Every finding on record at The Heights of Tyler

Based on observation, record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet residents highest practicable physical, mental, and psychosocial needs for 1 of 4 residents reviewed for care plans, (Resident #1). Resident #1 was not care planned for making allegations of a consensual relationship with a staff member (CNA B), including that the staff member would no longer provide care for her. This failure could place residents at risk of not having their individualized needs met, and a decline in their quality of care and life. Findings included: Record review of the undated face sheet indicated Resident #1 was a [AGE] year-old female that admitted [DATE]. Record review of the physician's orders dated 3/24/26 indicated Resident #1 had diagnoses that included: Generalized Anxiety Disorder (persistent, excessive, and uncontrollable worry about every day, routine matters for at least 6 months), chronic atrial fibrillation (rapid irregular electrical signals causing the upper heart chambers to quiver instead of contracting properly), osteoarthritis (degenerative joint disease where protective cartilage on bone ends breaks down), and Dementia without behaviors (decline in mental ability such as memory loss, confusion, and behavioral changes-severe enough to interfere with daily life). Record review of the quarterly MDS dated [DATE] indicated Resident #1 had adequate hearing, clear speech, understood others and was understood by others. She had a BIMS score of 15 indicating she was cognitively intact. The MDS indicated Resident #1 was dependent for chair to bed transfer and rolling left and right in bed. Record review of the care plan dated 6/20/25 indicated for her self-care deficit, Resident #1 had osteoarthritis of both shoulders and hips. She required a 2-person assist for bed mobility and turning and repositioning. One of the interventions for ADL's was I prefer female staff only. This intervention was initiated 3/24/26. The care plan indicated she had impaired cognitive function/dementia or impaired thought processes. The care plan also indicated she took antianxiety medication. Record review of the PIR dated 3/7/26 indicated Resident #1 alleged that she had consensual relations with a care giver. Resident was requested to go to local hospital for evaluation. Resident refused. Internal resident assessment by licensed nurse revealed no trauma, no injury and no emotional effect. Licensed nurse noted noticeable increased confusion to baseline. Resident physician also evaluated in person.For the provider response: Alleged perpetrator put on suspension pending investigation. Resident interviewed by community administrator. Resident presented high level of confusion to baseline. Resident reports of the event varied in time of day and date several times. Resident also stated 'Never mind I'm just a crazy old lady.'. The PIR also indicated, Most interviews supported that this resident has been fixated on the accused - always requesting that he perform her care.The PIR indicated the facility determined the alleged abuse did not occur. During an interview on 3/24/26 at 10:06 AM, LVN A said Resident #1 was confused at times. She would tell stories about things that did not happen when she was confused. She said sometimes she got reality mixed up with the music she listened to. She said Resident #1 was recently telling her a story about her grandson. She knew Resident #1 was confused and the story could not have been true. She said Resident #1 was very fond of CNA B. She said she was obsessed with him. During an observation and interview on 3/24/26 at 10:21 AM, Resident #1 was in her w/c sitting on a mechanical lift pad (specialized fabric support used with a mechanical lift to safely transfer individuals with limited mobility from chair to bed). She was a larger woman with glasses on, and her hair done. Resident #1 said she and CNA B were in love and had consensual sex. She said she had sex with CNA B this month. She said she did not remember the day, but it was around 7:00 PM and her roommate was in the room. Then, she said her roommate was not in the room. She said it was alright and she wanted him to do that, it was consensual. She said she felt safe at the facility and was not afraid of anyone. She asked if it was March now. This surveyor said yes. She said maybe it was not this month, that it must have been in February it happened. She had not talked to CNA B since then. He was not her aide anymore. She said she saw CNA B at the nurse's desk when she was in therapy this morning. They did not speak. She said he was always nice to her and had always been nice. She said CNA B was the nicest person here. She said the ADM told her a staff could not have a relationship with a resident. She said if they were in love, it should be okay. She said CNA B did not say anything about being in love with her. She just knew it in her heart. Resident #1 said she does not plan on having sex with CNA B again because she does not want either of them to get into trouble. She hopes CNA B does not get into trouble, he is a nice kid and has a child he is raising. During an interview on 3/24/26 at 10:39 AM, CNA B said he was [AGE] years old. He said he had definitely never had any sort of a romantic or sexual relationship with Resident #1 and would not have. He said he believed she was obsessed with him. Staff were telling him she asked about him. He said this was the first he had heard about he and Resident #1 being in love. He worked 7:00 AM to 7:00 PM most days. He said Resident #1's roommate was usually in the room when he and staff provided care for Resident #1, but in the past he had probably cared for her with only himself in the room. He did not remember. He said to transfer her with the mechanical lift there had to be 2 staff. He said the ADM called him at home on Saturday 3/7/26 to suspend him, and he had not provided care for her since then. He was rarely assigned to her (prior to 3/7/26) and usually worked on the back section or the front section of that hall. Resident #1 was in the middle section, but he did help when short staffed. CNA B said most people did not know his actual name. He had a nickname {nickname}. He said she started calling him his nickname and adding her last name to it. (ie: {nickname} her last name). He asked Resident #1 to call him by his {nickname} or his first name. At first she was calling him her son, then it went to {nickname} and her last name. Everyone called him {nickname} and Resident #1 did not know his actual name until he told her. He said he had been suspended during the investigation and was back at work once the investigation concluded. During an interview on 3/24/26 at 1:08 PM, MDS C said she did not care plan Resident #1's allegation with CNA B. She said that would have been the responsibility of MDS E, the other MDS nurse. She said MDS E should have care planned it because the care plan tells the story of the resident. She said nurses or CNA's would need to know about the alleged incident because it could have been considered a behavior and they would better know how to handle the situation. During an interview on 3/24/26 at 1:25 PM, LVN D looked through Resident #1's care plan and said she did not see that Resident #1 was care planned for the accusation and incident with CNA B. She said that should have been on the care plan. During an interview and record review on 3/24/26 at 1:30 PM, the DON said Resident #1 was obsessed with CNA B. She said she knew that nothing had happened between Resident #1 and CNA B. She said CNA B would not ever work with or provide care for Resident #1 again. She said he does not even work on that hall anymore. She said they had never had issues or concerns about CNA B. She looked at Resident #1's care plan and said under ADL's the care plan indicated I prefer female staff. This surveyor asked her when that was put in the care plan and she clicked on it. She showed this surveyor, the date was 3/24/26. She said Today. She said the care plan saying she preferred female staff did not make sense because Resident #1 had no problems with males and preferred CNA B. She looked through the rest of the care plan and there was nothing there addressing Resident #1 alleging she had a consensual sexual relationship with a staff. She said there should have been something put in the care plan that she had claimed this so that the nurses knew about it. She said it was first the responsibility of MDS E, then after that it was her responsibility. She said everyone knew this had happened and she could not figure out how it was missed, and that the care plan did not address it. She said the care plan should have been updated immediately and should have been updated on the day it was called in to the State, 3/7/26. She said MDS E did not work on Tuesdays (today). She said she would have to make sure they went over care plans in their morning meetings to make sure they were getting everything on the care plans that should be there. During an interview on 3/24/26 at 2:18 PM, ADON F said Resident #1 was very confused at times and other times seemed very with it. She said at the time Resident #1 made the allegation about CNA B she had a UTI. She said Resident #1 should have been care planned for claiming a consensual relationship with a staff because if she was stating that was happening and was having moments of confusion it should be in the care plan. If that particular staff had been moved to a different hall, that should have also been care planned. She said the care plans being accurate was important so that other staff would know what was going on. The MDS nurses were responsible for updating a care plan. ADON F said she did not update care plans unless directed by the DON to do so. But, she said any nurse could update a care plan at any time if they wanted to. During an interview on 3/24/26 at 2:49 PM, the ADM said Resident #1 liked several men that were staff, but nothing ever came up like this. He said, Maybe it should have been care planned that Resident #1 made that allegation. But, they had done a good job to make sure all staff knew what was going on so they could protect the residents and staff. The ADM said he would keep CNA B off of Resident #1's hall and CNA B would not provide care for her in order to protect them both. He said the MDS nurses were primarily responsible for making sure the care plans were accurate. He said any nurse could work on a care plan. Ultimately the DON was responsible for care plans being updated and accurate. During a telephone interview on 3/24/26 at 4:26 PM, MDS E returned my call. She said she had been an MDS nurse for approximately 1.5 years. She said she was responsible for Resident #1's care planning. She said she should have care planned Resident #1 for the allegation of a consensual sexual relationship with staff. She said she did not really know how to word it. When asked by this surveyor why she did not update the care plan, MDS E said she did not know how to answer the question. She said it was important to care plan everything about a resident and everything had to be care planned for a resident so that staff knew what was going on. She said care planning Resident #1 for her allegation would have helped to protect her and staff. She said the allegation was a major issue. She said it was her job to make sure it was in the care plan. She said she did not know if anyone oversaw her care plans to make sure she had care planned everything necessary. Record review of a care plan policy with a revised date of January 2023 indicated: Guidelines:Care Plans The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventative measures. The care plan may also include the expressed preferences. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan should be initiated upon admission, continued to be developed during the initial 48-72 hours., throughout the completion of the admission comprehensive assessment. The care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the RAI manual. Additional updates to the care plan may be done as indicated. The care plan should be prepared, reviewed and updated in accordance with the RAI guidance on a routine cadence (admission, quarterly, annually and with significant change). Additionally, the care plan should be modified as appropriate and on an as needed basis as per the RAI instructions.

Based on observations, interviews and record review, the facility failed to ensure sanitation and housekeeping services were sufficient to maintain a clean and sanitary interior environment, including areas under resident's beds, for 4 of 11 resident rooms observed, (room [ROOM NUMBER] A & B, room [ROOM NUMBER] A & B, room [ROOM NUMBER] A & B, and room [ROOM NUMBER] A & B), observed for sanitary conditions. The facility failed to ensure and maintain a clean and sanitary interior environment, as evidenced by trash not empty, dust accumulation, debris, and lack of routine or incomplete daily housekeeping in resident's rooms and under-bed cleaning. These failures could result in inadequate sanitation, increased risk of respiratory irritation, infection, or pest attraction.Findings include: room [ROOM NUMBER]On 02/23/2026 at 9:30 AM, during an observation of room [ROOM NUMBER] A & B, revealed visible dust and lint accumulation, plastic spoons under the resident's bed, and scattered paper debris accumulated on the floor. The bedside trash container was full of trash and PPE gowns. During an observation and interview on 02/24/2026 at 10:37 AM, Resident #65, room [ROOM NUMBER]A, stated housekeeping typically cleaned the room daily, over the past couple of days during the weekend, the room was not cleaned, and trash was not emptied. The trash container was full of PPE gowns, and other trash. Resident #64, room [ROOM NUMBER]B, the floor was observed with paper debris, and dust and lint build-up were noted under the bed. room [ROOM NUMBER]On 02/23/2026 at 9:35 AM, an observation of room [ROOM NUMBER] A & B revealed visible dust, and lint, accumulated under the resident's beds (A & B). The bedside trash container was full of trash and PPE gowns. During an observation and interview on 02/24/2026 at 10:45 AM, Resident #127, room [ROOM NUMBER]A, reported that the trash container was full over the weekend and that her family member had to empty the trash herself. The resident further stated that the floor had not been cleaned since the previous week. There was paper debris on the floor, and dust accumulated under the bed. During an observation and interview on 02/24/2026 at 10:50 AM, a visitor of Resident #131, room [ROOM NUMBER]B, stated that housekeeping did not clean or mop the floor over the weekend. The bathroom trash container with PPE gowns was not empty, paper debris on the floor, dust and debris under bed. room [ROOM NUMBER]On 02/23/2026 at 9:40 AM, an observation of Room#107 revealed visible dust build-up, lint, candy wrapper, plastic spoon, and debris accumulated under the resident's beds, and on floor in (room [ROOM NUMBER] A). Additional observations noted that trash container was full. During an interview and observation on 02/24/2026 at 11:15 AM Resident # 90, room [ROOM NUMBER]B stated housekeeping cleaned the room, but could not state if cleaning under the bed was performed. Observation noted debris under the bed, including paper wrappers, a plastic spoon, and dust accumulation under the bed remained present after a housekeeping cleaning request made on 02/23/2026 related to a water spill. room [ROOM NUMBER]On 02/23/2026 at 9:45 AM, an observation of room [ROOM NUMBER] revealed visible dust build-up, lint, and debris accumulated under the resident's beds (A & B). During an observation and interview on 2/24/2026 at 10:55 AM, Resident # 35, 110A, stated housekeeping came to room daily, mop and empty the trash containers, but do not mop under the bed. The floor during interview had paper debris and dust accumulated under the bed. During an interview on 2/24/2026 at 11:00 AM, Resident #86, room [ROOM NUMBER]B, stated that housekeeping cleaned the room daily, including mopping and emptying trash in the room and bathroom. There was paper debris and dust accumulation under the bed. During an interview and observation on 02/25/2026 at 2:30 PM, the Housekeeper/Laundry Supervisor stated that resident rooms receive daily cleaning. She stated housekeepers are trained to clean resident rooms daily, including under beds by moving the bed when debris was visible by using a five- step and seven-step cleaning process. The Housekeeping/Laundry Supervisor stated that four housekeeping staff are scheduled daily, with one staff member assigned to each hallway, to provide routine facility cleaning. She stated that after housekeeping staff leave for the day, laundry staff provide housekeeping coverage until 7:00 PM. Coverage after 7:00p.m. was provided by nursing staff, including CNAs, and cleaning supplies are available to address spills or debris on the floor. Housekeeping/Laundry Supervisor observed rooms 101,103, and 107 visible debris under resident beds, indicating the routine cleaning did not consistently include under-bed area, despite under-bed cleaning being identified as a part of the five-step and seven step cleaning process. During an interview on 02/25/2026 at 2:45 PM housekeeper stated she previously served as a lead housekeeper and trainer and reported that staff are trained to use a five-step and seven-cleaning process, which includes moving beds when debris is visibly noted. She stated she frequently covers shifts when staff are absent due to call-ins. She further states that housekeeping training and in-services are provided by a contracted company. During an interview on 02/25/2026 at 02:50 PM, the Housekeeper company district manager stated that housekeeping staff are trained to clean resident rooms daily, including under beds, by moving the bed when debris is visible noted. She states housekeeping staff are trained to use a five- step and seven-step cleaning process in which copies of steps are posted inside supply closet door. She stated she expected housekeeping staff to follow the guidelines using the using the five- step and seven-step cleaning process. During an interview on 02/25/2026 at 3:00 PM CNA E stated after 7:00 PM. Nursing staff, including CNAs, provide housekeeping coverage and cleaning supplies are available in the supply area to address spills and debris on the floor. During an interview on 02/25/2026 at 3:15 PM CNA F stated after 7:00 PM, nursing staff provide housekeeping coverage and that cleaning supplies are in the supply area to address spills, accidents, and debris on the floor. During an interview on 02/24/2026 at 3:30 PM the DON stated that staff are informed that after housekeeping staff leave for the day, laundry staff provide housekeeping coverage until 7:00p.m. She stated that after 7:00 PM nursing staff, including CNAs, provide housekeeping coverage and that cleaning supplies are available to address spills, incidents, or debris on floors and in resident rooms. During an interview on 02/24/2026 at approximately 4:00 PM, the Administrator stated that housekeeping services are provided by a contracted company. He reported that housekeeping staff are trained to clean resident rooms daily, including cleaning them under beds by moving them when visible debris was present. He further stated that staff are trained in a five-step and seven-step cleaning process, with procedures posted on the inside of the housekeeping supply closet. The Administrator stated that the housekeeping manager/supervisor oversees daily operations. He also introduces the contracted company's district housekeeping manager and stated that he expected housekeeping staff to adherer to established company protocols and guidelines. A review of the February 2026 staffing schedule showed twice-daily deep-clean/focus room checks for rooms 101, 107, 213, 314, 402, and 407. Housekeeping shifts were scheduled from 8:00 a.m. to 2:00 p.m., 8:00 a.m. to 3:30 p.m., and 9:00 a.m. to 4:00 p.m., with laundry staff covering housekeeping duties from 4:00 p.m. to 7:00 p.m. A review of the contracted company's five-step daily patient/resident room cleaning procedure (dated 1/1/2000), showed that housekeeping staff are trained to empty trash, clean hard surfaces, spot clean walls, dustmop and damp mop. The procedure requires moving furniture as needed to clean the entire floor, including behind beds and dressers, and alone baseboards. A review of the contracted company's seven-step daily washroom cleaning procedure (dated 1/1/2000), indicated that housekeeping staff are instructed to check supplies, empty trash, clean and sanitize sinks, tubs, and commodes, spot clean walls or partitions, and dust mop and damp mop floors using an approved germicide solution to disinfect surfaces. A review of the Residents Room Cleaning Policy No. 008 (dated and last reviewed 2/1/2025) indicated staff must follow infection control precautions when cleaning. Floors are to be dust mopped, damp mopped, per infection control standards. Rooms are regularly cleaned and disinfected, with emphasis on high-touch surfaces such as light switches, bed rails doorknobs, and call lights.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed food service safety , in that: *Steam tables were dirty with food spatter on glass on all 4 Satellite Kitchens *12 Dirty cookie sheets containing carbon build-up on rack *2 Dirty muffins pans containing carbon build up were stacked against each other *Dishwasher test log, had been filled in and completed for the entire day These failures could place residents who ate food from the kitchen at risk of foodborne illness Findings included: During observations and interviews on 02/23/2026, the following was noted in the kitchen and satellite kitchens: *At 8:45 AM there were carbon built up on 2 muffin pans stacked against each other, 12 large dirty cooking sheets with carbon build up on a rack in the main kitchen and the DM said that was a build up over years and would have to check on replacing them. *At 9:45 AM Hall 200 steam table glass had spatter on the glass and dirty bottom shelf. *At 11:06 an interview with DA A identified the dishwashing/pot sink temperature sheet and stated he did pre-sign by initialing for the remainder of the day noon and night, he said he knew he was not sign until it was actually completed according to the Food Preparation and Service Policy, dated revised October 1, 2018. He said, this could cause food to be served in a manner that my not be safe and unclean. *At 11:07 AM on Hall 300 steam table glass had spatter on the glass and dirty bottom shelf. During an interview with DA B she said it was her responsibility as the server to clean the steam table and she has neglected to clean per policy. *At 11:12 AM on Hall 400 steam table glass had spatter on the glass and dirty bottom shelf. *At 11:55 AM on Hall 100 steam table glass had spatter on the glass and dirty bottom shelf. During a follow up visit to the kitchen on 02/24/2026 an interview with DM and the Clinical Director of Operations at 11:00 AM, the DM said she was trained and able to handle the current situation of the kitchen, temps recorded, and steam table cleaned, by making sue the kitchen staff who are assigned to the satellite kitchens clean their steam tables, and DA record temps as they obtain the temps. She had her food managers certification. During an interview on 02/24/2026 at 9:42 AM the DM said she did not have any documentation that staff have been in-serviced on kitchen sanitation. She said she could do it today. A review of documentation provided by the Clinical Director of Operations indicated on 02/24/2026 the kitchen staff was in-serviced on required to clean their steam tables, obtaining temperature and recording right date and time. Review of facility policy for Food Preparation and Service dated revised October 1, 2018. Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.

Based on observations, interviews, and record reviews. the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 2 of 3 residents (Resident #18, Resident #63) reviewed for oxygen therapy. The facility failed to ensure Resident #18 received oxygen at the rate ordered by the physician. Resident #18's oxygen was set at 3.5 LPM on 2 consecutive days and at 4.0 LPM on the third day instead of 2 LPM as ordered by the physician.The facility failed to ensure Resident #63's nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) was stored in a bag when not in use. These failures could place residents who receive oxygen therapy at risk for respiratory distress and infection.The findings included: 1.Record review of a face sheet dated 02/24/2026 indicated Resident #18 was a [AGE] year-old female who re-admitted to the facility on [DATE]. She had diagnoses which included COPD (chronic obstructive pulmonary disease - a progressive, irreversible lung disease causing obstruction, inflammation, and chronic airflow blockage) and dementia. Record review of an annual MDS dated [DATE] indicated Resident #18 had a BIMS score of 3 indicating her cognition was severely impaired. The MDS also indicated Resident #18 received oxygen therapy. Record review of a care plan dated 01/13/2025 noted Resident #18 had a concern for shortness of breath with interventions to address it which included the administration of oxygen as ordered by the physician. Record review of Resident #18's physician's orders dated 02/24/2026 indicated an order dated 01/30/2025 for her to receive oxygen via nasal canula at a flow rate of 2 LPM (liters per minute) continuously. During an observation and interview on 02/23/2026 at 10:28 AM, Resident #18 was receiving oxygen at flow rate of 3.5 LPM via nasal cannula. Resident #18 said she did not know anything about the oxygen except that she could not breathe without it. She said she was comfortable and respirations were noted to be even and unlabored. During an observation on 02/24/2026 at 02:00 PM, Resident #18 was noted receiving oxygen at a flow rate of 3.5 LPM via nasal cannula. During an observation on 02/25/2026 at 08:10 AM, Resident #18 was noted receiving oxygen at a flow rate of4.0 LPM via nasal cannula. During an interview on 02/25/2026 at 08:15 AM, LVN D checked Resident #18's physician's orders and said Resident #18 was to receive oxygen via nasal cannula at a flow rate of 2.0 LPM. She said she did not know why the oxygen setting was incorrect. She said the nurses were responsible for monitoring the oxygen delivery flow rates. LVN D said incorrect oxygen flow rates could compromise a person's respiratory status. During an interview on 02/25/2026 at 08:30 AM, the DON said the nurses were responsible for monitoring oxygen administration and ensuring the oxygen flow rates were set at the rate ordered by the physician. The DON said oxygen rates set higher than those ordered by the physician could place residents at risk for respiratory distress. She said over oxygenating could cause a resident to decrease their respirations and become oxygen deprived. The DON said she and the ADONs were responsible for ensuring the nurses followed the physicians' orders and the facility's policies regarding oxygen administration. Record review of the facility's Oxygen Administration Policy dated 03/14/2019 indicated the following: Compliance guidelines: A resident receives oxygen therapy when there is an order by a physician.Procedure:3. Obtain physician orders for oxygen administration. Orders should include the following:c. flow rate delivery. 2.Record review of Resident #63's undated face sheet indicated Resident # was a [AGE] year-old male admitted [DATE] with diagnoses including Other Specified Chronic Obstructive Pulmonary Disease (a respiratory illness that involves chronic obstruction of lung airflow) and Acute Respiratory Failure, Unspecified (a respiratory illness that occurs when the lungs fail to adequately exchange oxygen and carbon dioxide). Record review of Resident #63's most recent Quarterly MDS dated [DATE] indicated Resident #63 utilized a wheelchair and was fully dependent on staff for transfer between bed and wheelchair. The MDS indicated he had a BIMS score of 4, indicating severe cognitive impairment. The MDS indicated he had difficulty focusing attention and exhibited disorganized thinking. The MDS indicated Resident #63 had oxygen therapy while a resident and within the last 14 days. Record review of Resident #63's comprehensive care plan dated 06/18/2024, last updated 12/23/2025, indicated Resident #63 was at risk for shortness of breath and utilized oxygen therapy related to respiratory disease. Interventions included oxygen as ordered/recommended by physician. Record review of Resident #63's orders indicated:*Change O2 and/or nebulizer tubing Q Week, start date 10/27/2024, revision date 03/28/2025. *Oxygen at 2-3 Liters per nasal cannula for signs and symptoms of shortness of breath/comfort continuous, start date 10/27/2024, revision date 11/20/2025. *May use oxygen at 2-3 liters for comfort when in room resting and when out of room/bed as tolerated and intermittently for comfort, start date not indicated, revision date 10/22/2024. During an observation on 02/23/2026 at 10:09 AM, Resident #63's nasal cannula was on the floor beside the oxygen concentrator, not stored in a bag, in his room. During an interview on 02/25/2026 at 10:48, LVN J indicated that the oxygen concentrator in the shared bedroom was Resident #63's. LVN J indicated that this was her first day to work this week and she was unaware that Resident #63's nasal cannula had been improperly stored. LVN J indicated the risk of Resident #63's nasal cannula being on the floor instead of in a bag would be the potential for infection. During an interview on 02/25/2026 at 11:15 AM, ADON K indicated that she was responsible for ensuring that nursing staff are completing appropriate tasks. ADON K indicated that she was unaware of why Resident #63's nasal cannula would be found on the floor. ADON K indicated that the risk to Resident #63 of his nasal cannula being placed on the floor would be the potential for infection. During an interview on 02/25/2026 at 2:22 PM, the DON indicated that the nasal cannula was properly stored when it was in a bag. The DON indicated that the nurse was responsible for ensuring this was completed properly and that she was responsible for ensuring the nurse complete their appropriate tasks. The DON indicated that the risk to Resident #63 of his nasal cannula being placed on the floor is that debris could enter the cannula and cause infection. Record review of facility's Oxygen - Respiratory Tubing/Equipment Management policy dated 02/12/2018, revised January 2022, indicated the following: Compliance guidelines:To maintain properly functioning equipment and decrease the potential for the spread of infection by maintaining clean equipment and tubing bottles and masks.

Based on observations, interviews, and record review, the facility failed to ensure MDS data accurately reflected the resident's status for 1 of 6 residents (Resident #76) reviewed for MDS accuracy. This facility failed to indicate Resident #76's current nutritional approach was by feeding tube in MDS dated [DATE]. This failure could put residents at risk for an inaccurate comprehensive assessment record. The findings included: Record review of Resident #76's undated face sheet indicated Resident #76 was an [AGE] year-old male admitted [DATE] with diagnoses including Dysphagia, Unspecified (difficulty swallowing), Gastrostomy Status (indicating a person has undergone a procedure resulting in a permanent opening in the stomach for nutritional support), and Gastro-Esophageal Reflux Disease without Esophagitis (a condition in which stomach acid frequently flows back into the esophagus). Record review of Resident #76's admission MDS dated [DATE] indicated Resident #76 had unclear speech, was rarely/never understood, and usually had the ability to understand others. The MDS indicated Resident #76 had a BIMS score of 14, indicating normal thinking and memory. The MDS indicated Resident #76 utilized a wheelchair and was dependent on staff for all functional abilities. Section K0520 of the MDS indicated the Resident #76 had received Parenteral/IV feeding and a feeding tube while not a resident and. Section K0520 of the MDS did not indicate that Resident #76 received Parenteral/IV feeding and a feeding tube while a resident. Record review of Resident #76's comprehensive care plan dated 12/22/2025 indicated Resident #76 was at risk for nutritional deficits and/or dehydration. Interventions included nurse to provide enteral feedings and flushes as recommended by physician. Record review of Resident #76's orders indicated:*Enteral Feed, dated 12/09/2025*Every shift, flush G-Tube with 50cc of water before and after medication pass and feeding administration, dated 12/4/2025. *Every shift, confirm G-Tube placement per auscultation and aspiration before any feeding/medication/flush administered, dated 12/04/2025. *Formula: Jevity 1.5 at 55 cc/hr for 24 hours, dated 12/04/2025 Record review of Resident #76's hospital records dated 12/04/2025 indicated that an interventional radiology guided percutaneous endoscopic gastrostomy tube placement (a procedure used to insert a feeding tube directly into the stomach for people who cannot eat orally) was performed on 11/25/2025. During an observation on 02/23/2026 at 10:25 AM, Resident #76 was observed lying in bed. A Jevity formula bag and water bag was observed hanging beside the bed and Resident #76 nodded his head when asked if he received tube feeding. During an interview on 02/25/2026 at 10:35 AM, with both MDS LVN L and corporate MDS support nurse indicated MDS LVN L and MDS LVN M were responsible for completing the MDS. MDS LVN L indicated that MDS LVN M completed Resident #76's MDS, but was not present at the facility at the time of interview. The corporate MDS support nurse indicated she was responsible for overseeing the MDS process and ensuring accurate assessment. The corporate MDS support nurse indicated that MDS assessments were conducted by utilizing information from residents' charts, resident interview, and family interview. MDS LVN L indicated that it is likely that Resident #76's nutritional status was selected in error and indicated that completing the assessments can be tedious and that they have difficulty completing the assessments due to performing other responsibilities, including working as direct care staff. The corporate MDS support nurse indicated that it was important to have an accurate MDS assessment in order to provide proper care and transfer of information. The corporate MDS support nurse indicated that there was not a facility policy on accurate MDS assessments and that they utilized the RAI manual. During an interview on 02/26/2026 at 1:20 PM, the ADM indicated the MDS nurses were responsible for completing MDS assessments and that he was responsible for ensuring these are done correctly. The ADM indicated that the corporate MDS support nurse completed reimbursement follow ups. The ADM indicated that the MDS was completed through record review and interviews. The ADM was unable to provide a potential risk to residents for the MDS assessment not being accurately completed. The ADM indicated that there was no facility policy on accurate MDS assessments and that the facility utilized the RAI manual.

Based on interviews, and record review, the facility failed to meet professional standards of care for 1 of 6 residents (Resident #3) reviewed for professional standards when diagnosing a mental health disorder. The facility did not ensure Resident #3 had sufficient clinical documentation to support a new diagnosis of schizophrenia. This failure could place residents at an increased risk of inappropriate care planning, psychosocial stigma, and future treatment decisions based on incorrect clinical information. The findings included: Record review of Resident #3's undated face sheet indicated Resident #3 was an [AGE] year-old female originally admitted to the facility on [DATE] and most recently admitted on [DATE] and had the diagnoses of Alzheimer's Disease with Late Onset (a form of dementia that typically begins after the age of 65 characterized by memory and cognitive issues); Schizophrenia, Unspecified (a psychiatric diagnosis used when a person exhibits hallucinations, delusions, disorganized thinking, or abnormal behavior); Manic Episode, Severe with Psychotic Symptoms (characterized by a period of elevated mood, energy, and increased activity often accompanied by a break from reality); and Insomnia due to Medical Condition (a sleep disorder characterized by difficulty falling asleep, staying asleep, or waking too early and not being able to return to sleep). Record review of Resident #3's most recent Quarterly MDS, dated [DATE], indicated Resident #3 had clear speech, was usually understood, and usually understands others. The MDS indicated Resident #3 had a BIMS of 3, indicating severe problems with thinking or memory. The MDS indicated that Resident #3 had no evidence of an acute change in mental status from the baseline and did not exhibit inattention, disorganized thinking, or altered levels of consciousness. Record review of Resident #3's comprehensive care plan, revised 12/04/2026, indicated Resident #3 required anti-psychotic medication. Interventions included monitoring, documenting, and reporting to the MD signs and symptoms of psychotropic drug complications. Record review on 02/24/2026 at 10:20 AM of Resident #3's diagnosis report indicated that the diagnosis of Schizophrenia, Unspecified was created on 01/05/2026. Record review of Resident #3's medication orders indicated an order dated 03/28/2025 and revised 01/07/2026 for Olanzapine Tablet 5 MG (an antipsychotic medication used to treat mental health conditions such as Schizophrenia) 1 tablet by mouth at bedtime for Mania/Schizophrenia. A record review of Resident #3's inpatient psychiatric hospitalization records dated 01/25/2022 through 02/11/2022 indicated within the initial psychiatric evaluation dated 01/25/2022 indicated a current diagnosis of dementia with behavioral disturbance. The discharge summary within these records dated 02/11/2022 indicated a discharge diagnosis of dementia with behavioral disturbance. The inpatient psychiatric hospitalizations records did not indicate a diagnosis of Schizophrenia. Record review of Resident #3's referral documentation from hospice received by the facility on 03/05/2025 indicated the diagnoses of Alzheimer's Disease with Late Onset, Other Specified Depressive Episodes, Other Specified Anxiety Disorders, and Insomnia due to Medical Condition. The medication report on this documentation dated 03/05/2025 indicated Resident #3 was prescribed Olanzapine 5 MG 1 tablet orally at bedtime for sleep and anxiety dated 12/20/2024. A visit note report on this documentation dated 02/27/2025 indicated Resident #3 was not assessed for psychiatric symptoms. Record review of a progress note dated 01/05/2026 at 4:57 PM by MDS LVN M indicated the MD clarified Olanzapine diagnosis to Mania/Schizophrenia. The progress note indicated Resident #3's family was present and indicated to the doctor that Resident #3 used to speak to invisible people in her room or when alone and that Resident #3 was placed on Olanzapine during an inpatient psychiatric stay. Record review on 02/25/2026 at 3:18 PM of an undated medication consent indicated Resident #3 had the psychiatric condition of Mania/Schizophrenia and was prescribed Olanzapine 5 MG 1 tablet at bedtime. Record review on 02/25/2026 at 3:19 PM of a medication consent signed by Resident #3's representative on 4/23/2025 indicated Olanzapine 5 MG use for the diagnosis of psychotic disorder. During a telephone interview on 02/25/2026 at 2:38 PM, Resident #3's representative indicated he was unaware of the clinical indication for Resident #3 to receive an anti-psychotic medication. Resident #3's representative indicated that the facility provided her anti-psychotic medication like she's supposed to take it. During a telephone interview on 02/25/2026 at 2:54 PM, the MD indicated that the diagnosis of Schizophrenia was based on clinical findings. The MD indicated that Resident #3 had been prescribed Olanzapine by hospice prior to her admission to the facility and he continued this medication. The MD indicated that he had not reviewed any documentation from the local mental health agency and that Resident #3's representative indicated that Resident #3 had been hospitalized at an inpatient psychiatric hospital and obtained the diagnosis of Schizophrenia. The MD indicated he was not a psychiatrist, that he thought he had reviewed the documentation from the inpatient psychiatric hospital, and that he believed he was following the diagnosis that a previous psychiatrist had provided Resident #3. During an interview on 02/25/2026 at 3:40 PM, with LVN MDS M, the DON, and the VP of Clinical Operations, LVN MDS M indicated she had attended a care plan meeting with Resident #3's representative who indicated that Resident #3 had an inpatient psychiatric hospitalization and requested she continued to be prescribed Olanzapine. The VP of Clinical Operations and the DON indicated that they did not have documentation of Resident #3's previous inpatient psychiatric hospitalized but were obtaining it. During an interview on 02/25/2026 at 3:57 PM, the ADM indicated that he was unaware of Resident #3 obtaining the new diagnosis of Schizophrenia. The ADM indicated that the DON was responsible for obtaining clinical documentation to support this diagnosis and that they had discussions daily regarding this. The ADM was unable to identify a risk to residents for obtaining a new diagnosis of Schizophrenia without sufficient clinical documentation. The ADM was asked for a policy regarding new psychiatric diagnoses and did not provide this prior to exit. During an interview on 02/25/2026 at 4:15 PM, the ADM was asked for a policy regarding new psychiatric diagnoses and did not provide this prior to exit. During an interview on 02/25/2026 at 4:29 PM, the VP of Clinical Operations and the DON provided Resident #3's previous inpatient psychiatric hospitalization. The VP of Clinical Operations indicated that these records were not available for review by the physician prior to making the diagnosis of Schizophrenia.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #16) reviewed for pharmacy services. LVN C failed to flush Resident #16's enteral tube with water during medication administration as ordered by the physician. This failure could place residents who receive medications via a gastric tube (also called an enteral tube) at risk for tube occlusion (clogging), medication-nutrient interactions, reduced drug efficacy, and potential toxicity. Findings included: Record review of a face sheet dated 02/24/2026 indicated Resident #16 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included spastic diplegic cerebral palsy (permanent, non-progressive neurological disorder appearing in infancy and caused by abnormal brain development), aphasia (unable to speak), adult failure to thrive, dysphagia (difficulty with swallowing), gastrostomy status (having a gastric tube), developmental disorder, and constipation. Record review of a quarterly MDS dated [DATE] indicated Resident #16 was rarely understood, dependent on staff for all activities of daily living, and received liquid nutrition via a gastrostomy tube. Record review of a care plan dated 10/08/2025 indicated Resident #16 was at risk for nutritional deficits and/or dehydration risks and included an intervention to provide fluids as ordered. Record review of the physician's orders dated 02/24/2026 indicated an order dated 11/16/2023 to flush the gastric tube with 30ml water before and after medication administration and flush with 5-10ml water between each medication. During an observation and interview on 02/24/2026 at 08:43 AM, LVN-C was noted to prepare Resident #16's medications and administer them to him via an enteral tube (a tube placed through the abdominal wall into the stomach). LVN-C prepared 6 crushed tablets, 1 powdered medication, and 1 packet of granules medication for a total of 8 individual cups of medications diluted and/or dissolved in water and took them to Resident #16's bedside table. LVN-C halted the infusion of liquid nutrition and disconnected the feeding pump tubing from Resident #16's gastric tube (enteral tube). LVN-C proceeded to administer the 8 medications, one after the other. After LVN-C administered the third medication, she turned toward the surveyor and said she did not give any water between the medications because Resident #16 did not tolerate it. She said Resident #16 got fussy if it took very long to give his medicines. LVN-C then continued to administer the remaining medications. LVN-C did not flush the gastric tube with water prior to administering the first medication. LVN-C did not flush the gastric tube between each of the 8 medications. LVN-C did not flush the gastric tube after administering the last medication. LVN-C then reconnected the feeding pump tubing to the gastric tube and restarted the flow of liquid nutrition. LVN-C discarded the empty medication cups, washed her hands, and returned to the cart. LVN-C said she had not spoken to the physician about Resident #16's orders for water flushes with his medication administration. LVN-C said she did not know if the water ordered for flushing the tube during medication administration was included in the calculation of Resident #16's water needs. LVN-C said the water flushes were to help prevent the gastric tube from getting clogged. During an interview on 02/24/2026 at 11:21 AM, the DON said she expected the nurses to follow the physicians' orders for gastric tube water flushes. She said the water flushes help minimize the risk of the tubes getting clogged, provide the resident with water for hydration purposes, and assist with absorption of the medications into the blood stream. The DON said she was responsible for ensuring the nurses followed the physicians' orders for administration of medications via the gastric tube route. Record review of the facility's policy entitled Medication Administration via Enteral Tube indicated the following: Compliance Guidelines: To administer medications through an enteral tube in an accurate, safe, timely and sanitary manner.

Based on observation, interview and record review the facility failed to ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls could be made without being overheard for 3 of 7 residents (Residents #4, #27, #33, #36, #53, #58 and #85) reviewed for telephone use. The facility failed to provide a phone that could be used in an area, which would prevent resident conversations from being overhead. This failure could place residents at risk of having conversations being overheard and privacy rights not being respected. The findings included: During a group interview on 10/29/24 at 9:30 AM, Residents #4, #31 and #36 said the facility did not provide a phone for them to use, that would allow them to have a private conversation. They said the facility did not have a cordless phone for them to use and they had to use the phone at the nurse's station or the phone at the reception's desk. During an interview on 10/29/24 at 10:43 AM, LVN-A said the facility used to have a cordless phone, but they didn't anymore. She said she was not sure what happened to the cordless phone. During an interview on 10/29/24 at 10:43 AM, the Workforce Manager said the facility did not have a cordless phone; they used too but they don't have one now. During an interview on 10/29/24 at 10:48 AM, LVN-C said they did not have a cordless phone. She said she believed it stopped working when the facility was having a new system installed. During an interview on 10/29/24 at 10:54 AM, the ADM said the facility did not have a cordless phone. She said they used to have one, but not at this time. She said the residents could use an office. She said she could get a new cordless phone today. During an interview with Resident #4 on 10/29/24 at 11:47 AM, she said she didn't know where she could go for a private conversation. She said she had just used the phone at the nurse station, and everyone could hear her conversation. During an interview with Resident #31on 10/29/24 at 11:51 AM, she said she would not know where to go for a private phone conversation. She said she could not go anywhere but the nurse's station. During an interview with Resident #36 on 10/29/24 at 12:53 PM, he said he did not have a cell phone, he had to use his [NAME] device. He said when he received a phone call, there was no private place for him to take the phone call. He said he would have to take it at the nurse's station or the reception's desk, and that's not private. During an interview with the Activity Director on 10/29/24 at 2:16 PM, she said the residents could go to the nurse station, the front desk or they could go to an office, to use the phone. She said that issue had never come up in a Resident Council meeting and she had never discussed where residents could go for private phone conversations. During an interview with the ADM on 10/29/24 at 2:26 PM, she said the facility did not have a policy on resident phone use.

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 1 of 4 residents (Residents #6) reviewed for pharmacy services. The facility failed to ensure a physician's order provided clearly written instructions for the dose of cholecalciferol (Vitamin D3) Resident #6 was to be given. This failure could place residents at risk for not receiving accurate doses of medications and the intended therapeutic response of prescribed medications. Findings included: A record review of Resident #6's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included Dementia (a group of thinking and social symptoms that may interfere with daily functioning) and Vitamin D (cholecalciferol) Deficiency. A record review of Resident #6's MDS dated [DATE] noted Resident #6 had a BIMS score of 15 which indicated her cognition was intact. A record review of Resident #6's October 2024 physician orders and MAR reflected an order dated 06/06/2022 for Resident #6 to be given Cholecalciferol capsule give 50,000 unit by mouth every Thursday. The order did not specify the strength of the cholecalciferol capsules being supplied nor the number of capsules to be given to equal the ordered dose of 50,000 unit. During an observation and interview on 10/30/2024 at 11:45 AM, MA A withdrew a bottle labeled Vitamin D3 5000 IU from the medication cart and said she gave 1 (one) capsule from the bottle to Resident #6 every Thursday. She said she did not know if Vitamin D3 and cholecalciferol were the same thing. She said she did not know if unit and IU were the same thing. She said the name of the medication on the physician's order should match the name of the medication on the bottle. She also said the order should say what strength the capsules in the bottle were and how many of those capsules to give to meet the ordered dose. MA A said medication aides were not allowed to calculate how many capsules were to be given. MA A said the order was not clear and could result in Resident #6 getting an inaccurate dose. MA A said she should tell the nurse if a physician's order did not match the label on the medication container or if an order was unclear. She said she had not told the nurse. During an interview with LVN B on 10/30/2024 at 10:40 AM, she said cholecalciferol 50,000 IU was not available as a stock medication. She said it would come from the pharmacy on a card with a label which contained instructions for administration. During an interview with the DCO on 10/30/2024 at 11:55 AM, she said she would clarify Resident #6's physician order for cholecalciferol and let the pharmacy know. A record review of the facility's policy Medication Administration reflected the following: 2.b. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any reason to question the dosage or directions, the physician's orders shall be checked for the correct dosage schedule. c. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved. A record review of the Texas Administrative Code: Title 26: Part 1: Chapter 557: Rule 557.105 indicated the following: A medication aide permitted under this chapter may not: (5) calculate resident's or client's medication dosages for administration .

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #304) reviewed for infection control practices. 1.RN A failed to don appropriate PPE prior to providing wound care to Resident #304. 2.CNA B failed to don appropriate PPE prior to providing incontinent care to Resident #304. These failures could place the residents under their care at risk for exposure to possible transmission of communicable diseases and infections. Findings included: A record review of Resident #304's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #304 had diagnoses which included cerebral infarction (stroke), heart failure, chronic kidney disease, and indwelling urethral catheter (a thin tube that is inserted into the bladder through the urethra to drain urine). A review of Resident #304's admission assessment dated [DATE] reflected she had a foley catheter (a flexible tube that is left in place and drains urine from the bladder into a collection bag) and open wounds to her coccyx, sacrum, and buttocks. A record review of Resident #304's physician orders reflected an order dated 10/29/2024 for EBP. An observation during the initial tour of the facility on 10/28/2024 at 11:02 AM, revealed RN A, RN B, and RN C to be at the bedside of Resident #304. RN A was noted to be wearing disposable gloves while providing wound care to Resident #304's upper buttocks. She applied small squares of collagen (a type of dressing used to promote healing) to several open wounds on the Resident's upper buttocks area and covered them with a clean, dry dressing. RN A did not have a disposable gown on over her clothing. RN B was assisting RN A and RN C was observing the care from the foot of the bed. RN B and RN C did not make any comments regarding the absence of or need for a disposable gown during the provision of wound care. After completion of the wound care, RN A, RN B, and RN C left the room. As they left the room, CNA B entered the room carrying a bag with incontinent care items which included a disposable brief. CNA B donned a pair of disposable gloves and proceeded to complete the incontinent care. CNA B did not put a gown on to cover her clothing. There was no signage on the door nor on the wall outside the door to communicate the need for EBP. An observation on 10/28/2024 at 04:41 PM revealed there was no signage on the door of Resident #304's room to indicate the need for EBP. An observation on 10/29/2024 at 08:12 AM revealed Resident #304 had sign on her door which indicated EBP was to be used when providing direct care activities. During an interview with RN A on 10/30/2024 at 11:30 AM, she said she was the Infection Preventionist. She said EBP signs were to be placed on the doors upon residents' admission to the facility if indicated. She said residents with indwelling devices and wounds required EBP. She said Resident #304 required EBP because she had open wounds and a foley catheter. She said she did not put a disposable gown over her clothes when she provided Resident #304 wound care. RN A said she should have put a gown on prior to initiating wound care. She said the purpose of EBP was to reduce the risk for the spread of infection. During an interview on 10/30/2024 at 12:05 PM, the staffing coordinator said CNA B was an agency aide and was not available for interview. During an interview on 10/30/2024 at 04:12 PM, RN D said an EBP sign on a resident's door meant gloves and gowns were to be worn when providing direct care to the resident. During an interview with CNA C on 10/30/2024 at 4:15 PM she said she was supposed to wear gloves and a gown when caring for a resident with an EBP sign on the door of their room. A record review of the facility's policy titled Infection Prevention and Control dated 03/13/20219 reflected the following: EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing Residents/Patients with the following clinical indication should be under EBP: Significant Wounds such as chronic wounds, ulcers, open PUI, or complicated/non-healing incisions or wounds and/or wounds requiring a dressing Indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. EBP should be utilized during high-contact care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use ., wound care. 12. Implementation of Isolation and/or Precautions: Post clear signage .on the door or wall outside of the resident room indicating the type of Precautions and required PPE For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves . A record review of the facility's policy titled Professional Standard of Care reflected the following: Practices a)Licensed nurses should practice within the constraints of applicable state laws and regulations governing their practice and should follow the guidelines contained in the communities' written policies and procedures

Based on interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 2 of 3 residents (Resident #1 and Resident #2) reviewed for accurate medical records. MA C failed to correctly document in the EMR with regards to Resident #1's metoprolol Tartrate 50 mg, on 9/14/24. MA E failed to correctly document in the EMR with regards to Resident #2's entresto 24/46 mg adminstration on 9/29/24. These failures could place resident's at risk of unnecessary treatment, adverse drug reactions, or inadequate treatment. Findings included: Record review of Resident #1's face sheet dated 10/4/24 indicated she was [AGE] years old readmitted to the facility on [DATE] with diagnoses including history of stroke, Type II diabetes, COPD ( chronic obstructive pulmonary disease-group of lung diseases that block airflow and make it difficult to breathe) A-Fib ( Atrial fibrillation is an abnormal heartbeat caused by extremely fast and irregular beats from the upper chambers of the heart) and high blood pressure. Record review of the MDS dated [DATE] indicated Resident #1 had unclear speech, usually others and usually made herself understood. The MDS indicated she had moderate cognitive impairment (BIMS of 10). The MDS indicated Resident #1 had no behavior of rejecting care. The MDS indicated Resident #1 was dependent on staff for; oral hygiene; toileting hygiene; showering/bathing; dressing the upper body; dressing the lower body; and putting on/taking off footwear. The MDS indicated Resident #1 required supervision or touching assistance with eating. Record review of the care plan dated 9/12/24 indicated Resident #1 had chronic health conditions, the care plan interventions included; administer medications as recommended by the physician; and monitor my vital signs as indicated. Record review of the physician order summary dated 10/4/24 indicated Resident #1 had an active order for metoprolol Tartrate 50 mg, 1 tablet two times a day related to high blood pressure. The order indicated the medication should be held for a SBP less than 110 mmHg or ;a DBP less than 60 mmHg or; a pulse less than 60bpm. Record review of Resident #1's MAR for September 2024 indicated she had been administered her metoprolol Tartrate 50 mg, 1 tablet with a pulse outside of the order parameters on the following dates; *9/14/24, heart rate 55 bpm administered by MA C; *9/18/24, heart rate 58 bpm administered by MA B; and *9/30/24, heart rate 56 bpm administered by MA B. During an interview on 10/4/24 at 1:55 p.m., MA C said she worked at the facility in a prn compacity. MA C said the hall Resident #1 resided on was not her usual hall. MA C said she would not have administered the metoprolol to Resident #1 with a heart rate less than 60 bpm. MA C said the medication works to lower blood pressure and heart rate and could cause Resident #1's heart rate to drop below a normal rate if it was administered with a heart rate below 60 bpm. MA C said the MAR requires the entrance of a heart rate with the administration of the medication and she would have entered the rate of 55 bpm. MA C said she had either documented the incorrect heart rate by mistake or documented the administration by mistake. 2. Record review of Resident #2's face sheet dated 10/4/24 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses which included degenerative disease of the basal ganglia (a degenerative condition that occurs when the basal ganglia, a set of brain structures that control speech, movement and posture) are damaged or fail to function, hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following stroke, aphasia ( affects a person's ability to express and understand written and spoken language) and high blood pressure. Record review of Resident #2's MDS dated [DATE] indicated he had unclear speech. The MDS indicated Resident #2 usually made himself understood and usually understood others. The MDS indicated Resident #2 had severe cognitive impairment (BIMS of 5). The MDS indicated he had no behavior of rejecting care. The MDS indicated Resident #2 was dependent on staff for toileting and putting on/taking off footwear. The MDS indicated Resident #2 required maximal assistance with showering/bathing and dressing the lower body. The MDS indicated he required partial assistance with oral hygiene, dressing the upper body, and personal hygiene. The MDS indicated he required set up/clean up assistance with eating. Record review of Resident #2's care plan dated indicated he had heart disease and was at risk for cardiac complications. The care plan interventions included; administer medications as ordered by my physician and monitor vital signs as indicated. Record review of the physician order summary dated 10/4/24 indicated Resident #1 had an active order for entresto 24/46 mg, 1 tab by mouth once a day for high blood pressure. The order indicated the medication should be held for a SBP less than 120 mmHg or ;a DBP less than 55 mmHg or; a pulse less than 55bpm. Record review of Resident #2's MAR (medication administration record) for September 2024 indicated he had been administered his entresto 24/46 mg, 1 tab with a pulse outside of the order parameters on 9/29/24. His heart rate was 53 bpm and the medication was administered by MA E. During an interview on 10/4/24 at 2:00 p.m., RN A said MAs should ensure they document vital signs and medication administration correctly. RN A said it was important that medical records are complete and accurate. RN A said incorrect documentation could negatively affect residents as nurse practitioners and physicians make treatment decisions in part based on the information in medical record. During an interview on 10/4/24 at 2:07 p.m., RN D said MAs should ensure they document vital signs and medication administration correctly. RN D said inaccurate documentation of vital signs and medication administration is incorrect information that may be used in treatment decisions. During an interview on 10/4/24 at 2:48 p.m., MA E said worked for a staffing agency and had worked regularly at the facility in the past (in 2023) but recently (September 2024) started working at the facility again. MA E said she had been a MA for [AGE] years and would not have Resident #2's entresto medication with a heart rate of 53 bpm even if there were not written parameters without checking with the nurse. MA E said she probably entered Resident #2's heart rate incorrectly if the administration was documented. MA E said the '5' and the '6' are right beside each other on the keyboard and she hit the wrong key. MA E said there was no doubt in her mind she had charted incorrectly. During an interview on 10/4/24 at 3:02 p.m., the Administrator said it was important for medical records to be accurate and expected staff to ensure they accurately documented vital signs and medication administration. Record review of the facility policy and procedure titled Medical Records revised January 2023 reflected, . Compliance Guidelines: A medical record is maintained for every person admitted to a community in accordance with accepted professional standards and practices . The medical record consists of but not limited to the following: . a record of the resident's assessments; the plan of care and services provided . The facility policy and procedure did not further elaborate on the importance of accurate vitals signs and medication as part of the medical record.

Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmacy services. MA B failed to hold Resident #1's metoprolol (a medication used to treat high blood pressure and elevated heart rate) when Resident #1's pulse was outside of the physician ordered parameters on 9/18/24 as well as 9/30/24. These failures could place residents at risk of receiving unnecessary medication and significant adverse effects from medication error. Findings included: Record review of Resident #1's face sheet dated 10/4/24 indicated she was [AGE] years old readmitted to the facility on [DATE] with diagnoses including history of stroke, Type II diabetes, COPD ( chronic obstructive pulmonary disease-group of lung diseases that block airflow and make it difficult to breathe) A-Fib ( Atrial fibrillation is an abnormal heartbeat caused by extremely fast and irregular beats from the upper chambers of the heart) and high blood pressure. Record review of the MDS dated [DATE] indicated Resident #1 had unclear speech, usually others and usually made herself understood. The MDS indicated she had moderate cognitive impairment (BIMS of 10). The MDS indicated Resident #1 had no behavior of rejecting care. The MDS indicated Resident #1 was dependent on staff for; oral hygiene; toileting hygiene; showering/bathing; dressing the upper body; dressing the lower body; and putting on/taking off footwear. The MDS indicated Resident #1 required supervision or touching assistance with eating. Record review of the care plan dated 9/12/24 indicated Resident #1 had chronic health conditions, the care plan interventions included; administer medications as recommended by the physician; and monitor my vital signs as indicated. Record review of the physician order summary dated 10/4/24 indicated Resident #1 had an active order for metoprolol Tartrate 50 mg, 1 tablet two times a day related to high blood pressure. The order indicated the medication should be held for a SBP less than 110 mmHg or ;a DBP less than 60 mmHg or; a pulse less than 60bpm. Record review of Resident #1's MAR (medication administration record) for September 2024 indicated she had been administered her metoprolol Tartrate 50 mg, 1 tablet with a pulse outside of the order parameters on the following dates; *9/14/24, heart rate 55 bpm administered by MA C; *9/18/24, heart rate 58 bpm administered by MA B; and *9/30/24, heart rate 56 bpm administered by MA B. Record review of Resident #1's MAR for October 2024 indicated she had been administered her metoprolol Tartrate 50 mg, 1 tablet with a pulse outside of the order parameters on 10/1/24. Her rate was 56 bpm, and the medication was administered by MA B. During an interview on 10/4/24 at 9:30 a.m. Resident #1 responded yes when asked if the facility had been administering her medications. Resident #1 was not able to identify her medications or if any medications had been held. During an interview on 10/4/24 at 1:55 p.m., MA C said she worked at the facility in a prn (as needed) compacity. MA C said the hall Resident #1 resided on was not her usual hall. MA C said she would not have administered the metoprolol to Resident #1 with a heart rate less than 60 bpm. MA C said the medication works to lower blood pressure and heart rate and could cause Resident #1's heart rate to drop below a normal rate if it was administered with a heart rate below 60 bpm. MA C said the MAR requires the entrance of a heart rate with the administration of the medication and she would have entered the rate of 55 bpm. MA C said she had either documented the incorrect heart rate by mistake or documented the administration by mistake. During an interview on 10/4/24 at 2:00 p.m., RN A said she was one of the 2 facility ADONs. RN A said MA B should not have administered Resident #1's metoprolol when her pulse was outside of the physician ordered parameters. RN A said metoprolol was a medication used to treat high blood pressure and lower heart rate. RN A said the medication being administered outside the parameters set by the physician could cause Resident #1's heart rate to drop to low. RN A said currently herself and RN D were working together with corporate to fulfill the duties of the DON role. RN A explained the facility had hired a new DON who would start in a few weeks. RN A said currently there was a system in place to identify when medications where held (not administered) to Resident but there was not a system in place to identify when a Resident had been administered medication outside ordered medication parameters. RN A explained in the EMR system if a MA documented a medication was not administered, they were required to enter a numerical code that indicated why the medication was held. RN A said she (RN A) could then run a report that would reflect why medications were held. RN A said there was no report she currently could run in the EMR system that would allow/ enable her to see when Residents were administered medications, despite documented vital signs outside of physician ordered parameters. RN A said she would speak to corporate office to see if EMR system could be worked to enable her to run such a report. During an interview on 10/4/24 at 2:07 p.m., RN D said she was one of the 2 facility ADONs. RN D said MA B should not have administered Resident #1's metoprolol when her pulse was outside of the physician ordered parameters. RN D said the medication being administered outside the parameters set by the physician could cause Resident #1's heart rate or blood pressure to drop to low. RN D said she was not aware of any report that could be ran to see if Residents were being administered medication outside of physician ordered parameters. RN D said it was important for Residents to be administered medications as ordered by the physician. During an interview on 10/4/24 at 2:20 p.m., MA B if she had documented she administered the metoprolol to Resident #1 on 9/18/24 and 9/30/24 she probably had administered it. MA B said she would like to think that she incorrectly documented either the pulse or the administration itself but could not say for sure. MA B said it was important to ensure residents were administered medications as ordered and in the case of Resident #1 and her metoprolol it was important because her heart rate could drop to low. During an interview on 10/4/24 at 3:02 p.m. the Administrator said it was important for residents to be administered medications as ordered by the physician/within physician ordered parameters for the health and safety of the residents. The Administrator said she planned to reach out to corporate to see if something could be changed in the EMR to allow better monitoring and compliance with physician ordered parameters. Record review of the facility policy and procedure titled Medication Administration, revised January 2024 stated . Resident medications are administered in an accurate, safe, timely, and sanitary manner . If applicable and/or prescribed, take vital signs or tests prior to administration of the dose . Administer medications as ordered by the physician.

Based on interview, and record review, the facility failed to ensure resident who were transported by the facility were free from abuse for 1 of 1 resident (Resident #1 ) reviewed for abuse. The facility failed to ensure Resident # 1 was protected from abuse. The noncompliance was identified as PNC. The noncompliance began on 09/22/2023 and ended on 09/27/2023. The facility had corrected the noncompliance before the survey began. This failure had the potential to affect all residents who depend on the facility for transportation to medical appointments or other social outings. The findings included: Record review of Resident #1's face sheet, dated 09/18/24, indicated the resident #1 was readmitted to the facility on [DATE], with diagnosis to include, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, unspecified severe protein-calorie malnutrition, other disorders of phosphorus metabolism (the body's phosphate levels are abnormal, either too high or too low), interstitial emphysema (when to air leaks into the lung's connective tissue, damaging lung structure) and cachexia (significant loss of muscle and fat mass). Resident #1 has a BIMS (Brief Interview for Mental Status) score of 05. Review of the facility's provider investigation report, dated 9/22/2023, indicated Resident #1 informed an un-named nurse manager, that Driver - A called her a stupid bitch, on 09/22/2023, while driving her to a medical appointment. During an interview on 09/17/24 at 1:44PM, Driver - A, said she was the van driver who transported Resident #1 to a medical appointment on 09/22/2023. She said she transported Resident # 1 to the address of the medical facility, she was given, but when she arrived, the medical facility informed her, they need to be somewhere else. She said when she loaded Resident #1 back up, Resident #1 was crying and yelling, saying she's suppose to have surgery that day and she wanted to get this thing off her foot. She said she told Resident #1, that was where they were going, and when she started driving, Resident #1 continued to cry, and got louder. She said she turned the radio up, thinking it would calm her down, but she got even louder. She said she reiterated to Resident #1 that was where they were going, that she was going to have surgery that day, that they were just sent to the wrong location. She said after getting to the next location, she went inside to double check that Resident #1 was having surgery at that location. She said the facility informed her that Resident #1 was not on the schedule for surgery. She said she call Medical Records - B, and informed her that she was bring Resident #1 back to the facility because she was not scheduled for surgery. She said she let Resident #1 know, she was not scheduled for surgery today, there was some kind of mix-up. She said Resident #1 kept crying and screaming, telling her she is supposed to have surgery that day and she wanted this thing off her foot. She said the radio was still on, she turned it up a little, Resident #1 got louder over the music, and she eventually said, god damn it, I'm doing the best I can, what the hell you want me to do. She said she brought Resident #1 back to the facility and put her at the nurse station where she continued to yell about having surgery. When asked, Driver- A said she had taken abuse and neglect training and she did not believe her use of god damn it or hell was verbal abuse. When asked to define verbal abuse, Driver - A said, making a resident feel uncomfortable or insulting them about their diagnosis. When asked if she received any disciplinary action, Driver - A said she was suspended for 2-3 days and had to go through abuse and neglect training again. Driver - A denied calling Resident #1 a stupid bitch. During interview on 09/17/2024 at 1:55PM, Medical Records - B said she noticed Resident #1 was fussing, yelling out a lot, when she was brought back to the facility, so she decided to ride with Driver - A, when she took Resident #1 back to her medical appointment. Medical Records B said she and Driver -A, did not have any conversation about Resident #1 behavior, during the drive to the appointment or returning from the appointment. Medical Records B said she was not aware of any name calling Driver - A, may have used towards Resident #1. During interview on 09/17/2024 at 2:35PM, the Administrator said she was not with the facility at the time of the incident. She said the former Administrator and the former DON are no longer with the facility. She said she was not aware of who the un-named nurse manager was, but she does not believe that person is with the facility. The Administrator said she is not aware of any performance issues with Driver - A, since she became the Administrator. Review of Driver - A's personnel file, on 09/18/2024, indicated an investigation of the allegation of abuse, was conducted and Driver - A did receive a suspension. The review also revealed Driver - A also completed abuse and neglect training on 09/27/2023. Since the time of the incident, there were no documented issues with the Van Driver. Review of a facility policy titled: Abuse Guidance: Preventing, Identifying and Reporting, with a revision date of 10/2022, revealed: Verbal abuse is the oral written or gesture language that willfully include the use of disparaging and derogatory term to residents or their family or within hearing distance, regardless of their age, ability to comprehend, or disability . The noncompliance was identified as PNC. The noncompliance began on 09/22/2023 and ended on 09/27/2023. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control practices. 1. The facility failed to ensure a wound vacuum cannister with red - brown liquid was not left in Resident #1's and Resident #2's room on 08/28/24. 2. The facility failed to ensure a brown substance was not present on the handrail in Resident #3's bathroom on 08/28/24. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1. Record review of Resident #1's face sheet, dated 08/28/24, indicated she was admitted to the facility on [DATE]. Her diagnoses included iron deficiency anemia secondary to blood loss (a deficiency of iron in the body related to a loss of blood), and chronic kidney disease (a disease where the kidneys do not function as well as they should). Record review of Resident #1's quarterly MDS assessment, dated 07/25/24, indicated she had a BIMS score of 1, which indicated severe cognitive impairment. Record review of Resident #1's progress note, dated 08/18/24, indicated her wound vacuum was removed and she was sent to the hospital on 08/18/24. During an observation on 08/28/24 at 11:00AM, Resident #1 was not in the room at this time. There was a facility wound vacuum at the bedside. It was half full of a brown - red substance. The tube was still connected to the canister, and it was dangling off the bedside table to the floor. During an interview on 08/28/24 at 11:02AM, the Administrator said Resident #1 was still in the hospital. During an observation on 08/28/24 at 1:51PM, the wound vacuum was still at bedside, half full of a brown-red substance, with the tube still dangling off the side of the bedside table to the floor. During an observation on 08/28/24 at 3:03PM, the wound vacuum was still at bedside, half full of a brown-red substance, with the tube still dangling off the side of the bedside table to the floor. Record review of Resident #2's face sheet, dated 08/28/24, indicated she was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), and cellulitis (a bacterial infection that affects the skin's deeper layers and the tissue underneath). Record review of Resident #2's Admission MDS assessment, dated 08/14/24, indicated she had a BIMS score of 15, which indicated intact cognition. She was usually understood and usually able to understand others. During an observation on 08/28/24 at 11:18AM, Resident #2 was in her wheelchair, in her and Resident #1's shared room, the wound vacuum was still present on Resident #1's side of the room, half full of a brown-red substance, with the tube still dangling off the side of the bedside table to the floor. During an interview on 08/28/24 at 3:05PM, Resident #2 was in bed, in her and Resident #1's shared room. She said she saw the wound vacuum on Resident #1's side of the room. She said it was gross and she thought the staff would have cleaned it up by now. 2. Record review of the face sheet dated 3/27/24 indicated Resident #3 was [AGE] years old female admitted on [DATE] with diagnoses including Amputation of Right Hand, Gangrene (a serious condition that occurs when tissue dies due to a lack of blood supply), Tachycardia (a heart rate that's faster than 100 beats per minute while at rest). Record review of the Quarterly MDS dated [DATE] indicated Resident #3 was understood and understood others. The MDS indicated a BIMS score of 06 which indicated Resident #3 was significantly cognitively impaired. The MDS indicated Resident #3 was dependent for toileting. During an observation and interview on 8/28/24 at 1:20 p.m. inside Resident #3's bathroom had an unknown brown substance on the toilet handrail. Resident #3 said that the feces had been there for two weeks. She said that she has not asked anyone to clean it up. During an observation on 8/28/24 at 3:40 p.m. inside Resident #3's bathroom a brown substance was observed smeared on the handrail for the toilet. During an interview on 08/28/24 at 3:42PM, ADON A said she did not expect the wound vacuum to be left at the bedside. She said she expected the staff to dispose of the canister and tubing into a biohazard bag once it was disconnected from the resident. She said that it was an infection control issue. She said the brown substance on the railing should have been cleaned by the aides. She said housekeeping was expected to clean everything but bodily fluids. During an interview on 08/28/24 at 3:53PM, Corporate Nurse B said her expectation was for the staff to properly discard of the biohazard material. She said housekeeping and nursing staff were responsible for cleanliness of the bathroom and ensuring there was not a brown substance on the handrails in the bathroom. She said the risk to the residents was possible infection. During an interview on 08/28/24 at 4:00PM, the Administrator said she expected the staff to clean up the biohazard material and to dispose of the wound vac canister and tubing. The risk to the residents would be infection. Nursing was responsible for cleaning up the canister and any staff were responsible for cleaning up the brown material. Record review of the facility's Infection and Prevention Control policy, last revised April 2024, stated: .The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program . 9. Prevention of Infection a. Important facets of infection prevention include: (1) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures; . .(5) educating staff and ensuring that they adhere to reporting exposures to potentially infectious materials; (6) educating staff and ensuring that they adhere to proper infection prevention and control practices when performing resident care activities as it pertains to his/her role responsibilities and situation . .(8) immunizing residents and staff to try to prevent illness; . .(10) disinfecting multi-patient use equipment or supplies after each use and stored appropriately; i.e., foot care equipment/supplies, including but not limited to nail clippers, scalers, files, and burr tools should be stored separated from clean, un-used foot care equipment or supplies. Reusable equipment or devices (e.g., scalers, electronic nail file, and surgical instruments) that are used on one resident should be cleaned and disinfection or sterilization prior to use according to manufacturer's instructions. If the manufacturer does not provide multi-patient use instructions, the device should not be used for multi-patient use .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen and 4 of 4 satellite kitchens reviewed for food service. Opened food packaging in the pantry and walk-in freezer were not closed after opening. Packages of food items were not labeled, dated, and re-sealed. A bulk container of popcorn had cups left inside the product. Food storage containers were not kept clean when stored. Satellite kitchens on the halls had soiled microwaves and dried coffee spills inside cabinet drawers. A carton of thickened liquid was not dated when opened. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations on 09/18/23, the following was noted in the kitchen: At 09:26 AM in the pantry a bulk plastic container of popcorn had a plastic cup and a Styrofoam cup stored inside the product. A plastic bag of raisin bran placed inside a zippered bag was not closed or dated and labeled. A 35 oz. bag of corn flakes was placed inside a zippered bag was not closed or labeled and dated. At 09:28 AM in the pantry an opened 16 oz. box of powdered sugar was not re-sealed or placed in a zippered bag. At 09:35 AM in the walk in freezer a case of beef patties was opened and the inner liner bag was left open and not re-closed. At 09:38 AM 2 plastic containers below the soup prep table had food debris present in the bottom of the containers and dried drips of a light brown unknown liquid. The containers were greasy to touch. During observations on 09/20/23, the following was noted in the satellite kitchens: At 1:50 PM in the hall 100 dining area: the microwave had splatters over all sides, was heavily stained and had a basket of French fries inside. The drawer under the coffee machine had dried drips of coffee in the bottom and on the top edges of the drawer. At 1:58 PM in the hall 200 dining area: the microwave had splatters over all sides and was heavily stained. The drawer under the coffee machine had a large pool of dried coffee in the bottom and dried drips on the top edges of the drawer. In the refrigerator there was one 46 oz. container of nectar thick orange juice that was not dated when it was opened. The packaging indicated After opening may be kept up to 7 days under refrigeration. At 2:07 PM in the hall 300 dining area: the microwave had splatters over all sides and was heavily stained. In the freezer there was a frozen gel pack that had a vanilla ice cream like substance frozen to the outside. At 2:17 PM in the hall 400 dining area: the microwave had splatters over all sides and was heavily stained. The drawer under the coffee machine had drips of dried coffee in the bottom and dried drips on the top edges of the drawer. During an interview on 09/19/23 at 5:00 PM, the DM said she had gone behind the surveyor and noticed the cups in the bulk bin of popcorn. She said weekend staff sometimes do not always keep things the way they have been taught to keep them. She said all dietary workers were trained to date, label, and re-seal opened items She said they had been taught to not store cups or scoops in the bulk storage bins. She said she removed the soiled containers from under the soup prep table. She said they were odd containers and lids. She said the containers did not have lids that fit and the lids did not have containers that fit so she threw them all away. She said they should have been thrown away a long time ago. She said the dietary staff were responsible for the satellite kitchens and they were to wipe down everything after each meal service. She said she made sure the refrigerators were clean and wiped down but did not indicate a schedule of doing so. Review of a Preventing Foodborne Illness-Food Handling Policy revised July 2014 indicated Policy Statement: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Review of The Texas Administrative Code (TAC) indicated the following: Preventing Contamination From Equipment, Utensils, and Linens. (a) Food shall only contact surfaces of: (1) equipment and utensils that are cleaned . and sanitized . Frequency of Cleaning. .(c) Nonfood-contact surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues The Food and Drug Administration Code at http://www.fda.gov/food/guidanceregulation current as of 02/03/2021 indicated the following: .Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. . Food Storage Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to dust or other contamination . . Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils . .(A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris .

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #102) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #102. The PASRR 1 Level screening did not indicate a diagnosis of mental illness, although the diagnosis was present upon admission. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #102's face sheet, dated 09/20/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included post-traumatic stress disorder (a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). The onset date was 08/18/23. Record review of Resident #102's admission MDS assessment, dated 09/21/23, indicated section A1500 was marked 0 or no. This indicated he was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section A1510 was not marked for level II PASRR conditions. The assessment indicated he had a BIMS score of 15, which indicated intact cognition. Record review of Resident #102's PASRR level 1 screening, dated 08/18/23, indicated section C0100 Mental illness was marked no, which indicated there was not evidence or an indicator that he had a mental illness. During an interview on 09/20/23 at 10:44 AM, the MDS Coordinator said she reviewed Resident #102's PASRR Level 1 assessment. She said she did not mark his PL1 as yes for mental illness. She said he had a diagnosis of PTSD and it should have been marked yes for mental illness. She said it was possible that the resident could have had PASRR services for his PTSD. She said she was going to resubmit a corrected PL1 to the local authority so that Resident #102 can be evaluated for PASRR services. During an interview on 09/20/23 at 02:01 PM, the ADON said she expected Resident #102's PASRR Level 1 to be marked yes for mental illness because of his diagnosis of PTSD. She said it was possible he could have qualified for services if it had been marked yes. During an interview on 09/20/23 at 02:07 PM, the DON said she expected Resident #102 to have a positive PASRR level 1 for mental illness. She said it was possible if his PL1 was marked positive for mental illness he may have qualified for services. She said he had a diagnosis of PTSD. During an interview on 09/20/23 at 02:12 PM, the Administrator said Resident #102 was being seen by the VA for his PTSD. She said she expected his PASRR level 1 to be marked yes for mental illness. She said it was likely missed because they have not worked with the VA before. She said she was not sure if he would have qualified for PASRR services because he received services through the VA. Record review of the facility's policy, specialized rehabilitative services, dated February 2017, stated: .Specialized services for MI [mental illness] or MR [mental retardation] For a resident with MI or MR, the community will ensure that the individual receives the services necessary to assist him or her in maintaining or achieving as much independence and self-determination as possible. The preadmission screening and resident review (PASRR) indicates specialized services required by the resident. The state is required to list those services in the report, as well as to provide or arrange for the provision of the services. Even if the state determines that the resident does not require specialized services, the community is still responsible for providing all services necessary to meet the resident's mental health or mental retardation needs. The community provides interventions that complement, reinforce, and are consistent with any specialized services (as defined by the resident's PASRR)

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #366) reviewed for respiratory care and services. The facility failed to obtain a physician's order for oxygen administration for Resident #366. The facility failed to follow their oxygen administration policy This failure could place residents at risk for developing respiratory complications. Findings included: Record review of Resident #366's face sheet, dated 09/19/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included encephalopathy (any disturbance of the brain's functioning that leads to problems like confusion and memory loss), cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area), and obstructive sleep apnea (a sleep disorder characterized by repeated obstruction to the airway during sleep). Record review of Resident #366's admission MDS assessment, dated 09/13/23, indicated she had a BIMS score of 06, which indicated she had severe cognitive impairment. She did not exhibit behaviors of rejection of care or wandering. She required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, toileting, and personal hygiene. The assessment indicated she did have oxygen therapy while not a resident. The assessment indicated she did not have oxygen therapy while a resident. Record review of Resident #366's physician's orders, dated 09/19/23, indicated she did not have an order for oxygen administration. Record review of Resident #366's care plan, created on 09/09/23, indicated a focus of I may be at risk for: self-care deficit, falls, skin concerns, pain, infection & nutritional/hydration concerns, and emotional distress. Interventions included: *Provide oxygen as ordered by physician. Follow community's protocols for changing tubing and filter cleaning as indicated. Further Record review of Resident #366's care plan, created on 09/09/23, indicated a focus of I am at risk for experiencing shortness of breath. Interventions included: *Alert my nurse for concentrator alarms and/or if my oxygen tank needs to be changed *Monitor for and report all abnormal and/or change in conditions to my doctor as indicated. *Monitor oxygen saturation as ordered by my doctor and as clinically indicated. *Provide oxygen as ordered/recommended by my physician. Record review of Resident #366's MAR for September 2023 indicated she did not have an order for oxygen administration. During an observation on 09/18/23 at 10:06 AM, Resident #366 was in her bed in her room. She had oxygen in place via a nasal cannula to her nose and the oxygen concentrator was set at 2 liters per minute. During an observation on 09/18/23 at 12:25 PM, Resident #366 had oxygen in place via nasal cannula. The oxygen concentrator was set at 2 liters per minute. She was lying in bed underneath a blanket in her room. During an observation on 09/19/23 at 11:45 AM, Resident #366 was lying in bed underneath a sheet. She had oxygen in place via nasal cannula. The oxygen concentrator was set to 2 liters per minute. During an observation on 09/19/23 at 04:18 PM, Resident #366 had oxygen in place via nasal cannula. The oxygen concentrator was set to 2 liters per minute. She was lying in bed in her room. During an observation on 09/20/23 at 08:58 AM, Resident #366 had oxygen in place via nasal cannula. The oxygen concentrator was set to 2 liters per minute. She was lying in bed in her room underneath a blanket. During an interview on 09/20/23 at 10:40 AM, LVN D said she was taking care of Resident #366 on 09/20/23. She said Resident #366 did not have an order for oxygen. She said Resident #366 should have an order for the nurses to administer oxygen. She said that the risk to the resident was that the nurses may not know she had oxygen and may not know to monitor the oxygen. She said it was possible for Resident #366's oxygen to be set too high and it could lower her respiratory drive and possibly send her to the hospital. She said the nurses also would not know the flow rate to set the oxygen. During an interview on 09/20/23 at 02:01 PM, the ADON said she expected the nurse to have an order for oxygen administration for Resident #366. She said the risk to the resident was that it was possible that an agency nurse or someone that was not familiar with her care would not know to monitor her oxygen or know the correct flow rate. During an interview on 09/20/23 at 02:07 PM, the DON said she expected Resident #366 to have an order for oxygen administration. She said the normal process was that the nurse would get an order for oxygen on admission. She said the risk to the resident was that it was possible that not everyone would know to apply her oxygen without an order. She said if an agency nurse or someone that was not familiar with her care took care of her they could not know to monitor her oxygen. During an interview on 09/20/23 at 02:12 PM, the Administrator said she expected Resident #366 to have an order for oxygen. She said she was not clinical, so she was unable to guess what the risk was. She said the nurses should be checking vital signs to ensure her oxygen was set correctly. Record review of the facility's policy for oxygen administration, last revised January 2022, stated: .A resident receives oxygen therapy when there is an order by a physician. The resident's disease, physical condition, and age will help determine the most appropriate method of administration and should be reflected in the physician order. Procedure . .3. Obtain physician orders for oxygen administration. Orders should include the following: a. oxygen source to be used (concentrator, tank, etc.) b. method of delivery (cannula, mask, etc.) c. flow rate of delivery d. oxygen saturation monitoring parameters, if indicated

Based on an interview and record review, the facility failed to ensure that the facility's medical director or his/her designee attended the Quality Assessment and Assurance/Quality Assurance and Performance Improvement Committee meetings, for 1 of 1 facility, reviewed for QAA/QAPI. The facility failed to ensure the medical director attended their QAA and QAPI meetings for the months of January 2023, February 2023 and March 2023. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings included: Review of the facility's QAA/QAPI meeting signature logs for the months of January through March 2023, revealed, meetings were conducted each month during that period. Neither the Medical Director nor his/her designee signed the sign-in sheets, nor was it indicated on the sign-in sheet that the Medical Director or his designee attended the QAA/QAPI meetings from January 2023 to March 2023, via zoom or by phone. The signature sign-in log also indicated, the Medical Director only attended 5 of 13 monthly QAA/QAPI meetings. During an interview on 09/20/2023 at 3:07 PM, the Administrator said the Medical Director receives a reminder letter of the QAA/QAPI meeting and sometimes they try to engage him by phone. She said she does not know why he did not attend the meetings, but they have a new Medical Director now. Review of the facility's policy Quality Assurance and Performance Improvement, dated February 2017, revealed, Compliance Guideline: The committee meets at least quarterly, and consist of the Director of Nursing, a physician designated by the community and at least 3 other community team members.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1of 6 residents (Resident #1) reviewed for significant medication errors. The facility did not provide Resident #1's physician ordered Potassium Chloride ER Tablet for four days. The noncompliance was identified as PNC. The IJ began on 8/12/2023 and ended on 8/17/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #1's face sheet, dated 8/25/23, indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Stage 3 kidney disease (means your kidneys have moderate damage that impairs their ability to filter waste and toxins from your blood), hyperlipidemia (means your blood has too many lipids (or fats), hypertension (means that your blood is pumping with more force than normal through your arteries), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), lung cancer, heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) and congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), and iron deficiency anemia (type of anemia that develops if you do not have enough iron in your body). Record review of Resident #1's lab results, dated 8/11/23, revealed her potassium level was 2.5, reference range 3.5 - 5.1. Record review of Resident #1's nurse note, dated 8/11/23, revealed the facility received critical labs from the laboratory, that residents K+ was 2.5. Notified doctor of results. Received orders to start Potassium Chloride 20 MEQ BID. Record review of Resident #1's physician order, dated 8/11/23, revealed the following: Potassium Chloride ER Tablet Extended Release 20 MEQ, give 1 tablet by mouth two times a day for Hypokalemia (a metabolic imbalance characterized by extremely low potassium levels in the blood). Order date 8/11/23, Start date 8/12/23, End date 8/18/23. Record review of Resident' #1's MAR from 8/1/23 to 8/31/23 revealed the following: Potassium Chloride ER Tablet Extended Release 20 MEQ, give 1 tablet by mouth two times a day for Hypokalemia. Start date 8/12/23 at 6:00 AM, Discontinued date 8/18/23 at 12:56 PM. The MAR indicated Resident #1 received the medication as prescribed from 8/12/23 to 8/15/23. Record review of Resident #1's lab results, dated 8/15/23, revealed her potassium level was 2.1, reference range 3.5 - 5.1. Record review of Resident #1's nurse note, dated 8/15/23, revealed the facility received critical low Potassium lab of 2.1. Also, received order to administer Potassium Chloride ER Tablet Extended Release 20 MEQ (2 tablets) now and 2 tablets after an hour. Record review of Resident #1's nurse note, dated 8/15/23, revealed the ADON wrote she spoke with the doctor regarding new orders for potassium and discussed sending Resident #1 to emergency room for critical lab level of potassium 2.1. Received new order per doctor to send Resident #1 to emergency room for evaluation. Charge nurse notified and instructed to call emergency room to give report and family to notify. Record review of Resident #1's incident report, dated 8/15/23, revealed the DON wrote the following: Nursing Description: Staff notified DON that [Resident #1] Potassium level was still low and now critically low K+ level, The PCP was notified and new orders were placed to give 40 meqs now and 40 meqs in 1 hour. Resident Description: [Resident #1] was alert and oriented with no N/V or chest pain she was unable to remember if she had received the K+ as scheduled. Description: Investigation began, called PCP due to [Resident #1] needing to be closely monitored, out of caution. Called all med aids and asked about administering the potassium they had all documented that it had been given. checked med cart K+ was not on cart. Checked med room, medication was available in medroom; no medications had been punched out of the card. Record review of Resident #1's hospital note, dated 8/15/23, revealed abnormal labs as chief complaint. Also, during emergency room evaluation, Resident #1 was alert and oriented, denied chest pains, palpitations, or shortness of breath. Hypokalemia, potassium was 2.1 on arrival. Potassium lab retaken in emergency room and was 2.1. During an interview with Resident #1's family member on 8/25/23 at 5:03 p.m., she said Resident #1's potassium was seriously low, and she missed at least 3 days of getting potassium medications because it was not given and as a result Resident #1 was admitted into the hospital on 8/15/23. She said Resident #1 told her at the hospital her heart felt like it was beating faster. During an interview on 8/25/23 at 2:30 p.m., the DON said Resident #1 currently had lung cancer and declined all treatments for cancer. She said Resident #1's health declined within the last couple of months and was on Hospice services. The DON stated the complaint visit was regarding Resident #1 due to medication error with potassium, four days was missed, and Resident #1 was sent to the hospital due to critical low potassium level. The DON said CMA B, CMA C, LVN D and CMA E were terminated due to documenting on the MAR they administered Resident #1's Potassium medication when they did not give Resident #1 her potassium medication. She said Resident #1's, 8/11/23, potassium labs came back low 2.5, the doctor ordered potassium and labs were done again on 8/15/23 but potassium results were more critically low, 2.1, which was lower than on 8/11/23. The DON said she was alerted and concerned by the 8/15/23 lab levels because Resident #1 was taking Potassium twice a day from 8/12/23 to 8/15/23 and potassium level should have improved. The DON said she personally went to the med cart and looked for Resident #1's potassium medication and did not find it, she said she found Resident #1's potassium in the medication room unopened and said, it was no way CMAs was giving Resident #1 her potassium medicine. The DON said Resident #1 never received Potassium after receiving the initial dose on 8/11/23. During an interview on 8/25/23 at 7:15 p.m., the DON said Resident #1 missed potassium medication on the following dates: 8/12/23, 8/13/23, 8/14/23 and 8/15/23 and was sent to the hospital on the 15th. During a telephone interview on 8/27/23 at 3:57 p.m., CMA B said she was terminated due to a medication error. She said on 8/14/23 she was rushing and did not see Resident 1's new potassium order and did not realize she marked the MAR which indicated it was given. CMA B said the DON asked for her to get Resident #1's potassium medication off the medication cart and she did not see it. During a telephone interview on 8/27/23 at 4:22 p.m., CMA C said on 8/15/23 she received a call from the DON regarding Resident #1's potassium medication. She said the DON explained Resident #1's potassium was extremely low and the new order for potassium was not given. CMA C said Resident #1's MAR was marked that potassium was given, but it was not. She said she was not aware she marked the medication was given and said she made a mistake because it was not intentional. CMA C said Resident #1's potassium medication was found in the medication room, and she had access to the medication room. She said the steps to administer medications were to first, read the MAR second, look at medication, check the dosage, check the resident name and third, administer the medication. CMA C said on 8/22/23 she received a call from the DON explaining she was terminated due to falsification of documentation on Resident #1's MAR. During a telephone interview on 8/27/23 at 5:21 p.m., LVN D said on 8/15/23 she received a call from the DON and the ADON asking if she gave Resident #1 her potassium medication. LVN D said she did not falsify documentation, because she gave Resident #1 another resident's potassium medication from the med cart. LVN D said she knew what she did was wrong, but she was busy giving meds and did not have time to go track down Resident #1's potassium medication so she borrowed another resident's med. LVN D said she could not recall what resident she borrowed the potassium pill from and did not document she gave another residents medication and did not notify the DON or the ADON on what she did. LVN D said the steps for administering medications were first, look at the MAR second, check dosage, check patient name, make sure order match MAR, check time and route, third, administer medication. She said she was suspended effective 8/15/23 and received another call on 8/22/23 that she was terminated for falsifying documentation. LVN D said the facility would not allow her to return to facility and felt the facility was throwing her and the other three staff under the bus because they were possibly trying to cover up something. During a telephone interview on 8/27/23 at 5:32 p.m., CMA E said on 8/12/23 Resident #1's Potassium order had changed, and she was not aware. She said on 8/19/23 she received a call to return to the facility regarding Resident #1 critical low potassium. CMA E said she never saw Resident #1's potassium on the med cart or listed on the MARs. The DON showed her Resident #1's MAR in question; CMA E said she was busy with 60 residents and tried to give them all their medications, so it was possible that she was rushing and accidently clicked she gave Resident #1 her potassium medication when she did not administer the medicine. CMA E said it was not intentional to falsify Resident #1's MAR. CMA E said when administering medications she first, compared the medication card to MAR; second she looked at the resident name, dosage and medicine to make sure everything was correct and third, she administered the medication. Record review of immediate response plan due to potential medication administration error, dated 8/15/23, indicated Resident #1 was noted with and abnormal K+ level. On 8/15/23 it was noted Resident #1 had an order for Potassium 20 meq by mouth twice a day to start the morning of 8/12/23. Medication was not administered per doctors' orders. Resident was assessed and stable. Immediate Response: As soon as potential medication error was identified nursing immediately assessed the resident. Outcome - Resident #1 presented stable, MD notified of abnormal lab results and potential medication error notification. Out of an abundance of caution MD ordered that resident be sent to the ER for evaluation and treatment as indicated. Risk Response: All residents prescribed a potassium supplement medication were assessed. Outcome - No negative outcomes or changes in condition were identified. Date Completed: 8/15/2023 *DON/ADON interviewed licensed nurse and medication aides responsible for the medication error. *DON/ADON re-educated: Proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. The Medication Administration policy was established 3/2019. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. -What to do if the medication was not on the cart and not available for administration example: check the medication room, check the carts thoroughly and if not located for medication aids, the med aid must notify the nurse, so that the nurse can ensure the needed medication was retrieved from the stat safe (emergency medication cart) so that the medication may be administered as ordered. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication and the nurse are to contact the MD to report status of the medication not being available for administration and following any additional orders provided. Date commenced: 8/15/23; Date completed: 8/15/23. *DON/ADON conducted an audit to validate all other residents who had an active potassium order had the correct medication available on the carts for administration and to ensure the medication was being administered as ordered. Audit was completed on 8/15/23. Outcome - Results of the potassium order audit revealed no medication administration discrepancies, and all potassium medications were available, on the carts and administered as per physician's orders. Date Completed: 8/15/23. *DON/ADON/Designee conducted interviews and an audit on MARS and medication carts were in order to validate those medications was available and being administered ordered. Outcome - No negative outcomes or changes in condition were identified. Date completed: 8/17/23. Systemic Response: DON/ADON will ensure all licensed nurses and medication aids (full -time, part - time, newly hired nurses and med aids and any agency staff) will receive the in-service prior to working their next shift. In-service training and re-education will be provided to all licensed nurses and medication aides regarding topics by the DON/ADON: *Re-education consisted of the following topics: Proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. The Medication Administration policy was established 3/2019. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. What to do if the medication was not on the cart and not available for administration example: check the medication room, check the carts thoroughly and if not located for medication aids, the med aid must notify the nurse, so that the nurse can ensure the needed medication was retrieved from the stat safe (emergency medication cart) so that the medication may be administered as ordered. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication and the nurse are to contact the MD to report status of the medication not being available for administration and following any additional orders provided. Date commenced: 8/15/23; Date completed: 8/15/23. *DON/ADON will ensure all licensed nurses and medication aids (full -time, part - time, newly hired nurses and med aids and any agency staff) will receive the in-service prior to working their next shift. * DON/ADON/Designee conducted interviews and an audit on MARS and medication carts were in order to validate those medications was available and being administered ordered. Outcome - No negative outcomes or changes in condition were identified. Date completed: 8/17/23. *IDT (to include but not limited to: Administrator/DON/ADON) and Medical Director conducted an QAPI to review issue and community's response plan in place. Date of completion: 8/18/23 Monitoring Response: The DON/ADON will conduct random at least weekly (1-7 days per week) audit of physician orders to validate availability of medications on the carts and observations of medication administration to validate medication administration competency. DON/ADON will conduct daily reviews during clinical start - up meeting (1-7days per week) review of new medication orders, pertinent lab results (K+ levels), progress notes, and nursing 24-hour report to ensure that appropriate interventions are in place as well as any additional follow up has been assigned. This plan will remain in place for the next two months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next two months. Interviews and record reviews were conducted on 8/28/23 from 6:00 p.m. through 8:00 p.m. and on 8/29/23 from 1:35 p.m. through 4:00 p.m., and included 3 RNs, 3 LVNs, 3 CMAs, and DON. Staff said they were trained on medication administration, documentation, medication refill process, and what to do if medications were not available. Staff were able to explain the proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. The Medication Administration policy was established 3/2019. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. Staff had knowledge on what to do if the medication was not on the cart and not available for administration example: check the medication room, check the carts thoroughly and if not located for medication aids, the med aid must notify the nurse, so that the nurse can ensure the needed medication was retrieved from the stat safe (emergency medication cart) so that the medication may be administered as ordered. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication and the nurse are to contact the MD to report status of the medication not being available for administration and following any additional orders provided. Record review of conduct and workplace expectation notice, dated 8/15/23, revealed the following: Staff: CMA B; Date of Policy violation: 8/14/23; Summary of violation: Medication administration error - documented meds were given when they were not. Falsified MAR document; Suspended effective 8/15/23 pending investigation results. Record review of conduct and workplace expectation notice, dated 8/15/23, revealed the following: Staff: CMA C; Dates of policy violation: 8/12/23 and 8/13/23; Summary of violation: Administered medication incorrectly - falsified MAR document stating med was given when it was not; Suspended effective 8/15/23 pending investigation results. Record review of conduct and workplace expectation notice dated 8/15/23 revealed the following: Staff: LVN D; Dates of policy violation: 8/12/23; Summary of violation: Administered medication incorrectly - falsified MAR document and charted med was given when it was not; Suspended effective 8/15/23 pending investigation results. Record review of conduct and workplace expectation notice dated 8/15/23 revealed the following: Staff: CMA E; Dates of policy violation: 8/14/23 and 8/15/23; Summary of violation: Did not administer med as directed - falsified MAR document; Suspended effective 8/15/23 pending investigation results. Record review of Medication administration Policy dated 3/15/19 revealed Resident medications are administered in an accurate, safe, timely, and sanitary manner .Documentation: Initial the electronic administration record after the medication is administered to the resident. The noncompliance was identified as PNC. The IJ began on 8/12/2023 and ended on 8/17/2023. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review, the facility failed to ensure, in accordance with State and Federal laws, medications were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 3 of 5 medication carts (100 Hall and 200 Hall Medication Carts) reviewed for pharmacy services. 1. RN G failed to ensure the Nurse Medication cart for 100 Hall was not left unlocked, unsecured, and unattended. 2. The facility failed to ensure the Nurse Medication Cart for 100 Hall and 200 Hall were not left unlocked, unsecured, and unattended near the nurse station. 3. The facility failed to ensure two medications (Fluticasone Propionate Nasal Spray 50 mcg and Ultra Lubricant Eye Drops) were left at Resident #2's bedside. 4. The facility failed to ensure CMA F did not leave a bottle of medication Phenytoin Extended Caps 100 mg (used to prevent and control seizures) on top of the 100 Hall medication cart unsecured, and unattended. These failures could place residents, of drug diversions or misuse of medications. Findings included: During an observation on 8/28/23 at 6:47 p.m., revealed the Medication cart for 100 hall had a bottle of Phenytoin Extended Caps 100 mg (used to prevent and control seizures) with three capsules unsecured and unattended on top of the cart. The cart was locked, and unattended for a few minutes. Residents and staff were observed passing by the medication cart. During an observation and interview on 8/29/23 at 1:51 p.m., Resident #2 had a box of Fluticasone Propionate Nasal Spray 50 mcg (used to relieve seasonal and year-round allergic and non-allergic nasal symptoms, such as stuffy/runny nose, itching, and sneezing); opened 7/23/23 and a box of Ultra Lubricant Eye Drops - Polyethylene glycol 400 0.4% & Propylene glycol 0.3% (medication is used to relieve dry, irritated eyes ); opened 7/9/23. She was walking out of her room and looked for a nurse to return the medications too. Resident #2 said a nurse gave her the medications earlier that morning for her to self-administer whenever she returned from therapy and now, she was ready to give them back. She said it was not her normal nurse, and she said she hoped she did not get anyone in trouble, but she just wanted to return the medications so she would not lose them. The State Surveyor gave both medications to the Administrator who was walking past Resident #2 room. During an observation on 8/29/23 at 2:37 p.m., revealed on 100 Hall a Nurse Medication Cart was unlocked and unattended on the hall by room [ROOM NUMBER]. All the drawers of the medication cart could be opened, and the medication were easily accessible. The cart was unattended. Residents were observed passing by the medication cart. During an observation on 9/1/23 at 10:50 a.m., 200 Hall Nurse Medication Cart was unlocked and unattended near the nurses station. All the drawers of the medication cart could be opened, and the medications was easily accessible. The cart was unattended for an unknown amount of time. Residents were observed passing by the medication cart. The State Surveyor informed the DON regarding the unlocked cart and the DON locked the cart. During an observation on 9/1/23 at 10:52 a.m., revealed the 100 Hall Nurse Medication Cart was unlocked and unattended near the nurses station. All the drawers of the medication cart could be opened, and the medications were easily accessible. The cart was unattended for an unknown amount of time. Residents were observed passing by the medication cart. The State Surveyor informed DON regarding the unlocked cart and DON locked the cart. During an interview on 8/28/23 at 6:50 p.m., CMA F said she left the medication on top of the cart because the resident was no longer on 100 Hall and had moved to 200 Hall, so she left the medication on top of the cart to put in the correct cart whenever she finished passing meds on the 100 hall. CMA F said she made a mistake because all meds should be locked away and the medication cart should be locked every time she walked away from the cart. During an interview on 8/29/23 at 2:39 p.m., RN G returned to the medication cart. The State Surveyor pointed out the nurse cart was left unlocked and unattended, and RN G said the medication carts were never supposed to be left unlocked and she didn't know why she did it, it was a mistake. During an interview on 9/1/23 at 11:15 a.m., the DON said medication carts should remain locked and secured anytime they were not attended. She said no medications should be left at the residents bedside unless the resident was assessed to self-administer; she said the facility did not have any residents who self-administered therefore, no medications should be at the bedside to self-administer. Record review of the medication cart use and storage policy, dated 3/15/19, revealed .1)Security: * The medication cart and its storage bins are kept locked until the specified time of medication administration. * If an emergency occurs during the medication pass, the nurse/medication aide securely locks the medication cart before attending to the emergency situation. * During routine administration of medications, the cart may be kept in the doorway of the resident's room with: - drawers unlocked and facing inward, and within sight of the nurse -no medications are kept on top of the cart.

Based on interview and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 4 (Resident #2) reviewed for pressure injuries. The facility failed to ensure Resident #2's did not develop a Stage 4 (a deep wound reaching muscle, ligaments, or bone) pressure ulcer. The facility failed to ensure Resident #2 received necessary treatment and services to promote healing and prevent infection of a Stage 4 pressure ulcer. The facility failed to update Resident #2's care plan to include development of a pressure ulcer and interventions to be taken. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/23/23 at 12:15 p.m. While the IJ was removed on 5/24/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: 1. Record review of consolidated physician orders dated 5/24/23 indicated Resident #2 was an [AGE] year-old female, admitted on [DATE] with diagnoses including displaced fracture of the right femur (fracture to the bone in the right thigh where the ends of the bone are not aligned), muscle weakness, lack of coordination, and hypertension (elevated blood pressure). The physician orders indicated Resident #2 had an order to cleanse her coccyx (small triangular bone at the base of the spinal column) with normal saline/wound cleanser, pat dry, apply collagen, and apply dry dressing daily starting 10/02/22. Record review of the Treatment Administration Record (TAR) dated October 2022 indicated Resident #2 only had wound care performed on 10/03/22, 10/04/22, 10/05/22, 10/06/22, 10/07/22, 10/1022, 10/11/22, 10/12/22, and 10/13/22. Record review of the comprehensive MDS dated [DATE] indicated Resident #2 understood others and was understood by others. The MDS indicated Resident #2 had a BIMS score of 05 and had severe cognitive impairment. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, and toileting. The MDS indicated Resident #2 was totally dependent with personal hygiene. The MDS indicated Resident #2 was at risk for developing pressure ulcers/injuries. The MDS indicated Resident #2 did not have any pressure ulcers. Record review of the care plan dated 9/27/22 indicated Resident #2 had fragile skin and was at risk for skin injury with no interventions in place. The care plan indicated Resident #2 had incontinence with no interventions in place. Record review of the Braden Scale for Predicting Pressure Sore Risk dated 9/28/22 Resident #2 was at risk for developing pressure sores. Record review of the nursing progress note dated 10/02/22 indicated Resident #2 was noted with a 3.5cm x 4.2cm x 0.1cm open area to the coccyx with red granulation to the wound bed, pink shearing to the outer edges, and a scant amount of drainage. Record review of the progress note from the wound care physician dated 10/07/22 indicated Resident #2 had a stage 4 pressure wound to the sacrum (area of the spine located at the end of the spine just above the coccyx) great than 1 day in duration, measuring 3cm x 6cm x 0.2cm, and 70% slough (yellowish white material in the wound bed). The progress noted indicated recommendations were made including reposition per facility protocol, a group-2 mattress (low air loss mattress), and a prealbumin (protein) level on 10/07/22 for Resident #2. Record review of the progress note from the wound care physician dated 10/10/22 indicated Resident #2 had a stage 4 pressure wound to the sacrum greater than 3 days in duration, measuring 3cm x 6cm x 0.2cm, and 70% slough. The progress noted indicated recommendations were made including reposition per facility protocol and a group-2 mattress (low air loss mattress). Record review of the Skin and Wound Evaluation dated 10/13/22 indicated Resident #2 had a facility acquired, stage 4 pressure wound to her sacrum. The Skin and Wound Evaluation indicated the pressure wound had been present for 1 week. The Skin and Wound Evaluation indicated the pressure wound measured 5.8cm x 3.4cm x 0.2cm with 80% slough. The Skin and Wound Evaluation indicated interventions for Resident #2's wound included wound care as ordered by the physician, positioning wedge, and turn/reposition program. Record review of the nursing progress note dated 10/13/22 indicated Resident #2's wound to the buttocks had a foul-smelling odor along with green slough. Record review of the nursing progress notes indicated Resident #2 discharged home on 10/14/22. During an interview on 5/17/23 at 10:44 p.m. the Treatment Nurse said he had been working at the facility for approximately 8 months. The Treatment Nurse said he did not remember Resident #2. During an interview on 5/17/23 at 2:05 pm the DON said she started at the facility on 2/28/23. The DON said the facility had a large turnover with clinical staff. The DON said none of the nurses currently working at the facility were employed at the facility in October 2022 except the Treatment Nurse. During an interview on 5/23/23 at 11:41 p.m. the DON said residents with low air loss mattresses should have an order in the physician orders. The DON said residents with stage 3 (full thickness tissue loss) or stage 4 pressure ulcers were automatically put on a low air loss mattress for prevention. The DON said residents with a stage 1 (pressure injury that is not open) or stage 2 (open wounds) pressure ulcer were not put on low air loss mattresses. During an interview on 5/23/23 at 11:55 a.m. the Corporate Nurse said low air loss mattresses were an intervention and did not require a physician order. The Corporate Nurse said a low air loss mattress could be identified as in intervention on the skin/wound assessment or on the resident's care plan. The Corporate Nurse said she did not believe Resident #2 was on a low air loss mattress. During an interview on 5/24/23 at 11:00 a.m. the Corporate Nurse said there was no way she could verify whether or not Resident #2 had a low air loss mattress when she was in the facility. Record review of the facility's Skin and Wound Management policy dated 3/14/19 indicated, Each resident receives the care and services necessary to retain or regain optimal skin integrity to the extent possible. Each resident is assessed to determine his or her risk for their skin integrity being compromised or the presence of wounds and/or pressure injuries. A plan of care should be developed and implemented based on the skin reviews/checks. If skin compromise occurs, the interdisciplinary team notifies the physician for any orders and those appropriate measures and additional interventions are put in place to minimize further compromising the skin and to aid in healing to the extent possible .Residents identified as at risk for development of pressure injuries should have a plan and interventions included in the care plan to address each risk factor individually .Residents with identified pressure injuries should be reviewed by the Interdisciplinary Team and a care plan should be developed, implemented, evaluated, and re-evaluated as clinically indicated . The Administrator was notified on 5/23/23 at 12:30 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 5/23/23 at 12:31 p.m. The facility's Plan of Removal was accepted on 5/23/23 at 6:26 p.m. and included: Resident #2 had an open area to the coccyx identified on 10/2/2022. Treatment orders were obtained on 10/2/2022. On 10/13/2022 a skin and wound evaluation on Resident #2 indicated a facility acquired stage 4 to the sacrum. Resident #2 discharged home on 10/14/2022. Conducted audit of: o DON/ADON conducted skin assessments were conducted on 100% of 107 residents on 5/23/2023. o All residents at risk of obtaining pressure ulcers have preventive measures in place documented in the care plan. Any discrepancies are addressed by DON/ADON/Wound Nurse. Completed on 5/23/2023. o All residents with pressure ulcers to ensure they are receiving necessary treatment and services to promote healing and prevent infection of pressure ulcer as ordered by physician and documented in care plan. Any discrepancies addressed by DON/ADON/Wound Nurse. Completed 5/23/2023. o All residents with pressure ulcers have person centered plan of care to include development of a pressure ulcer and interventions to be taken. Regional Director of Nurses reviewed the 7 residents with wounds. One resident needed an additional intervention. Wound Nurse/DON/ADON will update care plans and/or interventions upon any decline in pressure injury. Date commenced: 5/23/2023 Date completed: 5/24/2023 at 11:00am DON/ADON in-serviced licensed nurses regarding: o Skin assessment completed upon admission, readmission, weekly and as needed o Implementing the admission plan of care problem, goal, interventions for skin concerns, identified wounds and risk for skin injury. To include following physician orders regarding all wound care and wound care consultations. o Documentation process for identified skin wounds o Proper staging of wounds o Notifications of new wounds, changes, or deterioration of wounds and resolved wounds to MD, resident representative, and DON. o Communication with IDT of all wounds newly identified and/or admitted with o Low air loss mattresses will be used with stage 3 and 4 pressure injuries and/or as clinical indicated. Date commenced: 5/23/2023 Date of completion: 5/24/2023 at 11:00am Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working the next shift. DON/ADON will ensure administrative nursing staff in the community will provide in-service/education prior to team members working their assigned shift. The trainings will also be conducted with new hires. Risk Response: Residents who are at risk for skin breakdown may have the potential to have been affected by the deficient practice. DON/ADON conducted audit of: DON/ADON conducted skin assessments on 100% of 107 residents. All residents at risk of obtaining pressure ulcer have preventive measures in place. Any discrepancies addressed by DON/ADON/Wound Nurse. All residents with pressure ulcers to ensure they are receiving necessary treatment and services to promote healing and prevent infection of pressure ulcer as ordered by physician and documented in care plan. Any discrepancies addressed by DON/ADON/Wound Nurse. o All residents with pressure ulcers have person centered plan of care to include development of a pressure ulcer and interventions to be taken. Regional Director of Nurses reviewed the 7 residents with wounds. One resident needed an additional intervention. Wound Nurse/DON/ADON will update care plans and/or interventions upon any decline in pressure injury. Date commenced: 5/23/2023 Date completed: 5/24/2023 at 11:00am Systemic Response: DON/ADON in-serviced licensed nurses regarding: o Skin assessment completed upon admission, readmission, weekly and as needed o Implementing the admission plan of care problem, goal, interventions for skin concerns, identified wounds and risk for skin injury. To include following physician orders regarding all wound care and wound care consultations. o Documentation process for identified skin wounds o Proper staging of wounds o Notifications of new wounds, changes, or deterioration of wounds and resolved wounds to MD, resident representative, and DON. o Communication with IDT of all wounds newly identified and/or admitted with o Low air loss mattresses will be used with stage 3 and 4 pressure injuries and/or as clinical indicated. Date Commenced: 5/23/2023 Date Completed: 5/24/2023 at 11:00am Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Director of Nursing / ADON will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Monitoring Response: The Director of Nursing / ADON will conduct random weekly (1-7 days per week) audit of new admissions, readmissions, residents with pressure ulcers, and resident at risk to develop pressure ulcers to ensure appropriate interventions in place to prevent and treat and pressure ulcers. DNS/ADON will conduct daily reviews during clinical start-up meetings (1-7days per week) review of progress notes, SBARs and nursing 24-hour report to ensure that appropriate interventions are in place as well as any additional follow up has been assigned. This plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months and documented in the QAPI minutes. IDT and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date of completion: 5/24/2023 at 11:00am On 5/24/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of all residents indicated skin assessments had been performed on all residents in the facility. Records review of all residents with pressure sores indicated their care plans were up to date with appropriate interventions in place. Observations of all residents with pressure sores indicated interventions were implemented including low air loss mattresses, pressure reducing mattresses, wedge and pillows for positioning, and pressure relieving cushion in wheelchairs. Record review of a sample of residents at risk for pressure sores indicated care plans were up to date with appropriate interventions in place. Interviews of staff (RN Q works 6:00 a.m. to 6:00 p.m., LVN P works 6:00 a.m. to 6:00 p.m., RN S, works 6:00 p.m. to 6:00 a.m., LVN T works 6:00 p.m. to 6:00 a.m., LVN N works 6:00 a.m. to 6:00 p.m., RN U works 8:00 a.m. to 5:00 p.m., LVN R works 8:00 a.m. to 5:00 p.m., LVN V works all shifts, and LVN C works 6:00 a.m. to 6:00 p.m.) on 5/24/23 between 11:50 a.m. and 2:45 p.m. were able to identify when skin assessments should be performed, who can stage a wound, what the different stages of a wound were, what interventions should be in place for wound prevention and healing, and who to notify in the case of a newly identified or worsening wound. Record review of the QAPI sign in sheet indicated a QAPI meeting was held on 5/24/23 indicated all appropriate members if the Interdisciplinary Team were in attendance. While the IJ was removed on 5/24/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and records review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. 1. The facility failed to administer Resident #1 the appropriate dose of morphine. Resident #1 was administered 5ml (100mg) of morphine 20mg/ml when her order was for morphine 20mg/ml give 0.25ml (5mg) every 3 hours as needed resulting in adverse reactions of vomiting, itching, shaking, and twitching of the eyes. 2. The facility failed to monitor Resident #1 after administering 20 times the ordered dose of morphine. 3. The facility failed to ensure Resident #1's morphine order was properly transcribed. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/17/23 at 3:10 p.m. While the IJ was removed on 5/22/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for harm or death relating to being administered too much medication. Finding Include: 1. Record review of the face sheet dated 5/24/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, alcohol-induced dementia, and alcohol-induced psychotic disorder. Record review of the physician orders dated 5/01/23 through 3/31/2023 indicated Resident #1 had an order Morphine 20 mg/ml give 5ml by mouth every 3 hours as needed starting 3/30/23 and ending 5/15/23. The physician orders indicated Resident #1 had an order for Morphine 20mg/ml give 0.25 ml by mouth every 3 hours as needed starting 5/15/23. Record review if the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS did not indicated Resident #1 had a BIMS evaluation. The MDS indicated Resident #1 required extensive assistance with toileting and personal hygiene. The MDS indicated Resident #1 required limited assistance with bed mobility, transfers, and dressing. The MDS indicated Resident #1 required supervision with eating. Record review of the care plan last revised 3/17/23 indicted Resident #1 was at risk for experiencing discomfort or pain with interventions including administer medication to relieve pain as recommended by the physician and coordinate with the physician and review medications as indicated to ensure Resident #1 was on the least amount of medication at the lowest dose to treat her pain. Record review of the MAR dated May 2023 indicated Resident #1 had been administered 5ml of Morphine on 5/02/23 and 5/14/23. Record review of the undated Narcotic Count Sheet for Resident #1's Morphine 20mg/ml bottle indicated the dosage was Morphine 20mg/ml give 0.25ml every 3 hours as needed. The Narcotic Count Sheet indicated the initial amount of Morphine received was 30ml. The Narcotic Count Sheet indicated Resident #1 received 0.25ml of Morphine on 5/02/23 leaving 29.75ml in the bottle. The Narcotic Count Sheet indicated Resident #1 received 5ml of Morphine on 5/14/23 leaving 24.75ml in the bottle. Record review of Morphine container for Resident #1 indicated the order for her Morphine was Morphine 20mg/ml 0.25ml (5mg) by mouth every 3 hours as needed. Record review of the Nurse Progress Note dated 5/14/23 at 11:45 a.m. indicated Resident #1 was administered 5ml of Morphine. Record review of the Nurse Progress Note dated 5/14/23 at 3:01 p.m. indicated the Morphine was effective. Record review of the Nurse Progress Notes dated 5/15/23 at 5:20 a.m. written by RN K indicated Resident #1 had vomited all over her floor and down the hallway. The Nurse Progress Note indicated the nurse had taken Resident #1 to the bathroom to clean her up and noticed Resident #1 had scratch marks all over her legs, arms, chest, and shoulders. The Nurse Progress Note indicated Resident #1 was shaking and twitching her eyes. The Nurse Progress Note indicated the nurse sat Resident #1 at the nurse's station and pushed fluids. The Nurse Progress Note indicated the DON and hospice were notified. Record review of the Nurse Progress Note dated 5/15/23 at 8:26 a.m. written by the DON indicated she was notified at 1:00 a.m. by RN K that there may have been a medication error. The Nurse Progress Note indicated RN K was reviewing Resident #1's Narcotic Count Sheet and noticed it looked like the nurse on the previous shift had given 5ml of Morphine to Resident #1, but the bottle appeared to have 27ml instead of 24ml of Morphine in it. The Nursing Progress Note indicated the DON asked if Resident #1 was okay. The Nursing Progress Noted indicated RN K said Resident #1 was okay and was sleeping. The Nursing Progress Noted indicated the DON told RN K it was probably a writing error. The Nursing Progress Noted indicated the DON called back to the facility around 5:00 a.m. and was informed by RN K that Resident #1 was shaking, twitching, and vomited. The Nurse Progress Note indicated RN K told the DON she had notified hospice and the physician and was passing it off to the day shift to notify the family. Record review of Resident #1 vitals signs for May 2023 indicated she had blood pressure checks performed on 5/12/23 at 5:45 p.m., 5/15/23 at 4:25 p.m., and 5/18/23 at 7:08 p.m. The Vital Signs indicated Resident #1's pulse had been checked on 5/13/23 at 10:34 a.m., 5/15/23 at 8:23 a.m., and 5/16/23 at 8:53 a.m. The Vital Signs indicated Resident #1's respirations had been checked on 5/13/23 at 10:34 p.m., 5/15/23 at 8:23 a.m., and 5/17/23 at 12:29 p.m. During an interview on 5/17/23 at 8:55 a.m. the Hospice Director said the hospice company had been notified via message being left on 5/15/23 at 5:53 a.m. that Resident #1 had been administered 100mg (5ml) of Morphine. The Hospice Director said the hospice company did an audit of Resident #1's orders and determined Resident #1's order had been for Morphine 20mg/ml give 0.25ml (5mg) by mouth every 3 hours as needed. The Hospice Director said this order had been the order provided to the facility. The Hospice Director said the normal dose of Morphine they prescribe was 5-10mg, and they started patients on a very low dose. The Hospice Director said signs and symptoms of Morphine overdose included decreased level of consciousness and lethargy. The Hospice Director said the facility reported Resident #1 was itching and had vomited. The Hospice Director said they contacted their pharmacist regarding the overdose and he was shocked. The Hospice Director said their pharmacist had informed the hospice company 5ml (100mg) of morphine could have been a fatal dose. The Hospice Director said that she would expect the facility to monitor vital signs and perform neuro checks in the event of a morphine overdose. During an interview on 5/17/23 at 9:18 am LVN L said he entered the Morphine order on 3/30/23 for Resident #1. LVN L said the order he entered was incorrect and should have read Morphine 20mg/ml 0.25ml (5mg) by mouth every 3 hours as needed instead of Morphine 20mg/ml 5ml by mouth every 3 hours as needed. LVN L said he did not know the procedure for someone verifying orders once they were entered into the EMR. LVN L said when medications were administered the nurse or MA should compare the order on the MAR with the directions on the medication container. LVN L said if there was a discrepancy in the order and medication container it should be verified by the physician or pharmacy. LVN L said the morphine overdose Resident #1 received could have been fatal. LVN L said Resident #1's vital signs should have been monitored following the overdose. During an observation on 5/17/23 at 9:30 am Resident #1 was walking around the facility. Resident #1 had on a long-sleeved cardigan, long pants, and non-skid sicks. Resident #1 was confused and unable to be interviewed. During an interview on 5/17/23 at 9:44 am LVN M said she had been the nurse working on 5/14/23. LVN M said she administered Resident #1 Morphine 20mg/ml 5ml by mouth. LVN M said she compared the order to the order on the morphine box/bottle. LVN M said Resident #1's order was for Morphine 20mg/ml 5ml by mouth and the box/bottle read Morphine 20mg/ml 5mg (0.25ml) by mouth. LVN M said that 5ml and 5mg were the same. LVN M said Resident #1 was sleepy after she administered the morphine. LVN M said the morphine administered to Resident #1 was effective for her pain. LVN M said on 5/15/23 the DON informed her she had administered too much morphine to Resident #1 on 5/14/23. LVN M said the DON had told her she should have administered 0.5ml instead of 5ml of morphine to Resident #1. LVN M said the morphine overdose could have been fatal. LVN M said Resident #1's behaviors and vital signs should have been monitored following the overdose. During an interview on 5/17/23 at 10:02 am the DON said she had started at the facility in February 2023. The DON said she had been in her position since 4/21/23. The DON said the Morphine 20mg/ml 5ml by mouth was not the correct order for Resident #1. The DON said the policy at the facility was for nursing management to check orders after they were entered into the EMR. The DON said the incorrect order had been entered on 3/30/23 and the previous interim DON should have checked the orders. The DON said when administering medications staff should not administered by what the order says only. The DON said when administering medication staff should use the 5 rights of medication administration (Right Resident, Right Medication, Right Dose, Right Route, Right Time). The DON said the morphine overdose could have caused respiratory depression and death. The DON said in the event of a morphine overdose since morphine was a short acting medication vital signs should be monitored every shift for 24 hours. The DON said vital signs would be monitored more often or longer if an order was given by the physician. During an interview at 5/17/23 at 11:08 a.m. MA B said she only looked at the orders to verify medications and dosage when administering medications. MA B said she did not feel like she should have to compare the order to the medication. MA B said the orders on the MAR should be correct. MA B could only name 2 out of 5 (Right Resident and Right Medication) right of medication administration. During an interview on 5/17/23 at 12:09 pm the DON and the Corporate Nurse said the facility did not have a policy regarding medication errors. During an interview on 5/17/23 at 12:21 pm the Medical Director said he did not remember if he was contacted regarding Resident #1's morphine overdose but could not say for sure whether he was notified or not. The Medical Director said if he had been notified of the morphine overdose he would have ordered for an antidote to be administered and to monitor respiration every 5-10 minutes. The Medical Director said he probably would have not given an order for Resident #1 to be sent to the hospital due to her being on hospice. The Medical Director said it was hard to say if the morphine overdose could have been lethal. The Medical Director said it would depend on the patient and their tolerance to the medication. During an interview on 5/17/23 at 1:15 pm LVN N said mg and ml were not the same. LVN N said ml was a liquid measurement and mg was a dosage measurement. LVN N named the 5 rights of medication administration. LVN N said before administering medication the order on the MAR should be checked against the medication package. LVN N said if there was a discrepancy between the order and package the medication should not been give and clarification should be obtained. Record review of the facility's Medication Administration policy dated March 2019 indicated, Resident medications are administered in an accurate, safe, timely, and sanitary manner .If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders shall be checked for the correct dosage schedule. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved . The Administrator was notified on 5/17/2023 at 3:22 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 5/17/2023 at 3:23 p.m. The facility's Plan of Removal was accepted on 5/19/2023 at 3:15 p.m. and included: Resident #1 received morphine 5ml on 5/14/2023 @ 11:45am. On 5/15/2023 @ 5:20am resident noted with a change in her condition. encouraged fluids. The Night Shift LVN changed residents' clothes after resident was vomiting. They then sat her at the nurse's station to observe her. DNS/ADON in-serviced licensed nurses regarding monitoring patients with Changes in Condition and documentation. These are documented in the SBAR. Monitoring changes in condition takes place every shift until monitoring is no longer clinically indicated. Date commenced: 5/15/2023 Date completed: 5/18/2023 Day Shift LVN conducted a visual assessment of resident #1's status, observing and identifying symptoms presented on 5/15/2023. Outcome: On 5/15/2023 @ 5:20 am resident vomited on the floor, had scratch marks on her legs, arms, chest and shoulders. Resident also was shaking and twitching her eyes. Date Completed: 5/15/2023 Night Shift LVN notified Hospice at approximately 5:20am regarding patient's condition noted above. Date completed: 5/15/2023 Day Shift LVN who incorrectly transcribed the morphine order was educated by Director of Nursing on 5/15/2023 @ approximately 8:10am on proper processes for transcribing of physician orders into EMR. Day Shift LVN Nurse was suspended on 5/17/2023 pending results of the investigation. Date completed: 5/17/2023 Day Shift LVN who incorrectly administered resident's morphine order was educated on 5/15/2023 @ approximately 7:36am by the Director of Nursing on the proper process of medication administration, ensuring the correct resident, the correct medication, correct dose, correct route to be administered, correct documentation of administration, correct time, and monitoring of patient post administration of the medication. This includes verifying the medication administered record to the actual medication to be administered. Licensed Nurses were in-serviced regarding appropriate steps to take if medication error occurs, to include assessing resident, completing medication error report, notifying assigned physician and responsible party, and monitoring and/or intervention as indicated. All discrepancies will utilize the community's policy and procedure regarding Medication Administration. The Medication Administration policy was established on 3/2019. Day Shift LVN who incorrectly administered resident #1 morphine order was suspended on 5/17/2023 pending results of the investigation. Day Shift LVN is no longer working for the company as of 5/17/2023. Date completed: 5/17/2023 Director of Nursing / ADON conducted retraining for all licensed nursing staff on the importance of monitoring for signs and symptoms of narcotic medication (morphine) overdose signs/symptoms as well as emergency use of Narcan should a potential drug overdose occur. Narcan is available in the stat safe. The Narcan has always been available and in the stat safe. There were no orders at the time of the incident to administer Narcan to resident #1. Orders to administer Narcan were received as a result of the incident investigation. All residents who are on morphine have as needed orders for the administration of Narcan as well as monitoring for signs and symptoms of overuse of morphine. Date of commenced by: Director of Nursing / ADON 5/16/2023 Date of completion: 5/17/2023 Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. DON/ADON will ensure administrative nursing staff in the community will provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Risk Response: Residents who are prescribed liquid morphine may have the potential to be affected by the deficient practice. Director of Nursing / ADON conducted re-education to the identified nurses and medication aids regarding: The community's expected process for proper transcription of physician orders, medication administration, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration and monitoring of patient post administration. This includes verifying the medication administered record to the actual medication. Licensed Nurses were in-serviced regarding steps to take if medication error occurs, to include assessing resident, completing medication error report, notifying assigned physician and responsible party. All discrepancies will utilize the community's policy and procedure for Medication Administration. The Medication Administration policy was established on 3 3/2019. The DON/Corporate nurse were educated by SVP Clinical Operations on Accident/Incident Report and Investigation Guidelines established in 2019 and updated 1/2023. All licensed nurses were educated on when to administer Narcan. Morphine audit initiated on 5/17/23, completed on 5/18/23. All residents who have morphine on their administration record have accurate orders, monitoring for signs/symptoms of overdose, and as needed Narcan orders. Results of the morphine audit reveal no medication administration discrepancies. The audit was completed by the DON/ADON. Also, all licensed nurses were educated by the DON/ADON on the importance of monitoring for signs and symptoms of narcotic medication (morphine) overdose signs/symptoms as well as emergency use of Narcan should a potential drug overdose occur. Narcan is available in the stat safe. The Narcan has always been available and in the stat safe. All residents who are on morphine have as needed orders for the administration of Narcan as well as monitoring for signs and symptoms of overuse of morphine. There were no physician orders at the time of the incident for resident #1 for administration of Narcan. Orders for Narcan were received on 5/17/23 as a result of the incident investigation. DON/ADON conducted an audit for all residents who are on morphine for accuracy. Results of the morphine audit revealed no medication administration discrepancies. Date Commenced: 5/16/2023 Date of completion: 5/18/2023 All licensed nursing and certified medication aides were educated on the difference between milligrams and milliliters. Date commenced: 5/18/2023 Date of completion: 5/19/2023 Community Director of Nursing / ADON will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / ADON will ensure administrative nursing staff will in service licensed nurses prior to working their next assigned shift. These trainings will also be conducted with new hires. Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Inservice topics: Director of Nursing / ADON extended re-education to all licensed nurses and medication aids regarding: (nurses or medication aids will not assume next shift until re-education received) The community's expected process for proper transcription of physician orders, medication administration, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration and monitoring of patient post administration. This includes verifying the medication administered record to the actual medication. All discrepancies will utilize the community's policy and procedure for the Medication Administration policy. The medication administration policy was established 3/2019. Also re-educated on the importance of monitoring for signs and symptoms of narcotic medication (morphine) overdose signs/symptoms as well as emergency use of Narcan should a potential drug overdose occur. Narcan is available in the stat safe. The DON/ADON in-serviced all licensed nurses regarding Abuse & Neglect and Medication Administration, transcribing of physician orders, morphine Overdose signs/symptoms and the use of Narcan use. Date Commenced: 5/16/2023 Date Completed 5/17/2023 Community Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / Designee will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Monitoring Response: The Director of Nursing / ADON will conduct random weekly (1-7 days per week) audit of physician orders to validate the accuracy of transcribed orders within the E.H.R., observations of medication administration to validate medication administration competency. DNS/ADON will conduct daily reviews during clinical start-up meeting (1-7days per week) review of progress notes, SBARs and nursing 24-hour report to ensure that appropriate interventions are in place as well as any additional follow up has been assigned. This plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months. IDT and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date of completion: 5/17/2023 On 5/22/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Records Review of: -Change of Conditions Policy -Medication Administration Policy -Abuse Policy -All evidence of in-services and education per POR Staff interviewed were able to answer questions re: trainings/in-services noted in the Plan of Removals for IJ 1:51pm MA A (3yrs) 6-2 shift 2:00pm MA B (1yr) 6-2 shift 2:34pm LVN C (6.5 yrs.) All Shift 2:48pm LVN D (10 yrs.) 6a-6p Shift 3:02pm LVN E (AGENCY) 6a-2p, 2p-10p, 6a-6p Shift 3:16pm RN F (2.5yrs) 6a-10p Sat/Sun 3:30pm MA G (9mths) 2p-9p Shift 3:41pm LVN H (Med Nurse Only) 3.5yrs All Shift While the IJ was removed on 5/22/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents reviewed for pain. (Resident #1). The facility did not provide effective pain interventions for Resident #1 after she was found on the floor mat beside her bed. Resident #1 was given a dose of [MEDICATION NAME] sulfate. While waiting for x-ray results, Resident #1 continued to moan in pain and guard her right leg. She was not provided any additional pain medication. Approximately 6 hours after she was administered the first dose of pain medication, the x-ray results returned indicating a fractured femur. She was then given a 2nd dose of [MEDICATION NAME] and sent to the emergency room . This failure could place 44 residents who were not a pain management program at risk for not having effective pain control and decreased quality of life. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE], and discharged to the hospital on [DATE]. Her [DIAGNOSES REDACTED]. She had orders for Tylenol 325mg every 4 hours as needed for pain, [MEDICATION NAME] 50mg twice a day for pain, and [MEDICATION NAME] sulfate 20mg/ml 1ml every hour as needed for pain. An MDS dated [DATE] indicated Resident #1 rarely made herself understood and rarely understood others. She required extensive assistance with ADLs. She was incontinent of bowel and bladder. The MDS did not address the resident's pain. A care plan dated 07/10/18 indicated Resident #1 was at risk for pain and interventions included evaluating the effectiveness of pain interventions, observe and report any signs of non-verbal pain, and observe pain characteristics as needed. An incident report dated 07/10/18 indicated Resident #1 was moaning frequently, rubbing right thigh and knee, but did not verbalize site of pain. The incident report indicated Resident #1's air mattress had a slippery cover and soft sides. Neuro checks dated 07/10/18 for Resident #1 indicated the following: *12:00 a.m.-7/10 pain. Nursing notes dated 07/10/18 for Resident #1 indicated the following: *12:00 a.m.-called to room by roommate. Resident #1 was lying on her right side on the fall mat. Her head was on the floor between the bedside table and the bed. Assessed for injury. Resident complained of pain but unable to say where. The resident moaned when touched. Resident rubbing her right thigh and knee. Lifted back in bed by 3 staff; *12:10 a.m.-hospice notified of resident's fall. A MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Neuro checks dated 07/10/18 for Resident #1 indicated the following: *12:15 a.m.-7/10 pain; *12:30 a.m.-4/10 pain; *12:45 a.m.-4/10 pain; *1:15 a.m.-6/10 pain; Nursing notes dated 07/10/18 for Resident #1 indicated the following: *1:20 a.m.-hospice in facility and requested x-rays of Resident #1's right hip, femur, and knee; *1:21 a.m.-x-rays ordered. Neuro checks dated 07/10/18 for Resident #1 indicated the following: *1:33 a.m.-7/10 pain; *1:45 a.m.-0/10 pain; During an interview on 07/16/18 at 9:47 a.m., Resident #1's nephew said he was called on 07/10/18 at 1:18 a.m. and notified about Resident #1's fall. He said the nurse told him that the plan was to keep Resident #1 comfortable. He said he arrived at the facility at 2:10 a.m. and he could hear Resident #1 hollering in pain from down the hall. He said he looked at Resident #1's right leg and it was swollen. He said Resident #1 moaned in pain continuously until she was discharged to the hospital. He said after the facility received the x-ray results, he asked that Resident #1 be sent to the hospital. He said he was told by the nurse that Resident #1 received [MEDICATION NAME] before he arrived, and she received it again before she went to the hospital. He said the resident did not receive any additional pain medications throughout the night. Neuro checks dated 07/10/18 for Resident #1 indicated the following: *2:15 a.m.-0/10 pain; *2:45 a.m.-1/10 pain; *3:45 a.m.-0/10 pain; *4:45 a.m.-0/10 pain. X-ray results dated 07/10/18 indicated Resident #1 had an acute impacted distal femoral supracondylar fracture and it was reported to the facility at 5:19 a.m. Nursing notes dated 07/10/18 for Resident #1 indicated the following: *6:00 a.m.-hospice notified of x-ray results, family in facility and requested Resident #1 to be sent to hospital; EMS records dated 07/10/18 indicated EMS were called at 6:23 a.m. and arrived at the facility at 6:35 a.m. The records indicated Resident #1 had notable swelling to her right upper leg, right knee, and it was painful on palpation. The facility reported that Resident #1 fell at approximately midnight. Resident #1 verbalized ow while rubbing her right Nursing notes dated 07/10/18 for Resident #1 indicated the following: *6:40 a.m.-resident left facility via ambulance. A nursing home to hospital transfer form dated 07/10/18 indicated Resident #1 had pain to her right thigh and right knee. Resident #1 was rubbing her right thigh and grabbed at knee area when moved. During an observation and interview on 07/17/18 at 3:46 p.m., Resident #1 was admitted to another nursing facility. She had a brace on her right leg. She was able to answer yes/no questions. She did not remember falling or if she was in pain after her fall. She was unable to say if she was currently in pain and was unable to rate her pain using a 0-10 pain scale. During an interview on 07/17/18 at 3:13 p.m., LVN A said she was Resident #1's charge nurse on 07/10/18. She said she was notified that Resident #1 fell by Resident #2 (Resident #1's roommate) around 12:00 a.m. She said when she entered the room, Resident #1 was lying on the fall mat next to her bed. She said Resident #1's head was lying on the floor and was not on the fall mat. She said Resident #1 could not say how she fell or where she hurt but she was rubbing her right knee area and moaning out in pain. She said she could not recall if Resident #1's right leg was swollen. LVN A said she administered [MEDICATION NAME] to Resident #1 after her fall and she was not moaning as much but touching Resident #1's leg was still painful to her. She said she and 2 other staff were able to get Resident #1 back into the bed. She said she notified hospice of the fall and hospice arrived at the facility approximately 1.5 hours later. She said the hospice nurse told her to order x-rays of Resident #1's right knee, femur, and hip. She said mobile x-ray arrived and performed the x-rays. She said after 5:00 a.m., the facility received the x-ray results that showed Resident #1 had a fracture to her femur. She said Resident #1's family was notified and wanted her sent to the hospital. She said Resident #1 was sent to the hospital after 6:00 a.m. She said she administered another dose of [MEDICATION NAME] to Resident #1 before she was sent to the hospital. She said she did not send Resident #1 to the hospital after her fall because she was a hospice resident and hospice said they would come to the facility and observe her. During an interview on 07/17/18 at 4:28 p.m., CNA C said she worked the night that Resident #1 fell . She said Resident #1 was on the floor moaning. She said they were able to get her in the bed and Resident #1 continued to moan and did not want her right leg touched or moved. She said when she provided care through the night, Resident #1 was moaning and guarding her right leg. During an interview on 07/16/18 at 9:31 p.m., CNA D said on 07/10/18, she was at the nursing station when Resident #2 notified staff that Resident #1 fell . She said Resident #1 was lying on her right side on the fall mat by her bed. She said Resident #1 had her right leg drawn up close to her and was rubbing her right leg. She said Resident #1 was complaining of pain. She said she did not see LVN A assess Resident #1. She said LVN A only asked Resident #1 if she was hurting. During an interview on 07/16/18 at 9:43 p.m., LVN B said she went to Resident #1's room when staff were notified by Resident #2 of Resident #1's fall. She said Resident #1 was rubbing her right leg and moaning out in pain. She said she did not observe an assessment on Resident #1. She said Resident #1 was eventually sent to the hospital with a fractured femur. During an interview on 07/16/18 at 9:13 a.m., the paramedic that transported Resident #1 to the hospital on [DATE] said when he arrived at the facility, it was obvious that Resident #1 had a fracture to her right femur. He said Resident #1 was lying in her bed and rubbing her right leg and moaning in pain. He said the nurse told him that Resident #1 received [MEDICATION NAME] but the nurse could not say how much was administered or when it was administered. During an interview on 07/17/18 at 1:44 p.m., Resident #2 said she was Resident #1's roommate. She said she remembered the incident involving Resident #1 well. She said she remembered looking at her clock it was right after 11:00 p.m. and she got up to go to the bathroom and noticed Resident #1's covers were on the floor. She said she went to the bathroom and when she came out, Resident #1's feet were hanging on the side of the bed. She said she was unable to reach Resident #1's call light so she walked over to her call light and pressed it. She said she walked back over to Resident #1 and she was lying on the fall mat beside her bed. She said Resident #1 was moaning and groaning. She said she immediately notified nursing staff and 4 staff members came into the room. Resident #2 said staff moved Resident #1 back into her bed. She said she tried to go back to sleep but Resident #1 was moaning and saying Lord help me. An undated pain policy indicated .manifestations of resident discomfort such as crying and grimacing facial expression can supplement the assessment of pain severity. Examples of common pain behavior among cognitively impaired elderly residents include sighing, moaning, groaning, calling for help, rigid body movements, rubbing, guarding, and restricted movement . The CMS 672 dated 07/17/18 indicated 44 residents were on a pain management program.

Based on observation, interview, and record review, the facility failed to ensure residents received the necessary services to maintain good denture and oral hygiene for 1 of 5 reviewed for activities of daily living (Resident #1). The facility did not assist Resident #1 with his loose dentures. Resident #1's upper dentures were found lodged in his throat by the funeral home director after his death. An Immediate Jeopardy was determined to have existed from [DATE] through [DATE]. This was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 45 residents with dentures at risk for decreased quality of life, low self-esteem, and injury from not having denture care and 99 residents who required assistance with toileting at risk for skin breakdown, infections, and loss of dignity. Findings included: A consolidated physician order [REDACTED].#1 was a [AGE] year old male admitted on [DATE]. He was admitted to hospice on [DATE]. His [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. He required extensive assistance of one person for bed mobility, transfers, dressing, and personal hygiene. He required limited assistance of one person for eating. He used a wheelchair for mobility and was impaired on both sides of his upper extremities. He was on a mechanically altered diet, had no difficulty or pain with swallowing, and was not coded for loosely fitting dentures. Resident #1's care plan dated [DATE] and updated [DATE] indicated he required one staff participation with personal hygiene and oral care. Resident #1's care plan dated [DATE] indicated he had dental health problems related to his dentures and he needed to have arrangements coordinated for dental care/transportation as needed. During an interview on [DATE] at 10:42 a.m., LVN T said after a quarterly review on [DATE] and care plan meeting identified Resident #1's dentures did not fit properly, the social worker notified the family for a dental referral, and the family declined the referral. LVN T said no other actions were taken. She said denture care was supposed to be performed twice a day. She did not know if Resident #1's denture care was done per facility protocol. During an interview on [DATE] at 10:50 a.m., the Social Worker said the hospice nurse notified her a tooth was broken out of Resident #1's top dentures. She said she initiated a dental referral but his family declined to have the dental work done due to a previous balance was due on their account. She said an alternative dental service was offered but the daughter also declined this option. She said the usual procedure for denture issues was staff notified her, because she made all of the dental referrals. During an interview on [DATE] at 11:55 a.m., CNA V said she would find Resident #1's dentures in the drawer, but did not recall the last time she saw his dentures. She said she did not recall putting his dentures in or removing them. She said Resident #1 had lost weight and his dentures were loose. She said they flopped when he talked and said she did not think he had adhesive in. She said she did not put adhesive on, but thought the hospice aide might have assisted him. During an interview on [DATE] at 9:29 a.m., CNA C said Resident #1 required extensive assistance for ADLs before he was sick. She said he was confused, but conversant with staff. She said sometimes he had his dentures in and sometimes he did not. CNA C said Resident #1 was totally dependent and was changed in his bed after he got sick until he died . She said the protocol for denture care was the aide that assisted a resident up in the mornings was responsible to put their dentures in and the aide that put a resident to bed was responsible to take their dentures out and residents were not supposed to sleep in their dentures. She said she never took Resident #1's dentures out. She said his hospice aide did his oral care. A statement written by CNA C dated [DATE] indicated she worked the 11:00 p.m. to 7:00 a.m. shift and did not provide any oral care to Resident #1. During an interview on [DATE] at 10:40 a.m., CNA U said she was assigned to Resident #1 in late September. She said he had upper and lower dentures at that time and he was unable to put them in himself, but opened his mouth to facilitate when she applied adhesive and put Resident #1's dentures in for him. She said his dentures would flop in his mouth without adhesive and she often saw his dentures flop when she was not assigned to assist him. She said if a resident refused to remove their dentures at night, the aide was supposed to notify the charge nurse. She said she worked multiple times when Resident #1 still had his dentures in from the night before and she would remove them, clean them, apply adhesive, and reinsert them. She said Resident #1 had never refused this. A hospice communication note dated [DATE] by hospice RN M indicated hospice CNA N notified her she could not find Resident #1's upper dentures. She found his lower dentures on his table on that visit, and placed them in a denture cup in his top drawer. She indicated she looked throughout his room, and did not find them and notified Resident #1's daughter. During a telephone interview on [DATE] at 3:13 p.m., CNA A said she did not put in or remove Resident #1's dentures. She said the hospice aide and the hospice nurse primarily cared for Resident #1 and performed the oral and incontinent care. CNA A said she just offered assistance as needed. She said Resident #1 was normal the week before he died . CNA A said she assisted Resident #1 in his wheelchair and noted he ate well the week prior to his death. She said the last time she saw his bottom dentures, they were on the desk in his room. She did not recall the date. During an interview on [DATE] at 3:45 p.m., CNA R said she recalled working with Resident #1 on [DATE] and he had upper and lower dentures in, communicated and participated fine. She said his hands were contracted and he could not perform his own oral care, but sometimes removed his dentures and left them in strange places. She said she did not ever recall assisting to insert or remove Resident #1's dentures. She did not know when the last time his dentures were missing. Nursing notes for Resident #1 dated [DATE] at 11:59 a.m., indicated Resident #1 was not feeling well and was in bed. No meal or supplement were provided at that time. At 12:12 p.m., the resident was coughing. Upon assessment, the resident had a moderate amount of yellow sputum, and the hospice nurse was in the room. The hospice nurse said Resident #1 had an order for [REDACTED]. An x-ray report dated [DATE] indicated the x-ray was ordered due to Resident #1's abnormal chest sounds related to his cough. The x-ray report indicated the lungs were clear. During an interview on [DATE] at 12:06 p.m., CNA O said Resident #1 was assisted into his wheelchair for breakfast, self-propelled with his feet, and talked with her, as per his usual on Saturday, [DATE]. She said the aide who got the resident up was responsible for assisting the resident to put clean dentures with adhesive in their mouth before breakfast. She said Resident #1 was at his base line and drank a lot of coffee the last time she saw him on [DATE]. During an interview on [DATE] at 9:38 a.m., hospice CNA N said she worked Saturday [DATE] with Resident #1 and he had upper and lower dentures in his mouth between 9:00 a.m., and 10:00 a.m. She said she applied adhesive and inserted his dentures that morning. She said his dentures were always loose and fell out of his mouth and never had adhesive on them when she came. CNA N said aides never took them out at night. She said she found his dentures everywhere and said they were never in a denture cup during the year she was regularly assigned to Resident #1. She said he could not insert his dentures by himself, but felt he must be able to get them out, since she often found them on the bed, under the bed, and once, in a sock. She did not think staff would place them in a sock. A nursing note dated [DATE] at 11:30 a.m., indicated Resident #1 was given Tylenol with [MEDICATION NAME] #3 for pain. He said he slept wrong and his neck hurt. At 11:55 a.m., he drank 6 ounces of water and coughed some thick yellowish phlegm. He voiced no complaints of pain and no respiratory distress was noted. An undated Meal Percentage document revealed Resident #1 ate between 51 to 75 percent of three meals on [DATE]. During an interview on [DATE] at 12:22 p.m., LVN L said she was Resident #1's charge nurse on [DATE]. She said Resident #1 required extensive assistance to dress and was dependent on aides to put his dentures in. She said she thought CNA A put Resident #1's dentures in that morning. She said Resident #1 was his usual self that day. She said she found his dentures on the bed and placed them in a denture cup on the bedside table on [DATE]. LVN L said she thought Resident #1 could remove his dentures, but could not put them in, because he was not able to use his hands well. During an interview on [DATE] at 8:55 a.m., RN K said she thought Resident #1's top and bottom dentures were in his mouth on [DATE]. A nursing note on [DATE] at 4:17 a.m., indicated Resident #1 continued [MEDICATION NAME](antibiotic), was out of bed as his usual routine, and noted his cough improved. An undated Meal Percentage document revealed Resident #1 ate between 51 to 75 percent of two meals on [DATE]. During an interview on [DATE] at 3:35 p.m., CNA B said she worked with Resident #1 on [DATE] and he had both upper and lower dentures in. She said she did not recall doing denture care or using adhesive on his dentures that day. She could not recall the last time she assisted Resident #1 with his dentures. During a telephone interview on [DATE] at 11:11 a.m., hospice nurse RN M said Resident #1's dentures were always loose and he often misplaced them. She said she did not see him on the weekend, but on Monday [DATE], she initiated daily visits because she said he was transitioning to active dying. She said she did not recall he had dentures in on Monday. She said she suctioned him, but did not see dentures in his mouth. She said his head was hyper-extended and his tongue blocked the back of his throat and he breathed with his mouth open. An undated written statement by LVN Q indicated on [DATE], she was notified Resident #1 had secretions pooled in the front of his mouth. She cleaned the resident's mouth between his gums and lips and noted his top dentures with one tooth missing was in his mouth. During an interview on [DATE] at 12:06 p.m., CNA O said when she returned to work on [DATE], she was told Resident #1 was sick. She said she went to his room, but saw he was unresponsive, and she did not want to see him like that. She said he changed drastically from Saturday [DATE] to Monday [DATE]. She said she asked RN K why Resident #1's neck was bent back like that and RN K told her the resident had a crook in his neck. CNA O said Resident #1 appeared to be in pain. She did not recall if he had his dentures in that day. She said he had top and bottom dentures the last day she worked. She said Resident #1's dentures often fell out when he talked. She said the aide that got the resident up was responsible for using adhesive and putting the resident's dentures in, and the aide that put the resident to bed was responsible for removing dentures. During an interview on [DATE] at 9:38 a.m., hospice CNA N said on [DATE], Resident #1 had no upper or lower dentures at all. She said she did not work on [DATE], but when she returned on Monday, [DATE], he was in his wheelchair, but would not tolerate breakfast. She said he had phlegm and dried saliva. CNA N said she assisted him to bed with two other aides and he was bedfast from then on. She said he slept with his mouth open. During an interview on [DATE] at 9:29 a.m., CNA C said after Resident #1 became sick on [DATE], she figured the family had his dentures. She said she asked RN K about his dentures and was told RN K gave them to his family. A nursing note dated [DATE] at 6:54 p.m., indicated Resident #1's x-ray results were negative. At 6:59 p.m., the resident was resting in bed with no signs of distress, respiration was even and shallow. His lung sounds had mild crackles to upper lobes, and more course sounds to bases. The resident awakened to verbal commands and nodded his head yes or no. An undated Meal Percentage document revealed Resident #1 did not eat any meals on [DATE]. A nursing note dated [DATE] at 2:01 a.m., indicated Resident #1's respiration rate was 28, with grimacing noted. At 7:21 a.m., the resident was given [MEDICATION NAME] 20 ml by mouth every hour as needed for pain. Hospice orders indicated to discontinue all routine by mouth medications. During an interview on [DATE] at 12:48 p.m., LVN P said he only worked with Resident #1 on Tuesdays, and the resident had declined in the weeks prior to his death. He said on [DATE], Resident #1 was in bed, with his head extended back, mouth breathing, and was nonverbal. He said he opened his eyes, but looked past him with a fixed gaze. LVN P said Resident #1's dentures did not fit well due to the resident's weight loss, but could not recall if anything was done about the loose fitting dentures. LVN P said he did not recall Resident #1's dentures being in on [DATE]. LVN P said he was later notified that Resident #1's dentures were missing, but he did not recall who notified him, or when he was notified, and said he did not report it. During a telephone interview on [DATE] at 11:11 a.m., hospice nurse RN M said she reported Resident #1's top dentures were missing on Tuesday [DATE], to LVN P and the DON. She said the family was looking for them because they thought it might help his mouth from the sinking-in appearance due to his breathing through his mouth. A written statement by CNA W dated [DATE] indicated on [DATE], Resident #1 did not have his dentures in when she provided care. An undated Meal Percentage document revealed Resident #1 did not eat any meals on [DATE]. During an interview on [DATE] at 12:22 p.m., LVN L said when she worked on [DATE], Resident #1 was bedbound and at the end of life. She said he was flat on his back and nonresponsive. She said his neck was hyper-extended and she could not see down his throat. She said he did not gesture to his throat at all. An undated Meal Percentage document revealed Resident #1 did not eat any meals on [DATE]. During an interview on [DATE] at 8:55 a.m., RN K said on [DATE], Resident #1 did not have dentures in. She said she never suctioned him and he did not have any pooled secretions. She said his family was at his bedside and did not raise any concerns. RN K said before Resident #1 was sick, he regularly wore dentures, but they slipped when he talked. She said she thought CNA C put adhesive on the resident's dentures when she inserted them in his mouth. She said the aides usually took the residents' dentures out at night per their protocol. RN K said if a resident's dentures seemed to be ill-fitting, the nurse was supposed to leave a note for the social worker, but she did not recall if the social worker knew about Resident #1's ill-fitting dentures. A written statement by RN K dated [DATE] indicated she worked the 7:00 p.m. to 7:00 a.m., shift. She said she did not put Resident #1's dentures in or take them out on [DATE] or [DATE]. During a telephone interview on [DATE] at 11:11 a.m., hospice nurse RN M said she suctioned Resident #1 on [DATE], and recalled something yellowish at the back of his throat, that she assumed was sputum at the time, but looking back, it was probably his dentures. She said she did not want to make him gag by looking down his throat at that time. A statement written by the hospice nurse dated [DATE] at 4:25 p.m. indicated she provided Resident #1 with oral care. The note indicated something was noted to the back of his throat and she could not reach it with the swab. She did not want to gag him and thought it was likely sputum. An undated Meal Percentage document revealed Resident #1 did not eat any meals on [DATE]. During an interview on [DATE] at 3:35 p.m., CNA B said she was assigned to Resident #1 on [DATE]. She said he died at the end of her shift and she did not assist with his care. She said only the family was in his room when she ended her shift. She said on [DATE], Resident #1's dentures were definitely not in his mouth. She said his mouth was sunken in indicating to her he did not have his dentures in. She said the aides were looking for his dentures because the hospice nurse told them it would help his mouth stay closed, but she did not recall when or from whom she heard this. During a telephone interview on [DATE] at 8:10 a.m., the funeral director said when he picked up Resident #1's body from the facility on the night of [DATE], he picked up the resident's lower dentures in a denture cup from his bedside drawer, but his upper dentures were not found. He said later when he was doing post mortem oral care, he felt something hard at the back of Resident #1's throat, wedged behind his tongue. He said he had to use quite some force with forceps to remove full upper dentures from the resident's throat. He said the dentures were slimy with small food particles on them. He said the resident's daughter told him the nursing staff had been suctioning him and he did not understand how they did not see the piece of denture that was visible at the back of the throat. During an interview on [DATE] at 10:03 p.m., the DON said after Resident #1 passed away on [DATE], she learned from a hospice nurse that Resident #1's dentures were found in his throat by the funeral director on [DATE]. She said the hospice nurse, RN M, reported it to her when she was at the facility on [DATE], and said the funeral home had notified the hospice agency. She said she interviewed staff and dentures were seen in Resident #1's mouth on [DATE] by hospice CNA N. She said LVN L told her she saw Resident #1's top dentures lying on the bed on [DATE] and put them in a cup in the drawer. She said LVN Q did oral care [DATE] and said his dentures with one tooth missing were in his mouth. She said the administrator called the funeral director and verified that Resident #1's dentures were found in his throat and the family had not been contacted. She said the Social Worker contacted the family on [DATE]. She said she did not know how Resident #1's dentures came to be down his throat and said she did not know that could even happen. She said a thorough investigation was conducted and all residents were screened for ill-fitting dentures, and dental referrals were made for those identified. She said staff were in-serviced on oral care and to remove dentures each night. She said aides documented oral and denture care each shift and since [DATE], oral and denture care was specifically addressed and charted in the activities of daily living (ADL) tracker. She said refusals were also charted by nurses. During an interview on [DATE] at 9:25 a.m., the Social Worker said the DON told her the funeral home found Resident #1's top dentures in his throat. She said the DON asked her to notify his family. She made referrals to the dental service for the residents identified with loose dentures. She said there was an informal interdisciplinary team meeting with department heads to discuss what happened. She said it was never determined exactly when or how Resident #1's dentures became lodged in his throat. She said the facility self-reported the incident Friday [DATE], and the meeting was held after that. She said in the past, Resident #1's dentures had been misplaced, but usually resurfaced within a few days. She said she never did a formal grievance on them, because she followed up with staff and the dentures always turned up within a few days. She said if they did not turn up, she would have done a grievance on them. She said she discussed missing dentures or items in the daily morning meeting with department heads. She said the administrator and DON attended these meetings and were aware Resident #1's history of losing his dentures. She said she did not know his dentures were missing on [DATE], she said she thought they had been found the previous week. During an interview on [DATE] at 10:15 p.m., the administrator said he spoke with the funeral director and was told a small part of the dentures was visible in the throat and the dentures were removed from behind the back of the tongue with forceps. He said the funeral director said the dentures were phlegmy. He said upon investigation, no staff identified that resident had signs or symptoms of choking or distress. A Provider Investigation Report dated [DATE] indicated Resident 31 was on palliative hospice services and deceased [DATE]. His body was released to the funeral home. On [DATE], the funeral home notified the hospice company that he found Resident #1's dentures in his throat. The hospice company then notified the facility. The investigation summary indicated Resident #1 had a decline the last week of September and no signs/symptoms of choking or respiratory distress was noted over the last two weeks. The provider actions taken post-investigation included: 1. Identified all residents with dentures 2. Residents with loose dentures screened by therapy 3. Residents with loose dentures seen by dentist 4. In-service on denture care 5. Oral care two times a day for residents with dentures. Also, nurses are assisting residents to remove/cleanse and place dentures in a cup. During an interview on [DATE] at 2:53 p.m., the DON said she in-serviced staff on reporting missing items such as dentures missing. She said she was not notified Resident #1's dentures were missing until [DATE] after he deceased . During an interview on [DATE] at 11:24 a.m., Resident #5 said she made sure she took her dentures out herself each night because she was afraid she might swallow them if she did not. She said the staff did not assist her with this. A Routine Resident Care policy dated ,[DATE] indicated .5. Residents shall be encouraged or assisted to perform mouth care morning and night. A Certified Nursing Assistant Position Agreement dated [DATE] indicated ' .Provides C.N.A. tasks to assigned residents per C.N.A. competency guidelines. On [DATE] at 10:15 a.m., the administrator and DON were informed that an Immediate Jeopardy was determined to have existed from [DATE] through [DATE]. The Immediate Jeopardy was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. The Immediate Jeopardy was removed on [DATE] because, prior to surveyor entrance, the facility had in-serviced all staff regarding reporting all missing items, including dentures, and performing oral and denture care twice daily. The DON and SW screened all resident with dentures and identified 5 residents with ill-fitted dentures and set up dental services for them. CNA documentation was initiated in the ADL tracker to specifically document twice daily denture care. Residents with dentures had their care plans updated and those requiring assistance with their dentures were documented on their treatment records twice a day. An in-service dated [DATE] indicated all staff were in-serviced to perform oral and denture care twice a day and report any missing items, including dentures to the supervisor. An undated list of Residents with Dentures received [DATE] indicated 45 residents had dentures.

Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit neglect for 1 of 5 residents reviewed for neglect. (Resident #1) The facility did not assist Resident #1 with his loose dentures. Resident #1's upper dentures were found lodged in his throat by the funeral home director after his death. An Immediate Jeopardy was determined to have existed from [DATE] through [DATE]. This was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 45 residents with dentures at risk of neglect, choking, or death due to improper oral care or death due to failure to consistently assist residents with dentures. Findings included: A consolidated physician order [REDACTED].#1 was a [AGE] year old male admitted on [DATE]. He was admitted to hospice on [DATE]. His [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. He required extensive assistance of one person for bed mobility, transfers, dressing, and personal hygiene. He required limited assistance of one person for eating. He used a wheelchair for mobility and was impaired on both sides of his upper extremities. He was on a mechanically altered diet, had no difficulty or pain with swallowing, and was not coded for loosely fitting dentures. Resident #1's care plan dated [DATE] and updated [DATE] indicated he required one staff participation with personal hygiene and oral care. Resident #1's care plan dated [DATE] indicated he had dental health problems related to his dentures and he needed to have arrangements coordinated for dental care/transportation as needed. During an interview on [DATE] at 10:42 a.m., LVN T said after a quarterly review on [DATE] and care plan meeting identified Resident #1's dentures did not fit properly, the social worker notified the family for a dental referral, and the family declined the referral. LVN T said no other actions were taken. She said denture care was supposed to be performed twice a day. She did not know if Resident #1's denture care was done per facility protocol. During an interview on [DATE] at 10:50 a.m., the Social Worker said the hospice nurse notified her a tooth was broken out of Resident #1's top dentures. She said she initiated a dental referral but his family declined to have the dental work done due to a previous balance was due on their account. She said an alternative dental service was offered but the daughter also declined this option. She said the usual procedure for denture issues was staff notified her, because she made all of the dental referrals. During an interview on [DATE] at 11:55 a.m., CNA V said she would find Resident #1's dentures in the drawer, but did not recall the last time she saw his dentures. She said she did not recall putting his dentures in or removing them. She said Resident #1 had lost weight and his dentures were loose. She said they flopped when he talked and said she did not think he had adhesive in. She said she did not put adhesive on, but thought the hospice aide might have assisted him. During an interview on [DATE] at 9:29 a.m., CNA C said Resident #1 required extensive assistance for ADLs before he was sick. She said he was confused, but conversant with staff. She said sometimes he had his dentures in and sometimes he did not. CNA C said Resident #1 was totally dependent and was changed in his bed after he got sick until he died . She said the protocol for denture care was the aide that assisted a resident up in the mornings was responsible to put their dentures in and the aide that put a resident to bed was responsible to take their dentures out and residents were not supposed to sleep in their dentures. She said she never took Resident #1's dentures out. She said his hospice aide did his oral care. A statement written by CNA C dated [DATE] indicated she worked the 11:00 p.m. to 7:00 a.m. shift and did not provide any oral care to Resident #1. During an interview on [DATE] at 10:40 a.m., CNA U said she was assigned to Resident #1 in late September. She said he had upper and lower dentures at that time and he was unable to put them in himself, but opened his mouth to facilitate when she applied adhesive and put Resident #1's dentures in for him. She said his dentures would flop in his mouth without adhesive and she often saw his dentures flop when she was not assigned to assist him. She said if a resident refused to remove their dentures at night, the aide was supposed to notify the charge nurse. She said she worked multiple times when Resident #1 still had his dentures in from the night before and she would remove them, clean them, apply adhesive, and reinsert them. She said Resident #1 had never refused this. A hospice communication note dated [DATE] by hospice RN M indicated hospice CNA N notified her she could not find Resident #1's upper dentures. She found his lower dentures on his table on that visit, and placed them in a denture cup in his top drawer. She indicated she looked throughout his room, and did not find them and notified Resident #1's daughter. During a telephone interview on [DATE] at 3:13 p.m., CNA A said she did not put in or remove Resident #1's dentures. She said the hospice aide and the hospice nurse primarily cared for Resident #1 and performed the oral and incontinent care. CNA A said she just offered assistance as needed. She said Resident #1 was normal the week before he died . CNA A said she assisted Resident #1 in his wheelchair and noted he ate well the week prior to his death. She said the last time she saw his bottom dentures, they were on the desk in his room. She did not recall the date. During an interview on [DATE] at 3:45 p.m., CNA R said she recalled working with Resident #1 on [DATE] and he had upper and lower dentures in, communicated and participated fine. She said his hands were contracted and he could not perform his own oral care, but sometimes removed his dentures and left them in strange places. She said she did not ever recall assisting to insert or remove Resident #1's dentures. She did not know when the last time his dentures were missing. Nursing notes for Resident #1 dated [DATE] at 11:59 a.m., indicated Resident #1 was not feeling well and was in bed. No meal or supplement were provided at that time. At 12:12 p.m., the resident was coughing. Upon assessment, the resident had a moderate amount of yellow sputum, and the hospice nurse was in the room. The hospice nurse said Resident #1 had an order for [REDACTED]. An x-ray report dated [DATE] indicated the x-ray was ordered due to Resident #1's abnormal chest sounds related to his cough. The x-ray report indicated the lungs were clear. During an interview on [DATE] at 12:06 p.m., CNA O said Resident #1 was assisted into his wheelchair for breakfast, self-propelled with his feet, and talked with her, as per his usual on Saturday, [DATE]. She said the aide who got the resident up was responsible for assisting the resident to put clean dentures with adhesive in their mouth before breakfast. She said Resident #1 was at his base line and drank a lot of coffee the last time she saw him on [DATE]. During an interview on [DATE] at 9:38 a.m., hospice CNA N said she worked Saturday [DATE] with Resident #1 and he had upper and lower dentures in his mouth between 9:00 a.m., and 10:00 a.m. She said she applied adhesive and inserted his dentures that morning. She said his dentures were always loose and fell out of his mouth and never had adhesive on them when she came. CNA N said aides never took them out at night. She said she found his dentures everywhere and said they were never in a denture cup during the year she was regularly assigned to Resident #1. She said he could not insert his dentures by himself, but felt he must be able to get them out, since she often found them on the bed, under the bed, and once, in a sock. She did not think staff would place them in a sock. A nursing note dated [DATE] at 11:30 a.m., indicated Resident #1 was given Tylenol with [MEDICATION NAME] #3 for pain. He said he slept wrong and his neck hurt. At 11:55 a.m., he drank 6 ounces of water and coughed some thick yellowish phlegm. He voiced no complaints of pain and no respiratory distress was noted. An undated Meal Percentage document revealed Resident #1 ate between 51 to 75 percent of three meals on [DATE]. During an interview on [DATE] at 12:22 p.m., LVN L said she was Resident #1's charge nurse on [DATE]. She said Resident #1 required extensive assistance to dress and was dependent on aides to put his dentures in. She said she thought CNA A put Resident #1's dentures in that morning. She said Resident #1 was his usual self that day. She said she found his dentures on the bed and placed them in a denture cup on the bedside table on [DATE]. LVN L said she thought Resident #1 could remove his dentures, but could not put them in, because he was not able to use his hands well. During an interview on [DATE] at 8:55 a.m., RN K said she thought Resident #1's top and bottom dentures were in his mouth on [DATE]. A nursing note on [DATE] at 4:17 a.m., indicated Resident #1 continued [MEDICATION NAME](antibiotic), was out of bed as his usual routine, and noted his cough improved. An undated Meal Percentage document revealed Resident #1 ate between 51 to 75 percent of two meals on [DATE]. During an interview on [DATE] at 3:35 p.m., CNA B said she worked with Resident #1 on [DATE] and he had both upper and lower dentures in. She said she did not recall doing denture care or using adhesive on his dentures that day. She could not recall the last time she assisted Resident #1 with his dentures. During a telephone interview on [DATE] at 11:11 a.m., hospice nurse RN M said Resident #1's dentures were always loose and he often misplaced them. She said she did not see him on the weekend, but on Monday [DATE], she initiated daily visits because she said he was transitioning to active dying. She said she did not recall he had dentures in on Monday. She said she suctioned him, but did not see dentures in his mouth. She said his head was hyper-extended and his tongue blocked the back of his throat and he breathed with his mouth open. An undated written statement by LVN Q indicated on [DATE], she was notified Resident #1 had secretions pooled in the front of his mouth. She cleaned the resident's mouth between his gums and lips and noted his top dentures with one tooth missing was in his mouth. During an interview on [DATE] at 12:06 p.m., CNA O said when she returned to work on [DATE], she was told Resident #1 was sick. She said she went to his room, but saw he was unresponsive, and she did not want to see him like that. She said he changed drastically from Saturday [DATE] to Monday [DATE]. She said she asked RN K why Resident #1's neck was bent back like that and RN K told her the resident had a crook in his neck. CNA O said Resident #1 appeared to be in pain. She did not recall if he had his dentures in that day. She said he had top and bottom dentures the last day she worked. She said Resident #1's dentures often fell out when he talked. She said the aide that got the resident up was responsible for using adhesive and putting the resident's dentures in, and the aide that put the resident to bed was responsible for removing dentures. During an interview on [DATE] at 9:38 a.m., hospice CNA N said on [DATE], Resident #1 had no upper or lower dentures at all. She said she did not work on [DATE], but when she returned on Monday, [DATE], he was in his wheelchair, but would not tolerate breakfast. She said he had phlegm and dried saliva. CNA N said she assisted him to bed with two other aides and he was bedfast from then on. She said he slept with his mouth open. During an interview on [DATE] at 9:29 a.m., CNA C said after Resident #1 became sick on [DATE], she figured the family had his dentures. She said she asked RN K about his dentures and was told RN K gave them to his family. A nursing note dated [DATE] at 6:54 p.m., indicated Resident #1's x-ray results were negative. At 6:59 p.m., the resident was resting in bed with no signs of distress, respiration was even and shallow. His lung sounds had mild crackles to upper lobes, and more course sounds to bases. The resident awakened to verbal commands and nodded his head yes or no. An undated Meal Percentage document revealed Resident #1 did not eat any meals on [DATE]. A nursing note dated [DATE] at 2:01 a.m., indicated Resident #1's respiration rate was 28, with grimacing noted. At 7:21 a.m., the resident was given [MEDICATION NAME] 20 ml by mouth every hour as needed for pain. Hospice orders indicated to discontinue all routine by mouth medications. During an interview on [DATE] at 12:48 p.m., LVN P said he only worked with Resident #1 on Tuesdays, and the resident had declined in the weeks prior to his death. He said on [DATE], Resident #1 was in bed, with his head extended back, mouth breathing, and was nonverbal. He said he opened his eyes, but looked past him with a fixed gaze. LVN P said Resident #1's dentures did not fit well due to the resident's weight loss, but could not recall if anything was done about the loose fitting dentures. LVN P said he did not recall Resident #1's dentures being in on [DATE]. LVN P said he was later notified that Resident #1's dentures were missing, but he did not recall who notified him, or when he was notified, and said he did not report it. During a telephone interview on [DATE] at 11:11 a.m., hospice nurse RN M said she reported Resident #1's top dentures were missing on Tuesday [DATE], to LVN P and the DON. She said the family was looking for them because they thought it might help his mouth from the sinking-in appearance due to his breathing through his mouth. A written statement by CNA W dated [DATE] indicated on [DATE], Resident #1 did not have his dentures in when she provided care. An undated Meal Percentage document revealed Resident #1 did not eat any meals on [DATE]. During an interview on [DATE] at 12:22 p.m., LVN L said when she worked on [DATE], Resident #1 was bedbound and at the end of life. She said he was flat on his back and nonresponsive. She said his neck was hyper-extended and she could not see down his throat. She said he did not gesture to his throat at all. An undated Meal Percentage document revealed Resident #1 did not eat any meals on [DATE]. During an interview on [DATE] at 8:55 a.m., RN K said on [DATE], Resident #1 did not have dentures in. She said she never suctioned him and he did not have any pooled secretions. She said his family was at his bedside and did not raise any concerns. RN K said before Resident #1 was sick, he regularly wore dentures, but they slipped when he talked. She said she thought CNA C put adhesive on the resident's dentures when she inserted them in his mouth. She said the aides usually took the residents' dentures out at night per their protocol. RN K said if a resident's dentures seemed to be ill-fitting, the nurse was supposed to leave a note for the social worker, but she did not recall if the social worker knew about Resident #1's ill-fitting dentures. A written statement by RN K dated [DATE] indicated she worked the 7:00 p.m. to 7:00 a.m., shift. She said she did not put Resident #1's dentures in or take them out on [DATE] or [DATE]. During a telephone interview on [DATE] at 11:11 a.m., hospice nurse RN M said she suctioned Resident #1 on [DATE], and recalled something yellowish at the back of his throat, that she assumed was sputum at the time, but looking back, it was probably his dentures. She said she did not want to make him gag by looking down his throat at that time. A statement written by the hospice nurse dated [DATE] at 4:25 p.m. indicated she provided Resident #1 with oral care. The note indicated something was noted to the back of his throat and she could not reach it with the swab. She did not want to gag him and thought it was likely sputum. An undated Meal Percentage document revealed Resident #1 did not eat any meals on [DATE]. During an interview on [DATE] at 3:35 p.m., CNA B said she was assigned to Resident #1 on [DATE]. She said he died at the end of her shift and she did not assist with his care. She said only the family was in his room when she ended her shift. She said on [DATE], Resident #1's dentures were definitely not in his mouth. She said his mouth was sunken in indicating to her he did not have his dentures in. She said the aides were looking for his dentures because the hospice nurse told them it would help his mouth stay closed, but she did not recall when or from whom she heard this. During a telephone interview on [DATE] at 8:10 a.m., the funeral director said when he picked up Resident #1's body from the facility on the night of [DATE], he picked up the resident's lower dentures in a denture cup from his bedside drawer, but his upper dentures were not found. He said later when he was doing post mortem oral care, he felt something hard at the back of Resident #1's throat, wedged behind his tongue. He said he had to use quite some force with forceps to remove full upper dentures from the resident's throat. He said the dentures were slimy with small food particles on them. He said the resident's daughter told him the nursing staff had been suctioning him and he did not understand how they did not see the piece of denture that was visible at the back of the throat. During an interview on [DATE] at 10:03 p.m., the DON said after Resident #1 passed away on [DATE], she learned from a hospice nurse that Resident #1's dentures were found in his throat by the funeral director on [DATE]. She said the hospice nurse, RN M, reported it to her when she was at the facility on [DATE], and said the funeral home had notified the hospice agency. She said she interviewed staff and dentures were seen in Resident #1's mouth on [DATE] by hospice CNA N. She said LVN L told her she saw Resident #1's top dentures lying on the bed on [DATE] and put them in a cup in the drawer. She said LVN Q did oral care [DATE] and said his dentures with one tooth missing were in his mouth. She said the administrator called the funeral director and verified that Resident #1's dentures were found in his throat and the family had not been contacted. She said the Social Worker contacted the family on [DATE]. She said she did not know how Resident #1's dentures came to be down his throat and said she did not know that could even happen. She said a thorough investigation was conducted and all residents were screened for ill-fitting dentures, and dental referrals were made for those identified. She said staff were in-serviced on oral care and to remove dentures each night. She said aides documented oral and denture care each shift and since [DATE], oral and denture care was specifically addressed and charted in the activities of daily living (ADL) tracker. She said refusals were also charted by nurses. During an interview on [DATE] at 9:25 a.m., the Social Worker said the DON told her the funeral home found Resident #1's top dentures in his throat. She said the DON asked her to notify his family. She made referrals to the dental service for the residents identified with loose dentures. She said there was an informal interdisciplinary team meeting with department heads to discuss what happened. She said it was never determined exactly when or how Resident #1's dentures became lodged in his throat. She said the facility self-reported the incident Friday [DATE], and the meeting was held after that. She said in the past, Resident #1's dentures had been misplaced, but usually resurfaced within a few days. She said she never did a formal grievance on them, because she followed up with staff and the dentures always turned up within a few days. She said if they did not turn up, she would have done a grievance on them. She said she discussed missing dentures or items in the daily morning meeting with department heads. She said the administrator and DON attended these meetings and were aware Resident #1's history of losing his dentures. She said she did not know his dentures were missing on [DATE], she said she thought they had been found the previous week. During an interview on [DATE] at 10:15 p.m., the administrator said he spoke with the funeral director and was told a small part of the dentures was visible in the throat and the dentures were removed from behind the back of the tongue with forceps. He said the funeral director said the dentures were phlegmy. He said upon investigation, no staff identified that resident had signs or symptoms of choking or distress. A Provider Investigation Report dated [DATE] indicated Resident 31 was on palliative hospice services and deceased [DATE]. His body was released to the funeral home. On [DATE], the funeral home notified the hospice company that he found Resident #1's dentures in his throat. The hospice company then notified the facility. The investigation summary indicated Resident #1 had a decline the last week of September and no signs/symptoms of choking or respiratory distress was noted over the last two weeks. The provider actions taken post-investigation included: 1. Identified all residents with dentures 2. Residents with loose dentures screened by therapy 3. Residents with loose dentures seen by dentist 4. In-service on denture care 5. Oral care two times a day for residents with dentures. Also, nurses are assisting residents to remove/cleanse and place dentures in a cup. During an interview on [DATE] at 2:53 p.m., the DON said she in-serviced staff on reporting missing items such as dentures missing. She said she was not notified Resident #1's dentures were missing until [DATE] after he deceased . During an interview on [DATE] at 11:24 a.m., Resident #5 said she made sure she took her dentures out herself each night because she was afraid she might swallow them if she did not. She said the staff did not assist her with this. The facility's undated Abuse/Neglect Policy last defined neglect as, .the failure to provide goods and services, necessary to avoid physical harm, mental anguish, or mental health illness . A Routine Resident Care policy dated ,[DATE] indicated .5. Residents shall be encouraged or assisted to perform mouth care morning and night. A Certified Nursing Assistant Position Agreement dated [DATE] indicated ' .Provides C.N.A. tasks to assigned residents per C.N.A. competency guidelines. On [DATE] at 10:15 a.m., the administrator and DON were informed that an Immediate Jeopardy was determined to have existed from [DATE] through [DATE]. The Immediate Jeopardy was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. The Immediate Jeopardy was removed on [DATE] because, prior to surveyor entrance, the facility had in-serviced all staff regarding reporting all missing items, including dentures, and performing oral and denture care twice daily. The DON and SW screened all resident with dentures and identified 5 residents with ill-fitted dentures and set up dental services for them. CNA documentation was initiated in the ADL tracker to specifically document twice daily denture care. Residents with dentures had their care plans updated and those requiring assistance with their dentures were documented on their treatment records twice a day. An in-service dated [DATE] indicated all staff were in-serviced to perform oral and denture care twice a day and report any missing items, including dentures to the supervisor. An undated list of Residents with Dentures received [DATE] indicated 45 residents had dentures.

Based on interview and record review, the facility failed to implement their policies and procedures to prohibit neglect for 1 of 4 residents reviewed for neglect. (Resident #1) Resident #1 required the assistance of 2 people for transfers. CNA A transferred Resident #1 by herself, resulting in an incident that reinjured the resident's recently repaired leg fracture. This failure contributed to Resident #1's increased pain and non-healing of the fracture. This failure could place 84 residents who required assistance with transfers at risk of injury. Findings included: Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1 understood and was able to make others understand her. She had a cognition score of 15 (00 being the most impaired and 15 being the no impairment).She had no signs of [MEDICAL CONDITION], no signs of depression, and no behaviors. The MDS indicated Resident #1 required extensive, two-person assistance with transfers and bed mobility. Resident #1 did not walk. She had impairment of one leg and used a wheelchair for mobility. The MDS indicated Resident #1 had a history of [REDACTED]. The MDS indicated Resident #1 had no pain within 5 days prior to the assessment. The MDS indicated Resident #1 had a fall that resulted in a fracture. Resident #1 weighed 203 pounds and was 5 foot 6 inches tall. A nursing care plan dated 09/03/13 indicated Resident #1 required total assistance for ADLs: bed mobility, transfers, toileting, and eating. According to the MDS, total assistance indicated full staff performance every time during a 7-day period. An ADL report dated September 2013 indicated on 09/15/13 evening shift Resident #1 was totally dependent on staff for transferring and required two-person physical assistance. The ADL sheet was electronically signed by CNA A. Nursing Progress Notes dated 09/16/13 at 12:04 p.m. indicated Resident #1 complained of pain during physical therapy and told LVN B that she may have put some weight on her leg the night of 09/15/13 when she was transferred. Resident #1 requested something for pain. A physical therapy note dated 09/16/13 at 12:28 p.m.,noted Resident #1 reported that on the evening of 09/15/13, a CNA was transferring her to bed and the CNA was unable to complete the transfer and lowered her to the floor. The note indicated Resident #1 reported her leg got twisted under her and she has had pain since the incident. During an interview on 10/18/13 at 12:04 p.m., CNA A said on the evening of 09/15/13, she transferred Resident #1 from the wheelchair to the bed by herself. CNA A said she knew Resident #1 required two people for a transfer. CNA C was working on the hall with her, was pregnant, and could not help with any transfers. She said Resident #1 never fell and was not lowered to the ground. CNA A said the facility did not have CNA sheets and she knew how to care for the residents by what the nurses tell them to do. CNA A said Resident #1 was alert and did not have memory impairment. During an interview on 10/18/13 at 12:07 p.m., the administrator said the CNAs know how to transfer residents by looking at their ADL sheets. The Administrator said the care plan indication of "total assistance" would be the same as the definition found on the MDS, full staff performance every time during a 7-day period. During an interview on 10/18/13 at 12:43 p.m., Resident #1 said CNA A transferred her by herself because CNA C was pregnant and could not assist. Resident #1 said CNA A got her from the wheelchair to the bed, but CNA A landed on top of her causing the resident to bear weight to keep them both from sliding off of the bed. Resident #1 said she was making progress in physical therapy until the incident. She said CNA A was doing more than she was able to do by herself. Resident #1 said her left leg got twisted when she was laid back on the bed before the CNA lifted the resident's legs onto the bed and positioned her. During an interview on 10/18/13 at 2:30 p.m., CNA A said when she transferred Resident #1 the evening of 09/15/13, " We made it to the bed...She was not standing using her legs... It was difficult..." CNA A denied landing on top of Resident #1 after the transfer. During an interview on 10/18/13 at 8:30 a.m., PT D indicated the nursing staff was notified of the incident through a computerized system called a PCC. He said the PCC data deletes itself after a couple of weeks. He said in the notification, he wrote the exact same thing that was in his physical therapy note dated 09/16/13 at 12:28 p.m. PT D said Resident #1 continued to have increased pain after reporting the incident to him. At 10:45 a.m., PT D said if Resident #1 was nauseated or in pain, they did the therapy in her bed. PT D said Resident #1 was alert, oriented, and did not have impaired memory. During an interview on 10/18/13 at 8:49 a.m., the DON said Resident #1 was at the facility following ankle surgery. She said Resident #1 left the facility because she ran out of her 20 day supplemental insurance. The DON said the daughter reported Resident #1 was transferred by one staff member only instead of two. The DON thought the one-person transfer was done by CNA C, but was not certain. The DON said an incident report and investigation were not done because the resident did not fall. The DON said after Resident #1 returned from her orthopedic follow-up on 09/17/13, signs were posted over her bed to indicate she was not to bear weight on her left leg. During an interview on 10/18/13 at 09:10 a.m., Resident #1's daughter said she did not witness CNA A transferring Resident #1. Three other family members stood in the hallway and knew that CNA A was the only staff member in the room during the transfer. The daughter said the next morning on 09/16/13 at around 10:00 a.m., Resident #1 complained her left leg hurt her all night long. The daughter said she reported Resident #1's pain to LVN B and the resident was given Tylenol. The daughter said LVN B told her Resident #1 needed an x-ray, but it would be quicker just to wait until the orthopedic follow-up visit on 09/17/13.The daughter said on 09/16/13, Resident #1's son told PT what happened the evening of 09/15/13 when one CNA transferred her. The daughter said on 09/17/13, the orthopedic doctor told her the visit's x-ray results showed the distal fixated femur fracture had shifted, likely due to weight bearing, and if it shifted any more, they would have to repeat surgery. The daughter said when she returned Resident #1 to the facility, she told the administrator. The administrator told her they would move Resident #1 to a hall that had more CNAs to assist with transferring her. The daughter said Resident #1 was never moved, and the administrator said it was because there were two CNAs on that hall and that fixed the problem. The daughter said shortly after the incident, she received a certified letter in the mail saying Resident #1 would no longer receive physical therapy because she was not making any progress. The daughter said she moved her mother to another facility where she was receiving physical therapy and learning how to use a transfer board because of the damage caused by the incident. During an interview on 10/18/13 at 10:02 a.m., LVN B said on 09/16/13, Resident #1's daughter told her she was in pain. LVN B said the physical therapist did not tell her about a transferring incident, only that Resident #1 was in pain. LVN B said Resident #1 asked her for Tylenol and told her she may have put weight on her left leg during a transfer on the evening of 09/15/13. LVN B said she was unaware of an incident and did not receive a notification from the physical therapy department. She was only told Resident #1 was in pain. LVN B said she was the first nurse that the increase in pain was reported to. LVN B said she documented Resident #1 denied falling. LVN B said she offered to get a physician order [REDACTED].#1 was transferred with the assistance of only one CNA, but she did know who. LVN B said she reported the increase in pain to the DON and the DON told her to find out what happened. LVN B said Resident #1 told her the increase in pain occurred during a transfer. LVN B said Resident #1 was alert and oriented and able to recall facts accurately. During an interview on 10/18/13 at 11:02 a.m., the administrator said Resident #1's daughter took her to her orthopedic follow-up visit on 09/17/13. Resident #1 had an x-ray done that indicated the resident's internally fixated fractured leg had a shift in the fracture, and the orthopedic doctor advised the resident was not to bear weight on her left leg. The administrator said she made signs to hang over the Resident #1's bed indicating she was not to bear weight on her left leg and she also notified all of the staff. The administrator said the daughter told her Resident #1 was transferred with the assistance of only one staff member on the evening of 09/15/13, but she did not know there was a reason to do an incident report and investigation because she did not see this as neglect. During an interview on 10/18/13 at 11:45 a.m., the administrator said she talked with the CNAs on shift the evening of 09/15/13, and CNA A said she transferred Resident #1 from the wheelchair to the bed by herself. During an interview on 10/18/13 at 2:53 p.m., the administrator said they did not have any orders or notes from Resident #1's follow-up visit with the orthopedic doctor on 09/17/13. After exit, on 10/21/13 at 1:55 p.m., the surveyor received a fax from the facility containing the following: 1. An orthopedic follow-up progress note dated 09/17/13 at 3:21 p.m. indicated Resident #1 stated twice the facility staff tried to assist her without appropriate assistants. The note indicated Resident #1 said she placed her full weight down to prevent further fall and injury on both occasions. An x-ray of the left femur indicated obvious changes in alignment of the fracture compared to the films after surgery. The note indicated Resident #1 must have appropriate assistance for transfers and physical therapy at the nursing home. 2. An orthopedic follow-up visit dated 10/16/13 at 8:35 a.m. indicated Resident #1 and her daughter said she had a couple of incidents at the facility, one of them where she was dropped on her knee. The note indicated Resident #1 had displacement of the fracture and shortening of the left leg. An x-ray indicated shortening of the distal femur and a protrusion of the internal hardware under the knee joint. The note indicated Resident #1's left femur fracture had shifted. The physician indicated if he did not repeat surgery, the likelihood that she could use that leg in a meaningful way for transfers would be diminished. The Abuse policy and procedure dated May 2011 noted the following: "...report any incident of suspected incident of neglect or resident abus ...Policy Interpretation and Implementation...6. To assist in recognizing incidents of abuse, i.e., the following definitions of abuse are provided "...g. Neglect is defined as failure to provide goods and services necessary to avoid physical harm...the Administrator will appoint a member of management to investigate the alleged incident...b. Signs of actual physical neglect:...Inadequate provision of care... " The CMS 672 dated 10/17/13 indicated 84 residents required the assistance of staff for transfers.

Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit neglect for 1 of 4 residents reviewed for neglect. (Resident # 1) Resident #1 required the assistance of 2 people for transfers. CNA A transferred Resident #1 by herself, resulting in an incident that reinjured the resident's recently repaired leg fracture. This failure contributed to Resident #1's increased pain and non-healing of the fracture. This failure could place 84 residents who required assistance with transfers at risk of injury. Findings included: The Abuse policy and procedure dated May 2011 noted the following: "...report any incident of suspected incident of neglect or resident abus ...Policy Interpretation and Implementation...6. To assist in recognizing incidents of abuse, i.e., the following definitions of abuse are provided "...g. Neglect is defined as failure to provide goods and services necessary to avoid physical harm...the Administrator will appoint a member of management to investigate the alleged incident...b. Signs of actual physical neglect:...Inadequate provision of care... " Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1 understood and was able to make others understand her. She had a cognition score of 15 (00 being the most impaired and 15 being the no impairment).She had no signs of [MEDICAL CONDITION], no signs of depression, and no behaviors. The MDS indicated Resident #1 required extensive, two-person assistance with transfers and bed mobility. Resident #1 did not walk. She had impairment of one leg and used a wheelchair for mobility. The MDS indicated Resident #1 had a history of [REDACTED]. The MDS indicated Resident #1 had no pain within 5 days prior to the assessment. The MDS indicated Resident #1 had a fall that resulted in a fracture. Resident #1 weighed 203 pounds and was 5 foot 6 inches tall. A nursing care plan dated 09/03/13 indicated Resident #1 required total assistance for ADLs: bed mobility, transfers, toileting, and eating. According to the MDS, total assistance indicated full staff performance every time during a 7-day period. An ADL report dated September 2013 indicated on 09/15/13 on the evening shift, Resident #1 was totally dependent on staff for transferring and required two-person physical assistance. The ADL sheet was electronically signed by CNA A. Nursing Progress Notes dated 09/16/13 at 12:04 p.m. indicated Resident #1 complained of pain during physical therapy and told LVN B that she may have put some weight on her leg the night of 09/15/13 when she was transferred. Resident #1 requested something for pain. A physical therapy note dated 09/16/13 at 12:28 p.m.,noted Resident #1 reported that on the evening of 09/15/13, a CNA was transferring her to bed and the CNA was unable to complete the transfer and lowered her to the floor. The note indicated Resident #1 reported her leg got twisted under her and she has had pain since the incident. During an interview on 10/18/13 at 12:04 p.m., CNA A said on the evening of 09/15/13, she transferred Resident #1 from the wheelchair to the bed by herself. CNA A said she knew Resident #1 required two people for a transfer. CNA C was working on the hall with her, was pregnant, and could not help with any transfers. She said Resident #1 never fell and was not lowered to the ground. CNA A said the facility did not have CNA sheets and she knew how to care for the residents by what the nurses tell them to do. CNA A said Resident #1 was alert and did not have memory impairment. During an interview on 10/18/13 at 12:07 p.m., the administrator said the CNAs know how to transfer residents by looking at their ADL sheets. The Administrator said the care plan indication of "total assistance" would be the same as the definition found on the MDS, full staff performance every time during a 7-day period. During an interview on 10/18/13 at 12:43 p.m., Resident #1 said CNA A transferred her by herself because CNA C was pregnant and could not assist. Resident #1 said CNA A got her from the wheelchair to the bed, but CNA A landed on top of her causing the resident to bear weight to keep them both from sliding off of the bed. Resident #1 said she was making progress in physical therapy until the incident. She said CNA A was doing more than she was able to do by herself. Resident #1 said her left leg got twisted when she was laid back on the bed before the CNA lifted the resident's legs onto the bed and positioned her. During an interview on 10/18/13 at 2:30 p.m., CNA A said when she transferred Resident #1 the evening of 09/15/13, " We made it to the bed...She was not standing using her legs... It was difficult..." CNA A denied landing on top of Resident #1 after the transfer. During an interview on 10/18/13 at 8:30 a.m., PT D indicated the nursing staff was notified of the incident through a computerized system called a PCC. He said the PCC data deletes itself after a couple of weeks. He said in the notification, he wrote the exact same thing that was in his physical therapy note dated 09/16/13 at 12:28 p.m. PT D said Resident #1 continued to have increased pain after reporting the incident to him. At 10:45 a.m., PT D said if Resident #1 was nauseated or in pain, they did the therapy in her bed. PT D said Resident #1 was alert, oriented, and did not have impaired memory. During an interview on 10/18/13 at 8:49 a.m., the DON said Resident #1 was at the facility following ankle surgery. She said Resident #1 left the facility because she ran out of her 20 day supplemental insurance. The DON said the daughter reported Resident #1 was transferred by one staff member only instead of two. The DON thought the one-person transfer was done by CNA C, but was not certain. The DON said an incident report and investigation were not done because the resident did not fall. The DON said after Resident #1 returned from her orthopedic follow-up on 09/17/13, signs were posted over her bed to indicate she was not to bear weight on her left leg. During an interview on 10/18/13 at 09:10 a.m., Resident #1's daughter said she did not witness CNA A transferring Resident #1. Three other family members stood in the hallway and knew that CNA A was the only staff member in the room during the transfer. The daughter said the next morning on 09/16/13 at around 10:00 a.m., Resident #1 complained her left leg hurt her all night long. The daughter said she reported Resident #1's pain to LVN B and the resident was given Tylenol. The daughter said LVN B told her Resident #1 needed an x-ray, but it would be quicker just to wait until the orthopedic follow-up visit on 09/17/13.The daughter said on 09/16/13, Resident #1's son told PT what happened the evening of 09/15/13 when one CNA transferred her. The daughter said on 09/17/13, the orthopedic doctor told her the visit's x-ray results showed the distal fixated femur fracture had shifted, likely due to weight bearing, and if it shifted any more, they would have to repeat surgery. The daughter said when she returned Resident #1 to the facility, she told the administrator. The administrator told her they would move Resident #1 to a hall that had more CNAs to assist with transferring her. The daughter said Resident #1 was never moved, and the administrator said it was because there were two CNAs on that hall and that fixed the problem. The daughter said shortly after the incident, she received a certified letter in the mail saying Resident #1 would no longer receive physical therapy because she was not making any progress. The daughter said she moved her mother to another facility where she was receiving physical therapy and learning how to use a transfer board because of the damage caused by the incident. During an interview on 10/18/13 at 10:02 a.m., LVN B said on 09/16/13, Resident #1's daughter told her she was in pain. LVN B said the physical therapist did not tell her about a transferring incident, only that Resident #1 was in pain. LVN B said Resident #1 asked her for Tylenol and told her she may have put weight on her left leg during a transfer on the evening of 09/15/13. LVN B said she was unaware of an incident and did not receive a notification from the physical therapy department. She was only told Resident #1 was in pain. LVN B said she was the first nurse that the increase in pain was reported to. LVN B said she documented Resident #1 denied falling. LVN B said she offered to get a physician order [REDACTED].#1 was transferred with the assistance of only one CNA, but she did know who. LVN B said she reported the increase in pain to the DON and the DON told her to find out what happened. LVN B said Resident #1 told her the increase in pain occurred during a transfer. LVN B said Resident #1 was alert and oriented and able to recall facts accurately. During an interview on 10/18/13 at 11:02 a.m., the administrator said Resident #1's daughter took her to her orthopedic follow-up visit on 09/17/13. Resident #1 had an x-ray done that indicated the resident's internally fixated fractured leg had a shift in the fracture, and the orthopedic doctor advised the resident was not to bear weight on her left leg. The administrator said she made signs to hang over the Resident #1's bed indicating she was not to bear weight on her left leg and she also notified all of the staff. The administrator said the daughter told her Resident #1 was transferred with the assistance of only one staff member on the evening of 09/15/13, but she did not know there was a reason to do an incident report and investigation because she did not see this as neglect. During an interview on 10/18/13 at 11:45 a.m., the administrator said she talked with the CNAs on shift the evening of 09/15/13, and CNA A said she transferred Resident #1 from the wheelchair to the bed by herself. During an interview on 10/18/13 at 2:53 p.m., the administrator said they did not have any orders or notes from Resident #1's follow-up visit with the orthopedic doctor on 09/17/13. After exit, on 10/21/13 at 1:55 p.m., the surveyor received a fax from the facility containing the following: 1. An orthopedic follow-up progress note dated 09/17/13 at 3:21 p.m. indicated Resident #1 stated twice the facility staff tried to assist her without appropriate assistants. The note indicated Resident #1 said she placed her full weight down to prevent further fall and injury on both occasions. An x-ray of the left femur indicated obvious changes in alignment of the fracture compared to the films after surgery. The note indicated Resident #1 must have appropriate assistance for transfers and physical therapy at the nursing home. 2. An orthopedic follow-up visit dated 10/16/13 at 8:35 a.m. indicated Resident #1 and her daughter said she had a couple of incidents at the facility, one of them where she was dropped on her knee. The note indicated Resident #1 had displacement of the fracture and shortening of the left leg. An x-ray indicated shortening of the distal femur and a protrusion of the internal hardware under the knee joint. The note indicated Resident #1's left femur fracture had shifted. The physician indicated if he did not repeat surgery, the likelihood that she could use that leg in a meaningful way for transfers would be diminished. The CMS 672 dated 10/17/13 indicated 84 residents required the assistance of staff for transfers.

Based on observation, interview, and record review, the facility failed to ensure 2 of 4 residents reviewed for pressures sores received the necessary services to prevent the development of and promote the healing of pressure sores. (Resident #s 1 and 2) Resident #1 was admitted without pressure sores on 06/28/11. On 8/07/11, she was transferred to the hospital with three pressure sores which required debridement. A [MEDICAL CONDITION] was required due to the extensive pressure sore on her buttocks. The facility did not thoroughly assess Resident #1's pressure sores and did not consult with the physician regarding deterioration of the pressure sores. Resident #2's pressure sore to the left heel had eschar on 8/03/11. The physician was not notified until 08/09/11. The resident's heels were not off loaded as ordered. This failure contributed to Resident #1's development of three pressure sores, subsequent hospitalization and [MEDICAL CONDITION]. This failure could place 3 other residents with pressure sores at risk for decline in pressure sores and 59 residents who received preventative skin care at risk for development of pressure sores. Findings included: 1.) physician progress notes [REDACTED]. A skin assessment sheet dated 06/28/11 indicated Resident #1 was admitted with no skin problems. A Braden Scale dated 06/28/11 indicated Resident #1 was at moderate risk for pressure sores. A nursing note dated 07/08/11 indicated Resident #1's right heel was boggy. No other description was documented. Resident #1's MDS assessment dated [DATE] indicated she required extensive assistance with bed mobility and toilet use, had a catheter and was incontinent of bowel. Resident #1 had minimal problems in the area of mental status and had three Stage II pressure sores. The resident rejected care 4 to 6 days during the last 7 days but less than daily. Resident #1's dietary assessment dated [DATE] indicated the resident had no skin breakdown. A care plan dated 7/18/11 indicated Resident #1 had "actual impairment to skin integrity related to a yeast infection to the peri area and the buttocks." Staff were to encourage good nutrition and hydration, keep the resident's skin clean and dry and use Baza creme (antifungal cream) to the buttocks with each incontinent episode, and encourage the resident to be compliant with the turning schedule. The plan indicated Resident #1 was resistive to care related to non-compliance with treatment. The resident refused to be turned off her left side and refused to go back to bed after being up all day in her wheelchair. Non-pressure ulcer skin condition sheet weekly evaluations indicated the following for Resident #1: *07/10/11 - 3.5 cm x 3 cm open Stage II on the right buttock. There was no documentation regarding the right heel. *07/17/11 - 3.5 cm x 3 cm open Stage II on the right buttock. Both heels were hard. *07/24/11 - 3.5 cm x 3 cm open Stage II on the right buttock. [MEDICATION NAME] cream was to be applied to unstageable areas on both heels. *07/31/11 - 3 cm x 1 cm open area to right buttock. Left heel open with black scab, 1.5 cm x 2.1 cm. The non-pressure ulcer skin condition sheet weekly evaluations did not address depth, odor, drainage or color of Resident #1's pressure sores. There was no indication the physician was consulted for treatment changes. Nursing notes indicated the following regarding Resident #1: *07/13/11 - resident has skin problems; refer to skin book. *07/19/11 - skin breakdown to coccyx and multiple small abrasions to buttocks. *07/23/11 - area to buttocks healing slowly. *07/25/11 - coccyx wound had serosanguinous drainage; resident now on air mattress. *07/27/11 at 9:15 a.m. - area on coccyx almost healed; staff used cream to the area. *07/27/11 at 11:58 p.m. - wound to coccyx was red and had a foul odor. There was no documentation the physician was consulted. A communication to the physician dated 08/02/11 indicated a request to use Santyl on Resident #1's coccyx and left heel due to slough in the wound beds. A communication between the dietitian and the attending physician dated 08/04/11 indicated Resident #1 had impaired skin integrity and the recommendations were to add multivitamin with minerals, vitamin C, [MEDICATION NAME], protein powder, and zinc. The form was signed by the physician on 08/09/11, after the resident was discharged to the hospital. During an interview on 08/19/11 at 1:53 p.m., LVN A said the pressure sore on Resident #1's coccyx had slough, was dull grayish in color and had a foul odor. He said he was aware of the foul odor for "about a week" before he sent the resident to the hospital on [DATE]. LVN A said he notified the physician of the foul odor and was told to continue the same treatment. He said Resident #1 did not allow staff to reposition her often. During an interview on 08/19/11 at 3:50 p.m. the DON said skin assessments were to be completed and documented every week and when there was a change in the resident's skin. She said the physician should be notified when there were changes in pressure sores. The DON reviewed the skin report sheets dated 7/10, 7/17, 7/24 and 7/31/11 for Resident #1 and said there were no other weekly skin reports for the resident. She confirmed the incomplete documentation on Resident #1's skin sheets. She said in order to fix their problem of incomplete documentation, they changed skin assessment forms. The DON said they treated Resident #1's "wounds" with whirlpool baths and Baza cream. She said the physician was treating Resident #1 for a fungal infection "on her bottom". Physician orders [REDACTED]. Resident #1's hospital Surgical Consultation Observation Detail Report dated 08/08/11 indicated the surgeon was consulted due to the foul odor of Resident #1's pressure sores when she first arrived at the hospital. Resident #1 had extensive necrosis and nonviable tissue that comprised most of her sacrum, perineum, and part of her buttocks. Her right heel had an 8 cm wound that was "down to the bone." Debridement of the extensive sacral pressure sore required a [MEDICAL CONDITION] to keep stool out of the clean wound. Several initial debridements would be needed. The report indicated there would be no healing of the right foot (heel) pressure sore, and the right foot would probably need to be amputated. Hospital wound photographs, before debridement, dated 08/08/11 indicated the right foot (heel) pressure sore was 5 cm by 6 cm by 1.5 cm. The perirectal (sacral) pressure sore was 11.5 cm by 11.5 cm. laboratory results dated [DATE] indicated Resident #1's [MEDICATION NAME] level was 1.9 (reference range 3.4 to 4.8). 2.) July 2011 physician orders [REDACTED]. Staff were to off load both heels and keep both heels off the mattress. A Braden Scale dated 06/13/11 indicated Resident #2 was at low risk for pressure sores. A communication to the physician dated 6/14/11 indicated Resident #2 had been newly admitted with a 4.5 cm by 4.5 cm blister on her right heel. The form noted the physician's response was to off load the resident's heels, and he would see her that day. Resident #2's MDS dated [DATE] indicated she was incontinent of bowel and bladder, required extensive assistance with bed mobility, transfers, and personal hygiene. Resident #2 was at risk for pressure sores and had one or more unhealed pressure sores. There was no indication of the stage or number of pressure sores. A care plan initiated 6/21/11 indicated Resident #2's pressure sore to the left heel would be assessed, recorded and monitored weekly. The perimeter, wound bed and healing process were to be documented. Resident #2's heels were to be off loaded when she was in bed. Weekly wound documentation forms for Resident #2 indicated the following: *06/13/11 - 4 cm x 4.5 cm intact blisters to both heels; heels first observed. *06/21/11 - 4 cm x 4.5 cm intact blister; treatment to off load heels and diathermy. Location not indicated. *06/24/11 - 4 cm x 4.5 cm area to bilateral heels, "dark around edge." No indication which heel had the dark edge. *06/27/11 - 3.7 cm x 3.4 cm intact blister to the left heel and a 4 cm x 4.2 cm intact blister to the right foot. *07/07/11 - 4.8 cm x 4.8 cm; apply [MEDICATION NAME] and off load both heels. Location not indicated. *07/14/11 - 3.8 cm x 3.5 cm unstageable to left heel. No documentation regarding right heel. *07/22/11 - Stage I. No other information documented. *07/29/11 - Stage I. No other information documented. *08/08/11 - "left heel 8 cm length 5.5 cm wide with 5 cm opened with 3 cm black area in middle." Scant brown drainage and odor present. Hand written skilled nursing notes indicated Resident #2 had no skin problems on the following dates: June 21, 24 and 27; July 2, 5, 7, 14, and 15; and August 2 through 7, 2011. (including 8/03/11) A computerized nursing progress note for Resident #2 dated 08/03/11 at 7:40 p.m. indicated "right heel with thick eschar." A computerized nursing progress note dated 08/04/11 at 9:42 a.m. indicated there was a scab on Resident #2's heel from an old blister that was not intact and the treatment was [MEDICATION NAME] cream. A computerized nursing progress note dated 08/09/11 indicated Resident #2's left heel was open with a foul odor and the doctor was notified. During an observation on 08/18/11 at 10:30 a.m., the ADON removed the dressing from Resident #2's left heel. The resident was sitting in her wheelchair. The pressure sore was open and the wound bed was red and pink with a small amount of white slough in the center. During an interview on 8/18/11 at 3:30 p.m., Resident #2 said staff did not reposition her often. During an interview on 08/19/11 at 11:18 a.m., LVN D said Resident #2 had pressure sores on both heels which could have been caused by her shoes. She said the right heel healed but the left heel developed a dark hard area. The physician was notified 8/09/11 and the podiatrist debrided the left heel on 08/12/11. During an observation and interview on 8/19/11 at 2:15 p.m., Resident #2 was in bed on her back with both heels resting on the mattress. There was no pillow or other device under her legs. CNA C said Resident #2 was in that position when she came on duty at 2:00 p.m. CNA C said they made rounds for incontinent care and repositioning every two hours. During an interview on 08/19/11 at 3:12 p.m., LVN B said she first observed eschar on Resident #2's heel 08/03/11. She said she did not notify the physician because other staff told her the eschar was not new. During an interview on 08/19/11 at 3:50 p.m. the DON said skin assessments were to be completed and documented every week and when there was a change in the resident's skin. She said the physician should be notified when there were changes in pressure sores. The DON confirmed the incomplete documentation on Resident #2's skin sheets. An undated facility pressure ulcer policy, page 527, included, "A pressure ulcer is a lesion caused by unrelieved pressure that results in damage to underlying tissues. Most pressure ulcers develop over bony prominences where friction and shearing force combine with pressure to beak down skin and underlying tissues. About 95% of pressure ulcers occur in the lower part of the body, with the sacrum and the heel being the two most common sites that experience skin breakdown....Documentation: record the date and time of initial and subsequent treatments. Note the specific treatment given. Detail preventative strategies performed. Document the pressure ulcer's location and size (length, width, and depth); color and appearance of the wound bed; amount, odor, color and consistency of drainage; and the condition of the surrounding skin. Reassess pressure ulcers at least weekly. Note on the clinical record changes in the condition or size of the pressure ulcer and any elevation of skin temperature. Document when the physician was notified of pertinent abnormal observations." The National Pressure Ulcer Advisory Panel, Clinical Practice Guideline, 2009, pages 19-33, indicated, ".... a Stage II pressure sore was partial thickness skin loss presenting as a shallow open ulcer with a red pink wound bed without slough. May also present as an intact or open/ruptured serum-filled blister. An unstageable pressure sore was full thickness tissue loss in which the base of ulcer is covered by slough (yellow, tan, gray, green or brown and /or eschar (tan, brown, or black) in the wound bed.... Repositioning patients is an important component in the prevention of pressure ulcers. Pressure caused by lying or sitting on a particular part of the body can result in sustained deformation of soft tissues and, ultimately, in ischemia of the affected area. Repositioning involves a change in position of the lying or seated individual, with the purpose of relieving or redistributing pressure and enhancing comfort, undertaken at regular intervals." The CMS 672 dated 08/18/11 indicated 3 residents had pressure sores and 57 received preventative skin care.