadiness on feet. Record review of Resident #3's Comprehensive Care Plan, dated 03/05/26, reflected the resident was a fall risk and an intervention was to ensure his call light was within her reach.During an observation on 03/31/26 at 9:08 a.m., Resident #3 was lying in bed and her call light was located on her roommate's bed.Record review of Resident #4's Face Sheet, dated 03/31/26, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #4 had a diagnosis of paralysis on the right side of body. Record review of Resident #4's Quarterly MDS Assessment, dated 02/27/26, reflected the resident had a BIMS of 14 (intact cognitive response). The resident had active diagnosis of paralysis on the right side of body. Record review of Resident #4's Comprehensive Care Plan, dated 12/22/26, reflected the resident was a fall risk and an intervention was to ensure his call light was within her reach.During an observation on 03/31/26 at 9:10 a.m., Resident #4 was observed lying in bed and his call light was located on his nightstand, out of his reach.During an interview on 03/31/26 at 09:15 a.m., CNA J was informed by the Investigator of Resident #1, #2, #3, and #4's call light being within their reach. She stated the call bell should be within reach of the Resident even if they are unable to use the call bell. She stated it is the responsibility of everyone to make sure the call bell is within reach of all residents. She stated the risk of not having the call bell withing reach could be the resident having accidents and falls. During an interview on 03/31/26 at 09:20 a.m., LVN P was informed by the Investigator of Resident #1, #2, #3, and #4's call light being within their reach. She stated the call bell should always be within reach of the resident, she stated everyone is responsible to check during their rounds to make sure that the call bells are within reach. She stated the risk of not having the call bell within reach could be avoidable injuries and residents needs not being met timely.During an interview on 03/31/26 at 09:25 a.m., the DON was informed by the Investigator of Resident #1, #2, #3, and #4's call light not within their reach. She stated the call bell should always be within reach of the residents and that all staff were responsible for making sure they were reachable. She stated the risk of not having the call bell within reach could be delayed care or possible fall.Record review of the facility's policy titled, Call Light/Bell, dated 05/2020, revealed, It is the policy of this facility to provide the resident a means of communication with nursing staff. 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 observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 5 residents (Resident #5, #6 and #7) of five residents reviewed for respiratory care. The facility failed to ensure Resident #5's Nasal cannula connected to the oxygen concentrator and Nebulizer mask connected to the nebulizer machine were properly stored on 03/31/2026. The facility failed to ensure Resident #6's nasal cannula connected to the oxygen concentrator was properly stored and oxygen humidifier bottle left on nightstand was 1/4 full, cracked and dated 03/15/26 on 03/31/2026. The facility failed to ensure Resident #7's nasal cannula connected to the oxygen concentrator and Nebulizer mask connected to the nebulizer machine were properly stored on 03/31/2026. These failures could place the residents at risk of respiratory infection and not having their respiratory needs met.Findings included: During a Record review on 03/31/26 of Resident #5's Face Sheet, dated 03/31/26, revealed a [AGE] year-old male admitted on [DATE]. The resident was diagnosed with COPD (a progressive, long-term lung disease that makes it hard to breathe). During a Record review on 03/31/26 of Resident #5's Physician Order, dated 07/16/25 revealed orders for, change tubing, clean filter, change O2 water bottle and nebulizer kit (set of tools used with a nebulizer machine to turn liquid medicine into a fine mist (aerosol) that is inhaled directly into the lungs)weekly every night shift every Saturday. During an observation on 03/31/2026 at 9:01 a.m., Resident #5 was in his bed, awake. It was observed there was a nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date. During a Record review on 03/31/26 of Resident #6's Face Sheet, dated 03/31/26, revealed a [AGE] year-old female admitted [DATE]. The resident was diagnosed with asthma (lungs become swollen and narrowed making it hard to breathe). During a Record review on 03/31/26 of Resident #6's Physician Order, dated 07/16/25, revealed orders for, change tubing, clean filter and change O2 water bottle weekly every night shift every Saturday. During an observation on 03/31/2026 at 9:05 a.m., Resident #6 was in his bed, awake, nasal cannula connected to the oxygen concentrator was not bagged or labeled and oxygen humidifier bottle (a small plastic bottle attached to an oxygen concentrator or tank that adds moisture to the dry, therapeutic oxygen before it is inhaled)left on nightstand was 1/4 full, cracked and dated 03/15/26. During a Record review on 03/31/26 of Resident #7's Face Sheet, dated 03/31/26, revealed a [AGE] year-old female admitted [DATE]. The resident was diagnosed with COPD (a progressive, long-term lung disease that makes it hard to breathe). During a Record review on 03/31/26 of Resident #7's Physician Order, dated 02/17/25 revealed orders for, change tubing, clean filter, change O2 water bottle and Nebulizer Kit weekly every night shift every Saturday. During a Record Review on 03/31/26 of physicians order dated 06/22/25 revealed orders for, after nebulizer treatment, obtain and record pulse, O2 Sat, Tx minutes post med lung sounds (Lung sounds before medications are given). During an observation on 03/31/2026 at 9:01 a.m., Resident #7 was in his bed, awake. It was observed that there was a nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date. During an interview on 03/31/26 at 9:15 a.m., CNA J stated the oxygen tubing/and nebulizer mask should be always bagged when not in use, she stated she notifies the nurse if she notices any nebulizer mask or Oxygen tubing that is not bagged and dated. She stated the risk of not having the oxygen tube and nebulizer mask bagged could result in infection to the resident. During an interview on 03/31/26 at 9:40 a.m., LVN P stated the oxygen tube/nebulizer mask should always be bagged and dated, she stated they changed the bags once weekly and as needed if soiled. She stated the nurse was responsible for making sure they were bagged and dated, but the CNA reported to the nurse if she noticed they were not. She stated it was important to have them bagged to prevent bacterial infection. She stated the humidifier bottles were changed every 2-3 days or when empty During an interview on 03/31/26 at 9:53 a.m., DON stated the oxygen tube/nebulizer mask should always be bagged when not in use and the bags are changed and dated weekly or as needed if soiled, humidifier bottles are changed weekly or as needed. She stated the risk of not having the bags changed and dated could be an infection control issue, sepsis (when the immuned systems stops fighting infection and begins damaging it's own organs) hospitalization and life-threatening conditions. During a Record review on 03/31/26 of the facility's Infection Prevention and Control Program policy and procedure, dated 06.2021 and revised 05.2025 revealed: The infection prevention and control program is a facility-wide effort involving all disciplines and individualsand is an integral part of the quality assurance and performance improvement program. Goals Decrease the risk of infection to residents and personnel. Recognize infection control practices while providing care. Identify and correct problems relating to infection control. Ensure compliance with state and federal regulations related to infection control Promote individual resident's rights and well-being while trying to prevent and control the spread ofinfection. Monitor personnel health and safety.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 10 residents (Resident #9) reviewed medication administration, and for residents residing on two of four halls (Hall 100 and 200) reviewed for infection control The facility failed to ensure personal items were not stored on the medication carts located on the 100 and 200 halls on 03/31/2026.The facility failed to have staff sanitize hands after going from dirty to clean task before donning clean gloves and entered the resident room to administer medication. These failures could place residents at risk for infection. Findings included: During an interview and observation on 03/31/26 at 8:55 a.m., Medication Technician F was observed with a personal water bottle on top of the medication cart on 200 hall. She stated it was her personal water bottle, and she had brought it out to drink some water and she did not have time to put it up. She stated she could not have the water bottle on top of the medication cart because it was an infection control concern. During an observation on 03/31/26 at 9:04 a.m., the medication cart on the 100- hall had a personal water bottle sitting on top of the medication cart. During an interview on 03/31/26 at 09:10 a.m., LVN A stated she was passing out medication on 100 hall and the personal water bottle on the medication cart was hers. She stated she was thirsty and needed a drink of water. LVN A was observed sitting at the nurses' station during the interview and not at the medication cart. She stated they were not allowed to have personal items on the medication cart because it was an infection control concern. During an interview on 03/31/26 at 09:30 a.m., the Administrator and Corporate Nurse J were informed by the Surveyor of Medication Technician F and LVN A having personal items (water bottles) on top of the medication carts on the 100 and 200 halls. Corporate Nurse J stated staff were not to have any personal items on top of the medication carts because of infection control.During an interview on 03/31/26 at 10:10 a.m., the DON was informed by the Surveyor of Medication Technician F and LVN A having personal items (water bottles) on top of the medication carts on the 100 and 200 halls. The DON stated the nursing staff were not to have any personal items on top of the medication carts because of contamination.During a Record review of Resident #9's Face Sheet, dated 03/31/26, revealed an [AGE] year-old male, admitted [DATE]. Resident #9 had a diagnosis of dementia (a progressive loss of memory, reasoning and communication skills). During a Record review of Resident #9's MDS Assessment, dated 03/10/26, revealed the resident's BIMS was 7, which indicated severe cognitive impairment. The MDS Assessment reflected the resident had an active diagnosis of Dementia.During a Record review of Resident #9's care plan on 03/31/26, dated 12/03/25, revealed the resident was at risk of infection related to dialysis access with intervention of Enhanced Barrier Precaution during the provision of close contact care.During a Record review of Resident #9's physician orders on 03/31/26, dated 12/03/25, revealed, enhanced barrier precaution: PPE required for high resident contact care activities. Indication: Dialysis Access every shift for monitoring.During an observation on 03/31/26 at 10:30 am, Med Tech F picked her keys up from the floor after sanitizing her hands, she failed to sanitize her hand again before donning (putting on) clean gloves and entered Resident #9's room to administer medication.During an interview on 03/31/26 at 11:25 a.m., Med Tech F stated it was required she sanitized her hands whenever she touched a dirty surface or before each resident care and when she changed gloves. She stated the risk of not sanitizing her hands could cause bacteria to spread from resident to resident. She stated this could make them sick, cause a decline in health or even unnecessary hospitalization.During an interview on 03/31/26 at 12:35 p.m., LVN A stated hands should be sanitized between each resident and after performing a dirty task and between glove changes. She stated that sanitizing hands was a part of infection control. She stated the risk of not sanitizing hands could cause a spread of infection to residents, unnecessary antibiotic use or even hospitalization.During an interview on 03/31/26 at 2:50 p.m., DON stated sanitizing hands before putting on gloves and after taking them off or going from dirty to clean task was required per infection control policy to prevent spread on infection to the residents being served. She stated the risk of not performing hand hygiene could spread germs and make the residents sick.During a Document review on 03/31/26 of the facility's Infection Prevention and Control Program policy and procedure dated 06.2021 Revision/Review Date(s): 6.2021; 1.2022; 10.2022; 05.2025 revealed: The infection prevention and control program is a facility-wide effort involving all disciplines and individualsand is an integral part of the quality assurance and performance improvement program.Goals Decrease the risk of infection to residents and personnel. Recognize infection control practices while providing care. Identify and correct problems relating to infection control. Ensure compliance with state and federal regulations related to infection control Promote individual resident's rights and well-being while trying to prevent and control the spread ofinfection. Monitor personnel health and safety3. The facility personnel will conduct themselves and provide care in a way that minimizes the spreadof infection.a. Facility personnel with a communicable disease or infected skin lesion will not directly contactresidents or their food, if direct contact could transmit the disease; andb. Facility personnel will wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice.c. Validation of the personnel infection prevention and control practices are monitored by theinfection preventionist through skills competency evaluation such as observation of handhygiene.

Based on observation, interview, and record review, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 23 residents (Resident #9) reviewed for hazards. The facility failed to ensure Resident #9 did not have a can disinfectant spray and a bottle of hand cleaner spray in his room on 03/31/26. This failure could prevent the residents from having an environment that was free from hazards.Findings included: During a Record review of Resident #9's Face Sheet, dated 03/31/26, revealed an [AGE] year-old male, admitted [DATE]. Resident #9 had a diagnosis of Dementia (a progressive loss of memory, reasoning and communication skills). During a Record review of Resident #9's MDS Assessment, dated 03/10/26, revealed the resident's BIMS was 7, which indicated severe cognitive impairment. The MDS Assessment reflected the resident had an active diagnosis of Dementia. During an observation on 03/31/26 at 10:45 a.m., Resident #9 was sitting in his wheelchair, a can of disinfectant spray and hand sanitizer spray was observed on the chest of drawers in his room on 03/31/26. During an interview on 03/31/26 at 11:25 a.m., Med Tech F, she stated aerosol should not be in the residents' room, she stated confused residents could get a hold of it and spray it or even ingest it. She stated some might choke due to the smell or have an allergic reaction. During an interview on 03/31/26 at 12:35 p.m., LVN A stated that disinfectant sprays should not be kept in the resident room, everyone was responsible for checking and making sure hazardous items were removed from resident rooms as they make rounds. She stated having hazardous sprays in the room can pose a risk for cognitively impaired residents who could get a hold of it and spray it and inhaling it could make them sick or cause an allergic reaction. During an interview on 03/31/26 at 2:50 p.m., the DON that stated disinfectant sprays should not be in residents' room, anything that says keep out of reach of children should not be in resident room. She stated the risk of having aerosol sprays in residents' rooms could result in poisoning if a resident with respiratory issues gets a hold of it. She stated that all staff are responsible for making sure such sprays are not in room. She stated they provide education to residents if they bring such items into the facility.

Based on interview and record review, the facility failed to ensure care plans were developed with the resident and the resident's representative for 3 (Resident #3, Resident #7 and Resident #39) of 5 residents reviewed for comprehensive care plans. The facility failed to ensure that Resident #3, Resident #7 and Resident #39 or the resident's representative were invited to and participated in the resident's care plan meeting. This failure placed residents at risk for loss of independence, psychosocial well-being and the opportunity for them to participate in the planning of their care. Findings included: Record Review of Resident # 3's face sheet dated 03/11/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included COPD (a progressive but treatable lung disease that causes chronic air flow blockage) bipolar disorder (a mental health condition characterized by intense alternating mood swings), type II diabetes (a condition where the body resists insulin), depression and pulmonary hypertension (high blood pressure in the arteries of the lungs). Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 7 indicating severe cognitive impairment. Resident #3 required supervision or touching assistance with toileting and personal hygiene and partial assistance with showering and dressing. She was able to express her needs. In an interview on 03/11/2026 at 3:04 p.m., Resident #3 revealed she had never been invited to a care plan meeting and did not know what the purpose of the meeting was. Record review of Resident #3's electronic record reflected her last documented care plan was 03/31/2025. Record review of Resident #7's face sheet dated 03/11/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included traumatic brain injury (damage to the brain caused by an external physical force), post traumatic seizures (abnormal electrical brain events occurring after a traumatic brain injury), anemia (blood lacks enough healthy red blood cells), and mood disorder (a mental health condition characterized by long lasting disturbances in emotions). Record review of Resident #7's Quarterly MDS dated [DATE] reflected a BIMS score of 00 indicating the resident was unable to complete the interview. Resident #7 needed maximal assistance with toileting, showering, personal hygiene and dressing and moderate assistance with eating and oral hygiene. She was not able to express her needs. In an interview on 03/12/2026 at 3:12 p.m. with Resident #7's family member revealed she couldn't remember the last time she had been invited to a meeting, but it had been several months ago. Record review of Resident #7's electronic record reflected her last documented care plan was 11/06/2025. Record review of Resident #39's face sheet dated 03/11/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Sickle Cell disease, (a group of inherited red blood cells disorders that cause red blood cells to become hard and sticky) schizophrenia (a severe mental disorder characterized by a breakdown in the relationship between thought, emotion and behavior) hypertension (high blood pressure) and ileostomy status (a surgically created opening in the abdomen that connects the last part of the small intestine to the outside of the body). Record review of Resident #39's quarterly MDS dated [DATE] reflected a BIMS score of 13 indicating she was cognitively intact. Resident #39 was independent with eating, oral hygiene and personal hygiene. She needed set-up help with upper body dressing, supervision with showers and moderate assistance with toileting and lower body dressing. She was able to express her needs. In an interview on 03/11/2026 at 3:09 p.m. Resident # 39 revealed that it had possibly been around a year or so that she had her last care plan meeting. Record review of Resident #39's electronic record reflected her last documented care plan was 03/18/2025. In an interview on 03/11/2026 at 2:35 p.m. with the facility Social Worker revealed she had worked at the facility since June of 2025. She stated they have care plan meetings every Wednesday with the ADON, Activity Director, Dietary and Therapy to go over any concerns that the residents and/or family have. She looked up the dates in the electronic medical record of the last care plan meeting for Resident #3 and verified it was 03/31/2025, Resident #7's was 11/06/2025 and Resident # 39's was 03/18/2025. She stated the residents whose care plan meetings are scheduled for the week were documented in her journal but not in the electronic medical record. She stated they should be documented in the resident's medical record and that she must have missed those. She stated the risk to the residents is their concerns may not get addressed. In an interview on 03/11/2026 at 2:51 p.m. with the DON revealed the Social Worker sets up the weekly care plan meetings and her expectation is the meeting should be documented in the electronic medical record and completed on a weekly basis. The risk to the resident is they could have a change of condition that the IDT needed to be aware of. In an interview on 03/12/2026 at 2:56 p.m. with the Administrator revealed her expectation is the care plans should be documented in the medical record as that is the official record. The risk to the resident is there would be no communication regarding care or concerns. Review of the facility's policy/procedure for Care and Treatment/Care planning revealed the following, The MDS Coordinator, Social Services or designee staff will notify the resident, family and/or responsible party, and other interested parties designated by the resident, of the date and time of the care plan conference prior to the meeting. The resident's plan of care is reviewed and revised on an ongoing basis, quarterly at a minimum and/or as needed with changes in condition.

Based on observation, interview, and record review, based on the comprehensive assessment of a resident, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #45) of three residents reviewed for quality of care. The facility failed to ensure skin integrity changes were documented for Resident #45. This failure placed residents at risk for skin integrity changes occurring with no monitoring in place. Findings included: Record review of Resident #45's quarterly MDS Assessment, dated 01/14/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's cognitive skills for daily decision making were severely impaired. The resident's diagnoses included traumatic brain dysfunction, quadriplegia (inability to move arms and legs), and seizure disorder. Record review of Resident #45's Comprehensive Care Plan, dated 11/19/25, reflected:Potential for impaired skin integrity as evidenced by Braden Scale for predicting pressure ulcer risk.Facility interventions included:Pressure relieving device in place as needed for at risk areas and repositioning. Resident had an air mattress. Record review of Resident #45's clinical records for March 2026 did not reflect documentation for a skin assessment or an assessment of green bruises on Resident #45. Additionally, there was no documentation that reflected the resident had any injury after a fall. An observation and interview on 03/11/26 at 12:15 PM revealed Resident #45 was lying in bed. He was awake and alert and said he was, okay when asked. LVN B was in the room. The resident's arms and hands were contracted. He had faded, extensive bruising on his left upper arm and left forearm. He had the same color bruises on the top of his right hand. The resident could not say how he got the bruises. LVN B said she did not know how he got the bruises. LVN B said Resident #45 liked to sleep against the rail of the bed. An interview on 03/11/26 at 12:43 PM, CNA D stated he was new to the facility and 03/11/26 was the first time he had been assigned to care for Resident #45. CNA D said he did not pay attention to the bruises because they looked old. He said usually he reported bruises to the nurse, but Resident #45's bruises looked old. CNA D said he did not suspect abuse and would notify the Abuse Coordinator if he did. An interview on 03/11/26 at 12:55 PM, Resident #45's family member stated the resident had a camera in his room. The family member said she did not see anything happen to the resident other than a fall from his bed on 03/03/26. The family member said the resident fell on his left side and required two staff to put him in bed and that the bruises might have developed after the fall. Interviews on 03/11/25 at 1:45 PM and 2:00 PM, the DON stated Resident #45 had IV attempts on 02/16/26 and was sent to the hospital for the IV placement. The DON said she had a shower sheet that showed where a CNA had documented the bruises on Resident #45's arm. The DON provided a nurse note dated 02/20/26 that showed the resident had a yellow bruise on his left forearm. No documentation was provided by the DON regarding the current bruises. An email received from the Administrator on 03/11/26 at 2:31 PM revealed Resident #45 left the facility frequently for appointments/hospital visits. An interview on 03/11/26 at 4:30 PM, the ADON stated if staff observed bruises or injuries on a resident, they were supposed to document the issue and notify the physician. The ADON said failure to document assessments of injuries could lead to worsening skin issues. An interview on 03/12/26 at 2:11 PM, DON stated skin assessments were supposed to be completed on admission, every seven days, and as needed. She said skin assessments were supposed to be completed by the charge nurses, and the DON did not know why Resident #45 did not have a skin assessment for March 2026. The DON said nurse management was responsible for ensuring skin assessments were completed. The DON said failure to complete skin assessments could lead to worsening skin integrity. The DON said all staff were responsible for assessing residents and identifying skin issues. She said nurse management was responsible for ensuring resident skin issues were assessed and documented. Record review of the facility policy, Skin and Wound Management, revised April 2025, reflected: . A licensed nurse will assess/evaluate each pressure injury and/or non-pressure injury that exists on the resident. This assessment/evaluation should align with the scope of practice and include but not be limited to:1) Measuring the skin injury2) Staging the skin injury (when the cause is pressure)3) Describing the nature of the injury (e.g., pressure, stasis, surgical incision)4) Describing the location of the skin alteration5) Describing the characteristics of the skin alterationg. Ongoing Skin and Wound Assessments: A licensed nurse will assess/evaluate a resident's skin at least weekly.Areas of breakdown, excoriation, or discoloration, or other unusual findings (either initially identified at the time of admission or as new findings) must be documented in the nursing notes or on the appropriate weekly assessment form. (Skin Pressure Ulcer Weekly, Skin Ulcer Non-Pressure Weekly, or Skin Evaluation - PRN/Weekly)A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to:1) Measuring the skin injury2) Staging the skin injury (when the cause is pressure)3) Describing the nature of the injury (e.g., pressure, stasis, surgical incision)4) Describing the location of the skin alteration5) Describing the characteristics of the skin alteration6) Describing the progress with healing, and any barriers to healing which may exist7) Identifying any possible complications or signs/symptoms consistent with the possibility of infection.

Based on interview and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 6 residents reviewed for quality of care. -The facility failed to follow the Infectious Disease NP recommendation given on [DATE] to transfer Resident #1 to the hospital after the resident exhibited s/sx of an infection that included increased confusion, lethargy, hypotension (low blood pressure), and lab work that was positive for leukocytosis (elevated white blood cells). Resident #1 continued to be symptomatic and was not sent out to the hospital until [DATE] where he was diagnosed with acute metabolic encephalopathy (impaired brain function) due to sepsis (infection in bloodstream), UTI (infection of urinary system), aspiration pneumonia (lung infection) and infected decubitus ulcer (pressure ulcer). Resident #1 expired at a local hospital on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 03:56 PM and an IJ Template was provided to the Operations Manager at 05:38 PM. While the Operations Manager and Clinical Resource were notified that the IJ was removed on [DATE] at 3:36 PM, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents requiring assistance with incontinence care at risk for urinary tract infections that could lead to serious harm or death. Findings included : Record review of Resident #1's face sheet, dated [DATE], reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included: type II diabetes (body's inability to control blood glucose), hypotension (low blood pressure), dementia (loss of memory and thinking abilities), pressure ulcers, hx of urinary tract infection, hx of bacterial infection, hx of fracture of vertebrae (back fracture), and acute kidney failure. Record review of Resident #1's Nursing Home PPS MDS Assessment, dated [DATE], reflected Resident #1 had a BIMS score of 5, which indicated severe cognitive impairment. This document also reflected, under Section GG - Functional Abilities, Resident #1 was totally dependent on staff for toileting hygiene. Further review of the document reflected, under Section H-Bladder and Bowel, Resident #1 always had urinary incontinence. Record review of Resident #1's Care Plan, revised on [DATE], reflected the resident had a hx of UTIs and was on PO ABX prophylactically (as a preventative measure) indefinitely. Interventions included: Check for incontinence. Wash, rinse and dry soiled areas. Encourage adequate fluid intake. Give antibiotic therapy as ordered. Monitor and document for side effect and effectiveness. The care plan also reflected Resident #1 had bowel/bladder incontinence r/t confusion and impaired mobility. Interventions included: Incontinent: Check as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Monitor, document for s/sx of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, fouls smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Further review of this document reflected Resident #1 had the potential for pressure ulcer development r/t impaired mobility and incontinence. Interventions included: Monitor nutritional status. Serve diet as ordered, monitor intake and record. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Use lifting device, draw sheet, etc. to reduce friction. Weekly head to toe skin at risk assessment. Record review of Resident #1's progress notes, dated [DATE] at 9:00 AM by the FNP, reflected the following: . Increased confusion ***History of Present Illness*** [Resident #1], [AGE] year-old male long-term care resident of the facility, is being seen today for an acute visit due to increased confusion, as reported by nursing staff. The [Resident #1's], family noted that he appeared increasingly confused over the weekend. [Resident #1] is currently on prophylactic Macrobid due to recurrent UTls. On examination today, the [Resident #1] is sitting upright in a wheelchair in his room, in no acute distress. [Resident #1] reports he is doing well and appears at baseline mentation; however, he appears more tired than his baseline. Given the change in symptoms and family's concerns, CBC, BMP, and UA will be obtained to rule out acute infection. The patient denies any current UTI symptoms and any other clinical concerns today. Previously, [Resident #1] was hospitalized from [DATE] to [DATE], due to altered mental status secondary to UTI. He returned to the facility at baseline mentation. On [DATE], during his ER follow-up visit for UTI, he was noted to be at baseline mentation and able to recall his recent hospital stay. Prior to this, on [DATE], he was seen for UTI and was treated with cefdinir Record review of Resident #1's progress notes, dated [DATE] at 10:00 AM by the FNP, reflected the following: leukocytosis (elevated white blood cells) and suspected UT [sic] ***History of Present Illness*** [Resident #1], an [AGE] year-old male long-term 'care resident of the facility with a history of dementia and recurrent UTls, is being seen today for an acute visit due to leukocytosis and suspected UTI. CBC and BMP this morning revealed leukocytosis, with a white blood cell count of 11.6 per nursing. Nursing is continuing to attempt to obtain a UA; a straight cath was attempted but was unable to obtain urine. The [Resident #1] reports they will try again today. Nursing also reports the [Resident #1] was noted with increased confusion yesterday and asked where he was, which is not his baseline mentation. On examination, the patient was seen in the dining hall in no acute distress. He reports he is doing well and denies any UTI symptoms or any clinical concerns today. Previously, on [DATE], the [Resident #1] was seen for increased confusion, and labs were ordered to rule out acute causes of altered mental status. On [DATE], he was seen for possible shingles, and acyclovir (antiviral) and prednisone (steroid) were initiated for unilateral (one-sided) red blisters on the right mid back. On [DATE], [Resident #1] was seen for an ER follow-up for a UTI, during which he was noted to be at his baseline mentation and able to recall his recent hospital stay after being admitted for acute encephalopathy secondary to UTI. . ***Lab Results*** ,d+[DATE]: -- MAC (bacterium) Yes ,d+[DATE]: --- [NAME] (type of WBC) >100,000 ,d+[DATE]: CBC pending ,d+[DATE]: --- WBC 11.6 ; Range: 3XXX,d+[DATE].2 ,d+[DATE]: --- CBC pending ,d+[DATE]: UA pending ,d+[DATE]:-- UA pending ,d+[DATE]: BMP pending ,d+[DATE]: --- BMP pending * N39.0 - URINARY TRACT INFECTION, SITE NOT SPECIFIED *: The [Resident #1] presents today with leukocytosis (WBC 11.6) and suspected UTI. Nursing is continuing to attempt to obtain UA. Straight cath was attempted; however, unable to obtain urine. Will initiate cefdinir (abx)300 mg twice daily x 7 days with orders to initiate antibiotic after obtaining UA. * D72.829 - Elevated white blood cell count, unspecified *: CBC this morning revealed elevated WBC count of 11.6. Will monitor and trend with follow up labs. * R41.0 - Disorientation, unspecified *: The [Resident #1] was noted with increased confusion yesterday and asked where he was, which is not his baseline mentation. Given the change in symptoms, further evaluation is warranted to rule out acute causes of altered mental status Record review of Resident #1's lab result report, dated [DATE], reflected in part the following: Collection Date: [DATE] Received Date: [DATE] Reported Date: [DATE] Basic Metabolic Panel: Glucose-Results: 117; Range ,d+[DATE] . CBC: WBC-Results: 11.6, Range: 3XXX,d+[DATE].2 RBC-Results: 3.3; Range 3XXX,d+[DATE].5 . Record review of Resident #1's MAR, dated ,d+[DATE], reflected in part the following: -Cefdinir (abx) 300 mg; give 1 capsule by mouth two times a day for UTI for 7 days, may initiate antibiotic after obtaining UA. Order Date: [DATE] Medication administered: [DATE] (am/pm), [DATE] (am/pm), and [DATE] (am) Discontinue Date: [DATE] Record review of Resident #1's progress notes, dated [DATE] at 2:42 PM by the Infectious Disease NP, reflected the following: . ASSESSMENT AND PLAN; 1; [Resident #1] with acute cystitis (UTI). Urinalysis has been collected, results are pending. Slight leukocytosis. Treated with Cefdinir 300 mg q.12 hours x 7 days. We will watch for antibiotic-related side effects including C. diff (bacteria in colon) and nephrotoxicity (toxicity in the kidneys). We will follow clinical course and culture results. 2; [Resident #1] has diabetes with secondary complications. Further treatment per attending physician. 3; History of generalized muscle weakness. [Resident #1] is wheelchair bound. HPI: [Resident #1] is an [AGE] year-old gentleman, who has a history of multiple medical problems seen for evaluation. [Resident #1] was sitting in a wheelchair not able to give any reliable history. Past medical history as mentioned above. [Resident #1] is seen status post hospital stay due to altered mental status and lethargy. [Resident #1] was seen at [local hospital] and found to have 3rd degree heart block. [Resident #1] underwent a permanent pacemaker placement. [Resident #1] also found to have some pneumonia. [Resident #1] was discharged back to facility on po Levaquin (abx). . Record review of Resident #1's lab result report, dated [DATE], reflected in part the following: Collection Date: [DATE] Received Date: [DATE] Reported Date: [DATE] Urinalysis: Protein -Result: 30 (kidneys were not filtering blood properly); Range: Negative (flagged) Urine Culture: Organism: pseudomonas (bacteria that causes infection) . Record review of Resident #1's progress notes, dated [DATE] at 4:52 PM by the Infectious Disease NP, reflected the following: ASSESSMENT AND PLAN; 1; [Resident #1] with leukocytosis. Urinalysis on ,d+[DATE] unremarkable (no signs of infection). [Resident #1] was treated with Cefdinir 300 mg q.12 hours x 7 days however staff reported [Resident #1] had increased heart rate and hypotension. Recommendation for [Resident #1] to be seen in emergency department was made however [Resident #1] was not sent. Started IV Zosyn (abx) 3.375 g q.8 hours x 5 days. Stat CBC, BMP and chest x-ray ordered. We will follow clinical course and watch for antibiotic-related side effects including C. diff and nephrotoxicity. 2; [Resident #1] has diabetes with secondary complications. Further treatment per attending physician. 3; History of generalized muscle weakness. [Resident #1] is wheelchair bound . Record review of Resident #1's lab result report, dated [DATE], reflected in part the following: Collection Date: [DATE] Received Date: [DATE] Reported Date: [DATE] Basic Metabolic Panel: Glucose-Results: 117; Range ,d+[DATE] . CBC: WBC-Results: 8.9, Range: 3XXX,d+[DATE].2 RBC-Results: 3.1; Range 3XXX,d+[DATE].5 . Record Review of Resident #1's progress notes, [DATE]-[DATE], reflected there was not a note documenting why the resident was not sent out to the hospital as recommended by the Infectious Disease NP, or the conversation had between the former DON and the MD. Record review of Resident #1's progress notes, dated [DATE] at 5:46 PM by RN C, reflected the following: [Resident #1] vital signs were monitored, there were no signs of distress noted. Resting in bed. Record review of Resident #1's progress notes, dated [DATE] at 1:35 PM by RN B, reflected the following: [Resident #1] is alert and oriented *2 [sic] (awake and aware of identity and location but may not be aware of the time or current situation), slight confusion noted. [Resident #1] vital signs monitored and was BP ,d+[DATE] pulse 85b/min spo2 of 95 % in o2 21/min and RR 17 b/min and temp 98.7 [degrees] f. Stat CBC, CMP and chest Xray report was reviewed and notified [Infectious Disease NP] and MD about report. Resident antibiotic cefdinir and IV Zosyn (abx) was discontinued by [Infectious Disease NP], which was started because of leukocytosis and [Resident #1] WBC came normal. [Resident #1] kept on semi-Fowlers (medical posture where a patient lies on their back with their head and upper body raised ,d+[DATE] degrees) position to ease breathing. [Resident #1] was encouraged for fluid intake and timely fluid was given. [Resident #1] kept under close monitor for any change in his behavior and his condition. Ongoing plan of care. Will continue to monitor. Record review of Resident #1's progress notes, dated [DATE] at 5:40 PM by RN A, reflected the following: [Resident #1] was alert and oriented. spo2 was 95% maintained in o2 @ 2 I/m via nasal cannula. [Resident #1] was in semi-Fowlers position. [Resident #1] has no discomfort and pain. [Resident #1] safety was maintained. discontinue CEFDIFIR AND iv ANTIBIOTICS as normal WBC in recent report. Record review of Resident #1's progress notes, dated [DATE] at 5:58 AM by RN B, reflected the following: [Resident #1] is confused and drowsy confusion. [Resident #1] vital signs monitored and was BP ,d+[DATE] pulse 75b/min spo2 of 97 % in o2 2 I/min and RR 20 b/min and temp 98. 7 [degrees] f. [Resident #1] kept on semi-Fowlers position to ease breathing. [Resident #1] was encouraged for fluid intake and timely fluid was given. Resident kept under close monitor for any change in his behavior and his condition. Ongoing plan of care. Will continue to monitor. Record review of Resident #1's progress notes, dated [DATE] at 9:18 AM by RN A, reflected the following: [Resident #1] is confused and drowsy. [Resident #1] was not responded [sic] to verbal command properly. [Resident #1] vital signs monitored and was BP ,d+[DATE] pulse 73b/min spo2 of 95 % in o2 2 I/min and RR 20 b/min and temp 98.7 f. [Resident #1] kept on semi-Fowlers position to ease breathing. resident seems dehydrated and lethargic. [Resident #1] was encouraged for fluid intake, but he was not responding. [Resident #1] has changed in his behavior from last night. inform to [former DON] and [MD]. [Resident #1] [family] was witness for all [Resident #1] condition. [Resident #1] transported to [local hospital] at 7:35 am. Record review of Resident #1's hospital records, dated [DATE], reflected in part the following: [AGE] year-old male with past medical hx of dementia, chronic a fibrillation, type II diabetes, hypertension, pacemaker for third degree block, HLD, CVA, long term resident at [Nursing Facility] was sent to ER for altered mental status. [Resident #1] poor historian and dementia, unable to obtain HPI. [Resident #1] [family] was at bedside and reported that for past one week he has been getting weaker and getting more lethargic. [Family] reported to nursing staff the change in his status. Today [Resident #1] was not responding to nursing staff and found to have low blood pressure with fever so was sent via EMS. . Significant Findings/Diagnostic Studies: -admitted for acute metabolic encephalopathy due to sepsis -Workup showed UTI aspiration pneumonia and infected decubitus ulcer . -Urine culture growing Pseudomonas -Blood culture Bacteroides (nitrogen-fixing bacterium) -Tissue culture showed multiple organisms -Received IV antibiotics -Palliative care evaluated [Resident #1] because of advanced dementia and poor prognosis. [Family] wanted hospice . Further review of this document reflected it did not indicate which infection, the UTI or infected decubitus ulcer, caused Resident #1 to become septic. Record review of Resident #1's order summary report, dated [DATE], reflected in part the following: -Lactobacillus rhamnosus (probiotic used for gut health) oral capsule; Give 1 capsule by mouth one time a day for restore normal flora Order Date: [DATE] End Date: [DATE] -Macrobid oral capsule 100 MG; Give 1 capsule by mouth one time a day for UTI prophylaxis Order Date: [DATE] End Date: [DATE] -Cefdinir Capsule 300 MG: Give 1 capsule by mouth two times a day for UTI for 7 days Order Date: [DATE] End Date: [DATE] In an interview on [DATE] at 9:25 AM, Resident #1's family stated the resident resided at the nursing facility for about 4 years and there were concerns with the care throughout the stay; however, the resident wanted to remain there. The family stated different family members visited Resident #1 almost daily and were active in his care planning. The family stated she visited Resident #1 on [DATE] and found that the resident was not acting like himself, so she asked the former DON to complete a urine test. The family stated after 2 days, the urine test still had not been completed and the former DON stated he forgot to order it. The family stated the urine sample was finally taken on [DATE]. She stated the wound care MD contacted her on [DATE] and informed that Resident #1 had been placed on a broadband antibiotic and fluids for symptoms of a UTI. The family stated on the morning of [DATE], the family could see on the video monitor in Resident #1's room that something was wrong with him, so they went up to the nursing facility. The family stated Resident #1 was unarousable and they demanded that 911 be called. She stated Resident #1 was transported to the local hospital and was diagnosed with severe sepsis from a UTI and wound infection . The family stated the infection was too severe and hospice was the only option. The family stated they agreed to transfer Resident #1 to a hospice center, and he expired on [DATE]. In an interview on [DATE] at 1:29 PM, RN A stated she worked at the facility for 2 months. She stated she worked with Resident #1 on [DATE] when he was sent out to the hospital. RN A stated when she came on shift at 6:00 AM, she received report from RN B that Resident #1 had not acted like himself during the evening and night shift. RN A stated it was reported that the resident slept a lot and was not expressing himself like usual. RN A stated during her rounds, she noticed he had a change in condition. She stated Resident #1 was alert but would not respond verbally and was very low energy. RN A stated Resident #1's family came to the facility around 7:00 AM and agreed that something was wrong. RN A stated she called 911, then notified the former DON and MD. She stated Resident #1 was transported to the hospital by EMS. RN A stated she worked with Resident #1 over the past few days, and he showed gradual changes. She stated he seemed less aroused each day, but he was seeing the MD throughout the week and was on antibiotics, so she was not alarmed. In an interview on [DATE] at 3:17 PM, Wound Care Nurse/LVN E stated she worked at the facility since [DATE]. She stated she provided wound care to Resident #1 and recalled him receiving treatment for a pressure wound on his right heel and coccyx (tailbone) that had some small areas that were dark; however, most of the wound was beefy and pink with healing tissue. She stated she last rounded on Resident #1 with the Wound Care MD on [DATE] and there were no signs of infection to either wound. LVN E stated the Wound Care MD wanted to debride the wound on Resident #1's coccyx but he was waiting for it to soften more. She stated the Wound Care MD did not seem to have any major concerns for Resident #1's wounds. In an interview on [DATE] at 3:30 PM, the Wound Care MD stated his last round with Resident #1 was on [DATE]. He stated Resident #1's wound on his coccyx had no eschar (dead tissue) and no signs of infection. The Wound Care MD stated the wound needed to be debrided but it needed to soften a little more. He stated a debridement would have allowed him to see deeper into the wound; however, when he felt the wound, it did not feel squishy which indicated the tissue underneath was stable and there were no signs of infection. He stated he ordered an air mattress for Resident #1 to relieve more pressure and encourage healing, but there were no significant concerns for any of the resident's wounds. In an interview on [DATE] at 4:15 PM with the Clinical Resource and DON, the Clinical Resource stated he would normally only go to the facility on ce a week and was not aware of all the details regarding Resident #1; however, he was gathering information via record review and speaking with staff. The DON stated she started working at the facility 5 days ago and was also unaware. The Clinical Resource stated a UA for Resident #1 was collected on [DATE] after he exhibited s/sx of a UTI, and the result was positive for a bacterium. The Clinical Resource stated Resident #1 was started on a PO abx by the FNP; however, it was discontinued on [DATE] by the Infectious Disease NP after a second set of labs came back negative for an infection. The Clinical Resource stated according to the progress notes, the Infectious Disease NP wanted Resident #1 sent out to the hospital on [DATE] due to s/sx of an infection but the resident was not sent out. The Clinical Resource stated he spoke with LVN L, who worked with the resident that day, to see why he was not sent out and she informed them she attempted to notify the MD before sending Resident #1 out, but she was unable to reach him. The Clinical Resource stated LVN L told him that she then passed the information to the former DON, who reached out to the MD himself, and he reported that the MD advised against sending Resident #1 out to the hospital. In an interview on [DATE] at 11:08 AM, the FNP stated she visited Resident #1 on [DATE] and she noticed that he was more confused than usual; however, he did not look as bad as the staff had reported. The FNP stated she put in an order for blood work and a UA. The FNP stated the nurses had a hard time collecting the urine for the UA initially, which was what took so long for it to be collected. She stated she also ordered PO abx but told staff not to start it until the UA resulted so that the medication would not alter the results. The FNP stated the UA resulted on [DATE] and was positive for a UTI and the PO abx should have been started . The FNP stated she was off work on [DATE] and [DATE] and when she returned the following week, she found that Resident #1 has been transferred to the hospital. Attempted interview on [DATE] at 11:28 AM with LVN L was unsuccessful due to no response to call. In an interview on [DATE] at 11:32 AM, the Infectious Disease NP stated he visited Resident #1 on ,d+[DATE] and reviewed lab work ordered by the FNP. He stated the lab work showed Resident #1's WBC was elevated, and he was positive for leukocytosis. The Infectious Disease NP stated Resident #1 had already been started on PO abx. He stated the nurse reported that day that Resident #1's blood pressure was low, and he was continuing to show s/sx of an infection. The Infectious Disease NP stated he recommended that Resident #1 be sent to the hospital based on his hx of infections and sepsis. The Infectious Disease NP stated he ordered another set of labs and IV abx in the meantime on [DATE]. The Infectious Disease NP stated he was not informed whether Resident #1 was sent to the hospital as recommended on [DATE]. He stated when he gave a recommendation, it was up to the facility to follow it or consult with the MD. He stated the expectation was for the facility to notify him if they decided against his recommendation. The Infectious Disease NP also stated he was not informed whether the IV abx were started. He stated the labs he ordered resulted on [DATE] and the results showed Resident #1's WBC was within normal range, the leukocytosis resolved, and the UA was unremarkable, so he discontinued the PO abx order by the FNP and the IV abx ordered by him. He stated Resident #1 also did not have a fever and his chest X-ray was negative for pneumonia. The Infectious Disease NP stated when he returned to the facility on [DATE], he found that Resident #1 had been discharged to the hospital. In an interview on [DATE] at 12:17 PM, RN B stated she worked at the facility for about 6 months. She stated she worked with Resident #1 during the evening on [DATE]. She stated an order for IV abx was put in by the Infectious Disease NP earlier that day, but he discontinued it along with the PO abx later that day. She stated she was about to contact the provider to come insert the PICC line just as the order was discontinued, so the IV abx was never started. RN B stated the previous nurse gave report that Resident #1 had been drowsy and was not as responsive as usual. RN B stated Resident #1 had been that way for a few days and had seen the FNP. In an interview on [DATE] at 3:04 PM, the MD stated the facility attempted to notify him of Resident #1's change of condition and initially could not reach him; however, he called back and spoke with the former DON. The MD stated he recalled having a conversation with the former DON about Resident #1 being sent out to the hospital as recommended by the Infectious Disease NP, and he did not object to it. The MD stated from what he understood regarding the symptoms Resident #1 was exhibiting, based on his history of infections and the hemodynamics (study of blood flow), the resident appearing unstable he could not think of a rationale against sending him out. The MD stated the former DON would not have had the authority to decide to not send Resident #1 out himself. The MD stated it was reasonable to get Resident #1 assessed at the hospital, so he was not placed at an increased risk of getting sepsis due to his hx. In an interview on [DATE] at 2:45 PM, the Operations Manager stated the former DON was not terminated for any reasons directly related to Resident #1 because management was unaware of the issue prior to the investigation; however, it was for poor job performance and lack of follow up on tasks and concerns, which was similar to the incident of miscommunicating information from the MD regarding Resident #1. Attempted interview on [DATE] at 4:06 PM with LVN L was unsuccessful due to no response to call. Attempted interview on [DATE] at 11:21 AM with LVN L was unsuccessful due to no response to call. Record review of the facility's policy titled Nursing Administration-Incontinence, Urinary, revised ,d+[DATE], reflected in part the following: Policy: It is the policy of this facility that: . 2. A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. Purpose: 1. Each resident who is incontinent of urine is identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible. PROCEDURES: Assessment: 1. Resident will be evaluated at admission, quarterly and whenever there is a change in cognition, physical ability, or urinary tract function. This evaluation is to include identification of individuals with reversible and irreversible (bladder tumors and spinal cord disease) causes of incontinence. . Interventions: 1. Provide Incontinent Care. . 4. Treat underlying conditions that have a potentially negative impact on the degree of continence (delirium causing urinary incontinence related to acute confusion). . The Operations Manager, Clinical Resource, and DON were notified of an Immediate Jeopardy (IJ) on [DATE] at 5:38 PM, due to the above failures and the IJ Template was provided at 05:38 PM. The facility's Plan of Removal (POR) was accepted on [DATE] at 8:34 AM and included: [Nursing Facility] Plan of Removal . [DATE] Version 1 Per the information provided in the IJ Template given on [DATE], the facility failed to follow the Nurse Practitioner's recommendation to send Resident #1 to the hospital for symptoms of an infection. Immediate Action 1. The Medical Director was notified of IJ on [DATE] at 5:52pm by the Clinical Resource RN. 2. Resident #1 was transferred to the hospital on [DATE] and did not return to the facility. 3. The DON, Clinical Resource RN, and Cluster Partner RN initiated an audit on [DATE] that will be completed on [DATE] on all residents currently being treated for a UTI to ensure orders are in place and care plans updated. 4. Training and knowledge checks for changes in condition, UTI, and sepsis will be completed with all nursing staff. This training will be initiated on [DATE] and will be completed by [DATE]. This training will be provided by the Director of Nursing, Cluster Partner DONs/RNs, and Clinical Resource RNs. 5. This training will be completed with all nursing staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for agency /PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 6. An ad hoc meeting regarding items in the IJ template will be completed on [DATE]. Attendees will include the Medical Director, DON, Clinical Resource RN, Administrator, Operations Manager, and Cluster Partner DON/RN and will include the plan of removal items and interventions. 7. Daily monitoring will be completed by the DON to include review of the 24-hour report for signs and symptoms of UTI, sepsis, and change of condition. 8. The Directors of Nursing or Clinical Resource RN will verify staff knowledge checks on change of condition, signs and symptoms of a UTI and sepsis with 10 nursing staff weekly. 9. All changes of condition will be reviewed at the weekly clinical meeting. The Medical Director will be notified for recommendations as necessary. Attendees at this meeting will include DON, wound nurse, Clinical Resource RN, Director of Rehab, MDS nurse. This process will begin [DATE] and will be ongoing. 10. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. On [DATE] the investigator began monitoring (9:45 AM-02:45 PM) to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Observations, interviews , and record reviews on [DATE] from 10:00 AM-11:15 AM of Residents #1, #2, #5, #6, #7, and #8 revealed no further concerns for incontinence care or infections. Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status. Observations and interviews with residents and/or RPs revealed no concerns for change of condition or quality of care received. Record review of a document provided by the Clinical Resource titled Order Listing Report, dated [DATE]-[DATE], reflected all residents with active UTIs received a chart audit to ensure that orders were in place and care plans were updated. Record review of a document provided by the Clinical Resource titled 24 Hour Summary, dated [DATE]-[DATE], reflected all residents received a clinical assessment for s/sx of

Based on interview and record review, the facility failed 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 for one (Resident #1) of three residents reviewed for pain management. The facility failed to ensure Resident #1 received scheduled doses of her pain medications. This failure could affect residents by placing them at risk of not receiving pain medications as ordered resulting in a high level of pain, and loss of quality of life. Findings included: Review of Resident #1's face sheet, dated 08/04/23, revealed she was a [AGE] year-old-female admitted on [DATE] with diagnoses of morbid obesity, Type 2 diabetes mellitus, anxiety disorder, chronic pain, lymphedema, and acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. Review if Resident #1's MDS, dated [DATE], revealed she had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. It further revealed she was on routine (scheduled) and PRN (as needed) pain medications. Review of Resident #1's Care Plans, dated 09/22/22 revealed the following: Focus: Is on pain medication therapy r/t Crohn's disease and chronic pain syndrome. Goal: Will be free of any discomfort through the review date of 09/29/23. Interventions: Administer medication as ordered. Review of Resident #1's Physician's Orders for the month of July 2023 revealed she was ordered: Hydrocodone-Acetaminophen Tablet 10-325 MG *Controlled Drug* Give 1 tablet by mouth every 4 hours for Chronic Pain. The order date was 01/25/23. Review of Resident # 1's Medication Administration Record (MAR) for the month of July 2023 revealed the following: *07/30/23 at 2:00 AM Resident #1 received her dose of Hydrocodone-Acetaminophen 10-325 MG as ordered and her pain level was a 3. *07/30/23 at 6:00 AM, Resident #1 did not receive her dose of Hydrocodone-Acetaminophen 10-325 MG as ordered. The MAR indicated her pain level was a 0 and there was no nurses note explaining why she did not receive it. *07/30/23 at 10:00 AM, Resident #1 did not receive her dose of Hydrocodone-Acetaminophen 10-325 MG as ordered. The MAR had an X in the level of pain and the nurses note dated 07/30/23 at 11:00 AM revealed, Med not available .F/U done.Awaiting delivery. *07/30/23 at 2:00 PM Resident #1 did not receive her dose of Hydrocodone-Acetaminophen 10-325 MG as ordered. The MAR was blank and the nurses note dated 07/30/23 at 1:34 PM revealed, Pharmacy and doctor was called and notified. This was a 16 hour stretch with no pain medication administered. *07/30/23 at 6:00 PM Resident #1 received her Hydrocodone-Acetaminophen 10-325 MG as ordered and her pain level was a 7 on a scale of 1-10 with 10 being the worse pain. *07/30/23 at 10:00 PM Resident #1 did not receive her Hydrocodone-Acetaminophen 10-325 MG as ordered. There was an X in pain level and there was no nurses note. *07/31/23 at 2:00 AM Resident# 1 did not receive her Hydrocodone-Acetaminophen 10-325 MG as ordered. There was an X in the MAR for pain level and the nurses note dated 08/31/23 at 2:03 AM revealed, Medication not available. *07/31/23 at 6:00 AM Resident #1's received her Hydrocodone-Acetaminophen 10-325 MG as ordered and her pain level was a 10. Review of Resident #1's Care Plans dated 09/22/22 revealed the following: *Focus: Is on pain medication therapy related to (r/t) Crohn's (Disease) and chronic pain syndrome. *Goal: Will be free of any discomfort through the review date 09/29/23. *Interventions: Administer medications as ordered. An interview with Resident #1 on 08/04/23 at 2:00 PM , she stated the day they ran out of her hydrocodone she revealed, it was horrible, I was in so much pain and then I was scolded for crying because I was keeping my roommate awake. They did not even ask how I was doing. Resident #1 denied the facility had ever run out of her Fentanyl 50 microgram/hour patch. She stated that would have made it much worse. She said she did not know how they could let her run out of pain medicine. An interview with the DON on 08/04/23 at 4:03 PM revealed, he did not know why Resident #1 had run out of her Hydrocodone. The DON said he had not been there when it happened as he had taken some time off. He asked the surveyor if they (nurses) had pulled any from the emergency kit (E-kit) as they were available in the E-kit. The DON said if it had been an agency nurse, they should have contacted the pharmacy, the MDS RN, or himself about calling the pharmacy and getting an access code to the E-kit. The DON said the agency nurse should be aware that they can call the pharmacy or us to get access to the e-kit. An interview with the MDS RN on 08/04/23 at 4:38 PM revealed Resident #1 had received her Hydrocodone-Acetaminophen 10-325 MG around 6:00 PM on 07/30/23. She said the nurse on duty had started calling the doctor for a triplicate to be sent to pharmacy around 1:30 PM on 07/30/23. She said there was a five-day run out period on the card of medications and they had not been able to get ahold of the physician. The MDS RN said they had to have the triplicate to get a code from the pharmacy for the E-kit. The MDS RN said the Medication Aide (MA) should have let the nurse and the doctor know when they were getting low so a triplicate could have been received before they had run out. An interview with the Admin. on 08/04/23 at 4:38 PM revealed Resident #1 would call her constantly if she ran out of pain med and she had been on the phone with her and her significant other about it on the 30th, letting them know what was going on. She stated the DON had quit a few days before that weekend, so it was not until around 5:45 PM they called the MDS RN, and she had called the pharmacy and gotten one from the E-Kit. Since the DON had quit, he could not access to the e-kit so if they had called him, he would have redirected them to call the MDS RN. The Admin. stated to make sure running out of pain medications would not happen again, they would start notifying the doctor sooner and follow up to make sure the triplicate was sent so they did not run out again. The Admin. said she thought their Regional Nurse had started an in-service on when and how to order pain medication that required a triplicate from the physician. The surveyor requested a copy of the in-service. An interview with the DON on 08/04/23 at 7:09 PM revealed there had been no in-service done on the reordering of medications that require a triplicate. The DON stated they did not have a policy on and procedure on re-ordering pain medications that require a triplicate. The DON state he would look for a policy on re-ordering medications. An interview with the DON on 08/04/23 at 7:36 PM revealed they did not have a policy on re-ordering medications. Review of the facility's current policy and procedure Administration of Medications dated 07/2017 revealed, It is the policy of this Facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant.

Based on observation, interview, record review, and policy review, the facility failed to assess fall risk and develop and implement a care plan with appropriate resident specific interventions to ensure one resident (Resident (R) 21) out of a total sample of 27 residents was free from accidents. R21 sustained harm when she experienced a fall causing a fractured nose. Findings include: Review of the facility's Safety and Supervision of Residents policy, dated July 2017, revealed, . The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents . The facility-oriented and resident oriented approaches to safety are used together to implement a systems approach to safety which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly . Review of R21's undated Face Sheet, located under the Profile tab of her Electronic Medical Record (EMR), revealed R21 was admitted to the facility on [DATE]. Review of R21's diagnoses, located in the EMR under the Diagnosis tab, revealed diagnoses which included COVID-19, metabolic [CONDITION(S)] (change in brain function), unspecified dementia without behavioral disturbances, and generalized anxiety disorder. Review of R21's admission Minimum Data Assessment (MDS) with an Assessment Reference Date (ARD) of 03/14 21 revealed a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating severely impaired cognition. Further review of this MDS revealed R21 required limited assistance of one for bed mobility, transfers, and ambulation; needed assistance to maintain balance when ambulating; needed assistance to stabilize when moving from a seated to a standing position; had an undetermined fall history prior to admission and no falls since admission; and had received no anti-anxiety medications within the past seven days. Review of the EMR Assessments, located under the Assessment tab revealed no fall risk assessment was done upon R21's admission to the facility, therefore no care plan was initiated for a risk of falls. Review of R21's Interdisciplinary Team (IDT) progress notes, dated 03/16/21 at 1:09 AM and located under the Progress Notes tab of her EMR, revealed, . Resident awake and alert to self, sitting in wheelchair in room watching television. When asked if she was sleepy resident stated, 'No I have to get up and walk.' Review of R21's IDT notes, dated 03/16/21 at 7:00 AM, revealed, . resident stayed up most of the night according to night nurse, she stayed awaked, no aggressive [sic] or verbal behaviors toward staff noted . Review of R21's Order Review Report provided by the Director of Nursing (DON) revealed a physician's order, initiated on 03/16/21, for [MEDICATION(S)] (an anti-anxiety medication known to affect cognition and balance) 0.5 milligrams (mg) twice daily for a diagnosis of anxiety. R21's physician was not available during the survey to discuss the rationale for ordering [MEDICATION(S)] twice a day. Review of R21's Fall Investigation Worksheet, located under the Assessments tab of her EMR, revealed an entry dated 03/18/21 at 2:45 AM, . Resident found on floor on side of bed in room . No bumps, bruises, or other injuries noted . Review of the Recommendations/Interventions area of the form revealed, . Physical therapy to screen and treat if needed for strength and mobility . educate [resident] to use call light if need assistance. Keep bed in lowest position. Ensure call light within reach . Further review of the Fall Investigation Worksheet revealed R21 had been started on [MEDICATION(S)] within the past 72 hours. Review of R21's Physical Therapy Plan of Care and Occupational Therapy Plan of Care, provided by the facility Program Director (Rehab Services Manager), revealed R21 was already receiving physical and occupational therapy beginning on 03/11/21. Review of R21's care plan, provided by the DON and initiated on 03/18/21, revealed a new care plan problem area for, . Actual fall with no injuries related to poor balance and unsteady gait. The interventions included, Educate [resident] to use call light for assistance when needed, and Physical therapy to screen and treat if indicated. No other interventions were implemented at that time. The care plan did not address how education to use the call light was appropriate for R21 who was severely impaired cognitively, describe how a physical therapy screening was an effective intervention for a resident already on therapy services, or the how the recent addition of an anti-anxiety medication might impact the resident's risk for falls. Review of R21's Fall Investigation Worksheet, dated 03/26/21 at 10:45 AM and located under the Assessments tab of her EMR, revealed . Resident is unable to follow commands, unable to keep a steady gait and tends to wander a lot. Attempted to self-transfer from bed to wheelchair. The Recommendations/Interventions area of the form documented, . Re-directed [resident] to ask for assistance when needed. Ensure call light within reach. Ensure bed in lowest position. Staff to keep [resident] in close observation. Review of the area of the form to document, Activity at the time of the fall or what the resident was trying to do revealed, Unknown and that an x-ray of her skull was ordered to rule out injury. Review of the Radiology Report, dated 03/26/21 and located under the Laboratory tab of her hard chart, revealed, R21 had . nondisplaced fracture of the nasal bone is present with soft tissue swelling . During an interview on 06/02/21 at 10:56 AM, the MDS nurse revealed she would develop a resident's comprehensive care plan when the resident was admitted to the facility, but most revisions for a falls care plan would be added by the DON after a resident fell . The MDS nurse stated that the post-fall care plan interventions should be resident-specific and personalized to the resident's abilities and needs. The MDS Nurse stated that in her experience educating a resident to use their call light was not an effective or appropriate intervention for a resident with severely impaired cognition, and that it should be ascertained whether a resident was already on therapy caseload before adding that item as a fall intervention. An observation on 06/01/21 at 3:50 PM, revealed R21 lying on her bed in her room's bed was in the low position and a concave mattress was in place. R21 was able to confirm her name when asked but was unable to answer any further interview questions. An observation on 06/03/21 at 10:45 AM, revealed R21 was sitting at the edge of her bed, with her buttocks between the upper and lower bolsters of her concave mattress. R21 was wearing only an incontinence brief, with a red nightshirt lying across the foot of her bed. On 06/03/21 at 10:54 AM Registered Nurse (RN) 6 entered R21's room and assisted her to put her nightshirt on and lie down in bed. During an interview on 06/03/21 at 11:00 AM, RN6 revealed she was new to the facility and not familiar with R21 but saw her without a shirt so assisted her to put on the shirt. RN6 stated she did not know that R21 had a fall history. During an interview on 06/03/21 at 2:15 PM, the DON revealed R21 was admitted on to the facility's COVID unit on 03/10/21. The DON stated that she was prohibited from physically going onto the COVID unit per a state health directive (only staff working permanently on the COVID unit were allowed to enter) but she had been told R21 was constantly trying to stand up and wander. The DON stated that she aware R21 had been started on [MEDICATION(S)], but unaware that it was two days before her first fall, and it had not been evaluated in conjunction with the resident's falls. The DON reviewed the interventions added to R21's care plan after her fall on 03/18/21 and stated that educating R21 to use her call light was something we always do, we want the residents to feel comfortable using their call lights, but was probably not effective given R21's cognitive impairment. The DON stated asking for a Physical Therapy and Occupational Therapy evaluation for a resident who had fallen was, Just standard, something we always do, but admitted ly we don't always know who's already on therapy. The DON stated that the facility had added the concave mattress to R21's care plan on 04/22/21 after they spoke to R21's family and discovered that she had experienced a number of falls from bed before her admission to the facility. The DON stated it was her expectation that a resident's fall history and ideas for interventions would be obtained at the time a resident was admitted to the facility, and she was not sure why the facility had not reach out to the family for a complete fall history at the time of admission but instead waited 43 days.

Based on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [REDACTED].#1) of four residents reviewed for CPR. The facility failed to immediately provide CPR and call 911 for Resident #1, who was a full code and wanted all possible life saving measures in the event her heart or breathing stopped when LVN A found the resident unresponsive and without vital signs. Resident #1 expired in the facility on [DATE]. An Immediate Jeopardy (IJ) existed from [DATE] to [DATE]. The IJ was determined to be past noncompliance as the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation. This failure placed residents who were a full code status at risk of death. Findings included: Review of Resident #1's face sheet dated [DATE] indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Review of Resident #1's electronic medical record on [DATE] revealed no code status or physician's orders [REDACTED]. Review of Resident #1's paper medical chart revealed the first sheet was a green sheet of paper that reflected FULL CODE CPR and included Resident #1's name as well. Her paper medical chart further revealed a handwritten note dated and signed by Resident #1 on [DATE] that reflected, Please remove the D.N.R. from my chart. This note further reflected in large letters, .Attention: Remove DNR from chart at patient's request. There was no order or DNR found in the chart or a Physician's telephone order for a code status. Review of Resident #1's nursing note dated [DATE] at 18:37 (6:37 PM), completed by LVN A revealed: Patient found unresponsive @ 1745 (5:45 PM). no palpable pulse, hospice notified, MD notified, DON notified, RP notified, RP states patient is DNR she does not want the patient resuscitated she stated she sent in DNR to social worker, social worker said RP sent the DNR in via text. The DON stated that was not valid, the patient needed to be coded, CPR was initiated, 911 called. (There was no indication of when CPR was actually started.) During a telephone interview on [DATE] at 1:59 PM, EMS Chief stated the initial 911 call from the facility came in at 16:16 (6:16 PM) and they arrived on the scene at 18:21 (6:21 PM). He stated CPR was being conducted when they arrived. During an interview on [DATE] at 4:25 PM, the DON said it was her understanding about the events of [DATE] that LVN A had called her (Per the phone log at 5:17 PM) and she was not by her telephone so had not gotten the call, but a minute or so later LVN A had texted. The DON said she called LVN A back (Per the DONs phone log at 6:06 PM) and asked her what was going on. LVN A had said Resident #1 was not breathing so the DON asked her what time LVN A had last seen her. LVN A had said around 3:00 PM but she had a problem because Resident #1's RP had called and told her she had sent the paper work to the SW for a DNR. The DON stated while she was talking to LVN A, she texted the SW, who had not answered so she instructed LVN A to call Resident #1's Hospice company. The Hospice company told her not to start CPR on Resident #1. The DON said after she had gotten ahold of the SW and found out she had only received a text with the MPOA papers and not a DNR from the RP for Resident #1, she called LVN A back (Per the DONs phone log at 6:08 PM) and told her to start CPR and call 911. The DON said LVN A had started CPR while she was on the phone with her. The surveyor asked what the facility's protocol if there was a question about a resident's code status. The DON said they were to start CPR immediately but she and LVN A were trying to do the right thing if Resident #1 wanted to be a DNR. The DON had her cell phone out, so the surveyor asked to see the times and have her explain the phone calls made on [DATE]. When the surveyor informed the DON, it was 51 minutes after the initial call made to her by LVN A, the DON stated that since that had happened they had done some training. Review of the DON's cell phone calls dated [DATE] between LVN A and the DON revealed the following: On [DATE] at 5:17 PM the DON missed a call from LVN A. On [DATE] at 6:06 PM there was a missed outgoing call from the DON to LVN A who had not answered. On [DATE] at 6:08 PM the DON had called LVN A again and she had answered. During a telephone interview on [DATE] at 3:35 PM, LVN A said she had been at the facility and taken care of Resident #1 on Saturday, [DATE], 6:00 AM to 10:00 PM. She stated Resident #1 had been having some difficulty breathing when she first came on shift. LVN A had administered Resident #1's breathing treatment and given her pain medicine, then checked on her periodically throughout the day. LVN A stated in report that morning she had been told Resident #1 was having a rapid heart and breathing rate. She said her heart rate was still high but other vitals had calmed down. When LVN A went down later that evening, Resident #1 had no pulse or respirations, so she had gone to her chart and checked for her code status. She notified the DON, Admin, 911 and the physician that she had found her unresponsive. The surveyor asked LVN A if she had called all those people before starting CPR and she stated she had started CPR and called all those people at Resident #1's bedside using her cell phone. LVN A said the other nurse was with her and helped, they had gotten the AED out, placed the pads on the resident and it told them to stand back and initiated a shock. Then the EMS was there and took over the CPR. LVN A also said she had called the hospice company from her cell phone at the bedside as well. When asked if there had been a question about Resident #1's DNR status, LVN A said no, because her chart reflected full code. During a telephone interview on [DATE] at 3:50 PM, LVN B said he had been at the facility on Saturday [DATE] and had helped LVN A with CPR on Resident #1. He stated he heard them call a code, so he jumped in and took the crash cart into Resident #1's room and they started CPR. He stated no, they had not used the AED because the EMS showed up and took over so there was no time. He stated they had switched out compressions and breaths. LVN B stated LVN A had called 911 from the bedside, but not Hospice, DON, Administrator, or Physician. It was around 6:,[DATE]:15 PM when LVN Be ran over to help. An interview on [DATE] at 5:25 PM with the DON, Administrator and the ED, the Administrator stated if there is a question about a code status they were to start CPR immediately, so they had done in-services starting the next day on [DATE] when he had heard what happened. The Administrator said he had initiated re-training of LVN A and the DON because she had not done the right thing as well. He stated he had in-serviced them on what to do if a resident is found unresponsive, with no pulse or respirations, they were to check the chart for a code status. If there was not an OOH-DNR and signed physician's orders [REDACTED]. The Administrator said all nurses had been re-trained and they had audited all resident charts to make sure their code status was correct and on their charts with the correct paperwork. Review of the facility's policy and procedure for Cardiopulmonary Resuscitation revised [DATE], revealed: .6. If an individual (resident, visitor, or staff) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; . 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. The Administrator, ED, and DON were notified on [DATE] at 6:05 PM, that an Immediate Jeopardy existed from [DATE] to [DATE]. The Administrator was provided with the IJ template at this time. The facility took the following corrective actions prior to entrance on [DATE]: 1. The Administrator directly in-serviced LVN A and the DON on [DATE]. 2. The facility has in-serviced nurses as they came on shift and completed training prior to surveyor entry on [DATE]. 3. All resident charts were audited, and all code statuses found to be correct before entry on [DATE]. 4. The Quality Assurance Committee met on [DATE] and created a performance Improvement Plan regarding the issue as follows: Problem: Failure to recognize and implement CPR in a timely fashion. Action: A. What corrective action taken for resident found to have been affected by the deficient practice? 1. Nurses responsible for failure to initiate CPR were re-educated by the Administrator who is also an RN, on [DATE]. B. How other residents with potential to be affected by the same deficient practice will be identified? 1. An audit was performed on [DATE] by the social worker on all charts ensuring code status was accurate and up to date. No discrepancies were found. Audits will be conducted X 3 weekly for 6 weeks and randomly audited after. Any discrepancies found will be corrected and reported to facility QAPI. 2. An in-service was conducted on [DATE] for the licensed nurses on duty to ensure they understand that a Out of Hospital DNR and a signed DNR Physician order [REDACTED]. If the Out of Hospital DNR and DNR Physician order [REDACTED]. 3. All licensed nurses had 1:1 in-service by the DON or designee regarding advanced directives, CPR, and out of hospital DNRs. C. What measures will be put in place or what systemic changes will be made to ensure that the deficient practice does not recur? 1. Upon admission, The Director of Admissions, Director of Business Development, Social Services Director, and /or designee will review code statue with family/patient. If the code status cannot be verified the resident will be considered a full code until the necessary paper work is in place. SW will reach out to the patient/POA to ensure necessary documentation for code status is in place on the chart. For weekend hours, RN Weekend Supervisor/Manager on duty will review admissions to ensure code status is known and documented appropriately over the weekend. 2. Department Heads and/or Manager on Duties, and Nursing Administration will be in-serviced by Admin/Don on advanced directives and OOH DNR. 3. New hired licensed nurses will be in-serviced o code status verification, and advance directives upon hire and quarterly. D. How the corrective actions will be monitored to ensure practice is being corrected. What's in place to monitor? 1. Findings of audits will be reviewed X 3 weekly by Administrator for any areas that need to be corrected and compliance. Any discrepancies will be reported to IDT and addressed in QAPI. 2. Findings will also be reviewed with the Medical Director. Any discrepancies will be reported and addressed with the MD and IDT. Monitoring of the facility's response revealed: Review of the in-service given from [DATE] to [DATE] revealed they were instructed to ensure they understand that a Out of Hospital DNR and a signed DNR Physician order [REDACTED]. If the Out of Hospital DNR and DNR Physician order [REDACTED]. Interviews on [DATE] from 2:49 PM through 3:50 PM with MA C, LVN D, CNA E, and LVN B revealed they knew what to do if they found a resident unresponsive, with no respirations or heart rate, where to find the resident's code status in the chart, and if there was a question of the code status they must start CPR immediately. Interviews on [DATE] from 4:25 PM through 6:28 PM with the DON, LVN G and LVN H revealed they knew what to do if they found a resident unresponsive, with no respirations or heart rate, where to find the resident's code status in the chart, and if there was a question of the code status must start CPR immediately. Interviews on [DATE] from 1:47 PM through 2:13 PM with LVN J, LVN K and LVN I revealed they knew what to do if they found a resident unresponsive, with no respirations or heart rate, where to find the resident's code status in the chart, and if there was a question of the code status must start CPR immediately. Interviews on [DATE] from 10:02 AM through 2:21 PM with LVN L, LVN A and RN M revealed they knew what to do if they found a resident unresponsive, with no respirations or heart rate, where to find the resident's code status in the chart, and if there was a question of the code status must start CPR immediately. An Immediate Jeopardy (IJ) existed from [DATE] to [DATE]. The IJ was determined to be past noncompliance as the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation.

Based on observation, interview, and record review, the facility failed to ensure foods were served in the appropriate form for 3 (Residents #1, #3, and #10) of 10 residents reviewed for mechanically altered diets. The facility failed to serve Residents #1, #3, and #10 mechanically soft foods, which was what their physicians ordered. Resident #10 choked and gasped for breath. An Immediate Jeopardy (IJ) was identified on 05/23/17 at 4:30 p.m. While the IJ was removed on 05/25/17, the facility remained out of compliance at a severity level of potential for actual harm that is not immediate jeopardy and a scope of pattern due to the facility's monitoring of the effectiveness of the plan of removal. These failures placed 32 residents with orders for either mechanical soft or puree diets at risk of choking, aspiration, aspiration pneumonia, and death. Findings included: 1. Review of Resident #10's Face Sheet, dated 05/25/17, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident #10's MDS assessment, dated 05/01/17, reflected Resident #10 required a mechanically altered diet while she was a resident at the facility. Review of Resident #10's Service Plan reflected she required a mechanical soft diet. This portion of the Service Plan was most recently revised on 05/31/16. Review of Resident #10's Medication Review Report (physician's orders [REDACTED].#10 had an order to receive mechanically soft textured foods. This order was initiated on 01/19/17. Review of Resident #10's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground chicken parmesan with spaghetti sauce, spaghetti noodles, sliced broccoli florets, dinner roll/bread, margarine, and butterscotch pudding. Observation on 05/23/17 at 12:23 p.m. revealed Resident #10 was served a whole piece of chicken parmesan (not mechanically chopped or ground) and whole pieces of broccoli florets. During an interview with the Food Service Manager on 05/23/17 at 12:40 p.m., she stated meal tickets were current and reflective of each resident's ordered diet. The Food Service Manager stated meal trays were initially checked for accuracy prior to leaving the kitchen by the last person on the meal tray line. After the meal trays left the kitchen, both a nurse and a nurse aide were also required to check the meal trays for accuracy prior to serving the residents. The Food Service Manager stated all meal trays were checked for accuracy today, prior to leaving the kitchen for the lunch meal service. She was notified Resident #1 and Resident #3 did not receive mechanical soft meals during the lunch meal service. Observation on 05/23/17 at 12:44 p.m. revealed Resident #10 was sitting in her room, repeatedly pointing to her throat. Initially, she was not making any sound while pointing to her throat. Resident #10 then made a gurgling sound. The Food Service Manager yelled for the assistance of a nurse. Observation on 05/24/2017 at 12:45 p.m. revealed three staff members were in Resident #10's room, including one nurse. Resident #10 was found to be grasping for breath. The nurse was telling Resident #10 to continue to spit. The nurse stated she could not do the [MEDICATION NAME] maneuver, as Resident #10 had a [DIAGNOSES REDACTED].#10 was spitting up mid-size particles of food. During an interview with CNA C on 5/23/17 at 12:48 p.m., she was unaware of Resident #10's diet orders. She stated Resident #10 was ordered a regular texture diet. During an interview with resident #10 on 05/24/17 at 4:00 p.m. revealed that resident did not understand what mechanical soft diet was. Resident stated that today was the only time her meal was not chopped. Resident #10 said that during lunch she had a throat problem. Resident #10 could not articulate what occurred however, she demonstrated the event by grasping her throat. 2. Review of Resident #1's Face Sheet, dated 05/25/17, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 04/13/17, reflected she was cognitively intact. She was identified as requiring a mechanically altered diet with supervision and setup help for meals. Review of Resident #1's Medication Review Report (physician's orders [REDACTED]. Review of Resident #1's Service Plan, undated, reflected she required a mechanical soft diet. The facility's intervention included providing and serving her diet as ordered. This portion of the Service Plan was most recently revised on 05/31/16. Review of Resident #1's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground chicken parmesan with spaghetti sauce, spaghetti noodles, sliced broccoli florets, dinner roll/bread, margarine, and butterscotch pudding. Observation on 05/23/17 at 12:35 p.m. revealed Resident #1 was served a whole piece of chicken parmesan, spaghetti noodles, whole pieces of broccoli florets, a dinner roll, margarine, and butterscotch pudding. The chicken was not mechanically ground or chopped. Resident #1 attempted to cut the chicken with her utensils. She obtained the attention of CNA C by saying, I need you to cut my meat. I can't even do it. CNA C then cut Resident #1's chicken into pieces that were approximately 1 inch long by 1 inch wide. She also cut Resident #1's broccoli florets prior to leaving the room. During an interview with Resident #1 on 05/24/17 at 9:40 a.m., she reported prior to 05/23/17, she never received a mechanical soft diet. She stated she always received full pieces of meat and she had staff members cut the meat for her. During an interview with CNA C on 05/24/17 at 1:45 p.m., she stated Resident #1 was ordered a mechanical soft diet. She stated she was aware of the requirement to review meal tickets, which identified each resident's specific diet order. She stated on 05/23/17, she cut up Resident #1's food because Resident #1 requested for the meat to be cut. When asked why she did not return the tray to the kitchen and request a mechanical soft meal tray, CNA C did not provide an answer. 3. Review of Resident #3's Face Sheet, dated 05/25/17, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment, dated 03/13/17, reflected she was cognitively impaired. She was identified as requiring a mechanically altered diet with supervision and setup help for meals. Review of Resident #3's Medication Review Report (physician's orders [REDACTED]. Review of Resident #3's Service Plan, undated, reflected she required a mechanical soft diet. The facility's intervention included providing and serving her diet as ordered. This portion of the Service Plan was most recently revised on 05/25/17. Review of Resident #3's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground lemon pepper fish with white sauce, buttered rice, yellow squash, bread, and butterscotch pudding. Observation on 05/23/17 at 11:55 a.m. revealed Resident #3 was served a whole piece of lemon pepper fish, buttered rice, yellow squash, bread, and butterscotch pudding. The fish was not mechanically ground or chopped. She did not eat the meat. During an interview with Resident #3 on 05/24/17 at 9:30 a.m., she reported prior to 05/23/17, there had been various occasions in which she did not receive a mechanical soft diet. She said when she did not receive the correct diet, she would cut the meat herself. 4. During an interview with LVN J on 05/23/17 at 1:39 p.m. he stated that he was responsible for checking the meals to insure that correct meals for the correct consistency such as puree, mechanical soft, or regular. LVN J said that a CNA would check meals when delivering. He said that the Food Service Manager should be checking the trays and tickets as well. LVN J was not sure why the incorrect textured meals were not caught. During an interview with the Director of Nursing on 05/23/17 at 2:40 p.m., she stated the facility initiated in-services on the importance of ensuring residents received correct meals as ordered by the physician. She stated Resident #1, Resident #3, and Resident #10 were placed on 72-hour checks due to receiving the incorrect diet. The Director of Nursing stated, There's no sugar coating a failure occurred. During an interview with the Regional Nurse Consultant on 05/24/17 at 4:49 p.m., she stated the facility's policy regarding mechanical soft diets was to ensure all meats were mechanically ground. She stated the facility did not consider chopped meats to be a mechanical soft texture, unless there was a specific physician's orders [REDACTED]. The Regional Nurse Consultant stated no residents at the facility were currently ordered chopped meats. During an interview with the facility medical director on 05/25/17 at 11:58 a.m. revealed that the facility contacted him regarding the wrong textured meal being served to Resident #3 and he has followed up with the resident and facility. Review of a current list of residents with their dietary orders, which was provided by the Food Service Manager and dated 05/23/17, reflected 24 residents required a mechanical soft texture and 8 residents required a pureed texture. Review of the facility's Consistency of Modified Diets handout, which was identified as being provided to staff members by the Regional Nurse Consultant and was undated, reflected, .Mechanical Soft: This is a more advanced texture that may be used to transition a regular diet. It consists of ground meats, with soft fruits and vegetables, and most bread products . Review of the facility's Reporting Abuse to Facility Management Policy and Procedure, dated 12/2009, reflected, .'Neglect' is defined as failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress . Review of the facility's Resident Nutrition Services Policy and Procedure, dated 04/2010, reflected, .Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance . The Policy and Procedure also reflected, . 2. Nursing personnel will ensure that residents are served the correct food tray. 3. Prior to serving the food tray, the Nurse Aide/Feeding Assistant must check the tray card to ensure that the correct food tray is being served to the resident. If there is doubt, the Nurse Supervisor will check the written physician's orders [REDACTED]. An Immediate Jeopardy was identified on 05/23/17 at 4:30 p.m. The Administrator and DON were notified of the Immediate Jeopardy on 05/23/17 at 4:30 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/25/17 at 11:53 a.m. and reflected the following: Resident #10 was immediately assessed by LVN N on 5/23/17 at 12:56 PM and no respiratory distress was noted. Then RT completed an assessment of the residents respiratory status on 5/23/17 at 4:23 PM and no respiratory distress was noted. Resident #10's physician was notified of the resident receiving an incorrect diet on 5/23/17 at 1:16 PM and order was received for a STAT chest x-ray and a referral for speech therapy. STAT x-ray was completed on 5/23/17 at 5:05 PM and results were borderline large heart without evidence of [MEDICAL CONDITION] or volume overload and no other acute process are demonstrated which were reported to the physician at 6:40 pm. The residents care plan and care kardex were updated to reflect resident's current status. Resident was placed on 72-hour monitoring for respiratory distress. Resident #1 was immediately assessed by RT on 5/23/17 at 1:50 PM and no respiratory distress. Resident #1 position was notified of resident receiving an incorrect diet on 5/23/17 at 2:02 PM and orders received for speech therapy evaluation. Resident #1 responsible party was notified of resident receiving an incorrect diet on 5/23/17 at 1:26 PM. Resident's care plan and care kardex were updated to reflect the resident's current status. Resident was placed on 72-hour monitoring for respiratory distress. Resident #3 was immediately assessed by the LVN N on 5/23/17 at 1:18 PM and no respiratory distress noted. Resident #3 physician was notified of resident receiving it incorrect diet on 5/23/17 at 2:05 PM and orders received for speech therapy evaluation. Resident's care plan and care kardex were updated to reflect the resident's current status. Resident was placed on a 72-hour monitoring for respiratory distress. How were other residents at risk to be affected by this deficient practice identified? An audit was completed on 5/23/17 by Director of Nurses to determine which residents receive a specialized diet. 30 residents were identified at risk to be affected by the alleged deficient practice. A comparative audit of physician's orders [REDACTED]. 1 tray card was noted to not match the current positions diet order. The tray card system was updated by Food Service Manager to reflect the current order. An audit was completed on 5/23/17 by Director of Nurses to determine residents who have a [DIAGNOSES REDACTED]. The licensed and certified nursing staff were educated by the MDS Nurse on 5/23/17 on the process for checking tray cards against the diet served to ensure correct diet is served. Any tray that is prepared incorrectly will be immediately sent back to the kitchen for correction and the tray will not be served until corrected. Newly hired staff will receive this education during new hire orientation. Licensed and certified nursing staff will not be allowed to work until they receive the education. The licensed nursing staff were in-serviced by the MDS Nurse on 5/23/17 on completing a dietary communication form for newly admitted and readmitted resident's and any residents who have a diet order change. The dietary staff were educated by Dietary Manager on 5/23/17 on preparing and serving the correct diet as indicated on the resident tray card. The cooks were educated by Dietary Manager on 5/23/17 on checking the recipe for mechanically altered food preparation. Newly hired dietary staff will receive this education during new hire orientation. Dietary staff will not be allowed to work until they receive the education. Each meal service will have a licensed nurse check each trade for correct diet and will send any incorrectly served diets back to the kitchen for correction. Monitoring of meals will be completed as follows: 200 Hall nurse will check all trays for breakfast, 300 Hall nurse will check lunch, and 200 Hall nurse would check all trays for dinner. Daily monitoring of meal service by a nurse manager began on 5/23/17 to ensure all trays are checked for correct diet prior to being delivered to the resident. We can monitoring of meal service to ensure all trays are checked for correct diet will be completed by the Weekend Supervisor. Dietary staff have implemented a double check for every meal beginning with breakfast on 5/24/17 to ensure the correct diet is being prepared and served. The double check will consist of the cook checking the diet against the tray card and then the dietary aid will complete a final check prior to being sent out to nursing. The licensed and certified nursing staff were in serviced on 5/23/17 by Director of Nurses on Abuse and Neglect. Licensed and certified nursing staff will not be allowed to work until they receive the education. All staff have been given a posttest on therapeutic diets and neglect. Posttest will be checked for completion and accuracy by Director of Nurses. Director of Nurses or designee (LVN O, ADON Q, LVN R, MDS Nurse, and RN S) will complete a daily check of all 3 meals X 3 days to ensure compliance with system. Any discrepancies noted will be immediately reported to the Quality Assurance and Performance Improvement committee for evaluation and correction. The Registered Dietitian or designee will complete monitoring of the tray line to ensure continued compliance. Any discrepancies noted will be immediately reported to the Quality Assurance and Performance Improvement committee for evaluation and correction. The Director of Nurses or designees (LVN O, ADON Q, LVN R, MDS Nurse, and RN S) will monitor three meals a day, seven days a week for two weeks to ensure effectiveness of in-service/training. Random checks will be performed monthly x3 months and any negative findings will be reported to the QAPI committee. Quality Assurance An Impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 5/23/17 with the Medical Director. Employees responsible for checking accuracy of therapeutic diet was LVN I who was suspended pending investigation on 5/23/17 for nursing. Food Service Manager has received counseling and education on responsibility for ensuring trays are checked by the cook and the dietary aid on 5/23/17. Dietary Aide, was suspended on 5/23/17 pending investigation for failing to ensure therapeutic diet or being served to residents. During an interview with Administrator on 5/25/17 at 10:53 a.m. stated that he supervises staff by walking around the facility, reviewing different reports, and observation of administration staff. He stated that he will talk to staff about what's going on in the facility and that this is usually addressed in the daily stand up meeting. Administrator stated that the IJ occurred possibly due to the cook not looking at the trays to find out if it matched the ticket. Since the incident Administrator said that he has followed-up with the nurse checking trays throughout the day, the staff has received an in-service, the nurses are checking the trays as the layers of systems in place to check trays. During an interview with MDS Nurse on 5/25/17 at 11:46 a.m. revealed that she supervises staff to ensure that they are following policy/procedures by doing observation rounds, interviewing residents and using a customer satisfaction survey. MDS nurse said that the IJ occurred when dietary out the wrong diet on the tray, the nurse failed to review the tray, and the person who delivered the tray failed to verify the diet as prescribed. Since the occurrence she has talked to the charge nurses on the floors, and the nurse manager in the dining room to see if the trays are correct. The nurses on the floor check the tray the CNA check the trays. A dietary report is run in the morning by the charge nurse who will review the report and check the trays. An in-service was conducted detailing food consistency. A dietary tray of two different food consistencies puree, and mechanical soft were shown as part of the in-service. In addition, a handout was given to staff about consistency diets. During an interview with the Speech Language Pathologist on 05/26/17 at 11:40 a.m., she stated she conducted Speech Therapy screenings for Resident #1, Resident #3, and Resident #10 on 05/25/17. She said these screenings were due to the residents receiving the incorrect diet on 05/23/17. The Speech Language Pathologist stated her recommendations were for Resident #1, Resident #3, and Resident #10 to continue on mechanical soft diets. Interview on 5/24/17 - 5/25/17 with CMA/CNA D, CMA E, CNA F, CNA G, CNA H, LVN J, CNA K, LVN L, LVN M, LVN N representing staff from all three shifts were interview regarding the in-service and training they received on the facility's therapeutic diets identifying food consistency, checking trays during meal times to ensure residents receive their prescribed diets. Interviews with CMA/CNA D, CMA E, CNA F, CNA G, CNA H, LVN J, CNA K, LVN L, LVN M, LVN N revealed that they were able to identify food consistency, checking trays during meal times to ensure residents receive their prescribed diets. Facility in-services were reviewed and reflected: Checking Trays During Meal Times dated 5/23/2017 revealed that 31 staff attended the in-service. Therapeutic Diets dated 5/24/2017 revealed that 42 staff attended the in-service. Diet Checks dated 5/24/2017 revealed that 25 staff attended the in-service. Observations of meal service on 5/23/17 at 6:00 p.m., 5/24/17 for breakfast service and lunch revealed the facility ensured meal trays were checked for accuracy by staff prior to serving the trays to residents. These observations also revealed residents received their ordered diets. The Administrator and the Regional Nurse Consultant were notified on 05/25/17 at 11:53 a.m. that the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed on 05/25/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to facility's monitoring of effectiveness of the plan of removal. Review of a current list of residents with their dietary orders, which was provided by the Food Service Manager and dated 05/23/17, reflected 24 residents required a mechanical soft texture and 8 residents required a pureed texture.

Based on observation, interview, and record review, the administrator failed to administrator the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental, and psychosocial, well-being for 3 of 10 residents reviewed for mechanical altered diets. 1. The administrator failed to implement the facility's Resident Nutrition Service Policy and Procedure and the Reporting Abuse to Facility Management Policy and Procedure. 2. The MDS Nurse failed to supervise nursing staff to ensure they were following the facility's policies and procedures. 3. LVN J failed to follow Resident Nutrition Services Policy and Procedure. 4. The Food Service Manager failed to supervise dietary staff to ensure the meal trays for were checked for accuracy before they left the kitchen to be served to residents. Resident #10 choked and gasped for breath on 05/23/17 after she was served food that was not mechanically altered as her physician ordered. An Immediate Jeopardy (IJ) was identified on 05/23/17 at 4:30 p.m. While the IJ was removed on 05/25/17, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's of monitoring of the effectiveness of the plan of removal. These failures placed 32 residents with orders for either mechanical soft or puree diets at risk of choking, aspiration, aspiration pneumonia, and death. Findings included: 1. Review of Resident #10's Face Sheet, dated 05/25/17, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident #10's MDS assessment, dated 05/01/17, reflected Resident #10 required a mechanically altered diet while she was a resident at the facility. Review of Resident #10's Service Plan reflected she required a mechanical soft diet. This portion of the Service Plan was most recently revised on 05/31/16. Review of Resident #10's Medication Review Report (physician's orders [REDACTED].#10 had an order to receive mechanically soft textured foods. This order was initiated on 01/19/17. Review of Resident #10's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground chicken parmesan with spaghetti sauce, spaghetti noodles, sliced broccoli florets, dinner roll/bread, margarine, and butterscotch pudding. Observation on 05/23/17 at 12:23 p.m. revealed Resident #10 was served a whole piece of chicken parmesan (not mechanically chopped or ground) and whole pieces of broccoli florets. During an interview with the Food Service Manager on 05/23/17 at 12:40 p.m., she stated meal tickets were current and reflective of each resident's ordered diet. The Food Service Manager stated meal trays were initially checked for accuracy prior to leaving the kitchen by the last person on the meal tray line. After the meal trays left the kitchen, both a nurse and a nurse aide were also required to check the meal trays for accuracy prior to serving the residents. The Food Service Manager stated all meal trays were checked for accuracy today, prior to leaving the kitchen for the lunch meal service. She was notified Resident #1 and Resident #3 did not receive mechanical soft meals during the lunch meal service. Observation on 05/23/17 at 12:44 p.m. revealed Resident #10 was sitting in her room, repeatedly pointing to her throat. Initially, she was not making any sound while pointing to her throat. Resident #10 then made a gurgling sound. The Food Service Manager yelled for the assistance of a nurse. Observation on 05/24/2017 at 12:45 p.m. revealed three staff members were in Resident #10's room, including one nurse. Resident #10 was found to be grasping for breath. The nurse was telling Resident #10 to continue to spit. The nurse stated she could not do the [MEDICATION NAME] maneuver, as Resident #10 had a [DIAGNOSES REDACTED].#10 was spitting up mid-size particles of food. During an interview with CNA C on 5/23/17 at 12:48 p.m., she was unaware of Resident #10's diet orders. She stated Resident #10 was ordered a regular texture diet. During an interview with resident #10 on 05/24/17 at 4:00 p.m. revealed that resident did not understand what mechanical soft diet was. Resident stated that today was the only time her meal was not chopped. Resident #10 said that during lunch she had a throat problem. Resident #10 could not articulate what occurred however, she demonstrated the event by grasping her throat. 2. Review of Resident #1's Face Sheet, dated 05/25/17, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 04/13/17, reflected she was cognitively intact. She was identified as requiring a mechanically altered diet with supervision and setup help for meals. Review of Resident #1's Medication Review Report (physician's orders [REDACTED]. Review of Resident #1's Service Plan, undated, reflected she required a mechanical soft diet. The facility's intervention included providing and serving her diet as ordered. This portion of the Service Plan was most recently revised on 05/31/16. Review of Resident #1's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground chicken parmesan with spaghetti sauce, spaghetti noodles, sliced broccoli florets, dinner roll/bread, margarine, and butterscotch pudding. Observation on 05/23/17 at 12:35 p.m. revealed Resident #1 was served a whole piece of chicken parmesan, spaghetti noodles, whole pieces of broccoli florets, a dinner roll, margarine, and butterscotch pudding. The chicken was not mechanically ground or chopped. Resident #1 attempted to cut the chicken with her utensils. She obtained the attention of CNA C by saying, I need you to cut my meat. I can't even do it. CNA C then cut Resident #1's chicken into pieces that were approximately 1 inch long by 1 inch wide. She also cut Resident #1's broccoli florets prior to leaving the room. During an interview with Resident #1 on 05/24/17 at 9:40 a.m., she reported prior to 05/23/17, she never received a mechanical soft diet. She stated she always received full pieces of meat and she had staff members cut the meat for her. During an interview with CNA C on 05/24/17 at 1:45 p.m., she stated Resident #1 was ordered a mechanical soft diet. She stated she was aware of the requirement to review meal tickets, which identified each resident's specific diet order. She stated on 05/23/17, she cut up Resident #1's food because Resident #1 requested for the meat to be cut. When asked why she did not return the tray to the kitchen and request a mechanical soft meal tray, CNA C did not provide an answer. 3. Review of Resident #3's Face Sheet, dated 05/25/17, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment, dated 03/13/17, reflected she was cognitively impaired. She was identified as requiring a mechanically altered diet with supervision and setup help for meals. Review of Resident #3's Medication Review Report (physician's orders [REDACTED]. Review of Resident #3's Service Plan, undated, reflected she required a mechanical soft diet. The facility's intervention included providing and serving her diet as ordered. This portion of the Service Plan was most recently revised on 05/25/17. Review of Resident #3's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground lemon pepper fish with white sauce, buttered rice, yellow squash, bread, and butterscotch pudding. Observation on 05/23/17 at 11:55 a.m. revealed Resident #3 was served a whole piece of lemon pepper fish, buttered rice, yellow squash, bread, and butterscotch pudding. The fish was not mechanically ground or chopped. She did not eat the meat. During an interview with Resident #3 on 05/24/17 at 9:30 a.m., she reported prior to 05/23/17, there had been various occasions in which she did not receive a mechanical soft diet. She said when she did not receive the correct diet, she would cut the meat herself. 4. During an interview with LVN J on 05/23/17 at 1:39 p.m. he stated that he was responsible for checking the meals to insure that correct meals for the correct consistency such as puree, mechanical soft, or regular. LVN J said that a CNA would check meals when delivering. He said that the Food Service Manager should be checking the trays and tickets as well. LVN J was not sure why the incorrect textured meals were not caught. During an interview with the Director of Nursing on 05/23/17 at 2:40 p.m., she stated the facility initiated in-services on the importance of ensuring residents received correct meals as ordered by the physician. She stated Resident #1, Resident #3, and Resident #10 were placed on 72-hour checks due to receiving the incorrect diet. The Director of Nursing stated, There's no sugar coating a failure occurred. During an interview with the Regional Nurse Consultant on 05/24/17 at 4:49 p.m., she stated the facility's policy regarding mechanical soft diets was to ensure all meats were mechanically ground. She stated the facility did not consider chopped meats to be a mechanical soft texture, unless there was a specific physician's orders [REDACTED]. The Regional Nurse Consultant stated no residents at the facility were currently ordered chopped meats. During an interview with the facility medical director on 05/25/17 at 11:58 a.m. revealed that the facility contacted him regarding the wrong textured meal being served to Resident #3 and he has followed up with the resident and facility. Review of a current list of residents with their dietary orders, which was provided by the Food Service Manager and dated 05/23/17, reflected 24 residents required a mechanical soft texture and 8 residents required a pureed texture. Review of the facility's Consistency of Modified Diets handout, which was identified as being provided to staff members by the Regional Nurse Consultant and was undated, reflected, .Mechanical Soft: This is a more advanced texture that may be used to transition a regular diet. It consists of ground meats, with soft fruits and vegetables, and most bread products . Review of the facility's Reporting Abuse to Facility Management Policy and Procedure, dated 12/2009, reflected, .'Neglect' is defined as failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress . Review of the facility's Resident Nutrition Services Policy and Procedure, dated 04/2010, reflected, .Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance . The Policy and Procedure also reflected, . 2. Nursing personnel will ensure that residents are served the correct food tray. 3. Prior to serving the food tray, the Nurse Aide/Feeding Assistant must check the tray card to ensure that the correct food tray is being served to the resident. If there is doubt, the Nurse Supervisor will check the written physician's orders [REDACTED]. An Immediate Jeopardy was identified on 05/23/17 at 4:30 p.m. The Administrator and DON were notified of the Immediate Jeopardy on 05/23/17 at 4:30 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/25/17 at 11:53 a.m. and reflected the following: Resident #10 was immediately assessed by LVN N on 5/23/17 at 12:56 PM and no respiratory distress was noted. Then RT completed an assessment of the residents respiratory status on 5/23/17 at 4:23 PM and no respiratory distress was noted. Resident #10's physician was notified of the resident receiving an incorrect diet on 5/23/17 at 1:16 PM and order was received for a STAT chest x-ray and a referral for speech therapy. STAT x-ray was completed on 5/23/17 at 5:05 PM and results were borderline large heart without evidence of [MEDICAL CONDITION] or volume overload and no other acute process are demonstrated which were reported to the physician at 6:40 pm. The residents care plan and care kardex were updated to reflect resident's current status. Resident was placed on 72-hour monitoring for respiratory distress. Resident #1 was immediately assessed by RT on 5/23/17 at 1:50 PM and no respiratory distress. Resident #1 position was notified of resident receiving an incorrect diet on 5/23/17 at 2:02 PM and orders received for speech therapy evaluation. Resident #1 responsible party was notified of resident receiving an incorrect diet on 5/23/17 at 1:26 PM. Resident's care plan and care kardex were updated to reflect the resident's current status. Resident was placed on 72-hour monitoring for respiratory distress. Resident #3 was immediately assessed by the LVN N on 5/23/17 at 1:18 PM and no respiratory distress noted. Resident #3 physician was notified of resident receiving it incorrect diet on 5/23/17 at 2:05 PM and orders received for speech therapy evaluation. Resident's care plan and care kardex were updated to reflect the resident's current status. Resident was placed on a 72-hour monitoring for respiratory distress. How were other residents at risk to be affected by this deficient practice identified? An audit was completed on 5/23/17 by Director of Nurses to determine which residents receive a specialized diet. 30 residents were identified at risk to be affected by the alleged deficient practice. A comparative audit of physician's orders [REDACTED]. 1 tray card was noted to not match the current positions diet order. The tray card system was updated by Food Service Manager to reflect the current order. An audit was completed on 5/23/17 by Director of Nurses to determine residents who have a [DIAGNOSES REDACTED]. The licensed and certified nursing staff were educated by the MDS Nurse on 5/23/17 on the process for checking tray cards against the diet served to ensure correct diet is served. Any tray that is prepared incorrectly will be immediately sent back to the kitchen for correction and the tray will not be served until corrected. Newly hired staff will receive this education during new hire orientation. Licensed and certified nursing staff will not be allowed to work until they receive the education. The licensed nursing staff were in-serviced by the MDS Nurse on 5/23/17 on completing a dietary communication form for newly admitted and readmitted resident's and any residents who have a diet order change. The dietary staff were educated by Dietary Manager on 5/23/17 on preparing and serving the correct diet as indicated on the resident tray card. The cooks were educated by Dietary Manager on 5/23/17 on checking the recipe for mechanically altered food preparation. Newly hired dietary staff will receive this education during new hire orientation. Dietary staff will not be allowed to work until they receive the education. Each meal service will have a licensed nurse check each trade for correct diet and will send any incorrectly served diets back to the kitchen for correction. Monitoring of meals will be completed as follows: 200 Hall nurse will check all trays for breakfast, 300 Hall nurse will check lunch, and 200 Hall nurse would check all trays for dinner. Daily monitoring of meal service by a nurse manager began on 5/23/17 to ensure all trays are checked for correct diet prior to being delivered to the resident. We can monitoring of meal service to ensure all trays are checked for correct diet will be completed by the Weekend Supervisor. Dietary staff have implemented a double check for every meal beginning with breakfast on 5/24/17 to ensure the correct diet is being prepared and served. The double check will consist of the cook checking the diet against the tray card and then the dietary aid will complete a final check prior to being sent out to nursing. The licensed and certified nursing staff were in serviced on 5/23/17 by Director of Nurses on Abuse and Neglect. Licensed and certified nursing staff will not be allowed to work until they receive the education. All staff have been given a posttest on therapeutic diets and neglect. Posttest will be checked for completion and accuracy by Director of Nurses. Director of Nurses or designee (LVN O, ADON Q, LVN R, MDS Nurse, and RN S) will complete a daily check of all 3 meals X 3 days to ensure compliance with system. Any discrepancies noted will be immediately reported to the Quality Assurance and Performance Improvement committee for evaluation and correction. The Registered Dietitian or designee will complete monitoring of the tray line to ensure continued compliance. Any discrepancies noted will be immediately reported to the Quality Assurance and Performance Improvement committee for evaluation and correction. The Director of Nurses or designees (LVN O, ADON Q, LVN R, MDS Nurse, and RN S) will monitor three meals a day, seven days a week for two weeks to ensure effectiveness of in-service/training. Random checks will be performed monthly x3 months and any negative findings will be reported to the QAPI committee. Quality Assurance An Impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 5/23/17 with the Medical Director. Employees responsible for checking accuracy of therapeutic diet was LVN I who was suspended pending investigation on 5/23/17 for nursing. Food Service Manager has received counseling and education on responsibility for ensuring trays are checked by the cook and the dietary aid on 5/23/17. Dietary Aide, was suspended on 5/23/17 pending investigation for failing to ensure therapeutic diet or being served to residents. During an interview with Administrator on 5/25/17 at 10:53 a.m. stated that he supervises staff by walking around the facility, reviewing different reports, and observation of administration staff. He stated that he will talk to staff about what's going on in the facility and that this is usually addressed in the daily stand up meeting. Administrator stated that the IJ occurred possibly due to the cook not looking at the trays to find out if it matched the ticket. Since the incident Administrator said that he has followed-up with the nurse checking trays throughout the day, the staff has received an in-service, the nurses are checking the trays as the layers of systems in place to check trays. During an interview with MDS Nurse on 5/25/17 at 11:46 a.m. revealed that she supervises staff to ensure that they are following policy/procedures by doing observation rounds, interviewing residents and using a customer satisfaction survey. MDS nurse said that the IJ occurred when dietary out the wrong diet on the tray, the nurse failed to review the tray, and the person who delivered the tray failed to verify the diet as prescribed. Since the occurrence she has talked to the charge nurses on the floors, and the nurse manager in the dining room to see if the trays are correct. The nurses on the floor check the tray the CNA check the trays. A dietary report is run in the morning by the charge nurse who will review the report and check the trays. An in-service was conducted detailing food consistency. A dietary tray of two different food consistencies puree, and mechanical soft were shown as part of the in-service. In addition, a handout was given to staff about consistency diets. During an interview with the Speech Language Pathologist on 05/26/17 at 11:40 a.m., she stated she conducted Speech Therapy screenings for Resident #1, Resident #3, and Resident #10 on 05/25/17. She said these screenings were due to the residents receiving the incorrect diet on 05/23/17. The Speech Language Pathologist stated her recommendations were for Resident #1, Resident #3, and Resident #10 to continue on mechanical soft diets. Interview on 5/24/17 - 5/25/17 with CMA/CNA D, CMA E, CNA F, CNA G, CNA H, LVN J, CNA K, LVN L, LVN M, LVN N representing staff from all three shifts were interview regarding the in-service and training they received on the facility's therapeutic diets identifying food consistency, checking trays during meal times to ensure residents receive their prescribed diets. Interviews with CMA/CNA D, CMA E, CNA F, CNA G, CNA H, LVN J, CNA K, LVN L, LVN M, LVN N revealed that they were able to identify food consistency, checking trays during meal times to ensure residents receive their prescribed diets. Facility in-services were reviewed and reflected: Checking Trays During Meal Times dated 5/23/2017 revealed that 31 staff attended the in-service. Therapeutic Diets dated 5/24/2017 revealed that 42 staff attended the in-service. Diet Checks dated 5/24/2017 revealed that 25 staff attended the in-service. Observations of meal service on 5/23/17 at 6:00 p.m., 5/24/17 for breakfast service and lunch revealed the facility ensured meal trays were checked for accuracy by staff prior to serving the trays to residents. These observations also revealed residents received their ordered diets. The Administrator and the Regional Nurse Consultant were notified on 05/25/17 at 11:53 a.m. that the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed on 05/25/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to facility's monitoring of effectiveness of the plan of removal. Review of a current list of residents with their dietary orders, which was provided by the Food Service Manager and dated 05/23/17, reflected 24 residents required a mechanical soft texture and 8 residents required a pureed texture.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for 3 (Residents #1, #3, and #10) of 10 residents reviewed for mechanically altered diets. The facility failed to serve Residents #1, #3, and #10, who ate their meals in their rooms, mechanically soft foods, which was what their physicians ordered. Resident #10 choked and gasped for breath. An Immediate Jeopardy (IJ) was identified on 05/23/17 at 4:30 p.m. While the IJ was removed on 05/25/17, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's monitoring of the effectiveness of the plan of removal. These failures placed 32 residents with orders for either mechanical soft or puree diets at risk of choking, aspiration, aspiration pneumonia, and death. Findings included: Review of the facility's Reporting Abuse to Facility Management Policy and Procedure, dated 12/2009, reflected, .'Neglect' is defined as failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress . Review of the facility's Resident Nutrition Services Policy and Procedure, dated 04/2010, reflected, .Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance . The Policy and Procedure also reflected, . 2. Nursing personnel will ensure that residents are served the correct food tray. 3. Prior to serving the food tray, the Nurse Aide/Feeding Assistant must check the tray card to ensure that the correct food tray is being served to the resident. If there is doubt, the Nurse Supervisor will check the written physician's orders [REDACTED]. 1. Review of Resident #10's Face Sheet, dated 05/25/17, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident #10's MDS assessment, dated 05/01/17, reflected Resident #10 required a mechanically altered diet while she was a resident at the facility. Review of Resident #10's Service Plan reflected she required a mechanical soft diet. This portion of the Service Plan was most recently revised on 05/31/16. Review of Resident #10's Medication Review Report (physician's orders [REDACTED].#10 had an order to receive mechanically soft textured foods. This order was initiated on 01/19/17. Review of Resident #10's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground chicken parmesan with spaghetti sauce, spaghetti noodles, sliced broccoli florets, dinner roll/bread, margarine, and butterscotch pudding. Observation on 05/23/17 at 12:23 p.m. revealed Resident #10 was served a whole piece of chicken parmesan (not mechanically chopped or ground) and whole pieces of broccoli florets. During an interview with the Food Service Manager on 05/23/17 at 12:40 p.m., she stated meal tickets were current and reflective of each resident's ordered diet. The Food Service Manager stated meal trays were initially checked for accuracy prior to leaving the kitchen by the last person on the meal tray line. After the meal trays left the kitchen, both a nurse and a nurse aide were also required to check the meal trays for accuracy prior to serving the residents. The Food Service Manager stated all meal trays were checked for accuracy today, prior to leaving the kitchen for the lunch meal service. She was notified Resident #1 and Resident #3 did not receive mechanical soft meals during the lunch meal service. Observation on 05/23/17 at 12:44 p.m. revealed Resident #10 was sitting in her room, repeatedly pointing to her throat. Initially, she was not making any sound while pointing to her throat. Resident #10 then made a gurgling sound. The Food Service Manager yelled for the assistance of a nurse. Observation on 05/24/2017 at 12:45 p.m. revealed three staff members were in Resident #10's room, including one nurse. Resident #10 was found to be grasping for breath. The nurse was telling Resident #10 to continue to spit. The nurse stated she could not do the [MEDICATION NAME] maneuver, as Resident #10 had a [DIAGNOSES REDACTED].#10 was spitting up mid-size particles of food. During an interview with CNA C on 5/23/17 at 12:48 p.m., she was unaware of Resident #10's diet orders. She stated Resident #10 was ordered a regular texture diet. During an interview with resident #10 on 05/24/17 at 4:00 p.m. revealed that resident did not understand what mechanical soft diet was. Resident stated that today was the only time her meal was not chopped. Resident #10 said that during lunch she had a throat problem. Resident #10 could not articulate what occurred however, she demonstrated the event by grasping her throat. 2. Review of Resident #1's Face Sheet, dated 05/25/17, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 04/13/17, reflected she was cognitively intact. She was identified as requiring a mechanically altered diet with supervision and setup help for meals. Review of Resident #1's Medication Review Report (physician's orders [REDACTED]. Review of Resident #1's Service Plan, undated, reflected she required a mechanical soft diet. The facility's intervention included providing and serving her diet as ordered. This portion of the Service Plan was most recently revised on 05/31/16. Review of Resident #1's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground chicken parmesan with spaghetti sauce, spaghetti noodles, sliced broccoli florets, dinner roll/bread, margarine, and butterscotch pudding. Observation on 05/23/17 at 12:35 p.m. revealed Resident #1 was served a whole piece of chicken parmesan, spaghetti noodles, whole pieces of broccoli florets, a dinner roll, margarine, and butterscotch pudding. The chicken was not mechanically ground or chopped. Resident #1 attempted to cut the chicken with her utensils. She obtained the attention of CNA C by saying, I need you to cut my meat. I can't even do it. CNA C then cut Resident #1's chicken into pieces that were approximately 1 inch long by 1 inch wide. She also cut Resident #1's broccoli florets prior to leaving the room. During an interview with Resident #1 on 05/24/17 at 9:40 a.m., she reported prior to 05/23/17, she never received a mechanical soft diet. She stated she always received full pieces of meat and she had staff members cut the meat for her. During an interview with CNA C on 05/24/17 at 1:45 p.m., she stated Resident #1 was ordered a mechanical soft diet. She stated she was aware of the requirement to review meal tickets, which identified each resident's specific diet order. She stated on 05/23/17, she cut up Resident #1's food because Resident #1 requested for the meat to be cut. When asked why she did not return the tray to the kitchen and request a mechanical soft meal tray, CNA C did not provide an answer. 3. Review of Resident #3's Face Sheet, dated 05/25/17, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment, dated 03/13/17, reflected she was cognitively impaired. She was identified as requiring a mechanically altered diet with supervision and setup help for meals. Review of Resident #3's Medication Review Report (physician's orders [REDACTED]. Review of Resident #3's Service Plan, undated, reflected she required a mechanical soft diet. The facility's intervention included providing and serving her diet as ordered. This portion of the Service Plan was most recently revised on 05/25/17. Review of Resident #3's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground lemon pepper fish with white sauce, buttered rice, yellow squash, bread, and butterscotch pudding. Observation on 05/23/17 at 11:55 a.m. revealed Resident #3 was served a whole piece of lemon pepper fish, buttered rice, yellow squash, bread, and butterscotch pudding. The fish was not mechanically ground or chopped. She did not eat the meat. During an interview with Resident #3 on 05/24/17 at 9:30 a.m., she reported prior to 05/23/17, there had been various occasions in which she did not receive a mechanical soft diet. She said when she did not receive the correct diet, she would cut the meat herself. 4. During an interview with LVN J on 05/23/17 at 1:39 p.m. he stated that he was responsible for checking the meals to insure that correct meals for the correct consistency such as puree, mechanical soft, or regular. LVN J said that a CNA would check meals when delivering. He said that the Food Service Manager should be checking the trays and tickets as well. LVN J was not sure why the incorrect textured meals were not caught. During an interview with the Director of Nursing on 05/23/17 at 2:40 p.m., she stated the facility initiated in-services on the importance of ensuring residents received correct meals as ordered by the physician. She stated Resident #1, Resident #3, and Resident #10 were placed on 72-hour checks due to receiving the incorrect diet. The Director of Nursing stated, There's no sugar coating a failure occurred. During an interview with the Regional Nurse Consultant on 05/24/17 at 4:49 p.m., she stated the facility's policy regarding mechanical soft diets was to ensure all meats were mechanically ground. She stated the facility did not consider chopped meats to be a mechanical soft texture, unless there was a specific physician's orders [REDACTED]. The Regional Nurse Consultant stated no residents at the facility were currently ordered chopped meats. During an interview with the facility medical director on 05/25/17 at 11:58 a.m. revealed that the facility contacted him regarding the wrong textured meal being served to Resident #3 and he has followed up with the resident and facility. Review of a current list of residents with their dietary orders, which was provided by the Food Service Manager and dated 05/23/17, reflected 24 residents required a mechanical soft texture and 8 residents required a pureed texture. Review of the facility's Consistency of Modified Diets handout, which was identified as being provided to staff members by the Regional Nurse Consultant and was undated, reflected, .Mechanical Soft: This is a more advanced texture that may be used to transition a regular diet. It consists of ground meats, with soft fruits and vegetables, and most bread products . An Immediate Jeopardy was identified on 05/23/17 at 4:30 p.m. The Administrator and DON were notified of the Immediate Jeopardy on 05/23/17 at 4:30 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/25/17 at 11:53 a.m. and reflected the following: Resident #10 was immediately assessed by LVN N on 5/23/17 at 12:56 PM and no respiratory distress was noted. Then RT completed an assessment of the residents respiratory status on 5/23/17 at 4:23 PM and no respiratory distress was noted. Resident #10's physician was notified of the resident receiving an incorrect diet on 5/23/17 at 1:16 PM and order was received for a STAT chest x-ray and a referral for speech therapy. STAT x-ray was completed on 5/23/17 at 5:05 PM and results were borderline large heart without evidence of [MEDICAL CONDITION] or volume overload and no other acute process are demonstrated which were reported to the physician at 6:40 pm. The residents care plan and care kardex were updated to reflect resident's current status. Resident was placed on 72-hour monitoring for respiratory distress. Resident #1 was immediately assessed by RT on 5/23/17 at 1:50 PM and no respiratory distress. Resident #1 position was notified of resident receiving an incorrect diet on 5/23/17 at 2:02 PM and orders received for speech therapy evaluation. Resident #1 responsible party was notified of resident receiving an incorrect diet on 5/23/17 at 1:26 PM. Resident's care plan and care kardex were updated to reflect the resident's current status. Resident was placed on 72-hour monitoring for respiratory distress. Resident #3 was immediately assessed by the LVN N on 5/23/17 at 1:18 PM and no respiratory distress noted. Resident #3 physician was notified of resident receiving it incorrect diet on 5/23/17 at 2:05 PM and orders received for speech therapy evaluation. Resident's care plan and care kardex were updated to reflect the resident's current status. Resident was placed on a 72-hour monitoring for respiratory distress. How were other residents at risk to be affected by this deficient practice identified? An audit was completed on 5/23/17 by Director of Nurses to determine which residents receive a specialized diet. 30 residents were identified at risk to be affected by the alleged deficient practice. A comparative audit of physician's orders [REDACTED]. 1 tray card was noted to not match the current positions diet order. The tray card system was updated by Food Service Manager to reflect the current order. An audit was completed on 5/23/17 by Director of Nurses to determine residents who have a [DIAGNOSES REDACTED]. The licensed and certified nursing staff were educated by the MDS Nurse on 5/23/17 on the process for checking tray cards against the diet served to ensure correct diet is served. Any tray that is prepared incorrectly will be immediately sent back to the kitchen for correction and the tray will not be served until corrected. Newly hired staff will receive this education during new hire orientation. Licensed and certified nursing staff will not be allowed to work until they receive the education. The licensed nursing staff were in-serviced by the MDS Nurse on 5/23/17 on completing a dietary communication form for newly admitted and readmitted resident's and any residents who have a diet order change. The dietary staff were educated by Dietary Manager on 5/23/17 on preparing and serving the correct diet as indicated on the resident tray card. The cooks were educated by Dietary Manager on 5/23/17 on checking the recipe for mechanically altered food preparation. Newly hired dietary staff will receive this education during new hire orientation. Dietary staff will not be allowed to work until they receive the education. Each meal service will have a licensed nurse check each trade for correct diet and will send any incorrectly served diets back to the kitchen for correction. Monitoring of meals will be completed as follows: 200 Hall nurse will check all trays for breakfast, 300 Hall nurse will check lunch, and 200 Hall nurse would check all trays for dinner. Daily monitoring of meal service by a nurse manager began on 5/23/17 to ensure all trays are checked for correct diet prior to being delivered to the resident. We can monitoring of meal service to ensure all trays are checked for correct diet will be completed by the Weekend Supervisor. Dietary staff have implemented a double check for every meal beginning with breakfast on 5/24/17 to ensure the correct diet is being prepared and served. The double check will consist of the cook checking the diet against the tray card and then the dietary aid will complete a final check prior to being sent out to nursing. The licensed and certified nursing staff were in serviced on 5/23/17 by Director of Nurses on Abuse and Neglect. Licensed and certified nursing staff will not be allowed to work until they receive the education. All staff have been given a posttest on therapeutic diets and neglect. Posttest will be checked for completion and accuracy by Director of Nurses. Director of Nurses or designee (LVN O, ADON Q, LVN R, MDS Nurse, and RN S) will complete a daily check of all 3 meals X 3 days to ensure compliance with system. Any discrepancies noted will be immediately reported to the Quality Assurance and Performance Improvement committee for evaluation and correction. The Registered Dietitian or designee will complete monitoring of the tray line to ensure continued compliance. Any discrepancies noted will be immediately reported to the Quality Assurance and Performance Improvement committee for evaluation and correction. The Director of Nurses or designees (LVN O, ADON Q, LVN R, MDS Nurse, and RN S) will monitor three meals a day, seven days a week for two weeks to ensure effectiveness of in-service/training. Random checks will be performed monthly x3 months and any negative findings will be reported to the QAPI committee. Quality Assurance An Impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 5/23/17 with the Medical Director. Employees responsible for checking accuracy of therapeutic diet was LVN I who was suspended pending investigation on 5/23/17 for nursing. Food Service Manager has received counseling and education on responsibility for ensuring trays are checked by the cook and the dietary aid on 5/23/17. Dietary Aide, was suspended on 5/23/17 pending investigation for failing to ensure therapeutic diet or being served to residents. During an interview with Administrator on 5/25/17 at 10:53 a.m. stated that he supervises staff by walking around the facility, reviewing different reports, and observation of administration staff. He stated that he will talk to staff about what's going on in the facility and that this is usually addressed in the daily stand up meeting. Administrator stated that the IJ occurred possibly due to the cook not looking at the trays to find out if it matched the ticket. Since the incident Administrator said that he has followed-up with the nurse checking trays throughout the day, the staff has received an in-service, the nurses are checking the trays as the layers of systems in place to check trays. During an interview with MDS Nurse on 5/25/17 at 11:46 a.m. revealed that she supervises staff to ensure that they are following policy/procedures by doing observation rounds, interviewing residents and using a customer satisfaction survey. MDS nurse said that the IJ occurred when dietary out the wrong diet on the tray, the nurse failed to review the tray, and the person who delivered the tray failed to verify the diet as prescribed. Since the occurrence she has talked to the charge nurses on the floors, and the nurse manager in the dining room to see if the trays are correct. The nurses on the floor check the tray the CNA check the trays. A dietary report is run in the morning by the charge nurse who will review the report and check the trays. An in-service was conducted detailing food consistency. A dietary tray of two different food consistencies puree, and mechanical soft were shown as part of the in-service. In addition, a handout was given to staff about consistency diets. During an interview with the Speech Language Pathologist on 05/26/17 at 11:40 a.m., she stated she conducted Speech Therapy screenings for Resident #1, Resident #3, and Resident #10 on 05/25/17. She said these screenings were due to the residents receiving the incorrect diet on 05/23/17. The Speech Language Pathologist stated her recommendations were for Resident #1, Resident #3, and Resident #10 to continue on mechanical soft diets. Interview on 5/24/17 - 5/25/17 with CMA/CNA D, CMA E, CNA F, CNA G, CNA H, LVN J, CNA K, LVN L, LVN M, LVN N representing staff from all three shifts were interview regarding the in-service and training they received on the facility's therapeutic diets identifying food consistency, checking trays during meal times to ensure residents receive their prescribed diets. Interviews with CMA/CNA D, CMA E, CNA F, CNA G, CNA H, LVN J, CNA K, LVN L, LVN M, LVN N revealed that they were able to identify food consistency, checking trays during meal times to ensure residents receive their prescribed diets. Facility in-services were reviewed and reflected: Checking Trays During Meal Times dated 5/23/2017 revealed that 31 staff attended the in-service. Therapeutic Diets dated 5/24/2017 revealed that 42 staff attended the in-service. Diet Checks dated 5/24/2017 revealed that 25 staff attended the in-service. Observations of meal service on 5/23/17 at 6:00 p.m., 5/24/17 for breakfast service and lunch revealed the facility ensured meal trays were checked for accuracy by staff prior to serving the trays to residents. These observations also revealed residents received their ordered diets. The Administrator and the Regional Nurse Consultant were notified on 05/25/17 at 11:53 a.m. that the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed on 05/25/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to facility's monitoring of effectiveness of the plan of removal. Review of a current list of residents with their dietary orders, which was provided by the Food Service Manager and dated 05/23/17, reflected 24 residents required a mechanical soft texture and 8 residents required a pureed texture.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs for 3 (Residents #1, #3, and #10) of 10 residents reviewed for mechanically altered diets. The facility failed to serve Residents #1, #3, and #10 mechanically soft foods, which was what their physicians ordered. Resident #10 choked and gasped for breath. An Immediate Jeopardy (IJ) was identified on 05/23/17 at 4:30 p.m. While the IJ was removed on 05/25/17, the facility remained out of compliance at a severity level of potential for actual harm that is not immediate jeopardy and a scope of pattern due to the facility's monitoring of the effectiveness of the plan of removal. These failures placed 32 residents with orders for either mechanical soft or puree diets at risk of choking, aspiration, aspiration pneumonia, and death. Findings included: 1. Review of Resident #10's Face Sheet, dated 05/25/17, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident #10's MDS assessment, dated 05/01/17, reflected Resident #10 required a mechanically altered diet while she was a resident at the facility. Review of Resident #10's Service Plan reflected she required a mechanical soft diet. This portion of the Service Plan was most recently revised on 05/31/16. Review of Resident #10's Medication Review Report (physician's orders [REDACTED].#10 had an order to receive mechanically soft textured foods. This order was initiated on 01/19/17. Review of Resident #10's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground chicken parmesan with spaghetti sauce, spaghetti noodles, sliced broccoli florets, dinner roll/bread, margarine, and butterscotch pudding. Observation on 05/23/17 at 12:23 p.m. revealed Resident #10 was served a whole piece of chicken parmesan (not mechanically chopped or ground) and whole pieces of broccoli florets. During an interview with the Food Service Manager on 05/23/17 at 12:40 p.m., she stated meal tickets were current and reflective of each resident's ordered diet. The Food Service Manager stated meal trays were initially checked for accuracy prior to leaving the kitchen by the last person on the meal tray line. After the meal trays left the kitchen, both a nurse and a nurse aide were also required to check the meal trays for accuracy prior to serving the residents. The Food Service Manager stated all meal trays were checked for accuracy today, prior to leaving the kitchen for the lunch meal service. She was notified Resident #1 and Resident #3 did not receive mechanical soft meals during the lunch meal service. Observation on 05/23/17 at 12:44 p.m. revealed Resident #10 was sitting in her room, repeatedly pointing to her throat. Initially, she was not making any sound while pointing to her throat. Resident #10 then made a gurgling sound. The Food Service Manager yelled for the assistance of a nurse. Observation on 05/24/2017 at 12:45 p.m. revealed three staff members were in Resident #10's room, including one nurse. Resident #10 was found to be grasping for breath. The nurse was telling Resident #10 to continue to spit. The nurse stated she could not do the [MEDICATION NAME] maneuver, as Resident #10 had a [DIAGNOSES REDACTED].#10 was spitting up mid-size particles of food. During an interview with CNA C on 5/23/17 at 12:48 p.m., she was unaware of Resident #10's diet orders. She stated Resident #10 was ordered a regular texture diet. During an interview with resident #10 on 05/24/17 at 4:00 p.m. revealed that resident did not understand what mechanical soft diet was. Resident stated that today was the only time her meal was not chopped. Resident #10 said that during lunch she had a throat problem. Resident #10 could not articulate what occurred however, she demonstrated the event by grasping her throat. 2. Review of Resident #1's Face Sheet, dated 05/25/17, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 04/13/17, reflected she was cognitively intact. She was identified as requiring a mechanically altered diet with supervision and setup help for meals. Review of Resident #1's Medication Review Report (physician's orders [REDACTED]. Review of Resident #1's Service Plan, undated, reflected she required a mechanical soft diet. The facility's intervention included providing and serving her diet as ordered. This portion of the Service Plan was most recently revised on 05/31/16. Review of Resident #1's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground chicken parmesan with spaghetti sauce, spaghetti noodles, sliced broccoli florets, dinner roll/bread, margarine, and butterscotch pudding. Observation on 05/23/17 at 12:35 p.m. revealed Resident #1 was served a whole piece of chicken parmesan, spaghetti noodles, whole pieces of broccoli florets, a dinner roll, margarine, and butterscotch pudding. The chicken was not mechanically ground or chopped. Resident #1 attempted to cut the chicken with her utensils. She obtained the attention of CNA C by saying, I need you to cut my meat. I can't even do it. CNA C then cut Resident #1's chicken into pieces that were approximately 1 inch long by 1 inch wide. She also cut Resident #1's broccoli florets prior to leaving the room. During an interview with Resident #1 on 05/24/17 at 9:40 a.m., she reported prior to 05/23/17, she never received a mechanical soft diet. She stated she always received full pieces of meat and she had staff members cut the meat for her. During an interview with CNA C on 05/24/17 at 1:45 p.m., she stated Resident #1 was ordered a mechanical soft diet. She stated she was aware of the requirement to review meal tickets, which identified each resident's specific diet order. She stated on 05/23/17, she cut up Resident #1's food because Resident #1 requested for the meat to be cut. When asked why she did not return the tray to the kitchen and request a mechanical soft meal tray, CNA C did not provide an answer. 3. Review of Resident #3's Face Sheet, dated 05/25/17, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment, dated 03/13/17, reflected she was cognitively impaired. She was identified as requiring a mechanically altered diet with supervision and setup help for meals. Review of Resident #3's Medication Review Report (physician's orders [REDACTED]. Review of Resident #3's Service Plan, undated, reflected she required a mechanical soft diet. The facility's intervention included providing and serving her diet as ordered. This portion of the Service Plan was most recently revised on 05/25/17. Review of Resident #3's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground lemon pepper fish with white sauce, buttered rice, yellow squash, bread, and butterscotch pudding. Observation on 05/23/17 at 11:55 a.m. revealed Resident #3 was served a whole piece of lemon pepper fish, buttered rice, yellow squash, bread, and butterscotch pudding. The fish was not mechanically ground or chopped. She did not eat the meat. During an interview with Resident #3 on 05/24/17 at 9:30 a.m., she reported prior to 05/23/17, there had been various occasions in which she did not receive a mechanical soft diet. She said when she did not receive the correct diet, she would cut the meat herself. 4. During an interview with LVN J on 05/23/17 at 1:39 p.m. he stated that he was responsible for checking the meals to insure that correct meals for the correct consistency such as puree, mechanical soft, or regular. LVN J said that a CNA would check meals when delivering. He said that the Food Service Manager should be checking the trays and tickets as well. LVN J was not sure why the incorrect textured meals were not caught. During an interview with the Director of Nursing on 05/23/17 at 2:40 p.m., she stated the facility initiated in-services on the importance of ensuring residents received correct meals as ordered by the physician. She stated Resident #1, Resident #3, and Resident #10 were placed on 72-hour checks due to receiving the incorrect diet. The Director of Nursing stated, There's no sugar coating a failure occurred. During an interview with the Regional Nurse Consultant on 05/24/17 at 4:49 p.m., she stated the facility's policy regarding mechanical soft diets was to ensure all meats were mechanically ground. She stated the facility did not consider chopped meats to be a mechanical soft texture, unless there was a specific physician's orders [REDACTED]. The Regional Nurse Consultant stated no residents at the facility were currently ordered chopped meats. During an interview with the facility medical director on 05/25/17 at 11:58 a.m. revealed that the facility contacted him regarding the wrong textured meal being served to Resident #3 and he has followed up with the resident and facility. Review of a current list of residents with their dietary orders, which was provided by the Food Service Manager and dated 05/23/17, reflected 24 residents required a mechanical soft texture and 8 residents required a pureed texture. Review of the facility's Consistency of Modified Diets handout, which was identified as being provided to staff members by the Regional Nurse Consultant and was undated, reflected, .Mechanical Soft: This is a more advanced texture that may be used to transition a regular diet. It consists of ground meats, with soft fruits and vegetables, and most bread products . Review of the facility's Resident Nutrition Services Policy and Procedure, dated 04/2010, reflected, .Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance . The Policy and Procedure also reflected, . 2. Nursing personnel will ensure that residents are served the correct food tray. 3. Prior to serving the food tray, the Nurse Aide/Feeding Assistant must check the tray card to ensure that the correct food tray is being served to the resident. If there is doubt, the Nurse Supervisor will check the written physician's orders [REDACTED]. An Immediate Jeopardy was identified on 05/23/17 at 4:30 p.m. The Administrator and DON were notified of the Immediate Jeopardy on 05/23/17 at 4:30 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/25/17 at 11:53 a.m. and reflected the following: Resident #10 was immediately assessed by LVN N on 5/23/17 at 12:56 PM and no respiratory distress was noted. Then RT completed an assessment of the residents respiratory status on 5/23/17 at 4:23 PM and no respiratory distress was noted. Resident #10's physician was notified of the resident receiving an incorrect diet on 5/23/17 at 1:16 PM and order was received for a STAT chest x-ray and a referral for speech therapy. STAT x-ray was completed on 5/23/17 at 5:05 PM and results were borderline large heart without evidence of [MEDICAL CONDITION] or volume overload and no other acute process are demonstrated which were reported to the physician at 6:40 pm. The residents care plan and care kardex were updated to reflect resident's current status. Resident was placed on 72-hour monitoring for respiratory distress. Resident #1 was immediately assessed by RT on 5/23/17 at 1:50 PM and no respiratory distress. Resident #1 position was notified of resident receiving an incorrect diet on 5/23/17 at 2:02 PM and orders received for speech therapy evaluation. Resident #1 responsible party was notified of resident receiving an incorrect diet on 5/23/17 at 1:26 PM. Resident's care plan and care kardex were updated to reflect the resident's current status. Resident was placed on 72-hour monitoring for respiratory distress. Resident #3 was immediately assessed by the LVN N on 5/23/17 at 1:18 PM and no respiratory distress noted. Resident #3 physician was notified of resident receiving it incorrect diet on 5/23/17 at 2:05 PM and orders received for speech therapy evaluation. Resident's care plan and care kardex were updated to reflect the resident's current status. Resident was placed on a 72-hour monitoring for respiratory distress. How were other residents at risk to be affected by this deficient practice identified? An audit was completed on 5/23/17 by Director of Nurses to determine which residents receive a specialized diet. 30 residents were identified at risk to be affected by the alleged deficient practice. A comparative audit of physician's orders [REDACTED]. 1 tray card was noted to not match the current positions diet order. The tray card system was updated by Food Service Manager to reflect the current order. An audit was completed on 5/23/17 by Director of Nurses to determine residents who have a [DIAGNOSES REDACTED]. The licensed and certified nursing staff were educated by the MDS Nurse on 5/23/17 on the process for checking tray cards against the diet served to ensure correct diet is served. Any tray that is prepared incorrectly will be immediately sent back to the kitchen for correction and the tray will not be served until corrected. Newly hired staff will receive this education during new hire orientation. Licensed and certified nursing staff will not be allowed to work until they receive the education. The licensed nursing staff were in-serviced by the MDS Nurse on 5/23/17 on completing a dietary communication form for newly admitted and readmitted resident's and any residents who have a diet order change. The dietary staff were educated by Dietary Manager on 5/23/17 on preparing and serving the correct diet as indicated on the resident tray card. The cooks were educated by Dietary Manager on 5/23/17 on checking the recipe for mechanically altered food preparation. Newly hired dietary staff will receive this education during new hire orientation. Dietary staff will not be allowed to work until they receive the education. Each meal service will have a licensed nurse check each trade for correct diet and will send any incorrectly served diets back to the kitchen for correction. Monitoring of meals will be completed as follows: 200 Hall nurse will check all trays for breakfast, 300 Hall nurse will check lunch, and 200 Hall nurse would check all trays for dinner. Daily monitoring of meal service by a nurse manager began on 5/23/17 to ensure all trays are checked for correct diet prior to being delivered to the resident. We can monitoring of meal service to ensure all trays are checked for correct diet will be completed by the Weekend Supervisor. Dietary staff have implemented a double check for every meal beginning with breakfast on 5/24/17 to ensure the correct diet is being prepared and served. The double check will consist of the cook checking the diet against the tray card and then the dietary aid will complete a final check prior to being sent out to nursing. The licensed and certified nursing staff were in serviced on 5/23/17 by Director of Nurses on Abuse and Neglect. Licensed and certified nursing staff will not be allowed to work until they receive the education. All staff have been given a posttest on therapeutic diets and neglect. Posttest will be checked for completion and accuracy by Director of Nurses. Director of Nurses or designee (LVN O, ADON Q, LVN R, MDS Nurse, and RN S) will complete a daily check of all 3 meals X 3 days to ensure compliance with system. Any discrepancies noted will be immediately reported to the Quality Assurance and Performance Improvement committee for evaluation and correction. The Registered Dietitian or designee will complete monitoring of the tray line to ensure continued compliance. Any discrepancies noted will be immediately reported to the Quality Assurance and Performance Improvement committee for evaluation and correction. The Director of Nurses or designees (LVN O, ADON Q, LVN R, MDS Nurse, and RN S) will monitor three meals a day, seven days a week for two weeks to ensure effectiveness of in-service/training. Random checks will be performed monthly x3 months and any negative findings will be reported to the QAPI committee. Quality Assurance An Impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 5/23/17 with the Medical Director. Employees responsible for checking accuracy of therapeutic diet was LVN I who was suspended pending investigation on 5/23/17 for nursing. Food Service Manager has received counseling and education on responsibility for ensuring trays are checked by the cook and the dietary aid on 5/23/17. Dietary Aide, was suspended on 5/23/17 pending investigation for failing to ensure therapeutic diet or being served to residents. During an interview with Administrator on 5/25/17 at 10:53 a.m. stated that he supervises staff by walking around the facility, reviewing different reports, and observation of administration staff. He stated that he will talk to staff about what's going on in the facility and that this is usually addressed in the daily stand up meeting. Administrator stated that the IJ occurred possibly due to the cook not looking at the trays to find out if it matched the ticket. Since the incident Administrator said that he has followed-up with the nurse checking trays throughout the day, the staff has received an in-service, the nurses are checking the trays as the layers of systems in place to check trays. During an interview with MDS Nurse on 5/25/17 at 11:46 a.m. revealed that she supervises staff to ensure that they are following policy/procedures by doing observation rounds, interviewing residents and using a customer satisfaction survey. MDS nurse said that the IJ occurred when dietary out the wrong diet on the tray, the nurse failed to review the tray, and the person who delivered the tray failed to verify the diet as prescribed. Since the occurrence she has talked to the charge nurses on the floors, and the nurse manager in the dining room to see if the trays are correct. The nurses on the floor check the tray the CNA check the trays. A dietary report is run in the morning by the charge nurse who will review the report and check the trays. An in-service was conducted detailing food consistency. A dietary tray of two different food consistencies puree, and mechanical soft were shown as part of the in-service. In addition, a handout was given to staff about consistency diets. During an interview with the Speech Language Pathologist on 05/26/17 at 11:40 a.m., she stated she conducted Speech Therapy screenings for Resident #1, Resident #3, and Resident #10 on 05/25/17. She said these screenings were due to the residents receiving the incorrect diet on 05/23/17. The Speech Language Pathologist stated her recommendations were for Resident #1, Resident #3, and Resident #10 to continue on mechanical soft diets. Interview on 5/24/17 - 5/25/17 with CMA/CNA D, CMA E, CNA F, CNA G, CNA H, LVN J, CNA K, LVN L, LVN M, LVN N representing staff from all three shifts were interview regarding the in-service and training they received on the facility's therapeutic diets identifying food consistency, checking trays during meal times to ensure residents receive their prescribed diets. Interviews with CMA/CNA D, CMA E, CNA F, CNA G, CNA H, LVN J, CNA K, LVN L, LVN M, LVN N revealed that they were able to identify food consistency, checking trays during meal times to ensure residents receive their prescribed diets. Facility in-services were reviewed and reflected: Checking Trays During Meal Times dated 5/23/2017 revealed that 31 staff attended the in-service. Therapeutic Diets dated 5/24/2017 revealed that 42 staff attended the in-service. Diet Checks dated 5/24/2017 revealed that 25 staff attended the in-service. Observations of meal service on 5/23/17 at 6:00 p.m., 5/24/17 for breakfast service and lunch revealed the facility ensured meal trays were checked for accuracy by staff prior to serving the trays to residents. These observations also revealed residents received their ordered diets. The Administrator and the Regional Nurse Consultant were notified on 05/25/17 at 11:53 a.m. that the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed on 05/25/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to facility's monitoring of effectiveness of the plan of removal. Review of a current list of residents with their dietary orders, which was provided by the Food Service Manager and dated 05/23/17, reflected 24 residents required a mechanical soft texture and 8 residents required a pureed texture.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for 3 (Residents #1, #3, and #10) of 10 residents reviewed for mechanically altered diets. The facility failed to serve Residents #1, #3, and #10, who ate their meals in their rooms, mechanically soft foods, which was what their physicians ordered. Resident #10 choked and gasped for breath. An Immediate Jeopardy (IJ) was identified on 05/23/17 at 4:30 p.m. While the IJ was removed on 05/25/17, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's monitoring of the effectiveness of the plan of removal. These failures placed 32 residents with orders for either mechanical soft or puree diets at risk of choking, aspiration, aspiration pneumonia, and death. Findings included: Review of the facility's Reporting Abuse to Facility Management Policy and Procedure, dated 12/2009, reflected, .'Neglect' is defined as failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress . Review of the facility's Resident Nutrition Services Policy and Procedure, dated 04/2010, reflected, .Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance . The Policy and Procedure also reflected, . 2. Nursing personnel will ensure that residents are served the correct food tray. 3. Prior to serving the food tray, the Nurse Aide/Feeding Assistant must check the tray card to ensure that the correct food tray is being served to the resident. If there is doubt, the Nurse Supervisor will check the written physician's orders [REDACTED]. 1. Review of Resident #10's Face Sheet, dated 05/25/17, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident #10's MDS assessment, dated 05/01/17, reflected Resident #10 required a mechanically altered diet while she was a resident at the facility. Review of Resident #10's Service Plan reflected she required a mechanical soft diet. This portion of the Service Plan was most recently revised on 05/31/16. Review of Resident #10's Medication Review Report (physician's orders [REDACTED].#10 had an order to receive mechanically soft textured foods. This order was initiated on 01/19/17. Review of Resident #10's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground chicken parmesan with spaghetti sauce, spaghetti noodles, sliced broccoli florets, dinner roll/bread, margarine, and butterscotch pudding. Observation on 05/23/17 at 12:23 p.m. revealed Resident #10 was served a whole piece of chicken parmesan (not mechanically chopped or ground) and whole pieces of broccoli florets. During an interview with the Food Service Manager on 05/23/17 at 12:40 p.m., she stated meal tickets were current and reflective of each resident's ordered diet. The Food Service Manager stated meal trays were initially checked for accuracy prior to leaving the kitchen by the last person on the meal tray line. After the meal trays left the kitchen, both a nurse and a nurse aide were also required to check the meal trays for accuracy prior to serving the residents. The Food Service Manager stated all meal trays were checked for accuracy today, prior to leaving the kitchen for the lunch meal service. She was notified Resident #1 and Resident #3 did not receive mechanical soft meals during the lunch meal service. Observation on 05/23/17 at 12:44 p.m. revealed Resident #10 was sitting in her room, repeatedly pointing to her throat. Initially, she was not making any sound while pointing to her throat. Resident #10 then made a gurgling sound. The Food Service Manager yelled for the assistance of a nurse. Observation on 05/24/2017 at 12:45 p.m. revealed three staff members were in Resident #10's room, including one nurse. Resident #10 was found to be grasping for breath. The nurse was telling Resident #10 to continue to spit. The nurse stated she could not do the [MEDICATION NAME] maneuver, as Resident #10 had a [DIAGNOSES REDACTED].#10 was spitting up mid-size particles of food. During an interview with CNA C on 5/23/17 at 12:48 p.m., she was unaware of Resident #10's diet orders. She stated Resident #10 was ordered a regular texture diet. During an interview with resident #10 on 05/24/17 at 4:00 p.m. revealed that resident did not understand what mechanical soft diet was. Resident stated that today was the only time her meal was not chopped. Resident #10 said that during lunch she had a throat problem. Resident #10 could not articulate what occurred however, she demonstrated the event by grasping her throat. 2. Review of Resident #1's Face Sheet, dated 05/25/17, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 04/13/17, reflected she was cognitively intact. She was identified as requiring a mechanically altered diet with supervision and setup help for meals. Review of Resident #1's Medication Review Report (physician's orders [REDACTED]. Review of Resident #1's Service Plan, undated, reflected she required a mechanical soft diet. The facility's intervention included providing and serving her diet as ordered. This portion of the Service Plan was most recently revised on 05/31/16. Review of Resident #1's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground chicken parmesan with spaghetti sauce, spaghetti noodles, sliced broccoli florets, dinner roll/bread, margarine, and butterscotch pudding. Observation on 05/23/17 at 12:35 p.m. revealed Resident #1 was served a whole piece of chicken parmesan, spaghetti noodles, whole pieces of broccoli florets, a dinner roll, margarine, and butterscotch pudding. The chicken was not mechanically ground or chopped. Resident #1 attempted to cut the chicken with her utensils. She obtained the attention of CNA C by saying, I need you to cut my meat. I can't even do it. CNA C then cut Resident #1's chicken into pieces that were approximately 1 inch long by 1 inch wide. She also cut Resident #1's broccoli florets prior to leaving the room. During an interview with Resident #1 on 05/24/17 at 9:40 a.m., she reported prior to 05/23/17, she never received a mechanical soft diet. She stated she always received full pieces of meat and she had staff members cut the meat for her. During an interview with CNA C on 05/24/17 at 1:45 p.m., she stated Resident #1 was ordered a mechanical soft diet. She stated she was aware of the requirement to review meal tickets, which identified each resident's specific diet order. She stated on 05/23/17, she cut up Resident #1's food because Resident #1 requested for the meat to be cut. When asked why she did not return the tray to the kitchen and request a mechanical soft meal tray, CNA C did not provide an answer. 3. Review of Resident #3's Face Sheet, dated 05/25/17, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment, dated 03/13/17, reflected she was cognitively impaired. She was identified as requiring a mechanically altered diet with supervision and setup help for meals. Review of Resident #3's Medication Review Report (physician's orders [REDACTED]. Review of Resident #3's Service Plan, undated, reflected she required a mechanical soft diet. The facility's intervention included providing and serving her diet as ordered. This portion of the Service Plan was most recently revised on 05/25/17. Review of Resident #3's Meal Ticket, served with her meal on 05/23/17, reflected she was to receive food items including ground lemon pepper fish with white sauce, buttered rice, yellow squash, bread, and butterscotch pudding. Observation on 05/23/17 at 11:55 a.m. revealed Resident #3 was served a whole piece of lemon pepper fish, buttered rice, yellow squash, bread, and butterscotch pudding. The fish was not mechanically ground or chopped. She did not eat the meat. During an interview with Resident #3 on 05/24/17 at 9:30 a.m., she reported prior to 05/23/17, there had been various occasions in which she did not receive a mechanical soft diet. She said when she did not receive the correct diet, she would cut the meat herself. 4. During an interview with LVN J on 05/23/17 at 1:39 p.m. he stated that he was responsible for checking the meals to insure that correct meals for the correct consistency such as puree, mechanical soft, or regular. LVN J said that a CNA would check meals when delivering. He said that the Food Service Manager should be checking the trays and tickets as well. LVN J was not sure why the incorrect textured meals were not caught. During an interview with the Director of Nursing on 05/23/17 at 2:40 p.m., she stated the facility initiated in-services on the importance of ensuring residents received correct meals as ordered by the physician. She stated Resident #1, Resident #3, and Resident #10 were placed on 72-hour checks due to receiving the incorrect diet. The Director of Nursing stated, There's no sugar coating a failure occurred. During an interview with the Regional Nurse Consultant on 05/24/17 at 4:49 p.m., she stated the facility's policy regarding mechanical soft diets was to ensure all meats were mechanically ground. She stated the facility did not consider chopped meats to be a mechanical soft texture, unless there was a specific physician's orders [REDACTED]. The Regional Nurse Consultant stated no residents at the facility were currently ordered chopped meats. During an interview with the facility medical director on 05/25/17 at 11:58 a.m. revealed that the facility contacted him regarding the wrong textured meal being served to Resident #3 and he has followed up with the resident and facility. Review of a current list of residents with their dietary orders, which was provided by the Food Service Manager and dated 05/23/17, reflected 24 residents required a mechanical soft texture and 8 residents required a pureed texture. Review of the facility's Consistency of Modified Diets handout, which was identified as being provided to staff members by the Regional Nurse Consultant and was undated, reflected, .Mechanical Soft: This is a more advanced texture that may be used to transition a regular diet. It consists of ground meats, with soft fruits and vegetables, and most bread products . An Immediate Jeopardy was identified on 05/23/17 at 4:30 p.m. The Administrator and DON were notified of the Immediate Jeopardy on 05/23/17 at 4:30 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/25/17 at 11:53 a.m. and reflected the following: Resident #10 was immediately assessed by LVN N on 5/23/17 at 12:56 PM and no respiratory distress was noted. Then RT completed an assessment of the residents respiratory status on 5/23/17 at 4:23 PM and no respiratory distress was noted. Resident #10's physician was notified of the resident receiving an incorrect diet on 5/23/17 at 1:16 PM and order was received for a STAT chest x-ray and a referral for speech therapy. STAT x-ray was completed on 5/23/17 at 5:05 PM and results were borderline large heart without evidence of [MEDICAL CONDITION] or volume overload and no other acute process are demonstrated which were reported to the physician at 6:40 pm. The residents care plan and care kardex were updated to reflect resident's current status. Resident was placed on 72-hour monitoring for respiratory distress. Resident #1 was immediately assessed by RT on 5/23/17 at 1:50 PM and no respiratory distress. Resident #1 position was notified of resident receiving an incorrect diet on 5/23/17 at 2:02 PM and orders received for speech therapy evaluation. Resident #1 responsible party was notified of resident receiving an incorrect diet on 5/23/17 at 1:26 PM. Resident's care plan and care kardex were updated to reflect the resident's current status. Resident was placed on 72-hour monitoring for respiratory distress. Resident #3 was immediately assessed by the LVN N on 5/23/17 at 1:18 PM and no respiratory distress noted. Resident #3 physician was notified of resident receiving it incorrect diet on 5/23/17 at 2:05 PM and orders received for speech therapy evaluation. Resident's care plan and care kardex were updated to reflect the resident's current status. Resident was placed on a 72-hour monitoring for respiratory distress. How were other residents at risk to be affected by this deficient practice identified? An audit was completed on 5/23/17 by Director of Nurses to determine which residents receive a specialized diet. 30 residents were identified at risk to be affected by the alleged deficient practice. A comparative audit of physician's orders [REDACTED]. 1 tray card was noted to not match the current positions diet order. The tray card system was updated by Food Service Manager to reflect the current order. An audit was completed on 5/23/17 by Director of Nurses to determine residents who have a [DIAGNOSES REDACTED]. The licensed and certified nursing staff were educated by the MDS Nurse on 5/23/17 on the process for checking tray cards against the diet served to ensure correct diet is served. Any tray that is prepared incorrectly will be immediately sent back to the kitchen for correction and the tray will not be served until corrected. Newly hired staff will receive this education during new hire orientation. Licensed and certified nursing staff will not be allowed to work until they receive the education. The licensed nursing staff were in-serviced by the MDS Nurse on 5/23/17 on completing a dietary communication form for newly admitted and readmitted resident's and any residents who have a diet order change. The dietary staff were educated by Dietary Manager on 5/23/17 on preparing and serving the correct diet as indicated on the resident tray card. The cooks were educated by Dietary Manager on 5/23/17 on checking the recipe for mechanically altered food preparation. Newly hired dietary staff will receive this education during new hire orientation. Dietary staff will not be allowed to work until they receive the education. Each meal service will have a licensed nurse check each trade for correct diet and will send any incorrectly served diets back to the kitchen for correction. Monitoring of meals will be completed as follows: 200 Hall nurse will check all trays for breakfast, 300 Hall nurse will check lunch, and 200 Hall nurse would check all trays for dinner. Daily monitoring of meal service by a nurse manager began on 5/23/17 to ensure all trays are checked for correct diet prior to being delivered to the resident. We can monitoring of meal service to ensure all trays are checked for correct diet will be completed by the Weekend Supervisor. Dietary staff have implemented a double check for every meal beginning with breakfast on 5/24/17 to ensure the correct diet is being prepared and served. The double check will consist of the cook checking the diet against the tray card and then the dietary aid will complete a final check prior to being sent out to nursing. The licensed and certified nursing staff were in serviced on 5/23/17 by Director of Nurses on Abuse and Neglect. Licensed and certified nursing staff will not be allowed to work until they receive the education. All staff have been given a posttest on therapeutic diets and neglect. Posttest will be checked for completion and accuracy by Director of Nurses. Director of Nurses or designee (LVN O, ADON Q, LVN R, MDS Nurse, and RN S) will complete a daily check of all 3 meals X 3 days to ensure compliance with system. Any discrepancies noted will be immediately reported to the Quality Assurance and Performance Improvement committee for evaluation and correction. The Registered Dietitian or designee will complete monitoring of the tray line to ensure continued compliance. Any discrepancies noted will be immediately reported to the Quality Assurance and Performance Improvement committee for evaluation and correction. The Director of Nurses or designees (LVN O, ADON Q, LVN R, MDS Nurse, and RN S) will monitor three meals a day, seven days a week for two weeks to ensure effectiveness of in-service/training. Random checks will be performed monthly x3 months and any negative findings will be reported to the QAPI committee. Quality Assurance An Impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 5/23/17 with the Medical Director. Employees responsible for checking accuracy of therapeutic diet was LVN I who was suspended pending investigation on 5/23/17 for nursing. Food Service Manager has received counseling and education on responsibility for ensuring trays are checked by the cook and the dietary aid on 5/23/17. Dietary Aide, was suspended on 5/23/17 pending investigation for failing to ensure therapeutic diet or being served to residents. During an interview with Administrator on 5/25/17 at 10:53 a.m. stated that he supervises staff by walking around the facility, reviewing different reports, and observation of administration staff. He stated that he will talk to staff about what's going on in the facility and that this is usually addressed in the daily stand up meeting. Administrator stated that the IJ occurred possibly due to the cook not looking at the trays to find out if it matched the ticket. Since the incident Administrator said that he has followed-up with the nurse checking trays throughout the day, the staff has received an in-service, the nurses are checking the trays as the layers of systems in place to check trays. During an interview with MDS Nurse on 5/25/17 at 11:46 a.m. revealed that she supervises staff to ensure that they are following policy/procedures by doing observation rounds, interviewing residents and using a customer satisfaction survey. MDS nurse said that the IJ occurred when dietary out the wrong diet on the tray, the nurse failed to review the tray, and the person who delivered the tray failed to verify the diet as prescribed. Since the occurrence she has talked to the charge nurses on the floors, and the nurse manager in the dining room to see if the trays are correct. The nurses on the floor check the tray the CNA check the trays. A dietary report is run in the morning by the charge nurse who will review the report and check the trays. An in-service was conducted detailing food consistency. A dietary tray of two different food consistencies puree, and mechanical soft were shown as part of the in-service. In addition, a handout was given to staff about consistency diets. During an interview with the Speech Language Pathologist on 05/26/17 at 11:40 a.m., she stated she conducted Speech Therapy screenings for Resident #1, Resident #3, and Resident #10 on 05/25/17. She said these screenings were due to the residents receiving the incorrect diet on 05/23/17. The Speech Language Pathologist stated her recommendations were for Resident #1, Resident #3, and Resident #10 to continue on mechanical soft diets. Interview on 5/24/17 - 5/25/17 with CMA/CNA D, CMA E, CNA F, CNA G, CNA H, LVN J, CNA K, LVN L, LVN M, LVN N representing staff from all three shifts were interview regarding the in-service and training they received on the facility's therapeutic diets identifying food consistency, checking trays during meal times to ensure residents receive their prescribed diets. Interviews with CMA/CNA D, CMA E, CNA F, CNA G, CNA H, LVN J, CNA K, LVN L, LVN M, LVN N revealed that they were able to identify food consistency, checking trays during meal times to ensure residents receive their prescribed diets. Facility in-services were reviewed and reflected: Checking Trays During Meal Times dated 5/23/2017 revealed that 31 staff attended the in-service. Therapeutic Diets dated 5/24/2017 revealed that 42 staff attended the in-service. Diet Checks dated 5/24/2017 revealed that 25 staff attended the in-service. Observations of meal service on 5/23/17 at 6:00 p.m., 5/24/17 for breakfast service and lunch revealed the facility ensured meal trays were checked for accuracy by staff prior to serving the trays to residents. These observations also revealed residents received their ordered diets. The Administrator and the Regional Nurse Consultant were notified on 05/25/17 at 11:53 a.m. that the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed on 05/25/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to facility's monitoring of effectiveness of the plan of removal. Review of a current list of residents with their dietary orders, which was provided by the Food Service Manager and dated 05/23/17, reflected 24 residents required a mechanical soft texture and 8 residents required a pureed texture.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #1) of six residents reviewed for weight loss were provided nutrition as ordered by the physician 1. Resident #1 had physician orders [REDACTED]. As the resident continued to show nutritional decline, through weight loss and low [MEDICATION NAME], an order was written to add [MEDICATION NAME] AC, 250 ml [MEDICATION NAME] at 8:00 p.m. and 2:00 a.m. The facility stopped giving the resident [MEDICATION NAME] feedings when less than 50% of a meal was consumed, although there was no order to discontinue these feedings and the resident's weight continued to decline. Resident #1 loss from 147.9 pounds in February 2012 to 129 pounds in May 2012, a 13% weight loss. These failures resulted in Resident #1's weight loss and nutritional decline and could affect the three residents identified with significant weight loss. Findings included: 1. Review of the MDS assessment dated [DATE] revealed Resident #1 had [DIAGNOSES REDACTED]. Physician order [REDACTED]. 2. Review of the admission orders [REDACTED]. 3. Review of the Yearly Weight Record for Resident #1 revealed an admission height of five feet, five inches. Resident #1's weight was recorded (in pounds) as follows: Month Week Weight Re-weigh FEB 1 165 150.6 2 150.6 147.9 3 144.8 4 145 MAR 1 144.5 2 144.4 3 140.8 140.7 4 138.9 APR 1 136.8 2 134.9 3 132.8 4 133.6 The facility 6 Month Weight Report reflected Resident #1's weight for Week 1 in May was 130.2. Aide A was interviewed on 5/10/12 at 10:53 a.m. Aide A revealed she was one of two staff who routinely weighed the residents. The surveyor asked about the first two weights in February. The first weight was 165 and the reweigh was 150.6. Aide A stated the reweigh was usually done within 24 hours to see if the weight was stable. Aide A stated Resident #1 had a lot of fluid when admitted and had a lot of [MEDICAL CONDITION]. 4. The Dietitian completed a Comprehensive Nutritional Assessment on 02/28/12, following the resident's re-admission from a hospital stay, 02/21/12 - 02/24/12. Resident #1's weight was 144.8. The Dietitian calculated a 12.4% weight loss since the resident's admission on 02/06/12. The Dietitian wrote Resident #1 was at increased risk for [MEDICAL CONDITION] and wrote the following order dated 02/28/12: "If resident consumes <50% of diet at meals, give [MEDICATION NAME] AC, 1 can [MEDICATION NAME] in PEG tube." The order was signed by Resident #1's physician. Per the manufacturers' website, Diabetisource AC is a tube feeding formula designed to meet the unique nutritional needs of patients with Diabetes. One can (250 ml) provides 300 calories. (Retrieved on 05/25/12 at http://www.nestle-nutrition.com/products/Product.aspx?ProductId= 95e-206c-4c4b-a578-c199fe94cf04.) The Dietitian's Progress Note dated 03/31/12 reflected Resident #1's weight was stable over the past 30 days. The March weight was 144.5. The Dietitian noted a decreased [MEDICATION NAME] level of 2.2, indicating moderate visceral protein depletion. The Dietitian's note dated 04/12/12 reflected Resident #1 had sustained a significant weight loss of 5.3% over the past 30 days. The Yearly Weight Record reflected a weight of 136.8 for the first week of April. The Dietitian's plan was to add [MEDICATION NAME] AC, 250 ml [MEDICATION NAME] at 8:00 p.m. and 2:00 a.m. to provide 600 calories and 30 grams of protein. The Dietitian wrote the order the same date and it was signed by the resident's physician. 5. Review of the MAR for April 2012 revealed The [MEDICATION NAME] AC [MEDICATION NAME] at 8:00 p.m. and 2:00 a.m. was started on 02/14/2012. Further review of the MAR indicated If resident consumes less than 50% of diet at meals, give [MEDICATION NAME] AC 1 can [MEDICATION NAME] via Peg tube". The last [MEDICATION NAME] feeding under this order was given on 04/17/12 at breakfast. Review of the May 2012 MAR indicated If resident consumes less than 50% of diet at meals, give [MEDICATION NAME] AC 1 can [MEDICATION NAME] via Peg tube". There was no documentation any [MEDICATION NAME] feedings had been given if Resident #1 ate less that 50% of her meals. Review of the physician's orders [REDACTED]. 6. The Dietitian was interviewed several times on 05/10/12 at between 11:35 a.m. - 12: 50 p.m. The MARs were reviewed during the interviews. She stated when she wrote the order on 04/12/12 to add the [MEDICATION NAME] feedings at 8:00 p.m. and 2:00 a.m., she did not discontinue the order for [MEDICATION NAME] feedings if the resident ate less than 50% of her meals. Her intention was for the resident to get scheduled [MEDICATION NAME] feedings twice a day, at 8:00 p.m. and 2:00 a.m. If the resident ate less than 50% of her meals at meal time, she was to receive the additional tube feedings. The meal consumption records were reviewed with the Dietitian. Review of the CNA Directed Care sheet, used to record meal consumption on paper, revealed numerous dates between 4/12/12 and 4/30/12 that Resident # 1 consumed less than 50% of her meal. There were also numerous blanks where the percent of meal consumed was not recorded. Review of the computerized printout for 4/23/12 - 4/30/12 (initiated by the facility in April 2012) revealed 17 meals where the amount consumed was less than 50% or the resident refused. Review of the computerized printout for 05/1/12 - 05/10/12 revealed 17 meals where the amount consumed was less than 50% or the resident refused. Resident #1 had continued to lose weight between 4/12/12 and 5/10/12. 7. Observation on 05/10/12 at 12:02 p.m. revealed Resident #1 was served lunch in her room. At 12:03 p.m., an aide entered the room and washed her hands. At 12:06 p.m., she began to assist Resident #1 with her meal. The aide was observed to talk with the resident and encourage meal consumption. The aide was observed to leave Resident #1's room at 12:50 p.m. In an interview at that time, the aide revealed Resident #1 "only ate a few bits. She hardly ate anything today." Observation at 12:52 p.m. of the aide talking to the nurse for Resident #1 revealed she was reporting to her the amount of lunch consumed by Resident #1. 8. Resident #1 was weighed in the surveyor's presence on 5/10/12 at 2:08 p.m. The resident's weight was 129, representing a significant weight loss of 13% in three months (between February 2012 (stable weight of 147.9) and May 2012). Review of the CMS 672 Resident Census and Conditions of Residents, dated 05/09/12 and provided by the DON as current reflected a census of 110 with three resident identified with unplanned significant weight/loss gain.

Based on observation, interview and record review, the facilty failed to implement policies and procedures which prohibited neglect of residents for one (Resident #1) of five residents reviewed. Resident #1 was visually monitored once on the eight-hour night shift and was found to have committed suicide when found by staff in the morning. The following failures took place from 9:00 PM on [DATE] to 7:00 AM on [DATE]. LVN A saw Resident #1 once in eight hours at 1:00 AM and took his vital signs. LVN A did not monitor Resident #1 closely because he was "independent" with his walker for toileting even though the resident had a chair/bed alarm due to requiring assistance and his getting out of bed without waiting for assistance. CNA B did not give report to CNA C at change of shift in the evening which would have made him aware Resident #1 had not been discharged . CNA C was assigned to Resident #1 on the night shift. CNA C did not see the resident in the room decided the resident was discharged and did not report the resident as missing to the night shift charge nurse. CNA C did not give report to oncoming staff at change of shift in the morning. LVN D did not make resident rounds when coming on the shift on the morning of [DATE] and was unaware Resident #1 was not in his bed. CNA E did not notify LVN D she could not find Resident #1. These failures affected Resident #1 resulting in his being observed once during the eight-hour night shift and his successfully committing suicide. Had Resident #1 been observed every two hours his suicide might have been prevented. These failures could affect the facility's 24 residents who resided on the same hall as Resident #1 placing them at risk for not being checked frequently enough to provide the care and treatment they needed to ensure their comfort, health, and well-being. Findings included: Review of the face sheet dated [DATE] revealed Resident #1 was a [AGE] year-old male admitted from the hospital to the facility on [DATE]. Review of the hospital's admission orders [REDACTED]. Resident #1's hospital medical and surgical history dated [DATE] reflected the following Diagnoses: [REDACTED]. The hospital's psychiatric consultation dated [DATE] for Resident #1 reflected the resident was alert during the interview, oriented to place, city, month and the year. There was no evidence of [MEDICAL CONDITION] in the past several days. Review of the Facility Elopement Risk Assessment revealed Resident #1 was cognitively impaired with poor decision-making skills and had visual and auditory deficits. The facility's Admission Nursing Evaluation dated [DATE] for Resident #1 reflected the resident had memory problems. Resident #1 also required the assistance of one person for bed mobility, transfers, walking/locomotion, dressing, eating, toileting, personal/hygiene and bathing. Review of the facility's Incident/Accident Report dated [DATE] at 7:45 AM revealed LVN D walked into Resident #1's room and found the resident "face down on the floor between the B bed et (and) the air conditioner with a cloth tied around his neck at one end et to the top rail of the bed on the other end. Resident was blue, lifeless, et __ (without) vitals." Resident #1's cognitive state was marked as confused and a [DIAGNOSES REDACTED]. The resident's pulse, respirations, blood pressure and oxygen saturation level were all documented as zero. The resident's outcome was marked "death." The Incident/Accident Report further reflected CPR was initiated at 7:50 AM on [DATE] (sic). The Report was signed at the bottom by LVN D, the DON and the Administrator. The DON's signature was the only one dated and the date was [DATE]. The back side of the Report was entitled "Fall Investigation Worksheet" and had a large X drawn through it. There was no documentation on it. The Administrator was contacted on [DATE] at approximately 4:15 PM to fax the Investigation Report of the incident involving Resident #1 to the surveyor. Review of the facility's Investigation Report, which was signed by the Administrator and dated [DATE], revealed the following: Resident #1 was found on [DATE] at 7:35 AM with a sheet tied around his neck and to the bed rail. The assessment found him without vitals and CPR was initiated. The police, 911, the physician and family were called. A copy of the Progress Notes dated [DATE] at 7:45 AM and signed by LVN D from Resident #1's clinical record was included with the Investigation Report. There was one other statement included with the facility's Investigation Report, which was dated [DATE] and signed by LVN A. There was no statement or interview with CNA C, who was assigned to provide care for Resident #1. There were no other interviews or statements from any other staff, family members or residents to determine whether Resident #1 had a noticeable change in the way he had been responding to staff and family. Review of the Progress Notes signed by LVN D and dated [DATE] at 7:45 AM revealed Resident #1 was found by a nursing assistant on the floor between the B bed and the wall with the air conditioner. The progress note reflected Resident #1 had a piece of cloth tied around his neck with one end tied to the bed. When the resident was found, the Wound Care Nurse cut the cloth from around the resident's neck and CPR was initiated. Paramedics arrived at 8:00 AM. CPR was stopped at 8:00 AM when the paramedics arrived. The Medical Examiner pronounced Resident #1's death at 7:45 AM. Resident #1's family member was notified at 8:05 AM as well as the Police and Medical Examiner. The Medical Examiner arrived at 9:00 AM, did an investigation, and took the body away. LVN A's statement dated [DATE] reflected: "I reported to work at 10:00 pm. Received report from the outgoing nurse. At 1100 (11:00 PM) I went to check on pts Mr. ____ (Resident #1) was in bed with eyes closed (sic). Rise and fall of chest noted. V/S checked at 0100 am (1:00 AM) were T 97.8 P 74 R18 BP ,[DATE]. NO S/S of distress noted. No c/o pain voiced." Interview on [DATE] at 11:25 AM with LVN A revealed she was the night shift charge nurse for Resident #1's hall from 10:00 PM to 6:00 AM on [DATE]. LVN A stated she saw Resident #1 at 1:00 AM on [DATE]. She stated she checked his vital signs at that time. LVN A remembered Resident #1's blood pressure was ,[DATE] and his respirations were 18 breaths per minute. She could not recall the resident's pulse and temperature. LVN A stated she did not monitor or check on Resident #1 at any other time during the night, because he was independent with a walker for toileting, and he had not used his call light. LVN A stated she did "nursing rounds" every two hours for residents, who needed frequent monitoring. She stated for residents who did not require much help, she monitored them every three to four hours. LVN A stated she thought Resident #1 was in bed all night, but she did not check to see. She stated when she saw Resident #1 at 1:00 AM, she had not noticed any change in his behavior. When queried about the shift change report, LVN A said she had reported they did not visually check Resident #1. The Investigation Summary of the Investigation Report reflected the following: "____ (Resident #1) was found dead with a sheet tied around his neck and to the bed rail. Mr._____ (Resident #1) was evaluated by nursing staff at 1:30 am and staff checked his vitals and all within normal limits. Resident was resting soundly and did not verbalize any signs of distress or depression. Door to room open all night and staff made rounds throughout the night (sic). According to police ____ (Resident #1) committed suicide by hanging." Interview on [DATE] at 11:55 AM with CNA C revealed he worked on Resident #1's hall on the night shift of [DATE]. CNA C stated he was PRN staff and was called to work, because the scheduled CNA had "called in" for the shift. CNA C said when he arrived at work, he made rounds but did not see any residents in what he now knew was Resident #1's room. CNA C stated he thought Resident #1 had been discharged . CNA C stated he was assigned by the charge nurse to take vital signs in a number of rooms, including Resident #1's room. He stated he did not take Resident #1's vital signs, because there was no resident in the room. CNA C said at the beginning of his shift, he did not get any report from the CNA going off duty. He further stated he did not give any report to the oncoming CNA at the end of his shift, because that person was late for work. When queried about Resident #1's vital signs, CNA C stated he did not know if LVN A took Resident #1's vital signs. When queried by the surveyor as to why he did not notify the charge nurse about not taking the vital signs of Resident #1 because the resident was not there, CNA C stated he only notified the charge nurse when there was a problem with a resident's vital signs. The Investigation Report reflected the Provider Action taken Post-Investigation was to conduct in-serivces on making resident rounds and to base room (sic) observation on the need of the resident and the resident's request. Surveyor interviews with LVN A and CNA C revealed Resident #1 was only observed once during the 10 PM - 6 AM shift from [DATE] - [DATE]. Interview on [DATE] at 9:40 AM with CNA E revealed she and CNA F were the first to find Resident #1. CNA E stated she went to Resident #1's room but did not see him in his room. Shortly after, CNA E stated she went back to Resident #1's room, and she still did not see him there. CNA E stated CNA F was in the hallway at Resident #1's room. CNA E said she went to CNA F and told her she was looking for Resident #1, when CNA F asked, "Why is he on the floor?" CNA E stated they ran into Resident #1's room and found the resident lying face down on his stomach. CNA E stated Resident #1 had a bed sheet around his neck. She called the charge nurse, LVN D, who came and checked Resident #1's pulse. The charge nurse called for LVN J. CNA E stated the nurses brought a crash cart and started CPR. During the same interview, CNA E told the surveyor Resident #1 was a new resident. She described Resident #1 as "quiet and never talked much." CNA E added she cared for Resident #1 on Thursday, [DATE]. CNA E stated she worked on Monday ([DATE]) from 6 AM to 2 PM. CNA E stated when she went to make rounds at 6:30 AM, she did not see Resident #1. She then said the facility's policy and procedure was for the CNA to make rounds to check residents first by taking a vitals sheet, then rounds after breakfast, before lunch and after lunch. On [DATE] at 9:55 AM, CNA E showed Resident #1's room to the surveyor. Observation revealed the room was a double room with only one bed in it, the B bed, was against the outside wall. A housekeeper was cleaning the room. CNA E told the surveyor Resident #1 had hung himself. She explained Resident #1 had tied a bed sheet around his neck and hung it from the siderail of his old roommate's bed. CNA E then stated the bed currently in the room was not the bed Resident #1 used. CNA E explained Resident #1's roommate had a much larger bed (bariatric), and she thought the facility had returned the bed to the owner. CNA E walked into the room to the bed. She pointed her finger to between the bed and the wall and stated Resident #1 was found between the bed and the wall. She explained Resident #1 attached the end of the bed sheet to the bedrail of the bariatric bed, and then tied the other end of the sheet around his neck. During an interview on [DATE] at 1:00 PM, CNA I said she worked on [DATE] from 10:00 PM until [DATE] through 6:00 AM, but did not work on Resident #1's hall nor did she know Resident #1. CNA I stated the facility policy and procedure was to do rounds every two hours: at midnight, 2:00 AM, 4:00 AM and 6:00 AM. CNA I stated the policy also required staff to answer residents' call lights. CNA I told the surveyor at the end of the shift, before she left her hall, she checked to make sure her residents were breathing. CNA I said she went from room to room and then reported on each resident at the end of the shift. Interview on [DATE] at 1:15 PM with CNA F revealed on [DATE], she worked the 6:00 AM to 2:00 PM shift. CNA F stated at approximately 7:15 AM, she was standing in the hallway facing Resident #1's room, talking to CNA E. CNA F told the surveyor she looked into the room and saw Resident #1 on the floor. She said Resident #1 was lying on the floor with his heels pointing outwards. Resident #1's legs were only visible from below the knee. CNA F stated she asked CNA E, "Why is he on the floor?" CNA E turned around and looked and then called the charge nurse, LVN D to come immediately. CNA F stated LVN D come and attempted to wake the resident by shaking the resident's shoulders and asking, "___ (Resident #1), are you okay?" CNA F said LVN D left the room and got LVN G. CNA F stated LVN G was just arriving and was still at the time clock. Both nurses arrived back to Resident #1's room. During the same interview, CNA F described Resident #1 as quiet and not talking much. CNA F said the resident needed assistance with his meals and had a tendency of getting out of bed without help. CNA F said she told Resident #1 to call for assistance when he wanted to use the bathroom. CNA F further stated Resident #1 had a bed alarm because he would try to get out of bed without help. When queried about the facility policy and procedures for making rounds on the residents, CNA F stated CNAs were to make resident rounds every two hours. Interview on [DATE] at 1:25 PM with LVN K revealed she worked on [DATE] (Saturday) on the 2:00 PM to 10:00 PM shift, but did not work on Resident #1's hall. LVN K stated she saw Resident #1 last between 9:35 PM - 9:45 PM. LVN K said Resident #1 was in bed sleeping at that time. LVN K stated Resident #1 had his covers on and the siderail on his bed was in the upright position. LVN K added it was the first time for her to work with Resident #1. LVN K stated the policy of the facility was to do resident rounds at the beginning and at the end of the shift. LVN K told the surveyor she did rounds when she had time and sometimes she did rounds every two hours. Interview on [DATE] at 2:00 PM revealed LVN M worked on the 200 and 300 Halls. LVN M stated she worked the 2:00 PM - 10:00 PM shifts on [DATE] (Sunday) and [DATE] (Monday). LVN M stated there was no emergency situation during her shifts. LVN M stated she did not know Resident #1. LVN M stated the facility policy was to check residents at the beginning of the shift, in between the shift at least two to three hours and at the end of the shift. Interview on [DATE] at 2:15 PM with LVN D revealed she worked on Resident #1's hall on [DATE] from 6:00 AM until 2:00 PM. LVN D stated she relieved LVN A. LVN D stated she did not check to see if all the residents were in their rooms. LVN D stated CNA I alerted her to go to Resident #1's room. LVN D stated it was 7:45 AM on [DATE] when she walked into Resident #1's room. Resident #1 was lying face down on the floor between the B bed and the wall with the air conditioner. LVN D said she called Resident #1's name, but he did not respond. LVN D stated when she looked up, she saw the bed sheet tied from the bed to Resident #1's neck. LVN D said when she saw the bed sheet, she was surprised. LVN D stated she shook Resident #1 a couple of times. LVN D stated she called Resident #1 and he did not respond. LVN D stated she untied the bed sheet from the bed. LVN D stated she asked CNA E and CNA J to get her some help. LVN D stated Resident #1's room had a large bariatric bed. LVN D told the surveyor she had to push the bed out of the way to get to Resident #1. LVN D stated she then assessed Resident # 1. LVN D stated LVN J went to the nurses station to check for Resident #1's code status. LVN J returned and said Resident #1 was a full code. LVN P said LVN O and LVN H started CPR on Resident #1. LVN D said LVN P did chest compressions and LVN O used the Ambu bag. LVN D said the paramedics arrived at 8:00 AM. LVN D said when the paramedics turned Resident #1, he was stiff and blue in color. LVN D said the paramedics told the staff there was nothing they could do for him. LVN D stated the Medical Examiner arrived at 9:00 AM. LVN D stated after the Medical Examiner finished an assessment on Resident #1, he took the body with him. Interview on [DATE] at 3:45 PM with RN N revealed she admitted Resident #1 on [DATE]. RN N stated she worked with Resident #1 for three days. RN N stated she did not notice any changes in him. RN N stated on [DATE], after assisting Resident #1 to the bathroom, he stated, "Let me sit here for awhile." RN N said Resident #1 was a quiet man but talked when his family member was visiting. RN N said Resident #1 needed assistance with his meals and his family member fed him on [DATE]. When the surveyor queried the RN about the facility's policy on resident rounds, RN N stated the facility policy was to check residents every two hours. RN N stated she made quick rounds before taking over the shift and before handing over her shift to the oncoming nurse. During an interview on [DATE] at 4:00 PM, LVN J stated when she was called to Resident #1's room by CNA E, the resident was on the floor. LVN J said Resident #1 looked like he was sleeping on his stomach, turned slightly to one side. LVN J said LVN D was in the room when she arrived. LVN J said LVN D told her she had not been able to check the resident's chart or call anyone, and LVN J ran to the nurse's station to check Resident #1's advance directives and code status. LVN J said Resident #1 was a full code, so she called 911. LVN J stated she then called LVN P (on another hall) to bring the crash cart to Resident #1's room. LVN J stated a new Treatment Nurse went to help LVN P. LVN J stated LVN P and the Treatment Nurse started the code. LVN J stated she was the one handing over the supplies from the crash cart to LVN P and the Treatment Nurse. LVN J said LVN P and the Treatment Nurse did CPR until the paramedics arrived. LVN J stated when the paramedics took over the CPR, LVN P and the Treatment Nurse went to the nurse's station. LVN J said LVN D stayed with the paramedics. Interview with LVN O on [DATE] at 4:35 PM revealed on [DATE] he was a new orientee waiting for the arrival of the DON. LVN O stated he was in the living area close to the front door reading a magazine when he saw some staff running with the crash cart. LVN O stated he followed them around the hall to see if he could help. When he got into the room, he saw a resident lying face down on the floor between the bed and the wall. LVN O stated the nurse told him she had untied a knot on the side rail. LVN O said there was a sheet tied very tightly around the resident's neck. LVN O said he used his scissors to get the sheet off the resident's neck. Then he rolled the resident on his back and started CPR. LVN O said another nurse did CPR on the resident with him until the paramedics arrived and took over. Interview on [DATE] at 9:25 AM with CNA B revealed she worked double weekend shifts. CNA B said she worked from 6:00 AM in the morning until 10:00 PM at night. CNA B stated she worked on Resident #1's hall and took care of the resident all day on [DATE] (Saturday) and all day on [DATE] (Sunday). CNA B stated Resident #1 required total assistance with feeding. He could eat finger foods by himself. CNA B added Resident #1 could not sit up straight by himself and was leaning over when he was sitting in a chair. CNA B stated at 8:45 PM on Sunday night ([DATE]) she assisted Resident #1 to bed. CNA B said she did a spot check at 9:30 PM and saw Resident #1 had gotten out of bed and was sitting up in the wheelchair. CNA B said she asked him, "Do you want to lay back down? Because I'm ready to go home at 10:00 PM." CNA B said she then asked Resident #1 if he needed anything, and he said, "No," and he was not ready to go back to bed. CNA B said Resident #1 told her he was not tired. CNA B said she told Resident #1, "Have a good week. I will see you next week." CNA B said it was the last time she saw him and he looked okay. CNA B stated he did not seem as if anything was bothering him. CNA B stated she did not give report at the end of her shift because she had to leave five minutes early to pick her husband up from work. When queried about whether the CNA had noticed any changes in Resident #1's behavior, whether he seemed depressed or was he making negative remarks or even making remarks about taking his life, CNA B responded the resident had not seemed any different than usual and she had not noticed any changes. When queried about the facility's policy regarding resident rounds, CNA B stated the facility policy and procedure was to do resident rounds every two hours. CNA B stated she did resident rounds every one-and-a-half hours. CNA B stated she made her rounds less than two hours for residents who voided large amounts. Interview on [DATE] at 10:50 AM with LVN P revealed he did not know Resident #1. LVN P stated when they called the code for Resident #1, he rushed to the room to help, and there were nurses already in the room. LVN P said when he went in the room, the resident was on the floor on his side facing the window. LVN P said he and the Treatment Nurse turned Resident #1, put him flat on the back board and started CPR. LVN P said after they had been doing CPR for approximately five minutes before the paramedics arrived. LVN P said the paramedics took over the CPR and he left the room. Interview on [DATE] at noon revealed CNA Q worked the night shift from 10:00 PM to 6:00 AM on the 100, 200, 300 and 400 Halls. CNA Q told the surveyor he worked with Resident #1 on [DATE] (Thursday) and [DATE] (Friday). CNA Q said Resident #1 was weak and not able to get up by himself. CNA Q said Resident #1 needed his assistance to sit up in bed. CNA Q said the last time he saw Resident #1 was on [DATE] at around 5:30 AM during his last resident round. The CNA stated when he went into the room, he said, "Hi Mr. _____ (Resident #1), how are you doing?" CNA Q said Resident #1 did not respond to him. CNA Q stated he checked to see if Resident #1 was incontinent of urine and he was not, so he covered him up. CNA Q said Resident #1's roommate was in the room. Interview with CNA/MA R on [DATE] at 1:10 PM revealed she worked on Resident #1's hall on [DATE] (Saturday). CNA/MA R stated she passed medication on the 2:00 PM to 10:00 PM shift and worked as a CNA on the 10:00 PM to 6:00 AM shift. CNA/MA R said Resident #1 accepted his medications and drank some water. Resident #1 asked her to explain to him all his medications before he swallowed them. CNA/MA R said she worked on [DATE] and [DATE] with Resident #1. CNA/MA R stated Resident #1 typically sat in the chair for a little bit and then went back to bed. CNA/MA R said Resident #1 was able to use the restroom on his own. CNA/MA R said she did not notice any changes in behavior in Resident #1. CNA/MA R said Resident #1 was hard of hearing and did not talk much. CNA/MA R added she had to speak loudly for Resident #1 to hear her. When queried about the facility's policy about resident rounds, CNA/ MA R stated the facility's policy and procedure was to do resident rounds every two hours. CNA/MA R told the surveyor she did her rounds every hour and when she was handing over the shift to the oncoming CNA. Interview on [DATE] at 2:20 PM revealed CNA S worked on Resident #1's hall on the 2:00 PM to 10:00 PM shift. CNA S said Resident #1 was a new resident when she first worked with him on [DATE] (Thursday). CNA S stated Resident #1's roommate had his call light on. When she went in to answer the call light, she introduced herself to Resident #1. CNA S stated she told Resident #1 when he needed anything to let her know. CNA S said Resident #1 was like any normal resident and he was very nice. CNA S said Resident #1 walked with assistance to the bathroom. CNA S stated Resident #1's roommate told her the night shift did not answer the call lights. CNA S stated Resident #1 had a bed/chair alarm because he had a tendency to get out of bed. CNA S then stated Resident #1 needed assistance to go to the bathroom. Resident #1's roommate said the night shift did not answer the call lights, and Resident #1 would get up to the bathroom by himself. CNA S stated she saw Resident #1 last on [DATE] (Friday) at 10:00 PM. CNA S stated Resident #1 was in bed when she left her shift. When queried about the facility policy regarding resident rounds, CNA S said the facility policy was to check residents every two hours. CNA S stated she checked her residents more frequently than that and did not wait for two hours. CNA S stated she would provide report on the residents to the oncoming CNA. Interview on [DATE] at 1:30 PM with RN T revealed she worked three days with Resident #1 on Wednesday ([DATE]), Thursday ([DATE]) and on Saturday night ([DATE]). RN T stated she did not notice any changes in Resident #1. RN T stated Resident #1's roommate always turned the call light on for Resident #1. RN T said the roommate would tell whoever answered the light what Resident #1 needed. RN T said she read in the transfer report from the hospital Resident #1 was incontinent of urine at night. RN T stated when she worked at night she told the CNAs to keep an eye on Resident #1 so the roommate would not have to call for assistance. RN T said Resident #1's roommate was discharged home on Saturday ([DATE]). RN T said on Saturday Resident #1 came out of his room ambulating with a walker and asked her who was in charge. RN T said she told Resident # 1 she was in charge. RN T added she was in the break room and pulled out a chair for Resident #1 to sit down because she thought he would fall. Resident #1 sat down on the chair and held to his seat. Resident #1 told RN T he forgot what he wanted to say. RN T said she then walked Resident #1 back to his room and put him back to bed. RN T stated she asked Resident #1 "Did you think of what you wanted to say?" RN T said Resident #1 said, "No." RN T stated she then told Resident #1, "Have a good night." RN T stated she could not recall if Resident #1 had a bed alarm. Interview on [DATE] at 3:40 PM with the DON revealed she was notified on [DATE] at 7:50 AM by LVN D Resident # 1 was found on the floor dead. The DON stated she LVN D if she had called 911 and LVN D replied, "Yes." The DON said she arrived at the facility at 8:00 AM and 911 had been called. The DON said the police officers and the paramedics were in Resident #1's room. The DON told the surveyor she was in the resident's room but could not go over to where Resident #1 was. The DON said she could not see the body and all she could see were Resident #1's "two white feet, from the calf to the feet sticking up." The DON then stated Resident #1 was lying on the floor between the bed and the far wall. The DON then stated Resident #1 tied the bed sheet around his neck to the bedrail. The DON said the bed Resident # 1 tied the bed sheet to was returned to the company. The DON told the surveyor she had seen Resident #1 previously when she was in the room speaking with the resident's roommate. The DON said Resident #1 was occasionally incontinent. The DON stated there was no set time for the nurses and CNAs to check the residents. The DON stated Resident #1 had a bed alarm because he would get out of bed without using his call light to request assistance. The DON was queried if Resident #1 was capable of removing his bed alarm. The DON replied she did not know whether Resident #1 could remove his bed alarm. When asked about the facility's policy for resident rounds the DON stated there was no written policy on when to check residents. The DON then told the surveyor it was expected for staff to check the residents every two hours. The surveyor then queried the DON about the facility's policies and procedures on nursing practice. The DON stated the facility did not have a policy and procedure on nursing practice. The DON stated the "Senior Care Centers Policy Statement" reflected the Senior Care Center followed the federal and state laws, regulations, and local ordinances (health laws). During a confidential interview, the interviewee stated he/she last saw Resident #1 on [DATE] between 6:00 PM-7:00 PM. He/she stated Resident #1 was sleepy and talkative. He/she stated Resident #1 was quiet most of the time. He/she stated Resident #1 told him/her he thought he made a mistake. He/she stated Resident #1 said, "I could have stayed at ____ (another rehab)." He/she stated he/she told Resident #1 Medicare would not pay for him to stay at another rehab. He/she stated he/she told Resident #1 if he preferred another facility he/she would transfer him. He/she stated Resident #1 did not answer. He/she stated Resident #1 was not depressed. He/she stated he/she did not see any changes in Resident #1. He/she stated Resident #1 was using a wheelchair and a walker for ambulation. He/she stated Resident #1 had a bed alarm. He/she stated Resident #1 had a bed alarm because he had a tendency to get up (without help). He/she stated he/she did not know if Resident #1 was capable of setting his bed alarm off. He/she stated Resident # 1 was occasionally incontinent of urine. He/she stated Resident #1 called for assistance sometimes and sometimes he did not. He/she stated when he/she left the faciity on [DATE], he/she said to Resident #1, "Goodbye. I will see you tomorrow. I love you." He/she stated Resident #1 answered back, "I love you. Bye, ____ (nick name). Thank you for coming to visit me." Interview on [DATE] at 1:00 PM with the Clinical Nurse Specialist revealed the facility did not have any policies and/or procedures. The Clinical Nurse Specialist stated the facility abided by state and federal policies/procedures. The Clinical Nurse Specialist stated the facility used "best practices." The Administrator provided the facility's current abuse/neglect prohibition policies and procedures on [DATE]. The facility's policy and procedure consisted of one undated piece of paper entitled Facility Investigation - Policy/Procedure. The following items were also included were: Provider Letter #,[DATE]-Guidelines for Reporting Incidents dated [DATE]; Attachment 2, Resident-to-Resident Incidents; Attachment 3, Flowchart for resident-to-resident inappropriate/unwanted behavior dated [DATE]; Provider Investigation Report dated [DATE] (from the DADS handbook); Texas Administrative Code, Title 40, Part 1, Chapter 19, Subchpater B, Rule 19,101, Definitions and Subchapter G, Rule 19.602 Incidents of Abuse and Neglect Reportable to the Texas Department of Human Services (DHS) and Law Enforcement Agencies by Facilities dated [DATE]; the Health & Safety Code, Chapter 242, Convalescent and Nursing Homes and Related Institutions, Subchapter A, General Provisions: Reporting of Abuse and Neglect ([DATE]); Contents of Report ([DATE]); Anonymous Reports of Abuse and Neglect ([DATE]); Processing of Reports ([DATE]); Investigation and Report of Department or Designated Agency ([DATE]); and Confidentiality ([DATE]). The Texas Administrative Code defines neglect as a deprivation or failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to a resident. The facility's policy and procedure reflected under Neglect the facility must determine if an injury, harm, or death of a resident was due to a facility failure to provide services, treatment, or care to a resident.

Based on observation, interview and record review, the facilty failed to implement policies and procedures which prohibited neglect of residents for one (Resident #1) of five residents reviewed. Resident #1 was visually monitored once on the eight-hour night shift and was found to have committed suicide when found by staff in the morning. The following failures took place from 9:00 PM on [DATE] to 7:00 AM on [DATE]. LVN A saw Resident #1 once in eight hours at 1:00 AM and took his vital signs. LVN A did not monitor Resident #1 closely because he was "independent" with his walker for toileting even though the resident had a chair/bed alarm due to requiring assistance and his getting out of bed without waiting for assistance. CNA B did not give report to CNA C at change of shift in the evening which would have made him aware Resident #1 had not been discharged . CNA C was assigned to Resident #1 on the night shift. CNA C did not see the resident in the room decided the resident was discharged and did not report the resident as missing to the night shift charge nurse. CNA C did not give report to oncoming staff at change of shift in the morning. LVN D did not make resident rounds when coming on the shift on the morning of [DATE] and was unaware Resident #1 was not in his bed. CNA E did not notify LVN D she could not find Resident #1. These failures affected Resident #1 resulting in his being observed once during the eight-hour night shift and his successfully committing suicide. Had Resident #1 been observed every two hours his suicide might have been prevented. These failures could affect the facility's 24 residents who resided on the same hall as Resident #1 placing them at risk for not being checked frequently enough to provide the care and treatment they needed to ensure their comfort, health, and well-being. Findings included: The Administrator provided the facility's current abuse/neglect prohibition policies and procedures on [DATE]. The facility's policy and procedure consisted of one undated piece of paper entitled Facility Investigation - Policy/Procedure. The following items were also included: Provider Letter #,[DATE]-Guidelines for Reporting Incidents dated [DATE]; Attachment 2, Resident-to-Resident Incidents; Attachment 3, Flowchart for resident-to-resident inappropriate/unwanted behavior dated [DATE]; Provider Investigation Report dated [DATE] (from the DADS handbook); Texas Administrative Code, Title 40, Part 1, Chapter 19, Subchpater B, Rule 19,101, Definitions and Subchapter G, Rule 19.602 Incidents of Abuse and Neglect Reportable to the Texas Department of Human Services (DHS) and Law Enforcement Agencies by Facilities dated [DATE]; the Health & Safety Code, Chapter 242, Convalescent and Nursing Homes and Related Institutions, Subchapter A, General Provisions: Reporting of Abuse and Neglect ([DATE]); Contents of Report ([DATE]); Anonymous Reports of Abuse and Neglect ([DATE]); Processing of Reports ([DATE]); Investigation and Report of Department or Designated Agency ([DATE]); and Confidentiality ([DATE]). The Texas Administrative Code defined neglect as a deprivation or failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to a resident. The facility's policy and procedure reflected under Neglect, the facility must determine if an injury, harm, or death of a resident was due to a facility failure to provide services, treatment, or care to a resident. Also, if the death of a resident involves unusual circumstances that cast doubt upon the death being from natural causes, the death must be reported. The facility's policy/procedure for the Investigation Report reflected to list and identifiy all witnesses who had knowledge of the incident. The Investigation Summary should summarize the provider's investigative procedures concisely, facutally and objectively. Summarize the investigator's analysis of supporting documents, such as interviews, witness statements, injury reports, diagrams, life satisfaction surveys, observations and other appropriate evidence. The investigator's conclusion regarding the allegation and conclusion regarding any contributing facility practices and recommendations needs to be written/stated clearly. Include how the investigator arrived at these conclusions and recommendations. The actions the facility took as a result of the investigative findings needs to be included in the Investigation Report. Review of the face sheet dated [DATE] revealed Resident #1 was a [AGE] year-old male admitted from the hospital to the facility on [DATE]. Review of the hospital's admission orders [REDACTED]. Resident #1's hospital medical and surgical history dated [DATE] reflected the following Diagnoses: [REDACTED]. The hospital's psychiatric consultation dated [DATE] for Resident #1 reflected the resident was alert during the interview, oriented to place, city, month and the year. There was no evidence of [MEDICAL CONDITION] in the past several days. Review of the Facility Elopement Risk Assessment revealed Resident #1 was cognitively impaired with poor decision-making skills and had visual and auditory deficits. The facility's Admission Nursing Evaluation dated [DATE] for Resident #1 reflected the resident had memory problems. Resident #1 also required the assistance of one person for bed mobility, transfers, walking/locomotion, dressing, eating, toileting, personal/hygiene and bathing. Review of the facility's Incident/Accident Report dated [DATE] at 7:45 AM revealed LVN D walked into Resident #1's room and found the resident "face down on the floor between the B bed (and) et the air conditioner with a cloth tied around his neck at one end et to the top rail of the bed on the other end. Resident was blue, lifeless, et __ (without) vitals." Resident #1's cognitive state was marked as confused and a [DIAGNOSES REDACTED]. The resident's pulse, respirations, blood pressure and oxygen saturation level were all documented as zero. The resident's outcome was marked death. The Incident/Accident Report further reflected CPR was initiated at 7:50 AM on [DATE] (sic). The Report was signed at the bottom by LVN D, the DON and the Administrator. The DON's signature was the only one dated and the date was [DATE]. The back side of the Report was entitled "Fall Investigation Worksheet" and had a large X drawn through it. There was no documentation on it. The Administrator was contacted on [DATE] at approximately 4:15 PM to fax the Investigation Report of the incident involving Resident #1 to the surveyor. Review of the facility's Investigation Report, which was signed by the Administrator and dated [DATE], revealed the following: Resident #1 was found on [DATE] at 7:35 AM with a sheet tied around his neck and to the bed rail. Assessment found him without vitals and CPR was initiated. The police, 911, the physician and family were called. A copy of the Progress Notes dated [DATE] at 7:45 AM and signed by LVN D from Resident #1's clinical record was included with the Investigation Report. There was one other statement included with the facility's Investigation Report, which was dated [DATE] and signed by LVN A. There was no statement or interview with CNA C, who was assigned to provide care for Resident #1. There were no other interviews or statements from any other staff, family members or residents to determine whether Resident #1 had a noticeable change in the way he had been responding to staff and family. Review of the Progress Notes signed by LVN D and dated [DATE] at 7:45 AM revealed Resident #1 was found by a nursing assistant on the floor between the B-bed and the wall with the air conditioner. The progress note reflected Resident #1 had a piece of cloth tied around his neck with one end tied to the bed. When the resident was found, the Wound Care Nurse cut the cloth from around the resident's neck and CPR was initiated. Paramedics arrived at 8:00 AM. CPR was stopped at 8:00 AM when the paramedics arrived. The Medical Examiner pronounced Resident #1's death at 7:45 AM when LVN D came to his room. Resident #1's family member was notified at 8:05 AM as well as the Police and Coroner. The Coroner arrived at 9:00 AM, did an investigation, and took the body away. LVN A's statement dated [DATE] reflected: "I reported to work at 10:00 pm. Received report from the outgoing nurse. At 2300 (11:00 PM) I went to check on pts Mr. ____ (Resident #1) was in bed with eyes closed (sic). Rise and fall of chest noted. V/S checked at 0100 am (1:00 AM) were T 97.8 P 74 R18 BP ,[DATE]. NO S/S of distress noted. No c/o pain voiced." Interview on [DATE] at 11:25 AM with LVN A revealed she was the night charge nurse for Resident #1's hall on [DATE] from 10:00 PM until [DATE] through 6:00 AM. LVN A stated she saw Resident #1 at 1:00 AM on [DATE]. She stated she checked his vital signs at that time. LVN A remembered Resident #1's blood pressure was ,[DATE] and his respirations were 18/minute. She could not recall the resident's pulse and temperature. LVN A stated she did not monitor or check on Resident #1 at any other time during the night, because he was independent with a walker for toileting, and he had not used his call light. LVN A stated she did "nursing rounds" every two hours for residents, who needed frequent monitoring. She stated for residents who did not require much help, she monitored them every three to four hours. LVN A stated she thought Resident #1 was in bed all night, but she did not check to see. She stated when she saw Resident #1 at 1:00 AM, she had not noticed any change in his behavior. When queried about the shift change report, LVN A said she had reported they did not visually check Resident #1. The Investigation Summary of the Investigation Report reflected the following: "____ (Resident #1) was found dead with a sheet tied around his neck and to the bed rail. Mr. Smith was evaluated by nursing staff at 1:30 am (AM) and staff checked his vitals and all within normal limits. Resident was resting soundly and did not verbalize any signs of distress or depression. Door to room open all night and staff made rounds throughout the night (sic). According to police ____ (Resident #1) committed suicide by hanging." Interview on [DATE] at 11:55 AM with CNA C revealed he worked Resident #1's hall on [DATE] friom 10:00 PM until [DATE] through 6:00 AM. CNA C stated he was PRN staff and was called to work, because the scheduled CNA had "called in" for the shift (as not being able to work). CNA C said when he arrived at work, he made rounds but did not see any residents in what he now knew was Resident #1's room. CNA C stated he thought Resident #1 had been discharged . CNA C stated he was assigned by the charge nurse to take vital signs in a number of rooms, including Resident #1's room. He stated he did not take Resident #1's vital signs, because there was no resident in the room. CNA C said at the beginning of his shift, he did not get any report from the CNA going off duty. He further stated he did not give any report to the oncoming CNA at the end of his shift, because that person was late for work. When queried about Resident #1's vital signs, CNA C stated he did not know if LVN A took Resident #1's vital signs. When queried by the surveyor as to why he did not notify the charge nurse about not taking vital signs of Resident #1 because the resident was not there, CNA C stated he only notified the charge nurse when there was a problem with a resident's vital signs. The Investigation Report reflected the Provider Action taken Post-Investigation was to conduct in-serivces on making resident rounds and to base room (sic) observation on the need of the resident and the resident's request. Surveyor interviews with LVN A and CNA C revealed Resident #1 was only observed once during the 10 PM - 6 AM shift from [DATE] - [DATE]. Interview on [DATE] at 9:40 AM with CNA E revealed she and CNA F were the first to find Resident #1. CNA E stated she went to Resident #1's room but did not see him in his room. Shortly after, CNA E stated she went back to Resident #1's room, and she still did not see him there. CNA E stated CNA F was in the hallway at Resident #1's room. CNA E said she went to CNA F and told her she was looking for Resident #1, when CNA F asked, "Why is he on the floor?" CNA E stated they ran into Resident #1's room and found the resident lying on his stomach with his face down. CNA E stated Resident #1 had a bed sheet around his neck. She called the charge nurse, LVN D, who came and checked Resident #1's pulse. The charge nurse called for LVN J. CNA E stated the nurses brought a crash cart and started CPR. During the same interview, CNA E told the surveyor Resident #1 was a new resident. She described Resident #1 as "quiet and never talked much." CNA E added she cared for Resident #1 on Thursday, [DATE]. CNA E stated she worked on Monday ([DATE]) from 6 AM to 2 PM. CNA E stated when she went to make rounds at 6:30 AM, she did not see Resident #1. She then said the facility's policy and procedure was for the CNA to make rounds to check residents first by taking a vitals sheet, then rounds after breakfast, before lunch and after lunch. On [DATE] at 9:55 AM, CNA E showed Resident #1's room to the surveyor. Observation revealed the room was a double room with only one bed in it, the B-bed, which was against the outside wall. A housekeeper was cleaning the room. CNA E told the surveyor Resident #1 had hung himself. She explained Resident #1 had tied a bed sheet around his neck and hung it from the siderail of his old roommate's bed. CNA E then stated the bed currently in the room was not the bed Resident #1 used. CNA E explained Resident #1's roommate had a much bigger bed (bariatric), and she thought the facility had returned the bed to the owner. CNA E walked into the room to the bed. She pointed her finger to between the bed and the wall and stated Resident #1 was found between the bed and the wall. She explained Resident #1 attached the end of the bed sheet to the bedrail of the bariatric bed, and then tied his neck around with the sheet. During an interview on [DATE] at 1:00 PM, CNA I said she worked on [DATE] from 10:00 PM until [DATE] through 6:00 AM but did not work on Resident #1's hall nor did she know Resident #1. CNA I stated the facility policy and procedure was to do rounds every two hours: at midnight, 2:00 AM, 4:00 AM and 6:00 AM. CNA I stated the policy also required staff to answer residents' call lights. CNA I told the surveyor at the end of the shift, before she left her hall, she checked to make sure her residents were breathing. CNA I said she went from room to room and then reported on each resident at the end of the shift. Interview on [DATE] at 1:15 PM with CNA F revealed on [DATE], she worked the 6:00 AM to 2:00 PM shift. CNA F stated at approximately 7:15 AM, she was standing on the hallway facing Resident #1's room, talking to CNA E. CNA F told the surveyor she looked into the room and saw Resident #1 on the floor. She said Resident #1 was lying on the floor with his heels pointing outwards. Resident #1's legs were only visible from below the knee. CNA F stated she asked CNA E, "Why is he on the floor?" CNA E turned around and looked and then called the charge nurse, LVN D to come immediately. CNA F stated LVN D came and attempted to wake the resident by shaking the resident's shoulders and asking, "___ (Resident #1), are you okay?" CNA F said LVN D left the room and got LVN G. CNA F stated LVN G was just arriving and was still at the time clock. Both nurses arrived back to Resident #1's room. During the same interview, CNA F described Resident #1 as quiet and not talking much. CNA F said the resident needed assistance with his meals and had a tendency of getting out of bed without help. CNA F said she told Resident #1 to call for assistance when he wanted to use the bathroom. CNA F further stated Resident #1 had a bed alarm because he would try to get out of bed without help. When queried about the facility policy and procedures for making rounds on the residents, CNA F stated CNAs were to make resident rounds every two hours. Interview on [DATE] at 1:25 PM with LVN K revealed she worked on [DATE] (Saturday) on the 2:00 PM to 10:00 PM shift, but did not work on Resident #1's hall. LVN K stated she saw Resident #1 last between 9:35 - 9:45 PM. LVN K said Resident #1 was in bed sleeping at that time. LVN K stated Resident #1 had his covers on and the siderail on his bed was in the upright position. LVN K added it was the first time for her to work with Resident #1. LVN K stated the policy of the facility was to do resident rounds at the beginning and at the end of the shift. LVN K told the surveyor she did rounds when she had time and sometimes she did rounds every two hours. Interview on [DATE] at 2:00 PM revealed LVN M worked on 200 and 300 Halls. LVN M stated she worked the 2:00 - 10:00 PM shifts on [DATE] (Sunday) and [DATE] (Monday). LVN M stated there was no emergency situation during her shifts. LVN M stated she did not know Resident #1. LVN M stated the facility policy was to check residents at the beginning of the shift, in between the shift at least two to three hours and at the end of the shift. Interview on [DATE] at 2:15 PM with LVN D revealed she worked on Resident #1's hall on [DATE] from 6:00 AM until 2:00 PM. LVN D stated she relieved LVN A. LVN D stated she did not check to see if all the residents were in their rooms. LVN D stated CNA I alerted her to go to Resident #1's room. LVN D stated it was 7:45 AM on [DATE] when she walked into Resident #1's room. Resident #1 was lying face down on the floor between the B bed and the wall with the air conditioner. LVN D said she called Resident #1's name, but he did not respond. LVN D stated when she looked up, she saw the bed sheet tied from the bed to Resident #1's neck. LVN D said when she saw the bed sheet, she was surprised. LVN D stated she shook Resident #1 a couple of times. LVN D stated she called Resident #1 and he did not respond. LVN D stated she untied the bed sheet from the bed. LVN D stated she asked CNA E and CNA J to get her some help. LVN D stated Resident #1's room had a large bariatric bed. LVN D told the surveyor she had to push the bed out of the way to get to Resident #1. LVN D stated she then assessed Resident # 1. LVN D stated LVN J went to the nurses station to check for Resident #1's code status. LVN J returned and said Resident #1 was a full code. LVN P said LVN O and LVN H started CPR on Resident #1. LVN D said LVN P did chest compressions and LVN O used the Ambu bag. LVN D said the paramedics arrived at 8:00 AM. LVN D said when the paramedics turned Resident #1, he was stiff and blue in color. LVN D said the paramedics told the staff there was nothing they could do for him. LVN D stated the Medical Examiner arrived at 9:00 AM. LVN D stated after the Medical Examiner finished an assessment on Resident #1, he took the body with him. Interview on [DATE] at 3:45 PM with RN N revealed she admitted Resident #1 on [DATE]. RN N stated she worked with Resident #1 for three days. RN N stated she did not notice any changes in him. RN N stated on [DATE], after assisting Resident #1 to the bathroom, he stated, "Let me sit here for awhile." RN N said Resident #1 was a quiet man but talked when his family member was visiting. RN N said Resident #1 needed assistance with his meals and his family member fed him on [DATE]. When the surveyor queried the RN about the facility's policy on resident rounds, RN N stated the facility policy was to check residents every two hours. RN N stated she made quick rounds before taking over the shift and before handing over her shift to the oncoming nurse. During an interview on [DATE] at 4:00 PM, LVN J stated when she was called to Resident #1's room by CNA E, the resident was on the floor. LVN J said Resident #1 looked like he was sleeping on his stomach, turned slightly to one side. LVN J said LVN D was in the room when she arrived. LVN J said LVN D told her she had not been able to check the resident's chart or call anyone, and LVN J ran to the nurse's station to check Resident #1's advance directives and code status. LVN J said Resident #1 was a full code, so she called 911. LVN J stated she then called LVN P (on another hall) to bring the crash cart to Resident #1's room. LVN J stated a new Treatment Nurse went to help LVN P. LVN J stated LVN P and the Treatment Nurse started the code. LVN J stated she was the one handing over the supplies from the crash cart to LVN P and the Treatment Nurse. LVN J said LVN P and the Treatment Nurse did CPR until the paramedics arrived. LVN J stated when the paramedics took over the CPR, LVN P and the Treatment Nurse went to the nurse's station. LVN J said LVN D stayed with the paramedics. Interview with LVN O on [DATE] at 4:35 PM revealed on [DATE] he was a new orientee waiting for the arrival of the DON. LVN O stated he was in the living area close to the front door reading a magazine when he saw some staff running with crash cart. LVN O stated he followed them around the hall to see if he could help. When he got into the room, he saw a resident lying face down on the floor between the bed and the wall. LVN O stated the nurse told him she had untied a knot on the side rail. LVN O said there was a sheet tied very tightly around the resident's neck. LVN O said he used his scissors to get the sheet off the resident's neck. Then he rolled the resident on his back and started CPR. LVN O said another nurse did CPR on the resident with him until the paramedics arrived and took over. Interview on [DATE] at 9:25 AM with CNA B revealed she worked double weekend shifts. CNA B said she worked from 6:00 AM in the morning until 10:00 PM at night. CNA B stated she worked on Resident #1's hall and took care of the resident all day on [DATE] (Saturday) and all day on [DATE] (Sunday). CNA B stated Resident #1 was a feeder, and he could eat finger foods by himself. CNA B added Resident #1 could not sit up straight by himself and was leaning over when he was sitting in a chair. CNA B stated at 8:45 PM on Sunday night ([DATE]), she assisted Resident #1 to bed. CNA B said she did a spot check at 9:30 PM, and saw Resident #1 had gotten out of bed and was sitting up in the wheelchair. CNA B said she asked him, "Do you want to lay back down? Because I'm ready to go home at 10:00 PM." CNA B said she then asked Resident #1 if he needed anything, and he said, "No," and he was not ready to go back to bed. CNA B said Resident #1 told her he was not tired. CNA B said she told Resident #1, "Have a good week. I will see you next week." CNA B said it was the last time she saw him, and he looked okay. CNA B stated he did not seem as if anything was bothering him. CNA B stated she did not give report at the end of her shift because she had to leave five minutes early to pick her husband up from work. When queried about whether the CNA had noticed any changes in Resident #1's behavior, whether he seemed depressed or was making negative remarks or even making remarks about taking his life, CNA B responded the resident had not seemed any different than usual and she had not noticed any changes. When queried about the facility's policy regarding resident rounds, CNA B stated the facility policy and procedure was to do resident rounds every two hours. CNA B stated she did resident rounds every one-and-a-half hours. CNA B stated she made her rounds less than two hours for heavy wetters. Interview on [DATE] at 10:50 AM with LVN P revealed he did not know Resident #1. LVN P stated they called the code for Resident #1, he rushed to the room to help, and there were nurses already in the room. LVN P said when he went in the room, the resident was on the floor on his side facing the window. LVN P said he and the Treatment Nurse turned Resident #1, put him flat on the board and started CPR. LVN P said after they had been doing CPR for approximately five minutes before, the paramedics arrived. LVN P said the paramedics took over the CPR, and he left the room. Interview on [DATE] at noon revealed CNA Q worked the night shift from 10:00 PM to 6:00 AM on the 100, 200, 300 and 400 Halls. CNA Q told the surveyor he worked with Resident #1 on [DATE] (Thursday) and [DATE] (Friday). CNA Q said Resident #1 was weak and not able to get up by himself. CNA Q said Resident #1 needed his assistance to sit up in bed. CNA Q said the last time he saw Resident #1 was on [DATE] at around 5:30 AM during his last resident round. The CNA stated when he went in to the room, he said, "Hi Mr. (Resident #1), how are you doing?" CNA Q said Resident #1 did not respond to him. CNA Q stated he checked to see if Resident #1 was wet, and he was not, so he covered him up. CNA Q said Resident #1's roommate was in the room. Interview with CNA/MA R on [DATE] at 1:10 PM revealed she worked on Resident #1's hall on [DATE] (Saturday). CNA/MA R stated she passed medication on the 2:00 PM to 10:00 PM shift and worked as a CNA on the 10:00 PM to 6:00 AM shift. CNA/MA R said Resident #1 accepted his medications and drank some water. Resident #1 asked her to explain to him all his medications before he swallowed them. CNA/MA R said she worked on [DATE] and [DATE] with Resident #1. CNA/MA R stated Resident #1 typically sat in the chair for a little bit and then went back to bed. CNA/MA R said Resident #1 was able to use the restroom on his own. CNA/MA R said she did not notice any changes in behavior in Resident #1. CNA/MA R said Resident #1 was hard of hearing and did not talk much. CNA/MA R added she had to speak loudly for Resident #1 to hear her. When queried about the facility's policy about resident rounds, CNA/ MA R stated the facility's policy and procedure was to do resident rounds every two hours. CNA/MA R told the surveyor she did her rounds every hour and when she was handing over the shift to the oncoming CNA. Interview on [DATE] at 2:20 PM revealed CNA S worked on Resident #1's hall on the 2:00 PM to 10:00 PM shift. CNA S said Resident #1 was a new resident when she first worked with him on [DATE] (Thursday). CNA S stated Resident #1's roommate had his call light on. When she went in to answer the call light, she introduced herself to Resident #1. CNA S stated she told Resident #1 when he needed anything to let her know. CNA S said Resident #1 was like any normal resident, and he was very nice. CNA S said Resident #1 walked with assistance to the bathroom. CNA S stated Resident #1's roommate told her the night shift did not answer the call lights. CNA S stated Resident #1 had a bed/chair alarm because he had a tendency to get out of bed. CNA S then stated Resident #1 needed assistance to go to the bathroom. Resident #1's roommate said the night shift did not answer the call lights, and Resident #1 would get up to the bathroom by himself. So then Resident #1 had a bed/chair alarm. CNA S stated she saw Resident #1 last on [DATE] (Friday) at 10:00 PM. CNA S stated Resident #1 was in bed when she left her shift. When queried about the facility policy regarding resident rounds, CNA S said the facility policy was to check residents every two hours. CNA S stated she checked her residents more frequently than that and did not wait for two hours. CNA S stated she would provide report on the residents to the oncoming CNA. Interview on [DATE] at 1:30 PM with RN T revealed she worked three days with Resident #1 on Wednesday ([DATE]), Thursday ([DATE]) and on Saturday night ([DATE]). RN T stated she did not notice any changes in Resident #1. RN T stated the roommate always turned the call light on for Resident #1. RN T said the roommate would tell whoever answered the light what Resident #1 needed. RN T said she read in the transfer report from the hospital Resident #1 was incontinent of urine at night. RN T stated when she worked at night, she told her CNAs to keep an eye on Resident #1 so the roommate would not have to call for assistance. RN T said Resident #1's roommate was discharged home on Saturday ([DATE]). RN T said on Saturday, Resident #1 came out of his room ambulating with a walker and asked her who was in charge. RN T said she told Resident # 1 she was in charge. RN T added she was in the break room., and pulled out a chair for Resident #1 to sit down, because she thought he would fall. Resident #1 sat down on the chair and held to his seat. Resident #1 told RN T he forgot what he wanted to say. RN T said she then walked Resident #1 back to his room and put him back to bed. RN T stated she asked Resident #1, "Did you think of what you wanted to say?" RN T said Resident #1 said, "No." RN T stated she then told Resident #1, "Have a good night." RN T stated she could not recall if Resident #1 had a bed alarm. Interview on [DATE] at 3:40 PM with the DON revealed she was notified on [DATE] at 7:50 AM by the charge nurse that Resident # 1 was found on the floor dead. The DON stated that she asked if LVN D had called 911, and the charge nurse answered, "Yes." The DON said she arrived at the facility at 8:00 AM, and 911 had been called. The DON said the police officers and the paramedics were in Resident #1's the room. The DON told the surveyor she was in the resident's room, but could not go over to where Resident #1 was. The DON said she could not see the body and all she could see were Resident #1's "two white feet, from the calf to the feet, sticking up." The DON then stated Resident #1 was lying on the floor, between the bed and the far wall. The DON then stated Resident #1 tied the bed sheet around his neck to the bedrail. The DON said the bed Resident # 1 tied the bed sheet to was returned to the company. The DON told the surveyor she had seen Resident #1 previously when she was in the room speaking with the resident's roommate. The DON said Resident #1 was occasionally incontinent, and a resident who was occasionally incontinent.The DON stated there was no set time for the nurses and CNAs to check the residents. The DON stated Resident #1 had a bed alarm because he got out of bed without using his call light to request assistance. The DON was queried if Resident #1 was capable of taking his bed alarm off. The DON replied, she did not know Resident #1 could take off his bed alarm. When asked about the facility's policy for resident rounds, the DON stated there was no written policy on when to check residents. The DON then told the surveyor it was expected for staff to check the residents every two hours. The surveyor then queried the DON about the facility's policies and procedures on nursing practice. The DON stated the facility did not have a policy and procedure on nursing practice. The DON stated the "Senior Care Centers Policy Statement" reflected reflected the Senior Care Center followed the federal and state laws, regulations and local ordinances (health laws). During a confidential interview, the interviewee stated he/she last saw Resident #1 on [DATE]between 6PM-7PM. He/she stated Resident #1 was sleepy and talkative. He/she stated Resident #1 was quiet most of the time. He/she stated Resident # 1 told him/her he thought he made a mistake. He/she stated Resident #1 said, "I could have stayed at ____ (another rehab)." He/she stated he/she told Resident #1 Medicare would not pay for him to stay at another rehab. He/she stated she told Resident #1 if he preferred another facility, he/she would transfer him. He/she stated Resident #1 did not answer. He/she stated Resident #1 was not depressed. He/s

Based on observation, interview, and record review, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for four (Residents #2, #3, #14, and #20) of twelve residents reviewed for infection control practices. 1) On 06/07/11, the facility identified Residents #3, #14, and #20 (who had gone to the hospital) as having a [DIAGNOSES REDACTED]. 2) Ten (CNAs E, F, G, I, NN, V, Unidentified CNA, Housekeeper K, Unidentified Housekeeper and Maintenance R) of 16 staff observed did not know or did not follow the facility's infection control policies and procedures. One (CNA F) of one CNA did not cleanse the feces from the penis and catheter and did not change gloves/wash hands when soiled. Five (CNAs E, F, G, I, and NN) of 12 CNAs left the room of a resident with[DIAGNOSES REDACTED] without washing their hands. Four (CNAs E, G, NN, Unidentified CNA) of 12 CNAs provided care for a resident with[DIAGNOSES REDACTED] without wearing appropriate personal protective equipment. Three (CNAs E, F and G) of 12 CNAs contaminated furniture, linens, wipes, and personal resident items in the room of a resident with[DIAGNOSES REDACTED] Two (CNAs F and I) of 12 CNAs stepped in Resident #3's feces and then left his room. Two (CNA V and Housekeeper K) of 16 staff did not know the procedure to clean up blood. One (one Unidentified Housekeeper) of three staff did not follow contact isolation precautions when cleaning a mattress. Four (CNAs E, F, G and I) of 12 CNAs did not perform appropriate hand hygiene when leaving the room of residents with[DIAGNOSES REDACTED] and then handling clean linens belonging to other residents, assisting other residents and staff. Two (Housekeeper K and Maintenance R) of four staff did not use the "sugar bag" for soiled clothing per factory instructions. The facility's Infection Control Program did not include the identification of[DIAGNOSES REDACTED] in Residents #3, #14 and #20 and there was no evidence of tracking and trending infections. An Immediate Jeopardy (IJ) was identified on 06/09/11. While the IJ was removed on 06/13/11, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not ____ immediate jeopardy" and a scope of "widespread" because staff were still being trained and the plan of removal was still being monitored for implementation and compliance. These failures could affect the facility's 106 residents, including Residents #1, #2, #3, #14, and #23, and placed them at risk for the potential of being exposed to[DIAGNOSES REDACTED], cross-contamination and infection resulting in the potential need for isolation procedures and techniques, antibiotics, skin irritation and excoriation, and potentially, admission to the hospital. Findings included: 1) On 06/07/11 at 10:48 AM, ADON B stated Resident #3 was on contact isolation, because he had[DIAGNOSES REDACTED]. She added his roommate, Resident #20 also had[DIAGNOSES REDACTED], but he had gone to the hospital due to some respiratory problems. Resident #3 had recently been in the hospital due to some "suicidal ideation," and was now on his second round of [MEDICATION NAME] (antibiotic). He had refused antibiotics the first three weeks he was here. The resident's door was closed and had a sign, which reflected, "See charge nurse before entering." When queried about infection control precautions, ADON B stated the facility was taking isolation procedures, "Just like the hospital." ADON B explained staff was supposed to wear gowns, gloves and masks to enter the room. The staff was also required to use good hand washing and keep the linens and the trash inside the room. The clean gowns, gloves, masks, red plastic biohazard trash bags, and water soluble laundry bags (also called "sugar bags") were outside the room in the hallway on an overbed table for staff and visitors to wear. Review of the Centers for Disease Control and Prevention (CDC) article entitled "Frequently Asked Questions About Clostridium Difficile for Health Care Providers" dated 03/22/11 revealed Clostridium difficile was shed in feces. "Any surface, device, or material (e.g., toilets, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. Clostridium difficile can live for long periods on surfaces... People who have other illnesses or conditions requiring prolonged use of antibiotics, and the elderly, are at greater risk of acquiring this disease... Symptoms can range from mild to severe diarrhea, pseudomembranous colitis, toxic megacolon, sepsis, and ultimately death." (http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html.) Observation on 06/07/11 at 2:30 PM revealed CNA E was in Resident #3's room removing the bed linens from Resident #20's bed, cleaning the oxygen concentrator and moving it in the room, wiping down the overbed table and putting items in the closet, her clothing coming into contact with many of the items. CNA E was wearing only gloves; she was not wearing a gown or a mask. The surveyor observed at this time there were no disposable isolation gowns on the table. At the time of the observation, ADON B was queried about the lack of isolation gowns. ADON B stated there were no isolation gowns in the facility. On 06/07/11 at 2:40 PM, CNA E was observed leaving Resident #3's room. At that time she was observed walking from resident room to resident room on the 100 hall talking to residents after having been observed in Resident #3's room, cleaning and touching items in his room without wearing an isolation gown. During an interview on 06/07/11 at 5:00 PM, CNA E stated she normally worked the 100 Hall from 6:00 AM until 10:00 PM on Saturday and Sunday. CNA E stated she was called into work today to "fill in." She stated she went into Resident #3's room to organize the room and pick up things. She said she took out the linens and cleaned the overbed table, because the resident in bed A went to the hospital. She stated she did not see disposable gowns on the table outside Resident #3's room, so she just went in without a gown. CNA E was asked if she provided incontinent care for Resident #3 without wearing a gown, and she replied, "Yes. When there were no gowns, I (still) have to change the diapers, so I do it without gowns." CNA E was queried as to what she did after leaving Resident #3's room. She revealed she worked "all over the floor" after caring for Resident #3 without a gown. She stated she had assisted five other residents after caring for Resident #3. She stated she assisted a resident across the hall from Resident #3 with care. CNA E stated she could use hospital gowns to avoid getting stains on her scrubs, but they were not available right now either. When queried about isolation procedures, the CNA said isolation required the staff to use a mask, gloves, gowns and red bags in the room. She stated Resident #3 had visitors earlier in the day, and now there were no more gowns. CNA E then added Resident #3 was often aggressive and had smeared feces on the bed rails and overbed table. CNA E stated Resident #3 often had feces on his hands and would throw his feces-filled briefs onto the floor. CNA E said Resident #3's roommate had diarrhea also, but he had been sent to the hospital During an interview on 06/07/11 at 5:30 PM, ADON B stated the gowns should come in sometime tonight. Review of the inservice records provided by LVN A revealed on 06/07/11, an in-service was conducted on using a hospital gown as a personal protective equipment if there were no isolation gowns. The in-service also reflected[DIAGNOSES REDACTED] was contagious and must be contained for the safety of residents. The sign-in sheet reflected 17 staff received this training. CNA I's name was not on the sign-in sheet as having attended the inservice. Interview with Central Supply/CNA AA at 5:23 PM on 06/07/11 revealed there were no disposable gowns in the facility. There were no gowns observed in the central supply room at that time. Interview with Central Supply/CNA AA at that time revealed the gowns should be received between 5:30 PM and 6:00 PM "today" with the order. In an interview on 06/07/11 at 5:53 PM with the Interim DON, she revealed the last isolation gown had "just been used." When asked what the CNAs were using to protect themselves when entering the isolation rooms, the Interim DON did not answer. In an interview on 06/07/11 at 6:15 PM with the Administrator, he stated the supply clerk, who had been sent to get additional disposable gowns, had not returned yet. During an interview on 06/07/11 at 6:50 PM, the Administrator stated he had now received 30 isolation gowns. Observation on 06/08/11 at 7:30 AM revealed gowns, gloves, masks, and isolation bags were on the overbed table in front of Resident #3's room. On 06/08/11 at 12:45 PM, CNA F was observed providing incontinent care to Resident #3. CNA F put on a disposable gown, gloves, and mask from the table outside the resident's room. Resident #3 was incontinent of a large amount of liquid, brown stool. CNA F used disposable wipes from a plastic container, which had been placed on the overbed table. CNA F repeatedly reached into the container of (clean) wipes with gloves, which were soiled with feces, as she cleaned the resident. CNA F placed the soiled brief and the soiled wipes into a small clear plastic bag she had placed on the bed. She did not clean the resident's penis or clean around the urinary catheter even though feces was observed on the resident's penis. Without changing gloves or washing her hands, CNA F picked up a new, clean brief (which she contaminated) and placed it on the resident. While still wearing the feces-soiled gloves, she removed the soiled bed linens and placed the linens into the isolation, water soluble laundry bag, leaving the resident lying on a bare mattress. She picked up the small clear plastic bag containing the soiled brief and wipes from the resident's mattress and put it into the red biohazard trash bag. CNA F then removed her gown, mask, and gloves and placed them into the red isolation trash container in the room. Without washing her hands, she opened the door and left Resident #3's room to retrieve some fresh linen. She then opened the door to the staff lounge and washed her hands in the staff's kitchen sink. After washing her hands, CNA F went to the linen cart and retrieved fresh linens. After putting on gloves, mask and gown, she went back into the resident's room and put the fresh linen on Resident #3's bed. She then removed the mask, gown and gloves and went to the staff lounge again to wash her hands in the staff's kitchen sink. (Note: This was the area used by staff to prepare their food and eat.) CNA F did not clean and disinfect the resident's overbed table after using it to hold the wipes and reaching into the wipes container with soiled hands. The overbed table was visibly stained with crusted substances. On 06/08/11 at 1:05 PM during meal observations, CNA G was observed in Resident #3's room. CNA G was wearing a gown and mask but no gloves. She placed the resident's lunch tray on his overbed table. The plastic service tray contained disposable dinnerware and utensils. With her ungloved hands, CNA G pushed the overbed table so Resident #3 could reach it. The overbed table was still visibly soiled with crusted substances observed previously. She then went to the door when laundry personnel passed Resident #3's clean clothing to her. She took the clean clothing, opened the closet door and placed it in the closet. CNA G then removed her gown and mask and left the resident's room without washing her hands. CNA G went directly down the hall to another resident's room four rooms away from Resident #3's room. The CNA entered the room, picked up a fresh towel from a chair in the room, and spread it across the other resident's chest in preparation for assisting with the meal. At that time, CNA G became aware of the surveyor's continued presence. She stated to the other resident, "Oh. I'll be right back. I need to wash my hands." She then washed her hands in the sink in the other resident's room. At 2:15 PM on 06/08/11, CNA I was observed in Resident #3's room. CNA I was not wearing a gown or mask. She had on only one glove. Using her gloved hand, she picked up the plastic service tray from the dirty overbed table. With her ungloved hand, she picked up the dinnerware and utensils the resident had used for his noon meal and placed them in the trash. She took off her one glove and threw it in the trash. Without washing her hands, she walked from the room carrying the plastic tray from Resident #3's room to the dining room. As she walked through the dining room, a resident at a table stopped her and asked for water. CNA I patted the resident with her hand and spoke to her. She then placed the plastic tray from Resident #3's room on the tray cart and went to the water dispenser. With her unwashed hands, she picked up a clean cup from the stack by the coffee urn and got the resident a glass of water. After delivering the water to the resident, she retrieved the snack cart from where it was sitting between the nurse's station and the dining room and pushed it to the 100 Hall. CNA had still not washed her hands. She picked up each individual snack to read the labels with the residents' names. She then began handing out the snacks, delivering them to five different residents, assisting them with opening the snacks or positioning the residents to assist them with being able to eat the snacks. CNA I had not washed her hands between handling Resident #3's isolation tray and soiled dishes, getting a glass of water for a resident, and delivering snacks to five residents. During an interview on 06/08/11 at 2:25 PM, CNA I revealed she had been a CNA for one year and three months. She stated the snack cart was for the entire building, and she was serving the 100 Hall residents. When queried, she confirmed Resident #3 was on isolation. Review of the in-service presented 06/08/11 at 4:00 PM, 4:40 PM and 5:15 PM revealed it contained information about[DIAGNOSES REDACTED] for health care providers from the CDC dated 09/23/04. The in-service sign-in sheet had 15 signatures. The information given to staff reflected any surface, which became contaminated with feces, may serve as a reservoir for[DIAGNOSES REDACTED] spores.[DIAGNOSES REDACTED] spores were transferred to patients mainly via the hands of healthcare personnel who had touched a contaminated surface or item. The information also detailed the cleaning of environmental surfaces and reusable devices. Review of Resident #3's physician's orders [REDACTED]. Resident #3's lab report dated 05/27/11 reflected the stool specimen was positive for[DIAGNOSES REDACTED] on 05/09/11, negative for[DIAGNOSES REDACTED] on 05/19/11 and positive for[DIAGNOSES REDACTED] on 05/26/11. A physician's orders [REDACTED]. [MEDICATION NAME] was an antibiotic used to treat[DIAGNOSES REDACTED]. Resident #3's physicians order dated 05/31/11 reflected an order to extend the administration of [MEDICATION NAME] 500 mg to three weeks. Physician's progress notes for Resident #3 on 05/31/11 reflected "...recurrence of C-Dif and continuing [MEDICATION NAME]." On 6/09/11 the Physician's progress notes reflected "Urine culture with [MEDICATION NAME] and Pseudomonas sepsis, Continue [MEDICATION NAME],[DIAGNOSES REDACTED] still active...." (Note: [MEDICATION NAME] and Pseudomonas are both bacteria that can be found in stool.) During an observation on 06/09/11 at 2:10 PM, CNA F and CNA I were observed assisting Resident #3. Resident #3 was lying on the floor yelling out, "Leave me to die." The room smelled strongly of feces. Both CNAs were dressed in gloves, gowns and masks. CNA F told the surveyor the resident sat on the floor, refused peri-care and stated, "Leave me to die." (Note: Resident #3 was not ambulatory.) CNA I and CNA F pulled the resident to a sitting position by his arms and then placed their hands under the resident's arms and grabbed his pants at the hip on either side. They then lifted him into the air with his feet dragging on the floor and placed his bottom on the edge of the bed. From the edge of the bed, one CNA grabbed the resident under the arms and one by the ankles and pivoted the resident into bed. With one CNA on either side of Resident #3, they reached under the resident's arms and dragged him to the head of the bed. No gait belt was used. As the resident was transferred, brown, liquid feces was observed smeared on the floor where the resident's buttocks had been. The resident and CNAs' feet were observed to step through the smeared liquid feces. When asked about the "brown liquid," CNA F replied it was "a spill of some kind." Following the transfer, the surveyor queried CNA F about Resident #3's lunch service. CNA F stated the resident received lunch on regular plates like the other residents. She stated she put the tray on the hall cart when Resident #3 finished eating. During an interview on 06/09/11 at 10:00 AM, the Interim DON informed the surveyors disposable eating utensils were not required for contact isolation. She stated the dish machine would sanitize the dishes. She stated the tray would get picked up and put on the hall cart and taken to the dish machine. She added the person washing dishes did not wear gloves when handling dishes, but did "wash their hands a lot." In an interview with the Administrator and the Interim DON, on 06/09/11 at 3:17 PM, the Interim DON stated[DIAGNOSES REDACTED] "spores can live a really long time," and that if a resident was smearing his feces, the staff should have been cleaning the side rails. When informed that an aide (CNA F) had stepped in a brown liquid substance that could have been feces, the Interim DON stated that she (CNA F) should not have stepped in the substance and continued to walk in and out of the room. The Interim DON also stated that she was aware that the facility needed to do more about infection control, but that she thought they were doing well because the infection (C-Diff) had not been spread to the other residents. The Administrator stated that he was going to "see this through to the end and find the short comings." He also stated that he "never realized how deadly serious regulatory services takes[DIAGNOSES REDACTED]." The Interim DON then stated, "I'll follow up with the feet thing. I can't say we've ever had an issue, but I'm not opposed to doing anything to protect the residents." 2) On 06/07/11 at approximately 10:15 AM, LVN LL told the surveyor Resident #14 was at the facility for antibiotic therapy. LVN LL stated the resident had[DIAGNOSES REDACTED] and was receiving [MEDICATION NAME]. LVN LL described the resident as being alert and oriented times two and incontinent. Observation revealed there was an isolation cart with supplies in front of the door to the resident's room. There was a sign on the door instructing visitors to see the nurse before entering the room. Resident #14, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's Progress Note for Resident #14 dated 04/18/11 reflected the resident was transferred to the facility from a local hospital after having been admitted for diarrhea and was diagnosed with [REDACTED]. The MDS assessment dated [DATE] reflected Resident #14 had not rejected care, and there had been no change in the resident's behavior. Resident #14's Care Plan dated 04/28/11 reflected the resident was being treated for [REDACTED]." Approaches included to follow contact isolation precautions, monitor lab as the physician orders, and notify visitors to see nurses' station prior to entrance into the resident's room. Further review of Resident #14's Care Plan dated 04/28/11 revealed the following problems: incontinent of both bladder and bowel, short/long-term memory problem, impaired cognitive skills for daily decision making, at risk for dehydration, at risk for pressure ulcers, requires assistance from staff with grooming and personal hygiene, mobility, bathing, toileting and eating. Resident #14's lab result dated 06/02/11 from a stool specimen collected on 06/01/11 reflected it was tested for[DIAGNOSES REDACTED] Toc A/B and[DIAGNOSES REDACTED] [MEDICATION NAME] with both results being Positive. A physician's Progress Note dated 06/06/11 regarding Resident #14 reflected, "F/U recurrent[DIAGNOSES REDACTED]. Restarted [MEDICATION NAME] 4 days ago. Diarrhea still Voluminous & foul smelling...." A physician's Progress Note dated 06/09/11 reflected the physician had followed up with the resident with "c diff recurrent. On Vanco x 3 days now - some mild intermittant (sic) nausea... So far 1 diarrhea stool today...." On 06/12/11 at 5:15 p.m., CNA MM and CNA NN were observed providing incontinent care for Resident #14. During the incontinent care, the CNAs ran out of gloves. CNA NN left the room to get more gloves from the isolation cart by the door without washing his hands. CNA NN returned to Resident #14's room, applied new gloves without washing hands and continued to assist in giving incontinent care to Resident #14. A mid-size biohazard bag in Resident #14's room at that time was observed to be over-flowing with soiled items onto the floor. CNA NN made an effort to shove the soiled briefs into the biohazard bag without success. During this time, CNA NN did not have a gown on and the biohazard bag with its overflowing soiled items was coming into contact with CNA NN's uniform. The surveyor asked CNA NN what he was trying to do, and CNA NN replied, "I know I'm not supposed to touch all these...." even more so, because it's getting on my uniform. "I know I messed up." 3) The Face Sheet for Resident #2 dated 04/22/11 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's initial MDS assessment dated [DATE] reflected he was alert and oriented to person, place and time. He did have trouble with recall. Resident #2 required supervision for transfers and walking. Resident #2 required limited assistance for dressing. Resident #2 had [DIAGNOSES REDACTED]. The June 2011 Physician order [REDACTED]. On 06/07/11 at 11:40 AM during initial tour, Resident #2 was observed in his room lying on the bed with a dressing covering his right eye, and a bandage wrapped around his head. LVN T stated Resident #2 had a "big hole on his face" and had skin cancer. The resident's room had a very foul-smelling odor, which LVN T said was due to the cancer. Observation at 6:42 PM on 06/07/11 revealed Resident #2 had a bandage over his right eye, and there was still a very foul odor in the resident's room. A) On 06/08/11 at 7:51 AM, Resident #6 (Resident #2's roommate) was observed in the hallway. When asked why he was in the hallway, the resident stated his room smelled like "hell." A foul, nauseating odor was prevalent in the hallway outside the residents' room. Upon entering their room at that time, the surveyor found Resident #2 sitting on the side of his bed without a dressing on his face. He had a large, deep open wound, which covered the right side of his face, from the eye socket to his mouth. A flap of flesh was hanging from his face approximately three inches in diameter. The base of the wound was bright red. Blood was dripping rapidly from the wound onto the resident's clothing and floor. Resident #2 was attempting to clean up the blood on the floor with a towel under his foot. The fetid odor was overwhelming. The surveyor called for assistance from staff. LVN T and CNA V responded. LVN T told the surveyor Resident #2 had removed his dressings. The surveyor observed CNA V using Clorox wipes cleaning up the blood from the floor in Resident #2's room. The surveyor heard CNA V report, "A visitor let us have Clorox wipes." The visitor had provided some wipes, and CNA V told the visitor she would replace the wipes the next day. At 7:59 AM on 06/08/11, CNA V was heard asking Resident #6 where he wanted to eat his breakfast. Resident #6 chose to eat his breakfast meal in the hallway with his breakfast tray on an overbed table. Observation at 9:01 AM on 06/08/11 revealed a six-inch blood stain was still on the floor by the door in Resident #2's room. Interview with LVN T at 9:05 AM on 06/08/11 revealed she had spoken with the Interim DON. LVN T stated the dressings had been reapplied to Resident #2. LVN T added Resident #2's wound was "dripping," and she wanted to contain it as much as possible. Interview with LVN T on 06/08/11 at 10:30 AM revealed when there was a blood spill on the floor, she would use Isolyser LTS spill kit to clean the floor. However, the LTS spill kit was not large enough to clean a large spill of blood. LVN T stated the special cleaning kit was in accordance with OSHA blood-borne pathogen regulations. Interview with Housekeeper K on 06/08/11 at 11:40 AM revealed she used Quat Disinfectant solution when there was a blood spill. Housekeeper K stated she would spray the blood spill with Quat Disinfectant and wipe the floor with a paper towel. Housekeeper K stated she would put the paper towel with the contaminated blood in the trash bag on her cart. Housekeeper K stated she would then mop the floor. Housekeeper K stated after mopping the floor, she would take the trash with the contaminated blood outside the building and empty it in the dumpster. Housekeeper K made no reference to the use of red biohazard bags or the biohazard storage room. Observation at 12:23 PM on 06/08/11 revealed the same blood stain was by the door to Resident #2's room. Interview with Resident #6 on 06/09/11 from 8:48 AM to 9:47 AM and from 1:46 PM to 2:02 PM revealed Resident #2 had pulled off his bandages and "threw the bandages down." Resident #6 stated the "blood came out everywhere." Resident #6 said Resident #2 would walk the hallways and sometimes went outside. The Social Service progress note dated 05/25/11 reflected Resident #6 stated his roommate (Resident #2) had "blood/fluid coming from his mouth/nose and leaves the spoiled towels lying around the room." 4) The Face Sheet dated 06/10/11 reflected Resident #6, a [AGE] year-old male, was originally admitted to the facility on [DATE] with a readmission date of [DATE]. Resident #6's annual MDS assessment dated [DATE] reflected he was alert and oriented, required limited assistance with transfers, dressing, and toilet use, and was continent of bowel and bladder. He fed himself independently. Resident #6 had [DIAGNOSES REDACTED]. Observation on 06/08/11 at 1:35 PM revealed Resident #2 had a wound on the right side of his face. LVN U was observed performing the wound treatment and was assisted by RN HH. The wound was approximately 8 cm x 6 cm with a depth of 5 cm. LVN U, the Treatment Nurse, washed her hands and put on clean gloves. She then left the room and went to her treatment cart outside Resident #2's room. LVN U spread a clean pad on top of her cart. She stated she was preparing a clean field. LVN U placed a pink, plastic tube of normal saline, Dakin's substitute, full strength solution, six 4x4 gauze pads, an ABD pad, a roll of Kerlix, carbo flex dressing and Q tips on the clean field. LVN U requested LVN T to premedicate the resident for pain. LVN T promptly came to the room and administered [MEDICATION NAME] Solution 1.5 ml by mouth. LVN U put on a mask. She then took the pad with the supplies from the treatment cart to Resident #2's room and placed it on his bedside table. LVN U removed her gloves and performed hand hygiene. After donning fresh gloves, LVN U removed the dressing on the resident's face and placed it in a plastic bag on the resident's bed. LVN U removed her contaminated gloves and performed hand hygiene. Observation of the wound revealed a large, open, deep wound surrounding and including his eye socket. There was a protruding flap of skin inside the eye socket. No eyeball was present. The wound had a very foul smelling odor. LVN U moistened a 4x4 gauze with normal saline and cleaned around the wound bed. LVN U did not change her gloves and wash her hands. LVN U then soaked a piece of cut Kerlix in the Dakin's substitute solution in a plastic cup (contaminating it) and packed the wound with the wet [MEDICATION NAME]. LVN U covered the wound with carbo flex dressing. LVN U placed an ABD pad over the carbo flex then wrapped the resident's head with Kerlix to hold the dressing in place. RN HH held Resident #2's head up while LVN U wrapped the Kerlix around his head. LVN U said she needed Medfix to help hold the bandage in place. The Medfix was not on her supply pad, so without removing her gloves and washing her hands, she opened the bedside table drawers. With her contaminated, gloved hands, LVN U moved and lifted things around inside Resident #2's drawer. LVN U finally found and pulled out the Medfix and applied it to the bandage. While still wearing the contaminated gloves, LVN U opened Resident #2's drawer again and returned the Medfix. LVN U took the plastic bag with the soiled dressing, which was on Resident #2's bed and tied it closed. REFER TO F9999 FOR THE CONTINUATION OF F0441 INFECTION CONTROL SS=L

Based on observation, interview, and record review, it was determined the Administrator failed to administer the facility in a manner, which enabled it to use its resources effectively and efficiently to ensure an Infection Control Program was maintained to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. The Administrator failed ensure: 1) The facility's Infection Control policies and procedures were being implemented; 2) The facility's Infection Control Program included the tracking and trending of infections including [MEDICAL CONDITIONS]; and 3) Facility staff were trained in following Infection Control procedures. An IJ was identified on 06/09/11. While the IJ was removed on 06/13/11, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not immediate jeopardy" and a scope of "widespread" because staff were still being trained and the plan of removal was still being monitored for implementation and compliance. These failures could affect the facility's 106 residents and placed them at risk for the potential of being exposed to [MEDICAL CONDITION], cross-contamination and infection resulting in the potential need for isolation procedures and techniques, antibiotics, skin irritation and excoriation, dehydration, unplanned weight loss, and potentially, admission to the hospital. Findings included: 1) On 06/07/11 at 10:48 AM, ADON B stated Resident #3 was on contact isolation, because he had [MEDICAL CONDITION]. She added his roommate, Resident #20 also had [MEDICAL CONDITION], but he had gone to the hospital due to some respiratory problems. The resident's door was closed and had a sign, which reflected, "See charge nurse before entering." When queried about infection control precautions, ADON B stated the facility was taking isolation procedures, "Just like the hospital." ADON B explained staff was supposed to wear gowns, gloves and masks to enter the room. The staff was also required to use good hand washing and keep the linens and the trash inside the room. The gowns, gloves, masks, red plastic biohazard trash bags, water soluble laundry bags (also called "sugar bags") were outside the room in the hallway on an overbed table. On 06/07/11 at 5:00 PM, CNA E was observed in Resident #3's room "picking up things" without a gown on. She stated at that time she did not see disposable gowns on the table outside Resident #3's room, so she just went in without a gown. CNA E was asked if she provided incontinent care for Resident #3 without wearing a gown, and she replied, "Yes. When there were no gowns, I (still) have to change the diapers, so I do it without gowns." CNA E was queried as to what she did after leaving Resident #3's room. She revealed she worked "all over the floor" after caring for Resident #3 without a gown. When queried about isolation procedures, the CNA said isolation required the staff to use a mask, gloves, gowns and red bags in the room. CNA E then added Resident #3 was often aggressive and had smeared feces on the bed rails and overbed table. CNA E stated Resident #3 often had feces on his hands and would throw his feces-filled briefs onto the floor. In an interview on 06/07/11 at 5:53 PM with the Interim DON, she revealed that the last isolation gown had just been used. When asked what the CNA's were using to protect themselves when entering isolation rooms, the Interim DON stated that she was not going to answer that question. The Interim DON then stated that she had informed the staff not to go into the isolation rooms without an isolation gown on, but was unable to provide proof of this in-service when asked. In an interview on, 06/07/11 at 5:53 PM, with the Administrator, he stated, "Once we learned that we were at a point of running out (of gowns) we took steps to get her (supply clerk) more." The Administrator also stated that the facility had taken steps to fix the breach in the system. Interview with Central Supply/CNA AA at 5:23 PM on 06/07/11 revealed there were no disposable gowns in the facility. There were no gowns observed in the central supply room at that time. Interview with Central Supply/CNA AA at that time revealed the gowns should be received between 5:30 PM and 6:00 PM "today" with the order. In an interview on, 06/07/11 at 6:15 PM, with the Administrator, he stated that the supply clerk who had been sent to get additional gowns had not returned yet. During an interview on 06/07/11 at 6:50 PM, the Administrator stated he had now received 30 isolation gowns. 2) 3) On 06/08/11 at 12:45 PM, CNA F was observed providing incontinent care to Resident #3. During the procedure CNA F cross-contaminated the container of (clean) wipes and a new clean brief, She opened the door and retrieved fresh linen while wearing her contaminated gloves. She then opened the door to the staff lounge and washed her hands in the staff's kitchen sink. After returning to the resident's room and providing care, she again washed her hands in the staff's kitchen sink. (Note: This was the area used by staff to prepare their food and eat.) CNA F did not clean and disinfect the resident's overbed table after using it to hold the wipes and reaching into the wipes container with soiled hands. The overbed table was visibly stained with crusted substances. On 06/08/11 at 1:05 PM during meal observations, CNA G placed the resident's lunch tray on his overbed table. The plastic service tray contained disposable dinnerware and utensils. With her ungloved hands, CNA G pushed the overbed table so Resident #3 could reach it. The overbed table was still visibly soiled with crusted substances observed previously. CNA G then removed her gown and mask and left the resident's room without washing her hands. CNA G went directly down the hall to another resident's room and began preparing them for meal service. At that time, CNA G became aware of the surveyor's continued presence. She stated to the other resident, "Oh. I'll be right back. I need to wash my hands." She then washed her hands in the sink in the other resident's room. At 2:15 PM on 06/08/11, CNA I was observed in Resident #3's room. CNA I was not wearing a gown or mask. She had on only one glove. Using her gloved hand, she picked up the plastic service tray from the dirty overbed table. With her ungloved hand, she picked up the dinnerware and utensils the resident had used for his noon meal and placed them in the trash. She took off her one glove and threw it in the trash. Without washing her hands, she walked from the room carrying the plastic tray from Resident #3's room to the dining room where she touch residents. With her unwashed hands, she picked up a clean cup from the stack by the coffee urn and got the resident a glass of water. After delivering the water to the resident, she retrieved the snack cart from where it was sitting between the nurse's station and the dining room and pushed it to the 100 Hall. CNA had still not washed her hands. She picked up each individual snack to read the labels with the residents' names. She then began handing out the snacks, delivering them to five different residents, assisting them with opening the snacks or positioning the residents to assist them with being able to eat the snacks. CNA I had not washed her hands between handling Resident #3's isolation tray and soiled dishes, getting a glass of water for a resident, and delivering snacks to five residents. 3) Resident #2's initial MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted on [DATE]. He was alert and oriented to person, place and time. He did have trouble with recall. Resident #2 required supervision for transfers and walking. Resident #2 required limited assistance for dressing. Resident #2 had [DIAGNOSES REDACTED]. On 06/07/11 at 11:40 AM during initial tour, Resident #2 was observed in his room lying on the bed with a dressing covering his right eye, and a bandage wrapped around his head. LVN T stated Resident #2 had a "big hole on his face" and had [MEDICAL CONDITION]. The resident's room had a very foul smelling odor, which LVN T said was due to [MEDICAL CONDITION]. Observation at 6:42 PM on 06/07/11 revealed Resident #2 had a bandage over his right eye, and there was still a very foul odor in the resident's room. On 06/08/11 at 7:51 AM, the surveyor found Resident #2 sitting on the side of his bed without a dressing on his face. He had a large, deep open wound, which covered the right side of his face, from the eye socket to his mouth. A flap of flesh was hanging from his face approximately three inches in diameter. The base of the wound was bright red. Blood was dripping rapidly from the wound onto the resident's clothing and floor. Resident #2 was attempting to clean up the blood on the floor with a towel under his foot. The fetid odor was overwhelming. The surveyor called for assistance from staff. LVN T and CNA V responded. LVN T told the surveyor Resident #2 had removed his dressings. The surveyor observed CNA V using "Clorox" wipes cleaning up the blood from the floor in Resident #2's room. The surveyor heard CNA V report, "A visitor let us have Clorox wipes." The visitor had provided some wipes, and CNA V told the visitor she would replace the wipes the next day. Observation at 9:01 AM on 06/08/11 revealed a six-inch blood stain was still on the floor by the door in Resident #2's room. Interview with LVN T at 9:05 AM on 06/08/11 revealed she had spoken with the Interim DON. LVN T stated the dressings had been reapplied to Resident #2. LVN T added Resident #2's wound was "dripping," and she wanted to contain it as much as possible. (Note: Resident #2 requested the surveyor not enter his room at this time.) Interview with LVN T on 06/08/11 at 10:30 AM revealed when there was a blood spill on the floor, she would use Isolyser LTS spill kit to clean the floor. However, the LTS spill kit was not large enough to clean a large spill of blood. LVN T stated the special cleaning kit was in accordance with OSHA blood-borne pathogen regulations. Interview with Housekeeper K on 06/08/11 at 11:40 AM revealed she used Quat Disinfectant solution when there was a blood spill. Housekeeper K stated she would spray the blood spill with Quat Disinfectant and wipe the floor with a paper towel. Housekeeper K stated she would put the paper towel with the contaminated blood in the trash bag on her cart. Housekeeper K stated she would then mop the floor. Housekeeper K stated after mopping the floor, she would take the trash with the contaminated blood outside the building and empty it in the dumpster. Housekeeper K made no reference to the use of red biohazard bags or the biohazard storage room. Observation at 12:23 PM on 06/08/11 revealed the same blood stain was by the door to Resident #2's room. Interview with Resident #6 on 06/09/11 from 8:48 AM to 9:47 AM and from 1:46 PM to 2:02 PM revealed Resident #2 had pulled off his bandages and "threw the bandages down." Resident #6 stated the "blood came out everywhere." Resident #6 said Resident #2 would walk the hallways and sometimes went outside. The Social Service progress note dated 05/25/11 reflected Resident #6 stated his roommate (Resident #2) had "blood/fluid coming from his mouth/nose and leaves the spoiled towels lying around the room." 4) On 06/08/11 at approximately 10:00 AM, the facility's current Infection Control policies and procedures and any Infection Control tracking and trending was requested from LVN A. At that time, LVN A revealed she was responsible for the Infection Control program in the facility. She stated she had been responsible for Infection Control in the past, but in February 2011 she had been relieved of that responsibility. She stated she was just reassigned those responsibilities again. Review of the Infection Logs provided by LVN A revealed a computer-generated form, which listed the name and room number of residents identified with infections, if the infection was community-acquired or nosocomial, the symptom onset date, infection category, type of pathogen, related diagnosis, if an antibiotic was being used and "status." An Infection Report-Basic, which provided a detailed report of the resident and the infection including, location of infection, symptoms, date of onset, diagnostic testing done (cultures), and interventions. Review of the logs for March, April, and May-June 2011 revealed: a) March 2011 - Eight residents were identified with infections. Four were nosocomial and four were community-acquired. Per the log, no cultures were done on any of the residents. Three of the eight were receiving antibiotics. Four of the eight residents identified had an attached Infection Report-Basic. On the March 2011 log, Resident #18 was identified with "Gastrointestinal" infection on 03/16/11, but no culture was done and he was not on antibiotics. An Infection Report - Basic form was attached to the log for Resident #18. It reflected Resident #18 was admitted on [DATE] with [MEDICAL CONDITION]. Under interventions, the form reflected the resident was receiving an antibiotic. The form did not identify the implementation of any special precautions, such as Contact Isolation. b) April 2011 - Ten residents were identified with infections. Six were nosocomial and four were community-acquired. Three of the ten residents were receiving antibiotics. Three of the ten residents identified on the log had an Infection Report-Basic forms attached to the log. On the April 2011 log, Resident #14 was identified with a "skin" infection on 04/30/11. No culture was done, but the resident was on antibiotics. An attached Infection Report-Basic form identified the resident had [MEDICAL CONDITION] and was treated with [MEDICATION NAME]. No culture was done. The rest of the form was not completed. c) May -June 2011 - Seven residents were identified with infections. All seven were identified as community-acquired. Three residents, including Residents #3 and #20, were identified with "Gastrointestinal" infections. Per the log, no cultures were done on any of the residents. Four of the seven residents were receiving antibiotics. (Note: A double asterisk (**) was noted by Resident #3's name. There was no explanation.) Only three of the seven residents identified on the log had an Infection Report-Basic forms attached to the log. Resident #3 was identified on the May 2011 log with a "Gastrointestinal" infection. The log reflected no culture was done, but the resident was on antibiotics. Resident #3 did not have an attachment with the log. There was nothing to identify the resident had [MEDICAL CONDITION] or was in Contact Isolation. Resident #20 was also identified on the log with a "Gastrointestinal" infection. The log reflected no culture was done. There was nothing to identify the resident had [MEDICAL CONDITION] or was in Contact Isolation. Interview with LVN A on 06/08/11 at approximately 10:00 AM revealed she was not sure what the Infection Report-Basic was. She stated the former DON had initiated it, but she had not had time to decided how it was utilized. She stated in the past she had utilized a tracking log and a facility map to track the infections. She just had not had time to get it started again. When asked about the facility's Infection Control Program, on 06/08/11 at 2:42 PM, Corporate Nurse D stated the facility had a new DON coming the following week and the facility was, "not as far as we'd like to be." Corporate Nurse D also stated that the facility was working hard to get systems in place. On 06/08/11 at 3:45 PM, the Interim DON stated she had a meeting last week with staff about Infection Log information. She stated she described how to color code the information and stated she described trying to track the staff caring for the residents. The Interim DON stated she did not produce the current reports, and she just started at the facility on 05/31/11. 5) The SHEA/APIC Guideline: Infection prevention and control in the long-term care facility, retrieved on 06/15/11 at <http://www.apic.org/Content/NavigationMenu/PracticeGuidance/APIC-SHEA_Guideline.pdf> and dated July 2008, reflected: "Person-to-person spread, particularly due to shared bathroom, dining, and rehabilitation facilities, plays a role in [MEDICAL CONDITION] gastroenteritis and in Shigella spp and[DIAGNOSES REDACTED]icile diarrhea ... To establish baseline infection rates, track progress, determine trends, and detect outbreaks, site-specific rates should be calculated. Routine analysis should try to explain the variation in site-specific rates... These surveillance data are used primarily to guide control activities, to plan educational programs, and to detect epidemics, but surveillance also may detect infections that require therapeutic action ... Process measures (e.g., surveillance of infection control practices) should also be part of the infection control and quality improvement programs and may be very helpful in identifying areas for improvement in practice and for monitoring compliance with regulatory aspects of the infection control program. Examples of process measures include observation of hand hygiene compliance, observation of correct catheter care technique, antibiotic utilization studies, timeliness in administering and reading TB skin tests... Infection control data, including rates, then need to be displayed and distributed to appropriate committees and personnel (including administration) and used in planning infection control efforts. The data should lead to specific interventions such as education and control programs ...." The guidelines further explained that "With Contact Precautions, wearing a gown and gloves for all interactions that may involve contact with the resident and their environment is advised, and eye protection is recommended when there is risk of splash or spray of respiratory or other body fluids ... An important aspect of infection control programs is the development and updating of infection control policies and procedures. Because practices change, they should be reviewed on a scheduled basis. Review of the Bloodborne Pathogens Exposure Control Plan is required to be done annually." Note: Provider letter 09-18 endorsed the SHEA/APIC guidelines as "a guide for the development of an effective infection control program." 6) Review of the Nursing Services Policy and Procedure Manual Infection Control dated as revised December 2007 and provided as current revealed general guidelines for " All Nursing Procedures " that included: "1. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. 2. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infections. (There was no further explanation or procedure for these precautions.) 3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents; b. When hands are visibly dirty or soiled with blood or other body fluids; c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; d. After removing gloves; e. After handling items potentially contaminated with blood, body fluids, or secretions; f. Before eating and after using a restroom; and g. When there is likely exposure to spores (i.e.., [DIAGNOSES REDACTED]icile ...) (Note: Alcohol-based hand rubs are inactive against spores. For effective mechanical removal of spores, wash hands for 30-60 seconds with soap and water or 2% [MEDICATION NAME].) ... 5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. 6. In addition to these general guidelines, refer to procedures for any specific infection control precautions that may be warranted." Laundry and Bedding, Soiled Policy Statement " Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. Policy ... 1. Soiled laundry and bedding ... contaminated with blood or other potentially infectious materials must be handled as little as possible and with a minimum of agitation ... 4. Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment (e.g., gowns if soiling of clothing is likely.) .... " Departmental (Environmental Services) -- Laundry and Linen "...4. To minimize possible contamination of the environment, use individual red plastic bags when gathering linen from resident with: ...f. Laundry/linen removed from an isolation room...." Review of the Infection Control policy and procedure revealed no reference to the use of "sugar bags." Medical Waste, Handling of 1. For the purpose of this policy, medical waste includes human blood and blood-soiled articles, contaminated items (i.e., soiled dressings) ... 4. Disposable items, which are contaminated with excretions or secretions from residents believed to be infectious, must be placed in red plastic bags and sealed, and either decontaminated with bleach (1:10 or 1:100 dilution), incinerated, or stored until removal from the premises...." Standard Precautions include the following practices: " ...d. Wash hands after removing gloves ... 2. Gloves... b. Wear gloves when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact... e. Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving form a 'dirty' site to a 'clean' one). f. Do not reuse gloves. g. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments .... 3. Gowns... a. Wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing.... 6. Environmental Contro... a. Ensure the environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces are appropriately cleaned ...." Review of the entire manual revealed no guidance on surveillance or analyzing infection control data. The manual did not have any reference to procedures for Contact Isolation. 7) An IJ was identified on 06/09/11 at 5:01 PM. The Administrator and the Interim DON were notified of the IJ in the areas of Infection Control and Administration. A Plan of Removal for the IJ was requested at that time. 8) In an interview with the Administrator, 06/10/11 at 9:37 AM, he stated he was hired as the Administrator on 03/09/11, and at that time, he changed the Quality Assurance (QA) meetings from quarterly to monthly. During this interview, the Administrator provided documents from the QA meetings regarding Infection Control. He stated at each monthly QA meeting, the former DON provided the month's Infection Log and a map of the facility with the identified infections marked on the map. The Administrator said he was aware there were two residents with [MEDICAL CONDITION], who resided in the facility, but "if they're (facility staff) doing such a poor job (of infection control) why wouldn't everyone have [MEDICAL CONDITION]?" When asked what resources, other than the policies and procedures the staff had available to them, the Administrator had no answer. 09) During an interview with Corporate Nurse D and the Interim DON on 06/10/11 at 12:54 PM, Corporate Nurse D stated [MEDICAL CONDITION] spores on inanimate objects die in four hours. When asked about the possibility of contamination from inanimate objects, the Interim DON stated, "The number one source for contamination is actual stool." Corporate Nurse D stated, "I accept that you're telling me that we have breaks in our system. I fully admit and we'll take very seriously anything that happens." When informed the CNAs were unaware of how to clean up a blood spill, Corporate Nurse D stated, "We have an education issue. We've got a huge job to do in re-education." 10) In an interview with Corporate Nurse D, on 06/12/11 at 5:04 PM, she stated the majority of the staff had been in-serviced, and no employees would be allowed to work until they had been educated. 11) On 06/13/11 at 12:06 PM, the Administrator was informed the facility's revised Plan of Removal for the IJ was accepted. 12) Review of the facility's revised Plan of Removal, which was accepted on 06/13/11 reflected the following: a) The facility will implement a facility-associated (nosocomial) infection and environment-surveillance program. A major function will be to promote infection control and prevention strategies through surveillance activities. Surveillance allows for identification ad monitoring of potential and actual infection sources. b) All infections will be entered into the tracking system. Information will be tracked and trended. Data will be analyzed and an infection control rate determined. Corrective action will be implemented as necessary. c) Facility will follow current CDC guidelines. d) Infection Control training is mandatory for all employees upon hire and annually. e) The Medical Director will review Infection Control Data as well as any performance improvement plan in place for accuracy and efficiency during QA. f) When an antibiotic is ordered, the Charge Nurse will initiate isolate precautions using "Disease Specific Precautions" located at the nursing station. Resources are available at the Nurses Station to aid in determining the type of isolation and PPE. The charge nurse will update the resident's status sheet, care plan and notify staff. ADONs will monitor Monday through Friday and the Weekend Supervisor will monitor to ensure compliance. Nurses have also been educated that if the resident presents with symptoms such as diarrhea, temperature or other suspicious symptoms they may be placed in isolation awaiting lab work or physician orders. g) The ADONs will bring new orders to the daily stand-up meetings for review and will update the department heads of the rest of the facility and ensure appropriate precautions are in place. Department heads will be responsible for informing their staff. h) The Infection Control Nurse will get copies of the orders for antibiotics to enter into the tracking system. Infections will be discussed at Weekly Standards of Care and the Infection Control Nurse will report the facility infection rated identified trends and the status of any action plans to the QI Committee monthly for review. Infections are logged and mapped to identify clusters. i) Approved bleach product was being used to disinfect resident equipment, rooms and floors. Isolation rooms are deep cleaned when isolation is discontinued. Dining carts are cleaned between each meal. Monitoring will be ongoing through the weekly SOC and weekly QA&A. j) Staff had been receiving re-education regarding Infection Control on each shift plus weekends effective from 06/11/11 and to be completed by 06/13/11. Training was to be done by the ADONs, Nurse Consultant, Weekend Supervisor and Infection Control Nurse. Monitoring was to be on-going and validation of training was to be through verbal questioning and skill observations at random. The facility Emergency Response Kit (blood spill) was presented to weekend and night staff and was to be presented today (06/11/11) and weekday staff through 06/13/11. k) All new employees will receive training as part of New Hire Orientation as part of online program with a pre and post test with a receipt of certificate of completion. k) The Medical Director would be presenting training on [MEDICAL CONDITION] for the staff. 13) Review of the information provided by the facility on 06/13/11/on the Inservices provided to staff revealed the following: 06/08/11 - Information on [MEDICAL CONDITION]. Attended by eight staff. 06/09/11 - Clean up of hazardous spills: to use a disinfectant with 1:10 dilution of bleach with locations where disinfectant can be found for use. Attended by nine staff. 06/10/11 - Removal of biohazardous items in resident's room, i.e., linen, trash. Attended by 12 staff. 06/10/11 - Contact Isolation - CNAs to follow-up with Charge Nurses to find out what Personal Protective Equipment (PPE) is needed when a resident is in isolation; Charge Nurses are responsible for CNAs being aware of what PPE is needed for a resident in isolation. Attended by 20 staff. 06/11/11 - "Sugar Bags" - Laundry bags for residents in isolation. Attended by five residents. 06/11/11 - Disinfecting the bathroom and shower equipment. Attended by 16 staff. 06/11/11 - 06/12/11 - 06/13/11 - Isolation Procedures. Attended by 56 residents. 06/12/11 - 06/13/11 - Emergency Response Safety Kit. Attended by 23 staff. 06/13/11 - Emergency Blood Spill. Attended by 15 staff. On 06/13/11, ADON A was inserviced on the Infection Control Nurse ' s Duties and Responsibilities. Information required for the Infection Log was reviewed and who the information was to be received from (the Charge Nurse). Follow-up was identified and emphasized for the case to be closed/resolved. Tracking and trending of infections were also included. 14) Review of the current employee list provided by the facility on 06/13/11 revealed at total of 114 employees. There were eight Medication Aides, 46 CNAs, 26 Charge Nurses, and three ADONs among the staff listed. 15) While the IJ was removed on 06/13/11, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not immediate jeopardy" and a scope of "widespread" because staff were still being trained, dietary was not using a cleaner on the dining room carts, which killed [MEDICAL CONDITION] and the plan of removal was still being monitored for implementation and compliance. 16) The CMS-672 (Resident Census and Conditions of Residents) dated 06/08/11 and signed by the Nurse Consultant reflected there was a census of 106 residents.

Based on observation, interview, and record review, it was determined the facility failed to ensure services were provided by one (LVN A) of four licensed staff, which met professional standards of quality by appropriately, timely and proficiently responding to Resident #1 when she was choking on food. CNA C fed Resident #1 some food and left her unsupervised in the dining room, where she became unresponsive due to choking on the food. LVN A responded to Resident #1 and failed to check her for choking before removing her from the dining room to her room and putting her to bed. Resident #1 expired at that time. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern" because all staff had not been inserviced and the facility was still monitoring for implementation of the Plan of Removal. These failures contributed to the death of Resident #1 and could affect any of the 34 residents in the facility, who required assistance with eating and required monitoring during meal times, placing them at risk for the potential of a delay in being provided emergency treatment for [REDACTED]. Findings included: 1. Excerpt from the Board of Nursing's Rules and Regulations 217.11. Standards of Nursing Practice The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses, and registered nurses with advanced practice authorization shall: ...(B) Implement measures to promote a safe environment for clients and others; ...(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations; ...(M) Institute appropriate nursing interventions that might be required to stabilize a client's conditions and/or prevent complications; ...(R) Be responsible for one's own continuing competence in nursing practice and individual professional growth.... 2. A review of the facility's Nursing Services Policy and Procedure Manual revised [DATE] revealed the following for the [MEDICATION NAME] Maneuver: Purpose: The purpose of this procedure is to prevent choking by expelling the foreign body airway obstruction. General guidelines. Unconscious Resident-lying down (or when unable to reach around the Resident). 1. Ease the Resident as gently as possible to the floor. 2. Call for help if assistance is not already present but do not leave the Resident unattended. 3. Position the Resident on his or her back with the arms at his or her side. 4. Perform abdominal thrusts as follows: a. Facing the Resident, kneel down and straddle the Resident's upper thighs with your body. b. Place the heel of one hand on the Resident's upper mid abdomen below the ribcage and above the naval and with fingers pointed toward the Resident's chest. c. Place the other hand directly over the positioned hand. d. Bring your shoulders over your hand. e. Use your body weight to press your hand into the Resident's upper abdomen with a quick upward thrust. 5. Perform the finger sweep maneuver to check for a foreign body as follows; a. Keep the Resident's face up. b. Perform the tongue-jaw lift to open the Resident's mouth (Note; moving the lower jaw moves the tongue off the throat and opens the airway). c. Perform the finger sweep using the index finger as a hook. 1. Insert your index finger into the Resident's mouth along the side of the cheek and across the base of the tongue. 2. Try to remove any foreign objects. 3. Avoid pushing foreign objects deeper into the throat. 4. Turn the Resident's head to one side if needed to sweep an object from the Resident's mouth. 6. Alternate steps four (4) and five (5) until the object is expelled. Arrange for the Resident to be evaluated by a physician immediately after the foreign body airway obstruction has been removed. 7. If unable to clear the foreign body from obstructing the airway arrange emergency transfer for the Resident to the nearest acute medical facility. 8. Proceed with CPR immediately if the Resident has no pulse or respirations. Documentation. The person performing this procedure should record the following information in the medical record. 1. The date and time the procedure was performed. 2. The name and the title of the individual/individuals who performed the procedure. 3. The exam time the choking began. 4. The exam time of any unconsciousness. 5. All assessment data obtained during the procedure. 6. The time the procedure was started and stopped. 7. The Resident's response to the procedure. 8. The signature and title of the person according to the data. Reporting. 1. Report results promptly to the supervisor and the attending physician. 2. Notify the attending personal physician of all assessment, data, observations, and results. 3. Report the information in accordance with the facility policy and professional standards. 3. The admission face sheet dated [DATE] reflected Resident #1, an [AGE] year-old female, was admitted on [DATE] with a readmission date of [DATE] with diagnoses, which included: [MEDICAL CONDITION], Cerebral Embolism with Infraction, Muscle Disuse Atrophy, Abnormal Posture, Abnormality of Gait, Muscle Weakness, Dysphagia, Convulsions, Hypertension and [MEDICAL CONDITION]. A review of Resident #1's most recent MDS assessment dated [DATE] revealed the resident had short-term memory loss and required the extensive assistance of one staff to provide physical assistance with eating. Resident #1 also required total assistance of facility staff with locomotion and transfers. A review of Resident #1's current care plan dated [DATE] revealed: Resident was in need of assistance with ADLs. Goal: All ADL needs will be met as evidenced by resident being clean, dry and odor free for the next 90 days. Interventions: Assist with feeding as needed. Set up help. Problem: Resident was a full code. Goals: Resident and family wishes will be honored during nursing facility stay. Interventions: Initiate CPR and Notify EMS. A review of the daily skilled nurses notes dated [DATE] revealed Resident #1 was alert, but confused with Memory Deficits. She required extensive assistance with eating with the assistance of one person providing physical help. The Dietician note dated [DATE] reflected a [DIAGNOSES REDACTED]. (No salt on table). It was further noted, "Resident spoonfed at meals..." According to www.merckmanual.com <http://www.merckmanual.com> retrieved on [DATE], "Dysphagia is difficulty swallowing. The condition results from impeded transport of liquids, solids, or both from the pharynx to the stomach... Complications: Dysphagia can lead to tracheal aspiration of ingested material, oral secretions, or both. Aspiration can cause acute pneumonia. Recurrent aspiration may eventually lead to [MEDICAL CONDITION]. Prolonged dysphagia often leads to inadequate nutrition and weight loss... ...Patients complain of difficulty initiating swallowing, nasal regurgitation, and tracheal aspiration followed by coughing. Most often, oropharyngeal dysphagia occurs in patients with neurological conditions or muscular disorders that affect skeletal muscles." In an interview with CNA E on [DATE] at 1:35 PM, she stated she had cared for Resident #1 for a year and a half. She stated Resident #1 had [MEDICAL CONDITION] and had needed more help and was total assistance with all ADLs. CNA E stated she had fed Resident #1 breakfast over the last two to three months and Resident #1 had required more time to eat, and it would take longer to feed her. 4. Nurse's Notes dated [DATE] at 5:00 PM reflected Resident #1 was sitting up in the wheelchair and taken to the dining room for supper. The notes reflected she was alert and verbally responsive with no signs or symptoms "...of any respiratory distress noted at this time. O2 Sat 94% on Room air." Normal oxygen saturation level is 95 - 100%. Same day at 5:40 PM, the Nurse's Notes reflected, "Resident was at the table with other residents and the CNA (CNA C) was getting ready to start feeding her when she suddenly slummed (sic) over on her side and the CNA noted she was not responsive. She alerted the nurse who was also in the dinning (sic) room and she rushed the pt. back to her room." At 5:45 PM: "Resident still breating (sic) (symbol for with) a weak carotid pulse. 911 call initiated." The Nurse's Notes were documented by LVN B. 5. Resident #5, whom the facility identified as alert and interviewable, was interviewed on [DATE] at 10:25 AM. She stated she was in the dining room when Resident #1 was in the dining room and had observed the resident being fed. Resident #5 stated there was a ,[DATE] CNA (CNA C, who worked the evening shift), who had been feeding the resident, who got up and left the dining room and then came back. "____ (Resident #1's) head was down. ___ (LVN A) came and took ____ (Resident #1) to her room." 6. In a confidential interview, the interviewee stated he/she had been sitting in the main dining room and had observed the CNA (CNA C) shovelling food into Resident #1's mouth. Resident #1 was sitting at the table, and the aide was there, and then the aide got up and walked away. CNA C left the dining room." I saw the resident slump over. I thought she was sick. The aide came in and lifted her head. Her head slumped back over. The aide called for (LVN A.) (LVN A) was at the kitchen door checking the tray cards. The aide called three or four times. (LVN A) got over there and lifted (Resident #1's) head. There was food coming out of her mouth. (Resident #1) was facing the wall." "Staff couldn't see her. We could. I looked over and the aide was gone. ____ (LVN A) took her out of the dining room. The fire people came in." The interviewee then stated, "There were two or three other residents at the table with ____ (Resident #1) at the time." The interviewee then stated again, LVN A came over and rolled Resident #1 out of the dining room. The nurse did not look in the resident's mouth before taking her out of the dining room. The interviewee then stated, Resident #1 should not have died . "I cried that night." 7. In an interview with Resident #6 on [DATE] at 10:50 AM, she stated she sat caddy-corner to the assisted dining table where Resident #1 sat. She stated, "...(CNA C) had put too much food in these people's mouth. I thought that before. So I would look over, and I would eat, then look over. The girl (CNA C) got up and left. A little bit later, the lady (Resident #1) had her head on the arm of the wheelchair. Her head was bent over. The aide came in, took the lady's head and pulled her up. The lady fell back again. The aide yelled. They pushed the lady right by our table. There was food coming out of her mouth, quite a bit. The fireman came." Resident #6 stated she was unsure how long the CNA had left Resident #1 alone. Resident #6 stated, "I thought to myself, why would they leave them sitting alone (referring to the residents at the assisted dining table)? I wondered were she went. She just fed and then left." 8. CNA I was interviewed on [DATE] at 3:10 PM. She stated on the day of the incident ([DATE]) with Resident #1, she had been assigned to work on the halls. During the meal service, she stayed on the hall to pass trays and answer call lights. CNA I stated she had walked into the dining room to get the tray cart on Thursday ([DATE]) and "met ____ (Resident #1) hanging down. There was milk or a liquid on her face. I was the first person who saw her. ____ (CNA C) wasn't around. No one was around. I started shouting and ____ (CNA C) came in and started yelling for ____ (LVN A)." CNA I then stated residents should not be left during meal service. 9. In an interview with LVN G on [DATE] at 3:40 PM, she stated she had been leaving the facility for the day on the day of the incident. She said she had been walking out and heard Resident #1 was coding. She stated she ran down to Resident #1's room. Resident #1 was not responding. LVN A and LVN B were removing food from Resident #1's mouth, finger sweeping the food out of Resident #1's mouth. "It was a white food, kind of pudding, white. They got enough out. ____ (LVN D) and I started CPR. The fire EMS came. They tried to Trachea her. The fireman stated he couldn't get a good clear path, because there was so much food. They were suctioning her, trying to get more food out. They were trying to get an airway. I didn't see her breathing." The DON provided a written statement by LVN G on [DATE] to the surveyor, which was dated [DATE]. The written statement reflected, "I was informed that ____ (Resident #1) was a none (sic) responsive I ran to her room where I saw ____ (LVN A) her charge nurse (LVN B) and ____ (LVN D) and several aids. ____ (LVN A and LVN B) were removing some thick white substance from her mouth while the CNA was cranking the head of the bed up. Upon removing the substance ____ (LVN A and LVN B) state that she was breathing and ____ (Resident #1) was turning blue. I state no she was not we need to start CPR I asked for the ambu bad (sic) to give two rescue breaths and I was informed that it was not on the cart I ran to the Oxygen room to look for the ambu bag and ____ (LVN A) said to look on her cart it might be there we could not find it. So I grab the O2 Sat machine ran back into ____ (Resident #1) where ____ (LVN D) was alone doing chess (sic) compression I switched with her and started chess compression her O2 Sat was low and we switch with doing chess compression until the fire department came. They started CPR and try to intubate her but the fire man said he can't get a clear view because of all the thick white substance. So they suction her and they continue to work on her upon exiting the facility." A review of the Week at a glance menu provided by the Dietary Manager on [DATE] revealed the evening meal on [DATE] was Chicken Spaghetti, Vegetable Medley, Garlic Bread and Angel Food Cake." 10. Although Resident #1's Nurse's Notes dated [DATE] reflected the resident had not been fed and CNA C was at the resident's side when she became unresponsive, subsequent interviews with residents and staff revealed: 1) Resident #1 had already been fed some supper; 2) CNA C left her unsupervised; 3) CNA I found the resident unresponsive; 4) LVN A removed her from the dining room without assessing Resident #1, checking her for choking or implementing the [MEDICATION NAME] Maneuver and took her to her room, where other staff called 911 and started CPR. 11. In an interview with CNA C on [DATE] at 2:15 PM, she was asked about the incident with Resident #1. CNA C stated, "We were in the dining room." She (CNA C) had been feeding Resident #1. Resident #2 and Resident #4 were at the table with Resident #1 also. CNA C stated she fed Resident #1 three or four bites and then got up, because she thought Resident #1 was done eating. CNA C stated she got up and went down the hallway and then came back to the dining room. CNA C stated when she returned, Resident #1 had "Milk coming out of her nose." CNA C stated Resident #1's head was hanging down. She lifted the resident's head. There was no response, and the resident's head fell down. CNA C said, "I called for the nurse, ___ (LVN A)." CNA C stated she lifted Resident #1's head again, and it went right back down. The surveyor asked CNA C if she was allowed to leave residents while feeding them, and CNA C replied, "We are not supposed to." In a subsequent interview with CNA C on [DATE] at 3:10 PM, she stated LVN A did not look in Resident #1's mouth before she took the resident out of the dining room. "She (LVN A) looked at her (Resident #1) and rolled her out of the dining room. The DON provided a written statement by CNA C on [DATE] to the surveyor, which was dated [DATE]. The written statement reflected, "I had just started feeding ____ (Resident #1). She took about four bites and drink (sic) her milk. I got up and went down the hall and came back. Found her head down she had milk coming from her nose. I immediately call the nurse in the dinning (sic) room. She came and got her and took her to her room." A review of CNA C's personnel file revealed she was hired on [DATE]. A review of the education topics CNA C had been trained on revealed there was no education record for feeding a dependent resident. A review of the "Nurse Aide Proficiency Checklist" completed on [DATE] and signed by LVN A as having completed satisfactorily revealed CNA C had not been evaluated on her proficiency when feeding residents. 12. In an interview with LVN A on [DATE] at 2:05 PM, the LVN stated she was monitoring the dining room when CNA C called her over. She stated Resident #1 was slumped over. She saw food on the resident's face. The resident was slumped over, and it looked like she had fallen in her food. LVN A said, "I took her out and put her in bed. Then I checked her, and there was no food. I started CPR." When LVN A was re-interviewed at 2:20 PM (15 minutes later), she stated she did not complete the nurses note in the facility record for Resident #1. LVN B had. LVN A stated she told LVN B what had happened. LVN A stated Resident #1 had been facing the wall in the dining room. The CNA had hollered for her. Resident #1 was still breathing, so she rolled her to her room and put her in bed. In an interview with a visitor on [DATE] at 5:20 PM, he/she stated he/she had observed Resident #1's head tilt over and saw the resident's lips were blue. "That was the first thing I noticed. I heard someone call for her. ___ (LVN A) came over and took her straight out of the dining room." 13. A review of the EMS notes dated [DATE] "AOS (Arrived on scene) to find PT (patient) being given CPR by facility staff. Assessed PT and started CPR attempted to place OPA (oropharyngeal airway) unable to due to thick Vomitus. Suctioned and attempted ET (endotracheal tube) tube placement. Unable to place Et tube due to thick vomitus and inability to visualize cords. Suctioned more with little effect and placed a king tube size 4." A review of the hospital records revealed the CPR notes dated [DATE] revealed at 6:32 PM "...attempting to re-intubated. pt suctioned with undigested food particles." A review of the hospital physician's progress note dated [DATE] revealed: "PT went into Vtach ([MEDICAL CONDITION]), defibrillated. Pt re-intubated (King tube removed) multiple noodles with food particles removed from airway. Pulse lost. CPR initiated again with ACLS. Pulse never sustained. Pt expired 1847 (6:47 PM) with 50 min CPR. Clinical impression: Aspiration." A review of the Coding summary hospital record revealed Resident #1 had final [DIAGNOSES REDACTED]." 14. On [DATE] at 5:40 PM, CNA C was observed sitting at a square dining table, which sat four. She sat diagonally at the edge of the table. Resident #2 was on the right side of the CNA, and Resident #8 was on her left side. CNA C was observed scooping Resident #2's pureed food onto a spoon and feeding Resident #2 sideways from where she was sitting. The CNA did not look at Resident #2. She stared straight ahead. She did not monitor the resident to ensure the resident swallowed her food. CNA C did not offer fluids nor did she speak to the resident during the meal service. Resident #8, who was sitting to the left of CNA C, was observed eating the top of her sandwich. CNA C also fed Resident #8 sideways. She did not look at whether the resident was chewing nor did she observe whether the resident swallowed the previous bite of food before giving Resident #8 another spoonful of food. A review of Resident #2's [DATE] physician's orders [REDACTED]. She had [DIAGNOSES REDACTED]. A review of (Resident #2's) dietician note dated [DATE] revealed "Resident is spoonfed pureed diet with thickened liquids." A review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 was not oriented and required the total assistance of one staff member to eat. Review of Resident #2's care plan, which was initiated on [DATE] revealed the following: Problem: Resident is in need of assistance with ADLs. Goals: All ADL needs will be met as evidenced by resident being clean, dry and odor free. Interventions: Assist of one person with feeding, Extensive, total. 15. The DON provided facility policies and procedures, which were current on [DATE] to the survey team. One of them, with a revised date of [DATE] was entitled "Assisting the Impaired Resident with In-Room Meals." The procedures listed to feed an impaired resident work equally well whether the resident was in their room or in the dining room. The procedures included: "...5. Season the resident's food according to his or her likes and in accordance with the resident's diet. 6. Use a spoon to feed the resident. 7. fill the spoon only half-full. Feed the resident from the tip of the spoon, not the side. 8. Put the food in one side of the resident's mouth so that he or she can chew it more easily... 9... 10. Alternate food and liquids...." 16. A review of the facility's current Nursing Services Policy and Procedure Manual revised [DATE] revealed the following for the [MEDICATION NAME] Maneuver: Purpose: The purpose of this procedure is to prevent choking by expelling the foreign body airway obstruction. General guidelines. Unconscious Resident-lying down (or when unable to reach around the Resident). 1. Ease the Resident as gently as possible to the floor. 2. Call for help if assistance is not already present but do not leave the Resident unattended. 3. Position the Resident on his or her back with the arms at his or her side. 4. Perform abdominal thrusts as follows: a. Facing the Resident, kneel down and straddle the Resident's upper thighs with your body. b. Place the heel of one hand on the Resident's upper mid abdomen below the ribcage and above the naval and with fingers pointed toward the Resident's chest. c. Place the other hand directly over the positioned hand. d. Bring your shoulders over your hand. e. Use your body weight to press your hand into the Resident's upper abdomen with a quick upward thrust. 5. Perform the finger sweep maneuver to check for a foreign body as follows; a. Keep the Resident's face up. b. Perform the tongue-jaw lift to open the Resident's mouth (Note; moving the lower jaw moves the tongue off the throat and opens the airway). c. Perform the finger sweep using the index finger as a hook. 1. Insert your index finger into the Resident's mouth along the side of the cheek and across the base of the tongue. 2. Try to remove any foreign objects. 3. Avoid pushing foreign objects deeper into the throat. 4. Turn the Resident's head to one side if needed to sweep an object from the Resident's mouth. 6. Alternate steps four (4) and five (5) until the object is expelled. Arrange for the Resident to be evaluated by a physician immediately after the foreign body airway obstruction has been removed. 7. If unable to clear the foreign body from obstructing the airway arrange emergency transfer for the Resident to the nearest acute medical facility. 8. Proceed with CPR immediately if the Resident has no pulse or respirations. Documentation. The person performing this procedure should record the following information in the medical record. 1. The date and time the procedure was performed. 2. The name and the title of the individual/individuals who performed the procedure. 3. The exam time the choking began. 4. The exam time of any unconsciousness. 5. All assessment data obtained during the procedure. 6. The time the procedure was started and stopped. 7. The Resident's response to the procedure. 8. The signature and title of the person according to the data. Reporting. 1. Report results promptly to the supervisor and the attending physician. 2. Notify the attending personal physician of all assessment, data, observations, and results. 3. Report the information in accordance with the facility policy and professional standards. 17. I. PROFESSIONAL STANDARDS: A. The Texas Board of Nursing documented in their rules and regulations in the Texas Administrative Code (TAC), Title 22, Part II, Chapter 217, Subsection 217.11, effective [DATE], a Licensed Vocational Nurse shall - - (1)(D) Accurately and completely report and document (i) the client's status including signs and symptoms, and (vi) contacts with other health care team members concerning significant events regarding client's status; - (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; - (N) clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medications and treatment. - (P) Collaborate with the client, members of the health care team, and when appropriate, the client's significant other (s) in the interest of the client's health care. 18. An IJ was identified on [DATE] at 11:45 AM. The Administrator and the DON were notified of the IJ in the areas of Quality of Care, Professional Standards and Administration with Substandard Quality of Care. A Plan of Removal for the IJ was requested at that time. 19. On [DATE] at 12:25 PM, CNA J was observed spoon feeding a pureed diet to Resident #3. There were also thickened liquids on the table. Resident #3 was seated in a geri-chair. CNA J stated to the surveyor when Resident #3 held his food in his mouth, he was finished eating. The CNA then pushed Resident #3 onto 200 Hall 200 and left him unattended for two minutes. At 12:27 PM, the surveyor observed Resident #3 in the geri-chair on the 200 Hall. The resident's mouth was slightly open, and the resident appeared to be asleep. The resident was unattended by staff. The surveyor observed the resident to have food in his mouth. The Administrator approached the surveyor, and the surveyor showed him the food in Resident #3's mouth. He summoned LVN K. At that time, CNA J walked past the resident. The Administrator said to CNA J, "He has food in his mouth." CNA J replied, "Yes, someone told me that when he has food like that, he's done eating." The Administrator called the DON over. The DON told LVN K to take the resident to his room. From 12:27 PM to 12:35 PM, LVN K attempted several times to awaken Resident #3, but was unsuccessful. The surveyor noted during that time, the resident did not appear to be in respiratory distress. LVN K looked for swabs in the resident's room but was not able to locate any. The DON left the room and sent swabs back with CNA L. LVN K used a swab to remove approximately one half spoonful of light yellow/tan pureed food. Resident #3 coughed twice. The Record of Admission for Resident #3, dated [DATE], reflected he had a [DIAGNOSES REDACTED]." Resident #3's physician's orders [REDACTED]. The orders also reflected "Aspiration Precautions." A review of the facility's "Restorative Nursing Educational Record" entitled "Feeding a Dependent Resident" (undated) and provided by the DON on [DATE] after the IJ was identified revealed this was how the residents should have been fed: 1. Wash hands. 2. Greet resident by preferred name. 3. Explain procedure and encourage resident's participation. 4. Position resident's head and body supported as straight. 5. Prepare resident for mealtime by providing dentures or other adaptive equipment necessary. 6. Check meal for correct diet and foods. 7. Provide clothing protector if necessary. 8. Explain to resident what you are going to do. 9. Check that hot foods are hot (not too hot) and cold foods are cold. 10. Offer fluids to moisten throat. 11. Feed with a spoon filled with food no more than half-full. Use the tip of spoon to feed, placing gentle downward pressure on the lips and center of tongue. 12. Feed the resident at a comfortable rate, allowing resident time to taste, chew, swallow and rest between bites. 13. Offer fluids between every third or fourth spoon of solid food. 14. Continue feeding until resident has had enough or meal is finished. 15. Assure that resident remains with head elevated for at least 30 minutes after meal if able. 16. Observe and report residents who eat poorly, difficulty swallowing, inability to chew, or changes in responsiveness. 17. Record and report the dietary intake and fluid of resident. 20. On [DATE] at 3:25 PM, the facility was informed the Plan of Removal had been accepted by the Regional Office. The Plan of Removal reflected: 1) Re-educated all licensed nurses on immediately assessing a resident with noted significant change of condition to include checking blood pressure, pulse, respirations, temperature, oxygen saturation, pain, mental status and range of motion prior to removing resident from location. A competency based test will be given to each licensed nurse. Re-educate all licensed nurses on [MEDICATION NAME] maneuver. CPR-certified staff are to be scheduled every shift in the facility. A CPR certification course is scheduled for [DATE] in the facility for licensed nurses and CNAs. This re-education and competency based test will be completed on [DATE] at 2:30 PM by the DON, ADON and Staff Development Coordinator. Licensed nurses, including weekend licensed nurses, will not be allowed to return to work without completing this reeducation and competency-based test. New hire licensed nurses will not be allowed to work without completing the reeducation and competency-based test as well. The Staff Development Coordinator will monitor new hires to ensure completion and compliance. 2) Any residents with a significant change of condition will be discussed in the daily morning meeting, which will be attended by the Administrator, the DON, and ADON, and the assessment of this resident and the documentation of this assessment, notification of MD and responsible party will be reviewed for compliance. Charge nurses will immediately notify the DON in person or by telephone of any resident with significant change in condition and provide a thorough report. Date of completion will be [DATE] at 2:30 PM. 3) Each licensed nurse will be reeducated and provided a competency test regarding procedures to follow during a medical emergency. During this training, the use of the emergency cart will be reviewed with all licensed nurses and a return demonstration of the emergency cart usage and equipment will be provided by the DON, ADON, and Staff Development Coordinator. Assign and reeducate 400 hall charges on checking and

Based on observation, interview and record review, it was determined the facility failed to ensure the necessary care and services were provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of one resident, whose closed record was reviewed and for three (Residents #2, #3 and #8 ) of three residents observed receiving meal assistance. CNA C had not been evaluated for feeding residents since coming to work at the facility. CNA C was feeding Resident #1, a resident with known swallowing problems. CNA C left Resident #1 unsupervised after having fed her chicken spaghetti. Resident #1 became unresponsive while left alone. LVN A removed Resident #1 from the dining room before assessing her for choking on food or trying the [MEDICATION NAME] Maneuver. Resident #1 could not be intubated by EMT personnel due to being unable to access an airway, and was pronounced deceased at the hospital. CNA C was feeding Residents #2 and #8 from an angle, and she was unable to adequately monitor the residents while eating. CNA C looked straight ahead while feeding the residents and did not watch to see if they swallowed their food. CNA C did not offer liquids to the residents. CNA C placed Residents #2 and #8 at risk for choking. Resident #3, a resident, who pocketed food, was fed by CNA J and pushed into the hallway with food still in his mouth and left alone. The resident fell asleep with food in his mouth, placing him at risk for choking. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern," because staff were still being trained and the facility was still monitoring implementation of the Plan of Removal. These failures contributed to the death of Resident #1 and could affect any of the 34 residents in the facility, who required assistance with eating and required monitoring during meal times, placing them at risk for the potential of a delay in being provided emergency treatment for [REDACTED]. Findings included: 1. The admission face sheet dated [DATE] reflected Resident #1, an [AGE] year-old female, was admitted on [DATE] with a readmission date of [DATE] with diagnoses, which included: [MEDICAL CONDITION], Cerebral Embolism with Infraction, Muscle Disuse Atrophy, Abnormal Posture, Abnormality of Gait, Muscle Weakness, Dysphagia, Convulsions, Hypertension and [MEDICAL CONDITION]. A review of Resident #1's most recent MDS assessment dated [DATE] revealed the resident had short-term memory loss and required the extensive assistance of one staff to provide physical assistance with eating. Resident #1 also required total assistance of facility staff with locomotion and transfers. A review of Resident #1's current care plan dated [DATE] revealed: Resident was in need of assistance with ADLs. Goal: All ADL needs will be met as evidenced by resident being clean, dry and odor free for the next 90 days. Interventions: Assist with feeding as needed. Set up help. Problem: Resident was a full code. Goals: Resident and family wishes will be honored during nursing facility stay. Interventions: Initiate CPR and Notify EMS. A review of the daily skilled nurses notes dated [DATE] revealed Resident #1 was alert, but confused with Memory Deficits. She required extensive assistance with eating with the assistance of one person providing physical help. The Dietician note dated [DATE] reflected a [DIAGNOSES REDACTED]. (No salt on table). It was further noted, "Resident spoonfed at meals..." According to www.merckmanual.com <http://www.merckmanual.com> retrieved on [DATE], "Dysphagia is difficulty swallowing. The condition results from impeded transport of liquids, solids, or both from the pharynx to the stomach... Complications: Dysphagia can lead to tracheal aspiration of ingested material, oral secretions, or both. Aspiration can cause acute pneumonia. Recurrent aspiration may eventually lead to [MEDICAL CONDITION]. Prolonged dysphagia often leads to inadequate nutrition and weight loss... ...Patients complain of difficulty initiating swallowing, nasal regurgitation, and tracheal aspiration followed by coughing. Most often, oropharyngeal dysphagia occurs in patients with neurological conditions or muscular disorders that affect skeletal muscles." In an interview with CNA E on [DATE] at 1:35 PM, she stated she had cared for Resident #1 for a year and a half. She stated Resident #1 had [MEDICAL CONDITION] and had needed more help and was total assistance with all ADLs. CNA E stated she had fed Resident #1 breakfast over the last two to three months and Resident #1 had required more time to eat, and it would take longer to feed her. 2. Nurse's Notes dated [DATE] at 5:00 PM reflected Resident #1 was sitting up in the wheelchair and taken to the dining room for supper. The notes reflected she was alert and verbally responsive with no signs or symptoms "...of any respiratory distress noted at this time. O2 Sat 94% on Room air." Normal oxygen saturation level is 95 - 100%. Same day at 5:40 PM, the Nurse's Notes reflected, "Resident was at the table with other residents and the CNA (CNA C) was getting ready to start feeding her when she suddenly slummed (sic) over on her side and the CNA noted she was not responsive. She alerted the nurse who was also in the dinning (sic) room and she rushed the pt. back to her room." At 5:45 PM: "Resident still breating (sic) (symbol for with) a weak carotid pulse. 911 call initiated." The Nurse's Notes were documented by LVN B. 3. Resident #5, whom the facility identified as alert and interviewable, was interviewed on [DATE] at 10:25 AM. She stated she was in the dining room when Resident #1 was in the dining room and had observed the resident being fed. Resident #5 stated there was a ,[DATE] CNA (CNA C, who worked the evening shift), who had been feeding the resident, who got up and left the dining room and then came back. "____ (Resident #1's) head was down. ___ (LVN A) came and took ____ (Resident #1) to her room." 4. In a confidential interview, the interviewee stated he/she had been sitting in the main dining room and had observed the CNA (CNA C) shovelling food into Resident #1's mouth. Resident #1 was sitting at the table, and the aide was there, and then the aide got up and walked away. CNA C left the dining room." I saw the resident slump over. I thought she was sick. The aide came in and lifted her head. Her head slumped back over. The aide called for (LVN A.) (LVN A) was at the kitchen door checking the tray cards. The aide called three or four times. (LVN A) got over there and lifted (Resident #1's) head. There was food coming out of her mouth. (Resident #1) was facing the wall." "Staff couldn't see her. We could. I looked over and the aide was gone. ____ (LVN A) took her out of the dining room. The fire people came in." The interviewee then stated, "There were two or three other residents at the table with ____ (Resident #1) at the time." The interviewee then stated again, LVN A came over and rolled Resident #1 out of the dining room. The nurse did not look in the resident's mouth before taking her out of the dining room. The interviewee then stated, Resident #1 should not have died . "I cried that night." 5. In an interview with Resident #6 on [DATE] at 10:50 AM, she stated she sat caddy-corner to the assisted dining table where Resident #1 sat. She stated, "...(CNA C) had put too much food in these people's mouth. I thought that before. So I would look over, and I would eat, then look over. The girl (CNA C) got up and left. A little bit later, the lady (Resident #1) had her head on the arm of the wheelchair. Her head was bent over. The aide came in, took the lady's head and pulled her up. The lady fell back again. The aide yelled. They pushed the lady right by our table. There was food coming out of her mouth, quite a bit. The fireman came." Resident #6 stated she was unsure how long the CNA had left Resident #1 alone. Resident #6 stated, "I thought to myself, why would they leave them sitting alone (referring to the residents at the assisted dining table)? I wondered were she went. She just fed and then left." 6. CNA I was interviewed on [DATE] at 3:10 PM. She stated on the day of the incident ([DATE]) with Resident #1, she had been assigned to work on the halls. During the meal service, she stayed on the hall to pass trays and answer call lights. CNA I stated she had walked into the dining room to get the tray cart on Thursday ([DATE]) and "met ____ (Resident #1) hanging down. There was milk or a liquid on her face. I was the first person who saw her. ____ (CNA C) wasn't around. No one was around. I started shouting and ____ (CNA C) came in and started yelling for ____ (LVN A)." CNA I then stated residents should not be left during meal service. 7. In an interview with LVN G on [DATE] at 3:40 PM, she stated she had been leaving the facility for the day on the day of the incident. She said she had been walking out and heard Resident #1 was coding. She stated she ran down to Resident #1's room. Resident #1 was not responding. LVN A and LVN B were removing food from Resident #1's mouth, finger sweeping the food out of Resident #1's mouth. "It was a white food, kind of pudding, white. They got enough out. ____ (LVN D) and I started CPR. The fire EMS came. They tried to Trachea her. The fireman stated he couldn't get a good clear path, because there was so much food. They were suctioning her, trying to get more food out. They were trying to get an airway. I didn't see her breathing." The DON provided a written statement by LVN G on [DATE] to the surveyor, which was dated [DATE]. The written statement reflected, "I was informed that ____ (Resident #1) was a none (sic) responsive I ran to her room where I saw ____ (LVN A) her charge nurse (LVN B) and ____ (LVN D) and several aids. ____ (LVN A and LVN B) were removing some thick white substance from her mouth while the CNA was cranking the head of the bed up. Upon removing the substance ____ (LVN A and LVN B) state that she was breathing and ____ (Resident #1) was turning blue. I state no she was not we need to start CPR I asked for the ambu bad (sic) to give two rescue breaths and I was informed that it was not on the cart I ran to the Oxygen room to look for the ambu bag and ____ (LVN A) said to look on her cart it might be there we could not find it. So I grab the O2 Sat machine ran back into ____ (Resident #1) where ____ (LVN D) was alone doing chess (sic) compression I switched with her and started chess compression her O2 Sat was low and we switch with doing chess compression until the fire department came. They started CPR and try to intubate her but the fire man said he can't get a clear view because of all the thick white substance. So they suction her and they continue to work on her upon exiting the facility." 8. A review of the Week at a glance menu provided by the Dietary Manager on [DATE] revealed the evening meal on [DATE] was Chicken Spaghetti, Vegetable Medley, Garlic Bread and Angel Food Cake." 9. Although Resident #1's Nurse's Notes dated [DATE] reflected the resident had not been fed and CNA C was at the resident's side when she became unresponsive, subsequent interviews with residents and staff revealed: 1) Resident #1 had already been fed some supper; 2) CNA C left her unsupervised; 3) CNA I found the resident unresponsive; 4) LVN A removed her from the dining room without assessing Resident #1, checking her for choking or implementing the [MEDICATION NAME] Maneuver and took her to her room, where other staff called 911 and started CPR. 10. In an interview with CNA C on [DATE] at 2:15 PM, she was asked about the incident with Resident #1. CNA C stated, "We were in the dining room." She (CNA C) had been feeding Resident #1. Resident #2 and Resident #4 were at the table with Resident #1 also. CNA C stated she fed Resident #1 three or four bites and then got up, because she thought Resident #1 was done eating. CNA C stated she got up and went down the hallway and then came back to the dining room. CNA C stated when she returned, Resident #1 had "Milk coming out of her nose." CNA C stated Resident #1's head was hanging down. She lifted the resident's head. There was no response, and the resident's head fell down. CNA C said, "I called for the nurse, ___ (LVN A)." CNA C stated she lifted Resident #1's head again, and it went right back down. The surveyor asked CNA C if she was allowed to leave residents while feeding them, and CNA C replied, "We are not supposed to." In a subsequent interview with CNA C on [DATE] at 3:10 PM, she stated LVN A did not look in Resident #1's mouth before she took the resident out of the dining room. "She (LVN A) looked at her (Resident #1) and rolled her out of the dining room. The DON provided a written statement by CNA C on [DATE] to the surveyor, which was dated [DATE]. The written statement reflected, "I had just started feeding ____ (Resident #1). She took about four bites and drink (sic) her milk. I got up and went down the hall and came back. Found her head down she had milk coming from her nose. I immediately call the nurse in the dinning (sic) room. She came and got her and took her to her room." A review of CNA C's personnel file revealed she was hired on [DATE]. A review of the education topics CNA C had been trained on revealed there was no education record for feeding a dependent resident. A review of the "Nurse Aide Proficiency Checklist" completed on [DATE] and signed by LVN A as having completed satisfactorily revealed CNA C had not been evaluated on her proficiency when feeding residents. 11. In an interview with LVN A on [DATE] at 2:05 PM, the LVN stated she was monitoring the dining room when CNA C called her over. She stated Resident #1 was slumped over. She saw food on the resident's face. The resident was slumped over, and it looked like she had fallen in her food. LVN A said, "I took her out and put her in bed. Then I checked her, and there was no food. I started CPR." When LVN A was re-interviewed at 2:20 PM (15 minutes later), she stated she did not complete the nurses note in the facility record for Resident #1. LVN B had. LVN A stated she told LVN B what had happened. LVN A stated Resident #1 had been facing the wall in the dining room. The CNA had hollered for her. Resident #1 was still breathing, so she rolled her to her room and put her in bed. In an interview with a visitor on [DATE] at 5:20 PM, he/she stated he/she had observed Resident #1's head tilt over and saw the resident's lips were blue. "That was the first thing I noticed. I heard someone call for her. ___ (LVN A) came over and took her straight out of the dining room." 12. A review of the EMS notes dated [DATE] "AOS (Arrived on scene) to find PT (patient) being given CPR by facility staff. Assessed PT and started CPR attempted to place OPA (oropharyngeal airway) unable to due to thick Vomitus. Suctioned and attempted ET (endotracheal tube) tube placement. Unable to place Et tube due to thick vomitus and inability to visualize cords. Suctioned more with little effect and placed a king tube size 4." A review of the hospital records revealed the CPR notes dated [DATE] revealed at 6:32 PM "...attempting to re-intubated. pt suctioned with undigested food particles." A review of the hospital physician's progress note dated [DATE] revealed: "PT went into Vtach ([MEDICAL CONDITION]), defibrillated. Pt re-intubated (King tube removed) multiple noodles with food particles removed from airway. Pulse lost. CPR initiated again with ACLS. Pulse never sustained. Pt expired 1847 (6:47 PM) with 50 min CPR. Clinical impression: Aspiration." A review of the Coding summary hospital record revealed Resident #1 had final [DIAGNOSES REDACTED]." 13. On [DATE] at 5:40 PM, CNA C was observed sitting at a square dining table, which sat four. She sat diagonally at the edge of the table. Resident #2 was on the right side of the CNA, and Resident #8 was on her left side. CNA C was observed scooping Resident #2's pureed food onto a spoon and feeding Resident #2 sideways from where she was sitting. The CNA did not look at Resident #2. She stared straight ahead. She did not monitor the resident to ensure the resident swallowed her food. CNA C did not offer fluids nor did she speak to the resident during the meal service. Resident #8, who was sitting to the left of CNA C, was observed eating the top of her sandwich. CNA C also fed Resident #8 sideways. She did not look at whether the resident was chewing nor did she observe whether the resident swallowed the previous bite of food before giving Resident #8 another spoonful of food. A review of Resident #2's [DATE] physician's orders [REDACTED]. She had [DIAGNOSES REDACTED]. A review of (Resident #2's) dietician note dated [DATE] revealed "Resident is spoonfed pureed diet with thickened liquids." A review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 was not oriented and required the total assistance of one staff member to eat. Review of Resident #2's care plan, which was initiated on [DATE] revealed the following: Problem: Resident is in need of assistance with ADLs. Goals: All ADL needs will be met as evidenced by resident being clean, dry and odor free. Interventions: Assist of one person with feeding, Extensive, total. 14. The DON provided facility policies and procedures, which were current on [DATE] to the survey team. One of them, with a revised date of [DATE] was entitled "Assisting the Impaired Resident with In-Room Meals." The procedures listed to feed an impaired resident work equally well whether the resident was in their room or in the dining room. The procedures included: "...5. Season the resident's food according to his or her likes and in accordance with the resident's diet. 6. Use a spoon to feed the resident. 7. fill the spoon only half-full. Feed the resident from the tip of the spoon, not the side. 8. Put the food in one side of the resident's mouth so that he or she can chew it more easily... 9... 10. Alternate food and liquids...." 15. A review of the facility's current Nursing Services Policy and Procedure Manual revised [DATE] revealed the following for the [MEDICATION NAME] Maneuver: Purpose: The purpose of this procedure is to prevent choking by expelling the foreign body airway obstruction. General guidelines. Unconscious Resident-lying down (or when unable to reach around the Resident). 1. Ease the Resident as gently as possible to the floor. 2. Call for help if assistance is not already present but do not leave the Resident unattended. 3. Position the Resident on his or her back with the arms at his or her side. 4. Perform abdominal thrusts as follows: a. Facing the Resident, kneel down and straddle the Resident's upper thighs with your body. b. Place the heel of one hand on the Resident's upper mid abdomen below the ribcage and above the naval and with fingers pointed toward the Resident's chest. c. Place the other hand directly over the positioned hand. d. Bring your shoulders over your hand. e. Use your body weight to press your hand into the Resident's upper abdomen with a quick upward thrust. 5. Perform the finger sweep maneuver to check for a foreign body as follows; a. Keep the Resident's face up. b. Perform the tongue-jaw lift to open the Resident's mouth (Note; moving the lower jaw moves the tongue off the throat and opens the airway). c. Perform the finger sweep using the index finger as a hook. 1. Insert your index finger into the Resident's mouth along the side of the cheek and across the base of the tongue. 2. Try to remove any foreign objects. 3. Avoid pushing foreign objects deeper into the throat. 4. Turn the Resident's head to one side if needed to sweep an object from the Resident's mouth. 6. Alternate steps four (4) and five (5) until the object is expelled. Arrange for the Resident to be evaluated by a physician immediately after the foreign body airway obstruction has been removed. 7. If unable to clear the foreign body from obstructing the airway arrange emergency transfer for the Resident to the nearest acute medical facility. 8. Proceed with CPR immediately if the Resident has no pulse or respirations. Documentation. The person performing this procedure should record the following information in the medical record. 1. The date and time the procedure was performed. 2. The name and the title of the individual/individuals who performed the procedure. 3. The exam time the choking began. 4. The exam time of any unconsciousness. 5. All assessment data obtained during the procedure. 6. The time the procedure was started and stopped. 7. The Resident's response to the procedure. 8. The signature and title of the person according to the data. Reporting. 1. Report results promptly to the supervisor and the attending physician. 2. Notify the attending personal physician of all assessment, data, observations, and results. 3. Report the information in accordance with the facility policy and professional standards. 16. I. PROFESSIONAL STANDARDS: A. The Texas Board of Nursing documented in their rules and regulations in the Texas Administrative Code (TAC), Title 22, Part II, Chapter 217, Subsection 217.11, effective [DATE], a Licensed Vocational Nurse shall - - (1)(D) Accurately and completely report and document (i) the client's status including signs and symptoms, and (vi) contacts with other health care team members concerning significant events regarding client's status; - (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; - (N) clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medications and treatment. - (P) Collaborate with the client, members of the health care team, and when appropriate, the client's significant other (s) in the interest of the client's health care. 17. An IJ was identified on [DATE] at 11:45 AM. The Administrator and the DON were notified of the IJ in the areas of Quality of Care, Professional Standards and Administration with Substandard Quality of Care. A Plan of Removal for the IJ was requested at that time. 18. On [DATE] at 12:25 PM, CNA J was observed spoon feeding a pureed diet to Resident #3. There were also thickened liquids on the table. Resident #3 was seated in a geri-chair. CNA J stated to the surveyor when Resident #3 held his food in his mouth, he was finished eating. The CNA then pushed Resident #3 onto 200 Hall 200 and left him unattended for two minutes. At 12:27 PM, the surveyor observed Resident #3 in the geri-chair on the 200 Hall. The resident's mouth was slightly open, and the resident appeared to be asleep. The resident was unattended by staff. The surveyor observed the resident to have food in his mouth. The Administrator approached the surveyor, and the surveyor showed him the food in Resident #3's mouth. He summoned LVN K. At that time, CNA J walked past the resident. The Administrator said to CNA J, "He has food in his mouth." CNA J replied, "Yes, someone told me that when he has food like that, he's done eating." The Administrator called the DON over. The DON told LVN K to take the resident to his room. From 12:27 PM to 12:35 PM, LVN K attempted several times to awaken Resident #3, but was unsuccessful. The surveyor noted during that time, the resident did not appear to be in respiratory distress. LVN K looked for swabs in the resident's room but was not able to locate any. The DON left the room and sent swabs back with CNA L. LVN K used a swab to remove approximately one half spoonful of light yellow/tan pureed food. Resident #3 coughed twice. The Record of Admission for Resident #3, dated [DATE], reflected he had a [DIAGNOSES REDACTED]." Resident #3's physician's orders [REDACTED]. The orders also reflected "Aspiration Precautions." A review of the facility's "Restorative Nursing Educational Record" entitled "Feeding a Dependent Resident" (undated) and provided by the DON on [DATE] after the IJ was identified revealed this was how the residents should have been fed: 1. Wash hands. 2. Greet resident by preferred name. 3. Explain procedure and encourage resident's participation. 4. Position resident's head and body supported as straight. 5. Prepare resident for mealtime by providing dentures or other adaptive equipment necessary. 6. Check meal for correct diet and foods. 7. Provide clothing protector if necessary. 8. Explain to resident what you are going to do. 9. Check that hot foods are hot (not too hot) and cold foods are cold. 10. Offer fluids to moisten throat. 11. Feed with a spoon filled with food no more than half-full. Use the tip of spoon to feed, placing gentle downward pressure on the lips and center of tongue. 12. Feed the resident at a comfortable rate, allowing resident time to taste, chew, swallow and rest between bites. 13. Offer fluids between every third or fourth spoon of solid food. 14. Continue feeding until resident has had enough or meal is finished. 15. Assure that resident remains with head elevated for at least 30 minutes after meal if able. 16. Observe and report residents who eat poorly, difficulty swallowing, inability to chew, or changes in responsiveness. 17. Record and report the dietary intake and fluid of resident. 19. On [DATE] at 3:25 PM, the facility was informed the Plan of Removal had been accepted by the Regional Office. The Plan of Removal reflected: 1) Re-educated all licensed nurses on immediately assessing a resident with noted significant change of condition to include checking blood pressure, pulse, respirations, temperature, oxygen saturation, pain, mental status and range of motion prior to removing resident from location. A competency based test will be given to each licensed nurse. Re-educate all licensed nurses on [MEDICATION NAME] maneuver. CPR-certified staff are to be scheduled every shift in the facility. A CPR certification course is scheduled for [DATE] in the facility for licensed nurses and CNAs. This re-education and competency based test will be completed on [DATE] at 2:30 PM by the DON, ADON and Staff Development Coordinator. Licensed nurses, including weekend licensed nurses, will not be allowed to return to work without completing this reeducation and competency-based test. New hire licensed nurses will not be allowed to work without completing the reeducation and competency-based test as well. The Staff Development Coordinator will monitor new hires to ensure completion and compliance. 2) Any residents with a significant change of condition will be discussed in the daily morning meeting, which will be attended by the Administrator, the DON, and ADON, and the assessment of this resident and the documentation of this assessment, notification of MD and responsible party will be reviewed for compliance. Charge nurses will immediately notify the DON in person or by telephone of any resident with significant change in condition and provide a thorough report. Date of completion will be [DATE] at 2:30 PM. 3) Each licensed nurse will be reeducated and provided a competency test regarding procedures to follow during a medical emergency. During this training, the use of the emergency cart will be reviewed with all licensed nurses and a return demonstration of the emergency cart usage and equipment will be provided by the DON, ADON, and Staff Development Coordinator. Assign and reeducate 400 hall charges on checking and monitoring crash cart to ensure supplies are available. The clinical record of each resident, who requires an emergency procedure will be reviewed for compliance during the daily morning meeting attended by the Administrator, the DON, and ADON. The date of completion will be [DATE] at 2:30 PM. 4) Reeducate all nursing staff on not leaving residents who require assistance with feeding unattended at the feeding table during meals and visually checking the resident's mouth for any food particles the resident may not have ingested. Charge nurses will monitor for compliance. Reeducation will be completed by the DON, ADON, and Staff Development Coordinator on [DATE] at 6:00 PM. A competency test will be given to all nursing staff. Completion date for this competency-based test will be [DATE]. Any nursing staff including the weekend staff who have not completed this reeducation and competency-based test will not be allowed to return to work. 5) Any resident who has been assessed as needing positioning during meals and with Dysphagia will be referred to speech therapy as needed on an ongoing basis. Review of the 24-hour report during daily morning meeting and any identified issues will be immediately addressed by the DON. 6) Staff members LVN A and CNA C were suspended pending investigation of providing inaccurate statements. One-to-one education with LVN B completed on [DATE] regarding accurate and based-on-fact documentation. All nursing staff will be cautioned by the DON, ADON, and Staffing Development Coordinator to answer questions accurately and truthfully. Date of completion [DATE] at 2:30 PM. 7) The DON and Administrator will monitor the reeducation and training program to ensure effectiveness and compliance. Any identified issues will be reviewed during the quarterly quality assurance meeting for three quarters and randomly thereafter. A QA meeting was scheduled for [DATE] at 1:00 PM. The Medical Director was unavailable, but the DON or Administrator will review the minutes with the Medical Director by phone today, [DATE] at 2:00 PM. 8 ) Dr. ____, the facility's Medical Director, was notified by the DON of the IJ situation on [DATE] at 1:00 PM. 20. Inservice sign-in sheets were provided with the Plan of Removal. The in-service records addressed the [MEDICATION NAME] Maneuver, CPR, documentation, and the facility's policy on assisting residents to eat. On [DATE] at 4:25 PM, the surveyor interviewed LVN O. She stated there was an in-service that morning. She was able to verbalize steps of assessment and interventions for unresponsive residents, including checking for pockets of food, the [MEDICATION NAME] maneuver and CPR. CNA Q was interviewed on [DATE] at 4:30 PM. He stated he had been in-serviced on feeding residents. He stated they had been instructed every time a resident was fed, they must give a sip of water. The staff had to sit with the resident afterward to ensure the resident had finished their food. A nurse had to come and check the resident's mouth for food before the resident left the dining room. CNA A stated if a resident choked, the staff must call for a supervisor to come and check the resident. On [DATE] at 4:33 p.m. the surveyor interviewed LVN Y. LVN Y stated an in-service was conducted, and topics of discussion were CPR, choking residents, process of steps when a resident chokes and/or becomes unconscious, Do Not Resuscitate (DNR) orders, and Code White (health emergency). He also verbalized a list