Every finding on record at Town and Country Nursing and Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for one of five residents (Resident #21) reviewed for care plans. The facility failed to update or add interventions to Resident #21's care plan given that the resident was positive for PASRR I at admissions (04/10/2026). This failure could place residents at risk of not receiving the necessary services or having the appropriate interventions to meet their current needs. The findings include: Record review of Resident #21's face sheet, dated 7/29/26 reflected a -[AGE] year-old female who was admitted to the facility on [DATE]. Resident #21's diagnoses included: bi-polar disorder (primary) (a mental health disorder associated with mood changes), alcohol dependence in remission, anxiety, and PTSD (a mental health condition associated with trauma). The RP was listed as: self.Record review of Resident#21's quarterly MDS, dated [DATE], reflected a BIMS score of 11, indicative of moderate impairment in cognition. Record review of Resident# 21's Care Plan, undated, revealed the problem of bi-polar disorder with interventions that included: medication administration and assessment of mood, behavior every shift. The CP also identified the resident with the diagnoses of PTSD with interventions that included: medication administration and psychotherapy/psychiatry referral PRN. [The CP did not document Resident #21 had a positive PASRR I for Mental Illness at admissions and a PSARR II had been completed at another county with no recommendations] Record review of Resident #21's physician orders, dated July 2026, reflected: the following psychotropics were ordered for the resident to treat her mental health diagnoses: buspirone 1 tablet 15 mg for times a day for anxiety, Hydroxyzine 1 tablet every 8 hours PRN for severe anxiety, and Lurasidone 1 tablet daily for Schizoaffective bipolar disorder. Record review of Resident#21's MAR (medication administration record), dated July 2026 reflected the resident was given the above mediations for her mental health diagnoses. Record review of Resident # 21's PASRR Level I Screening dated 1/10/26 revealed the resident triggered for Mental Illness. Record review of Resident #21's PASSR II revealed it was done on 1/22/26 with no recommended services. During an observation and interview on 7/29/26 at 11:25 a.m., Resident #21 was in the activity room participating in an activity. Resident #21 was alert and oriented to person, place, and time. The resident was ambulatory. The resident had no signs of injury, skin tears, or bruises. The resident revealed no signs of fear or anxiety. The resident stated she needed more stimulation. The resident stated she had PTSD and anxiety. The resident did not want to discuss the nature of the PTSD. The resident stated she had no complaints about the care she received in the facility to include medications and mental health services. The resident stated she had no complaints in general and denied any ANE. During an interview on 7/29/26 at 3:16 p.m., LVN A stated Resident # 21 triggered for PSARR I on 1/10/26 and the referral was made to the LA by another County; documented on the PASRR I form. LVN A stated if habilitation services (services like rehabilitative services such as PT, OT, ST and durable equipment) were recommended the facility was not notified by the LA (local authority) at time of resident's admissions on 1/10/26. LVN A stated she was not aware that Resident #21 had triggered for a PASRR II. LVN A stated that all residents admitted to a facility required a PASRR PL I and she had been employed as an MDS Nurse for 10 years and was familiar with the PASRR process. LVN A stated the system breakdown around the update of the CP involving PASRR might have occurred when the resident changed counties, and no alert occurred in the PASRR system notifying her (LVN A) of the resident's PASRR status. LVN A stated the Resident was private pay but had community Medicaid prior to admissions. [PASRR services are only for Medicaid eligible residents] LVN A stated she did not know the resident was PASRR positive requiring an update to the CP until the surveyor requested a copy of the PASRR I. During an interview on 7/29/26 at 3:39 p.m., LVN B stated she did not know that Resident #21 had triggered for a PASRR I and therefore the CP pan was not updated. LVN B stated the CP needed to be updated so that necessary services habilitative could be arranged. LVN B stated the breakdown in the PSARR process could have occurred when the resident moved between counties and the PL I was not requested at admissions. LVN B stated the admissions office was responsible for exploring PASRR documentation at admissions. LVN B stated it was the first time she realized the resident was positive when the surveyor requested a copy of the PASRR I and PASRR II. LVN B stated the CP needed to be updated for Resident #21. During an interview on 7/29/26 at 4:24 p.m., the admissions Coordinator stated the admissions process involved checking the status of every resident admitted in reference to the PASRR PL I screen. She stated the checking of the resident's [Resident #21] PL I was not captured and she had no explanation for the failure. During an interview on 7/29/26 at 4:43 p.m., the DON stated the process for PASRR was for nursing staff to check on a resident's PASRR status at admissions, during CP development and quarterly. The DON stated if a resident was PASRR positive the CP needed to be updated to ensure habilitative services were given to the resident. The DON stated she had no explanation why Resident #21's CP was not updated or the PL checked throughout the CP process. The DON stated she was not aware Resident #21's CP had not captured that Resident #21 was PASRR positive for MH. During an interview on 7/29/26 at 4:49 p.m., the Administrator stated that every resident admitted required a PL I. The Administrator stated that if the PL I triggered, a PL II would be needed and a referral made to the LA. The Administrator stated the admissions Coordinator was responsible for checking Resident # 21's PL I status at admissions. The Administrator stated she had no explanation why the PL I was not checked at admissions and why nursing staff did not capture the omission at the 7-day baseline CP, the 14-day comprehensive CP, and the Quarterly assessment to consider an update of the CP around Resident #21 being PASRR positive for MH. Record review of facility's policy entitled Baseline Plan dated 6/6/25, read: .The baseline replan will.Include the minimum healthcare information necessary to properly care for a resident including, but not limited to.PASARR recommendations, if applicable.

Based on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for one (1) of seven (7) residents (Resident #5) reviewed for accuracy of assessments. The facility failed to ensure Resident #5 was coded on her Quarterly MDS assessment, dated 05/07/2026, for having had weight loss of 11.9%, ten percent (10%) or more in the last six (6) months. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #5's admission Record, dated 07/30/2026, revealed a [AGE] year-old female. She was admitted on [DATE] and readmitted on [DATE]. Record review of Resident #5's Diagnosis Report, undated and accessed 07/30/2026 at 10:43 a.m., revealed diagnoses included liver cirrhosis (scarring of the liver typically caused by hepatitis viruses or chronic alcohol abuse), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and gastro-esophageal reflux disease (also known as acid-reflux disease or GERD, when the stomach contents flow back into the esophagus and cause discomfort such as heartburn). Record review of Resident #5's Quarterly MDS Assessment, dated 05/07/2026, revealed the assessment reference date and observation end date was 05/07/2026. The resident had a BIMS Score of 15, indicating she was cognitively intact. Under Section K - Swallowing/Nutritional Status of the MDS Assessment, Resident #5 was noted to have weighed 141 pounds on the most recent measure in the last 30 days. She was documented has having not lost or gained weight of 5% or more in the last month or 10% or more in the last 6 months. MDS G was noted to have completed Section K on 05/08/2026. The DON was noted to have signed the assessment as complete on 05/08/2026. Record review of Resident #5's Weight Summary, undated and accessed 07/30/2026 at 11:08 a.m., revealed Resident #5 had a weight of 140.6 pounds on 05/04/2026. She did not have another weight on the record until 05/17/2026, after Resident #5's Quarterly MDS Assessment observation end date. She had a weight of 159.7 pounds on 11/04/2025, indicating a 19.1 pound or 11.9% weight loss in six (6) months (11/04/2025 to 05/04/2026). Record review of Resident #5's Care Plan, undated and accessed 07/30/2026 at 12:20 p.m., revealed the following problem and interventions:- Problem: .4/15/2025 - [Resident #5] is attempting to lose weight, she received an order for Trizipitde [sic, a weight loss medication] per her request, date initiated 12/03/2018 and revised on 04/14/2025. - Intervention: Resident is losing weigh [sic], but the weight loss is planned. she [sic] takes topiramate [a weight loss medication] for weight loss., date initiated 07/22/2026. During an observation and interview with Resident #5 on 07/28/2026 at 02:02 p.m., Resident #5 did not appear underweight. Resident #5 did not report any complaints regarding the facility food or report unintentional weight loss. During an interview on 07/30/2026 at 04:05 p.m., MDS G stated she was one (1) of two (2) MDS nurses for the facility. She stated when documenting a resident's weight changes, she would look in the resident's electronic medical records to see if the system triggered the resident for having had a significant weight loss or gain in the last 30 days and last 180 days. She stated the system did not always trigger correctly, so she also used an online calculator by entering the dates and weights to calculate the weight change. She stated for Resident #5, the system did not trigger, and she also must have missed it when she completed the assessment. She stated she did not believe the incorrect coding of Resident #5's significant weight loss over the six (6)-month period would have impacted Resident #5's care. She stated the facility dietitian ran her own weight change reports and spoke with facility staff about the resident statuses, thus the weight change would have been identified and addressed by the facility dietitian regardless of the resident's MDS coding. During an interview on 07/31/2026 at 09:23 a.m., the RCS stated the facility did not have a policy on MDS Accuracy and just followed the RAI (Resident Assessment Instrument). During an interview on 07/31/2026 at 09:37 a.m., the Administrator stated she believed Resident #5's goal was for weight loss. She stated she believed if weight loss was the resident's goal, then she did not believe a mistake in coding the weight loss would have impacted Resident #5's care. She stated if weight loss was not the resident's goal, then the MDS Assessment having not shown a decline in the resident's weight could possibly impact whether the care plan would be triggered for that decline. During an interview on 07/31/2026 at 09:54 a.m., the DON stated she did not believe an error in coding a resident's significant weight loss in the MDS Assessment would impact the resident's care because the facility dietitian performed weekly visits to the facility and the dietitian checked the residents' weights herself. The DON stated the dietitian wrote intervention recommendations based on her own reviews of the residents' weights and not the coding from the MDS Assessments. The DON stated she reviewed the dietitian's recommended interventions and she would enter orders and care plan interventions based on the dietitian's recommendations.

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 13 residents (Resident #28) reviewed for medication administration: The facility failed to ensure LVN H crushed and administered each of Resident #28's medications separately: baclofen 5 mg, cholecalciferol 25 mcg, loratadine 10 mg, docusate sodium 100 mg and hydroxyzine 25 mg via PEG-tube utilizing gravity according to the facility policy on 7/31/2026. This failure could place residents at risk of medication interactions and stress to the resident's gastrointestinal system, which could result in a change in condition. The findings were: Record review of Resident #28's face sheet dated 7/31/2026 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses which included: cerebral palsy (movement disorder caused from a brain injury), severe intellectual disabilities and gastrostomy status (g-tube/feeding tube). Record review of Resident #28's quarterly MDS dated [DATE] revealed the resident was unable to complete a BIMS assessment due to both short term and long-term memory problems. His functional assessment revealed he required maximal assistance with ADL care and movement. His nutritional assessment revealed he required a feeding tube. Record review of Resident #28's physician orders revealed he was NPO (nothing by mouth) with a start date of 1/31/2025 with the following medication orders; Baclofen tablet 5 mg, give 1 tablet via PEG-tube, two times a day related to contracture of jointCholecalciferol tablet 25 mcg (1000 u), give 1 tablet via PEG-tube, one time a day for vitamin D3 supplement Claritin (loratadine) 10 mg tablet, give one tablet via PEG-tube, one time a day for seasonal allergiesDocusate Sodium 100 mg tablet, give one tablet via PEG-tube, two times a day related to constipation.Hydroxyzine 25 mg oral tablet, give 0.5 tablet, one time a day for anxiety. Record review of Resident #28's care plan dated 5/21/2026 revealed he had dysphagia (difficulty swallowing) with impaired swallowing ability requiring NPO status with interventions that included: tube feedings, flushes, and medications as ordered. During an observation on 7/31/2026 at 8:02 a.m., LVN H revealed the LVN crushed all medications: baclofen 5 mg, cholecalciferol 25 mcg, loratadine 10 mg, docusate sodium 100 mg and hydroxyzine 25 mg together, mixed them with approximately 60 cc of water in a cup, drew up the combined medication and water and administered them via g-tube by push to Resident #28. During an interview on 7/31/2026 at 9:57 am LVN H stated he had been a nurse for approximately one year. He stated he had been trained in his previous job on how to administer g-tube medications by crushing the medications together and administering them by push instead of gravity. He stated at this facility he demonstrated competencies in g-tube medication administration to his trainer, who no longer works at the facility, in the same manner. LVN H stated since the observation he had asked his colleagues and had learned that he did it incorrectly. He stated he should have crushed each medication separately and administered them separately by gravity instead of push. LVN H stated he did have access to facility policies on the computer. During an interview on 7/31/2026 at 10:51 am the DON stated she expected staff to follow facility protocol for g-tube (PEG-tube) medication administration. The DON stated each medication should be crushed separately and mixed with 10cc of water. She stated each medication should be administered separately via gravity and should not be pushed. The DON stated between each medication the tubing should be flushed with water. She stated it should be medication, flush, medication, flush. The DON stated it was important to follow this technique so each medication was in its own cup and could be isolated if needed based on the resident's vital signs or needs at the time. She stated it was important not to crush and mix the medication all at one time because some medications had the potential to interact with each other. Record review of LVN H Medication Pass Competency assessment dated [DATE] signed by an unknown person (illegible signature) revealed LVN H was a new hire at the time of the assessment and had successfully met the standards. The sequence of medication administration via assessment indicated: 2. Do not cocktail 2a. Crushed medications are not combined and not given all at once via feeding tube 2d.suspend crushed medications in 5-10 cc of water (or as ordered by MD) 8. tube flushed with 5-10 ml of water between each medication or with ordered amount. 8b. Medication will flow by gravity for those patients with large-bore tubes. Record review of the facility policy titled Enteral Tube Medication Administration dated 10/01/2019 revealed: Procedures: 7. Prepare medications for administration: B crush immediate-release tablets into a fine powder, and dissolve in 5-10 ml of warm water or prescribed amount, D. Dilute liquid medications with 10-30 ml of warm water or enteral formula. K. Remove plunger from the 60 ml catheter-tipped syringe and connect syringe to clamped tubing. L. Put 15-30 ml of water in syringe and flush tubing using gravity flow. M. Pour dissolved/dilute medication in syringe and unclamp tubing, allowing medication to flow to gravity. N. Flush with 5-10 ml warm water between each medication .

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #88) reviewed for infection control, in that: The facility failed to maintain standard infection control precautions while providing Resident #88 with perineal and catheter care. CNA's D and E did not perform hand hygiene and put on clean gloves when transitioning from a dirty to a clean procedure; did not use a new disposable wipe per stroke; cleaned the meatus while wearing dirty gloves; did not clean the indwelling catheter up to 4 inches; and did not replace the dirty brief for a clean brief. These failures could affect residents with an indwelling catheter and place them at risk for a urinary tract infection. The findings included: Record review of Resident #88's face sheet, dated 07/31/2026, revealed the resident was an [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of: overactive bladder (sudden, strong urge to urinate with frequent urination), obstructive and reflux uropathy(backflow of urine caused by an obstruction), dementia with anxiety (a decline in mental abilities that can often cause fear, worry, or panic), Parkinson's disease (slow brain disorder that can cause tremors, muscle stiffness, and slow motion), and Alzheimer's disease (a slow decline in memory, thinking, and daily functioning). Record review of Resident #88's Order Summary Report, dated 07/31/2026, revealed an order for: Indwelling Urinary catheter care Q shift and PRN, clean with soap and water/cleansing wipes every shift, with a start date of 07/24/2026 and no end date. Record review of Resident #88's Care Plan Report, dated 07/31/2026, revealed the resident's care plan addressed catheter care. The problem stated, The resident has Indwelling Catheter related to retention- Date Initiated: 07/28/2026. The goal stated, The resident will show no s/sx of urinary infection through review date. Date Initiated: 07/28/2026-Target Date: 10/26/2026. The interventions stated, CATHETER: The resident has 16F indwelling catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Date Initiated: 07/28/2026 Monitor and document intake and output as ordered, Date Initiated: 07/28/2026 Monitor for s/sx of discomfort on urination and frequency. Date Initiated: 07/28/2026 Monitor/document for pain/discomfort due to catheter. Date Initiated: 07/28/2026 Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Date Initiated: 07/28/2026 Observation on 07/30/2026 at 9:37 AM revealed CNA's D and E provided perineal and catheter care for Resident #88. CNA E used disposable peri-wipes to clean from underneath Resident #88's meatus, down the shaft, on the front and back of the penis, omitting the meatus. Then CNA E cleaned inside the folds of the groin, and proceeded to clean the scrotum. CNA E returned to the penis and cleaned the meatus where the indwelling catheter was inserted without removing her dirty gloves, performing hand hygiene, and putting on clean gloves. Further observation revealed neither CNA D or E changed their gloves or did any hand hygiene throughout the entire procedure. The resident's indwelling catheter tubing was never cleaned. CNAs D and E rolled the resident over to his right side, and CNA E proceeded to do rear peri care as she wiped the anal area from front to back and both buttocks from the lower to top buttocks. Observation revealed CNA E used a disposable peri-wipe which was folded and used for more than one stroke. CNAs D and E then turned Resident #88 back onto the already existing, dirty brief, and pulled the front of the dirty brief back onto the front of the perineal area. and reattached the straps. During an interview with CNA's D and E on 07/30/2026 at 9:50 AM, CNA E stated the consequences of not ensuring sanitized hands, with clean gloves while cleaning the meatus with an indwelling catheter, using the same disposable wash cloth more than once per stroke, and putting a used brief back on the resident could cause an infection. CNA D concurred with CNA E. During an interview with the Director of Nursing (DON)/Infection Preventionist (IP), on 07/31/2026 at 9:45 AM, the DON stated infections were prevented by following the proper hand-washing procedures, and staff should wash their hands when it was indicated for each activity. The DON stated this was important for quality of care, because residents had weakened immune systems and were more prone to acquiring infections. The DON further stated her expectations of staff while doing perineal care for a male with an indwelling catheter were that they follow proper procedures and wash their hands depending on the activity being performed. The DON stated her expectations of a used brief being changed for a new one during peri care were that if the brief were soiled then it should be changed. The DON stated it was important to follow infection control policies with hand hygiene, changing dirty gloves, infection prevention and control program measures, and replacing dirty briefs because it prevented infection and skin impairments. Record review of CNA D's Incontinent Care Skills Checklist, dated 03/12/2026, revealed under the category, Miscellaneous, bullets #5-7 states, (5) Wash hands, apply gloves. (6) remove soiled clothing and/or brief. (7) Remove gloves, sanitize hands and apply new gloves. Then the competency checklist proceeds to the female and male specific care categories. Under the category, Male Perineal Care, bullet #6 states, Wipe the tip of the penis at urethral meatus first. Using circular motion, cleanse from meatus outward and down shaft. If catheter is present, gently wipe the catheter tubing with new wipe or cloth from the meatus outward for at least 4 inches of tubing. Record review of CNA E's Incontinent Care Skills Checklist, dated 05/08/2026, revealed under the category, Miscellaneous, bullets #5-7 states, (5) Wash hands, apply gloves. (6) remove soiled clothing and/or brief. (7) Remove gloves, sanitize hands and apply new gloves. Then the competency checklist proceeds to the female and male specific care categories. Under the category, Male Perineal Care, bullet #6 states, Wipe the tip of the penis at urethral meatus first. Using circular motion, cleanse from meatus outward and down shaft. If catheter is present, gently wipe the catheter tubing with new wipe or cloth from the meatus outward for at least 4 inches of tubing. Record review of the facility's policy named, Perineal Care, dated 10/24/2022, revealed: Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate. Change gloves if soiled and continue with perineal care. Hold the shaft of the penis with one hand and wipe with the other. Begin cleansing at the tip of the penis at the urethral meatus using a circular motion and working outward. Cleanse the shaft of the penis, using downward strokes toward the scrotum. Use a separate section of the washcloth or a new disposable wipe with each stroke. Record review of the facility's policy named, Hand Hygiene, dated 10/24/2022, revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and vistors. This applies to all staff working in all locations within the facility.Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Record review of the facility's policy named, Infection Prevention and Control Program, dated 05/13/2023, revealed:(a) Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures, and (c) All staff shall use personal protective equipment according to established facility policy governing the use of PPE.All staff shall demonstrate competence in relevant infection control practices.

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect or exploitation or mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in bodily injury, to the State Survey Agency for 1 of 3 residents (Resident #2) reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report to the State Survey Agency (HHSC) an allegation of abuse when CNA C raised voice at a Resident #2 and called him a liar.This failure could place residents at risk for abuse and could lead to a diminished quality of life and harm.The Findings:Record review of Resident #2's admission Record, dated 07/10/2026, revealed a [AGE] year-old male that admitted to the facility on [DATE] with diagnoses including Unspecified Dementia (diagnosis given when a patient clearly has a cognitive decline and memory loss, but the exact underlying cause cannot be definitively determined); Cognitive Communication Deficit (difficulty with communication caused by disrupted thinking and impaired cognitive processes-such as attention, memory, and executive functioning-rather than a primary speech or language impairment); Depression (a common, serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities); and Other Speech and Language Deficits Following Other Cerebrovascular Disease (acquired communication disorders, such as cognitive-linguistic deficits, agraphia (writing impairment), and acalculia (mathematical difficulties), caused by strokes or brain blood vessel condition). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS 02, revealing severe cognitive impairment.Record review of Resident #2's Care Plan, dated 04/29/2026, revealed that resident has impaired cognition function and impaired thought process related to brain injury and dementia; communication problem related to ventricular shunt and dementia; and dependent on staff for all needs.Record review of Resident #2's Order Summary Report, dated 07/10/2026, revealed escitalopram oxalate 20mg one time a day for depression and divalproex sodium 125mg two capsules three times a day for behaviors.Record review of Resident #2's Progress Notes, dated 07/10/2026, revealed no note regarding incident in room where aide yelled at resident and called him a liar. Note for this incident found in Resident #1's Progress Notes. Record review of Resident #1's Progress Notes, dated 07/10/2026, revealed that the aide became upset when questioned about a situation and raised her voice and started telling the roommate (Resident #2) that he was lying.During an interview on 07/10/2026 at 1:34 pm, LVN B stated that there was an incident when an NPO resident had food in their room. When LVN B asked the roommate (Resident #2) about the food item Resident #2 stated it belonged to Resident #1. LVN B stated he questioned CNA C about the food item in the room and that Resident #2 had stated that CNA C had given the food to Resident #1. LVN B then revealed that CNA C raised her voice and began yelling in front of Resident #2 and that she did not give anything to Resident #1 and CNA C told Resident #2 that he was liar. LVN B stated he reported the incident to the DON and Assistant Administrator after attempts to contact the ADMIN on 07/10/2026 were futile. During an interview on 07/10/2026 at 4:18pm, the DON revealed that she did not witness the yelling, however it was reported to her by LVN B. The DON said she spoke to the ADMIN and CNA C regarding the situation. The DON said it was just a verbal conversation and was not documented. The DON stated that herself and CNA C had known the resident previously when they all lived in the community and she felt that the resident trusts them and would be honest. The DON said Resident #2 told her that LVN B was lying and that he had never said that about CNA C. The DON stated that LVN C tends to be dramatic about things. The DON stated that when allegations are initially made that they would report abuse to the state and that she does not believe that this incident was reported. The DON stated that she felt as though the situation was handled correctly.During an interview on 07/10/2026 at 4:45pm, ADMIN revealed that she was made aware of situation regarding CNA C and Resident #2 when they read the progress note at their next clinical meeting. The ADMIN stated she did not recall the Assistant Administrator saying anything but did recall the DON mentioning the situation. The ADMIN stated that the DON shared that Resident #2 sometimes gets names confused, as the resident will sometimes call the DON the name of CNA C. The ADMIN believes the DON spoke to CNA C regarding the concern and CNA C stated she did not yell at the resident or call him a liar and that the DON may have said that the resident claimed that LVN B was not telling the truth. The ADMIN stated that policy regarding abuse and neglect involves making sure the resident is safe, interviewing the resident or who made the allegation, suspend if necessary. The ADMIN stated that since Resident #2 stated that LVN B was lying, they felt they did not need to investigate and that the DON and CNA C have known Resident #2 for a long time. The ADMIN believes that the DON did interviews right away with everyone involved. The ADMIN stated that resident cognition should trump comfortability and relationship status when determining appropriate responses for investigating situations. The ADMIN stated she is not aware of Resident #2's BIMS score or cognitive level.CNA C was not available for interview, nor did CNA C return surveyors call on 07/10/2026 at 1:45 pm, 2:45 pm, and 3:50 pm. Record review of facility policy for Abuse, Neglect, and Exploitation, dated 07/11/2025, revealed that verbal abuse is acknowledged as a type of abuse, that the facility has procedures to assist staff in determining abuse (to include verbal). The policy also revealed Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse.; 5. Verbal abuse of a resident is overheard. Facility policy also covered Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview, observation, and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized for 1 of 6 residents (Resident #1) reviewed medical records. The facility failed to document Resident #1's multiple bruises on her skin assessment dated [DATE]. These failures could place residents at risk for inaccurate medical records.The findings were:Record review of Resident #1's admission record, dated 07/05/2026 reflected a [AGE] year-old female initially admitted [DATE] and re-admitted [DATE]. Record review of Resident #1's annual MDS assessment, dated 05/18/2026 reflected Resident #1 had a diagnosis of cognitive communication deficit, need for assistance with personal care, and dementia (loss of cognitive functioning that interferes with daily life and activities). It reflected Resident #1 had a BIMS score of 99, indicating the resident was unable to complete the interview. It further reflected that she had short-term and long-term memory problems. Record review of Resident #1's care plan, undated, reflected the following:problem [Resident #1] has fragile skin and is at increased risk for skin tears and bruising, initiated 07/08/2025, with intervention Weekly skin assessment by licensed nurse, initiated 07/08/2025problem [Resident #1] is at risk for pressure ulcer development related to incontinence, initiated 07/08/2025, with intervention Monitor/document/report PRN any changes in skin status: appearance, color., initiated 07/08/2025Record review of Resident #1's skin check assessments, dated 07/03/2026 and authored by ADON F, reflected Bruising was not noted as a skin issue.Record review of Resident #1's skin observation every shift for the last 30 days (06/07/2026-07/05/2026) reflected purple discoloration was noted on 06/26/2026 at 11:41 AM. During an interview on 07/05/2026 at 04:30 PM, Resident #1's responsible party revealed Resident #1 had bruises on her left eye and forehead. She revealed she knew that the resident received these bruises due to falls because she was contacted after each fall. She revealed it was important for the facility to document the bruising so that other facilities did not think Resident #1 was being abused. During an interview and observation on 07/06/2026 at 08:55AM, the [hospital] LVN revealed Resident #1 had bruising of different colors as follows: on the back of her right arm and left arms, bruise to right side of her forehead above her eyebrow, knee and shin bruising, and a black eye. Resident #1 did not respond to any questions. Resident #1 was attempting to get out of the hospital bed; she had a sitter to prevent Resident #1 from falling. Resident #1 had a black eye and multiple bruising on her arms and legs. During an interview on 07/06/2026 at 12:57 PM, MA C revealed Resident #1 had bruises on her legs, forehead and had a black eye. She revealed there was a place to document for bruising, but she did not document for Resident #1 because she assumed it was documented already. She revealed Resident #1's bruises should be documented to investigate and see what caused the bruising. She revealed it would be important to see bruising documentation, so she knew if the bruising was new or not. During an interview with LVN D and CNA B on 07/06/26 at 01:16 PM, LVN D revealed Resident #1 had bruising around her eye. She revealed she did not know Resident #1 had bruising to her legs. She revealed she would expect the CNAs to tell her if residents had bruises. CNA B revealed Resident #1 had bruises on her legs, but the CNAs did not document bruising on residents because the nurses documented the residents' bruises. LVN D revealed Resident #1 had a bruise on her knee and eye, and they should document bruising so they could track if it was healing and find out what caused the bruise if needed. During an interview on 07/06/2026 at 01:53 PM, ADON E and ADON F revealed the nurses documented skin changes like bruises in the residents' electronic medical record. ADON F was not sure about Resident #1 having bruises on her legs, but Resident #1 fell a lot and bruised easily. They revealed it would be important to document any bruises or skin changes so they could monitor bruising and see what was going on with the bruises or skin changes. They further revealed that documenting skin changes allowed them to investigate what was causing the bruise, like falls or from a laceration. During an interview on 07/06/2026 at 02:20PM, DON revealed Resident #1 bruised easily. She did not recall if Resident #1 had bruising on her arms or legs. Her expectation was for the nursing staff to tell her about skin issues like these bruises so they could find out what caused the bruises. Record review of the facility's policy Skin Assessment, dated 4/24/25, reflected . A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter .

Based on interviews and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #2 and Resident #3) of 10 residents reviewed for medical records. The facility failed to maintain a medication administration record for Resident #2's controlled medication. The facility failed to maintain a medication administration record for Resident #3's controlled medication. These failures placed residents at risk for missed treatment and medications which could result in decline in health and well-being.The findings included:1. Record review of Resident #2's admission Record, dated 04/23/2026, revealed a [AGE] year-old female admitted [DATE]. Resident #2 was not listed as her own responsible party with her (family member) listed as Emergency Contact #1. Record review of Resident #2's Medical Diagnoses, undated and accessed on 4/24/2026 at 8:37 p.m., revealed diagnoses including nontraumatic intracerebral hemorrhage, unspecified (is a type of stroke caused by spontaneous bleeding within the brain tissue, often associated with hypertension or other vascular risk factors, depression (common and serious mood disorder characterized by persistent feelings of sadness, loss of interest, and range of emotional physical problems), adult failure to thrive (is a syndrome in older adults characterized by weight loss, decreased appetite, poor nutrition, inactivity, and often cognitive or functional decline), altered mental status (describing any change in a person's awareness, cognition, or behavior from their baseline, ranging from mild confusion to complete unresponsiveness), and functional quadriplegia (inability to use all four extremities due to an extreme physical limitation).Record review of Resident #2's quarterly MDS, dated [DATE] and signed 03/04/2026 as completed, reflected a BIMS score of 12, indicating cognition intact. Resident #2 was documented as having health conditions, pain management and receiving scheduled pain regimen. Resident #2 was documented as having other health conditions, shortness of breath and having a condition or chronic disease that may result in a life expectancy of less than 6 months. Resident #2 was documented as receiving hospice care. Resident #2's functional abilities were documented as requiring supervision or touching assistance to partial/moderate assistance.Record review of Resident #2's care plan, undated and accessed on 04/23/2026 at 3:52 p.m., revealed Resident #2 had a terminal prognosis and was on hospice services and on pain medication therapy. The interventions included Administer medications as ordered by physician. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. [and] Work with nursing staff to provide maximum comfort for the resident. The care plan focus was created and initiated on 12/08/2025 and revised on 12/18/2025.Record review of Resident #2's Order Summary Report, dated Active Orders As of: 04/23/2026, reflected the order: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 4 hours as needed for Pain Give 0.25ml to equal 5mg (20mg/ml concentrate). Order noted as Active with order date, 12/15/2025, and start date, 12/15/2025. 2. Record review of Resident #3's admission Record, dated 04/24/2026, revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE]. Resident #3 was not listed as his own responsible party with his (family member) listed as Emergency Contact #1. Record review of Resident #3's Medical Diagnoses, undated and accessed on 4/24/2026 at 8:27 p.m., revealed diagnoses including chronic obstructive pulmonary disease (COPD) (progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants like cigarette smoke and air pollution), cognitive communication deficit (condition where cognitive impairments disrupt a person's ability to communicate effectively, despite intact language and speech abilities), rheumatoid arthritis (chronic autoimmune disease that primarily affects the joints, causing pain, swelling and stiffness), adult failure to thrive (is a syndrome in older adults characterized by weight loss, decreased appetite, poor nutrition, inactivity, and often cognitive or functional decline), and muscle wasting and atrophy (loss or thinning of muscle tissue that can result from disuse, aging, or underlying medical conditions). Record review of Resident #3's quarterly MDS, dated [DATE] and signed 03/10/2026 as completed, reflected a BIMS score of 12, indicating cognition intact. Resident #3 was documented as having health conditions, pain management and receiving scheduled pain regimen. Resident #3 was documented as having other health conditions, shortness of breath and having a condition or chronic disease that may result in a life expectancy of less than 6 months. Resident #3 was documented as receiving hospice care. Resident #3's functional abilities were documented as requiring supervision or touching assistance to substantial/maximal assistance.Record review of Resident #3's care plan, undated and accessed on 04/24/2026 at 8:27 p.m., revealed Resident #3 had a terminal prognosis and was on hospice services. The interventions included Administer pain medication as ordered. [and] Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. The care plan focus was created and initiated on 03/10/2026.Record review of Resident #3's Order Summary Report, dated Active Orders As of: 04/23/2026, reflected the order: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate) Give 0.25 ml sublingually every 3 hours as needed for pain/SOB Give 0.25 ml = 5 mg. Order noted as Active with order date, 12/15/2025, and start date, 12/15/2025.Record review of Resident #3's Order Summary Report, dated Active Orders As of: 04/23/2026, reflected the order:Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 10 mg by mouth every 3 hours as needed for Pain Give 0.5 ml= 10 mg. Order noted as Active with order date, 02/09/2026, and start date of 02/09/2026. During an observation and interview on 04/24/2026 at 12:52, Registered Nurse revealed Resident #2 had no narcotics stored in medication cart #1. RN was observed to review Resident #2's medication that was stored and secured in medication cart #1, she reviewed the narcotic binder, and the electronic medical record to identify if there were active orders for PRN morphine. She stated there was one active order for PRN morphine for Resident #2 and there was no PRN morphine being stored in medication cart #1 for Resident #2. She noted there was no hardcopy Individual Narcotic Record for Resident #2's PRN morphine order.During an observation and interview on 04/24/2026 at 1:06 p.m., LVN A revealed that if there was an active order on the resident's chart the medication should be present and readily available for a resident. LVN A was observed to review Resident #3's medication that was stored and secured in medication cart #2, she reviewed the narcotic binder and reviewed the electronic medical record to identify if there were active orders for PRN morphine. She noted there was no hardcopy Individual Narcotic Record for Resident #3's PRN morphine orders. She stated she recalled Resident #3's spouse did not want him to be on morphine and wanted the medication discontinued sometime in January 2026, but she was not aware of any documentation supporting this conversation.During an interview on 04/24/2026 at 3:23 p.m., the DON stated the PRN morphine for Resident #2 was not discontinued by the provider and she could not locate the Individual Narcotic Record for Resident #2. She said the PRN morphine for Resident #3 was not discontinued by the provider and she could not locate the Individual Narcotic Record for Resident #3. During a subsequent interview on 04/24/2026 at 9:10 p.m., the DON revealed that she could not locate the medication administration record/destruction record nor the morphine for Resident #2. She stated she believed the pharmacy made an error as it was never received. She stated she would be contacting the pharmacy for receipts of delivery.Record review of policy titled, Medication Administration, dated 10/24/2022, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 18. If medication is a controlled substance, sign narcotic book. 20. Correct any discrepancies and report to nurse manager. Record review of policy titled, Documentation in Medical Record, dated 10/24/2022, revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.Record review of policy titled, Medication Storage and Disposal, dated 10/01/2019, revealed Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. 3. All controlled substances remaining in the facility after a resident has been discharged , or the order is discontinued, are disposed of: A. In the facility by the Director of Nursing and/or consultant pharmacist (or others as allowed by state law) . 4. Disposition is documented on the individual controlled substance accountability record/book. 5. The Director of Nursing, nurse(s) and/or pharmacist witnessing the destruction ensures that the following information is entered on the individual controlled substance accountability. record/book: A. Date of destruction. B. Resident's name. C. Name and strength of medication. D. Prescription number. E. Amount of medication destroyed. F. Signatures of witnesses.

Based on interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #2 and Resident #3) of 3 residents reviewed for pharmacy services.The facility failed to ensure Resident #2 had her prescribed controlled medication, Morphine Sulfate (Concentrate) Solution 20 MG/ML available to meet her needs, disposing of controlled medication consistent with standards of practice, and documenting the administration of medications.The facility failed to ensure Resident #3 had his prescribed controlled medications, Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML and Morphine Sulfate (Concentrate) Solution 20 MG/ML available to meet his needs and documenting the administration of medications. These failures could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.The findings included:1. Record review of Resident #2's admission Record, dated 04/23/2026, revealed a [AGE] year-old female admitted [DATE]. Resident #2 was not listed as her own responsible party with her (family member) listed as Emergency Contact #1. Record review of Resident #2's Medical Diagnoses, undated and accessed on 4/24/2026 at 8:37 p.m., revealed diagnoses including nontraumatic intracerebral hemorrhage, unspecified (is a type of stroke caused by spontaneous bleeding within the brain tissue, often associated with hypertension or other vascular risk factors, depression (common and serious mood disorder characterized by persistent feelings of sadness, loss of interest, and range of emotional physical problems), adult failure to thrive (is a syndrome in older adults characterized by weight loss, decreased appetite, poor nutrition, inactivity, and often cognitive or functional decline), altered mental status (describing any change in a person's awareness, cognition, or behavior from their baseline, ranging from mild confusion to complete unresponsiveness), and functional quadriplegia (inability to use all four extremities due to an extreme physical limitation).Record review of Resident #2's quarterly MDS, dated [DATE] and signed 03/04/2026 as completed, reflected a BIMS score of 12, indicating cognition intact. Resident #2 was documented as having health conditions, pain management and receiving scheduled pain regimen. Resident #2 was documented as having other health conditions, shortness of breath and having a condition or chronic disease that may result in a life expectancy of less than 6 months. Resident #2 was documented as receiving hospice care. Resident #2's functional abilities were documented as requiring supervision or touching assistance to partial/moderate assistance.Record review of Resident #2's care plan, undated and accessed on 04/23/2026 at 3:52 p.m., revealed Resident #2 had a terminal prognosis and was on hospice services and on pain medication therapy. The interventions included Administer medications as ordered by physician. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. [and] Work with nursing staff to provide maximum comfort for the resident. The care plan focus was created and initiated on 12/08/2025 and revised on 12/18/2025.Record review of Resident #2's Order Summary Report, dated Active Orders As of: 04/23/2026, reflected the order: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 4 hours as needed for Pain Give 0.25ml to equal 5mg (20mg/ml concentrate). Order noted as Active with order date, 12/15/2025, and start date, 12/15/2025. 2. Record review of Resident #3's admission Record, dated 04/24/2026, revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE]. Resident #3 was not listed as his own responsible party with his (family member) listed as Emergency Contact #1. Record review of Resident #3's Medical Diagnoses, undated and accessed on 4/24/2026 at 8:27 p.m., revealed diagnoses including chronic obstructive pulmonary disease (COPD) (progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants like cigarette smoke and air pollution), cognitive communication deficit (condition where cognitive impairments disrupt a person's ability to communicate effectively, despite intact language and speech abilities), rheumatoid arthritis (chronic autoimmune disease that primarily affects the joints, causing pain, swelling and stiffness), adult failure to thrive (is a syndrome in older adults characterized by weight loss, decreased appetite, poor nutrition, inactivity, and often cognitive or functional decline), and muscle wasting and atrophy (loss or thinning of muscle tissue that can result from disuse, aging, or underlying medical conditions). Record review of Resident #3's quarterly MDS, dated [DATE] and signed 03/10/2026 as completed, reflected a BIMS score of 12, indicating cognition intact. Resident #3 was documented as having health conditions, pain management and receiving scheduled pain regimen. Resident #3 was documented as having other health conditions, shortness of breath and having a condition or chronic disease that may result in a life expectancy of less than 6 months. Resident #3 was documented as receiving hospice care. Resident #3's functional abilities were documented as requiring supervision or touching assistance to substantial/maximal assistance.Record review of Resident #3's care plan, undated and accessed on 04/24/2026 at 8:27 p.m., revealed Resident #3 had a terminal prognosis and was on hospice services. The interventions included Administer pain medication as ordered. [and] Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. The care plan focus was created and initiated on 03/10/2026.Record review of Resident #3's Order Summary Report, dated Active Orders As of: 04/23/2026, reflected the order: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate) Give 0.25 ml sublingually every 3 hours as needed for pain/SOB Give 0.25 ml = 5 mg. Order noted as Active with order date, 12/15/2025, and start date, 12/15/2025.Record review of Resident #3's Order Summary Report, dated Active Orders As of: 04/23/2026, reflected the order:Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 10 mg by mouth every 3 hours as needed for Pain Give 0.5 ml= 10 mg. Order noted as Active with order date, 02/09/2026, and start date of 02/09/2026. During an observation and interview on 04/24/2026 at 12:52, Registered Nurse revealed Resident #2 had no narcotics stored in medication cart #1. She stated that Resident #2 had never had PRN morphine available and hospice had never provided the facility with this narcotic. Registered Nurse stated the hospice nurse would be responsible for providing the facility with Resident #2's PRN morphine medication. She stated that Resident #2 does not exhibit pain and has not complained of pain for some time and had not required morphine. She stated that typically medications are discontinued if not administered but could not recall the timeframe. Registered Nurse was observed to review Resident #2's medication that was stored and secured in medication cart #1, she reviewed the narcotic binder, and the electronic medical record to identify if there were active orders for PRN morphine. She stated there was one active order for PRN morphine for Resident #2 and there was no PRN morphine being stored in medication cart #1 for Resident #2. She noted there was no hardcopy Individual Narcotic Record for Resident #2's PRN morphine order. She stated she was not aware of this active PRN narcotic for Resident #2 prior to today. Registered Nurse stated that not having PRN pain medication available in the facility for a resident can be detrimental to their care. During an observation and interview on 04/24/2026 at 1:06 p.m., LVN A revealed that if there was an active order on the resident's chart the medication should be present and readily available for a resident. She stated that the impact of not having pain medications onsite for a resident could hurt their pain management regimen. LVN A was observed to review Resident #3's medication that was stored and secured in medication cart #2, she reviewed the narcotic binder and reviewed the electronic medical record to identify if there were active orders for PRN morphine. She stated there were two active orders for PRN morphine for Resident #3 and there was no PRN morphine being stored in medication cart #2 for Resident #3. She noted there was no hardcopy Individual Narcotic Record for Resident #3's PRN morphine orders. She stated she recalled Resident #3's spouse did not want him to be on morphine and wanted the medication discontinued sometime in January 2026, but she was not aware of any documentation supporting this conversation.During a subsequent interview on 04/24/2026 at 1:51 p.m., LVN A noted that she was going to reach out to hospice and see if they want to discontinue the two PRN morphine orders or provide the facility with medication.During an interview on 04/24/2026 at 2:03 p.m., LVN B revealed if there are active orders for scheduled and PRN medications they should be in the facility and available. She stated that not having ordered medications on hand can be detrimental to a resident's care.During an interview on 04/24/2026 at 2:35 p.m., the Hospice RN revealed that not having ordered pain medication for a resident on hospice would not be a good thing and can harm them. She stated if there is an active order for pain medication it should be in the facility and available.During an interview on 04/24/2026 at 3:09 p.m., CMA revealed that not having scheduled or PRN medications available for a resident could cause them frustration.During an interview on 04/24/2026 at 3:23 p.m., the DON revealed that the unit nurse will communicate with the hospice nurse when medication is needed for a specific resident. She stated that when a resident complains of pain the nurse is required to check their electronic medical record for active pain orders. She stated that if narcotics were not ordered or available the resident would suffer in pain and it would be detrimental to their care. The DON stated hospice ordered and dispensed Resident #2's morphine on 12/04/2025 and if not administered in more than 60 days it would be discontinued. She stated that hospice said the morphine was dispensed on 12/04/2025 and they were under the impression the medication was still available because they could not find an order to discontinue. She stated the PRN morphine for Resident #2 was not discontinued by the provider and she could not locate the Individual Narcotic Record for Resident #2. The Director of Nursing stated that Resident #3 had one dose of morphine on 11/18/2025 0.25 ml and never administered again and then given to her for destruction on 03/02/2026. She stated the PRN morphine for Resident #3 was not discontinued by the provider and she could not locate the Individual Narcotic Record for Resident #2. During an interview on 04/24/2026 at 4:40 p.m., the Patient Care Manager revealed that there was an active PRN morphine order for Resident #2. She stated the hospice nurse and facility nurse should be communicating to ensure ordered medications are available and if not, hospice would order. She noted that if a patient discharges, passes away or no longer needs the ordered medications the hospice nurse would notify the facility nurse to destroy according to facility protocol. She stated the impact of not having active orders or comfort medication at the facility and the patient needs it for pain or morphine for shortness of breath could cause some discomfort. During an interview on 04/24/2026 at 4:55 p.m., the Clinical Team Leader revealed that there was an active order for PRN morphine 20 mg ml/oral concentrate, 3 hours as needed for Resident #3. She stated on the last visit with Resident #3 on 03/02/2026 the hospice nurse said they were not made aware the facility got rid of the PRN morphine and assumed they had it and that it was still active. She stated she was not sure what the communication issue was and it looked like a refill was needed. She stated the facility said they disposed of the medication earlier today and did not know why. She stated there was no documentation on their end of the facility communicating they were stopping the order. She stated the facility staff are required to collaborate with the hospice nurse for order changes or refills. The Clinical Team Leader stated that Resident #3 was admitted to hospice on 11/17/2025, and on 11/17/2025 PRN morphine ordered, and on 11/18/2025 PRN morphine was delivered to facility. She noted that on 1/9/2026 the hospice nurse documented facility nurse administered ordered morphine and Lorazepam SOB and shallow respirations, meant to treat shortness of breath and pain as he was diagnosed with COPD, respiratory diagnose. She noted the morphine and Lorazepam available at the facility just in case of an emergency as it could be problematic by not having it on hand. During an interview on 04/24/2026 at 5:20 p.m., the Director of Clinical Services revealed that the current orders written in the facility for Resident #2 include: Morphine PRN standard comfort pack, emergency e-kit to have on hand at the facility, combination of morphine, sublingual utilized as last resort for pain or SOB and is not a standard routine medication. She stated that she sees these medications as active, with no discontinuation orders. She stated the facility keeps a narcotic log, the order was filled and delivered to the facility and signed for on 12/05/2025 at 1:11 p.m., which was confirmed with their pharmacy. The Director of Clinical Services stated that the impact of not having this medication onsite depending on the severity of the symptoms and with location of facility if ordered stat, minimum of 2 hours to be delivered to the patient and the facility would have to utilize oxygen in the meantime. She stated if the medication was not available and in distress could affect them.During a subsequent interview on 04/24/2026 at 7:07 p.m., the DON stated she conducted an in-service on pain management and pain assessment and a second one on discontinuation of medications with the nurses that are currently present today. The DON stated that comfort medication packs are ordered and filled by hospice. The comfort pack includes morphine, and lorazepam. The hospice nurse will write the orders, and the facility will enter into the resident's electronic medical record. She said the information is passed on through the 24-hour report that they were placed on hospice and they have new hospice orders.During an interview on 04/24/2026 at 8:03 p.m., the Administrator stated complaint of pain protocol -the charge nurse should go and assess resident and depending what medications they have prescribed administer a pain medication. She stated if not present ideally should be notifying the physician. She stated the impact of not having pain meds available at the facility would be that pain would not be addressed and would affect residents physically and mentally.During a subsequent interview on 04/24/2026 at 9:10 p.m., the Director of Nursing revealed that she could not locate the medication administration record/destruction record nor the morphine for resident #2. She stated she believed the pharmacy made an error as it was never received. She stated she would be contacting the pharmacy for receipts of delivery.Record review of policy titled, Medication Administration, dated 10/24/2022, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 18. If medication is a controlled substance, sign narcotic book. 20. Correct any discrepancies and report to nurse manager. Record review of policy titled, Statement of Resident Rights, undated, revealed You have a right to: all care necessary for you to have the highest possible level of health.Record review of policy titled, Pain Management, dated 08/15/2022, revealed The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 1. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission.Record review of policy titled, Medication Storage and Disposal, dated 10/01/2019, revealed Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. 3. All controlled substances remaining in the facility after a resident has been discharged , or the order is discontinued, are disposed of: A. In the facility by the Director of Nursing and/or consultant pharmacist (or others as allowed by state law) . 4. Disposition is documented on the individual controlled substance accountability record/book. 5. The Director of Nursing, nurse(s) and/or pharmacist witnessing the destruction ensures that the following information is entered on the individual controlled substance accountability. record/book: A. Date of destruction. B. Resident's name. C. Name and strength of medication. D. Prescription number. E. Amount of medication destroyed. F. Signatures of witnesses.

Based on observation, interview, and record review the facility failed to ensure their posted nurse staffing information included the total number of actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in the facility reviewed for nurse staffing with 89 residents, in that: The facility's posted nurse staffing information did not include the actual hours worked by nursing staff. This failure placed residents at risk of not having accurate information posted about actual direct care hours worked and not receiving the appropriate level of care.The findings included: An observation of the facility's posted nurse staffing information on 01/07/2026 at 3:50 PM, revealed no documented actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift for the 6:00 AM- 2:00 PM, the 2:00 PM- 10:00 PM, or the 10:00 PM- 6:00 AM shifts. A record review of the facility's posted nurse staffing hours dated 10/01/2025 to 01/07/2026, revealed no documented actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift for the 6:00 AM- 2:00 PM, the 2:00 PM- 10:00 PM, or the 10:00 PM- 6:00 AM shifts. In a written communication from the Administrator on 01/08/2026 at 1:58 PM, when asked for the facility policy on posted nurse staffing information, the Administrator said no, the facility did not have a policy. During an interview with the facility's Administrator on 01/08/2026 at 2:27 PM, when asked who was responsible for posting the daily nurse staffing information, the Administrator stated, the staffing person was now responsible for posting the hours daily, but since she was new to the roll, it was a group effort but the Administrator was ultimately responsible for the posted nurse staffing information in the facility. When asked why the posted nurse staffing information did not include the actual hours worked by licensed and unlicensed nursing staff each shift, the Administrator responded, For some reason the actual hours worked were not transferred to the staff posting form. The Administrator could not state why the actual hours were not documented, but acknowledged the actual hours worked for nursing staff were not documented for 10/01/2025- 01/07/2026. When asked about the potential risk of not including actual hours worked by licensed and unlicensed nursing staff in the posted information, the Administrator stated that they would not know if the expected hours were met if the actual hours worked were not documented. During an interview with the facility's DON on 01/08/2026 at 4:00 PM, when asked why the posted nurse staffing information did not include the actual hours worked by licensed and unlicensed nursing staff each shift, the DON could not say why, but acknowledged the actual hours were not documented on the posted nurse staffing information.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of nine resident (Resident #2), in the facility reviewed for reportable events, in that: The facility failed to report an allegation of neglect when RN A did not follow physician's orders for administration of morphine for Resident #2. This failure placed residents at risks of preventing the appropriate authorities from taking necessary action to investigate the incident, not having systemic concerns identified, and preventing future errors from occurring. The findings included: A Record Review of Resident #2's admission Record dates 12/14/2025 documented a [AGE] year-old male resident with a current admission date of 06/20/2025 and an original admission date of 07/11/2024, with diagnoses including malignant neoplasm of lower lobe, right bronchus, or lung (lung cancer) and chronic obstructive pulmonary disease (a long-term, progressive lung disease that makes breathing difficult due to damaged airways). A Record Review of Resident #2's Order Summary Report dated 12/17/2025 reflected an order dated 11/19/2025 for the following: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 10 mg by mouth every 1 hours as needed for Pain/SOB Palliative Care Patient [Palliative care-specialized medical support focused on relieving symptoms, pain, and stress for people with serious illnesses]. A Record Review of Resident #2's Medication Administration Record dated 12/01/2025-12/31/2025 revealed the following medication signed as administered by RN Aon 12/09/2025 at 4:41 PM: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 10 mg by mouth every 1 hours as needed for Pain/SOB Palliative Care Patient. A Record Review of Resident #2's Morphine Sulphate Individual Resident's Controlled Substance Record (narcotic count sheet), dated 11/20/2025 revealed a 30 ml bottle of Morphine Sulphate 100mg/5ml was received by the facility. Continued review reflected on 12/09/2025 at 4:41 PM RN A signed out 10 mg of Morphine Sulfate as administered to Resident #2. Further review revealed the morphine started out with 30 ml, with 28 ml (or cc) of the medication left on hand after RN A administered the medication on 12/09/2025. During an interview and observation on 12/14/2025 at 5:25 PM, with the DON, observed Resident #2's Morphine Sulfate liquid bottle, the DON stated it has 28 ml, observed the measurements on the bottle and the liquid was at the 28 ml mark. The DON pointed out that the label on the bottle of Morphine Sulfate for Resident #2 instructed to give 0.5 ml q hour prn on the box label and the medication bottle. The DON stated she asked RN A how much morphine she administered to Resident #2 on 12/09/2025 and RN A said she gave the resident 2 ml of morphine. During an interview with RN A, on 12/15/2025 at 10:26 AM, when asked how much morphine she administered to Resident #2 on 12/09/2025, RN A stated I gave him . I looked at the dose, it seemed a bit high to me, the ordered dose was 10 mg, and I believe I gave him 10 mg . When asked how many milliliters she drew up, RN A stated she drew up the entire syringe, which was 1 ml. RN A stated it came to her attention that the dose should have been 0.5 ml. During an interview and observation with the Administrator on 12/16/2025 at 2:40 PM, when asked if the facility's response to Resident #2's medication error dated 12/09/2025 included reporting the incident to the State Survey Agency, the Administrator stated, We reviewed the medication error with our corporate team, and decided the incident did not meet the reportable criteria from the nursing facility provider letter 2024-14. The Administrator then stated Resident #2's morphine medication error on 12/09/2025 was not reported to the State Survey Agency as of 12/16/2025. When asked who was responsible for reporting, reportable events to the State Survey Agency, she stated, the Administrator. During an interview with the DON on 12/16/2025 at 4:28 PM, regarding the administration of Resident #2's Morphine Sulphate liquid medication, the DON was asked when did RN A give the medication, the DON stated on the 10/9/25 around 4:00 PM-4:30 PM. When the DON was asked how much medication was administered to Resident #2, the DON said, 2 ml which equaled 40mg. When asked how many milligrams were ordered the DON said, 10mg. When asked if the facility reported the incident to the State Survey agency, the DON stated that she and the Administrator consulted with their corporate team and decided it did not meet the criteria for reporting according to the State Provider Letter and was not reported. A record review of the facility's policy titled Abuse, Neglect, and Exploitation and dated 07/11/2025, reflected the definitions of activities associated with abuse, neglect, and exploitation including the definition of the following: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview, and record review, the facility failed to ensure that all alleged violations involving abuse/neglect/exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that caused the allegation did not involve abuse and did not involve serious bodily injury, to the administrator of the facility and other officials, including the State Survey Agency, in accordance with State Law through established procedures for 1 of 7 residents (Resident #1) reviewed for abuse and neglect.The facility failed to ensure Resident #1 had the proper medication given to the resident at the time of discharge.This deficient practice could place residents at risk of not being given proper medication on discharge resulting in an impaired health status.The findings included:1-Record review of Resident #1's face sheet dated 12/3/25 revealed an [AGE] year old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included type 2 diabetes (a condition in which the body does not use insulin properly), general anxiety disorder (a condition of excessive worry about every day things), and essential hypertension (a condition of high blood pressure).Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS of 15 (a score of intact cognition).Record review of Resident #1's care plan initiated on 8/5/25 revealed the resident had a self care performance deficit.Record review of Resident #1's nursing progress notes revealed the resident was discharged home on 8/19/25.2-Record review of Resident #2's face sheet dated 12/3/25 revealed the [AGE] year old male who was originally admitted on [DATE]. Resident 32 had diagnosis which included alzheimers disease (a condition on progressive brain disorder), cerebral infarction (a condition in which there is a blockage in the brain), and peripheral vascular disease (a problem with circulation of blood in the veins)Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS of 0 (a score of severe cognitive impairment)Record review of Resident #2's care plan initiated 9/8/23 revealed the resident had a self-care performance deficit.Record review of Resident # 2's nursing progress notes revealed the resident's care was continued in the facility.During an interview on 12/2//25 at 200pm with the VA Social worker stated Resident #1 had not taken any of Resident #2's medications that were found at the home residence of Resident #1 as they had been sent home with him in error at the time of his discharge from the facilityDuring an interview on 12/2/25 at 220pm with the VA Nurse Practitioner stated Resident #1 had not taken any of Resident #2's medications that were found at the home residence of Resident #1 as they had been sent home with him in error at the time of his discharge.During an interview on 12/3/25 with the Administrator, Director of Nurses (DON) and Assistant Director of Nurses (ADON) the ADON stated she completed the discharge of Resident #1 on 8/19/25 from the facility and mistakenly placed four of Resident #2's medication in with Resident #1's discharge medications. Resident #2's medications that were given to Resident #1 at the time of his discharge from the facility included the following medications: (Trazadone 50mg, Tenisartine 80mg, Pepcid 20 mg, and Celexa 10 mg). The DON stated she had received a call from VA Nursing on 8/22/25 informing her Resident #1 was seen in his home by the VA Nurse and the four medications were sent home in error with Resident #1 had been destroyed by the VA Nurse. The DON stated the VA Nurse advised her that Resident #1 had not taken any of Resident #2's medications sent in error during his discharge. The DON stated that Resident #2's medications had been re-ordered and there were no missed medication administrations of the four medications (Trazadone 50mg,Tenisartine 80mg, Pepcid 20mg, and Celexa 10 mg) and that Resident #2 remained as a resident at the facility .The DON stated on 8/22/25 she and the ADON went to the home residence of Resident #1 and confirmed with Resident #1 he had not taken any of Resident #2's medications that were sent home with him in error at the time of his discharge. The Administrator stated the following in-services were completed by staff in follow-up to the discharge incident of Resident #1.a. Protocol for-Discharge Medications Given to Residents-All nursing staffb. Medication Administration Procedures Post Test-All nursing staffc. Abuse/Neglect Policy-All facility staffd. Hippa- Privacy Policy-All facility staffDuring an interview on 12/3/25 with the Administrator and ADON they stated that the risk to the residents of being given the wrong medications on discharge could impact the resident's health status. The Administrator stated the medication error incident was not reported to Tx HHS at the time of the incident as they were advised by the facility's regional staff that report of the medication discharge error to Tx HHS was not necessaryRecord review of in-services # a-d competed at the facility on 8/25/25 revealed that the selected staff received the in-services as noted by the Administrator and DON.Record review of the facility policy titled-Medication Reconciliation dated 4//10/23 revealed If sending medications home with resident, verify medications match physician orders.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5% for 28 medication administration opportunities with 3 errors resulting in a 10% medication error rate, for 2 of 4 (Residents #1 and #37) reviewed for medication administration. 1. The facility failed to ensure Resident #1 received medications Amiodarone (used to regulate rapid and/or irregular heart rhythms) and Apixaban (used to prevent blood clots) as ordered by the physician. 2. The facility failed to ensure Resident #37 received medication Xifaxan (used to treat the brain function decline that can occur secondary to liver damage) as ordered by the physician. These failures could result in residents not receiving the intended therapeutic benefits of medications. Findings included: Record review of Resident #1's face sheet dated 5/22/2025 revealed an [AGE] year-old female, admitted to the facility on [DATE]. The resident had relevant diagnoses of atrial fibrillation (a condition that causes rapid, irregular heartbeats and can cause blood clots) and cerebral infarction (a blood clot in the brain causing brain damage). Record review of Resident #1's quarterly MDS assessment, submitted 4/23/2025, revealed a BIMS score of 12, indicating moderately impaired cognition. Review of Resident #1's active physician's orders reflected the following: a. Amiodarone Hcl oral tablet 200mg; give 1 tablet by mouth one time a day for arrythmias (order date 4/22/2025) b. Apixaban oral tablet 2.5mg; give 1 tablet by mouth two times a day for a-fib (order date 4/22/2025) During an observation of medication administration on 5/22/2025 at 9:03 AM for Resident #1, LVN E was observed withholding Apixaban. LVN E confirmed that the medication was not found in the medication cart and was out of stock in the back-up supply within the e-kit. LVN E was interviewed simultaneously to the observation and stated the facility process was to order medications prior to having zero tablets available for administration. Since the medication had not been ordered, she stated she would order it immediately, notify the DON or ADON and the provider, and the resident should receive the next scheduled dose but would not receive that morning dose of Apixaban. Also, during the same observation of Resident #1's medication administration, LVN E was observed witholding Amiodarone after taking Resident #1's blood pressure and receiving a value of 110/79. In an interview performed simultaneously, LVN E stated the resident's blood pressure was below the ordered parameters for the medication, and the medication would not be given. During a record review occurring after the observation, it was revealed the physician did not include blood pressure parameters for Amiodarone, as the medication was ordered for treatment of the resident's heart rhythm. Record review of Resident #37's face sheet dated 5/22/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] with a relevant diagnosis of unspecified cirrhosis of liver (progressive damage to the liver inhibiting proper function that leads to decline in brain function). Review of Resident #37's quarterly MDS assessment submitted on 2/28/2025 revealed a BIMS score of 14, indicating intact cognition. Review of Resident #37's active physician orders reflected an order for Xifaxan tablet 550mg; give 1 tablet by mouth two times a day for cirrhosis. During an observation of medication administration for Resident #37 on 5/22/2025 at 9:26 AM, LVN E was unable to locate the Xifaxan for administration. In a simultaneous interview, LVN E stated the medication should have been ordered prior to having zero tablets available for administration. She also reported that medication was not included in the facility's stock on back-up medications for emergencies, so she would re-order and notify the DON or ADON as well as the provider. In an interview with the DON on 5/22/2025 at 9:10 AM, the DON stated the facility used a local pharmacy in order to receive out of stock medications needed for administration. She said the medications would be received the same day. The DON also confirmed the medications should have been ordered prior so the residents did not miss an ordered dose. Review of the facility police titled Medication Administration (implemented 10/24/2022) revealed on page 1, item 1. keep medication cart . stocked with adequate supplies. Item 8. stated obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters (emphasis added for clarity).

Based on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision abilities for 1 (Resident #12) of 1 residents reviewed for quality of care. The facility failed to provide necessary arrangements to repair broken eyeglasses for Resident #12. This failure could lead to injury and/or decreased quality of life. Findings included: Record review of Resident #12's face sheet dated 5/20/2025 revealed an [AGE] year old male, admitted to the facility on [DATE]. Relevant diagnoses included unsteadiness on feet and muscle wasting and atrophy. Review of Resident #12's quarterly MDS assessment submitted 4/1/2025, reflected a BIMS score of 09, indicating moderately impaired cognition. Resident #12 was assessed as having vision impairment, and the resident required corrective lenses. Record of review of a progress note dated 5/2/2025, written by LSW, revealed the following: One of [Resident #12]'s ear pieces on his glasses is missing. Referred to [optometrist]. Record review of a scanned document titled Request for Services/Consultation dated 5/12/2025 revealed a written request for an optometry appointment due to broken eyeglasses and decreased visual acuity. In an interview on 5/20/2025 at 10:10 AM, Resident #12 stated his glasses were broken approximately a month prior. He said he had reported the issue to the facility and was not aware of an appointment to get the glasses fixed. The resident reported difficulty watching television and seeing other objects in the distance but stated he was able to ambulate/use wheelchair and had not fallen or injured himself due to not having glasses. During observation on 5/20/2025 at 10:10 a.m., Resident #12's glasses were observed and noted to be missing both ear pieces required to affix the glasses to the resident's face. In an interview on 5/21/2025 at 10:00 AM. with the LSW, the LSW confirmed awareness of the broken eyeglasses. She did not know the glasses were missing both ear pieces and felt that the glasses were in usable condition when missing only one side piece. She confirmed a referral had been done for an optometry appointment but stated an appointment time had not been set. She estimated the typical timeline from referral to appointment time to be a couple of months and said she could make alternative arrangements for a different optometry provider due to the glasses missing both ear pieces. In a subsequent interview with LSW on 5/22/2025 at 11:00 AM, the LSW reported she had not yet confirmed an optometry appointment. the LSW said she was going to arrange for transportation to take Resident #12 to a different location that would allow for evaluation without an appointment.

Based on observation, resident and staff interviews, and record reviews, the facility failed to ensure that residents' environment remained as free of accident hazards as possible for 1 of 4 residents (Resident #14) reviewed for quality of care. The facility failed to ensure Resident #14 had cushioned hip covers (hipsters) in place at all times. This failure could place residents at an increased risk for injury related to falls. The findings include: Record review of Resident #14's face sheet dated 5/22/25 revealed an [AGE] year-old female admitted [DATE] and readmitted [DATE]. Diagnoses included Alzheimer's dementia (memory loss that affects learning and memory), COPD (Chronic Obstructive Pulmonary Disease, a progressive respiratory condition), Right femur (thigh bone) fracture, Right hip pain, dysphagia, abdominal aortic aneurysm, Bipolar Disorder (mood disorder ranging from depressive lows to manic highs), emphysema (a condition that causes breathlessness), Hypertension, Cardiomegaly, Polyosteoarthritis (arthritis in five or more joints simultaneously). Record review of Resident #14's Quarterly MDS assessment dated [DATE] revealed resident presented with upper and lower extremity range of motion deficits, required moderate assistance in self-feeding, upper body dressing and transfers, and maximum assistance in toileting, bathing, lower body dressing and bed mobility. Record review of Resident #14's BIMS (Basic Interview for Mental Status) assessment dated [DATE] revealed she had a score of 3 indicating severe cognitive impairment. Record review of Resident #14's Comprehensive Care Plan, printed 5/22/25 revealed the resident was at risk for injury related to falls due to osteoporosis (a condition where the bones become thin and weak, increasing the risk of fractures, especially in the spine, hip, and wrist) and one intervention was to wear padded hip protectors to prevent hip fractures. Record review of physician's order dated 12/27/2024 revealed order to Ensure resident is wearing hipsters (cushioned hip protectors) at all times every shift for fall precautions. In observations on 5/20/25 at 10:06 a.m., 5/21/25 at 12:36 p.m., and 5/22/25 at 10:00 a.m., hipsters were not utilized. In an interview on 5/21/25 at 12:40 p.m. with CNA H, CNA H revealed that Resident #14 was supposed to wear hip protectors for safety. In an interview on 5/21/25 at 1:49 p.m. with PT G, he revealed that the resident was evaluated on re-admission and padded hip protectors were identified as preventative measures. He stated nursing staff was responsible for placing hip protectors. In an interview with the DON on 5/22/25 at 1:00 p.m., the DON stated that the Charge Nurse was responsible for ensuring hip protectors were utilized and that she (the DON) is ultimately responsible for ensuring ordered devices were utilized. The DON stated she expected the nursing staff to follow the physician's orders. The DON stated that not utilizing hip protectors placed Resident #14 at greater risk for injury related to falls due to debilitating diagnoses. Record review of the facility's policy Fall Prevention, dated [DATE], reflected, It is the policy of this facility to provide an environment that remains as free of accident hazards as possible and provide each resident with appropriate assessment and interventions to minimize complications if a fall occurs.

Based on interviews, and record reviews, , the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 (#19) residents reviewed for quality of care in that: Resident #19's pacemaker maker, model, and additional information was not documented in his chart. This could affect residents with pacemakers and could result in residents not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. The Findings were: Record review of Resident # 19's Admission Record dated 5/21/2025 revealed he was admitted on [DATE], age was 83 no diagnosis description was documented for a cardiac pacemaker . Record review of Resident # 19's MDS assessment dated [DATE] revealed the presence of cardiac pacemaker, and he had a BIMS score of 8/15 (moderate cognitive impairment). Resident # 19's care plan dated 5/15/2025 revealed he had a pacemaker related to Atrial fibrillation. The interventions for Resident #19's pacemaker included will remain free from s/sx of pacemaker malfunction or failure through the review date, Monitor VITAL SIGNS as ordered. Notify MD of significant abnormalities. Notify MD of significant abnormalities. Monitor/document/report PRN any s/sx of altered cardiac output or pacemaker malfunction: dizziness, syncope, difficulty breathing (Dyspnea), pulse rate lower than programmed rate, lower than baseline B/P, Pacemaker checks as ordered, resident's Pacemaker information: (no make and model was added). Record review of Resident # 19's consolidated orders for May 2025 nothing related to his pacemaker's make and model. Observation on 5/21/2025 at 4:13 PM with Resident # 19 revealed with his hand pointed to his left chest area, indicating his cardiac pacemaker. During an interview on 5/21/2025 at 4:14 PM with Resident #19, he stated he had a cardiac pacemaker and pointed to his left chest area. During an interview on 5/1/2025 at 4:14 PM, LVN B confirmed that Resident #19 had a pacemaker. During an interview on 5/21/2025 04:59 PM, the DON confirmed Resident #19 had a pacemaker and had the make and model in an email. The DON stated she had not placed the information in Resident #19's record. During an interview on 5/22/2025 at 10:13 AM with the corporate Admin, (SHE) stated there was no pacemaker policy. During an interview on 05/22/25 11:42 AM with the CP, she stated she put in the care plan for the pacemaker on 4/10/25 for Resident #19. The CP stated she added the make and model of the cardiac pacemaker on 5/21/2025. During an interview on 5/22/2025 at 12:57 PM with the DON, she confirmed there was no order for Resident #19's pacemaker. The DON's expectation was that resident devices, such as a pacemaker, would have a physician's order. The DON stated the risk would be not have monitoring and adverse effects, such as heart failure.

Based on record review, interviews and observation, the facility failed to ensure residents (Resident #63) was able to communicate in preferred Language to caregivers for 1 of 4 residents reviewed for resident rights. Resident #63 who was English speaking only had difficulty communicating with primarily Spanish-speaking caregivers using communication tools. This failure could place residents at risk for not being informed about care and treatment that may affect resident's well-being and being able to participate in daily plan of care and delay in treatment. Findings included: Record review of Resident #63's face sheet revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Diagnoses included Alzheimer's Disease (progressive Brain disorder that slowly destroys memory and thinking skills), Bipolar Disorder (mental health disease of high and low mood swings), Diabetes Type II (bodies difficulty to regular sugar), Hypertension (high blood pressure), Atrial Fibrillation (irregular heart rhythm), lymphedema (tissue swelling caused by fluid buildup), encephalopathy (brain disease or damage). Record review of Quarterly MDS assessment dated [DATE] revealed BIMS (Basic Interview of Mental Status) Score of 11 indicating moderate cognitive impairment and required supervision with self-feeding, toilet hygiene, dressing, bed mobility, bathing and gait. During an interview with Resident #63 on 5/20/25 at 10:30 a.m., Resident #63 stated she had difficulty communicating with staff who are non-English speaking. An observation of CNA H on 5/20/25 at 12:25 p.m., revealed that she did not read or speak English but that she had an application on her phone to facilitate communication with non-Spanish speaking residents. CNA H was asked to demonstrate the use of the translation application with Resident #8 but she was unable to manipulate the translation application and effectively communicate with Resident #8. An observation of CNA I on 5/20/25 at 12:45 p.m., revealed she did not speak English but she had an application on her phone to communicate with non-Spanish speaking residents. CNA I was asked to demonstrate the translation application with Resident #8 and was unable to effectively communicate questions to Resident #8. A review of Resident Council meeting minutes dated 1/15/2025, revealed residents in attendance identified a language barrier and residents having a hard time communicating. During an interview with the DON on 5/20/25 at 1:00 p.m., the DON stated that all staff were advised to utilize translation application when communicating with residents who do not speak their native language. DON stated that staff are advised to notify Charge Nurse of communication difficulties with residents who do not speak their native language. DON stated that staff's inability to communicate with residents could affect their care and well-being and potentially cause harm if needs are not met timely. Review of the facility policy titled, The Facility Manual, revised 7/14/2020, reflected Resident Rights, Rights of Elderly Individuals, Rights of the Elderly (j) A person providing services shall fully inform an elderly individual, in language that the individual can understand, of the individual's total medical condition and shall notify the individual whenever there is a significant change in the person's medical condition.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's needs for 1 of 8 (#81) residents reviewed for comprehensive resident centered care. 1. The facility failed to provide care planning for the use of a wheelchair seatbelt restraint for Resident #81. 2. The facility failed to revise the comprehensive care plan for Resident #81 after hospitalization s resulting from the dislodgement of the resident's g-tube. This failure could lead to residents not receiving the care necessary to meet their highest practicable well-being. Findings included: Record review of Resident #81's face sheet dated 5/20/2025 revealed a [AGE] year old female, initially admitted to the facility on [DATE]. Relevant diagnoses included Lennox-Gastaut Syndrome (a severe disorder characterized by multiple seizure types and cognitive and behavioral problems); dependence on wheelchair; aphasia (difficulties with speech); and gastrostomy status (a surgical opening in the abdomen to allow for the intake of food and medication directly into the stomach). Review of Resident #81's quarterly MDS dated [DATE] revealed a BIMS score was not assessed due to the resident's communication deficits. Question P0100 item E. of the MDS (trunk restraint used in chair or out of bed) was assessed as 0. not used. 1. Record review of Resident #81's comprehensive care plan revealed the following related to the seatbelt restraint: a. Problem: [Resident #81] is at risk for falls r/t seizures, poor safety awareness, confusion (date initiated: 12/01/2024). Interventions: Make sure resident has hear seat belt on when she sits up in her wheelchair; she has a medical need for it (date initiated 12/02/2024). b. Problem: [Resident #81] has a seizure disorder and wears a soft helmet and has a wheelchair seat belt for safety (date initiated 12/11/2024). Interventions: Ensure [Resident #81]'s seat belt is in place when she is in her wheelchair for her safety related to falls. Respect her right to refuse to wear (date initiated 04/02/2025). Restraint assessment related to wheelchair belt per facility policy date initiated 04/02/2025. The comprehensive care plan did not include interventions to prevent and address any risks related to the use of the restraint, how to meet the needs of the resident during periods of restraint, monitoring/supervision to be provided during the use of the restraint, or parameters for release of the restraint. A review of active physician's orders did not reveal an order to apply the seatbelt restraint or parameters for monitoring or removal. A scanned document dated 12/2/2024 titled physical restraint/DME/monitoring device consent revealed a checkbox for physical restraint and a check mark indicating permission for the facility to use restraints as needed in accordance with the resident's comprehensive care plan and physician's order. The area underneath type of restraint to be used (list only one) was not filled in with the type of restraint. This document was signed by the resident's mother and the ADON. Resident #81 was observed in her wheelchair wearing the seatbelt restraint on 5/20/2025 at 12:03 PM self propelling through the communal dining areas. She was again observed 5/22/2025 at 9:00 AM in the communal sitting area of the east hall near in her wheelchair with the seatbelt restraint in place, and 5/22/2025 at 1:07 PM in the dining area eating lunch in her wheelchair with the seatbelt restraint in place. In an interview on 5/21/24 at 9:50 a.m., LVN A stated Resident #81 used the seatbelt restraint every time she was in the wheelchair. LVN A stated there is a task within the TAR for staff to document the resident was wearing the restraint and that there should be a physician's order for application of the restraint. She stated the application of the seatbelt restraint is just known by the facility staff. She was not aware of any additional documentation or assessment requirements for the seatbelt restraint. CM Nurse was identified by the facility as responsible for care plans, and she was interviewed on 5/22/2025 at 10:50 AM. She stated the seatbelt restraint is addressed in the problem area of seizure disorder. She stated there was no care planning for the seatbelt as a restraint. In an interview conducted on 5/22/2025 at 12:30 PM, the DON explained Resident #81 had been using the wheelchair since admission to the facility due to falls with injury prior to admission, and the restraint use was continued upon admission at the request of the resident's mother. She stated there had been no less restrictive alternatives attempted prior to the use of restraint at the facility. She reported there was no formal documentation process for the supervision and monitoring of the restraint while it is in place, but the staff supervised and monitored the restraint use throughout the day and also by the rounding performed by the DON. She said the seatbelt restraint was only removed at the end of the day, when the resident was going to bed, and she previously made one attempt to perform a test of the resident's ability to independently release the restraint but the resident refused to participate. The DON stated the need for the seatbelt restraint was periodically re-evaluated but that alternatives were not considered because Resident #81's mother requested continued use. The DON confirmed a physician's order and care planning for the restraint should be present in the EMR. 2. Review of Resident #81's quarterly MDS dated [DATE] revealed a BIMS score was not assessed due to the resident's communication deficits. Record review of the resident's comprehensive care plan, date printed 5/20/2025, did not reveal care planning to prevent dislodgement of the g-tube. Further record review of the assigned tasks within the electronic medical record did not reveal a task to check placement / presence of the abdominal binder. Record review of Resident #81's progress notes indicated the resident required hospitalization on [DATE] and 5/15/25 for g-tube replacement. Progress notes did not indicate how the tube became dislodged. Resident #81 was observed on 5/22/2025 at 1:07 PM with the abdominal binder in place. LVN A stated in an interview conducted on 5/21/2025 at 9:50 AM that Resident #81 would occasionally pull on the g-tube, but she had not witnessed Resident #81 intentionally dislodge the device. She stated Resident #81 was wearing an abdominal binder at this time, to prevent dislodgement of the device, and nursing staff would check for placement out of routine. She reported there was no task within the electronic medical record to check for placement. In an interview on 5/22/2025 at 10:50 AM, CP Nurse identified as being primarily responsible for maintaining the care plans for residents. CP Nurse reported her process for updating care plans included running a daily audit report and attendance to daily morning meetings. She stated she had not yet made any updates to Resident #81's care plan regarding potential dislodgement. She also stated she wanted to do more research on the issue to ensure the correct interventions were in place. In an interview with the DON on 5/22/2025 at 12:30 PM, she reported Resident #81 was now wearing an abdominal binder to prevent the g-tube from being dislodged. She stated the staff should be checking fore placement of the abdominal binder, and the task should be present in the electronic medical record to ensure it is completed routinely. Record review of the facility policy titled Restraints (date implemented 8/15/2022) revealed the following: The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptoms. The care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint.

Based on observation, interview, and record review, the facility failed to ensure the resident assessments accurately reflected the resident's status for 1 of 8 residents (Resident #81) who were reviewed for resident assessments. The facility failed to document the use of a restraint device in Resident #81's quarterly MDS dated [DATE]. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Record review of Resident #81's face sheet dated 5/20/2025 revealed a [AGE] year old female, initially admitted to the facility on [DATE]. Relevant diagnoses included Lennox-Gastaut Syndrome (a severe disorder characterized by multiple seizure types and cognitive and behavioral problems); dependence on wheelchair; aphasia (difficulties with speech); and gastrostomy status (a surgical opening in the abdomen to allow for the intake of food and medication directly into the stomach). Review of Resident #81's quarterly MDS dated [DATE] revealed a BIMS score was not assessed due to the resident's communication deficits. Question P0100 item E. of the MDS (trunk restraint used in chair or out of bed) was assessed as 0. not used. No active physician order was located within the EMR for application of the seatbelt. Resident #81's comprehensive care plan included an intervention dated 12/02/2024 as follows: Make sure resident has her seat belt on when she sits up in her wheelchair; she has a medical need for it. A scanned document dated 12/2/2024 titled physical restraint/DME/monitoring device consent revealed a checkbox for physical restraint and a check mark indicating permission for the facility to use restraints as needed in accordance with the resident's comprehensive care plan and physician's order. This document was signed by the resident's mother and the ADON. An additional scanned document dated 11/29/2024 titled pre-restraint assessment/screening indicated resident admitted with seatbelt and that the seatbelt would be used for the time parameters when placed in w/c. This document includes a physician's signature and 4 illegible signatures of the interdisciplinary care team. Resident #81 was observed in her wheelchair wearing the seatbelt on 5/20/2025 at 12:03 PM, 5/22/2025 at 9:00 AM, and 5/22/2025 at 1:07 PM. LVN A reported in an interview 5/20/2025 at 9:50 AM that Resident #81 uses the seatbelt device every time that she is in her wheelchair. In an interview with the MDS Nurse on 5/21/2025 at 3:29, she explained data used to complete the restraint section Resident #81's quarterly MDS was obtained from the MAR. As the MAR did not include an order for staff to apply the seatbelt/restraint, the assessment regarding restraint use was documented as no. She also reported awareness that Resident #81 has used the seatbelt since admission. A document titled Restraint and Involuntary Seclusion located within a facility manual titled Facility Manual revealed use of restraints and their release must be documented in the clinical record.

Based on observation, interview, and record review, the facility failed to ensure the use of the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for 1 of 1 (Resident #81) residents reviewed for restraints. The facility failed to provide assessment, care planning, and ongoing re-evaluation of the use of a seatbelt restraint for Resident #81. Findings included: Record review of Resident #81's face sheet dated 5/20/2025 revealed a [AGE] year old female, initially admitted to the facility on [DATE]. Relevant diagnoses included Lennox-Gastaut Syndrome (a severe disorder characterized by multiple seizure types and cognitive and behavioral problems); dependence on wheelchair; aphasia (difficulties with speech); and gastrostomy status (a surgical opening in the abdomen to allow for the intake of food and medication directly into the stomach). Review of Resident #81's quarterly MDS assessment dated [DATE] revealed the BIMS score was not assessed due to the resident's communication deficits. Resident #81 was assessed as not using a trunk restraint. Record review of Resident #81's comprehensive care plan revealed the following related to the seatbelt restraint: a. Problem: [Resident #81] is at risk for falls r/t seizures, poor safety awareness, confusion (date initiated: 12/01/2024). Interventions: Make sure resident has hear seat belt on when she sits up in her wheelchair; she has a medical need for it (date initiated 12/02/2024). b. Problem: [Resident #81] has a seizure disorder and wears a soft helmet and has a wheelchair seat belt for safety (date initiated 12/11/2024). Interventions: Ensure [Resident #81]'s seat belt is in place when she is in her wheelchair for her safety related to falls. Respect her right to refuse to wear (date initiated 04/02/2025). Restraint assessment related to wheelchair belt per facility policy date initiated 04/02/2025. The comprehensive care plan did not include interventions to prevent and address any risks related to the use of the restraint, how to meet the needs of the resident during periods of restraint, monitoring/supervision to be provided during the use of the restraint, or parameters for release of the restraint. A review of active physician's orders did not reveal an order to apply the seatbelt restraint or parameters for monitoring or removal. Record review of Resident #81's MAR and TAR for May 2025 revealed scheduled tasks as follows: a. Resident to wear seatbelt when out of bed; it benefits outweigh any risks [sic]/every shift (start date 3/27/2025 10:00 PM, discontinue date 5/16/2025 9:37 AM) b. Resident to wear seatbelt in wheelchair when out of bed; benefits outweigh risks/every shift (start date 5/21/2025 10:00 PM) No additional monitoring or directives for the seatbelt were contained within the MAR or TAR. Review of all assessments documented in the EMR from Resident #81's admission on 11/29/2024 through the survey date did not reveal an assessment specifically related to restraint use. The skilled nursing assessment documented on 5/21/2025 by the ADON was reviewed to determine if this assessment included restraints, but it was not revealed to be an topic covered by this assessment. A scanned document dated 12/2/2024 titled physical restraint/DME/monitoring device consent revealed a checkbox for physical restraint and a check mark indicating permission for the facility to use restraints as needed in accordance with the resident's comprehensive care plan and physician's order. The area underneath type of restraint to be used (list only one) was not filled in with the type of restraint. This document was signed by the resident's mother and the ADON. An additional scanned document titled Pre-restraint Assessment/Screening, dated 11/29/2024, listed a diagnosis of Lennox-Gastaut Syndrome and type of restraint currently used as seatbelt. The time parameters when used was entered as when placed in w/c. The reason for restraint was documented as seizure disorder and a check mark was documented next to balance problem. In the next section, the document asked, what measures were implemented prior to restraint use? The author documented resident admitted with seatbelt. The recommended plan of action was documented as continue to use seatbelt for seizure disorders to keep resident from falling. This document was signed on 12/2/2024 by the physician and four others identified as the interdisciplinary care team. Resident #81 was observed in her wheelchair wearing the seatbelt restraint on 5/20/2025 at 12:03 PM self propelling through the communal dining areas. She was again observed 5/22/2025 at 9:00 AM in the communal sitting area of the east hall near in her wheelchair with the seatbelt restraint in place, and 5/22/2025 at 1:07 PM in the dining area eating lunch in her wheelchair with the seatbelt restraint in place. During an interview on 5/21/25 at 9:50 a.m., LVN A stated Resident #81 used the seatbelt restraint every time she in the wheelchair. LVN A stated there is a task within the TAR for staff to document the resident is wearing the restraint and that there should be a physician's order for application of the restraint. PT reported in an interview on 5/21/2025 at 11:17 that she did not think Resident #81 could unlatch the seatbelt restraint independently. She stated that the resident's mother was adamant about the use of the seatbelt restraint due to previous falls prior to admission. She reported no concerns about entrapment when Resident #81 has seizures while restrained in the wheelchair and no injuries to the resident related to restraint use since admission. In an interview conducted on 5/22/2025 at 12:30 PM, the DON explained Resident #81 had been using the wheelchair since admission to the facility due to falls with injury prior to admission, and the restraint use was continued upon admission at the request of the resident's mother. She stated there had been no less restrictive alternatives attempted prior to the use of restraint at the facility. She reported there was no formal documentation process for the supervision and monitoring of the restraint while it is in place, but the staff supervise and monitor the restraint use throughout the day and also by the rounding performed by the DON. She said the seatbelt restraint was only removed at the end of the day, when the resident was going to bed, and she previously made one attempt to perform a test of the resident's ability to independently release the restraint, but the resident refused to participate. The DON stated the need for the seatbelt restraint was periodically re-evaluated but that alternatives were not considered because Resident #81's mother requested continued use. The DON confirmed a physician's order and care planning for the restraint should be present in the EMR. Record review of the facility policy titled Restraints (date implemented 8/15/2022) revealed the following: a. Behavioral interventions should be used and exhausted prior to application of a physical restraint. b. Before a resident is restrained, the facility will determine . a. How the use of restraints would treat the medical symptom b. The length of time the restraint is anticipated to be used to treatt the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released. c. The type of direct monitoring and supervision that will be provided during use of the restraint. d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place c. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptoms. The care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint. d. The . resident's representative may request the use of a physical restraint, however the facility is responsible for evaluating the appropriateness of the request.

Based on record review and resident interview, the facility failed to ensure resident of the right to participate in the development and implementation of his/her person-centered plan of care for 1 of 5 (Resident #61) residents reviewed for resident rights. The facility failed to invite and include the input of Resident #61 as members of the interdisciplinary team in Care Conference meetings. This failure could place residents at risk of not receiving the interventions, treatments, and care necessary for the resident to reach their highest practicable physical, mental, and psychosocial well-being by not involving the resident in Care Plan Conference meetings. The findings included: Record review of Resident #61's face sheet date 5/22/25 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Diagnoses included peripheral Neuropathy (a condition that damages the nerves), hypertension (high blood pressure), dysphagia (swallowing difficulty), osteomyelitis (infection of bone marrow), Benign Prostatic Hyperplasia (enlarged prostate causing urination difficulty in men). Record review of BIMS (Basic Interview for Mental Status) dated 3/12/25 revealed Score of 15 indicating intact cognition. During an interview on 5/20/25 at 10:30 a.m., Resident #61 stated he had not been invited to a Care Plan meeting in a long time. Resident #61 stated he has gone to one Meeting sometime last year. During an interview on 5/21/25 at 3:15 p.m., the MDS Nurse stated that she kept a copy of care plan letters that were sent to the Responsible Party. MDS Nurse verified that the resident's son did receive an invitation to the Care Plan meeting held on 1/8/25 and 4/9/25. The MDS Nurse stated that the son did not attend the review meeting or voice concerns. The MDS Nurse stated that Interdisciplinary Team Members should have invited Resident #61 to the meeting as he was cognitively able to participate in individual plan of care. During an interview on 5/22/25 at 11:30 p.m., the DON stated that she expected Care Plan Meeting to include the resident if he/she were cognitively able to participate in plan of care regardless of whether or not the family member was informed of the meeting. During an interview on 5/22/25 at 11:50 a.m., ADMIN stated her expectation was for IDT (Interdisciplinary Team) members involve residents who were alert and able to participate in the care plan review meetings. Record review of Care Plan Signature sheets revealed that the last time Resident #61 attended a Care Plan meeting was August 2024. Review of the facility policy titled, Facility Manual, Revised 7/14/2020, Resident Rights, Admissions Policy revealed, .the resident and his or her Representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan .The facility will inform the resident, legal representative, responsible party, or other appropriate person in advance of the time and place of this conference.

Based on observation, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmacy services in that: The facility failed to follow physician orders for the fentanyl patch resulting in Resident #1 becoming unresponsive and suffering respiratory failure. An Immediate Jeopardy was identified on 7/25/24 at 3:15 PM. While the Immediate Jeopardy was removed on 7/26/24 at 4:15 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents and place them at risk for not receiving a therapeutic effect, could result in a decline in health, and overdose or death. The findings included: Record review of Resident #1 face sheet dated 7/24/24, Resident# 1 was a [AGE] year-old male admitted on [DATE] with diagnoses that included: COPD (chronic obstructive pulmonary disease), DM (diabetes), HTN (hypertension) , Bipolar disorder, quadriplegia non ambulatory. He discharged to hospital on 7/16/24. Record review of Resident #1's physician orders dated July 2024 revealed: Fentanyl patch 50 mcg change every 72 hours. Narcan PRN for opioid overdose [no order to monitor for opioid overdose] Record review of Resident #1's MAR July 2024 revealed: 7/13/24-removed from the abdomen's left upper quadrant (9:38 AM) and applied fentanyl path (09:38) by RN A to the abdomen's right lower quadrant. 7/16/24- removed from the abdomen's lower upper quadrant (9:58 AM) and applied to the lower upper quadrant (09:58) [by LVN B witnessed by LVN F]. Record review of EMS run sheet, dated 7/16/24 revealed: On 7/16/24 at 11:44 PM, EMS was dispatched to NF because Resident #1 was unresponsive and suffering respiratory failure. Resident #1, in the ambulance, was found with 2 fentanyl patches on body not reported by the facility. At the ER, resident was administered Narcan twice for a fentanyl overdose. Record review of EMS Run Sheet dated 7/16/24 revealed the following timeline: 7/16/24 at 11:44 PM EMS dispatched to NF. 7/16/24 at 11:59 arrived at patient. 7/17/24 at 00:29 AM arrived at ER. Also, The EMS narrative read: Medic 3 (Paramedic E) dispatched to nursing home for a 74 yo (year old) male that is unresponsive and difficulty breathing patient lethargic and with swallow breathing .Patient pupils presented pin point bilaterally .the patient was placed on a 12 lead ECG that revealed the patient in atrial flutter and RVR (rapid ventricular rhythm) .Upon further examination it was found that the patient presented with 2 Fentanyl patches that had not been reported to EMS crew by Nursing Home staff . Record review of Resident #1's hospital record MD C note dated 7/17/24 at 5:58 AM read: HPI (History of Present Illness .Chief Complaint: unresponsive .74 yo (year old) M (male) with hx (history) of quadriplegia, chronic pain, recently dx (diagnosed ) HCC (liver cancer) with mets (metabolic equivalents) to the lumbar spine, DM (diabetes), HTN (hypertension), COPD, mood disordered .concern for narcotic overdose .Per report [patient] was brought in from SNF (skilled nursing facility) with concern for decreased responsiveness. Patient was found to have multiple fentanyl patches on him in the ER (emergency room ) .He was noted to be hypoxic (lack of oxygen) in the ER and was placed on bi-pap (breathing mask) with improvement in [respiratory] status . Record review of Resident #1's hospital record MD H note dated 7/17/24 at 5:58 AM read: .At ER patient received a dose of Narcan and his fentanyl patch (unknown dose and quantity) was removed, then he rather quickly woke up and was conversant. After few hours patient once again became lethargic and required repeat dosing of Narcan, thus was started on Narcan drip .Diagnosis, Assessment & Plan .Impression .1. Fentanyl Overdose . Observation and interview on7/24/24 at 9:00 AM, Resident #1 was in bed on a ventilator in the ICU in a local hospital. Resident #1 had difficulties communicating because of the ventilator apparatus in his month. [Surveyor employed an thumbs up (meaning yes) and thumbs down (meaning no) interview technique. Resident #1 responded with thumbs up to the direct question whether he felt he received too much fentanyl and was overdose. [Resident #1 was too exhausted to continue the interview] During an interview on 7/23/24 at 12:45 PM, the DON stated: her internal investigation revealed there was no overdose of Resident #1. The DON stated that the facility could account for all the fentanyl patches given to the resident (Resident #1) for the past month (July 2024). The DON stated the resident was sent to the ER because of respiratory failure. The DON stated the facility had Narcan in the e-kit; and there were two other residents on fentanyl patches [Resident #2 and #3] During an interview on 7/24/24 at 9:05 AM, RN (ICU) stated: the resident was slightly sedated and was scheduled for a trach. The RN (ICU) stated that the hospital progress notes revealed that numerous fentanyl patches had been found on the resident in the ER. The RN (ICU) stated, the ER staff administered Narcan twice to counteract a drug overdose. During an interview on 7/24/24 at 10:50 AM, EMS Administrator, stated: EMS responded on 7/17/24 to an unresponsive resident at the nursing home. The EMS Administrator stated that the EMS staff was not told by nursing home staff that the resident had fentanyl patches. The EMS Administrator stated that in the ambulance the resident was found by the paramedics with two fentanyl patches. The EMS Administrator stated the treatment given to the resident in the ambulance was breathing treatment, heart medication and monitoring. During a telephone interview with Resident #1's primary physician on 7/24/2024 at 3:36 PM , she stated Fentanyl patch for pain should be removed every 72 hours and then a new one placed. If one were left on it would exceed the dose ordered by the physician, and respiratory and other overdose symptoms such as unresponsiveness could occur if overdosed was present. During a telephone interview with the facility RN A on 7/24/24 at 3:45 PM she stated she remembered Resident #1 having the Fentanyl patch ordered for pain. She stated she removed one and placed a new one the weekend before [7/13/24] before Resident #1 was sent to the hospital 7/17/24. She further stated she knew that only one patch should be placed on a resident at one time because an overdose could occur. During a telephone interview on 7/25/24 at 9:00 AM, witnessed by the Chief of EMS, Paramedic D [driver in the ambulance] stated that Paramedic E found two fentanyl patches on the resident's body in the ambulance. Paramedic D stated one patch was at the LLQ abdomen and the second patch was at the right upper shoulder. Paramedic D stated the LLQ patch was new and dated but the date was not recorded by EMS and the second patch on the upper right shoulder appeared to have reached the 7 day mark (date was not recorded by EMS); mcg were unknown on both patches. Paramedic D was present at the ER when the ER staff removed both patches and the physician stated they were fentanyl. Paramedic D stated once the 2 patches were removed the resident became responsive. During a telephone interview on 7/25/24 at 10:00 AM, LVN B stated: he removed and applied a fentanyl patch [on Resident #1] on 7/16/24 witnessed by LVN F. LVN B stated that he only lifted the resident's T-shirt chest high but did not strip the resident or search for other patches. LVN B stated he documented the removal and application of the fentanyl patch on the MAR July 2024. LVN B stated he could not recall the location of the patch removed and applied. LVN B stated he was familiar with fentanyl protocols. During an interview on 7/25/24 at 10:15 AM, LVN F stated she was present when LVN B removed and applied a fentanyl patch to Resident (#1's) abdomen. LVN F stated she could not recall where the location where the old patch removed and the location of the new patch. LVN F stated that the resident was not stripped or T-Shirt removed to check on the existence of any other fentanyl patch. LVN F stated that the removed patch was discarded in the sharps-container. LVN F stated he was familiar with fentanyl protocols. During a telephone interview on 7/25/24 at 10:30 AM, RN A stated, that she removed and applied a fentanyl patch to the RLQ (right left quadrant) . RN A stated that on 7/13/24 she did not strip down the resident or search for other fentanyl patches. RN A stated she gave the resident a bed bath on 7/14/24 and the resident only had one fentanyl patch present. During telephone interview on 7/25/24 at 11:55 AM, CNA G stated that: she gave Resident #1 a bed bath on 7/16/24 between 9:00 AM and 11:00 AM and noticed two patches on the resident's knees one on each knee and a patch on the floor. CNA G stated that there were no patches on the resident's abdomen and she did not see any other patches on the resident's body. CNA G stated she threw the patch on the floor in the trash can and did not know whether it was a fentanyl patch. CNA G stated that she informed LVN B that she threw the patch on the floor in the trash can. During a telephone interview on 7/25/24 at noon, LVN B stated that he was never told by CNA G that she found an unknown patch on the floor in Resident #1's room and threw it in the trash can. During an interview on 7/25/24 at 1:19 PM, the DON stated: she could not explain why the resident's hospital report stated, multiple fentanyl patches. The DON stated the resident sweated a lot and starting in July 2024 the location of the fentanyl patch was moved to the abdomen. The DON stated that when a resident was on an order for fentanyl patches the patch is removed and applied every 72 hours. The DON stated a fentanyl patch could be placed on the abdomen, back , shoulder and any fatty place; and should be dated. The DON stated if a medical patch was found on the floor, regardless as to whether it was fentanyl, the nurse should be informed and not thrown in a trash can; and disposed as medical waste. The DON stated the resident was sent to theER on [DATE] because the resident had respiratory distress at 12:47 AM and altered mental status. The DON stated that Resident #1 was a quadriplegic, required total dependency for transfer and mobility. The DON stated the resident had usage of his arms and could remove a patch. The DON stated that best practice when removing a applying a fentanyl patch should be to do a full body search. The DON stated it was an unfortunate incident and LVN B and LVN F were competent and knowledgeable about the facility's fentanyl protocol. Record review of facility's investigation file, undated, revealed the following written statements: 7/23/24 LVN B: he only removed and applied one fentanyl patch. LVN B stated he did not see other patches Because he wears a T-shirt. 7/22/24; CNA H stated that she only saw one patch on the resident [present on 7/14/24 when bed bath was given by RN A] Record review of LVN B's Medication Pass Competency assessment dated [DATE] revealed LVN B was competent in Transdermal Patches which included: .old patch removed .Two nurses witnessed and signed for controlled substance wasting (fentanyl patch removal) .patch is dated and timed .Patches rotated to site as stated on MAR and placement documented. Record review of LVN F's Medication Pass Competency assessment dated [DATE] revealed LVN B was competent in Transdermal Patches which included: .old patch removed .Two nurses witnessed and signed for controlled substance wasting (fentanyl patch removal) .patch is dated and timed .Patches rotated to site as stated on MAR and placement documented. Record review of facility's Mediation Administration: Transdermal (Patch) Application dated revised 10/101/19 read: .Identify the location on the body for patch placement .Remove old path from body .Label path with date and nurse's initials .Document placement site on MAR .Fentanyl Patches require the path to be folded after removal, destroyed per policy and state regulations, dropped in the Sharps container and a witness be present to sign . The Administrator and the DON were notified of the Immediate Jeopardy on 7/25/24 at 3:15 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 7/26/24 at 10:53 AM and reflected the following: Nursing and Rehabilitation LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On 7/25/2024, the facility was notified by the surveyor that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. The alleged immediate jeopardy allegations are as follows: Issue: F755 Pharmacy Services/Procedures/Pharmacist/Records For Residents Involved: Resident #1: Resident #1 is currently in the hospital. To Identify Any Other Residents to Have the Potential: The Director of Nursing and/ or designee has reviewed all current residents with fentanyl patch orders as of 7/22/24. The Director of Nursing and/ or designee has observed current residents for appropriate patch placement and documentation 7/22/24. The Director of Nursing and/ or designee will review new admissions to ensure that any new orders for fentanyl patch are complete and patch is placed appropriately. Education/ System Change: The Director of Nursing or designee began re-education on the following: Licensed nursing staff received re-education on appropriate order, placement and documentation of fentanyl patch, including identifying S/S of possible overdose. Licensed Nursing Staff re-educated on appropriate disposal of Fentanyl Patches Licensed Nursing Staff re-educated on validation of patch placement. Direct care staff re-educated on communication to supervisor of any displaced or dislodged patch, to ensure M.D. orders are followed. Re-education initiated on 7/22/24 with Licensed Staff and completed with Licensed staff and Direct care staff on 7/25/24. Those that are PRN, PTO/FMLA will complete prior to next schedule shift. Re-education will continue for any new hires and as part of the orientation process. Re-education will be validated using employee roster. Monitoring: The Director of Nursing or designee will review the 24- hour report in the morning clinical meeting to ensure that any new orders for fentanyl patch are documented and placed appropriately. This will begin 7/26/24 and will be an ongoing process. The Director of Nursing or designee will ensure new admissions have complete orders and correct placement for fentanyl patch. Placement of patches will be rotated on upper body. The facility does have Narcan available in the event of an overdose situation for residents who are prescribed Fentanyl. The Director of Nursing or designee will monitor compliance every shift x 4 weeks, then every shift 3 times per week x 4 weeks, then 1 x a week times 4 weeks. The results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continued as needed. The DON or designee will utilize a validation log to document findings. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the admissions and the 24-hour report in the morning clinical meeting. An Ad-Hoc QAPI was conducted on July 25, 2024, by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning F755 and to develop the above-mentioned plan of care. We respectfully submit this action plan for removal of Immediate Jeopardy. Sincerely, Administrator Verification of Plan of Removal: Key Observations:. Observation on 7/26/24 at 1:20 PM revealed Resident #1 had not returned to the facility . Observation on 7/26/24 at 4:20 PM to 4:25 PM revealed that there were 3 injectable Narcan in the emergency kit locked in the medication room; and one Narcan spray in Nurse cart. Key Interviews: During an interview on 7/26/24 at 1:22 PM, the DON stated: she reviewed all current residents with fentanyl patch orders as of 7/22/24 and there were only two residents present in the facility; Resident #2 and Resident #3. The DON stated: there were no new admissions on 7/25-7/26/24. The DON stated for new admissions, she would ensure that any new orders for fentanyl patch were complete and patch is placed appropriately. The DON added: there were no new admissions on 7/25-7/26/24. The DON stated for new admissions she would ensure that any new orders for fentanyl patch are complete and patch is placed appropriately. In interviews on 07/26/24 from 1:45 PM to 3:15 PM with 4 day shift (6 a.m. to 6 p.m.) nursing staff ( 2 LVNs and 2 CNAs), 5 evening shift (2 p.m. to 10 p.m.) nursing staff (2 LVNs, 3 CNAs) and 3 night shift (10 p.m. to 6:00 a.m.) (2 RNs, 1 CNA) revealed they had been in-serviced on the S/S (signs and symptoms) of overdose, disposal of fentanyl patches, validation of placement, communications, and on the 5 rights in medication administration especially involving fentanyl patches. During an interview on 7/26/24 at 2:00 PM, the Administrator stated that the issue of new admissions and any concerns with the 2 residents on fentanyl patches was discussed at the 7/25 and 7/26/24 morning meetings. During an interview on 7/26/24 at 2:06 PM, the Regional Nurse stated that ad-hoc QAPI meeting on 7/25/24 discussed the fentanyl protocol and the need for nursing staff to adhere to the protocol. The Regional Nurse stated that the physician present at the meeting by telephone was requested to state in the physician's order the location of the fentanyl patch. Key Record Review Record review of the Resident Roster dated 7/26/24 revealed Resident #1 no longer resided in the facility. Record review of current residents with fentanyl patch orders as of 7/22/24 revealed only two residents on fentanyl patches; Resident #2 and Resident #3. Record review of facility's Fentanyl Audit F755 (form) dated July 26-27, 2024, revealed only 2 residents on fentanyl patches; Resident #2 and Resident #3. The audits were contained in the facility's POR binder. Record review of facility's Admissions/Discharge list dated 7/26/24 revealed non new admissions. Record review of the in-service from 7/25/24 to 7/26/24 revealed 100% completion of 49 nursing staff trained on fentanyl protocol, placement, proper disposal, location, dating, and signatures (see attached sheet). Form also present for non-license nursing staff on communications and patches found. Record review of facility's morning report dated 7/15/24-7/26/24 revealed the report was reviewed and signed by the DON and the Administrator. Record review of ad-hoc QAPI meeting held on 7/25/24 with the Medical Director present by telephone. On 7/26/24 at 4:50 PM the Administrator was informed the POR was validated and Immediacy was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal.

48366 Based on observations, interviews, and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 of 24 Residents (Residents #15, #47, #50, and #82) reviewed for safety, monitoring, and supervision. 1. The facility failed to monitor and supervise Resident #50's multiple incidents of drinking beer and receiving quetiapine (used to treat the symptoms of mental illness that caused disturbed or unusual thinking), Zolpidem (used to treat difficulty falling asleep or staying asleep; a class of medications called sedative-hypnotics) and hydrocodone (a narcotic analgesic agent for the treatment of moderate to moderately severe pain) with subsequent falls, possession of cigarettes and a personal lighter while assessed as a smoker who needed supervision. 2. The facility failed to monitor and supervise Resident #15's multiple incidents of drinking beer and receiving methadone with subsequent falls, possession of cigarettes and a personal lighter while assessed as an unsafe smoker who needed supervision. 3. The facility failed to monitor and supervise Resident #47's multiple incidents of Resident #47 allegedly drinking unprescribed alcohol and having extra Percocet's on hand. 4. The facility failed to ensure Resident #82 was safe in the facility by allowing her to have toxic hair dye without Doctor's orders or supervision. An Immediate Jeopardy (IJ) was identified on 03/29/2024. While the IJ was removed on 03/31/2024, the facility remained out of compliance at a scope of pattern with risk for harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place residents at risk for serious harm, accidents, or major injury. The findings included: 1. Resident #50 A record review on 03/30/2024 of the Texas Unified License Information Portal website for July 2023 to March 03/30/2024, accessed 03/30/2024, revealed no facility related report for Resident #50. A record review of Resident #50's admission record dated 03/27/2024 revealed an admitted [DATE] with diagnoses which included schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), alcohol abuse, ataxia (Loss of coordination of voluntary muscle movements), nicotine dependence, dementia (A group of symptoms that affects memory, thinking and interferes with daily life) and malignant neoplasm of skin of nose (a cancer that can spread). A record review of Resident #50's admission MDS assessment, dated 01/17/2024, revealed Resident #50 was a [AGE] year-old male admitted for long term care and was assessed with a BIMS score of 15 out of a possible 15 which indicated no cognition impairment. Further review reveled resident #50 used a walker and needed set up or clean up assistance .supervision or touching assistance with ADL's. A record review of Resident #50's care plan dated 03/26/2024, revealed, (Resident #50) enjoys drinking beer and may have one 12 0z. beer as desired one time a day per MD order (Resident #50) is suspected of drinking while off facility premises when he signs himself out to go out on pass. Patent education unsuccessful Date Initiated: 02/09/2021 Revision on: 08/19/2023 .Administer beer as per MD orders Date Initiated: 02/09/2021; Beer to be kept in medication room refrigerator. Date Initiated: 02/09/2021; Resident must supply own beer Date Initiated: 02/09/2021 . further review revealed (Resident #50) is a smoker. (Resident #50) refused to sign the facility smoking policy. Educated resident of facility policy, still refused to sign (Resident #50) is non-compliant with facility policies, and smoking policies Date Initiated: 12/26/2018 Revision on: 05/10/2023 . The resident requires SUPERVISION while smoking. Date Initiated: 05/10/2023 .The resident's smoking supplies are stored in secure area behind the nurses station; Date Initiated: 12/26/2018; Revision on: 05/21/2021 . (Resident #50) has impaired cognitive function and impaired thought processes r/t Dementia Date Initiated: 03/21/2019 A record review of Resident #50's Nursing - Smoking Safety Screen dated 01/17/2024, signed by LVN R, revealed resident #50 needed supervision while smoking. A record review of Resident #50's physician's orders dated 03/27/2024 revealed resident #50 was prescribed quetiapine 500mg oral tablets by mouth at bedtime, 01:00 AM, for schizophrenia disorder; zolpidem 5mg by mouth at bedtime, 01:00 AM, for insomnia; and hydrocodone - acetaminophen 7.5mg/325mg by mouth 4 times a day (02:00 AM, 08:00 AM, 02:00 PM, and 08:00 PM, for pain in knees . Further review revealed resident #50 was also prescribed 1 12-ounce beer daily at 07:00 PM. A record review of resident #50's doctors progress note dated 08/15/2023 revealed Dr. S documented resident 50's HPI (History of Present Illness), [AGE] year-old white male at facility for long term care, seen today for regulatory physician visit, and follow up of multiple complex medical issues. He has a past medical history of EtOH (alcohol) dependence, weakness with falls, COPD, . tobacco use disorder . he has a history of surreptitious (secret) EtOH (alcohol) use .assessment and plan .EtOH abuse: ongoing chronic intermittent issue. Is allowed a small agreed upon amount of beer A record review of Resident #50's medical record revealed nursing progress notes and medication administration documentation as follows: 08/18/2023 at 05:38 AM LVN Z documented Resident (#50) pulled bathroom light, aids reported patient was on the floor, in between bathroom and bed, facing up. Patient had a strong odor of alcohol. Nurse asked Resident if he has been drinking alcohol, patient answers yes, free beer, when nurse question where he received it from he did not answer and only states it was free beer patient vitals were taken upon arrival blood pressure 98/67, 96.8 temp (temperature), R (respirations) 18, 02% 95, patient refused full assessment, nurse was able to do a quick assessment, no skin tear, no redness noted to head, back, arms or legs. Patient denies pain, patient denies hitting his head, patient denies range of motion assessment, patient denies help too bed, CNA moved his [NAME] to his side and he was able to get up on his own. Patient denies neuro checks and further assessment. Resident was given his 12 AM, 1:00 AM, and 2:00 AM meds; at that time nurse did not notice any alcohol odor on him. The patient was hanging out in the front of the building and the back patio area with other residents this evening. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's August 2023 Medication Administration Record revealed LVN Z documented on 08/18/2023 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 400mg at 01:18 AM. 08/20/2023 at 02:07 AM LVN Y documented, Resident (#50) was found on the floor by the CNA. Resident (#50) awake and responsive. He was on the floor close to the restroom with walker by his feet. Resident unable to state what happened or how he fell . He kept repeating I'm OK Resident did report he was drinking outside. He had been back for less than an hour when found on floor. Vital signs within normal limits. No injury noted. No complaints of pain voiced. Resident (#50) was assisted up to his feet and he was able to use walker but needed staff to hold him up. He made it to the bed where he immediately fell asleep and started snoring. [NAME] and call bell within reach. Door left open to keep a lookout for him. No other complaints at this time. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's August 2023 Medication Administration Record revealed LVN Y documented on 08/20/2023 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 400mg at 01:01 AM. 09/02/2023 at 02:30 AM LVN A documented, Resident finally in bed. Slurs words. Resident does not smell like alcohol but behaving the same on days he is inebriated. Resident already had night meds and is drowsy. Blood pressure earlier tonight around 12:00 AM was 140/92. Blood pressure lower at this time. Will sometimes get up from laying position and has blood pressure drop and will have fall where he sits down. Gets up by himself. Assisted tonight. Still no injury noted. neuros within normal limits for him. Has range of movement in all extremities. No complaint of pain. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's September 2023 Medication Administration Record revealed LVN A documented on 09/02/2023 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 400mg at 12:52 AM. 09/12/2023 at 02:39 PM the Activities Director T documented, Resident (#50) was sitting on the patio at 1:30 PM (staff) let resident know it was not smoke break time yet. Resident replied angrily 'I am allowed to sit out here.' I walked out to the patio at 1:45, Resident asked if (staff) had told me to come. I saw a lighter tightly held in his right hand and he had a cigar (unlit) hidden behind the ashtray. Resident did not move the cigar or lighter until (staff) came out at 2:00 PM for smoke break, he then hid them quickly and accepted two more cigars from her. Further review revealed the note was also posted to the facility's 24-hour report. 10/01/2023 at 12:56 AM LVN A documented, Resident (#50) had recent fall outside and hit face. Has not complained of pain so far tonight. Gets scheduled pain med at night. Able to move all extremities. Uses rollator, ambulates. Had X-ray done recently of right ankle. No fractures, injury. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's October 2023 Medication Administration Record revealed LVN A documented on 10/01/2023 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 400mg at 01:16 AM. 10/02/2023 at 01:54 AM LVN A documented Resident (#50) had recent fall outside. CMA witnessed incident. resident did not hit head, had no injuries noted. neuros have been within normal limits for him. has had no complaint of pain. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's October 2023 Medication Administration Record revealed LVN A documented on 10/02/2023 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 400mg at 01:19 AM. 02/18/2024 11:59 AM the Administrator documented, Witnessed (Resident #50) smoking in smoking patio during a non-smoking time. Approached (Resident #50) and he stated, 'you caught me.' Discussed the importance of smoking during supervised smoking times only to prevent any injuries. Discussed he is not allowed to keep smoking materials on his person and all smoking materials are to be turned in at the end of each smoke break. (Resident #50) voiced understanding and stated he does not have any other smoking materials on his person. Asked where he obtained cigarette and how he lit it, he again denied having any smoking materials on his person. He states it won't happen again. (Resident #50) does sign himself out on pass frequently. Explained to (Resident #50) if he purchases smoking materials when out on pass, two turn in smoking materials to charge nurse. he voiced understanding. Administrator, LNFA. Further review revealed the note was also posted to the facility's 24-hour report. 03/05/2024 at 12:35 AM LVN A documented Resident (#50) seen lowering himself to one knee outside on West. nurse from [NAME] witness resident lowering himself. nurse helped him back up. resident came back over to east. CNA from [NAME] came over to inform east nurse who went over looking for him. nurse on [NAME] informed nurse on east what occurred. resident without injury resident in room at this time. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's March 2024 Medication Administration Record revealed LVN A documented on 03/05/2024 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 500mg at 01:00 AM. 03/05/2024 06:50 PM LVN C documented, Resident (#50) did not wait for nurse on [NAME] side to escort for smoking break even after he was told not to be outside smoking on own will continue to assess. Further review revealed the note was also posted to the facility's 24-hour report. 03/18/2024 at 01:20 AM LVN A documented Resident (#50) reported to have fall outside at front of building, reported by CNA on [NAME] and another Resident. Resident then came back over to east on rollator and explained several times until he stated what occurred. Stated he was sitting on rollator, leaned over to put in code to get in front lobby area under carport, and rollator slipped out from behind him, he went down on one knee and caught himself with right arm on planter pot, had episode of dizziness, took a few deep breaths, got himself up and back on rollator. No injury noted, had on shoes. Went on down hall. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's March 2024 Medication Administration Record revealed LVN A documented on 03/18/2024 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 500mg at 01:00 AM. 03/19/2024 at 02:49 AM LVN A documented (Resident #50) had recent fall outside of building. no injury noted. no complaint of pain. neuros within normal limits. Further review revealed the note was also posted to the facility's 24-hour report. A record review of Resident #50's March 2024 Medication Administration Record revealed LVN A documented on 03/19/2024 she administered Resident #50's zolpidem 5mg at midnight, hydrocodone 7.5mg at 02:00 AM, and quetiapine 500mg at 01:00 AM. 03/20/2024 at 11:19 PM LVN C documented had an assisted fall while walking through the doorway from smoking no injuries. Reported to (the physician group). Further review revealed the note was also posted to the facility's 24-hour report. 03/25/2024 05:39 PM the Administrator documented, Administrator made aware resident may have smoking materials on his person. Administrator visited with Resident #50. States he does not have any cigarettes but did give Administrator his lighter. Re-educated Resident #50 on importance of safety, turning in all smoking materials to charge nurse or any manager, and not keeping smoking materials on his person or room while in facility. resident voiced understanding. Administrator LNFA. Further review revealed the note was also posted to the facility's 24-hour report. 2. Resident #15 A record review on 03/30/2024 of the Texas Unified License Information Portal website for July 2023 to March 03/30/2024, accessed 03/30/2024, revealed no facility related report for Resident #15. A record review of Resident #15's admission record dated 03/26/2024 revealed an admitted [DATE] with diagnoses which included alcoholic cirrhosis of liver (a condition in which your liver is scarred and permanently damaged), viral Hepatitis C (a virus that attacks the liver and leads to inflammation), and alcohol abuse. A record review of Resident #15's admission MDS assessment, dated 02/02/2024, revealed Resident #15 was a [AGE] year-old male admitted for long term care and was assessed with a BIMS score of 15 out of a possible 15 which indicated no cognition impairment. Further review reveled resident #50 used a wheelchair and needed set up or clean up assistance .supervision or touching assistance with the wheelchair. A record review of Resident #15's care plan dated 03/26/2024, revealed, (Resident #15) enjoys drinking beer and may have one 12 0z. beer as desired one time a day per MD order .beer to be kept in medication room refrigerator .(Resident #15) must provide own beer .(Resident #15) is a smoker. (Resident #15) is at times non-compliant with facility policies and smoking policy. (Resident #15) refused to sign the facility smoking policy . instruct resident about the facility policy on smoking; locations, times, safety concerns . the resident requires supervision while smoking . the resident smoking supplies are stored at the nurses station A record review of Resident #15's Nursing - Smoking Safety Screen dated 01/30/2024, signed by the MDS Nurse, revealed resident #15 could not safely use a lighter and needed supervision while smoking. A record review of Resident #15's physician's orders dated 03/27/2024 revealed resident #15 was prescribed cyclobenzaprine 10mg (a muscle relaxer) give every 8 hours, 12:00 AM, 08:00 AM, and 04:00 PM; methadone 5mg (a narcotic used to treat opioid use) give 1 tablet .every 8 hours, 07:00 AM, 3:00 PM, and 11:00 PM; Tylenol with codeine#3 (used to relieve mild to moderate pain. Codeine belongs to a class of medications called opiate (narcotic) analgesics), and 1 12-ounce beer at 07:00 PM. A record review of resident #15's Nurse Practitioner notes revealed NP B documented on 03/02/2024 at 06:09 PM, . patient (Resident #15) is a chronic methadone user. Staff reports that the patient checks himself out a few times a week and wheels himself to the bar down the street or to the convenience store and buys beer and sits outside and drinks beer. Staff reports administration is aware Further review revealed the note was also posted to the facility's 24-hour report. A record review of resident #15's medical record revealed nursing progress notes as follows: On 12/21/2023 at 12:15 AM RN U documented, Resident on cement sidewalk proximal to employee after hours door near the bushes. he is left side lying in front of his wheelchair. It is drizzling rain. Per another male resident, it began to rain and resident rounding the corner too fast and slid out of the wheelchair. The witness stated that he did not hit his head on the sidewalk. Resident was out on pass at the time. Further review revealed the note was also posted to the facility's 24-hour report. On 12/23/2023 at 10:57 PM RN U documented, Resident had slipped out of wheelchair outside while out on pass Further review revealed the note was also posted to the facility's 24-hour report. On 12/24/2023 at 11:20 PM LVN A documented, Resident (#15) had slipped out of wheelchair outside while out on pass. No injuries, neuros within normal limits for him. Alert and verbal. Has no complaint of any pain from falling out of wheelchair. Further review revealed the note was also posted to the facility's 24-hour report. 02/18/2024 at 12:05 PM the Administrator documented, Witnessed (Resident #15) smoking during a non-smoking time in patio. Upon approaching (Resident #15), he immediately put out the cigarette in ashtray. Discussed the importance of following smoking policy and supervised smoking to prevent any injuries. (Resident #15) frequently attempting to change the subject / topic; redirected conversation and he voiced understanding. (Resident #15) frequently goes out on pass and discussed turning in all smoking materials to charge nurse should he purchase any smoking materials while out on pass. He voiced understanding. Administrator, LNFA. Further review revealed the note was also posted to the facility's 24-hour report. 03/05/2024 at 06:42 PM LVN C documented, Resident (#15) ask to have door unlocked so he could go outside I'll hit him know everyone is waiting on [NAME] nurse to take him that she will be here in a minute and he said no I can go outside whenever I want I said yes but not to smoke on your own he left and is smoking outside even after being told to wait for nurse from [NAME] side. Further review revealed the note was also posted to the facility's 24-hour report. 03/25/2024 at 06:28 PM the Administrator documented, Administrator made aware that (Resident #15) may have smoking materials on his person. Administrator, senior administrator, and RCS visited (Resident #15) in room. (Resident #15) initially denied having smoking materials. discussed concern for his safety and the safety of other residents. he was asked again if he had smoking materials at which time he produced 2 packs of cigarettes. he was asked if he had a lighter and he produced a lighter as well. read educated importance of turning in all smoking materials to the charge nurse or any manager. (Resident #15) does go out on pass and he was educated on turning in smoking material if he purchases and brings back smoking materials to the facility. Administrator, LNFA. Further review revealed the note was also posted to the facility's 24-hour report. 1. and 2. Residents #50 and #15 During an observation on 03/25/2024 at 02:24 PM revealed Resident #50 and resident #15 seated outside in the designated smoking patio. The facility's Activities Assistant was in control of a large yellow metal cabinet on wheels which contained the facility Residents smoking materials, for example, cigarettes, and lighters. Resident #50 and Resident #15 were observed seated at a patio table. Resident #50 and Resident #15 were observed to each reach into their pockets and produce cigarettes and personal lighters. Resident #50 proceeded to light and begin to smoke a cigarette. Resident #15 was observed to place a cigarette in his mouth but held his lighter in his hand. The Activities Assistant presented resident #50 with an additional 2 cigarettes and did not offer to light Resident #50's cigarette because it was already lit. The Activities Assistant presented Resident #15 with an additional 2 cigarettes and used her lighter to ignite resident #15's cigarette. During an interview on 03/25/2024 at 02:40 PM the Activities Assistant V stated Resident #50 had his lighter and cigarettes in his possession and did not light Resident #50's cigarette because it was already lit. The Activities Assistant stated she did light Resident #15's cigarette and gave him an additional 2 cigarettes. The Activities Assistant V stated resident #50 and Resident #15 did have their cigarettes and lighters on their person and have a history of going out and purchasing their cigarettes and lighters. The Activities Assistant V stated the practice of keeping cigarettes and lighters was against facility policy and would report the incident to the Activities Director. During an interview on 03/26/2024 at 04:55 PM LVN C stated Residents #50 and #15 were often smoking unsupervised. LVN C stated Residents #15 and #50 had a history of signing themselves out every evening around 6 to 7 PM and would return around 11PM to midnight. LVN C stated Residents #15 and #50 had a history of smelling like beer because they had an order for beer. LVN C stated she had often signed resident #50's and resident #15's medication administration record for the order to administer the beer even though the facility kept no beer for the residents, we don't have beer here .they sign themselves out and maybe buy beer .I don't know what they do when they sign themselves out. LVN C stated she had verbally told the leadership of the resident's routine but could not elaborate details of the reports. LVN C stated she had not documented any incident reports or reports to the physicians. During an interview on 03/28/2024 at 03:00 PM LVN C stated for Residents #15 and #50 she often signed the medication administration record for the order to administer the beer without administering the beer. LVN C she did not report Residents #15 and #50 might be drinking off the premises and if they smell like beer it is because they have an order for beer. During an interview on 03/31/2024 at 02:43 PM LVN A stated she worked the 10PM to 6AM shift on the hall for Residents #50 and #15. LVN A stated Residents #50 and #15 had a history of signing themselves out and leaving the facility on the shift before she arrived. LVN A stated Residents #50 and #15 would return back to the facility usually around 11PM to midnight. LVN A stated Residents #50 and #15 would sometimes return to the facility smelling like alcohol and then would be administered their scheduled quetiapine; zolpidem; and hydrocodone. LVN A stated Residents #50 and #15 had a history of falling around these times, from midnight to 2AM. LVN A stated she had documented the episodes of falls with the suspicion of Residents #50 and #15 drinking alcohol while away from the facility. Interviews by leadership for residents #15, and #50: During an interview on 03/28/2024 at 10:48 AM, NP B stated she worked for the Medical Director and had been calling upon the facility since August 2023. NP B stated Residents #15 and #50 had a history of signing out at 6:00 PM and returning at midnight and falling. NP B stated, prior to February 2024, she had not received report that residents had returned from being out on pass and had fallen while smelling like beer. NP B stated she spoke to the Administrator and the Medical Director and said the Administrator and the DON knew of the allegation of alcohol abuse off property as evidenced by the progress notes and care plans. During an interview on 03/28/24 at 11:14 PM the DON stated the incidents for Residents #15 and #50 were documented as falls and not connected to the use of alcohol while out on pass and the few incidents where nurses documented alcohol were in August and September 2023 when she first started and did not understand Resident #15 and #50's routines. The DON stated she was unaware the facility had no beer to administer to residents #15 and #50. The DON stated she was unaware Nurses were signing the MAR as if they were administering the beer without administering the Beer. The DON stated she interviewed the Nurses who had documented as such, and they reported to her they believed they were documenting the residents were receiving beer while out on pass. The DON stated she was not informed by NP B or any of her nursing staff the suspicion Residents were drinking alcohol. The DON stated the notes regarding unsupervised smoking and possession of lighters were reviewed by the Administrator and herself. The DON stated the Administrator wrote some of those progress notes. The DON stated she had expectations the Administrator would have reported those incidents to the state agency and investigated those incidents for safety reasons. 3. Resident #47 A record review of Resident #47's admission record revealed an initial admitted [DATE] with diagnoses which included cirrhosis of the liver (degenerative disease of the liver resulting in scarring and liver failure), major depressive disorder, cognitive communication deficit (difficulty with communication that has an underly cause in a cognitive deficit), unsteadiness of feet, anxiety disorder, and age-related physical debility (physical weakness). A record review of Resident #47's annual MDS assessment dated [DATE] revealed Resident #47 had a BIMS of 15 out of 15 indicating intact cognition. A record review of Resident #47's care plan, undated, revealed the following: [Resident #47] has liver disease r/t cirrhosis with interventions that included Give medications as ordered, date initiated 12/18/2018. A record review of Resident #47's Order Summary report revealed no orders for alcohol consumption and Percocet Tablet 10-325 MG (oxycodone-acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain **Administer medication with a full glass of water**. A record review of TULIP on 03/27/2024 revealed an intake on 01/11/2024, reported by an anonymous complainant, revealed My second concern is a situation where a resident #47 is reported for having empty liquor bottles in her room and is known. To be pocketing her Percocet and trading them with a visitor for the liquor. There were no intakes in TULIP reported by the facility from December 2023 to present day involving Resident #47. A record review of Resident #47's nursing note, dated 02/03/2024 at 09:50 PM and authored by LVN AI, revealed, Dayshift CNA notified nurses resident was on the floor after falling. Oncoming nurse entered room to find resident lying on her back sideways across bed. CNA notified nurse patient was assisted back into bed. Resident was assisted with proper repositioning on bed. Appears groggy and eyes with glossy appearance. Disoriented. Laughing when asked what happened and how she fell . CNA answered she slipped on her shoes. Resident stated, yeah I sure did slip on my shoes. Speech slurred. Strong smell of alcohol. Off going nurse in room for verification of this. Bed low, call light in reach. Resident educated on fall precautions and importance of not getting OOB by herself. Encouraged her to call for any assistance needed. Also encouraged use of RW with ambulation. [DON] was notified of unwitnessed fall and patient current symptoms/condition. Attempted to call on call NP/MD for [MD AH] but not able to reach on call. 72-hour neuro checks initiated. A record review of Resident #47's Doctor's Progress Note, dated 02/08/2024 and signed by MD AH, revealed, [Resident #47 had a fall secondary to being inebriated. They state that the family member of another resident is trading [NAME] and alcohol for her percocets. They have tried to stop this. They are aware of the situation and are looking into it . They have searched her room and are trying to get rid of her alcohol. She is allowed to have some wine at night but not to have [NAME] being the hard alcohol and get inebriated. A record review of Resident #47's nursing note, dated 03/20/2024 at 01:15 PM and authored by LVN D, revealed, Several pills found under and next to residents wheelchair, some pills wrapped in Kleenex appearing slightly dissolved. Pills with identifying numbers verified with pills in card of Percocet. [Doctor's group] called and message left requesting a return call. All supervisors notified. During an interview on 03/28/24 at 09:39 AM, Confidential Staff Member AF revealed Resident #47 had an incident where she dropped percocets in a public area. This was reported to her supervisors. She further revealed she made Resident #47 take her medications nurse's desk so the medications dissolve by the time she goes to her room. During an interview on 03/28/24 at 10:48 AM, NP B revealed she was unaware of what family is providing [NAME] to Resident #47. NP B further revealed this incident could have potential for death due to polypharmacy and possible consequences could include sedation, falls, and injuries. 4. Resident #82 A record review of Resident #82's admission record revealed an initial admitted [DATE] with diagnoses which included Alzheimer's disease (degenerative brain disease that causes a gradual decline in memory, thinking, and reasoning skills), dementia (loss of cognitive functioning that interferes with daily life and activities), amnesia (loss of memory), and muscle wasting and atrophy. A record review of Resident #82's annual MDS assessment dated [DATE] revealed Resident #82 had a BIMS of 11 out of 15 indicating moderate mental cognition impairment. A record review of Resident #82's care plan, undated, revealed the following: [Resident #82] has an ADL self-care performance deficit r/t Weakness with interventions that included BATHING/SHOWERING: [Resident #82] requires extensive assistance by (1) staff with bathing/showering [Resident #82] orders items online and has them delivered to facility often. She will refuse to let staff assess what she has ordered. Redirection unsuccessful with intervention of Encourage (Resident #82) to let staff assess items ordered online for safety. Respect her right to refuse, date initiated 03/25/24. During an observation on 03/25/24 at 10:20 AM, there were hair dye components of a [TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 24 residents reviewed for medication storage. 1. The facility failed to store Resident #52's medications which were kept at her bedside which resulted in an incident on 11/22/2023, when she was hospitalized and diagnosed with overdose related to self-medication with Diphenhydramine (an antihistamines; used for relief from symptoms related to hay fever, upper respiratory allergy, or cold symptoms) and hydrocodone (a narcotic analgesic agent for the treatment of moderate to moderately severe pain). An Immediate Jeopardy (IJ) was identified on 03/29/2024. While the IJ was removed on 03/31/2024, the facility remained out of compliance at a scope of pattern with risk for harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place residents at risk for serious harm accidents. The findings included: Resident #52. A record review of Resident #52's admission record revealed an initial admitted [DATE] with diagnoses which included depression, cirrhosis of the liver (permanent scarring that damages your liver and interfere with its functioning), altered mental status, and need for assistance with personal care. A record review of Resident #52's annual MDS assessment dated [DATE] revealed Resident #2 had a BIMS of 06 out of 15 indicating severe mental cognition impairment. A record review of Resident #52's care plan, undated, revealed the following: [Resident #52] is resistive to care at times. Refuses certain medications often . with an intervention Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care., initiated 05/30/2023. [Resident #52] has liver disease [related to] cirrhosis with an intervention Give medications as ordered, initiated 10/04/2022. [Resident #52] uses anti-anxiety medications [related to] Anxiety with an intervention Monitor the resident for safety. The resident is taking ANTI-ANXIETY meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia ., initiated 10/04/2022. A record review of Resident #52's hospital documents, dated 02/19/24, revealed Resident #52 was admitted [DATE] with chief complaint of loss of consciousness. The hospital documents reflected EMS was called and on their arrival, there was note of a large bottle of Benadryl as well as Norco. There was some concern for polypharmacy. The toxicology report on 02/16/2024 at 05:47 PM revealed urine opiates screen was positive. The hospital documents further revealed likely altered mental status secondary to medication effect. A record review or Resident #52's Medication Administration Record for February, dated 03/28/24, revealed Resident #52 did not take Norco Tablet 7.5-325 MG (Give 1 tablet by mouth every 6 hours as needed for pain. Ensure resident drinks full glass of water after medication. Do not exceed 3 grams of acetaminophen in 24 hours) from 02/13/24 to 02/19/24. Acetaminophen-Codeine Tablet 300-30 MG (Give 1 tablet by mouth every 6 hours as needed for Pain. Do not exceed 3Gm of [acetaminophen] in 24-hour period) was last given on 02/15/24 at 06:00 AM and at 02:27 PM. During an interview on 03/27/24 at 05:30 PM, Resident #52 revealed she did not remember why she was in the hospital on 02/16/24. Resident #52 did not remember if she had taken any medications before being hospitalized . Resident #52 revealed a family member brought in the medications but would not disclose who brought them in. She further revealed maybe she was taking Tylenol PM because she was self-medicating. She further revealed she did not know she had to let anyone know what she gets from outside of the facility. She further revealed no staff came in to inspect what she kept in her room. During an interview on 03/28/24 at 12:26 PM, the DON revealed she had asked Resident #52 where she got the medications that were at her bedside on 02/16/2024, but Resident #52 did not want to identify who brought the medications to her. The DON further revealed the facility educated Resident #52's RP to check with the nursing station before bringing anything to the resident. During an interview on 03/28/24 at 01:58 PM, Resident #52's RP revealed he was surprised by the 02/16/24 incident that led the hospitalization of Resident #52. He was told Resident #52 had bottle of Norco. The RP further revealed he did not know he could not bring in some OTC medications like TUMS. He did not know where Resident #52 was receiving the other OTC medications that were at her bedside. The RP was made aware to go through the nursing station when bringing anything to the resident. During an interview on 03/31/24 at 06:49 PM, MD AJ revealed she was aware Resident #52 had medications at her bed side last month. She revealed this would cause Resident #52 to be at risk of overdosing and she could have been given discharge orders due to this incident. She further revealed overdosing could cause hospitalization s. She added having OTC medications like Tylenol could cause liver problems if too much was taken. She further added there was a possibility of death if there was an over intake of opiates. During an interview on 03/28/24 at 12:26 PM the DON stated she and the department heads, including the Administrator, every weekday morning reviewed the previous days documents for all residents to include incident reports, grievance reports, 24-hour reports and all progress notes to include physician and nurse practitioner notes. During an interview on 03/28/24 at 12:38 PM the Administrator was asked if she was aware of resident #52's incident when she was discovered with AMS and pills at the bedside the Administrator stated she was. The administrator was asked if she could share some details about Resident #52; the Administrator stated she did not know much about Resident #52. During an interview on 03/28/2024 at 02:00 PM, the DON stated she had reported to the Administrator Resident #52's incident with altered mental status and need for hospitalization . A record review of an anonymous email to the corporate organization for this facility, provided by Confidential Staff member AF and dated 08/07/2023, revealed, The reason I am writing is because I no longer feel I or any of my other direct care coworkers can safely and confidently provide the care and services our special resident deserve . Our company has allowed agency but due to the cost they have begun cutting back on caregivers . the extent of cutting back is exceeding to the point of promoting unsafe and hazardous practices . I have expressed my concerns to management, I have written letters signed by other staff, I have reached as far as I can to try and resolve this issue with no results . Management is aware of this issue and I have personally witnessed them cover things up to try to consolidate the results of an unreported incident to an already open incident . We have reported unsupervised smoking and consumption of alcohol to management multiple times due to intoxication resulting in falls and cigarette burns to residents who fall asleep smoking. A plan was put into place and an alarm was placed on the doorway to alert staff if someone is going out, however the alarm is constantly disarmed therefore allowing incidents to continue happening. I cannot help but feel as though management does not care . Please help me. I want my residents to be safe, feel safe, and trust they are always being cared for by people who truly care. I don't know what else to do. I do want this complaint to remain anonymous due to fear of retaliation. A record review of the facility's Resident Admission Agreement, revised 10/14/2021, revealed The resident has the right to retain and use personal possessions . unless doing so would infringe upon the rights, health, or safety of other residents. It further revealed prohibited items include smoking or tobacco products, lighters, other smoking paraphernalia or illegal substances. Additions and deletions to the inventory shall be brought to the attention of the facility's administration so that records remain current. The Facility may terminate this Agreement by discharging the Resident in accordance with state and federal law. A record review of the facility's Medication and Disposal policy dated 10/01/19, revealed, Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate for the judgment of the facilities interdisciplinary resident assessment team. Procedure: a written order for the bedside storage of medication is present in the residence medical record. bedside storage of medications is indicated on the resident medication administration record and in the care plan for the appropriate medications. 4 residents who self-administer medications the following conditions are met for bedside storage to occur; the manner of storage prevents access by other residents. lockable drawers or cabinets are required only if unlock storage is deemed inappropriate. facility management should have a copy of the key in addition to the resident. the medications provided to the resident for bedside storage are kept in containers dispensed by the pharmacy or in the original container if a non-prescription medication. the bedside medication record is reviewed on each nursing shift, and the administration information is transferred to the medication administration record kept at the nurse's station. notation of each self-administered dose is made by placing a check mark in the appropriate space and noting in the nursing comments the initials of the nurse who obtained the information from the resident. the resident is instructed in the proper use of bedside medications, including what the medication is for, how it is to be used, how often it is to be used . the completion of this instruction is documented in the residence medical record A record review of the facility's Abuse, Neglect, and Exploitation policy dated 08/15/22, revealed, it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . identification of abuse, neglect and exploitation . the facility will have written procedures to assist staff in identifying the different types of abuse- mental /verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. this includes staff to resident abuse and certain resident to resident altercations. possible indicators of abuse include, but are not limited to: . physical marks such as bruises or patterned appearances such as a handprint, built a ring mark on a resident body, physical injury of a resident, of unknown source . The administrator was given the IJ template and notified of the IJ(Immediate Jeopardy) on 3/29/24 and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 03/30/2024. plan of removal For Those Affected: On 3/29/24, the Licensed Nurse assessed residents # 15 related to consumption of alcohol and Tylenol with Codeine and Methadone. No ill effects noted. Care plan updated 3/30/24 to reflect his behavior with non-compliance with smoking and assumed alcohol consumption while out on pass. Refuses nurse assessment at times. An order was received on 3/27/24, to call the physician if returns from on pass impaired. On 3/29/24, the Licensed Nurse assessed resident #50 related to alcohol consumption and administered Seroquel, Ambien, and Hydrocodone. Not ill effects noted. Care plan updated 3/30/24 to reflect his behavior with non-compliance with smoking and assumed alcohol consumption while out on pass. Refuses nurse assessment at times. On 3/29124, the License Nurse assessed resident #52 related to Altered Mental Status with suspected overmedication. No ill effects were noted. Care plan updated 3/30/24 to reflect to note history of non-compliance re OTC medications. Interventions in place to daily monitoring compliance with not keeping medications at bedside. Interventions included: Resident #52 and RP were re-educated on importance of not having medications at bedside; RP will provide any medications he purchases for resident #52 to the licensed nurse. Staff to monitor daily to ensure no medications are found at bedside. Facility wide monitoring started 3-30-2024 to monitor for any non-compliance for any medications at bedside for all residents. Identify Others Affected: Those with orders allowing out on pass are identified. Those who smoke are identified. Those that have orders for alcohol consumption are identified. Those that self- medicate are identified. Those with Changes in Condition Actions Taken: The Director of Nursing or designee began reeducation for all staff on the following: o Abuse and Neglect o Recognition of Change of Condition including those who are impaired to call physician upon their return to include suspected alcohol consumption. This was completed 3-29- 24 & 3-30-24. o Self-Administration of Medications. No residents currently at facility self-administer medications. o Smoking Policy including Paraphernalia o Policy for Resident Personal Possessions Re-education initiated 3/29/24 and completed on 3/30/24 with all staff. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment. Beginning 3/29/24 and ongoing, newly hired and agency staff will receive this training during orientation prior to providing care to the residents. The training will include the above-stated educational components. On 3/29/24, an Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the plan of removal. Safe Smoking assessments were conducted By ADON'S on 3/30/2024 for all smokers. All paraphernalia must be surrendered by all smokers to the staff upon return from their smoking break and secured on designated cart. If resident assessed as impaired (inebriated), a change of condition will be done, and MD will be notified for further instructions on giving or holding medications. The physician on-call services are available 24/7 and/or Medical Director (or designee). All Licensed Nurses re-educated on resident with orders with alcohol consumption have revisions to reflect amount of alcohol consumed. This was conducted on 3/29/24. Order revision conducted on 3/29/24 to require additional documentation if alcohol is administered. Monitoring: Beginning 3/29/24 and going, The DON/designee will: Monitor that residents with intact cognition are allowed to sign in and out on pass. That residents who smoke do in a designated smoke area and time. Those with orders to go out on pass were re-education to check back with facility upon return and are asked by the Licensed Nurse that they return their smoking paraphernalia. Those that return from out on pass and determined to be impaired, have assessment completed and that the Physician is notified regarding their condition. Staff re-education completed on 3- 29-2024 & 3-30-2024. Required actions such as notifications to MD (or designee), RP, Administrator, DON. Those that Self Administer are doing as physician ordered. Monitoring will be completed per nurse managers Monday thru Friday and by Weekend Supervisor/Designee on weekends to ensure no medications at bed side. When staff administer medications, facility practice is that nurse will stay with resident to ensure medications are swallowed. Media alert sent 3/30/24 to families that all medications brought into facility must be turned into the nurse for proper storage and administration by licensed staff. Plan of Removal Verification For Those Affected: On 3/29/24, the Licensed Nurse assessed residents # 15 related to consumption of alcohol and Tylenol with Codeine and Methadone. No ill effects noted. Care plan updated 3/30/24 to reflect his behavior with non-compliance with smoking and assumed alcohol consumption while out on pass. Refuses nurse assessment at times. Record review of Resident #15's progress note dated 3/29/2024 and written at 8:38 PM by ADON 1 reflected, Resident assessment completed: Resident is alert and oriented, BIMS=15. Resident propels self in w/c. Resident is frequently signing self out on pass and leaving from the facility alone. MD made aware and states resident is safe to go out on pass per self. Resident re-educated to sign RELEASE OF RESPONSIBILITY FOR LEAVE OF ABSENCE form prior to leaving facility and to check back in with facility staff upon return. Record review of Resident #15's progress note, dated 3/29/2024 and written at 9:33 PM by the DON reflected, Call placed to MD and verified order to remain in place for resident to be allowed to be administered (1) 12 oz beer during 2-10 shift, unless resident has gone out on pass or received alcohol beverages. Resident is aware of this order and aware when he goes out on pass, if he appears cognitively or physically impaired, the charge nurse will hold his medication per MD order and notify the MD, DON and administrator. Resident is aware the facility can assist resident with purchasing the alcoholic beverages and the facility will maintain control of these alcohol beverages and will administer them to the resident per MD order. Resident verbalized understanding and agrees with above plan of care. Record review of Resident #15's care plan, dated reflected, [Resident 15] has a behavior problem related to non-compliance with facility policies. [Resident 15] is non-complaint with assumed alcohol consumption while out on pass and refuses nursing to assess upon return at times with date initiated of 3/30/2024 and interventions including, Administer medications as ordered. Monitor/document for side effects and effectiveness.; Anticipate and meet the resident's needs.; Educate [Resident 15] on importance of following facility policies.; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident.; If resident appears cognitively or physically impaired after they return from Out on pass, the charge nurse must complete an assessment and change of condition, and immediately notify the MD, RP, DON and Administrator.; Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed., all with a date initiated of 3/30/2024. Record review of Resident #15's care plan, dated reflected, [Resident 15] has a behavior problem related to non-compliance with facility policies. [Resident 15] is non-complaint with assumed alcohol consumption while out on pass and refuses nursing to assess upon return at times. With intervention, If resident appears cognitively or physically impaired after they return from Out on pass, the charge nurse must complete an assessment and change of condition, and immediately notify the MD, RP, DON and Administrator. With a care plan revision and interventions dated 3/30/2024. Interview on 3/31/2024 at 4:10, the DON stated that if a resident declines an assessment, they document, notify the Physician, RP, DON, and Administrator. An order was received on 3/27/24, to call the physician if returns from on pass impaired. Record review of Resident #15's orders revealed an order with a start date of 3/29/2024 reading, If resident appears cognitively or physically impaired after they return from Out on pass, the charge nurse must complete an assessment and change of condition, and immediately notify the MD, RP, DON and Administrator. Ordered by the Medical Director. Record review of Resident #50's orders revealed an order with a start date of 3/29/2024 reading, If resident appears cognitively or physically impaired after they return from Out on pass, the charge nurse must complete an assessment and change of condition, and immediately notify the MD, RP, DON and Administrator. Ordered by the MD. Interview on 3/31/2024 at 4:08 PM, the DON stated that the expectation is that the nursing staff will call the physician as soon as the impairment is recognized. On 3/29/24, the Licensed Nurse assessed resident #50 related to alcohol consumption and administered Seroquel, Ambien, and Hydrocodone. Not ill effects noted. Care plan updated 3/30/24 to reflect his behavior with non-compliance with smoking and assumed alcohol consumption while out on pass. Refuses nurse assessment at times. Record review of Resident #50's progress note dated 3/29/2024 and written at 8:39 PM by ADON 1 reflected, Resident assessment completed: Resident is alert and oriented, BIMS=15. Resident is ambulatory with walker. Resident is frequently signing self out on pass and leaving from the facility alone. MD made aware and states resident is safe to go out on pass per self. Resident re-educated to sign RELEASE OF RESPONSIBILITY FOR LEAVE OF ABSENCE form prior to leaving facility and to check back in with facility staff upon return. Record review of Resident #50's progress note, dated 3/29/2024 and written at 9:33 PM by the DON reflected, Call placed to MD and verified order to remain in place for resident to be allowed to be administered (1) 12 oz beer during 2-10 shift, unless resident has gone out on pass or received alcohol beverages. Resident is aware of this order and aware when he goes out on pass, if he appears cognitively or physically impaired, the charge nurse will hold his medication per MD order and notify the MD, DON and administrator. Resident is aware the facility can assist resident with purchasing the alcoholic beverages and the facility will maintain control of these alcohol beverages and will administer them to the resident per MD order. Resident verbalized understanding and agrees with above plan of care. Record review of Resident #50's care plan reflected a problem dated 3/30/2024, [Resident #50] has a behavior problem related to non-compliance with facility policies. [Resident #50] is non-complaint with assumed alcohol consumption while out on pass and refuses nursing to assess upon return at times., with interventions including, If resident appears cognitively or physically impaired after they return from Out on pass, the charge nurse must complete an assessment and change of condition, and immediately notify the MD, RP, DON and Administrator. With a care plan revision and intervention date of 3/30/2024. On 3/29124, the License Nurse assessed resident #52 related to Altered Mental Status with suspected overmedication. No ill effects were noted. Care plan updated 3/30/24 to reflect to note history of non-compliance re OTC medications. Interventions in place to daily monitoring compliance with not keeping medications at bedside. Interventions included: Resident #52 and RP were re-educated on importance of not having medications at bedside; RP will provide any medications he purchases for resident #52 to the licensed nurse. Staff to monitor daily to ensure no medications are found at bedside. Record review of Resident #52's progress notes revealed a note written on 3/29/2024 and written at 7:29 PM by ADON 2 revealed, Resident assessment completed; Resident alert, able to voice needs/concerns to staff. VS- 121/77, 75, 17, 98.1, O2 98% RA. Resident denies any pain or discomfort at this time. Able to move all extremities without difficulty and follow commands. BIMS assessment completed, scored 10. This nurse asked resident if she remembered the recent care meeting regarding having OTC medications at bedside, resident stated yes and that she has been compliant and currently has no OTC medications at bedside. Resident laying in bed playing solitaire on cell phone prior to and after assessment. Call light within reach. Will continue with current POC. Record review of Resident #52's care plan revealed a problem of, [Resident #52] has a history of non-compliance regarding facility policies regarding OTC medications. [Resident #52] was found with OTC medication bottles in her room, putting [Resident #52] at risk for polypharmacy and medical complications related to excessive intake of OTC with interventions including, [Resident #52] and RP educated on importance of not having medications at bedside.; RP will provide any medications he purchases for [Resident #52] to the nurse; Staff to monitor to ensure no medications are found at bedside with care plan revision date and intervention dates of 3/30/2024. Interview 3/31/2024 at 4:11 PM, the DON stated that the nurses and nurse management team (DON, ADON, MDS Nurses, and Charge Nurses) will ensure with a form that is being filled out daily for each resident room that there are no prohibited items such as over-the-counter medication, cigarettes, lighters, or any paraphernalia that can be a danger to residents. Facility wide monitoring started 3-30-2024 to monitor for any non-compliance for any medications at bedside for all residents. Record review of document titled, Monitoring F689 revealed a checklist by room number with a requirement to check off and initial that no paraphernalia that could be a danger to residents was observed in the room. Interview on 3/31/2024 at 4:13 PM, the DON stated that the nurse management team to include the DON, ADON, MDS Nurse, and Charge Nurses will monitor by completing a daily form that includes each resident's room to ensure there are no prohibited items such as over-the-counter medication, cigarettes, lighters, or any paraphernalia that can be a danger to residents. The DON further stated that they will complete this monitoring form daily for 30 days, 4 times a week for the following 14 days, and 2 times a week for the 14 days following that. Observation on 3/31/2024 at 5:15 PM revealed the DON inspecting rooms [ROOM NUMBER] for unsafe items. Identify Others Affected: Those with orders allowing out on pass are identified. Interview on 3/31/2024 5:34 PM, the DON stated that the residents listed on the document provided were permitted to go out on pass as ordered. Record review revealed the following residents had orders to be able to be allowed to go out on pass: Resident #48 Resident #15 Resident #50 Resident #21 Resident #18 Resident #62 Resident #92 Those who smoke are identified. A record review of the POR revealed 15 residents were identified as residents who smoke; 1. Resident #50 2. Resident #15 3. Resident #2 4. Resident #62 5. Resident #12 a. During an interview on 03/29/2024 at 04:40 PM resident #12 stated she was educated on smoking safety with supervision and only during the designated smoking times six times a day. 6. Resident #41 7. Resident #49 8. Resident #92 9. Resident #7 10. Resident #31 11. Resident #45 12. Resident #66 13. Resident #13 14. Resident #150 15. Resident #11 Those that have orders for alcohol consumption are identified. Record review revealed Resident #15 and Resident #50 had orders for alcohol consumption. Those that self- medicate are identified. Record review revealed no resident self-medicate. Interview on 3/31/2024 at 4:56 PM, the DON stated that no residents self-administer medications. Those with Changes in Condition During an interview on 03/31/2024 at 04:25 the DON stated all the census had a potential for a change of condition for which all the staff had received in-services for nurses to recognize changes of condition, document, complete the sbar, notify the physician, and notify the don, the representative, the progress notes are auto to the 24-hr report which are reviewed the next morning during the department head meetings which in include the don and the administrator. Actions Taken: The Director of Nursing or designee began reeducation for all staff on the following: o Abuse and Neglect o Recognition of Change of Condition including those who are impaired to call physician upon their return to include suspected alcohol consumption. This was completed 3-29- 24 & 3-30-24. o Self-Administration of Medications. No residents currently at facility self-administer medications. o Smoking Policy including Paraphernalia o Policy for Resident Personal Possessions Re-education initiated 3/29/24 and completed on 3/30/24 with all staff. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment. A record review of the facility's employee roster dated, 03/31/2024 revealed 105 employees. 66% of employees, 69 of the 105, were interviewed to confirm receiving in-services for IJ F689. A record review of the facility's employee roster dated, 03/31/2024 revealed of the 105 employees, 34 were nurses. A sample of 23 nurses, 10 on the 6 am to 2 pm shift, 10 on the 2 pm to 10 pm shift, and 3 (of 3) on the 10 pm to 6 am shift, were interviewed to confirm receiving in-services for IJ F689. A record review of the facility's employee roster dated, 03/31/2024 revealed of the 105 employees 35 were CNAs. A sample of 24 CNAs, 11 on the 6 am to 2 pm shift, 7 on the 2 pm to 10 pm shift, and 6 on the 10 pm to 6 am shift, were interviewed to confirm receiving in-services for IJ F689. Record review of document titled In-service training report, dated 3/28/2024, with the topic Reportable Incidents, ANE Prevention, and Reporting revealed 99 of 105 staff signed off as having completed the in-service. Record review of document titled In-service training report, dated 3/28/2024, with the topic Change in condition revealed 99 of 105 staff signed off as having completed the in-service. Record review of document titled In-service training report, dated 3/29/2024, with the topic Medication Administration revealed 99 of 105 staff signed off as having completed the in-service. Record review of document titled In-service training report, dated 3/29/2024, with the topic Personal Belongings revealed 99 of 105 staff signed off as having completed the in-service. Record review of document titled In-service training report, dated 3/29/2024 and 3/30/2024, with the topic Resident's going out on pass revealed 99 of 105 staff signed off as having completed the in-service. Record review of document titled In-service training report, dated 3/28/2024, with the topic Smoking Policy revealed 99 of 105 staff signed off as having completed the in-service. Record review of document titled In-service training report, dated 3/30/2024, with the topic Alcohol revealed 99 of 105 staff signed off as having completed the in-service. Interview on 3/31/2024 at 12:51 PM, LVN F stated they primarily work from 2 pm until 10 pm, trainings consisted of information relating to residents coming back from pass and doing assessments to ensure they are not incapacitated in any way, and if they are incapacitated or impaired the nurses must do a change in condition and call the physician. She stated they also went over smoking, resident personal items, abuse and neglect, and reporting any abuse and neglect. Interview on 3/31/2024 at 12:55 PM, CNA G stated they primarily work from 6 am until 2 pm, revealed they were in-serviced for reporting abuse and neglect to the administrator, as well as smoking, ensuring residents do not have any dangerous possessions such as lighters, cigarettes, and

Based on interview and record review the facility failed to provide treatment and prevention of [MEDICAL CONDITION] for 1 of 5 Residents (Resident #1) reviewed for quality of care, in that: Resident #1 did not receive 20 of 21 doses of [MEDICATION NAME] tablet 32.4 mg (medication used to control [MEDICAL CONDITION]). As a result, Resident #1 suffered from [MEDICAL CONDITION] and was hospitalized . This deficient practice was determined to be past non-compliance, with an immediate jeopardy situation that began on [DATE] and ended on [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. This deficient practice could place residents who received [MEDICAL CONDITION] medication at risk for not receiving therapeutic treatment and could place them at risk for harm or death. The findings were: Record review of Resident #1's admission record dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's care plan dated [DATE] revealed (Resident #1 had) a [MEDICAL CONDITION] disorder. Interventions: give medications as order. Obtain and monitor lab/diagnostic work as ordered. Report result to MD and follow up as indicated. Record review of Resident #1's physician progress notes [REDACTED]. [MEDICAL CONDITION] disorder: stable on combination of [MEDICATION NAME], and [MEDICATION NAME]. Labs from [DATE] are reasonable and no recent [MEDICAL CONDITION] activity. Record review of Resident #1's progress note dated [DATE] at 7:10 AM written by RN A revealed Resident #1 had [MEDICAL CONDITION] lasted approx. 2 minutes at which point (Resident #1) turned pale white and lips cyanotic and then lost consciousness. Resident #1 was having increased respirations. (Resident #1) was moved to his bed with (head of the bed elevated) and neurological checks started. Vital sign: (blood pressure) ,[DATE], (pulse) 103, (oxygen saturation) 95%, (Respiration)24. (Nurse Practitioner) notified and family notified. Record review of Resident #1's progress note dated [DATE] at 9:41 AM written by RN A revealed (Resident #1 was) lying in bed and this nurse went to check vital sign (and observed Resident #1) had (second) [MEDICAL CONDITION] lasted (approximately) 1.5 minutes at which point Resident #1 color became pale lips cyanotic and Resident #1 loss consciousness. Vital signs: (blood pressure) ,[DATE], (pulse) 107, (oxygen saturation) 96%, (respiration) 24. (Nurse practitioner) notified. Family member notified and wanted Resident#1 to (send) out to ER. (Nurse Practitioner) gave order to send Resident #1 out (per) family member's request. (New order) stat - [MEDICATION NAME] level, [MEDICATION NAME] level, [MEDICATION NAME] level, CBC, CMP. Blood drawn, and pickup ordered. Interview on [DATE] at 4:19 PM with RN A confirmed Resident#1 was up in wheel chair and drinking coffee in the dining room and had [MEDICAL CONDITION]. RN A described Resident #1 had violent [MEDICAL CONDITION], his body clenched and his whole body was stiff. RN A further described Resident #1's tongue stuck out, his bottom denture fell out, his face was pale, his lips were cyanotic. RN A confirmed Resident #1 had [MEDICAL CONDITION] for two and half minutes. When Resident #1's [MEDICAL CONDITION] concluded, RN A with MA E tilted his wheel chair and transported resident back to his room. RN A said she checked Resident #1's vital signs - Resident #1 was non-responsive, breathing was labored, using accessory muscle to breath, and tachypnea (rapid, shallow breathing). RN A confirmed Resident #1 became minimally responsive after [MEDICAL CONDITION] activity - pupils round and slow to react, lung sound clear, tongue swollen, good oxygen saturation level and Resident #1 began stabilizing after [MEDICAL CONDITION] activity. RN A confirmed Resident #1 did not answer her questions, but Resident #1 responded by looking up when RN A called his name. RN A said she remained with Resident #1 for about 10 - 15 minute to ensure Resident #1 was stable. RN A confirmed while she was on the phone with the doctor and family, RN A asked the CNA to observe Resident #1 to watch for signs of [MEDICAL CONDITION] activity. RN A confirmed when CNA was about to check Resident #1's vital signs, Resident#1 had another [MEDICAL CONDITION], and the CNA informed RN A to check on Resident #1. RN A confirmed Resident #1 had [MEDICAL CONDITION] activity. When Resident #1 was stable from his second [MEDICAL CONDITION], she notified the Nurse Practitioner and Resident #1's family. RN A confirmed she received an order to draw Resident #1's blood to check the drug level of [MEDICAL CONDITION] medication and to transfer Resident #1 to local hospital per Nurse Practitioner's order and family request. Record review of Resident #1's diagnostic laboratory dated [DATE] revealed [MEDICATION NAME] level was 6.8 ug/mL which meant the medication was lower than normal therapeutic level (therapeutic range for [MEDICATION NAME] is 15 - 40 ug/mL). During an interview on [DATE] at 5:57 PM with the DON, she confirmed Resident #1's drug levels in July ([MEDICATION NAME], and [MEDICATION NAME]) were all within therapeutic range. The DON further confirmed the drug level of [MEDICATION NAME] was low on [DATE] because Resident #1 did not receive his medication. Record review of resident #1's ambulance record dated [DATE] revealed Nursing staff states (Resident #1) had two [MEDICAL CONDITION] an hour apart from each other. The first [MEDICAL CONDITION] was around 0900 (9:00 AM) followed by another [MEDICAL CONDITION] around 1000 (10:00 AM). (Resident #1 had primary history) of [MEDICAL CONDITION] and takes [MEDICATION NAME] to control [MEDICAL CONDITION]. (Resident #1) received his medication this morning and is compliant with all other medications. (Resident #1) [MEDICAL CONDITION] was reported a grand mal [MEDICATION NAME] ,[DATE] minutes. No trauma noted from [MEDICAL CONDITION]. (Resident #1) was moved to stretcher and secured with all straps and 2 guard rails. (Resident #1) was transported to main local hospital. (Resident #1) had a [MEDICAL CONDITION] while in route to hospital and was placed in right side with airway suctioned for appx 10 seconds to clear secretions. (Resident #1) remained in postictal state (altered state of consciousness after [MEDICAL CONDITION] activity) during transport. Vital signs were continuously monitored and stable. Arrived to destination and (Resident #1) care released to receiving RN. Record review of Resident #1's physician order [REDACTED]. (G40.509) Start date [DATE]. Record review of Resident #1's narcotic sheet titled individual control drug record dated from [DATE] to 8/ ,[DATE] revealed [MEDICATION NAME] 32.4 mg give 1 tablet by mouth 3 times a day was completed on [DATE] at 2000 (8:00 PM) with 0 amount remaining. Record review of Resident #1's medication administration record dated [DATE] - [DATE] revealed administration schedule for [MEDICATION NAME] tablet 32.4 mg at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM). Further review revealed the medication scheduled at 0800 (8:00 AM) and 1400 (2:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 0800 (8:00 AM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM) on [DATE] was coded 5 - hold/see progress notes and coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 2000 (8:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 0800 (8:00 AM) and 1400 (2:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 1400 (2:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered. Record review of Resident #1's progress note dated on [DATE] at 8:59 AM written by MA B revealed [MEDICATION NAME] Tablet 32.4 MG Give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) in progress. Record review of Resident #1's progress note dated on [DATE] at 8:21 PM written by MA B revealed [MEDICATION NAME] Tablet 32.4 MG Give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) in progress. During an interview on [DATE] at 1:37 PM with MA B, he confirmed he did not administer [MEDICATION NAME] 32.4 mg for Resident #1 on [DATE] scheduled at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM), on [DATE] scheduled at 2000 (8:00 PM), and on [DATE] at 2000 (8:00 PM) because the medication was out of supply. MA B stated he made mistakes to document with check marks on Resident #1's MAR on [DATE] at 2000 (8:00 PM) and [DATE] at 2000 (8:00 PM) as administering the [MEDICATION NAME] 32.4 mg, and MA B said he should have coded as 9 on Resident #1's MAR and documented under progress note that the medication was still in process to deliver. During the interview with MA B, he confirmed he informed RN A and LVN I the [MEDICATION NAME] for Resident #1 was out of supply. MA B said he wrote the information down on a Post-It note and gave it to the nurses so that the nurses would call the pharmacy to refill the medication. MA B further confirmed he did not follow up with the nurses or inform the DON about the [MEDICATION NAME] for Resident #1 being out of supply because he did not work all the time in the East unit where Resident #1 resided. He stated he mainly worked in West unit. During an interview on [DATE] at 10:11 AM, RN A confirmed she did not recall if a medication aide informed her about the [MEDICATION NAME] for Resident #1 being completely out of supply. RN A confirmed when there was no [MEDICAL CONDITION] medication to administer for any Resident, she monitored if the Resident had any sign and symptom of [MEDICAL CONDITION]. RN A confirmed she received in-service and understood if the medication was out of supply, the medication aide had to inform the charge nurse, charge nurse would call pharmacy to make sure the medication was delivered, and if the medication aide was about to document the medication was not available to administer, and pharmacy had not delivered the medication, then charge nurse had to inform the ADON or DON. RN A confirmed she did not recall if she informed the ADON and DON about the [MEDICATION NAME] being not available to administer to Resident #1. RN A confirmed when the medication was not available to give to any resident, she would call the physician when she needed a new prescription to refill or authorization paperwork. RN also confirmed she would call physician if the medication for the resident was not available and resident had symptoms. RN confirmed she did not call the physician when the medication for any resident was completely out because she could resolve with the pharmacy. Record review of Resident #1's progress note dated [DATE] at 10:20 AM written by MA C revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (g40.509) Medication on order. Record review of Resident #1's progress note dated [DATE] at 8:24 PM written by MA C revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (g40.509) Medication on order. Interview via telephone on [DATE] at 5:59 PM with MA C confirmed he did not administer [MEDICATION NAME] 32.4 mg for Resident #1 on [DATE] scheduled at 0800 (8:00 AM) and 1400 (2:00 PM) and on [DATE] scheduled at 2000 (8:00 PM) because the medication was out of supply. MA C further confirmed he made an error when he documented on Resident #1's MAR that he administered the [MEDICATION NAME] 32.4 mg, but the medication was not available to give. MA C stated he wrote Resident #1's name and medication on a piece of paper and gave to the nurse, and the nurse would call pharmacy to refill. MA C said he did not remember which nurse he gave the information to. Record review of Resident #1's progress note dated [DATE] at 5:42 AM written by MA D revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) pending delivery. Interview via telephone on [DATE] at 11:00 AM with MA D confirmed the [MEDICATION NAME] 32.4 mg was not available to administered for Resident #1 on [DATE] scheduled at 0800 (8:00 AM) and 1400 (2:00 PM). MA D confirmed she informed LVN H about the [MEDICATION NAME] for Resident #1 was out of supply, and she saw LVN H call the pharmacy to refilled Resident #1's [MEDICATION NAME]. MA D confirmed she did not inform the ADON or DON when Resident #1's [MEDICATION NAME] was out of supply because she assumed LVN H informed ADON or DON during clinical meeting. Record review of Resident #1's progress note dated on [DATE] at 8:05 AM written by MA E revealed [MEDICATION NAME] Tablet 32.4 MG Give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509). Pending medication from pharmacy. Record review of Resident #1's progress note dated on [DATE] at 1:11 PM written by MA E revealed [MEDICATION NAME] Tablet 32.4 MG Give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509). Pending medication from pharmacy, notified charge nurse. During an interview on [DATE] at 3:05 PM with MA E, she confirmed she did not administer [MEDICATION NAME] 32.4 mg for Resident #1 on [DATE] scheduled at 0800 (8:00 AM) and 1400 (2:00 PM) because there was no medication to give and the medication was pending delivery from pharmacy. MA E confirmed she informed LVN H that Resident #1's [MEDICATION NAME] was not available to administer. Record review of Resident #1's progress note dated [DATE] at 9:47 PM written by MA F revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) on order. Record review of Resident #1's progress note date [DATE] at 11:20 AM written by MA G revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) Pending from pharmacy. Record review of Resident #1's progress note date [DATE] at 1:09 PM written by MA G revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) Pending from pharmacy. Record review of Resident #1's progress note date [DATE] at 1:52 PM by MA G revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) Pending from pharmacy. Interview via telephone on [DATE] at 11:43 AM with MA G confirmed the [MEDICATION NAME] for Resident #1 was out of supplies for couple days. MA G stated she did not remember what date the medication was not available to give to Resident #1. MA G confirmed she recalled the [MEDICATION NAME] was out of supply, and she informed LVN H. Interview via telephone on [DATE] at 1:06 PM with LVN H confirmed the medication aide informed her on [DATE] about the [MEDICATION NAME] for Resident #1 needing refill. LVN H stated she did not recall the [MEDICATION NAME] was low on supply or completely out of supply. LVN H stated she called the pharmacy and pharmacy said they would get the medication out to the facility. LVN H stated she did not remember what date the [MEDICATION NAME] was not delivered, prior to her calling pharmacy again. LVN H said when she called pharmacy the second time, pharmacy informed they need the physician's prescription to refill the [MEDICATION NAME] for Resident #1. LVN H explained when the pharmacy need refill prescription or authorization, pharmacy communicated with a nurse manager via email instead of informing the floor nurse, so the floor nurse only knew if the pharmacy need refilled prescription or authorization when the floor nurse called pharmacy to ask about why the medication had not been delivered. LVN H said she went to physician website to fill out a form to request refill for [MEDICATION NAME]. LVN H confirmed she did not remember what date she completed the request form for refill of the [MEDICATION NAME] for Resident #1. LVN H added when the physician signed the refilled request form, the physician would send the prescription refill to the pharmacy. LVN H further confirmed she did not remember when the [MEDICATION NAME] was delivered to the facility. LVN H confirmed she did not call the doctor or inform the ADON or DON about the [MEDICATION NAME] that was out of supply because she just kept following up with the pharmacy. Interview on [DATE] at 1:59 PM with LVN I confirmed MA F informed her on [DATE] that the [MEDICATION NAME] for Resident #1 was out of supply. LVN I confirmed she completed a request form and faxed to physician office to inform the physician that the medication was out of supply and needed refill. LVN I confirmed the [MEDICATION NAME] was delivered on [DATE] around 2:30 PM. LVN I confirmed there was no communication from the previous shift about the [MEDICATION NAME] for Resident #1 being out of supply. LVN I confirmed she did not inform the DON or ADON regarding the [MEDICATION NAME] being out of supply for Resident #1. Interview on [DATE] at 5:18 PM with the Administrator confirmed she was not aware of the [MEDICATION NAME] for Resident #1 ran out. The Administrator further confirmed medication aide and charge nurse should have informed the Administrator about Resident #1's [MEDICATION NAME] was out of supply. During an interview on [DATE] at 5:49 PM with the DON, she confirmed she was not aware of the [MEDICATION NAME] for Resident #1 was out of supply until Resident #1's family member brought it to her attention on [DATE] because Resident #1 called to inform his family member. The DON further confirmed based on the documentation on Resident #1's MAR, the [MEDICATION NAME] was not administered to Resident #1 from [DATE] at 0800 through [DATE] at 1400. During an interview on [DATE] at 6:18 PM, the DON confirmed the medication aid should check the medication cart by going over each blister pack to ensure the medication availability at minimum for 3 days. If the medication was not available, the medication aide had to notify the charge nurse, then, charge nurse should have notified the physician. The DON further confirmed depending on certain medication, the physician could put the medication on hold for 2 days. The DON stated the charge nurse should have informed the DON so that the DON could order the [MEDICATION NAME] from a contracted emergency pharmacy for 2 - 3 days supplies for Resident #1. Interview on [DATE] at 6:54 PM with the DON confirmed [DATE] was delivery date indicated on three blister packs - [MEDICATION NAME] 32.4 mg for Resident #1. Interview on [DATE] at 6:55 PM with the DON and RN J - ADON confirmed staff did not inform them when the [MEDICATION NAME] for Resident #1 was out of supply. Interview on [DATE] at 2:22 PM with RN J confirmed she did not know the supply of [MEDICATION NAME] for Resident #1 was low. RN J - ADON confirmed the nurse and medication aide on the East side did not communicate with the RN J ADON regarding Resident #1's [MEDICATION NAME] was not available. RN J ADON further confirmed she did not audit the medication cart on East unit and did not check the fax for reordering medication on East unit to ensure enough medication supply for Resident #1. Interview on [DATE] at 4:16 PM with the DON confirmed she did not review the shift report on Resident #1 from [DATE] to [DATE] because she was off work on [DATE] and she assisted state surveyor on [DATE] and [DATE], therefore, she did not see the documentation of medication aide on the [MEDICATION NAME] not available for Resident #1. Interview on [DATE] at 5:21 PM with the Administrator confirmed there was a lack of communication between the facility and the pharmacy. The Administrator confirmed the facility did not call pharmacy, pharmacy did not let the facility know the order refill request was needed, and staff did not inform the administrator or DON about Resident #1 was out of [MEDICATION NAME]. The Administrator confirmed [DATE] was the date when the facility faxed the refill order form to the pharmacy, and pharmacy received refill order on [DATE]. The Administrator said the physician office could not provide any log to show when the facility notified the physician office to get refill order request. The Administrator also said she did not know when pharmacy contacted physician regarding refill order request for Resident #1's [MEDICATION NAME]. Record review of fax confirmation titled Refill Reorder Form dated [DATE] revealed Resident #1's name and [MEDICATION NAME] 32.4 mg was faxed to pharmacy on [DATE] at 2:20 PM. Record review of Electronic Order Status Inquiry for Resident #1 dated [DATE] revealed This prescription ([MEDICATION NAME] tablet 32.4 mg) has been electronically signed. Facility/provider sent [DATE]. Message broker received [DATE] 06:06 PM. Interview on [DATE] at 4:07 PM with pharmacy general manager confirmed if nursing facility call and request stat order (immediately/urgent order) for the [MEDICATION NAME], the pharmacy would delivery medication within ,[DATE] hours. Record review of the facility's undated policy titled Medication ordering: Operating and monitoring system revealed To ensure all medications, pursuant to a valid physician order, are available in the facility at all times . Nursing should be ordering meds when they are down to 5 - 7 days' supply. Nursing must identify refill is in facility when they are down to 3 days' supply. Nursing must identify refill is in facility when they are down to 3-day supply and place refill card in med cart. Nursing must indicate any change of direction to pharmacy on reorder sheet. All incidents of meds not available during med pass should be reported to DON immediately. Monitoring: nurse management should verify all nurses have been in-serviced on med order/reorder system. Re-order book should be audited on daily basis to verify all med orders can be accounted for. Med carts should be audited on a weekly basis to verify no less than 3-day supply of med are available. It was determined these failures placed Resident #1 in an immediate Jeopardy (IJ) situation from [DATE] to [DATE]. The facility took the following action to correct the non-compliance from [DATE] through [DATE]: - Weekly medication cart audits to be completed by DON/ADON to assure medication availability, medication labeled correctly, no expired medication on cart and identify any issues. - Each day a medication audit report pulled to include 9 to identify medication not given for reason and follow-up immediately. - [DATE] an in-service on medication availability to guarantee to have a minimum 3 days of medication available at all times. Also completed in-service if medication is not on cart after order to bring awareness to the ADON/DON immediately. - Communication form to be completed by charge nurse with medication availability follow up: resident name, medication, issue, follow-up and corrective action taken. This form is to be reviewed daily by DON/ADON. Observation on [DATE] at 6:54 AM with the DON revealed there were three blister packs (30 tablets/blister pack) of [MEDICATION NAME] 32.4 mg for Resident #1 dated [DATE] in the narcotic locked box. Further observation revealed one tablet was taken out from one of the blister packs. Interview with the DON on [DATE] at 6:54 PM confirmed the date of [DATE] on the blister pack of [MEDICATION NAME] 32.4 mg for Resident #1 was the date the medication was delivered. Record review of Resident #1's narcotic sheet titled individual control drug record dated [DATE] revealed [MEDICATION NAME] 32.4 mg give 1 tablet by mouth 3 times a day was administered the first dose for Resident #1 at 2000 on [DATE] with amount remaining 89 of 90 tablets of [MEDICATION NAME] 32.4 mg. Interview on [DATE] 12:19 PM with MA F confirmed she administered the evening dose of [MEDICATION NAME] to Resident #1 on [DATE]. MA F further confirmed she received supplies of 90 pills and punch out one pill for Resident #1's evening dose. Record review of Medication Administration Record of Resident #2, #3, #4 and #5 revealed they did not miss any dose of their [MEDICAL CONDITION] medication from [DATE] through [DATE]. Observation of medication administration on [DATE] at 3:36 PM revealed RN A administered the [MEDICATION NAME] to Resident #2 via feeding tube as physician order. Interview on [DATE] at 10:11 AM with RN A confirmed she received and understood in-service on ordering medication. RN A stated if the medication was out of supply the medication aide had to inform the charge nurse, charge nurse would call pharmacy to make sure the medication was delivered, and if the medication was not delivered by the next day to document the medication was not available on the MAR and indicate pharmacy had not delivered the medication. Then charge nurse had to inform the ADON or DON. Interview on [DATE] at 11:17 AM with MA D confirmed she received and in-service on ordering medication on [DATE]. MA D further confirmed she had to inform the charge nurse to call pharmacy for medication refill when there were 3 to 4-day supplies. MA D stated when the medication was out of supply, she had to notify the ADON or ADON. Interviews with 7 interviewable Residents on [DATE], they confirmed they had not missed any dose of medication recently. Interview on [DATE] at 2:25 PM with RN J - ADON, she confirmed providing in-service for charge nurses and medication aides regarding there was a binder in place for any communication that staff had with pharmacy. RN J - ADON confirmed there would be a communication form for medication aide, charge nurse, and ADON to initial daily to hold accountable for resident medication supply. RN J - ADON confirmed she also trained new hire or temporary staff the same process and protocol for obtaining medication and ensure enough medication supply for residents in the facility. RN ADON confirmed she had to ensure with staff what had been ordered, what pending delivery, and make sure the communication log matched the pharmacy log. RN ADON confirmed when the medication was out of supply, staff had to notify the physician immediately and would order the medication through emergency pharmacy. RN ADON confirmed in-service staff once a month to ensure staff know what to do when the medication was not available to administer for resident. RN ADON confirmed she would randomly pick staff and ask question to test their knowledge on obtaining and re-ordering medication for resident. Interview on [DATE] at 4:27 PM with the DON, she confirmed she would continue checking with staff during clinical meeting to ensure medications available for residents. The DON confirmed she continued in-service staff regarding ordering medication in timely manner, if medication was not available staff should check the emergency kit and immediately contact pharmacy to follow up on the medication delivery. The DON confirmed every medication aide and nurse had her phone number, so they could contact the DON any time regarding the medication supply for residents. The DON confirmed communication form utilized to ensure communication among staff to obtain the medication for resident in timely manner. The DON confirmed she and the ADON would monitor the communication form and make sure any issue resolved during the shift. The DON further confirmed she would make rounds and ask staff on the floor if there was any issue with medication supply for residents to ensure staff knew what they were supposed to do. Interview on [DATE] at 4:38 PM with the DON confirmed she would continue to provide staff with in-service and competence check off regarding ordering the medication and administering medication. The DON confirmed there was a test for staff to complete to ensure staff understanding the in-service and training. Interview on [DATE] at 4:39 PM with the DON confirmed she would document any finding or concern with the current interventions, check if the system needed to be improved, continued with nurse competency for 90 days or more. DON further confirmed medication cart audits continued to see if there was anything wrong and ensure there was no gap in the process of obtaining medication for Resident. The DON confirmed Resident #1's incident regarding missed doses of [MEDICATION NAME] would be discussed in QAPI meeting to prevent happening again. Interview on [DATE] at 4:41 PM with the DON confirmed she ensured staff utilized communication board and shift change report to communicate among staff to make sure medication available for residents. Interview on [DATE] at 5:28 PM with the Administrator confirmed to prevent Residents' medications out of supply, staff were required to notify the Administrator or DON if the medication ran lower than 3-day supply, utilize communication form among staff, ask staff during clinical meeting need to ensure medication enough for resident; audit medication cart and medication once a week. Interview on [DATE] at 5:39 PM the Administrator confirmed the incident of Resident #1 would be discussed in QAPI meeting every month until the facility saw the improvements. The Administrator further confirmed new hire would have to go through all training from abuse/neglect and orientation on acquiring medication before working on the floor.

Based on interview and record review, the facility failed to implement policies and procedures that prevent neglect for 1 of 5 Residents (Resident #1) whose care was reviewed for neglect, in that: The facility failed to implement their neglect policy that assured residents were free from neglect by having the structures and processes in place to provide needed medications for Resident #1. As a result, Resident #1 missed 20 of 21 doses of [MEDICATION NAME] tablet 32.4 mg (medication was used to control [MEDICAL CONDITION]), suffered from [MEDICAL CONDITION], and was hospitalized . This deficient practice was determined to be past non-compliance, with an immediate jeopardy situation that began on [DATE] and ended on [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. This deficient practice could place residents who received [MEDICAL CONDITION] medication at risk for not receiving therapeutic treatment and could place them at risk for for physical harm, pain, mental anguish, emotional distress or death. The findings were: Record review of the facility policy titled with Abuse prevention program dated ,[DATE] revealed Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Further review revealed the policy did not have definition of neglect. Record review of Resident #1's admission record dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's care plan dated [DATE] revealed (Resident #1 had) a [MEDICAL CONDITION] disorder. Interventions: give medications as order. Obtain and monitor lab/diagnostic work as ordered. Report result to MD and follow up as indicated. Record review of Resident #1's physician progress notes [REDACTED]. [MEDICAL CONDITION] disorder: stable on combination of [MEDICATION NAME], and [MEDICATION NAME]. Labs from [DATE] are reasonable and no recent [MEDICAL CONDITION] activity. Record review of Resident #1's progress note dated [DATE] at 7:10 AM written by RN A revealed Resident #1 had [MEDICAL CONDITION] lasted approx. 2 minutes at which point (Resident #1) turned pale white and lips cyanotic and then lost consciousness. Resident #1 was having increased respirations. (Resident #1) was moved to his bed with (head of the bed elevated) and neurological checks started. Vital sign: (blood pressure) ,[DATE], (pulse) 103, (oxygen saturation) 95%, (Respiration)24. (Nurse Practitioner) notified and family notified. Record review of Resident #1's progress note dated [DATE] at 9:41 AM written by RN A revealed (Resident #1 was) lying in bed and this nurse went to check vital sign (and observed Resident #1) had (second) [MEDICAL CONDITION] lasted (approximately) 1.5 minutes at which point Resident #1 color became pale lips cyanotic and Resident #1 loss consciousness. Vital sings: (blood pressure) ,[DATE], (pulse) 107, (oxygen saturation) 96%, (respiration) 24. (Nurse practitioner) notified. Family member notified and wanted Resident#1 to (send) out to ER. (Nurse Practitioner) gave order to send Resident #1 out (per) family member's request. (New order) stat - [MEDICATION NAME] level, [MEDICATION NAME] level, [MEDICATION NAME] level, CBC, CMP. Blood drawn, and pickup ordered. Interview on [DATE] at 4:19 PM with RN A confirmed Resident#1 was up in wheel chair and drinking coffee in the dining room and had [MEDICAL CONDITION]. RN A described Resident #1 had violent [MEDICAL CONDITION], his body clenched and his whole body was stiff. RN A further described Resident #1's tongue stuck out, his bottom denture fell out, his face was pale, his lips were cyanotic. RN A confirmed Resident #1 had [MEDICAL CONDITION] for two and half minutes. When Resident #1's [MEDICAL CONDITION] concluded, RN A with MA E tilted his wheel chair and transported resident back to his room. RN A said she checked Resident #1's vital signs - Resident #1 was non-responsive, breathing was labored, using accessory muscle to breath, and tachypnea (rapid, shallow breathing). RN A confirmed Resident #1 became minimally responsive after [MEDICAL CONDITION] activity - pupils round and slow to react, lung sound clear, tongue swollen, good oxygen saturation level and Resident #1 began stabilizing after [MEDICAL CONDITION] activity. RN A confirmed Resident #1 did not answer her questions, but Resident #1 responded by looking up when RN A called his name. RN A said she remained with Resident #1 for about 10 - 15 minute to ensure Resident #1 was stable. RN A confirmed while she was on the phone with the doctor and family, RN A asked the CNA to observe Resident #1 to watch for signs of [MEDICAL CONDITION] activity. RN A confirmed when CNA was about to check Resident #1's vital signs, Resident#1 had another [MEDICAL CONDITION], and the CNA informed RN A to check on Resident #1. RN A confirmed Resident #1 had [MEDICAL CONDITION] activity. When Resident #1 was stable from his second [MEDICAL CONDITION], she notified the Nurse Practitioner and Resident #1's family. RN A confirmed she received an order to draw Resident #1's blood to check the drug level of [MEDICAL CONDITION] medication and to transfer Resident #1 to local hospital per Nurse Practitioner's order and family request. Record review of Resident #1's diagnostic laboratory dated [DATE] revealed [MEDICATION NAME] level was 6.8 ug/mL which meant the medication was lower than normal therapeutic level (therapeutic range for [MEDICATION NAME] is 15 - 40 ug/mL). During an interview on [DATE] at 5:57 PM with the DON, she confirmed Resident #1's drug levels in July ([MEDICATION NAME], and [MEDICATION NAME]) were all within therapeutic range. The DON further confirmed the drug level of [MEDICATION NAME] was low on [DATE] because Resident #1 did not receive his medication. Record review of resident #1's ambulance record dated [DATE] revealed Nursing staff states (Resident #1) had two [MEDICAL CONDITION] an hour apart from each other. The first [MEDICAL CONDITION] was around 0900 (9:00 AM) followed by another [MEDICAL CONDITION] around 1000 (10:00 AM). (Resident #1 had primary history) of [MEDICAL CONDITION] and takes [MEDICATION NAME] to control [MEDICAL CONDITION]. (Resident #1) received his medication this morning and is compliant with all other medications. (Resident #1) [MEDICAL CONDITION] was reported a grand mal [MEDICATION NAME] ,[DATE] minutes. No trauma noted from [MEDICAL CONDITION]. (Resident #1) was moved to stretcher and secured with all straps and 2 guard rails. (Resident #1) was transported to main local hospital. (Resident #1) had a [MEDICAL CONDITION] while in route to hospital and was placed in right side with airway suctioned for appx 10 seconds to clear secretions. (Resident #1) remained in postictal state (altered state of consciousness after [MEDICAL CONDITION] activity) during transport. Vital signs were continuously monitored and stable. Arrived to destination and (Resident #1) care released to receiving RN. Record review of Resident #1's physician order dated [DATE] revealed an order of [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times per day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable (not easily controlled or managed), without [DIAGNOSES REDACTED]. (G40.509) Start date [DATE]. Record review of Resident #1's narcotic sheet titled individual control drug record dated from [DATE] to 8/ ,[DATE] revealed [MEDICATION NAME] 32.4 mg give 1 tablet by mouth 3 times a day was completed on [DATE] at 2000 (8:00 PM) with 0 amount remaining. Record review of Resident #1's medication administration record dated [DATE] - [DATE] revealed administration schedule for [MEDICATION NAME] tablet 32.4 mg at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM). Further review revealed the medication scheduled at 0800 (8:00 AM) and 1400 (2:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 0800 (8:00 AM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM) on [DATE] was coded 5 - hold/see progress notes and coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 2000 (8:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 0800 (8:00 AM) and 1400 (2:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 1400 (2:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered. Record review of Resident #1's progress note dated on [DATE] at 8:59 AM written by MA B revealed [MEDICATION NAME] Tablet 32.4 MG Give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) in progress. Record review of Resident #1's progress note dated on [DATE] at 8:21 PM written by MA B revealed [MEDICATION NAME] Tablet 32.4 MG Give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) in progress. During an interview on [DATE] at 1:37 PM with MA B, he confirmed he did not administer [MEDICATION NAME] 32.4 mg for Resident #1 on [DATE] scheduled at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM), on [DATE] scheduled at 2000 (8:00 PM), and on [DATE] at 2000 (8:00 PM) because the medication was out of supply. MA B stated he made mistakes to document with check marks on Resident #1's MAR on [DATE] at 2000 (8:00 PM) and [DATE] at 2000 (8:00 PM) as administering the [MEDICATION NAME] 32.4 mg, and MA B said he should have coded as 9 on Resident #1's MAR and documented under progress note that the medication was still in process to deliver. During the interview with MA B, he confirmed he informed RN A and LVN I the [MEDICATION NAME] for Resident #1 was out of supply. MA B said he wrote the information down on a Post-It note and gave it to the nurses so that the nurses would call the pharmacy to refill the medication. MA B further confirmed he did not follow up with the nurses or inform the DON about the [MEDICATION NAME] for Resident #1 being out of supply because he did not work all the time in the East unit where Resident #1 resided. He stated he mainly worked in West unit. During an interview on [DATE] at 10:11 AM, RN A confirmed she did not recall if a medication aide informed her about the [MEDICATION NAME] for Resident #1 being completely out of supply. RN A confirmed when there was no [MEDICAL CONDITION] medication to administer for any Resident, she monitored if the Resident had any sign and symptom of [MEDICAL CONDITION]. RN A confirmed she received in-service and understood if the medication was out of supply, the medication aide had to inform the charge nurse, charge nurse would call pharmacy to make sure the medication was delivered, and if the medication aide was about to document the medication was not available to administer, and pharmacy had not delivered the medication, then charge nurse had to inform the ADON or DON. RN A confirmed she did not recall if she informed the ADON and DON about the [MEDICATION NAME] being not available to administer to Resident #1. RN A confirmed when the medication was not available to give to any resident, she would call the physician when she needed a new prescription to refill or authorization paperwork. RN also confirmed she would call physician if the medication for the resident was not available and resident had symptoms. RN confirmed she did not call the physician when the medication for any resident was completely out because she could resolve with the pharmacy. Record review of Resident #1's progress note dated [DATE] at 10:20 AM written by MA C revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (g40.509) Medication on order. Record review of Resident #1's progress note dated [DATE] at 8:24 PM written by MA C revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (g40.509) Medication on order. Interview via telephone on [DATE] at 5:59 PM with MA C confirmed he did not administer [MEDICATION NAME] 32.4 mg for Resident #1 on [DATE] scheduled at 0800 (8:00 AM) and 1400 (2:00 PM) and on [DATE] scheduled at 2000 (8:00 PM) because the medication was out of supply. MA C further confirmed he made an error when he documented on Resident #1's MAR that he administered the [MEDICATION NAME] 32.4 mg, but the medication was not available to give. MA C stated he wrote Resident #1's name and medication on a piece of paper and gave to the nurse, and the nurse would call pharmacy to refill. MA C said he did not remember which nurse he gave the information to. Record review of Resident #1's progress note dated [DATE] at 5:42 AM written by MA D revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) pending delivery. Interview via telephone on [DATE] at 11:00 AM with MA D confirmed the [MEDICATION NAME] 32.4 mg was not available to administered for Resident #1 on [DATE] scheduled at 0800 (8:00 AM) and 1400 (2:00 PM). MA D confirmed she informed LVN H about the [MEDICATION NAME] for Resident #1 was out of supply, and she saw LVN H call the pharmacy to refilled Resident #1's [MEDICATION NAME]. MA D confirmed she did not inform the ADON or DON when Resident #1's [MEDICATION NAME] was out of supply because she assumed LVN H informed ADON or DON during clinical meeting. Record review of Resident #1's progress note dated on [DATE] at 8:05 AM written by MA E revealed [MEDICATION NAME] Tablet 32.4 MG Give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509). Pending medication from pharmacy. Record review of Resident #1's progress note dated on [DATE] at 1:11 PM written by MA E revealed [MEDICATION NAME] Tablet 32.4 MG Give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509). Pending medication from pharmacy, notified charge nurse. Interview on [DATE] at 3:05 PM with MA E, she confirmed she did not administer [MEDICATION NAME] 32.4 mg for Resident #1 on [DATE] scheduled at 0800 (8:00 AM) and 1400 (2:00 PM) because there was no medication to give and the medication was pending delivery from pharmacy. MA E confirmed she informed LVN H that Resident #1's [MEDICATION NAME] was not available to administer. Record review of Resident #1's progress note dated [DATE] at 9:47 PM written by MA F revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) on order. Record review of Resident #1's progress note date [DATE] at 11:20 AM written by MA G revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) Pending from pharmacy. Record review of Resident #1's progress note date [DATE] at 1:09 PM written by MA G revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) Pending from pharmacy. Record review of Resident #1's progress note date [DATE] at 1:52 PM by MA G revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) Pending from pharmacy. Interview via telephone on [DATE] at 11:43 AM with MA G confirmed the [MEDICATION NAME] for Resident #1 was out of supplies for couple days. MA G stated she did not remember what date the medication was not available to give to Resident #1. MA G confirmed she recalled the [MEDICATION NAME] was out of supply, and she informed LVN H. Interview via telephone on [DATE] at 1:06 PM with LVN H confirmed the medication aide informed her on [DATE] about the [MEDICATION NAME] for Resident #1 needed to refill. LVN H stated she did not recall the [MEDICATION NAME] was low on supply or completely out of supply. LVN H stated she called the pharmacy and pharmacy said they would get the medication out to the facility. LVN H stated she did not remember what date when the [MEDICATION NAME] was not delivered, and she called pharmacy again. LVN H said when she called pharmacy on the second time, pharmacy informed they need the physician's prescription to refill the [MEDICATION NAME] for Resident #1. LVN H explained when the pharmacy need refill prescription or authorization, pharmacy communicated with nurse manager via email instead of informing the floor nurse, so the floor nurse only know if the pharmacy need refilled prescription or authorization when the floor nurse called pharmacy to ask why the medication had not been delivery. LVN H said she went to physician website to fill out a form to request refill for [MEDICATION NAME]. LVN H confirmed she did not remember what date she complete the request form for refill the [MEDICATION NAME] for Resident #1. LVN H added when the physician signed the refilled request form, the physician would send the prescription refill to the pharmacy. LVN H further confirmed she did not remember when the [MEDICATION NAME] was delivered to the facility. LVN H confirmed she did not call the doctor or inform the ADON or DON about the [MEDICATION NAME] that was out of supply because she just kept following up with the pharmacy. Interview on [DATE] at 1:59 PM with LVN I confirmed MA F informed her on [DATE] that the [MEDICATION NAME] for Resident #1 was out of supply. LVN I confirmed she filled a request form and fax to physician office to inform the physician that the medication was out of supply and need to refill. LVN I confirmed the [MEDICATION NAME] was delivered on [DATE] around 2:30 PM. LVN I confirmed there was no communication from the previous shift about the [MEDICATION NAME] for Resident #1 was out of supply. LVN I confirmed she did not inform the DON or ADON regarding the [MEDICATION NAME] was out of supply for Resident #1. Interview on [DATE] at 5:18 PM with the Administrator confirmed she was not aware of the [MEDICATION NAME] for Resident #1 ran out. The Administrator further confirmed medication aide and charge nurse should have informed the Administrator about Resident #1's [MEDICATION NAME] was out of supply. During an interview on [DATE] at 5:49 PM with the DON, she confirmed she was not aware of the [MEDICATION NAME] for Resident #1 was out of supply until Resident #1's family member brought it to her attention on [DATE] because Resident #1 called to inform his family member. The DON further confirmed based on the documentation on Resident #1's MAR, the [MEDICATION NAME] was not administered to Resident #1 from [DATE] at 0800 through [DATE] at 1400. Interview on [DATE] at 6:18 PM with the DON confirmed the medication aid should check the medication cart by going over each blister pack to ensure the medication availability at minimum for 3 days. If the medication not available, the mediation aide had to notify the charge nurse, then, charge nurse should have notified the physician. The DON further confirmed depend on certain medication, the physician could put the medication on hold for 2 days. The DON stated charge nurse should have informed the DON so that the DON could order the [MEDICATION NAME] from a contracted emergency pharmacy for 2 - 3 days supplies for Resident #1. Interview on [DATE] at 6:54 PM with the DON confirmed [DATE] was delivery date indicated on three blister packs - [MEDICATION NAME] 32.4 mg for Resident #1. Interview on [DATE] at 6:55 PM with the DON and RN J - ADON confirmed staff did not informed them when the [MEDICATION NAME] for Resident #1 was out of supply. Interview on [DATE] at 2:22 PM with RN J confirmed she did not know the supply of [MEDICATION NAME] for Resident #1 was low. RN J - ADON confirmed the nurse and medication aide on the East side did not communicate with the RN J ADON regarding Resident #1's [MEDICATION NAME] was not available. RN J ADON further confirmed she did not audit the medication cart on East unit and did not check the fax for reordering medication on East unit to ensure enough medication supply for Resident #1. Interview on [DATE] at 2:37 PM with RN J - ADON confirmed information regarding abuse coordinator and phone number posted on the wall on hallway both units; in-service staff regarding neglect quarterly by lecturing or computer. RN J - ADON confirmed there was test post the training to ensure staff understand the training on neglect. RN J - ADON confirmed she made sure staff not burn out by balance out over time to ensure staff not getting burn out. Staff had to report any suspect neglect or any behavior of neglect to the Administrator - abuse coordinator. Interview on [DATE] at 4:16 PM with the DON confirmed she did not review the shift report on Resident #1 from [DATE] to [DATE] because she was off work on [DATE] and she assisted state surveyor on [DATE] and [DATE], therefore, she did not see the documentation of medication aide on the [MEDICATION NAME] not available for Resident #1. Interview on [DATE] at 4:44 PM with the DON confirmed she considered it was neglect regarding the [MEDICATION NAME] was not available to administer for Resident #1 because the facility fail to provide medical needs for Resident #1 and resulted Resident #1 had [MEDICAL CONDITION]. The DON further confirmed it was her responsibility to prevent neglect happened again. Interview on [DATE] at 4:44 PM with the DON confirmed the facility policy on neglect was providing in-service and training for staff on different forms of neglect. The DON further confirmed anyone including herself involved in Resident #1's incident would receive disciplinary action. The DON stated she would conduct the investigation of neglect related to Resident #1. The DON confirmed to prevent neglect she would continue implementing in-service, competency check, monitoring progress of the interventions to make sure in the right direction. Interview on [DATE] at 5:21 PM with the Administrator confirmed there was a lack of the communication between the facility and the pharmacy. The Administrator confirmed the facility did not call pharmacy, pharmacy did not let the facility know the order refill request was needed, and staff did not inform the administrator or DON about Resident #1 was out of [MEDICATION NAME]. The Administrator confirmed [DATE] was the date when the facility faxed the refill order form to the pharmacy, and pharmacy received refill order on [DATE]. The Administrator said the physician office could not provide any log to show when the facility notify the physician office to get refill order request. The Administrator also said she did not know when pharmacy contact with physician regarding refill order request for Resident #1's [MEDICATION NAME]. Record review of fax confirmation titled Refill Reorder Form dated [DATE] revealed Resident #1's name and [MEDICATION NAME] 32.4 mg was faxed to pharmacy on [DATE] at 2:20 PM. Record review of Electronic Order Status Inquiry for Resident #1 dated [DATE] revealed This prescription ([MEDICATION NAME] tablet 32.4 mg) has been electronically signed. Facility/provider sent [DATE]. Message broker received [DATE] 06:06 PM. Interview on [DATE] at 4:07 PM with pharmacy general manager confirmed if nursing facility call and request stat order (immediately/urgent order) for the [MEDICATION NAME], the pharmacy would delivery medication within ,[DATE] hours. Interview on [DATE] at 5:31 PM with the Administrator confirmed the unavailability of [MEDICATION NAME] to administer for Resident #1 was neglect because it caused harm to him and lack of oversight to obtain Resident #1's [MEDICATION NAME] in timely manner. Interview on [DATE] at 5:36 PM The Administrator confirmed the facility policy on neglect was report immediately to the Administrator any type of neglect so that the Administrator can start investigation. The Administrator confirmed to prevent neglect in the facility by making round, speaking with staff, family, and residents, and educating staff. The Administrator confirmed re-educate staff on neglect, ask staff what they know about neglect and who to report, and spot check staff by walking around to make sure staff doing things right. Record review of the facility's undated policy titled with Medication ordering: Operating and monitoring system revealed To ensure all medications, pursuant to a valid physician order, are available in the facility at all times . Nursing should be ordering meds when they are down to 5 - 7-day supply. Nursing must identify refill is in facility when they are down to 3-day supply. Nursing must identify refill is in facility when they are down to 3-day supply and place refill card in med cart. Nursing must indicate any change of direction to pharmacy on reorder sheet. All incidents of meds not available during med pass should be reported to DON immediately. Monitoring: nurse management should verify all nurses have been in-serviced on med order/reorder system. Re-order book should be audited on daily basis to verify all med orders can be accounted for. Med carts should be audited on a weekly basis to verify no less than 3-day supply of med are available. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from [DATE] to [DATE]. The facility took the following action to correct the non-compliance from [DATE] through [DATE]: - Weekly cart audits to be completed by DON/ADON for assure medication availability, medication labeled correctly, no expired medication on cart and identify any issues. - Each day a medication audit report pulled to include 9 to identify medication not given for reason and follow-up immediately. - [DATE] an in-service on medication availability to guarantee to have a minimum 3 days of medication available at all times. Also completed in-service if medication is not on cart after order to bring awareness to the ADON/DON immediately. - Communication form to be completed by charge nurse with medication availability follow up: resident name, medication, issue, follow-up and corrective action taken. This form is to be reviewed daily by DON/ADON. Observation on [DATE] at 6:54 AM with the DON revealed there were three blister packs (30 tablets/blister pack) of [MEDICATION NAME] 32.4 mg for Resident #1 dated [DATE] was in the narcotic locked box. Further observation revealed one tablet was taken out from one of the blister packs. Interview with the DON on [DATE] at 6:54 PM confirmed [DATE] on three blister packs of [MEDICATION NAME] 32.4 mg for Resident #1 was the date the medication was delivered. Record review of Resident #1's narcotic sheet titled with individual control drug record dated [DATE] revealed [MEDICATION NAME] 32.4 mg give 1 tablet by mouth 3 times a day was administered the first dose for Resident #1 at 2000 on [DATE] with amount remaining 89 of 90 tablets of [MEDICATION NAME] 32.4 mg. Interview on [DATE] 12:19 PM with MA F confirmed she administered the evening dose of [MEDICATION NAME] to Resident #3 on [DATE]. MA F further confirmed she received supplies of 90 pills and punch out one pill for Resident #1's evening dose. Record review of Medication Administration Record of Resident #2, #3, #4 and #5 revealed they did not miss any dose of their [MEDICAL CONDITION] medication from [DATE] through [DATE]. Observation of medication administration on [DATE] at 3:36 PM revealed RN A administered the [MEDICATION NAME] to Resident #2 via feeding tube as physician order. Interview on [DATE] at 10:11 AM with RN A confirmed she received and understood in-service on ordering medication. RN A stated if the medication was out of supply the medication aide had to inform the charge nurse, charge nurse would call pharmacy to make sure the medication was delivered, and if the medication was not delivered by the next day and about to document the medication was not available on the MAR and pharmacy had not delivered the medication, then charge nurse had to inform the ADON or DON. Interview on [DATE] at 11:17 AM with MA D confirmed she received and in-service on ordering medication on [DATE]. MA D further confirmed she had to inform the charge nurse to call pharmacy for medication refill when there were 3 to 4-day supplies. MA D stated when the medication was out of supply, she had to notify the ADON or ADON. Interviews with 7 interviewable Residents on [DATE], they confirmed they had not missed any dose of medication recently. Interview on [DATE] at 2:25 PM with RN J - ADON confirmed she provided in-service for charge nurse and medication aide regarding there was a binder in place for any communication that staff had with pharmacy. RN J - ADON confirmed there would be a communication form for medication aide, charge nurse, and ADON to initial daily to hold accountable for resident medication supply. RN J - ADON confirmed she also trained new hire or temporary staff the same process and protocol for obtaining medication and ensure enough medication supply for residents in the facility. RN ADON confirmed she had to ensure with staff what had been ordered, what pending delivery, and make sure what in the communication log match with the pharmacy log. RN ADON confirmed when the medication was out of supply staff had to notify the physician immediately and would order the medication through emergency pharmacy. RN ADON confirmed in-service staff once a month to ensure staff know what to do when the medication was not available to administer for resident. RN ADON confirmed she would randomly pick on staff and ask question to test their knowledge on obtaining and re-ordering medication for resident. Interview on [DATE] at 4:27 PM with the DON, she confirmed she would continue checking with staff during clinical meeting to ensure medications available for residents. The DON confirmed she continued in-service staff regarding ordering medication in timely manner, if medication was not available staff should check the emergency kit and immediately contact pharmacy to follow up on the medication delivery. The DON confirmed every medication aide and nurse had her phone number, so they could contact the DON any time regarding the medication supply for residents. The DON confirmed communication form utilized to ensure communication among staff to obtain the medication for resident in timely manner. The DON confirmed she and the ADON would monitor the communication form and make sure the issue resolved during the shift. The DON further confirmed she would make round and ask staff on the floor if there was any issue with medication supply for residents to ensure staff do what they supposed to. Interview on [DATE] at 4:38 PM with the DON confirmed she continue provide staff with in-service and competence check off regarding ordering the medication and administering medication. The DON confirmed there was a test for staff to complete to ensure staff understanding the i

Based on interview and record review, the facility failed to ensure residents were free from neglect for 1 of 5 Residents (Resident #1) whose care was reviewed for neglect, in that: The facility failed to implement their oversight and monitoring process to provide [MEDICATION NAME] tablet 32.4 mg (medication was used to control [MEDICAL CONDITION]) for Resident #1 that were necessary to avoid physical harm and fail to have structure in place to ensure the availability of [MEDICATION NAME] for Resident #1. As a result Resident #1 missed 20 of 21 doses of [MEDICATION NAME], suffered from [MEDICAL CONDITION], and was hospitalized . This deficient practice was determined to be past non-compliance, with an immediate jeopardy situation that began on [DATE] and ended on [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. This deficient practice could place residents who received [MEDICAL CONDITION] medication at risk for not receiving therapeutic treatment and could place them at risk for for physical harm, pain, mental anguish, emotional distress or death. The findings were: Record review of Resident #1's admission record dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's care plan dated [DATE] revealed (Resident #1 had) a [MEDICAL CONDITION] disorder. Interventions: give medications as order. Obtain and monitor lab/diagnostic work as ordered. Report result to MD and follow up as indicated. Record review of Resident #1's physician progress notes [REDACTED]. [MEDICAL CONDITION] disorder: stable on combination of [MEDICATION NAME], and [MEDICATION NAME]. Labs from [DATE] are reasonable and no recent [MEDICAL CONDITION] activity. Record review of Resident #1's progress note dated [DATE] at 7:10 AM written by RN A revealed Resident #1 had [MEDICAL CONDITION] lasted approx. 2 minutes at which point (Resident #1) turned pale white and lips cyanotic and then lost consciousness. Resident #1 was having increased respirations. (Resident #1) was moved to his bed with (head of the bed elevated) and neurological checks started. Vital sign: (blood pressure) ,[DATE], (pulse) 103, (oxygen saturation) 95%, (Respiration)24. (Nurse Practitioner) notified and family notified. Record review of Resident #1's progress note dated [DATE] at 9:41 AM written by RN A revealed (Resident #1 was) lying in bed and this nurse went to check vital sign (and observed Resident #1) had (second) [MEDICAL CONDITION] lasted (approximately) 1.5 minutes at which point Resident #1 color became pale lips cyanotic and Resident #1 loss consciousness. Vital sings: (blood pressure) ,[DATE], (pulse) 107, (oxygen saturation) 96%, (respiration) 24. (Nurse practitioner) notified. Family member notified and wanted Resident#1 to (send) out to ER. (Nurse Practitioner) gave order to send Resident #1 out (per) family member's request. (New order) stat - [MEDICATION NAME] level, [MEDICATION NAME] level, [MEDICATION NAME] level, CBC, CMP. Blood drawn, and pickup ordered. Interview on [DATE] at 4:19 PM with RN A confirmed Resident#1 was up in wheel chair and drinking coffee in the dining room and had [MEDICAL CONDITION]. RN A described Resident #1 had violent [MEDICAL CONDITION], his body clenched and his whole body was stiff. RN A further described Resident #1's tongue stuck out, his bottom denture fell out, his face was pale, his lips were cyanotic. RN A confirmed Resident #1 had [MEDICAL CONDITION] for two and half minutes. When Resident #1's [MEDICAL CONDITION] concluded, RN A with MA E tilted his wheel chair and transported resident back to his room. RN A said she checked Resident #1's vital signs - Resident #1 was non-responsive, breathing was labored, using accessory muscle to breath, and tachypnea (rapid, shallow breathing). RN A confirmed Resident #1 became minimally responsive after [MEDICAL CONDITION] activity - pupils round and slow to react, lung sound clear, tongue swollen, good oxygen saturation level and Resident #1 began stabilizing after [MEDICAL CONDITION] activity. RN A confirmed Resident #1 did not answer her questions, but Resident #1 responded by looking up when RN A called his name. RN A said she remained with Resident #1 for about 10 - 15 minute to ensure Resident #1 was stable. RN A confirmed while she was on the phone with the doctor and family, RN A asked the CNA to observe Resident #1 to watch for signs of [MEDICAL CONDITION] activity. RN A confirmed when CNA was about to check Resident #1's vital signs, Resident#1 had another [MEDICAL CONDITION], and the CNA informed RN A to check on Resident #1. RN A confirmed Resident #1 had [MEDICAL CONDITION] activity. When Resident #1 was stable from his second [MEDICAL CONDITION], she notified the Nurse Practitioner and Resident #1's family. RN A confirmed she received an order to draw Resident #1's blood to check the drug level of [MEDICAL CONDITION] medication and to transfer Resident #1 to local hospital per Nurse Practitioner's order and family request. Record review of Resident #1's diagnostic laboratory dated [DATE] revealed [MEDICATION NAME] level was 6.8 ug/mL which meant the medication was lower than normal therapeutic level (therapeutic range for [MEDICATION NAME] is 15 - 40 ug/mL). During an interview on [DATE] at 5:57 PM with the DON, she confirmed Resident #1's drug levels in July ([MEDICATION NAME], and [MEDICATION NAME]) were all within therapeutic range. The DON further confirmed the drug level of [MEDICATION NAME] was low on [DATE] because Resident #1 did not receive his medication. Record review of resident #1's ambulance record dated [DATE] revealed Nursing staff states (Resident #1) had two [MEDICAL CONDITION] an hour apart from each other. The first [MEDICAL CONDITION] was around 0900 (9:00 AM) followed by another [MEDICAL CONDITION] around 1000 (10:00 AM). (Resident #1 had primary history) of [MEDICAL CONDITION] and takes [MEDICATION NAME] to control [MEDICAL CONDITION]. (Resident #1) received his medication this morning and is compliant with all other medications. (Resident #1) [MEDICAL CONDITION] was reported a grand mal [MEDICATION NAME] ,[DATE] minutes. No trauma noted from [MEDICAL CONDITION]. (Resident #1) was moved to stretcher and secured with all straps and 2 guard rails. (Resident #1) was transported to main local hospital. (Resident #1) had a [MEDICAL CONDITION] while in route to hospital and was placed in right side with airway suctioned for appx 10 seconds to clear secretions. (Resident #1) remained in postictal state (altered state of consciousness after [MEDICAL CONDITION] activity) during transport. Vital signs were continuously monitored and stable. Arrived to destination and (Resident #1) care released to receiving RN. Record review of Resident #1's physician order dated [DATE] revealed an order of [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times per day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable (not easily controlled or managed), without [DIAGNOSES REDACTED]. (G40.509) Start date [DATE]. Record review of Resident #1's narcotic sheet titled individual control drug record dated from [DATE] to 8/ ,[DATE] revealed [MEDICATION NAME] 32.4 mg give 1 tablet by mouth 3 times a day was completed on [DATE] at 2000 (8:00 PM) with 0 amount remaining. Record review of Resident #1's medication administration record dated [DATE] - [DATE] revealed administration schedule for [MEDICATION NAME] tablet 32.4 mg at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM). Further review revealed the medication scheduled at 0800 (8:00 AM) and 1400 (2:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 0800 (8:00 AM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM) on [DATE] was coded 5 - hold/see progress notes and coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 2000 (8:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 0800 (8:00 AM) and 1400 (2:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered; the medication schedule at 1400 (2:00 PM) on [DATE] was coded 9 - Other/see progress notes which meant the medication was not administered. Record review of Resident #1's progress note dated on [DATE] at 8:59 AM written by MA B revealed [MEDICATION NAME] Tablet 32.4 MG Give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) in progress. Record review of Resident #1's progress note dated on [DATE] at 8:21 PM written by MA B revealed [MEDICATION NAME] Tablet 32.4 MG Give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) in progress. During an interview on [DATE] at 1:37 PM with MA B, he confirmed he did not administer [MEDICATION NAME] 32.4 mg for Resident #1 on [DATE] scheduled at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM), on [DATE] scheduled at 2000 (8:00 PM), and on [DATE] at 2000 (8:00 PM) because the medication was out of supply. MA B stated he made mistakes to document with check marks on Resident #1's MAR on [DATE] at 2000 (8:00 PM) and [DATE] at 2000 (8:00 PM) as administering the [MEDICATION NAME] 32.4 mg, and MA B said he should have coded as 9 on Resident #1's MAR and documented under progress note that the medication was still in process to deliver. During the interview with MA B, he confirmed he informed RN A and LVN I the [MEDICATION NAME] for Resident #1 was out of supply. MA B said he wrote the information down on a Post-It note and gave it to the nurses so that the nurses would call the pharmacy to refill the medication. MA B further confirmed he did not follow up with the nurses or inform the DON about the [MEDICATION NAME] for Resident #1 being out of supply because he did not work all the time in the East unit where Resident #1 resided. He stated he mainly worked in West unit. During an interview on [DATE] at 10:11 AM, RN A confirmed she did not recall if a medication aide informed her about the [MEDICATION NAME] for Resident #1 being completely out of supply. RN A confirmed when there was no [MEDICAL CONDITION] medication to administer for any Resident, she monitored if the Resident had any sign and symptom of [MEDICAL CONDITION]. RN A confirmed she received in-service and understood if the medication was out of supply, the medication aide had to inform the charge nurse, charge nurse would call pharmacy to make sure the medication was delivered, and if the medication aide was about to document the medication was not available to administer, and pharmacy had not delivered the medication, then charge nurse had to inform the ADON or DON. RN A confirmed she did not recall if she informed the ADON and DON about the [MEDICATION NAME] being not available to administer to Resident #1. RN A confirmed when the medication was not available to give to any resident, she would call the physician when she needed a new prescription to refill or authorization paperwork. RN also confirmed she would call physician if the medication for the resident was not available and resident had symptoms. RN confirmed she did not call the physician when the medication for any resident was completely out because she could resolve with the pharmacy. Record review of Resident #1's progress note dated [DATE] at 10:20 AM written by MA C revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (g40.509) Medication on order. Record review of Resident #1's progress note dated [DATE] at 8:24 PM written by MA C revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (g40.509) Medication on order. Interview via telephone on [DATE] at 5:59 PM with MA C confirmed he did not administer [MEDICATION NAME] 32.4 mg for Resident #1 on [DATE] scheduled at 0800 (8:00 AM) and 1400 (2:00 PM) and on [DATE] scheduled at 2000 (8:00 PM) because the medication was out of supply. MA C further confirmed he made an error when he documented on Resident #1's MAR that he administered the [MEDICATION NAME] 32.4 mg, but the medication was not available to give. MA C stated he wrote Resident #1's name and medication on a piece of paper and gave to the nurse, and the nurse would call pharmacy to refill. MA C said he did not remember which nurse he gave the information to. Record review of Resident #1's progress note dated [DATE] at 5:42 AM written by MA D revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) pending delivery. Interview via telephone on [DATE] at 11:00 AM with MA D confirmed the [MEDICATION NAME] 32.4 mg was not available to administered for Resident #1 on [DATE] scheduled at 0800 (8:00 AM) and 1400 (2:00 PM). MA D confirmed she informed LVN H about the [MEDICATION NAME] for Resident #1 was out of supply, and she saw LVN H call the pharmacy to refilled Resident #1's [MEDICATION NAME]. MA D confirmed she did not inform the ADON or DON when Resident #1's [MEDICATION NAME] was out of supply because she assumed LVN H informed ADON or DON during clinical meeting. Record review of Resident #1's progress note dated on [DATE] at 8:05 AM written by MA E revealed [MEDICATION NAME] Tablet 32.4 MG Give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509). Pending medication from pharmacy. Record review of Resident #1's progress note dated on [DATE] at 1:11 PM written by MA E revealed [MEDICATION NAME] Tablet 32.4 MG Give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509). Pending medication from pharmacy, notified charge nurse. Interview on [DATE] at 3:05 PM with MA E, she confirmed she did not administer [MEDICATION NAME] 32.4 mg for Resident #1 on [DATE] scheduled at 0800 (8:00 AM) and 1400 (2:00 PM) because there was no medication to give and the medication was pending delivery from pharmacy. MA E confirmed she informed LVN H about Resident #1's [MEDICATION NAME] was not available to administer. Record review of Resident #1's progress note dated [DATE] at 9:47 PM written by MA F revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) on order. Record review of Resident #1's progress note date [DATE] at 11:20 AM written by MA G revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) Pending from pharmacy. Record review of Resident #1's progress note date [DATE] at 1:09 PM written by MA G revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) Pending from pharmacy. Record review of Resident #1's progress note date [DATE] at 1:52 PM by MA G revealed [MEDICATION NAME] tablet 32.4 mg give 1 tablet by mouth three times a day related to epileptic [MEDICAL CONDITION] related to external causes, not intractable, without [DIAGNOSES REDACTED] (G40.509) Pending from pharmacy. Interview via telephone on [DATE] at 11:43 AM with MA G confirmed the [MEDICATION NAME] for Resident #1 was out of supplies for couple days. MA G stated she did not remember what date the medication was not available to give to Resident #1. MA G confirmed she recalled the [MEDICATION NAME] was out of supply, and she informed LVN H. Interview via telephone on [DATE] at 1:06 PM with LVN H confirmed the medication aide informed her on [DATE] about the [MEDICATION NAME] for Resident #1 needed to refill. LVN H stated she did not recall the [MEDICATION NAME] was low on supply or completely out of supply. LVN H stated she called the pharmacy and pharmacy said they would get the medication out to the facility. LVN H stated she did not remember what date when the [MEDICATION NAME] was not delivered, and she called pharmacy again. LVN H said when she called pharmacy on the second time, pharmacy informed they need the physician's prescription to refill the [MEDICATION NAME] for Resident #1. LVN H explained when the pharmacy need refill prescription or authorization, pharmacy communicate with nurse manager via email instead of informing the floor nurse, so the floor nurse only know if the pharmacy need refilled prescription or authorization when the floor nurse called pharmacy to ask about why the medication had not been delivery. LVN H said she went to physician website to fill out a form to request refill for [MEDICATION NAME]. LVN H confirmed she did not remember what date she completed the request form for refill the [MEDICATION NAME] for Resident #1. LVN H added when the physician signed the refilled request form, the physician would send the prescription refill to the pharmacy. LVN H further confirmed she did not remember when the [MEDICATION NAME] was delivered to the facility. LVN H confirmed she did not call the doctor or inform the ADON or DON about the [MEDICATION NAME] that was out of supply because she just kept following up with the pharmacy. Interview on [DATE] at 1:59 PM with LVN I confirmed MA F informed her on [DATE] that the [MEDICATION NAME] for Resident #1 was out of supply. LVN I confirmed she filled a request form and fax to physician office to inform the physician that the medication was out of supply and need to refill. LVN I confirmed the [MEDICATION NAME] was delivered on [DATE] around 2:30 PM. LVN I confirmed there was no communication from the previous shift about the [MEDICATION NAME] for Resident #1 was out of supply. LVN I confirmed she did not inform the DON or ADON regarding the [MEDICATION NAME] was out of supply for Resident #1. Interview on [DATE] at 5:18 PM with the Administrator confirmed she was not aware of the [MEDICATION NAME] for Resident #1 ran out. The Administrator further confirmed medication aide and charge nurse should have informed the Administrator about Resident #1's [MEDICATION NAME] was out of supply. Interview on [DATE] at 5:49 PM with the DON, she confirmed she was not aware of the [MEDICATION NAME] for Resident #1 was out of supply until Resident #1's family member brought it to her attention on [DATE] because Resident #1 called to inform his family member. The DON further confirmed based on the documentation on Resident #1's MAR, the [MEDICATION NAME] was not administered to Resident #1 from [DATE] at 0800 (8:00 AM) through [DATE] at 1400 (2:00 PM). Interview on [DATE] at 6:18 PM with the DON confirmed the medication aide should check the medication cart by going over each blister pack to ensure the medication availability at minimum for 3 days. If the medication not available, the mediation aide had to notify the charge nurse, then, charge nurse should have notified the physician. The DON further confirmed depend on certain medication, the physician could put the medication on hold for 2 days. The DON stated charge nurse should have informed the DON so that the DON could order the [MEDICATION NAME] from a contracted emergency pharmacy for 2 - 3 days supplies for Resident #1. Interview on [DATE] at 6:54 PM with the DON confirmed [DATE] was delivery date indicated on three blister packs - [MEDICATION NAME] 32.4 mg for Resident #1. Interview on [DATE] at 6:55 PM with the DON and RN J - ADON confirmed staff did not informed them when the [MEDICATION NAME] for Resident #1 was out of supply. Interview on [DATE] at 2:22 PM with RN J confirmed she did not know the supply of [MEDICATION NAME] for Resident #1 was low. RN J - ADON confirmed the nurse and medication aide on the East side did not communicate with the RN J ADON regarding Resident #1's [MEDICATION NAME] was not available. RN J ADON further confirmed she did not audit the medication cart on East unit and did not check the fax for reordering medication on East unit to ensure enough medication supply for Resident #1. Interview on [DATE] at 4:16 PM with the DON confirmed she did not review the shift report on Resident #1 from [DATE] to [DATE] because she was off work on [DATE] and she assisted state surveyor on [DATE] and [DATE], therefore, she did not see the documentation of medication aide on the [MEDICATION NAME] not available for Resident #1. During an interview on [DATE] 4:44 PM with the DON, she confirmed she considered it was neglect regarding the [MEDICATION NAME] was not available to administer for Resident #1 because the facility failed to provide medical needs for Resident #1 and resulted in Resident #1 having [MEDICAL CONDITION]. The DON further confirmed it was her responsibility to prevent neglect from happening again. During an interview on [DATE] at 5:21 PM, the Administrator confirmed there was a lack of the communication between the facility and the pharmacy. The Administrator confirmed the facility did not call pharmacy, pharmacy did not let the facility know the order refill request was needed, and staff did not inform the administrator or DON that Resident #1 was out of [MEDICATION NAME]. The Administrator confirmed [DATE] was the date when the facility faxed the refill order form to the pharmacy, and pharmacy received refill order on [DATE]. The Administrator said the physician office could not provide any log to show when the facility notified the physician office to get refill order request. The Administrator also said she did not know when pharmacy contacted physician regarding refill order request for Resident #1's [MEDICATION NAME]. During an interview on [DATE] at 5:31 PM, the Administrator confirmed the unavailability of [MEDICATION NAME] to administer for Resident #1 was neglect because there was lack of oversight to obtain Resident #1's [MEDICATION NAME] in timely manner and it caused harm to him. Record review of fax confirmation titled Refill Reorder Form dated [DATE] revealed Resident #1's name and [MEDICATION NAME] 32.4 mg was faxed to pharmacy on [DATE] at 2:20 PM. Record review of Electronic Order Status Inquiry for Resident #1 dated [DATE] revealed This prescription ([MEDICATION NAME] tablet 32.4 mg) has been electronically signed. Facility/provider sent [DATE]. Message broker received [DATE] 06:06 PM. Interview on [DATE] at 4:07 PM with pharmacy general manager confirmed if nursing facility call and request stat order (immediately/urgent order) for the [MEDICATION NAME], the pharmacy would delivery medication within ,[DATE] hours. Record review of the facility's undated policy titled with Medication ordering: Operating and monitoring system revealed To ensure all medications, pursuant to a valid physician order, are available in the facility at all times . Nursing should be ordering meds when they are down to 5 - 7-day supply. Nursing must identify refill is in facility when they are down to 3-day supply. Nursing must identify refill is in facility when they are down to 3-day supply and place refill card in med cart. Nursing must indicate any change of direction to pharmacy on reorder sheet. All incidents of meds not available during med pass should be reported to DON immediately. Monitoring: nurse management should verify all nurses have been in-serviced on med order/reorder system. Re-order book should be audited on daily basis to verify all med orders can be accounted for. Med carts should be audited on a weekly basis to verify no less than 3-day supply of med are available. Record review of the facility policy titled with Abuse prevention program dated ,[DATE] revealed Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. It was determined these failures placed Resident #1 in an immediate Jeopardy (IJ) situation from [DATE] to [DATE]. The facility took the following action to correct the non-compliance from [DATE] through [DATE]: - Weekly cart audits to be completed by DON/ADON for assure medication availability, medication labeled correctly, no expired medication on cart and identify any issues. - Each day a medication audit report pulled to include 9 to identify medication not given for reason and follow-up immediately. - [DATE] an in-service on medication availability to guarantee to have a minimum 3 days of medication available at all times. Also completed in-service if medication is not on cart after order to bring awareness to the ADON/DON immediately. - Communication form to be completed by charge nurse with medication availability follow up: resident name, medication, issue, follow-up and corrective action taken. This form is to be reviewed daily by DON/ADON. Observation on [DATE] at 6:54 AM with the DON revealed there were three blister packs (30 tablets/blister pack) of [MEDICATION NAME] 32.4 mg for Resident #1 dated [DATE] was in the narcotic locked box. Further observation revealed one tablet was taken out from one of the blister packs. Interview with the DON on [DATE] at 6:54 PM confirmed the date of [DATE] on the blister pack of [MEDICATION NAME] 32.4 mg for Resident #1 was the date the medication was delivered. Record review of Resident #1's narcotic sheet titled with individual control drug record dated [DATE] revealed [MEDICATION NAME] 32.4 mg give 1 tablet by mouth 3 times a day was administered the first dose for Resident #1 at 2000 on [DATE] with amount remaining 89 of 90 tablets of [MEDICATION NAME] 32.4 mg. Interview on [DATE] 12:19 PM with MA F confirmed she administered the evening dose of [MEDICATION NAME] to Resident #3 on [DATE]. MA F further confirmed she received supplies of 90 pills and punch out one pill for Resident #1's evening dose. Record review of Medication Administration Record of Resident #2, #3, #4 and #5 revealed they did not miss any dose of their [MEDICAL CONDITION] medication from [DATE] through [DATE]. Observation of medication administration on [DATE] at 3:36 PM revealed RN A administered the [MEDICATION NAME] to Resident #2 via feeding tube as physician order. Interview on [DATE] at 10:11 AM with RN A confirmed she received and understood in-service on ordering medication. RN A stated if the medication was out of supply the medication aide had to inform the charge nurse, charge nurse would call pharmacy to make sure the medication was delivered, and if the medication was not delivered by the next day and about to document the medication was not available on the MAR and pharmacy had not delivered the medication, then charge nurse had to inform the ADON or DON. Interview on [DATE] at 11:17 AM with MA D confirmed she received and in-service on ordering medication on [DATE]. MA D further confirmed she had to inform the charge nurse to call pharmacy for medication refill when there were 3 to 4-day supplies. MA D stated when the medication was out of supply, she had to notify the ADON or ADON. Interview with 7 interviewable Residents on [DATE], they confirmed they had not missed any dose of medication recently. Interview on [DATE] at 2:25 PM with RN J - ADON confirmed she provided in-service for charge nurse and medication aide regarding there was a binder in place for any communication that staff had with pharmacy. RN J - ADON confirmed there would be a communication form for medication aide, charge nurse, and ADON to initial daily to hold accountable for resident medication supply. RN J - ADON confirmed she also trained new hire or temporary staff the same process and protocol for obtaining medication and ensure enough medication supply for residents in the facility. RN ADON confirmed she had to ensure with staff what had been ordered, what pending delivery, and make sure what in the communication log match with the pharmacy log. RN ADON confirmed when the medication was out of supply staff had to notify the physician immediately and would order the medication through emergency pharmacy. RN ADON confirmed in-service staff once a month to ensure staff know what to do when the medication was not available to administer for resident. RN ADON confirmed she would randomly pick on staff and ask question to test their knowledge on obtaining and re-ordering medication for resident. Interview on [DATE] at 4:27 PM with the DON, she confirmed she would continue checking with staff during clinical meeting to ensure medications available for residents. The DON confirmed she continued in-service staff regarding ordering medication in timely manner, if medication was not available staff should check the emergency kit and immediately contact pharmacy to follow up on the medication delivery. The DON confirmed every medication aide and nurse had her phone number, so they could contact the DON any time regarding the medication supply for residents. The DON confirmed communication form utilized to ensure communication among staff to obtain the medication for resident in timely manner. The DON confirmed she and the ADON would monitor the communication form and make sure the issue resolved during the shift. The DON further confirmed she would make round and ask staff on the floor if there was any issue with medication supply for residents to ensure staff do what they supposed to. Interview on [DATE] at 4:38 PM with the DON confirmed she continue provide staff with in-service and competence check off regarding ordering the medication and administering medication. The DON confirmed there was a test for staff to complete to ensure staff understanding the in-service and training. Interview on [DATE] at 4:39 PM with the DON confirmed she would document any finding or concern with the current interventions, check if the system needed to be improved, continued with nurse competency for 90 days or more. DON further confirmed continue with audit medication cart to see if there was anything wrong and ensure there was no gap in the process of obtaining medication for Resident. The DON confirmed the Resident #1's incident regarding missed doses of [MEDICATION NAME] would be discussed in QAPI meeting to prevent happening again. Interview on [DATE] at 4:41 PM with the DON confirmed she ensured staff utilize communication board and shift change report to communicate among staff to make sure medication available for residents. Interview on [DATE] at 5:28 PM with the Administrator confirmed to prevent Residents' medications out of supply, staff were required to notify with the administrator or DON if the medication run lower than 3-day supply, utilize communication form among staff, ask staff during clinical meeting need to ensure medication enough for resident; audit medication cart and medication once a week. Interview on [DATE] at 5:39 PM the Administrator confirmed the incident of Resident #1 would be discussed in QAPI meeting every month until the facility saw the improvements. The Administrator further confirmed new hire would have to go through all training from abuse/neglect and orientation on acquiring medication before working on the floor. Record review of staff employees' files revealed staff received abuse and neglect

Based on observation, interview and record review, the facility failed to implement the facility's policies and procedures that prohibited the neglect of 1 of 5 residents (#1) whose care was reviewed for neglect in that: The facility failed to feed Resident #1 when he should have been fed and was served cut up pieces of sausage instead of ground meat. As a result, Resident #1 choked on pieces of meat and died due to asphyxiation. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 39 residents with swallowing disorders and requiring mechanically altered food at risk for choking and aspiration of food due to not being served the appropriate form of food and not being fed. The findings were: 1. Review of the facility's abuse, neglect and exploitation prohibition policy dated [DATE] specified that neglect was defined as failure to provide goods and services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation or resident property, will include: identifying, correcting and intervening in situations in which abuse, neglect and/or misappropriation of patient property is more likely to occur. Review of the facility's health care guideline, dated [DATE], Dementia Care Dining Guidelines, resident with dementia included the following guidelines: a. Assessments need to address nutritional problems and resident characteristics such as poor dental health, swallowing difficulties or distractibility during meals that may affect food and fluid consumption (e.g., refer to dietitian for residents who are at high risk for nutritional problems; refer residents with swallowing difficulties to speech therapy for dysphagia evaluation). b. Staff sits on the side of the resident, make eye contact and speak with residents when assisting with meals. c. Residents are given enough time to open their mouth, chew and swallow. Drinks are offered regularly to moisten the mouth, wash food down and provide hydration. d. Staff is aware of resident's eating and nutritional issues. Review of the facility's policy for Meal Service in Dining Service date [DATE], revealed that staff were to: a. Check items on the tray against diet care for accuracy. b. Assure correct meal is served to the patient. c. Assist patient with eating and provide assistance/supervision based on patient's current level of self-performance in eating. 2. Review of Resident #1's undated admission face sheet revealed the resident was admitted to the facility on [DATE] with a medical history of [REDACTED]. Review of initial admission orders [REDACTED]. Review of the attending physician's history and physical dated [DATE] revealed that Resident #1 was a poor historian due to cognitive and psychiatric impairment as a result of a middle cerebral artery aneurysm rupture in 1992 and was admitted to the facility from the local state hospital after being treated for [REDACTED].#1 became agitated and aggressive and was difficult to understand due to hypophonic voice (soft speech, especially resulting from a lack of coordination in the vocal musculature and a common presentation in [MEDICAL CONDITION]). Review of the initial MDS dated [DATE] revealed the resident had a swallow disorder and required limited assistance. The resident's diet was mechanically altered. The most recent MDS dated [DATE] assessed Resident #1 having difficulty focusing attention and being easily distracted; and having disorganized thinking and incoherent (rambling or irrelevant conversation). Eating in section G (Functional Status) required 1 person's physical assistance. Section K, Swallowing/Nutritional Status did not assess for swallowing disorder. Review of a nutritional assessment dated [DATE] revealed Resident #1 required a regular/liberalized diet type, dysphagia advanced diet texture. (Dysphagia Advanced Diet is defined by the facility's diet manual dated 2015 as foods that are difficult to chew and/or swallow are modified in any of the following ways: chopped, ground, shredded. The nutritional assessment also documented that Resident #1 exhibited combative behavior by pushing plates off the tables during meals; and needed assistance with meals. Resident #1 was ordered food to be served on plastic plates due to throwing them. Review of the facility's dining room rounds tracking log, dated [DATE], documented that Resident #1 required total assistance with eating. Review of nursing notes dated [DATE] revealed documentation that Resident #1 was totally dependent for eating as the resident would attempt to feed himself, but was unable to put food safely in his mouth at one time. A second note dated [DATE] documented the resident was totally dependent (on staff) for eating. Review of a care plan dated [DATE] revealed that Resident #1 required extensive assist of 1 for eating. Extensive assistance included encouraging the resident to take small sips and bites; to encourage the resident to chew and swallow each bite; and to monitor the resident for signs/symptoms of aspiration such as coughing, watery eyes, and choking and/or moist sounding voice. There was no documentation in the care plan instructing staff to prevent the resident from grabbing at food and putting food into his mouth. Review of a speech therapist evaluation dated [DATE] revealed that Resident #1 had a mild oropharyngeal dysphagia (difficulty transferring food from the mouth into the pharynx and esophagus to initiate the involuntary swallowing process) and severe cognitive-communication deficit which impacted on his overall swallowing function, safety, understanding, verbal expression of his basic wants/needs, safety awareness, self-monitoring, reasoning, judgment, orientation, problem solving and executive function for toleration of least restrictive diet. The recommended strategies were: 100% closely supervised feedings with nursing assistance, upright positioning during meals, small bites/sips and additional dry swallows as indicated. Resident #1 required assistance with feeding secondary to impulsivity and executive function deficit, which impairs his ability to recall and use trained safety precautions for swallowing. Review of the attending physician's progress report dated [DATE] revealed that the resident was recovering from pneumonia and required nurses to anticipate the resident's needs. The attending physician documented that Resident #1resident had not had any recent choking episodes. Review of the menu for the evening meal on [DATE] revealed residents were served sausage, pepper and onions, parsley potato, seasoned spinach and dinner roll. According to a facility dietary manual dated [DATE] on the preparation of dysphagia advance diet, Sausage, Pepper and Onion, Ground, the sausage was to be ground as follows: transfer sausage to food processor, chop to rice size pieces. Transfer back to pan, stir. Review of an incident report dated [DATE] revealed that at 6:00 p.m., Resident #1 was sitting at a table with 2 other residents in the assisted dining room. The report described Resident #1 as needing extensive assistance for impulse control and supervision due to grabbing food. Resident #1 was unsupervised waiting to be served and began choking. Staff performed [MEDICATION NAME] and called 911. The resident was transported to the ER and died and was pronounced at 6:50 p.m. Review of an emergency provider report dated [DATE] revealed that Resident #1 had a [MEDICAL CONDITION] after choking on a piece of meat at the nursing home. Per EMS, pt. was found unresponsive after choking at 1800 today. EMS pulled out a lot of food out of our pt. as they intubated him. They do not know if someone performed the [MEDICATION NAME] maneuver. They were doing CPR when EMS got there. The provider report also assessed the resident with: Symmetric dilated pupils and face is cyanotic; and ET tube present with food debris in tube. The emergency physician determined that: Primary impression: Aspiration into airway. and Secondary impression: [MEDICAL CONDITION]. Time of death called at 1855. Review of Resident #1's tray card dated [DATE] revealed the resident was to be served dysphagia advance (textured) meals on a lip plate. During an interview on [DATE] at 12:05 p.m., the Food Service Manager stated that although she was not in the building on [DATE], she interviewed the cooks preparing the evening meal and they reported that Resident #1's tray was not served and was still on the last cart (#7), when the resident began to choke. The Food Service Manager stated that Resident #1 was probably served some other resident's tray. The Food Service Manager also stated that 24 residents within the facility were served dysphagia advance diets, including her father, who was a resident in the facility. During an interview on [DATE] at 2:30 p.m., RN N, Weekend Supervisor, stated that when she was called to the assisted dining room at 6:00 p.m. on [DATE], Resident #1 was already on the floor. She stated that she started CPR. When asked if she was in the dining room, RN N stated that she was outside in the parking lot speaking to her ex-husband. RN N stated that she observed a tray of food on the table where Resident #1 had been sitting, but did not recall what type of food was on the plate. She stated that CNA J, agency staff, was sitting at the table also. RN N stated that when she reported Resident #1 had choked to the resident's daughter, the daughter asked how this could happen because her father (Resident #1) was always fed and was not allowed to feed himself. RN N stated that she didn't know that and assumed the resident fed himself, because he had a plate with a rim. During an interview on [DATE] at 2:50 p.m., CNA G stated that Resident #1 was always fed by staff and that his tray was left on the cart and served last. CNA G stated that she was assisting in the dining room and that CNAs H and I were passing out trays, because CNA J didn't know the residents. During an interview on [DATE] at 3:00 p.m., CNA H stated that he worked the evening shift on [DATE] and was passing out trays to the residents. He reported that he had told CNA J twice to not allow Resident #1 to feed himself. CNA H stated that he placed the tray of food in front of Resident #1 and left the table to feed other residents. He stated that he had his back to Resident #1's table and did not see if Resident #1 fed himself, or if he had been fed. During an interview on [DATE] at 3:25 p.m., CNA I stated that she worked the evening shift on [DATE] and reported that all the facility staff knew that Resident #1 had to be fed, because the resident grabbed food off of other's plates and pushed food into his mouth. She stated that the incident was preventable. During an interview on [DATE] at 5:30 p.m., CNA K stated that other CNAs took turns feeding Resident #1 and that the resident was always served last, because of his behaviors. She stated that all the CNAs had an electronic notepad that described the care to be given to all the residents. During the interview, CNA K demonstrated the notepad and accessed the care plan of another resident that was fed. There were several choices regarding eating. CNA K stated that the resident required extensive assistance which he understood that the resident was to be fed. During an interview on ,[DATE] at 5:20 p.m., CNA L stated that Resident #1 was not allowed to feed himself. When asked how he knew the resident required to be fed, he stated that everyone knew the resident had to be fed and had fed him many times. He stated that Resident #1's tray was always kept out of reach so the resident could not grab the food. During an interview on [DATE] at 6:00 p.m., Medication Aide M stated that he had worked in the facility for [AGE] years and had fed Resident #1 on many occasions. He stated that the resident was not allowed to feed himself as he would grab food and push the food into his mouth. During an interview on [DATE] at 6:11 p.m., CNA J stated that he worked for a staffing agency and worked in the facility on [DATE] from 4:00 p.m. to 12:00 midnight. He stated that he was assigned to the hall in which Resident #1 had resided and understood that the resident required total care. CNA J stated that after providing incontinent care to Resident #1, he pushed the resident to the dining room in his wheelchair. CNA J stated that he was assigned to simultaneously feed 2 other residents (#2 and 3) and was seated between them, when Resident #1 was served his tray by CNA H. Resident #1 was sitting in his wheelchair across from him at the square table. He stated that CNA H placed the tray of food in front of Resident #1 and told him that he had to feed Resident #1. CNA J stated that he questioned the instructions and stated that he could not feed Resident #1 and the other 2 residents. CNA H then stated that Resident #1 could feed himself but was sloppy. CNA J stated that he was busy feeding the other 2 residents and did not see Resident #1 feed himself. He then noticed that Resident #1 had turned his wheelchair around and was propelling away from the table. CNA J stated that he observed LVN N speaking to the resident and asking if he was all right. CNA J stated that he suggested that maybe LVN N should sweep the resident's mouth for food. At that time, LVN N turned to CNA J and instructed him to call 911 at the nurses' station. During an interview on [DATE] at 2:25 p.m., the attending physician reported that he had been asked by the city's medical examiner how to categorize Resident #1's death, natural or accidental. The physician stated that he informed the medical examiner that due to the choking, the death was accidental. The physician stated that Resident #1 could not protect himself (from choking) due to his mental capacity. During an interview on [DATE] at 1:15 p.m., LVN S stated that she had worked the evening shift on [DATE] and was passing out trays to residents on the West Wing. She stated that she had observed the Weekend Supervisor standing in the parking lot outside of the building speaking with her ex-husband and little son. When she reentered the assisted feeding dining room, she noticed activity at a table and someone shouted to get the weekend supervisor. At that moment the supervisor appeared through another door and began to perform CPR. LVN S stated that she also assisted with compressions and while standing next to the table that Resident #1 sat at she noticed that the plate had cut up pieces of sausage and potatoes. She stated that when a mouth sweep was performed on the resident, pieces of meat were extracted. She stated that the meat was not ground and that they were pulling out chunks of meat. She stated that she had small children and cut pieces of meat in the same way so they could chew the meat. The Administrator was notified on [DATE] at 2:37 p.m. of an Immediate Jeopardy for the above failures and a Plan of Removal was requested. The facility's Plan of Removal was provided by the Administrator on [DATE] and included the following steps to be taken by the facility: a. On [DATE], the Center Nurse Executive (DON) revised the orientation onboarding guide for direct care agency staff which included orientation on Resident Rights, Abuse, Safety, Reports, Documentation, Skin Management and Meal Service to include feeding assistance, upright positioning, alternating food and fluids, multiple swallow and signs and symptoms of choking. All agency direct care staff could not begin their shift until the orientation was completed. b. On [DATE], the facility began in-servicing direct care nursing staff regarding the [MEDICATION NAME] maneuver and included signs and symptoms of choking. In-services also included the supervision of residents requiring assistance with meals and proper feeding techniques as specified by the speech therapy department. In-services were also conducted on how to redirect residents with behavioral disorders at meal time. c. On [DATE], the direct care staff were in-serviced on how to utilize the Kardex too (electric notepad) to communicate resident care plans. Staff was instructed on how to translate the codes which indicated specific instructions such as feeding and/or supervision. d. On [DATE], care plans of residents with dysphagia and swallowing issues were updated to include specific instructions specified by the Speech Therapy Department. Any resident presenting with swallowing difficulty was to be referred to the department for evaluation immediately and any and all recommendations would be reviewed by the Center Nurse Executive. e. On [DATE], nursing meal supervisors were in-serviced on the use of the Meal Supervision Tool in order to familiarize supervisors with the individual needs of each resident and to have them ensure that care plans were being implemented for each resident. The tool was to be utilized twice a day for 30 days and then during random observations. The Center Nurse Executive was to report the use of the tool and findings to the monthly Quality Assurance Committee, which included the Medical Director and Administrator. Verification of the Plan of Removal was as follows: Observations and interviews of both facility and agency direct care staff conducted on [DATE], confirmed that the in-services had been conducted. All employed staff members, with the exception of 3 weekend staff members, were in-serviced either during their shifts, or prior to starting their shifts. Observations during the evening meal on [DATE] confirmed that residents with dysphasia advance diets were being served the appropriately altered meal items. Observations during the dispersing of food items by the cooks during the evening meal confirmed that the chicken being served had undergone a grounding process prior to being served. On [DATE] at 7:30 p.m., the Administrator was informed that the IJ was removed. However, the facility remained out of compliance with a severity of actual harm with a scope identified as pattern. The facility reported that 39 residents had swallowing disorders.

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for 1of 5 residents (#1) who were reviewed for accidents in that: The facility failed to feed Resident #1 when he should have been fed and was served cut up pieces of sausage instead of ground meat. As a result, Resident #1 choked on pieces of meat and died due to asphyxiation. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 39 residents with swallowing disorders and requiring mechanically altered food at risk for choking and aspiration of food due to not being served the appropriate form of food and not being fed. The findings were: Review of Resident #1's undated admission face sheet revealed the resident was admitted to the facility on [DATE] with a medical history of [REDACTED]. Review of initial admission orders [REDACTED]. Review of the attending physician's history and physical dated [DATE] revealed that Resident #1 was a poor historian due to cognitive and psychiatric impairment as a result of a middle cerebral artery aneurysm rupture in 1992 and was admitted to the facility from the local state hospital after being treated for [REDACTED].#1 became agitated and aggressive and was difficult to understand due to hypophonic voice (soft speech, especially resulting from a lack of coordination in the vocal musculature and a common presentation in Parkinson's disease). Review of the initial MDS dated [DATE] revealed the resident had a swallow disorder and required limited assistance. The resident's diet was mechanically altered. The most recent MDS dated [DATE] assessed Resident #1 having difficulty focusing attention and being easily distracted; and having disorganized thinking and incoherent (rambling or irrelevant conversation). Eating in section G (Functional Status) required 1 person's physical assistance. Section K, Swallowing/Nutritional Status did not assess for swallowing disorder. Review of a nutritional assessment dated [DATE] revealed Resident #1 required a regular/liberalized diet type, dysphagia advanced diet texture. (Dysphagia Advanced Diet is defined by the facility's diet manual dated 2015 as foods that are difficult to chew and/or swallow are modified in any of the following ways: chopped, ground, shredded. The nutritional assessment also documented that Resident #1 exhibited combative behavior by pushing plates off the tables during meals; and needed assistance with meals. Resident #1 was ordered food to be served on plastic plates due to throwing them. Review of the facility's dining room rounds tracking log, dated [DATE], documented that Resident #1 required total assistance with eating. Review of nursing notes dated [DATE] revealed documentation that Resident #1 was totally dependent for eating as the resident would attempt to feed himself, but was unable to put food safely in his mouth at one time. A second note dated [DATE] documented the resident was totally dependent (on staff) for eating. Review of a care plan dated [DATE] revealed that Resident #1 required extensive assist of 1 for eating. Extensive assistance included encouraging the resident to take small sips and bites; to encourage the resident to chew and swallow each bite; and to monitor the resident for signs/symptoms of aspiration such as coughing, watery eyes, and choking and/or moist sounding voice. There was no documentation in the care plan instructing staff to prevent the resident from grabbing at food and putting food into his mouth. Review of a speech therapist evaluation dated [DATE] revealed that Resident #1 had a mild oropharyngeal dysphagia (difficulty transferring food from the mouth into the pharynx and esophagus to initiate the involuntary swallowing process) and severe cognitive-communication deficit which impacted on his overall swallowing function, safety, understanding, verbal expression of his basic wants/needs, safety awareness, self-monitoring, reasoning, judgment, orientation, problem solving and executive function for toleration of least restrictive diet. The recommended strategies were: 100% closely supervised feedings with nursing assistance, upright positioning during meals, small bites/sips and additional dry swallows as indicated. Resident #1 required assistance with feeding secondary to impulsivity and executive function deficit, which impairs his ability to recall and use trained safety precautions for swallowing. Review of the attending physician's progress report dated [DATE] revealed that the resident was recovering from pneumonia and required nurses to anticipate the resident's needs. The attending physician documented that Resident #1resident had not had any recent choking episodes. Review of the menu for the evening meal on [DATE] revealed residents were served sausage, pepper and onions, parsley potato, seasoned spinach and dinner roll. According to a facility dietary manual dated [DATE] on the preparation of dysphagia advance diet, Sausage, Pepper and Onion, Ground, the sausage was to be ground as follows: transfer sausage to food processor, chop to rice size pieces. Transfer back to pan, stir. Review of an incident report dated [DATE] revealed that at 6:00 p.m., Resident #1 was sitting at a table with 2 other residents in the assisted dining room. The report described Resident #1 as needing extensive assistance for impulse control and supervision due to grabbing food. Resident #1 was unsupervised waiting to be served and began choking. Staff performed Heimlich and called 911. The resident was transported to the ER and died and was pronounced at 6:50 p.m. Review of an emergency provider report dated [DATE] revealed that Resident #1 had a cardiac arrest after choking on a piece of meat at the nursing home. Per EMS, pt. was found unresponsive after choking at 1800 today. EMS pulled out a lot of food out of our pt. as they intubated him. They do not know if someone performed the Heimlich maneuver. They were doing CPR when EMS got there. The provider report also assessed the resident with: Symmetric dilated pupils and face is cyanotic; and ET tube present with food debris in tube. The emergency physician determined that: Primary impression: Aspiration into airway. and Secondary impression: cardiac arrest. Time of death called at 1855. Review of Resident #1's tray card dated [DATE] revealed the resident was to be served dysphagia advance (textured) meals on a lip plate. During an interview on [DATE] at 12:05 p.m., the Food Service Manager stated that although she was not in the building on [DATE], she interviewed the cooks preparing the evening meal and they reported that Resident #1's tray was not served and was still on the last cart (#7), when the resident began to choke. The Food Service Manager stated that Resident #1 was probably served some other resident's tray. The Food Service Manager also stated that 24 residents within the facility were served dysphagia advance diets, including her father, who was a resident in the facility. During an interview on [DATE] at 2:30 p.m., RN N, Weekend Supervisor, stated that when she was called to the assisted dining room at 6:00 p.m. on [DATE], Resident #1 was already on the floor. She stated that she started CPR. When asked if she was in the dining room, RN N stated that she was outside in the parking lot speaking to her ex-husband. RN N stated that she observed a tray of food on the table where Resident #1 had been sitting, but did not recall what type of food was on the plate. She stated that CNA J, agency staff, was sitting at the table also. RN N stated that when she reported Resident #1 had choked to the resident's daughter, the daughter asked how this could happen because her father (Resident #1) was always fed and was not allowed to feed himself. RN N stated that she didn't know that and assumed the resident fed himself, because he had a plate with a rim. During an interview on [DATE] at 2:50 p.m., CNA G stated that Resident #1 was always fed by staff and that his tray was left on the cart and served last. CNA G stated that she was assisting in the dining room and that CNAs H and I were passing out trays, because CNA J didn't know the residents. During an interview on [DATE] at 3:00 p.m., CNA H stated that he worked the evening shift on [DATE] and was passing out trays to the residents. He reported that he had told CNA J twice to not allow Resident #1 to feed himself. CNA H stated that he placed the tray of food in front of Resident #1 and left the table to feed other residents. He stated that he had his back to Resident #1's table and did not see if Resident #1 fed himself, or if he had been fed. During an interview on [DATE] at 3:25 p.m., CNA I stated that she worked the evening shift on [DATE] and reported that all the facility staff knew that Resident #1 had to be fed, because the resident grabbed food off of other's plates and pushed food into his mouth. She stated that the incident was preventable. During an interview on [DATE] at 5:30 p.m., CNA K stated that other CNAs took turns feeding Resident #1 and that the resident was always served last, because of his behaviors. She stated that all the CNAs had an electronic notepad that described the care to be given to all the residents. During the interview, CNA K demonstrated the notepad and accessed the care plan of another resident that was fed. There were several choices regarding eating. CNA K stated that the resident required extensive assistance which he understood that the resident was to be fed. During an interview on ,[DATE] at 5:20 p.m., CNA L stated that Resident #1 was not allowed to feed himself. When asked how he knew the resident required to be fed, he stated that everyone knew the resident had to be fed and had fed him many times. He stated that Resident #1's tray was always kept out of reach so the resident could not grab the food. During an interview on [DATE] at 6:00 p.m., Medication Aide M stated that he had worked in the facility for [AGE] years and had fed Resident #1 on many occasions. He stated that the resident was not allowed to feed himself as he would grab food and push the food into his mouth. During an interview on [DATE] at 6:11 p.m., CNA J stated that he worked for a staffing agency and worked in the facility on [DATE] from 4:00 p.m. to 12:00 midnight. He stated that he was assigned to the hall in which Resident #1 had resided and understood that the resident required total care. CNA J stated that after providing incontinent care to Resident #1, he pushed the resident to the dining room in his wheelchair. CNA J stated that he was assigned to simultaneously feed 2 other residents (#2 and 3) and was seated between them, when Resident #1 was served his tray by CNA H. Resident #1 was sitting in his wheelchair across from him at the square table. He stated that CNA H placed the tray of food in front of Resident #1 and told him that he had to feed Resident #1. CNA J stated that he questioned the instructions and stated that he could not feed Resident #1 and the other 2 residents. CNA H then stated that Resident #1 could feed himself but was sloppy. CNA J stated that he was busy feeding the other 2 residents and did not see Resident #1 feed himself. He then noticed that Resident #1 had turned his wheelchair around and was propelling away from the table. CNA J stated that he observed LVN N speaking to the resident and asking if he was all right. CNA J stated that he suggested that maybe LVN N should sweep the resident's mouth for food. At that time, LVN N turned to CNA J and instructed him to call 911 at the nurses' station. During an interview on [DATE] at 2:25 p.m., the attending physician reported that he had been asked by the city's medical examiner how to categorize Resident #1's death, natural or accidental. The physician stated that he informed the medical examiner that due to the choking, the death was accidental. The physician stated that Resident #1 could not protect himself (from choking) due to his mental capacity. During an interview on [DATE] at 1:15 p.m., LVN S stated that she had worked the evening shift on [DATE] and was passing out trays to residents on the West Wing. She stated that she had observed the Weekend Supervisor standing in the parking lot outside of the building speaking with her ex-husband and little son. When she reentered the assisted feeding dining room, she noticed activity at a table and someone shouted to get the weekend supervisor. At that moment the supervisor appeared through another door and began to perform CPR. LVN S stated that she also assisted with compressions and while standing next to the table that Resident #1 sat at she noticed that the plate had cut up pieces of sausage and potatoes. She stated that when a mouth sweep was performed on the resident, pieces of meat were extracted. She stated that the meat was not ground and that they were pulling out chunks of meat. She stated that she had small children and cut pieces of meat in the same way so they could chew the meat. Review of the facility's health care guideline, dated [DATE], Dementia Care Dining Guidelines, resident with dementia included the following guidelines: a. Assessments need to address nutritional problems and resident characteristics such as poor dental health, swallowing difficulties or distractibility during meals that may affect food and fluid consumption (e.g., refer to dietitian for residents who are at high risk for nutritional problems; refer residents with swallowing difficulties to speech therapy for dysphagia evaluation). b. Staff sits on the side of the resident, make eye contact and speak with residents when assisting with meals. c. Residents are given enough time to open their mouth, chew and swallow. Drinks are offered regularly to moisten the mouth, wash food down and provide hydration. d. Staff is aware of resident's eating and nutritional issues. Review of the facility's policy for Meal Service in Dining Service date [DATE], revealed that staff were to: a. Check items on the tray against diet care for accuracy. b. Assure correct meal is served to the patient. c. Assist patient with eating and provide assistance/supervision based on patient's current level of self-performance in eating. The Administrator was notified on [DATE] at 2:37 p.m. of an Immediate Jeopardy for the above failures and a Plan of Removal was requested. The facility's Plan of Removal was provided by the Administrator on [DATE] and included the following steps to be taken by the facility: a. On [DATE], the Center Nurse Executive (DON) revised the orientation onboarding guide for direct care agency staff which included orientation on Resident Rights, Abuse, Safety, Reports, Documentation, Skin Management and Meal Service to include feeding assistance, upright positioning, alternating food and fluids, multiple swallow and signs and symptoms of choking. All agency direct care staff could not begin their shift until the orientation was completed. b. On [DATE], the facility began in-servicing direct care nursing staff regarding the Heimlich maneuver and included signs and symptoms of choking. In-services also included the supervision of residents requiring assistance with meals and proper feeding techniques as specified by the speech therapy department. In-services were also conducted on how to redirect residents with behavioral disorders at meal time. c. On [DATE], the direct care staff were in-serviced on how to utilize the Kardex too (electric notepad) to communicate resident care plans. Staff was instructed on how to translate the codes which indicated specific instructions such as feeding and/or supervision. d. On [DATE], care plans of residents with dysphagia and swallowing issues were updated to include specific instructions specified by the Speech Therapy Department. Any resident presenting with swallowing difficulty was to be referred to the department for evaluation immediately and any and all recommendations would be reviewed by the Center Nurse Executive. e. On [DATE], nursing meal supervisors were in-serviced on the use of the Meal Supervision Tool in order to familiarize supervisors with the individual needs of each resident and to have them ensure that care plans were being implemented for each resident. The tool was to be utilized twice a day for 30 days and then during random observations. The Center Nurse Executive was to report the use of the tool and findings to the monthly Quality Assurance Committee, which included the Medical Director and Administrator. Verification of the Plan of Removal was as follows: Observations and interviews of both facility and agency direct care staff conducted on [DATE], confirmed that the in-services had been conducted. All employed staff members, with the exception of 3 weekend staff members, were in-serviced either during their shifts, or prior to starting their shifts. Observations during the evening meal on [DATE] confirmed that residents with dysphasia advance diets were being served the appropriately altered meal items. Observations during the dispersing of food items by the cooks during the evening meal confirmed that the chicken being served had undergone a grounding process prior to being served. On [DATE] at 7:30 p.m., the Administrator was informed that the IJ was removed. However, the facility remained out of compliance with a severity of actual harm with a scope identified as pattern. The facility reported that 39 residents had swallowing disorders.

Based on observation, interview and record review, the facility failed to failed to develop and implement policies and procedures that prohibited the neglect of 1 of 5 residents (#1) whose care was reviewed for neglect in that: The facility failed to feed Resident #1 when he should have been fed and was served cut up pieces of sausage instead of ground meat. As a result, Resident #1 choked on pieces of meat and died due to asphyxiation. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 39 residents with swallowing disorders and requiring mechanically altered food at risk for choking and aspiration of food due to not being served the appropriate form of food and not being fed. The findings were: Review of Resident #1's undated admission face sheet revealed the resident was admitted to the facility on [DATE] with a medical history of [REDACTED]. Review of initial admission orders [REDACTED]. Review of the attending physician's history and physical dated [DATE] revealed that Resident #1 was a poor historian due to cognitive and psychiatric impairment as a result of a middle cerebral artery aneurysm rupture in 1992 and was admitted to the facility from the local state hospital after being treated for [REDACTED].#1 became agitated and aggressive and was difficult to understand due to hypophonic voice (soft speech, especially resulting from a lack of coordination in the vocal musculature and a common presentation in [MEDICAL CONDITION]). Review of the initial MDS dated [DATE] revealed the resident had a swallow disorder and required limited assistance. The resident's diet was mechanically altered. The most recent MDS dated [DATE] assessed Resident #1 having difficulty focusing attention and being easily distracted; and having disorganized thinking and incoherent (rambling or irrelevant conversation). Eating in section G (Functional Status) required 1 person's physical assistance. Section K, Swallowing/Nutritional Status did not assess for swallowing disorder. Review of a nutritional assessment dated [DATE] revealed Resident #1 required a regular/liberalized diet type, dysphagia advanced diet texture. (Dysphagia Advanced Diet is defined by the facility's diet manual dated 2015 as foods that are difficult to chew and/or swallow are modified in any of the following ways: chopped, ground, shredded. The nutritional assessment also documented that Resident #1 exhibited combative behavior by pushing plates off the tables during meals; and needed assistance with meals. Resident #1 was ordered food to be served on plastic plates due to throwing them. Review of the facility's dining room rounds tracking log, dated [DATE], documented that Resident #1 required total assistance with eating. Review of nursing notes dated [DATE] revealed documentation that Resident #1 was totally dependent for eating as the resident would attempt to feed himself, but was unable to put food safely in his mouth at one time. A second note dated [DATE] documented the resident was totally dependent (on staff) for eating. Review of a care plan dated [DATE] revealed that Resident #1 required extensive assist of 1 for eating. Extensive assistance included encouraging the resident to take small sips and bites; to encourage the resident to chew and swallow each bite; and to monitor the resident for signs/symptoms of aspiration such as coughing, watery eyes, and choking and/or moist sounding voice. There was no documentation in the care plan instructing staff to prevent the resident from grabbing at food and putting food into his mouth. Review of a speech therapist evaluation dated [DATE] revealed that Resident #1 had a mild oropharyngeal dysphagia (difficulty transferring food from the mouth into the pharynx and esophagus to initiate the involuntary swallowing process) and severe cognitive-communication deficit which impacted on his overall swallowing function, safety, understanding, verbal expression of his basic wants/needs, safety awareness, self-monitoring, reasoning, judgment, orientation, problem solving and executive function for toleration of least restrictive diet. The recommended strategies were: 100% closely supervised feedings with nursing assistance, upright positioning during meals, small bites/sips and additional dry swallows as indicated. Resident #1 required assistance with feeding secondary to impulsivity and executive function deficit, which impairs his ability to recall and use trained safety precautions for swallowing. Review of the attending physician's progress report dated [DATE] revealed that the resident was recovering from pneumonia and required nurses to anticipate the resident's needs. The attending physician documented that Resident #1resident had not had any recent choking episodes. Review of the menu for the evening meal on [DATE] revealed residents were served sausage, pepper and onions, parsley potato, seasoned spinach and dinner roll. According to a facility dietary manual dated [DATE] on the preparation of dysphagia advance diet, Sausage, Pepper and Onion, Ground, the sausage was to be ground as follows: transfer sausage to food processor, chop to rice size pieces. Transfer back to pan, stir. Review of an incident report dated [DATE] revealed that at 6:00 p.m., Resident #1 was sitting at a table with 2 other residents in the assisted dining room. The report described Resident #1 as needing extensive assistance for impulse control and supervision due to grabbing food. Resident #1 was unsupervised waiting to be served and began choking. Staff performed [MEDICATION NAME] and called 911. The resident was transported to the ER and died and was pronounced at 6:50 p.m. Review of an emergency provider report dated [DATE] revealed that Resident #1 had a [MEDICAL CONDITION] after choking on a piece of meat at the nursing home. Per EMS, pt. was found unresponsive after choking at 1800 today. EMS pulled out a lot of food out of our pt. as they intubated him. They do not know if someone performed the [MEDICATION NAME] maneuver. They were doing CPR when EMS got there. The provider report also assessed the resident with: Symmetric dilated pupils and face is cyanotic; and ET tube present with food debris in tube. The emergency physician determined that: Primary impression: Aspiration into airway. and Secondary impression: [MEDICAL CONDITION]. Time of death called at 1855. Review of Resident #1's tray card dated [DATE] revealed the resident was to be served dysphagia advance (textured) meals on a lip plate. During an interview on [DATE] at 12:05 p.m., the Food Service Manager stated that although she was not in the building on [DATE], she interviewed the cooks preparing the evening meal and they reported that Resident #1's tray was not served and was still on the last cart (#7), when the resident began to choke. The Food Service Manager stated that Resident #1 was probably served some other resident's tray. The Food Service Manager also stated that 24 residents within the facility were served dysphagia advance diets, including her father, who was a resident in the facility. During an interview on [DATE] at 2:30 p.m., RN N, Weekend Supervisor, stated that when she was called to the assisted dining room at 6:00 p.m. on [DATE], Resident #1 was already on the floor. She stated that she started CPR. When asked if she was in the dining room, RN N stated that she was outside in the parking lot speaking to her ex-husband. RN N stated that she observed a tray of food on the table where Resident #1 had been sitting, but did not recall what type of food was on the plate. She stated that CNA J, agency staff, was sitting at the table also. RN N stated that when she reported Resident #1 had choked to the resident's daughter, the daughter asked how this could happen because her father (Resident #1) was always fed and was not allowed to feed himself. RN N stated that she didn't know that and assumed the resident fed himself, because he had a plate with a rim. During an interview on [DATE] at 2:50 p.m., CNA G stated that Resident #1 was always fed by staff and that his tray was left on the cart and served last. CNA G stated that she was assisting in the dining room and that CNAs H and I were passing out trays, because CNA J didn't know the residents. During an interview on [DATE] at 3:00 p.m., CNA H stated that he worked the evening shift on [DATE] and was passing out trays to the residents. He reported that he had told CNA J twice to not allow Resident #1 to feed himself. CNA H stated that he placed the tray of food in front of Resident #1 and left the table to feed other residents. He stated that he had his back to Resident #1's table and did not see if Resident #1 fed himself, or if he had been fed. During an interview on [DATE] at 3:25 p.m., CNA I stated that she worked the evening shift on [DATE] and reported that all the facility staff knew that Resident #1 had to be fed, because the resident grabbed food off of other's plates and pushed food into his mouth. She stated that the incident was preventable. During an interview on [DATE] at 5:30 p.m., CNA K stated that other CNAs took turns feeding Resident #1 and that the resident was always served last, because of his behaviors. She stated that all the CNAs had an electronic notepad that described the care to be given to all the residents. During the interview, CNA K demonstrated the notepad and accessed the care plan of another resident that was fed. There were several choices regarding eating. CNA K stated that the resident required extensive assistance which he understood that the resident was to be fed. During an interview on ,[DATE] at 5:20 p.m., CNA L stated that Resident #1 was not allowed to feed himself. When asked how he knew the resident required to be fed, he stated that everyone knew the resident had to be fed and had fed him many times. He stated that Resident #1's tray was always kept out of reach so the resident could not grab the food. During an interview on [DATE] at 6:00 p.m., Medication Aide M stated that he had worked in the facility for [AGE] years and had fed Resident #1 on many occasions. He stated that the resident was not allowed to feed himself as he would grab food and push the food into his mouth. During an interview on [DATE] at 6:11 p.m., CNA J stated that he worked for a staffing agency and worked in the facility on [DATE] from 4:00 p.m. to 12:00 midnight. He stated that he was assigned to the hall in which Resident #1 had resided and understood that the resident required total care. CNA J stated that after providing incontinent care to Resident #1, he pushed the resident to the dining room in his wheelchair. CNA J stated that he was assigned to simultaneously feed 2 other residents (#2 and 3) and was seated between them, when Resident #1 was served his tray by CNA H. Resident #1 was sitting in his wheelchair across from him at the square table. He stated that CNA H placed the tray of food in front of Resident #1 and told him that he had to feed Resident #1. CNA J stated that he questioned the instructions and stated that he could not feed Resident #1 and the other 2 residents. CNA H then stated that Resident #1 could feed himself but was sloppy. CNA J stated that he was busy feeding the other 2 residents and did not see Resident #1 feed himself. He then noticed that Resident #1 had turned his wheelchair around and was propelling away from the table. CNA J stated that he observed LVN N speaking to the resident and asking if he was all right. CNA J stated that he suggested that maybe LVN N should sweep the resident's mouth for food. At that time, LVN N turned to CNA J and instructed him to call 911 at the nurses' station. During an interview on [DATE] at 2:25 p.m., the attending physician reported that he had been asked by the city's medical examiner how to categorize Resident #1's death, natural or accidental. The physician stated that he informed the medical examiner that due to the choking, the death was accidental. The physician stated that Resident #1 could not protect himself (from choking) due to his mental capacity. During an interview on [DATE] at 1:15 p.m., LVN S stated that she had worked the evening shift on [DATE] and was passing out trays to residents on the West Wing. She stated that she had observed the Weekend Supervisor standing in the parking lot outside of the building speaking with her ex-husband and little son. When she reentered the assisted feeding dining room, she noticed activity at a table and someone shouted to get the weekend supervisor. At that moment the supervisor appeared through another door and began to perform CPR. LVN S stated that she also assisted with compressions and while standing next to the table that Resident #1 sat at she noticed that the plate had cut up pieces of sausage and potatoes. She stated that when a mouth sweep was performed on the resident, pieces of meat were extracted. She stated that the meat was not ground and that they were pulling out chunks of meat. She stated that she had small children and cut pieces of meat in the same way so they could chew the meat. Review of the facility's health care guideline, dated [DATE], Dementia Care Dining Guidelines, resident with dementia included the following guidelines: a. Assessments need to address nutritional problems and resident characteristics such as poor dental health, swallowing difficulties or distractibility during meals that may affect food and fluid consumption (e.g., refer to dietitian for residents who are at high risk for nutritional problems; refer residents with swallowing difficulties to speech therapy for dysphagia evaluation). b. Staff sits on the side of the resident, make eye contact and speak with residents when assisting with meals. c. Residents are given enough time to open their mouth, chew and swallow. Drinks are offered regularly to moisten the mouth, wash food down and provide hydration. d. Staff is aware of resident's eating and nutritional issues. Review of the facility's policy for Meal Service in Dining Service date [DATE], revealed that staff were to: a. Check items on the tray against diet care for accuracy. b. Assure correct meal is served to the patient. c. Assist patient with eating and provide assistance/supervision based on patient's current level of self-performance in eating. Review of the facility ' s abuse, neglect and exploitation prohibition policy dated [DATE] specified that neglect was defined as failure to provide goods and services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation or resident property, will include: identifying, correcting and intervening in situations in which abuse, neglect and/or misappropriation of patient property is more likely to occur. The Administrator was notified on [DATE] at 2:37 p.m. of an Immediate Jeopardy for the above failures and a Plan of Removal was requested. The facility's Plan of Removal was provided by the Administrator on [DATE] and included the following steps to be taken by the facility: a. On [DATE], the Center Nurse Executive (DON) revised the orientation onboarding guide for direct care agency staff which included orientation on Resident Rights, Abuse, Safety, Reports, Documentation, Skin Management and Meal Service to include feeding assistance, upright positioning, alternating food and fluids, multiple swallow and signs and symptoms of choking. All agency direct care staff could not begin their shift until the orientation was completed. b. On [DATE], the facility began in-servicing direct care nursing staff regarding the [MEDICATION NAME] maneuver and included signs and symptoms of choking. In-services also included the supervision of residents requiring assistance with meals and proper feeding techniques as specified by the speech therapy department. In-services were also conducted on how to redirect residents with behavioral disorders at meal time. c. On [DATE], the direct care staff were in-serviced on how to utilize the Kardex too (electric notepad) to communicate resident care plans. Staff was instructed on how to translate the codes which indicated specific instructions such as feeding and/or supervision. d. On [DATE], care plans of residents with dysphagia and swallowing issues were updated to include specific instructions specified by the Speech Therapy Department. Any resident presenting with swallowing difficulty was to be referred to the department for evaluation immediately and any and all recommendations would be reviewed by the Center Nurse Executive. e. On [DATE], nursing meal supervisors were in-serviced on the use of the Meal Supervision Tool in order to familiarize supervisors with the individual needs of each resident and to have them ensure that care plans were being implemented for each resident. The tool was to be utilized twice a day for 30 days and then during random observations. The Center Nurse Executive was to report the use of the tool and findings to the monthly Quality Assurance Committee, which included the Medical Director and Administrator. Verification of the Plan of Removal was as follows: Observations and interviews of both facility and agency direct care staff conducted on [DATE], confirmed that the in-services had been conducted. All employed staff members, with the exception of 3 weekend staff members, were in-serviced either during their shifts, or prior to starting their shifts. Observations during the evening meal on [DATE] confirmed that residents with dysphasia advance diets were being served the appropriately altered meal items. Observations during the dispersing of food items by the cooks during the evening meal confirmed that the chicken being served had undergone a grounding process prior to being served. On [DATE] at 7:30 p.m., the Administrator was informed that the IJ was removed. However, the facility remained out of compliance with a severity of actual harm with a scope identified as pattern. The facility reported that 39 residents had swallowing disorders.

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 11 residents (Resident #s 1 and 6) whose care was reviewed for safe eating/drinking in that: 1. Resident #1 was not being supervised during meal service and was not served all of her hot liquids in a cup with a lid as ordered. Kitchen staff were not consistently monitoring temperatures of coffee and hot liquids. Resident #1 spilled hot coffee on herself in the dining room which resulted in redness and tenderness to her upper leg. 2. Resident #6 was not served all of his hot liquids in a cup with a lid as ordered. Kitchen staff were not consistently monitoring temperatures of coffee and hot liquids. Resident #6 spilled hot soup on his legs while eating unsupervised in his room. His legs blistered as a result of the burn. These failures resulted in identification of an IJ (Immediate Jeopardy) on 9/14/16. While the IJ was removed on 9/14/16, the facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy due to the facility continuing to monitor the effectiveness of their plan of removal. These failures could affect 8 residents at the facility assessed to be at risk for coffee/hot liquid burns by contributing to injury. The findings were: 1. Record review of Resident #1's facesheet (dated 9/7/16) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's annual MDS assessment (ARD 8/2/16) revealed that she needed supervision and the assistance of one staff for eating and that her balance was not steady. She scored a 14 on the BIMS - indicating that she was cognitively intact. Record review of the facility's provider investigation report (signed and dated 9/12/16) for Resident #1's alleged neglect revealed that she was in the dining room getting herself a cup of coffee from the beverage cart and spilled coffee on herself. Resident #1 informed the nurse of the spill. She was immediately assessed and had a reddened area to her thigh. Resident #1 stated the area was tender but not painful. Her care plan was updated, staff were educated regarding hot beverages, a cup with a lid was ordered, and silver sulfadiazine 1% cream was ordered and applied. Investigation findings for the allegation of neglect were confirmed. Record review of Resident #1's 9/7/16 physician telephone order revealed that she was to be served hot beverages in a cup with a lid and that silver sulfadiazene 1% cream was to be applied to the affected area daily until resolved. Record review of Resident #1's change in condition skin check (dated 9/7/16) revealed that her left lateral leg was red and warm and measured 9.2 x 4 x 0 centimeters. Record review of Resident #1's care plan (updated 9/8/16 after the burn incident) revealed that she was to have a cup with a lid for all hot beverages. Record review of the kitchen's production worksheet report for 9/7/16 revealed that temperatures were recorded at dinner only. The dinner temperatures did not include coffee. Record review of a 9/7/16 inservice sign-in sheet revealed that dietary staff (including DAs D and E and Cook C) were taught about thermometer usage. The Thermometer Usage policy (dated 12/1/15) was reviewed with them. Record review of a 9/7/16 inservice sign-in sheet revealed that nursing staff were taught about assisting residents with hot beverages and monitoring the temperatures of these beverages. The Guidelines for Hot Beverages policy (dated 4/1/14) was reviewed with them. During an interview with Resident #1 at 11:58 a.m. on 9/13/16, she reported that kitchen staff brought her the cup of coffee that she spilled on her leg on 9/7/16 and that she did not get it herself. During an interview with MDS Nurse A at 3:30 p.m. on 9/13/16, she reported that CNA B reported Resident #1's coffee burn to her and that she was the first person to assess the area on 9/7/16. MDS Nurse A reported that Resident #1 did not have pants on and was covered with a blanket. The blanket covering her lap was wet and warm. MDS Nurse A reported that Resident #1's left upper thigh was bright pink/red and warm to touch but that Resident #1 did not complain of pain. MDS Nurse A reported that the incident happened after lunch and that Resident #1 said she had gotten the coffee from the beverage cart in the dining room. MDS Nurse A stated I personally think the coffee was served too hot. It was a while after lunch, and the coffee was in a carafe/pitcher. MDS Nurse A was unsure whether or not staff were in the dining room when she assessed Resident #1. She stated (CNA B) was taking the beverage cart to the kitchen when she saw (Resident #1) had burned herself. MDS Nurse A reported that the kitchen had gotten a brand new coffee maker not too long ago. During an interview with CNA B at 9:22 a.m. on 9/14/16, she reported that she was going to get a resident out of the small dining room on 9/7/16 when she heard someone yell. CNA B stated It was (Resident #1). She was getting coffee from the hydration cart in the big dining room. I asked her if she was okay, and she said she spilled a little coffee on herself. CNA B reported that MDS Nurse A assessed Resident #1 and that the area to her left lateral leg was red and tender to touch. CNA B reported that Resident #1 said Ow . ow! when MDS Nurse A assessed her. CNA B reported that MDS Nurse A was walking behind her and entered the big dining room after she did. She reported that nobody was in the big dining room supervising Resident #1 when Resident #1 served herself coffee from the hot beverage cart. CNA B stated Everybody was all cleared out. It was about 1:30/1:45 p.m. I guess they forgot to take out the hydration cart. CNA B reported that Resident #1 was using a maroon coffee cup without a lid. When asked what interventions were put in place after the incident, CNA B reported that the beverage cart had to be taken back to the kitchen immediately after meal service and that certain residents were to be served coffee in cups with lids only. When asked how staff knew which residents needed cups with lids, CNA B stated It depends - just what we know about the resident. I am using my personal judgment and am unaware of any kind of list. When asked if she thought the coffee was too hot on the day of Resident #1's coffee burn, CNA B stated I'm sure it was. During an interview with LVN G at 9:33 a.m. on 9/14/16, she reported that she was Resident #1's charge nurse on the day of her coffee burn (9/7/16). LVN G reported that CNA B came to her at approximately 1:30 p.m. and told her that Resident #1 was trying to get herself coffee and spilled it on her leg. LVN G reported that the hot beverage cart was still in the big dining room and was unsupervised when she went to assess Resident #1. She reported that Resident #1's leg was red. When asked what interventions were put in place after the incident, LVN G reported that the kitchen was supposed to put the coffee away after meals and that certain residents were supposed to be served coffee in a blue cup with a lid. When asked how staff knew which residents needed cups with lids, LVN G stated It says on their meal tickets. Someone from the nursing staff is in the dining room while coffee is served. Nursing staff should know, but there is nothing in writing. Observation of DA E taking the temperature of the coffee from the maker in the kitchen at 4:02 p.m. on 9/13/16 (after surveyor request) revealed that the coffee temperature was 166 degrees Fahrenheit. Observation at 4:04 p.m. on 9/13/16 revealed Resident #1 in her wheelchair at the kitchen door asking for coffee. Cook C dispensed coffee from the above maker into a blue cup with a lid and served it to Resident #1. Resident #1 placed the blue cup of coffee between her legs and self-propelled her wheelchair from the kitchen. Observation of Resident #1 eating dinner in the lobby area outside of the main dining room and the front nursing station at 5:28 p.m. on 9/13/16 revealed that no staff were present. Resident #1 had a blue cup with a lid in front of her. In addition to the blue cup with a lid, she had 2 maroon coffee mugs (both filled with what appeared-to-be coffee) without lids in front of her. During an interview with Resident #1 at this time, she confirmed that the mugs contained coffee. 2. Record review of Resident #6's electronic facesheet (not dated) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's annual MDS assessment (ARD 6/9/16) revealed that he needed supervision and setup help only for eating and that his balance was not steady. He scored a 9 on the BIMS - indicating moderate cognitive impairment. Record review of Resident #6's nursing progress note (dated 6/20/16) revealed that, at 1530 (3:30 p.m.), he spilled hot soup down his right leg and on top of his right foot. His pants and shoe and sock were immediately removed, and his leg and foot were pink but not blistered. At 1660 (5:00 p.m.), blisters were noted to his right foot and leg. Daily silvadene was ordered. Resident #6 complained of pain at a 3 on a 10-point scale. On 8/11/16, all burn areas to his right leg were documented as healed. Record review of Resident #6's 6/20/16 incident/accident report revealed that he fell asleep and spilled hot soup on himself in his room. Staff were inserviced and told that Resident #6 was to inform staff when he wanted soup or a hot drink and that staff were to take him to his room or to wherever he wanted to eat/drink it. Record review of Resident #6's 6/20/16 risk management system report revealed that he was carrying a cup of hot soup in a styrofoam cup with a lid and spilled it on himself (down his right leg, under his knee, and on top of his foot). Record review of the facility's initial submission provider investigation report for Resident #6's 6/20/16 incident revealed resident with minor burns from over warmed soup. Provider response was Nursing informed physician of occurrence and physician ordered application of silvadene treatment daily and monitoring of signs and symptoms of infection. Charge nurse also instructed dietary staff member to ensure food and/or beverages given to residents were not 'too hot'. Inservicing of nursing staff followed to address the need for promptness in reporting this type of incident to DON and administrator. Additionally, inservicing of dietary staff to ensure proper temperature of food and/or drink for residents is followed up with dietary manager. After an email was sent from the corporate nurse consultant to the administrator and recommended changes were made, record review of the facility's provider investigation report for Resident #6's 6/20/16 incident revealed that he had minor burns from soup. Investigation summary was Preliminary investigation has shown the dietary staff presented the resident with the bouillon soup which he requests on an almost daily basis. This was provided to him in a cup with a lid. Additionally, the charge nurse checked on the resident when he was outside of his door and had yelled for help. It was the charge nurse and the CNA who then removed the resident's trouser and sock, revealing a pinkish area on his leg and foot. At that time, the charge nurse phoned the physician and was given an order of silvadene cream to be applied daily and to monitor for signs and symptoms of infection. The treatment nurse then followed with placement of the silvadene cream and reassessed the area to find a blister was now apparent. The physician was recalled and again the order for silvadene was provided. Investigation findings were confirmed. Provider action taken post-investigation was Inservice with dietary staff regarding food temperatures, inservice regarding abuse/neglect for dietary staff, inservice for nursing staff regarding timeliness of reporting significant events, education for dietary staff to check temperatures of all prepared items requested before serving (prn requests), and an audit of meal temperatures will be conducted daily for one week. Record review of Resident #6's 6/21/16 physician telephone order revealed that he was to be served hot liquids in a cup with a lid and that silvadene cream 1% was to be applied to the affected area (for burn to right foot) twice daily. Record review of Resident #6's care plan (dated 6/23/16) revealed no documentation pertaining to hot liquids and/or a cup with a lid. During an interview with the regional nurse consultant at 12:00 p.m. on 9/15/16, she reviewed resident care plans with the surveyor and clarified that use covered cup when consuming hot beverages was added on 9/14/16. She confirmed that, although there were some residents needing covered cups prior to 9/14/16, this had not been care-planned. Record review of the kitchen's production worksheet report for 6/20/16 revealed that no temperatures were recorded. Record review of a 6/21/16 inservice sign-in sheet revealed that dietary staff (including DA D and Cook C) were taught about hot food safety. They were told that coffee, tea, soup, and broth should not be hotter than 180 degrees Fahrenheit and should be served in plastic, insulated mugs or bowls and not foam cups. The Guidelines for Hot Beverages policy (dated 4/1/14) was reviewed with them. Record review of a 6/21/16 inservice sign-in sheet revealed that all staff (including DA D and Cook C) were taught to assist residents with an unsteady gait in carrying soups or drinks from the kitchen and to place liquids received from the kitchen on stable furniture of resident's preference. Staff were to inform kitchen staff of residents who were not self-ambulatory and without present assistance if they requested hot liquids so that direct care staff could assist them. Record review of a 6/22/16 inservice sign-in sheet revealed that dietary staff (including DA D and Cook C) were taught about taking and recording the temperatures of all hot and cold foods to include hot water and coffee. The Thermometer Usage policy (dated 12/1/15) was reviewed with them. Record review of a 6/22/16 invoice revealed that the holding tank temperature of the coffee maker was adjusted to 184 degrees Fahrenheit per the dietary supervisor. Observation of Resident #6 eating dinner in the main dining room at 5:40 p.m. on 9/13/16 revealed that he was feeding himself pineapple tidbits and was shaking as he brought his spoon to his mouth, spilling pineapple tidbits on his shirt. He had a styrofoam cup without a lid in front of him and was taking sips from it. The styrofoam cup had what-appeared-to-be coffee in it. During an interview with Resident #6 at this time, he reported that the styrofoam cup contained coffee. During an interview with Cook C at 3:45 p.m. on 9/13/16, she reported that the dietary supervisor spoke with kitchen staff after Resident #1's burn incident and told them that certain people required a special blue cup with a lid for hot beverages. Cook C reported that kitchen staff were told that the coffee temperature could not be greater than 165 degrees Fahrenheit when it left the kitchen. Cook C stated I don't know what the temperature was at the time of (Resident #1's) burn. (Resident #6) has burned himself before too. We should be taking the temperatures of the coffee and foods before they go out, but we get so busy. I didn't know we were supposed to be taking the temperatures of the coffee until the supervisor inserviced us after (Resident #1) spilled her coffee. I just made the coffee and put it out. Cook C reported that the dietary supervisor adjusted the temperature on the coffee maker after Resident #1's incident and that kitchen staff were supposed to be keeping temperature logs now. She presented the surveyor with a red book in which all temperatures were supposed to be recorded (but were not) at this time. During an interview with DA E at 3:52 p.m. on 9/13/16, he reported that he checked coffee temperatures when I have time. If we're rushing, I forget. I don't take temperatures all of the time, but I try to remember. I try to keep it less than 165 (degrees Fahrenheit). Record review of the facility's temperature logs revealed that the temperature of the coffee was first recorded on 9/10/16 and was 165 degrees Fahrenheit. On 9/11/16, the coffee temperature was recorded once and was 165 degrees Fahrenheit. On 9/12/16, the coffee temperature was recorded twice and was 165 and 155 degrees Fahrenheit. On 9/13/16, the coffee temperature was recorded twice and was 160 and 165 degrees Fahrenheit. There were no food/hot liquid temperatures taken for breakfast or lunch 9/9/16; breakfast or lunch on 9/10/16; breakfast, lunch, or dinner on 9/11/16; breakfast, lunch, or dinner on 9/12/16; and breakfast and lunch on 9/13/16. During an interview with Cook C, DA D, and DA E at 4:04 p.m. on 9/13/16, they reported that the kitchen got a new coffee maker 2-3 weeks ago. They reported that there was no designated person for taking coffee temperatures. They reported that Resident #1 got her coffee from the kitchen on the day of her burn and was using a styrofoam cup without a lid. When asked which residents got a cup with a lid/how they knew which residents were to be served in the special cups, DA D stated Anyone with mobility problems, a walker, or a wheelchair. Cook C and DA E nodded in agreement. During an interview with the ADON at 4:10 p.m. on 9/13/16, she reported that Resident #6 spilled hot soup on himself on 6/20/16 and had blistering to his foot and legs. She stated I think the intervention for that was kitchen monitoring of temperatures. During a phone interview with the dietary supervisor at 4:18 p.m. on 9/13/16, he stated We don't have high temperature ranges. We have made efforts to make sure people aren't burning themselves. Certain residents use a blue cup with a lid - even if it spills, it comes out slowly. The dietary supervisor reported that the kitchen's old coffee maker was replaced approximately one month ago. He was on vacation at the time, and the new coffee maker was installed with the manufacturer settings. The dietary supervisor stated When (Resident #1's) burn happened, I had the maintenance man adjust the brew temperature range to 170 (degrees Fahrenheit). When asked if kitchen staff were doing any kind of temperature monitoring prior to Resident #1's burn incident, the dietary supervisor stated Some before. We started shortly before (Resident #1) got burned. When asked how kitchen staff monitored temperatures, the dietary supervisor stated We pour the coffee out of the maker and check it with a digital thermometer one time per meal 3 times per day. Staff are logging these temperatures in the kitchen red temperature log. The dietary supervisor reported that all temperatures taken by kitchen staff were supposed to be recorded in the red book. When asked what temperature was too high, the dietary supervisor stated I told them no greater than 180/185 (degrees Fahrenheit). If the temperature is higher than that, they are supposed to let it cool down before letting it leave the kitchen. The dietary supervisor reported that staff were supposed to be returning the hot beverage cart to the kitchen immediately after meal service but that Resident #1 served herself the hot coffee from the unsupervised hot beverage cart. During an interview with RN F at 5:41 p.m. on 9/13/16, when asked how she knew which residents needed to be served coffee in the blue mugs with lids, she stated They have to have an order for [REDACTED]. The kitchen sends out both cups. We serve based on who has what order. During an interview with DA D at 5:46 p.m. on 9/13/16, he reported that the coffee temperature for dinner was 165 (degrees Fahrenheit) when sent out on cart, I believe. During an interview with the dietary supervisor and the regional dietary manager at 10:10 a.m. on 9/14/16, they reported that there was a constant turnover of dietary staff but that the new processes for temperature monitoring should have been learned by now. The dietary supervisor confirmed that no food or liquid temperatures had been taken on 6/20/16 - the day of Resident #6's hot soup burn. During an interview with the RD at 12:20 p.m. on 9/14/16, she reported that Resident #6 often fell asleep when eating/drinking and that temperature monitoring had been a problem at the facility since she started working there in October of 2015. Record review of the facility's Guidelines for Hot Beverages policy (dated 4/1/14) revealed 1. Do not leave pots or urns of hot coffee or other hot beverages unattended - use toggle covers on urns to reduce risk of accidental dispensing. 2. Limit access of patients/residents to locations where hot beverages may be prepared or reheated such as break room and kitchen. 3. Discourage patients/residents from carrying cups of hot beverages without a lid while they are walking or moving in a wheelchair . Record review of the facility's Thermometer Usage policy (dated 12/1/15) revealed Food is tested throughout preparation and service to ensure the appropriate temperature is reached and maintained . Record the holding temperature of the foods being held for service on the production sheet. Action is taken if food is not within identified ranges, prior to service . Time/temperature control for safety foods reheated in a microwave for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees Fahrenheit and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating . Record review of the American Burn Association's Scald Injury Prevention Educator's Guide (not dated) revealed that exposure to a water temperature of 155 degrees Fahrenheit for a second could cause a third degree burn. The administrator was notified on 9/14/16 at 10:52 a.m. that an IJ situation had been identified due to the above failures. The facility's plan of removal was provided by the administrator on 9/14/16 and accepted on 9/14/16 at 5:06 p.m. The facility took the following actions (verified through observations of the dining areas and kitchen, interviews with residents and staff, and record reviews of resident assessments, care plans, and therapy evaluations) to remove the IJ: - The regional dietary manager conducted an inservice on the policy/procedure regarding food/beverage temperatures and recording to include a temperature range when served to resident of 135 to 155 degrees Fahrenheit for food/beverages served hot with the dietary supervisor on 9/14/16. - The dietary supervisor conducted an inservice on the policy/procedure regarding food/beverage temperatures and recording to include a temperature range when served to resident of 135 to 155 degrees Fahrenheit for food/beverages served hot with dietary staff on 9/13/16. - The dietary supervisor conducted an inservice on the facility guidelines for hot beverages and the policy/procedure for thermometer usage with dietary staff on 9/13/16. - The nurse practice educator conducted an inservice on the policy/procedure for meal service specific to assistance and supervision with direct care staff on 9/14/16. - The dietary supervisor started to bring food/beverage temperature logs to the morning meetings on 9/15/16. The administrator started to review these logs for completeness and compliance with temperature ranges on 9/15/16. The administrator will report the results of these reviews to the Quality Assurance (QA) Committee during the next 3 QA Committee meetings. The dietary supervisor will conduct inservices related to food/beverage temperatures and recording as needed per results of the reviews. - Utilizing the MDS assessments, nursing administration identified 57 residents requiring assistance with meals on 9/14/16. - Occupational therapy began screening of the residents identified as needing assistance per their Activities of Daily Living score in the eating section of the MDS on 9/14/16 to ensure residents could safely manage hot beverages. Per the results of the screens, occupational therapy will provide intervention recommendation to nursing services if identified as necessary. - Nursing administration began care-planning and implementing interventions per therapy recommendations to ensure residents could safely manage hot beverages on 9/14/16. - The administrator conducted an inservice on the center guidelines for hot beverages with department head meal monitors on 9/14/16. - The dietary supervisor began verification and documenting verification of food/beverage temperature prior to service to ensure compliance with temperature guidelines on 9/14/16. - The regional dietary manager started to develop (on 9/14/16) and the facility was to implement an onboarding guide for dietary agency staff to include center guidelines on food/beverage temperatures and recording. - All facility residents were provided with covered cups for hot beverage consumption on 9/15/16. If a resident was not in agreement with a covered cup, nursing administration began educating the resident/responsible party regarding the risks and included this on the resident's care plan. Observations of the dining rooms during dinner on 9/14/16, breakfast on 9/15/16, and lunch on 9/15/16 revealed that there was supervision at all times when the hot beverage cart was present. At breakfast and lunch on 9/15/16, all residents were served coffee/hot liquids in the new insulated cups with lids. The regional dietary manager was observed taking the temperatures of hot liquids/coffee at the time of meal service to residents. Interviews with dietary staff on 9/14/16 and 9/15/16 revealed that they had received training from the dietary supervisor and had learned that the temperatures of all hot liquids (including coffee and soup) were to be taken prior to them leaving the kitchen. The hot beverage cart was not to leave the kitchen unless nursing staff were present to supervise it. All temperatures were to be recorded in the red temperature monitoring log book. Residents were to be served coffee/hot liquids at temperatures within the 135 to 155 degrees Fahrenheit range, and all coffee/hot liquids were to be served to all residents in the new insulated cups with lids. Interviews with nursing and direct care staff on 9/14/16 and 9/15/16 revealed that they had received training from the nurse practice educator and had learned that the hot beverage cart was to be supervised at all times and that residents were to be served coffee/hot liquids at temperatures within the 135 to 155 degrees Fahrenheit range. All residents were to be served coffee/hot liquids in the the new insulated cups with lids. If a resident refused to use the new cup with lid, staff were to report the noncompliance to nursing administrative staff. Record review of the facility's temperature logs for dinner on 9/14/16 and breakfast on 9/15/16 revealed that they were complete and that temperatures for hot liquids were within the appropriate ranges. Record review of the occupational therapy screens for the 57 residents identified as needing assistance with eating based on their MDS assessments revealed that 16 were appropriate for occupational therapy evaluations and treatment. Record review of the care plans of 6 residents revealed that the need for covered cups with lids for coffee/hot liquids was added. Interview with the administrator on 9/15/16 revealed that she would be monitoring kitchen temperature logs at the morning meetings and addressing any issues with the dietary supervisor and the QA Committee. On 9/14/16 at 6:10 p.m., the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not an immediate jeopardy with the scope of pattern until all measures listed in the plan of removal were completed. According to information provided by the administrator on 9/20/16, there were 8 residents at risk for coffee/hot liquid burns.

Based on observations, interviews, and record reviews, the facility failed to develop and implement written policies and procedures that prohibited mistreatment, neglect, and abuse of residents and misappropriation of resident property for 2 of 11 residents (Resident #s 1 and 6) whose care was reviewed for safe eating/drinking in that: 1. Resident #1 was not being supervised during meal service and was not served all of her hot liquids in a cup with a lid as ordered. Kitchen staff were not consistently monitoring temperatures of coffee and hot liquids. Resident #1 spilled hot coffee on herself in the dining room which resulted in redness and tenderness to her upper leg. 2. Resident #6 was not served all of his hot liquids in a cup with a lid as ordered. Kitchen staff were not consistently monitoring temperatures of coffee and hot liquids. Resident #6 spilled hot soup on his legs while eating unsupervised in his room. His legs blistered as a result of the burn. These failures resulted in identification of an IJ (Immediate Jeopardy) on 9/14/16. While the IJ was removed on 9/14/16, the facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy due to the facility continuing to monitor the effectiveness of their plan of removal. These failures could affect 8 residents at the facility assessed to be at risk for coffee/hot [MEDICAL CONDITION] contributing to injury. The findings were: Record review of the facility's abuse prohibition policy (last revised 5/1/16) revealed (Corporation facilities) will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients . Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Record review of the facility's Guidelines for Hot Beverages policy (dated 4/1/14) revealed 1. Do not leave pots or urns of hot coffee or other hot beverages unattended - use toggle covers on urns to reduce risk of accidental dispensing. 2. Limit access of patients/residents to locations where hot beverages may be prepared or reheated such as break room and kitchen. 3. Discourage patients/residents from carrying cups of hot beverages without a lid while they are walking or moving in a wheelchair . Record review of the facility's Thermometer Usage policy (dated 12/1/15) revealed Food is tested throughout preparation and service to ensure the appropriate temperature is reached and maintained . Record the holding temperature of the foods being held for service on the production sheet. Action is taken if food is not within identified ranges, prior to service . Time/temperature control for safety foods reheated in a microwave for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees Fahrenheit and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating . 1. Record review of Resident #1's facesheet (dated 9/7/16) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's annual MDS assessment (ARD 8/2/16) revealed that she needed supervision and the assistance of one staff for eating and that her balance was not steady. She scored a 14 on the BIMS - indicating that she was cognitively intact. Record review of the facility's provider investigation report (signed and dated 9/12/16) for Resident #1's alleged neglect revealed that she was in the dining room getting herself a cup of coffee from the beverage cart and spilled coffee on herself. Resident #1 informed the nurse of the spill. She was immediately assessed and had a reddened area to her thigh. Resident #1 stated the area was tender but not painful. Her care plan was updated, staff were educated regarding hot beverages, a cup with a lid was ordered, and silver [MEDICATION NAME] 1% cream was ordered and applied. Investigation findings for the allegation of neglect were confirmed. Record review of Resident #1's 9/7/16 physician telephone order revealed that she was to be served hot beverages in a cup with a lid and that silver sulfadiazene 1% cream was to be applied to the affected area daily until resolved. Record review of Resident #1's change in condition skin check (dated 9/7/16) revealed that her left lateral leg was red and warm and measured 9.2 x 4 x 0 centimeters. Record review of Resident #1's care plan (updated 9/8/16 after the burn incident) revealed that she was to have a cup with a lid for all hot beverages. Record review of the kitchen's production worksheet report for 9/7/16 revealed that temperatures were recorded at dinner only. The dinner temperatures did not include coffee. Record review of a 9/7/16 inservice sign-in sheet revealed that dietary staff (including DAs D and E and Cook C) were taught about thermometer usage. The Thermometer Usage policy (dated 12/1/15) was reviewed with them. Record review of a 9/7/16 inservice sign-in sheet revealed that nursing staff were taught about assisting residents with hot beverages and monitoring the temperatures of these beverages. The Guidelines for Hot Beverages policy (dated 4/1/14) was reviewed with them. During an interview with Resident #1 at 11:58 a.m. on 9/13/16, she reported that kitchen staff brought her the cup of coffee that she spilled on her leg on 9/7/16 and that she did not get it herself. During an interview with MDS Nurse A at 3:30 p.m. on 9/13/16, she reported that CNA B reported Resident #1's coffee burn to her and that she was the first person to assess the area on 9/7/16. MDS Nurse A reported that Resident #1 did not have pants on and was covered with a blanket. The blanket covering her lap was wet and warm. MDS Nurse A reported that Resident #1's left upper thigh was bright pink/red and warm to touch but that Resident #1 did not complain of pain. MDS Nurse A reported that the incident happened after lunch and that Resident #1 said she had gotten the coffee from the beverage cart in the dining room. MDS Nurse A stated I personally think the coffee was served too hot. It was a while after lunch, and the coffee was in a carafe/pitcher. MDS Nurse A was unsure whether or not staff were in the dining room when she assessed Resident #1. She stated (CNA B) was taking the beverage cart to the kitchen when she saw (Resident #1) had burned herself. MDS Nurse A reported that the kitchen had gotten a brand new coffee maker not too long ago. During an interview with CNA B at 9:22 a.m. on 9/14/16, she reported that she was going to get a resident out of the small dining room on 9/7/16 when she heard someone yell. CNA B stated It was (Resident #1). She was getting coffee from the hydration cart in the big dining room. I asked her if she was okay, and she said she spilled a little coffee on herself. CNA B reported that MDS Nurse A assessed Resident #1 and that the area to her left lateral leg was red and tender to touch. CNA B reported that Resident #1 said Ow . ow! when MDS Nurse A assessed her. CNA B reported that MDS Nurse A was walking behind her and entered the big dining room after she did. She reported that nobody was in the big dining room supervising Resident #1 when Resident #1 served herself coffee from the hot beverage cart. CNA B stated Everybody was all cleared out. It was about 1:30/1:45 p.m. I guess they forgot to take out the hydration cart. CNA B reported that Resident #1 was using a maroon coffee cup without a lid. When asked what interventions were put in place after the incident, CNA B reported that the beverage cart had to be taken back to the kitchen immediately after meal service and that certain residents were to be served coffee in cups with lids only. When asked how staff knew which residents needed cups with lids, CNA B stated It depends - just what we know about the resident. I am using my personal judgment and am unaware of any kind of list. When asked if she thought the coffee was too hot on the day of Resident #1's coffee burn, CNA B stated I'm sure it was. During an interview with LVN G at 9:33 a.m. on 9/14/16, she reported that she was Resident #1's charge nurse on the day of her coffee burn (9/7/16). LVN G reported that CNA B came to her at approximately 1:30 p.m. and told her that Resident #1 was trying to get herself coffee and spilled it on her leg. LVN G reported that the hot beverage cart was still in the big dining room and was unsupervised when she went to assess Resident #1. She reported that Resident #1's leg was red. When asked what interventions were put in place after the incident, LVN G reported that the kitchen was supposed to put the coffee away after meals and that certain residents were supposed to be served coffee in a blue cup with a lid. When asked how staff knew which residents needed cups with lids, LVN G stated It says on their meal tickets. Someone from the nursing staff is in the dining room while coffee is served. Nursing staff should know, but there is nothing in writing. Observation of DA E taking the temperature of the coffee from the maker in the kitchen at 4:02 p.m. on 9/13/16 (after surveyor request) revealed that the coffee temperature was 166 degrees Fahrenheit. Observation at 4:04 p.m. on 9/13/16 revealed Resident #1 in her wheelchair at the kitchen door asking for coffee. Cook C dispensed coffee from the above maker into a blue cup with a lid and served it to Resident #1. Resident #1 placed the blue cup of coffee between her legs and self-propelled her wheelchair from the kitchen. Observation of Resident #1 eating dinner in the lobby area outside of the main dining room and the front nursing station at 5:28 p.m. on 9/13/16 revealed that no staff were present. Resident #1 had a blue cup with a lid in front of her. In addition to the blue cup with a lid, she had 2 maroon coffee mugs (both filled with what appeared-to-be coffee) without lids in front of her. During an interview with Resident #1 at this time, she confirmed that the mugs contained coffee. 2. Record review of Resident #6's electronic facesheet (not dated) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's annual MDS assessment (ARD 6/9/16) revealed that he needed supervision and setup help only for eating and that his balance was not steady. He scored a 9 on the BIMS - indicating moderate cognitive impairment. Record review of Resident #6's nursing progress note (dated 6/20/16) revealed that, at 1530 (3:30 p.m.), he spilled hot soup down his right leg and on top of his right foot. His pants and shoe and sock were immediately removed, and his leg and foot were pink but not blistered. At 1660 (5:00 p.m.), blisters were noted to his right foot and leg. Daily [MEDICATION NAME] was ordered. Resident #6 complained of pain at a 3 on a 10-point scale. On 8/11/16, all burn areas to his right leg were documented as healed. Record review of Resident #6's 6/20/16 incident/accident report revealed that he fell asleep and spilled hot soup on himself in his room. Staff were inserviced and told that Resident #6 was to inform staff when he wanted soup or a hot drink and that staff were to take him to his room or to wherever he wanted to eat/drink it. Record review of Resident #6's 6/20/16 risk management system report revealed that he was carrying a cup of hot soup in a styrofoam cup with a lid and spilled it on himself (down his right leg, under his knee, and on top of his foot). Record review of the facility's initial submission provider investigation report for Resident #6's 6/20/16 incident revealed resident with [MEDICAL CONDITION] over warmed soup. Provider response was Nursing informed physician of occurrence and physician ordered application of [MEDICATION NAME] treatment daily and monitoring of signs and symptoms of infection. Charge nurse also instructed dietary staff member to ensure food and/or beverages given to residents were not 'too hot'. Inservicing of nursing staff followed to address the need for promptness in reporting this type of incident to DON and administrator. Additionally, inservicing of dietary staff to ensure proper temperature of food and/or drink for residents is followed up with dietary manager. After an email was sent from the corporate nurse consultant to the administrator and recommended changes were made, record review of the facility's provider investigation report for Resident #6's 6/20/16 incident revealed that he had [MEDICAL CONDITION] soup. Investigation summary was Preliminary investigation has shown the dietary staff presented the resident with the bouillon soup which he requests on an almost daily basis. This was provided to him in a cup with a lid. Additionally, the charge nurse checked on the resident when he was outside of his door and had yelled for help. It was the charge nurse and the CNA who then removed the resident's trouser and sock, revealing a pinkish area on his leg and foot. At that time, the charge nurse phoned the physician and was given an order of [MEDICATION NAME] cream to be applied daily and to monitor for signs and symptoms of infection. The treatment nurse then followed with placement of the [MEDICATION NAME] cream and reassessed the area to find a blister was now apparent. The physician was recalled and again the order for [MEDICATION NAME] was provided. Investigation findings were confirmed. Provider action taken post-investigation was Inservice with dietary staff regarding food temperatures, inservice regarding abuse/neglect for dietary staff, inservice for nursing staff regarding timeliness of reporting significant events, education for dietary staff to check temperatures of all prepared items requested before serving (prn requests), and an audit of meal temperatures will be conducted daily for one week. Record review of Resident #6's 6/21/16 physician telephone order revealed that he was to be served hot liquids in a cup with a lid and that [MEDICATION NAME] cream 1% was to be applied to the affected area (for burn to right foot) twice daily. Record review of Resident #6's care plan (dated 6/23/16) revealed no documentation pertaining to hot liquids and/or a cup with a lid. During an interview with the regional nurse consultant at 12:00 p.m. on 9/15/16, she reviewed resident care plans with the surveyor and clarified that use covered cup when consuming hot beverages was added on 9/14/16. She confirmed that, although there were some residents needing covered cups prior to 9/14/16, this had not been care-planned. Record review of the kitchen's production worksheet report for 6/20/16 revealed that no temperatures were recorded. Record review of a 6/21/16 inservice sign-in sheet revealed that dietary staff (including DA D and Cook C) were taught about hot food safety. They were told that coffee, tea, soup, and broth should not be hotter than 180 degrees Fahrenheit and should be served in plastic, insulated mugs or bowls and not foam cups. The Guidelines for Hot Beverages policy (dated 4/1/14) was reviewed with them. Record review of a 6/21/16 inservice sign-in sheet revealed that all staff (including DA D and Cook C) were taught to assist residents with an unsteady gait in carrying soups or drinks from the kitchen and to place liquids received from the kitchen on stable furniture of resident's preference. Staff were to inform kitchen staff of residents who were not self-ambulatory and without present assistance if they requested hot liquids so that direct care staff could assist them. Record review of a 6/22/16 inservice sign-in sheet revealed that dietary staff (including DA D and Cook C) were taught about taking and recording the temperatures of all hot and cold foods to include hot water and coffee. The Thermometer Usage policy (dated 12/1/15) was reviewed with them. Record review of a 6/22/16 invoice revealed that the holding tank temperature of the coffee maker was adjusted to 184 degrees Fahrenheit per the dietary supervisor. Observation of Resident #6 eating dinner in the main dining room at 5:40 p.m. on 9/13/16 revealed that he was feeding himself pineapple tidbits and was shaking as he brought his spoon to his mouth, spilling pineapple tidbits on his shirt. He had a styrofoam cup without a lid in front of him and was taking sips from it. The styrofoam cup had what-appeared-to-be coffee in it. During an interview with Resident #6 at this time, he reported that the styrofoam cup contained coffee. During an interview with Cook C at 3:45 p.m. on 9/13/16, she reported that the dietary supervisor spoke with kitchen staff after Resident #1's burn incident and told them that certain people required a special blue cup with a lid for hot beverages. Cook C reported that kitchen staff were told that the coffee temperature could not be greater than 165 degrees Fahrenheit when it left the kitchen. Cook C stated I don't know what the temperature was at the time of (Resident #1's) burn. (Resident #6) has burned himself before too. We should be taking the temperatures of the coffee and foods before they go out, but we get so busy. I didn't know we were supposed to be taking the temperatures of the coffee until the supervisor inserviced us after (Resident #1) spilled her coffee. I just made the coffee and put it out. Cook C reported that the dietary supervisor adjusted the temperature on the coffee maker after Resident #1's incident and that kitchen staff were supposed to be keeping temperature logs now. She presented the surveyor with a red book in which all temperatures were supposed to be recorded (but were not) at this time. During an interview with DA E at 3:52 p.m. on 9/13/16, he reported that he checked coffee temperatures when I have time. If we're rushing, I forget. I don't take temperatures all of the time, but I try to remember. I try to keep it less than 165 (degrees Fahrenheit). Record review of the facility's temperature logs revealed that the temperature of the coffee was first recorded on 9/10/16 and was 165 degrees Fahrenheit. On 9/11/16, the coffee temperature was recorded once and was 165 degrees Fahrenheit. On 9/12/16, the coffee temperature was recorded twice and was 165 and 155 degrees Fahrenheit. On 9/13/16, the coffee temperature was recorded twice and was 160 and 165 degrees Fahrenheit. There were no food/hot liquid temperatures taken for breakfast or lunch 9/9/16; breakfast or lunch on 9/10/16; breakfast, lunch, or dinner on 9/11/16; breakfast, lunch, or dinner on 9/12/16; and breakfast and lunch on 9/13/16. During an interview with Cook C, DA D, and DA E at 4:04 p.m. on 9/13/16, they reported that the kitchen got a new coffee maker 2-3 weeks ago. They reported that there was no designated person for taking coffee temperatures. They reported that Resident #1 got her coffee from the kitchen on the day of her burn and was using a styrofoam cup without a lid. When asked which residents got a cup with a lid/how they knew which residents were to be served in the special cups, DA D stated Anyone with mobility problems, a walker, or a wheelchair. Cook C and DA E nodded in agreement. During an interview with the ADON at 4:10 p.m. on 9/13/16, she reported that Resident #6 spilled hot soup on himself on 6/20/16 and had blistering to his foot and legs. She stated I think the intervention for that was kitchen monitoring of temperatures. During a phone interview with the dietary supervisor at 4:18 p.m. on 9/13/16, he stated We don't have high temperature ranges. We have made efforts to make sure people aren't burning themselves. Certain residents use a blue cup with a lid - even if it spills, it comes out slowly. The dietary supervisor reported that the kitchen's old coffee maker was replaced approximately one month ago. He was on vacation at the time, and the new coffee maker was installed with the manufacturer settings. The dietary supervisor stated When (Resident #1's) burn happened, I had the maintenance man adjust the brew temperature range to 170 (degrees Fahrenheit). When asked if kitchen staff were doing any kind of temperature monitoring prior to Resident #1's burn incident, the dietary supervisor stated Some before. We started shortly before (Resident #1) got burned. When asked how kitchen staff monitored temperatures, the dietary supervisor stated We pour the coffee out of the maker and check it with a digital thermometer one time per meal 3 times per day. Staff are logging these temperatures in the kitchen red temperature log. The dietary supervisor reported that all temperatures taken by kitchen staff were supposed to be recorded in the red book. When asked what temperature was too high, the dietary supervisor stated I told them no greater than 180/185 (degrees Fahrenheit). If the temperature is higher than that, they are supposed to let it cool down before letting it leave the kitchen. The dietary supervisor reported that staff were supposed to be returning the hot beverage cart to the kitchen immediately after meal service but that Resident #1 served herself the hot coffee from the unsupervised hot beverage cart. During an interview with RN F at 5:41 p.m. on 9/13/16, when asked how she knew which residents needed to be served coffee in the blue mugs with lids, she stated They have to have an order for [REDACTED]. During an interview with DA D at 5:46 p.m. on 9/13/16, he reported that the coffee temperature for dinner was 165 (degrees Fahrenheit) when sent out on cart, I believe. During an interview with the dietary supervisor and the regional dietary manager at 10:10 a.m. on 9/14/16, they reported that there was a constant turnover of dietary staff but that the new processes for temperature monitoring should have been learned by now. The dietary supervisor confirmed that no food or liquid temperatures had been taken on 6/20/16 - the day of Resident #6's hot soup burn. During an interview with the RD at 12:20 p.m. on 9/14/16, she reported that Resident #6 often fell asleep when eating/drinking and that temperature monitoring had been a problem at the facility since she started working there in October of 2015. Record review of the American Burn Association's Scald Injury Prevention Educator's Guide (not dated) revealed that exposure to a water temperature of 155 degrees Fahrenheit for a second could cause a third degree burn. The administrator was notified on 9/14/16 at 10:52 a.m. that an IJ situation had been identified due to the above failures. The facility's plan of removal was provided by the administrator on 9/14/16 and accepted on 9/14/16 at 5:06 p.m. The facility took the following actions (verified through observations of the dining areas and kitchen, interviews with residents and staff, and record reviews of resident assessments, care plans, and therapy evaluations) to remove the IJ: - The regional dietary manager conducted an inservice on the policy/procedure regarding food/beverage temperatures and recording to include a temperature range when served to resident of 135 to 155 degrees Fahrenheit for food/beverages served hot with the dietary supervisor on 9/14/16. - The dietary supervisor conducted an inservice on the policy/procedure regarding food/beverage temperatures and recording to include a temperature range when served to resident of 135 to 155 degrees Fahrenheit for food/beverages served hot with dietary staff on 9/13/16. - The dietary supervisor conducted an inservice on the facility guidelines for hot beverages and the policy/procedure for thermometer usage with dietary staff on 9/13/16. - The nurse practice educator conducted an inservice on the policy/procedure for meal service specific to assistance and supervision with direct care staff on 9/14/16. - The dietary supervisor started to bring food/beverage temperature logs to the morning meetings on 9/15/16. The administrator started to review these logs for completeness and compliance with temperature ranges on 9/15/16. The administrator will report the results of these reviews to the Quality Assurance (QA) Committee during the next 3 QA Committee meetings. The dietary supervisor will conduct inservices related to food/beverage temperatures and recording as needed per results of the reviews. - Utilizing the MDS assessments, nursing administration identified 57 residents requiring assistance with meals on 9/14/16. - Occupational therapy began screening of the residents identified as needing assistance per their Activities of Daily Living score in the eating section of the MDS on 9/14/16 to ensure residents could safely manage hot beverages. Per the results of the screens, occupational therapy will provide intervention recommendation to nursing services if identified as necessary. - Nursing administration began care-planning and implementing interventions per therapy recommendations to ensure residents could safely manage hot beverages on 9/14/16. - The administrator conducted an inservice on the center guidelines for hot beverages with department head meal monitors on 9/14/16. - The dietary supervisor began verification and documenting verification of food/beverage temperature prior to service to ensure compliance with temperature guidelines on 9/14/16. - The regional dietary manager started to develop (on 9/14/16) and the facility was to implement an onboarding guide for dietary agency staff to include center guidelines on food/beverage temperatures and recording. - All facility residents were provided with covered cups for hot beverage consumption on 9/15/16. If a resident was not in agreement with a covered cup, nursing administration began educating the resident/responsible party regarding the risks and included this on the resident's care plan. Observations of the dining rooms during dinner on 9/14/16, breakfast on 9/15/16, and lunch on 9/15/16 revealed that there was supervision at all times when the hot beverage cart was present. At breakfast and lunch on 9/15/16, all residents were served coffee/hot liquids in the new insulated cups with lids. The regional dietary manager was observed taking the temperatures of hot liquids/coffee at the time of meal service to residents. Interviews with dietary staff on 9/14/16 and 9/15/16 revealed that they had received training from the dietary supervisor and had learned that the temperatures of all hot liquids (including coffee and soup) were to be taken prior to them leaving the kitchen. The hot beverage cart was not to leave the kitchen unless nursing staff were present to supervise it. All temperatures were to be recorded in the red temperature monitoring log book. Residents were to be served coffee/hot liquids at temperatures within the 135 to 155 degrees Fahrenheit range, and all coffee/hot liquids were to be served to all residents in the new insulated cups with lids. Interviews with nursing and direct care staff on 9/14/16 and 9/15/16 revealed that they had received training from the nurse practice educator and had learned that the hot beverage cart was to be supervised at all times and that residents were to be served coffee/hot liquids at temperatures within the 135 to 155 degrees Fahrenheit range. All residents were to be served coffee/hot liquids in the the new insulated cups with lids. If a resident refused to use the new cup with lid, staff were to report the noncompliance to nursing administrative staff. Record review of the facility's temperature logs for dinner on 9/14/16 and breakfast on 9/15/16 revealed that they were complete and that temperatures for hot liquids were within the appropriate ranges. Record review of the occupational therapy screens for the 57 residents identified as needing assistance with eating based on their MDS assessments revealed that 16 were appropriate for occupational therapy evaluations and treatment. Record review of the care plans of 6 residents revealed that the need for covered cups with lids for coffee/hot liquids was added. Interview with the administrator on 9/15/16 revealed that she would be monitoring kitchen temperature logs at the morning meetings and addressing any issues with the dietary supervisor and the QA Committee. On 9/14/16 at 6:10 p.m., the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not an immediate jeopardy with the scope of pattern until all measures listed in the plan of removal were completed. According to information provided by the administrator on 9/20/16, there were 8 residents at risk for coffee/hot liquid burns.

Based on observations, interviews, and record reviews, the facility failed to develop and implement written policies and procedures that prohibited mistreatment, neglect, and abuse of residents and misappropriation of resident property for 2 of 11 residents (Resident #s 1 and 6) whose care was reviewed for safe eating/drinking in that: 1. Resident #1 was not being supervised during meal service and was not served all of her hot liquids in a cup with a lid as ordered. Kitchen staff were not consistently monitoring temperatures of coffee and hot liquids. Resident #1 spilled hot coffee on herself in the dining room which resulted in redness and tenderness to her upper leg. 2. Resident #6 was not served all of his hot liquids in a cup with a lid as ordered. Kitchen staff were not consistently monitoring temperatures of coffee and hot liquids. Resident #6 spilled hot soup on his legs while eating unsupervised in his room. His legs blistered as a result of the burn. These failures resulted in identification of an IJ (Immediate Jeopardy) on 9/14/16. While the IJ was removed on 9/14/16, the facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy due to the facility continuing to monitor the effectiveness of their plan of removal. These failures could affect 8 residents at the facility assessed to be at risk for coffee/hot [MEDICAL CONDITION] contributing to injury. The findings were: 1. Record review of Resident #1's facesheet (dated 9/7/16) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's annual MDS assessment (ARD 8/2/16) revealed that she needed supervision and the assistance of one staff for eating and that her balance was not steady. She scored a 14 on the BIMS - indicating that she was cognitively intact. Record review of the facility's provider investigation report (signed and dated 9/12/16) for Resident #1's alleged neglect revealed that she was in the dining room getting herself a cup of coffee from the beverage cart and spilled coffee on herself. Resident #1 informed the nurse of the spill. She was immediately assessed and had a reddened area to her thigh. Resident #1 stated the area was tender but not painful. Her care plan was updated, staff were educated regarding hot beverages, a cup with a lid was ordered, and silver [MEDICATION NAME] 1% cream was ordered and applied. Investigation findings for the allegation of neglect were confirmed. Record review of Resident #1's 9/7/16 physician telephone order revealed that she was to be served hot beverages in a cup with a lid and that silver sulfadiazene 1% cream was to be applied to the affected area daily until resolved. Record review of Resident #1's change in condition skin check (dated 9/7/16) revealed that her left lateral leg was red and warm and measured 9.2 x 4 x 0 centimeters. Record review of Resident #1's care plan (updated 9/8/16 after the burn incident) revealed that she was to have a cup with a lid for all hot beverages. Record review of the kitchen's production worksheet report for 9/7/16 revealed that temperatures were recorded at dinner only. The dinner temperatures did not include coffee. Record review of a 9/7/16 inservice sign-in sheet revealed that dietary staff (including DAs D and E and Cook C) were taught about thermometer usage. The Thermometer Usage policy (dated 12/1/15) was reviewed with them. Record review of a 9/7/16 inservice sign-in sheet revealed that nursing staff were taught about assisting residents with hot beverages and monitoring the temperatures of these beverages. The Guidelines for Hot Beverages policy (dated 4/1/14) was reviewed with them. During an interview with Resident #1 at 11:58 a.m. on 9/13/16, she reported that kitchen staff brought her the cup of coffee that she spilled on her leg on 9/7/16 and that she did not get it herself. During an interview with MDS Nurse A at 3:30 p.m. on 9/13/16, she reported that CNA B reported Resident #1's coffee burn to her and that she was the first person to assess the area on 9/7/16. MDS Nurse A reported that Resident #1 did not have pants on and was covered with a blanket. The blanket covering her lap was wet and warm. MDS Nurse A reported that Resident #1's left upper thigh was bright pink/red and warm to touch but that Resident #1 did not complain of pain. MDS Nurse A reported that the incident happened after lunch and that Resident #1 said she had gotten the coffee from the beverage cart in the dining room. MDS Nurse A stated I personally think the coffee was served too hot. It was a while after lunch, and the coffee was in a carafe/pitcher. MDS Nurse A was unsure whether or not staff were in the dining room when she assessed Resident #1. She stated (CNA B) was taking the beverage cart to the kitchen when she saw (Resident #1) had burned herself. MDS Nurse A reported that the kitchen had gotten a brand new coffee maker not too long ago. During an interview with CNA B at 9:22 a.m. on 9/14/16, she reported that she was going to get a resident out of the small dining room on 9/7/16 when she heard someone yell. CNA B stated It was (Resident #1). She was getting coffee from the hydration cart in the big dining room. I asked her if she was okay, and she said she spilled a little coffee on herself. CNA B reported that MDS Nurse A assessed Resident #1 and that the area to her left lateral leg was red and tender to touch. CNA B reported that Resident #1 said Ow . ow! when MDS Nurse A assessed her. CNA B reported that MDS Nurse A was walking behind her and entered the big dining room after she did. She reported that nobody was in the big dining room supervising Resident #1 when Resident #1 served herself coffee from the hot beverage cart. CNA B stated Everybody was all cleared out. It was about 1:30/1:45 p.m. I guess they forgot to take out the hydration cart. CNA B reported that Resident #1 was using a maroon coffee cup without a lid. When asked what interventions were put in place after the incident, CNA B reported that the beverage cart had to be taken back to the kitchen immediately after meal service and that certain residents were to be served coffee in cups with lids only. When asked how staff knew which residents needed cups with lids, CNA B stated It depends - just what we know about the resident. I am using my personal judgment and am unaware of any kind of list. When asked if she thought the coffee was too hot on the day of Resident #1's coffee burn, CNA B stated I'm sure it was. During an interview with LVN G at 9:33 a.m. on 9/14/16, she reported that she was Resident #1's charge nurse on the day of her coffee burn (9/7/16). LVN G reported that CNA B came to her at approximately 1:30 p.m. and told her that Resident #1 was trying to get herself coffee and spilled it on her leg. LVN G reported that the hot beverage cart was still in the big dining room and was unsupervised when she went to assess Resident #1. She reported that Resident #1's leg was red. When asked what interventions were put in place after the incident, LVN G reported that the kitchen was supposed to put the coffee away after meals and that certain residents were supposed to be served coffee in a blue cup with a lid. When asked how staff knew which residents needed cups with lids, LVN G stated It says on their meal tickets. Someone from the nursing staff is in the dining room while coffee is served. Nursing staff should know, but there is nothing in writing. Observation of DA E taking the temperature of the coffee from the maker in the kitchen at 4:02 p.m. on 9/13/16 (after surveyor request) revealed that the coffee temperature was 166 degrees Fahrenheit. Observation at 4:04 p.m. on 9/13/16 revealed Resident #1 in her wheelchair at the kitchen door asking for coffee. Cook C dispensed coffee from the above maker into a blue cup with a lid and served it to Resident #1. Resident #1 placed the blue cup of coffee between her legs and self-propelled her wheelchair from the kitchen. Observation of Resident #1 eating dinner in the lobby area outside of the main dining room and the front nursing station at 5:28 p.m. on 9/13/16 revealed that no staff were present. Resident #1 had a blue cup with a lid in front of her. In addition to the blue cup with a lid, she had 2 maroon coffee mugs (both filled with what appeared-to-be coffee) without lids in front of her. During an interview with Resident #1 at this time, she confirmed that the mugs contained coffee. 2. Record review of Resident #6's electronic facesheet (not dated) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's annual MDS assessment (ARD 6/9/16) revealed that he needed supervision and setup help only for eating and that his balance was not steady. He scored a 9 on the BIMS - indicating moderate cognitive impairment. Record review of Resident #6's nursing progress note (dated 6/20/16) revealed that, at 1530 (3:30 p.m.), he spilled hot soup down his right leg and on top of his right foot. His pants and shoe and sock were immediately removed, and his leg and foot were pink but not blistered. At 1660 (5:00 p.m.), blisters were noted to his right foot and leg. Daily [MEDICATION NAME] was ordered. Resident #6 complained of pain at a 3 on a 10-point scale. On 8/11/16, all burn areas to his right leg were documented as healed. Record review of Resident #6's 6/20/16 incident/accident report revealed that he fell asleep and spilled hot soup on himself in his room. Staff were inserviced and told that Resident #6 was to inform staff when he wanted soup or a hot drink and that staff were to take him to his room or to wherever he wanted to eat/drink it. Record review of Resident #6's 6/20/16 risk management system report revealed that he was carrying a cup of hot soup in a styrofoam cup with a lid and spilled it on himself (down his right leg, under his knee, and on top of his foot). Record review of the facility's initial submission provider investigation report for Resident #6's 6/20/16 incident revealed resident with [MEDICAL CONDITION] over warmed soup. Provider response was Nursing informed physician of occurrence and physician ordered application of [MEDICATION NAME] treatment daily and monitoring of signs and symptoms of infection. Charge nurse also instructed dietary staff member to ensure food and/or beverages given to residents were not 'too hot'. Inservicing of nursing staff followed to address the need for promptness in reporting this type of incident to DON and administrator. Additionally, inservicing of dietary staff to ensure proper temperature of food and/or drink for residents is followed up with dietary manager. After an email was sent from the corporate nurse consultant to the administrator and recommended changes were made, record review of the facility's provider investigation report for Resident #6's 6/20/16 incident revealed that he had [MEDICAL CONDITION] soup. Investigation summary was Preliminary investigation has shown the dietary staff presented the resident with the bouillon soup which he requests on an almost daily basis. This was provided to him in a cup with a lid. Additionally, the charge nurse checked on the resident when he was outside of his door and had yelled for help. It was the charge nurse and the CNA who then removed the resident's trouser and sock, revealing a pinkish area on his leg and foot. At that time, the charge nurse phoned the physician and was given an order of [MEDICATION NAME] cream to be applied daily and to monitor for signs and symptoms of infection. The treatment nurse then followed with placement of the [MEDICATION NAME] cream and reassessed the area to find a blister was now apparent. The physician was recalled and again the order for [MEDICATION NAME] was provided. Investigation findings were confirmed. Provider action taken post-investigation was Inservice with dietary staff regarding food temperatures, inservice regarding abuse/neglect for dietary staff, inservice for nursing staff regarding timeliness of reporting significant events, education for dietary staff to check temperatures of all prepared items requested before serving (prn requests), and an audit of meal temperatures will be conducted daily for one week. Record review of Resident #6's 6/21/16 physician telephone order revealed that he was to be served hot liquids in a cup with a lid and that [MEDICATION NAME] cream 1% was to be applied to the affected area (for burn to right foot) twice daily. Record review of Resident #6's care plan (dated 6/23/16) revealed no documentation pertaining to hot liquids and/or a cup with a lid. During an interview with the regional nurse consultant at 12:00 p.m. on 9/15/16, she reviewed resident care plans with the surveyor and clarified that use covered cup when consuming hot beverages was added on 9/14/16. She confirmed that, although there were some residents needing covered cups prior to 9/14/16, this had not been care-planned. Record review of the kitchen's production worksheet report for 6/20/16 revealed that no temperatures were recorded. Record review of a 6/21/16 inservice sign-in sheet revealed that dietary staff (including DA D and Cook C) were taught about hot food safety. They were told that coffee, tea, soup, and broth should not be hotter than 180 degrees Fahrenheit and should be served in plastic, insulated mugs or bowls and not foam cups. The Guidelines for Hot Beverages policy (dated 4/1/14) was reviewed with them. Record review of a 6/21/16 inservice sign-in sheet revealed that all staff (including DA D and Cook C) were taught to assist residents with an unsteady gait in carrying soups or drinks from the kitchen and to place liquids received from the kitchen on stable furniture of resident's preference. Staff were to inform kitchen staff of residents who were not self-ambulatory and without present assistance if they requested hot liquids so that direct care staff could assist them. Record review of a 6/22/16 inservice sign-in sheet revealed that dietary staff (including DA D and Cook C) were taught about taking and recording the temperatures of all hot and cold foods to include hot water and coffee. The Thermometer Usage policy (dated 12/1/15) was reviewed with them. Record review of a 6/22/16 invoice revealed that the holding tank temperature of the coffee maker was adjusted to 184 degrees Fahrenheit per the dietary supervisor. Observation of Resident #6 eating dinner in the main dining room at 5:40 p.m. on 9/13/16 revealed that he was feeding himself pineapple tidbits and was shaking as he brought his spoon to his mouth, spilling pineapple tidbits on his shirt. He had a styrofoam cup without a lid in front of him and was taking sips from it. The styrofoam cup had what-appeared-to-be coffee in it. During an interview with Resident #6 at this time, he reported that the styrofoam cup contained coffee. During an interview with Cook C at 3:45 p.m. on 9/13/16, she reported that the dietary supervisor spoke with kitchen staff after Resident #1's burn incident and told them that certain people required a special blue cup with a lid for hot beverages. Cook C reported that kitchen staff were told that the coffee temperature could not be greater than 165 degrees Fahrenheit when it left the kitchen. Cook C stated I don't know what the temperature was at the time of (Resident #1's) burn. (Resident #6) has burned himself before too. We should be taking the temperatures of the coffee and foods before they go out, but we get so busy. I didn't know we were supposed to be taking the temperatures of the coffee until the supervisor inserviced us after (Resident #1) spilled her coffee. I just made the coffee and put it out. Cook C reported that the dietary supervisor adjusted the temperature on the coffee maker after Resident #1's incident and that kitchen staff were supposed to be keeping temperature logs now. She presented the surveyor with a red book in which all temperatures were supposed to be recorded (but were not) at this time. During an interview with DA E at 3:52 p.m. on 9/13/16, he reported that he checked coffee temperatures when I have time. If we're rushing, I forget. I don't take temperatures all of the time, but I try to remember. I try to keep it less than 165 (degrees Fahrenheit). Record review of the facility's temperature logs revealed that the temperature of the coffee was first recorded on 9/10/16 and was 165 degrees Fahrenheit. On 9/11/16, the coffee temperature was recorded once and was 165 degrees Fahrenheit. On 9/12/16, the coffee temperature was recorded twice and was 165 and 155 degrees Fahrenheit. On 9/13/16, the coffee temperature was recorded twice and was 160 and 165 degrees Fahrenheit. There were no food/hot liquid temperatures taken for breakfast or lunch 9/9/16; breakfast or lunch on 9/10/16; breakfast, lunch, or dinner on 9/11/16; breakfast, lunch, or dinner on 9/12/16; and breakfast and lunch on 9/13/16. During an interview with Cook C, DA D, and DA E at 4:04 p.m. on 9/13/16, they reported that the kitchen got a new coffee maker 2-3 weeks ago. They reported that there was no designated person for taking coffee temperatures. They reported that Resident #1 got her coffee from the kitchen on the day of her burn and was using a styrofoam cup without a lid. When asked which residents got a cup with a lid/how they knew which residents were to be served in the special cups, DA D stated Anyone with mobility problems, a walker, or a wheelchair. Cook C and DA E nodded in agreement. During an interview with the ADON at 4:10 p.m. on 9/13/16, she reported that Resident #6 spilled hot soup on himself on 6/20/16 and had blistering to his foot and legs. She stated I think the intervention for that was kitchen monitoring of temperatures. During a phone interview with the dietary supervisor at 4:18 p.m. on 9/13/16, he stated We don't have high temperature ranges. We have made efforts to make sure people aren't burning themselves. Certain residents use a blue cup with a lid - even if it spills, it comes out slowly. The dietary supervisor reported that the kitchen's old coffee maker was replaced approximately one month ago. He was on vacation at the time, and the new coffee maker was installed with the manufacturer settings. The dietary supervisor stated When (Resident #1's) burn happened, I had the maintenance man adjust the brew temperature range to 170 (degrees Fahrenheit). When asked if kitchen staff were doing any kind of temperature monitoring prior to Resident #1's burn incident, the dietary supervisor stated Some before. We started shortly before (Resident #1) got burned. When asked how kitchen staff monitored temperatures, the dietary supervisor stated We pour the coffee out of the maker and check it with a digital thermometer one time per meal 3 times per day. Staff are logging these temperatures in the kitchen red temperature log. The dietary supervisor reported that all temperatures taken by kitchen staff were supposed to be recorded in the red book. When asked what temperature was too high, the dietary supervisor stated I told them no greater than 180/185 (degrees Fahrenheit). If the temperature is higher than that, they are supposed to let it cool down before letting it leave the kitchen. The dietary supervisor reported that staff were supposed to be returning the hot beverage cart to the kitchen immediately after meal service but that Resident #1 served herself the hot coffee from the unsupervised hot beverage cart. During an interview with RN F at 5:41 p.m. on 9/13/16, when asked how she knew which residents needed to be served coffee in the blue mugs with lids, she stated They have to have an order for [REDACTED]. During an interview with DA D at 5:46 p.m. on 9/13/16, he reported that the coffee temperature for dinner was 165 (degrees Fahrenheit) when sent out on cart, I believe. During an interview with the dietary supervisor and the regional dietary manager at 10:10 a.m. on 9/14/16, they reported that there was a constant turnover of dietary staff but that the new processes for temperature monitoring should have been learned by now. The dietary supervisor confirmed that no food or liquid temperatures had been taken on 6/20/16 - the day of Resident #6's hot soup burn. During an interview with the RD at 12:20 p.m. on 9/14/16, she reported that Resident #6 often fell asleep when eating/drinking and that temperature monitoring had been a problem at the facility since she started working there in October of 2015. Record review of the facility's abuse prohibition policy (last revised 5/1/16) revealed (Corporation facilities) will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients . Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Record review of the facility's Guidelines for Hot Beverages policy (dated 4/1/14) revealed 1. Do not leave pots or urns of hot coffee or other hot beverages unattended - use toggle covers on urns to reduce risk of accidental dispensing. 2. Limit access of patients/residents to locations where hot beverages may be prepared or reheated such as break room and kitchen. 3. Discourage patients/residents from carrying cups of hot beverages without a lid while they are walking or moving in a wheelchair . Record review of the facility's Thermometer Usage policy (dated 12/1/15) revealed Food is tested throughout preparation and service to ensure the appropriate temperature is reached and maintained . Record the holding temperature of the foods being held for service on the production sheet. Action is taken if food is not within identified ranges, prior to service . Time/temperature control for safety foods reheated in a microwave for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees Fahrenheit and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating . Record review of the American Burn Association's Scald Injury Prevention Educator's Guide (not dated) revealed that exposure to a water temperature of 155 degrees Fahrenheit for a second could cause a third degree burn. The administrator was notified on 9/14/16 at 10:52 a.m. that an IJ situation had been identified due to the above failures. The facility's plan of removal was provided by the administrator on 9/14/16 and accepted on 9/14/16 at 5:06 p.m. The facility took the following actions (verified through observations of the dining areas and kitchen, interviews with residents and staff, and record reviews of resident assessments, care plans, and therapy evaluations) to remove the IJ: - The regional dietary manager conducted an inservice on the policy/procedure regarding food/beverage temperatures and recording to include a temperature range when served to resident of 135 to 155 degrees Fahrenheit for food/beverages served hot with the dietary supervisor on 9/14/16. - The dietary supervisor conducted an inservice on the policy/procedure regarding food/beverage temperatures and recording to include a temperature range when served to resident of 135 to 155 degrees Fahrenheit for food/beverages served hot with dietary staff on 9/13/16. - The dietary supervisor conducted an inservice on the facility guidelines for hot beverages and the policy/procedure for thermometer usage with dietary staff on 9/13/16. - The nurse practice educator conducted an inservice on the policy/procedure for meal service specific to assistance and supervision with direct care staff on 9/14/16. - The dietary supervisor started to bring food/beverage temperature logs to the morning meetings on 9/15/16. The administrator started to review these logs for completeness and compliance with temperature ranges on 9/15/16. The administrator will report the results of these reviews to the Quality Assurance (QA) Committee during the next 3 QA Committee meetings. The dietary supervisor will conduct inservices related to food/beverage temperatures and recording as needed per results of the reviews. - Utilizing the MDS assessments, nursing administration identified 57 residents requiring assistance with meals on 9/14/16. - Occupational therapy began screening of the residents identified as needing assistance per their Activities of Daily Living score in the eating section of the MDS on 9/14/16 to ensure residents could safely manage hot beverages. Per the results of the screens, occupational therapy will provide intervention recommendation to nursing services if identified as necessary. - Nursing administration began care-planning and implementing interventions per therapy recommendations to ensure residents could safely manage hot beverages on 9/14/16. - The administrator conducted an inservice on the center guidelines for hot beverages with department head meal monitors on 9/14/16. - The dietary supervisor began verification and documenting verification of food/beverage temperature prior to service to ensure compliance with temperature guidelines on 9/14/16. - The regional dietary manager started to develop (on 9/14/16) and the facility was to implement an onboarding guide for dietary agency staff to include center guidelines on food/beverage temperatures and recording. - All facility residents were provided with covered cups for hot beverage consumption on 9/15/16. If a resident was not in agreement with a covered cup, nursing administration began educating the resident/responsible party regarding the risks and included this on the resident's care plan. Observations of the dining rooms during dinner on 9/14/16, breakfast on 9/15/16, and lunch on 9/15/16 revealed that there was supervision at all times when the hot beverage cart was present. At breakfast and lunch on 9/15/16, all residents were served coffee/hot liquids in the new insulated cups with lids. The regional dietary manager was observed taking the temperatures of hot liquids/coffee at the time of meal service to residents. Interviews with dietary staff on 9/14/16 and 9/15/16 revealed that they had received training from the dietary supervisor and had learned that the temperatures of all hot liquids (including coffee and soup) were to be taken prior to them leaving the kitchen. The hot beverage cart was not to leave the kitchen unless nursing staff were present to supervise it. All temperatures were to be recorded in the red temperature monitoring log book. Residents were to be served coffee/hot liquids at temperatures within the 135 to 155 degrees Fahrenheit range, and all coffee/hot liquids were to be served to all residents in the new insulated cups with lids. Interviews with nursing and direct care staff on 9/14/16 and 9/15/16 revealed that they had received training from the nurse practice educator and had learned that the hot beverage cart was to be supervised at all times and that residents were to be served coffee/hot liquids at temperatures within the 135 to 155 degrees Fahrenheit range. All residents were to be served coffee/hot liquids in the the new insulated cups with lids. If a resident refused to use the new cup with lid, staff were to report the noncompliance to nursing administrative staff. Record review of the facility's temperature logs for dinner on 9/14/16 and breakfast on 9/15/16 revealed that they were complete and that temperatures for hot liquids were within the appropriate ranges. Record review of the occupational therapy screens for the 57 residents identified as needing assistance with eating based on their MDS assessments revealed that 16 were appropriate for occupational therapy evaluations and treatment. Record review of the care plans of 6 residents revealed that the need for covered cups with lids for coffee/hot liquids was added. Interview with the administrator on 9/15/16 revealed that she would be monitoring kitchen temperature logs at the morning meetings and addressing any issues with the dietary supervisor and the QA Committee. On 9/14/16 at 6:10 p.m., the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not an immediate jeopardy with the scope of pattern until all measures listed in the plan of removal were completed. According to information provided by the administrator on 9/20/16, there were 8 residents at risk for coffee/hot liquid burns

Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 2 of 11 residents (Resident #s 1 and 6) whose care was reviewed for safe eating/drinking in that: The administrator did not implement established company hot liquid/beverage and thermometer usage policies and procedures and supervise the dietary manager to ensure that the facility's hot liquid/beverage and thermometer usage policies and procedures were being followed and that adequate supervision was being provided. These failures resulted in identification of an IJ (Immediate Jeopardy) on 9/14/16. While the IJ was removed on 9/14/16, the facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy due to the facility continuing to monitor the effectiveness of their plan of removal. These failures could affect 8 residents at the facility assessed to be at risk for coffee/hot [MEDICAL CONDITION] contributing to injury. The findings were: During an interview with the administrator at 12:12 p.m. on 9/15/16, she reported that she started working at the facility on 6/27/16 and became the administrator on 8/2/16. When asked if she was aware of the kitchen hot liquid temperatures being an issue, the administrator reported that she knew about Resident #1's burn incident. The administrator reported that she became aware of Resident #1's burn incident through the incident/accident report being typed up in the computer system and the automatic administrator notification that resulted upon its completion. When asked what interventions were put in place after Resident #1's incident, the administrator reported that Resident #1 got a blue cup with a lid, that staff were told to supervise the hot beverage cart to ensure that residents were not helping themselves to liquids on it, and that dietary staff were told to check temperatures prior to liquids leaving the kitchen. When asked how she made sure that the interventions put in place were effective and/or being done, the administrator stated There were temperature logs. The dietary supervisor was supposed to be monitoring/checking the temperature logs to be sure staff were taking temperatures. I was under the impression that staff were taking the temperatures. I got no information from (the dietary supervisor) otherwise. The administrator then stated Now, after this IJ, (the dietary supervisor) will bring the temperature logs to the morning meetings and I will check to make sure they are being done. I will review the temperature logs every morning and keep track of them for our QA (Quality Assurace) meetings. The administrator reported that neither she nor the DON were at the facility for the last QA meeting. Therefore, she did not know whether or not kitchen temperatures were an issue that was discussed. When asked if Resident #1's incident with hot coffee could have been prevented, the administrator reported that she was advocate of resident rights and that Resident #1 had the right to hot coffee. However, she confirmed that the monitoring of kitchen temperatures to ensure that the coffee was not served too hot would have helped/possibly prevented the burn. 1. Record review of Resident #1's facesheet (dated 9/7/16) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's annual MDS assessment (ARD 8/2/16) revealed that she needed supervision and the assistance of one staff for eating and that her balance was not steady. She scored a 14 on the BIMS - indicating that she was cognitively intact. Record review of the facility's provider investigation report (signed and dated 9/12/16) for Resident #1's alleged neglect revealed that she was in the dining room getting herself a cup of coffee from the beverage cart and spilled coffee on herself. Resident #1 informed the nurse of the spill. She was immediately assessed and had a reddened area to her thigh. Resident #1 stated the area was tender but not painful. Her care plan was updated, staff were educated regarding hot beverages, a cup with a lid was ordered, and silver [MEDICATION NAME] 1% cream was ordered and applied. Investigation findings for the allegation of neglect were confirmed. Record review of Resident #1's 9/7/16 physician telephone order revealed that she was to be served hot beverages in a cup with a lid and that silver sulfadiazene 1% cream was to be applied to the affected area daily until resolved. Record review of Resident #1's change in condition skin check (dated 9/7/16) revealed that her left lateral leg was red and warm and measured 9.2 x 4 x 0 centimeters. Record review of Resident #1's care plan (updated 9/8/16 after the burn incident) revealed that she was to have a cup with a lid for all hot beverages. Record review of the kitchen's production worksheet report for 9/7/16 revealed that temperatures were recorded at dinner only. The dinner temperatures did not include coffee. Record review of a 9/7/16 inservice sign-in sheet revealed that dietary staff (including DAs D and E and Cook C) were taught about thermometer usage. The Thermometer Usage policy (dated 12/1/15) was reviewed with them. Record review of a 9/7/16 inservice sign-in sheet revealed that nursing staff were taught about assisting residents with hot beverages and monitoring the temperatures of these beverages. The Guidelines for Hot Beverages policy (dated 4/1/14) was reviewed with them. During an interview with Resident #1 at 11:58 a.m. on 9/13/16, she reported that kitchen staff brought her the cup of coffee that she spilled on her leg on 9/7/16 and that she did not get it herself. During an interview with MDS Nurse A at 3:30 p.m. on 9/13/16, she reported that CNA B reported Resident #1's coffee burn to her and that she was the first person to assess the area on 9/7/16. MDS Nurse A reported that Resident #1 did not have pants on and was covered with a blanket. The blanket covering her lap was wet and warm. MDS Nurse A reported that Resident #1's left upper thigh was bright pink/red and warm to touch but that Resident #1 did not complain of pain. MDS Nurse A reported that the incident happened after lunch and that Resident #1 said she had gotten the coffee from the beverage cart in the dining room. MDS Nurse A stated I personally think the coffee was served too hot. It was a while after lunch, and the coffee was in a carafe/pitcher. MDS Nurse A was unsure whether or not staff were in the dining room when she assessed Resident #1. She stated (CNA B) was taking the beverage cart to the kitchen when she saw (Resident #1) had burned herself. MDS Nurse A reported that the kitchen had gotten a brand new coffee maker not too long ago. During an interview with CNA B at 9:22 a.m. on 9/14/16, she reported that she was going to get a resident out of the small dining room on 9/7/16 when she heard someone yell. CNA B stated It was (Resident #1). She was getting coffee from the hydration cart in the big dining room. I asked her if she was okay, and she said she spilled a little coffee on herself. CNA B reported that MDS Nurse A assessed Resident #1 and that the area to her left lateral leg was red and tender to touch. CNA B reported that Resident #1 said Ow . ow! when MDS Nurse A assessed her. CNA B reported that MDS Nurse A was walking behind her and entered the big dining room after she did. She reported that nobody was in the big dining room supervising Resident #1 when Resident #1 served herself coffee from the hot beverage cart. CNA B stated Everybody was all cleared out. It was about 1:30/1:45 p.m. I guess they forgot to take out the hydration cart. CNA B reported that Resident #1 was using a maroon coffee cup without a lid. When asked what interventions were put in place after the incident, CNA B reported that the beverage cart had to be taken back to the kitchen immediately after meal service and that certain residents were to be served coffee in cups with lids only. When asked how staff knew which residents needed cups with lids, CNA B stated It depends - just what we know about the resident. I am using my personal judgment and am unaware of any kind of list. When asked if she thought the coffee was too hot on the day of Resident #1's coffee burn, CNA B stated I'm sure it was. During an interview with LVN G at 9:33 a.m. on 9/14/16, she reported that she was Resident #1's charge nurse on the day of her coffee burn (9/7/16). LVN G reported that CNA B came to her at approximately 1:30 p.m. and told her that Resident #1 was trying to get herself coffee and spilled it on her leg. LVN G reported that the hot beverage cart was still in the big dining room and was unsupervised when she went to assess Resident #1. She reported that Resident #1's leg was red. When asked what interventions were put in place after the incident, LVN G reported that the kitchen was supposed to put the coffee away after meals and that certain residents were supposed to be served coffee in a blue cup with a lid. When asked how staff knew which residents needed cups with lids, LVN G stated It says on their meal tickets. Someone from the nursing staff is in the dining room while coffee is served. Nursing staff should know, but there is nothing in writing. Observation of DA E taking the temperature of the coffee from the maker in the kitchen at 4:02 p.m. on 9/13/16 (after surveyor request) revealed that the coffee temperature was 166 degrees Fahrenheit. Observation at 4:04 p.m. on 9/13/16 revealed Resident #1 in her wheelchair at the kitchen door asking for coffee. Cook C dispensed coffee from the above maker into a blue cup with a lid and served it to Resident #1. Resident #1 placed the blue cup of coffee between her legs and self-propelled her wheelchair from the kitchen. Observation of Resident #1 eating dinner in the lobby area outside of the main dining room and the front nursing station at 5:28 p.m. on 9/13/16 revealed that no staff were present. Resident #1 had a blue cup with a lid in front of her. In addition to the blue cup with a lid, she had 2 maroon coffee mugs (both filled with what appeared-to-be coffee) without lids in front of her. During an interview with Resident #1 at this time, she confirmed that the mugs contained coffee. 2. Record review of Resident #6's electronic facesheet (not dated) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's annual MDS assessment (ARD 6/9/16) revealed that he needed supervision and setup help only for eating and that his balance was not steady. He scored a 9 on the BIMS - indicating moderate cognitive impairment. Record review of Resident #6's nursing progress note (dated 6/20/16) revealed that, at 1530 (3:30 p.m.), he spilled hot soup down his right leg and on top of his right foot. His pants and shoe and sock were immediately removed, and his leg and foot were pink but not blistered. At 1660 (5:00 p.m.), blisters were noted to his right foot and leg. Daily [MEDICATION NAME] was ordered. Resident #6 complained of pain at a 3 on a 10-point scale. On 8/11/16, all burn areas to his right leg were documented as healed. Record review of Resident #6's 6/20/16 incident/accident report revealed that he fell asleep and spilled hot soup on himself in his room. Staff were inserviced and told that Resident #6 was to inform staff when he wanted soup or a hot drink and that staff were to take him to his room or to wherever he wanted to eat/drink it. Record review of Resident #6's 6/20/16 risk management system report revealed that he was carrying a cup of hot soup in a styrofoam cup with a lid and spilled it on himself (down his right leg, under his knee, and on top of his foot). Record review of the facility's initial submission provider investigation report for Resident #6's 6/20/16 incident revealed resident with [MEDICAL CONDITION] over warmed soup. Provider response was Nursing informed physician of occurrence and physician ordered application of [MEDICATION NAME] treatment daily and monitoring of signs and symptoms of infection. Charge nurse also instructed dietary staff member to ensure food and/or beverages given to residents were not 'too hot'. Inservicing of nursing staff followed to address the need for promptness in reporting this type of incident to DON and administrator. Additionally, inservicing of dietary staff to ensure proper temperature of food and/or drink for residents is followed up with dietary manager. After an email was sent from the corporate nurse consultant to the administrator and recommended changes were made, record review of the facility's provider investigation report for Resident #6's 6/20/16 incident revealed that he had [MEDICAL CONDITION] soup. Investigation summary was Preliminary investigation has shown the dietary staff presented the resident with the bouillon soup which he requests on an almost daily basis. This was provided to him in a cup with a lid. Additionally, the charge nurse checked on the resident when he was outside of his door and had yelled for help. It was the charge nurse and the CNA who then removed the resident's trouser and sock, revealing a pinkish area on his leg and foot. At that time, the charge nurse phoned the physician and was given an order of [MEDICATION NAME] cream to be applied daily and to monitor for signs and symptoms of infection. The treatment nurse then followed with placement of the [MEDICATION NAME] cream and reassessed the area to find a blister was now apparent. The physician was recalled and again the order for [MEDICATION NAME] was provided. Investigation findings were confirmed. Provider action taken post-investigation was Inservice with dietary staff regarding food temperatures, inservice regarding abuse/neglect for dietary staff, inservice for nursing staff regarding timeliness of reporting significant events, education for dietary staff to check temperatures of all prepared items requested before serving (prn requests), and an audit of meal temperatures will be conducted daily for one week. Record review of Resident #6's 6/21/16 physician telephone order revealed that he was to be served hot liquids in a cup with a lid and that [MEDICATION NAME] cream 1% was to be applied to the affected area (for burn to right foot) twice daily. Record review of Resident #6's care plan (dated 6/23/16) revealed no documentation pertaining to hot liquids and/or a cup with a lid. During an interview with the regional nurse consultant at 12:00 p.m. on 9/15/16, she reviewed resident care plans with the surveyor and clarified that use covered cup when consuming hot beverages was added on 9/14/16. She confirmed that, although there were some residents needing covered cups prior to 9/14/16, this had not been care-planned. Record review of the kitchen's production worksheet report for 6/20/16 revealed that no temperatures were recorded. Record review of a 6/21/16 inservice sign-in sheet revealed that dietary staff (including DA D and Cook C) were taught about hot food safety. They were told that coffee, tea, soup, and broth should not be hotter than 180 degrees Fahrenheit and should be served in plastic, insulated mugs or bowls and not foam cups. The Guidelines for Hot Beverages policy (dated 4/1/14) was reviewed with them. Record review of a 6/21/16 inservice sign-in sheet revealed that all staff (including DA D and Cook C) were taught to assist residents with an unsteady gait in carrying soups or drinks from the kitchen and to place liquids received from the kitchen on stable furniture of resident's preference. Staff were to inform kitchen staff of residents who were not self-ambulatory and without present assistance if they requested hot liquids so that direct care staff could assist them. Record review of a 6/22/16 inservice sign-in sheet revealed that dietary staff (including DA D and Cook C) were taught about taking and recording the temperatures of all hot and cold foods to include hot water and coffee. The Thermometer Usage policy (dated 12/1/15) was reviewed with them. Record review of a 6/22/16 invoice revealed that the holding tank temperature of the coffee maker was adjusted to 184 degrees Fahrenheit per the dietary supervisor. Observation of Resident #6 eating dinner in the main dining room at 5:40 p.m. on 9/13/16 revealed that he was feeding himself pineapple tidbits and was shaking as he brought his spoon to his mouth, spilling pineapple tidbits on his shirt. He had a styrofoam cup without a lid in front of him and was taking sips from it. The styrofoam cup had what-appeared-to-be coffee in it. During an interview with Resident #6 at this time, he reported that the styrofoam cup contained coffee. During an interview with Cook C at 3:45 p.m. on 9/13/16, she reported that the dietary supervisor spoke with kitchen staff after Resident #1's burn incident and told them that certain people required a special blue cup with a lid for hot beverages. Cook C reported that kitchen staff were told that the coffee temperature could not be greater than 165 degrees Fahrenheit when it left the kitchen. Cook C stated I don't know what the temperature was at the time of (Resident #1's) burn. (Resident #6) has burned himself before too. We should be taking the temperatures of the coffee and foods before they go out, but we get so busy. I didn't know we were supposed to be taking the temperatures of the coffee until the supervisor inserviced us after (Resident #1) spilled her coffee. I just made the coffee and put it out. Cook C reported that the dietary supervisor adjusted the temperature on the coffee maker after Resident #1's incident and that kitchen staff were supposed to be keeping temperature logs now. She presented the surveyor with a red book in which all temperatures were supposed to be recorded (but were not) at this time. During an interview with DA E at 3:52 p.m. on 9/13/16, he reported that he checked coffee temperatures when I have time. If we're rushing, I forget. I don't take temperatures all of the time, but I try to remember. I try to keep it less than 165 (degrees Fahrenheit). Record review of the facility's temperature logs revealed that the temperature of the coffee was first recorded on 9/10/16 and was 165 degrees Fahrenheit. On 9/11/16, the coffee temperature was recorded once and was 165 degrees Fahrenheit. On 9/12/16, the coffee temperature was recorded twice and was 165 and 155 degrees Fahrenheit. On 9/13/16, the coffee temperature was recorded twice and was 160 and 165 degrees Fahrenheit. There were no food/hot liquid temperatures taken for breakfast or lunch 9/9/16; breakfast or lunch on 9/10/16; breakfast, lunch, or dinner on 9/11/16; breakfast, lunch, or dinner on 9/12/16; and breakfast and lunch on 9/13/16. During an interview with Cook C, DA D, and DA E at 4:04 p.m. on 9/13/16, they reported that the kitchen got a new coffee maker 2-3 weeks ago. They reported that there was no designated person for taking coffee temperatures. They reported that Resident #1 got her coffee from the kitchen on the day of her burn and was using a styrofoam cup without a lid. When asked which residents got a cup with a lid/how they knew which residents were to be served in the special cups, DA D stated Anyone with mobility problems, a walker, or a wheelchair. Cook C and DA E nodded in agreement. During an interview with the ADON at 4:10 p.m. on 9/13/16, she reported that Resident #6 spilled hot soup on himself on 6/20/16 and had blistering to his foot and legs. She stated I think the intervention for that was kitchen monitoring of temperatures. During a phone interview with the dietary supervisor at 4:18 p.m. on 9/13/16, he stated We don't have high temperature ranges. We have made efforts to make sure people aren't burning themselves. Certain residents use a blue cup with a lid - even if it spills, it comes out slowly. The dietary supervisor reported that the kitchen's old coffee maker was replaced approximately one month ago. He was on vacation at the time, and the new coffee maker was installed with the manufacturer settings. The dietary supervisor stated When (Resident #1's) burn happened, I had the maintenance man adjust the brew temperature range to 170 (degrees Fahrenheit). When asked if kitchen staff were doing any kind of temperature monitoring prior to Resident #1's burn incident, the dietary supervisor stated Some before. We started shortly before (Resident #1) got burned. When asked how kitchen staff monitored temperatures, the dietary supervisor stated We pour the coffee out of the maker and check it with a digital thermometer one time per meal 3 times per day. Staff are logging these temperatures in the kitchen red temperature log. The dietary supervisor reported that all temperatures taken by kitchen staff were supposed to be recorded in the red book. When asked what temperature was too high, the dietary supervisor stated I told them no greater than 180/185 (degrees Fahrenheit). If the temperature is higher than that, they are supposed to let it cool down before letting it leave the kitchen. The dietary supervisor reported that staff were supposed to be returning the hot beverage cart to the kitchen immediately after meal service but that Resident #1 served herself the hot coffee from the unsupervised hot beverage cart. During an interview with RN F at 5:41 p.m. on 9/13/16, when asked how she knew which residents needed to be served coffee in the blue mugs with lids, she stated They have to have an order for [REDACTED]. During an interview with DA D at 5:46 p.m. on 9/13/16, he reported that the coffee temperature for dinner was 165 (degrees Fahrenheit) when sent out on cart, I believe. During an interview with the dietary supervisor and the regional dietary manager at 10:10 a.m. on 9/14/16, they reported that there was a constant turnover of dietary staff but that the new processes for temperature monitoring should have been learned by now. The dietary supervisor confirmed that no food or liquid temperatures had been taken on 6/20/16 - the day of Resident #6's hot soup burn. During an interview with the RD at 12:20 p.m. on 9/14/16, she reported that Resident #6 often fell asleep when eating/drinking and that temperature monitoring had been a problem at the facility since she started working there in October of 2015. Record review of the facility's Guidelines for Hot Beverages policy (dated 4/1/14) revealed 1. Do not leave pots or urns of hot coffee or other hot beverages unattended - use toggle covers on urns to reduce risk of accidental dispensing. 2. Limit access of patients/residents to locations where hot beverages may be prepared or reheated such as break room and kitchen. 3. Discourage patients/residents from carrying cups of hot beverages without a lid while they are walking or moving in a wheelchair . Record review of the facility's Thermometer Usage policy (dated 12/1/15) revealed Food is tested throughout preparation and service to ensure the appropriate temperature is reached and maintained . Record the holding temperature of the foods being held for service on the production sheet. Action is taken if food is not within identified ranges, prior to service . Time/temperature control for safety foods reheated in a microwave for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees Fahrenheit and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating . Record review of the American Burn Association's Scald Injury Prevention Educator's Guide (not dated) revealed that exposure to a water temperature of 155 degrees Fahrenheit for a second could cause a third degree burn. The administrator was notified on 9/14/16 at 10:52 a.m. that an IJ situation had been identified due to the above failures. The facility's plan of removal was provided by the administrator on 9/14/16 and accepted on 9/14/16 at 5:06 p.m. The facility took the following actions (verified through observations of the dining areas and kitchen, interviews with residents and staff, and record reviews of resident assessments, care plans, and therapy evaluations) to remove the IJ: - The regional dietary manager conducted an inservice on the policy/procedure regarding food/beverage temperatures and recording to include a temperature range when served to resident of 135 to 155 degrees Fahrenheit for food/beverages served hot with the dietary supervisor on 9/14/16. - The dietary supervisor conducted an inservice on the policy/procedure regarding food/beverage temperatures and recording to include a temperature range when served to resident of 135 to 155 degrees Fahrenheit for food/beverages served hot with dietary staff on 9/13/16. - The dietary supervisor conducted an inservice on the facility guidelines for hot beverages and the policy/procedure for thermometer usage with dietary staff on 9/13/16. - The nurse practice educator conducted an inservice on the policy/procedure for meal service specific to assistance and supervision with direct care staff on 9/14/16. - The dietary supervisor started to bring food/beverage temperature logs to the morning meetings on 9/15/16. The administrator started to review these logs for completeness and compliance with temperature ranges on 9/15/16. The administrator will report the results of these reviews to the Quality Assurance (QA) Committee during the next 3 QA Committee meetings. The dietary supervisor will conduct inservices related to food/beverage temperatures and recording as needed per results of the reviews. - Utilizing the MDS assessments, nursing administration identified 57 residents requiring assistance with meals on 9/14/16. - Occupational therapy began screening of the residents identified as needing assistance per their Activities of Daily Living score in the eating section of the MDS on 9/14/16 to ensure residents could safely manage hot beverages. Per the results of the screens, occupational therapy will provide intervention recommendation to nursing services if identified as necessary. - Nursing administration began care-planning and implementing interventions per therapy recommendations to ensure residents could safely manage hot beverages on 9/14/16. - The administrator conducted an inservice on the center guidelines for hot beverages with department head meal monitors on 9/14/16. - The dietary supervisor began verification and documenting verification of food/beverage temperature prior to service to ensure compliance with temperature guidelines on 9/14/16. - The regional dietary manager started to develop (on 9/14/16) and the facility was to implement an onboarding guide for dietary agency staff to include center guidelines on food/beverage temperatures and recording. - All facility residents were provided with covered cups for hot beverage consumption on 9/15/16. If a resident was not in agreement with a covered cup, nursing administration began educating the resident/responsible party regarding the risks and included this on the resident's care plan. Observations of the dining rooms during dinner on 9/14/16, breakfast on 9/15/16, and lunch on 9/15/16 revealed that there was supervision at all times when the hot beverage cart was present. At breakfast and lunch on 9/15/16, all residents were served coffee/hot liquids in the new insulated cups with lids. The regional dietary manager was observed taking the temperatures of hot liquids/coffee at the time of meal service to residents. Interviews with dietary staff on 9/14/16 and 9/15/16 revealed that they had received training from the dietary supervisor and had learned that the temperatures of all hot liquids (including coffee and soup) were to be taken prior to them leaving the kitchen. The hot beverage cart was not to leave the kitchen unless nursing staff were present to supervise it. All temperatures were to be recorded in the red temperature monitoring log book. Residents were to be served coffee/hot liquids at temperatures within the 135 to 155 degrees Fahrenheit range, and all coffee/hot liquids were to be served to all residents in the new insulated cups with lids. Interviews with nursing and direct care staff on 9/14/16 and 9/15/16 revealed that they had received training from the nurse practice educator and had learned that the hot beverage cart was to be supervised at all times and that residents were to be served coffee/hot liquids at temperatures within the 135 to 155 degrees Fahrenheit range. All residents were to be served coffee/hot liquids in the the new insulated cups with lids. If a resident refused to use the new cup with lid, staff were to report the noncompliance to nursing administrative staff. Record review of the facility's temperature logs for dinner on 9/14/16 and breakfast on 9/15/16 revealed that they were complete and that temperatures for hot liquids were within the appropriate ranges. Record review of the occupational therapy screens for the 57 residents identified as needing assistance with eating based on their MDS assessments revealed that 16 were appropriate for occupational therapy evaluations and treatment. Record review of the care plans of 6 residents revealed that the need for covered cups with lids for coffee/hot liquids was added. Interview with the administrator on 9/15/16 revealed that she would be monitoring kitchen temperature logs at the morning meetings and addressing any issues with the dietary supervisor and the QA Committee. On 9/14/16 at 6:10 p.m., the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not an immediate jeopardy with the scope of pattern until all measures listed in the plan of removal were completed. Record review of the administrator's (Center Executive Director's) job description (dated 1/1/16) revealed Position Summary: Create an environment where staff members are highly engaged and are focused on providing the highest level of clinical care and [MEDICATION NAME] to patients, residents, and families. Responsible for assuring the center operates in full compliance with Federal and State regulations . Responsible for planning and is accountable for all activities and departments of the center subject to rules and regulations promulgated by government agencies to ensure proper health care to residents. The Center Executive Director administers, directs, and coordinates all activities of the center to ensure that the highest degree of quality of care is consistently provided to residents . Essential Functions: . Clinical Excellence 5. Creates an environment that is focused on patient and staff safety. Conducts required fire and disaster drills and maintains compliance with legal, safety, health, fire, and sanitation codes . Compliance . 8. Participates in education, monitoring and auditing activities and investigations, and implementing quality assurance and performance improvement processes as required. According to information provided by the administrator on 9/20/16, there were 8 residents at risk for coffee/hot liquid burns.

Based on record review, interviews and observations, the facility failed to ensure residents remained free of accident hazards and failed to provide adequate supervision for 2 of 6 residents (#1 and 5 while side rails were in use: 1. Resident #1: A side rail pad and bolster (a long, often cylindrical, cushion or pillow for a bed, sofa) were not in place as ordered by the physician ([DATE]) to prevent the resident from sliding off the bed onto the floor and the resident's head and jaw became entrapped between the side rail and mattress. The bed in use did not belong to the facility and the railing had approximately 7 inches of play (movement) between the mattress and side rail. Due to the excessive play, the resident's head and jaw became trapped between the mattress and the side rail resulting in mechanical asphyxiation (death) by accidental strangulation. 2. Resident #2: The side rail and pad were not in place to prevent the resident from falling out of bed; the side rail pad was not in place to prevent the prevent the resident from getting the right leg stuck in the side rail; and when the bed was changed for a low bed without a side rail, a 10 inch wide gap was created between the bed and bedside table placing the resident at risk for becoming trapped between the bed and table. These failures resulted in an Immediate Jeopardy which was identified and the facility remained out of compliance at a severity level of actual harm and pattern due to not all residents being evaluated by an Interdisciplinary Team for the use of side rails; not all staff had been in-serviced to evaluate unsafe use of side rails and environmental hazards; and the nursing staff had not been in-serviced on documenting observations of compliance with physician orders [REDACTED]. This deficient practice could affect 44 residents using side rails and could lead to the injury and even death. Findings were: A. Review of Resident #1's clinical record revealed a face sheet documenting the [AGE] year old resident's initial admission to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's "Provider Investigation Report" dated [DATE] documented that Resident #1 was found on [DATE] at 9:29 pm on the floor of her room with her head between the side rail and bed mattress. The resident was "pale and cold to touch, unresponsive and no pulse present." The resident's arms and entire body were lying on the floor and the Resident's "legs, hands and arms were (sic.) modeled." (Mottled skin is a condition in which the skin becomes discolored in irregular patches, especially on the hands and feet and may look blue and blotchy due to slow blood circulation.) The "Provider Report" documented that the resident's last fall was on [DATE] from bed to floor and that she had also had 2 recent incidents of seizures on [DATE] and [DATE]. The "Provider Report" documented that the possible cause of the resident's movement in the bed on [DATE] was due to a seizure. Review of nursing notes for Resident #1 revealed documentation of recent seizure activity: . On [DATE] the resident had a seizure that lasted between ,[DATE] seconds during the breakfast meal at 9:44 am. The resident became "somewhat pale...pt. tightened her lip and would not open her mouth." . On [DATE], a nurse documented that at 8:45 am the resident was observed having "seizure activity, jerking intermittently, focus stare, no loss of B/B no drooling noted." The resident was given Ativan (anti-anxiety) 0.5 mg SL. . At 12:30 pm on [DATE] the resident was up in a recliner for lunch and "began jerking and shaking again, focus stare again." Ativan 0.5.mg SL was administered. An incident report documented that on [DATE] at 11:00 pm, the resident was found to have a bruise to the right hand, 2nd knuckle. It was not determined how the injury occurred. However, the facility's assessment process documented that the side rails were up but not the side rail pad. Review of Resident #1's recent MDS assessment dated [DATE] indicated that the resident's cognitive level was unassessable due to the resident's unresponsiveness. Care plans documented a problem onset of falls/fall risk related to dx of dementia beginning on [DATE]: . [DATE] adding a pad alarm while in bed and a personal belt alarm to the wheelchair; . [DATE] being trapped between a mattress and side rail was on [DATE]due to a gap between the side rail and mattress; having a cord to the personal alarm being too long to set off the alarm in the event of a fall; attaching a magnetic alarm and tilt w/c 30 degrees while up in w/c for personal safety; and being found on floor by bed. A mat was placed in front of bed. . [DATE] finding a bruise to the right hand and 2nd knuckle area. Approaches included: "Implement appropriate measure (s) to prevent further occurrences (e.g. padded side rails....)." Review of a "fall risk" care plan dated [DATE] included placing a floor mat next to the bed. A care plan dated [DATE] addressed the resident requiring extensive assistance 1 to 2 persons to assist with bed mobility, etc. The approach included allowing the resident while in bed to move to and from a lying position, turning side to side, using both side rails for mobility and positioning the body while in bed. Review of consolidated physician's orders [REDACTED]. " Review of TARS for June and [DATE] revealed that the nursing staff was not initialing the document indicating that the side rails and/or side rail safety pads were in place. Listed on the TARS was the following: "Side rails ,[DATE] with bolster at foot of bed and floor mat." The column was not initialed. "Padded side rails x1 for restlessness and skin and extremity protection." The column was not initialed. "Hi/Low electric bed w/mat to floor and continued triangle wedge to foot of bed." The column was not initialed. During interview on [DATE] at 1:30 pm, LVN A (who found the resident in her room on [DATE]) stated that the devices were listed on the TARS and MARS for the nurses' FYI and the columns did not have to be initialed. LVN A stated that nurses entered the residents' rooms at some point in the shift and were to observe that the devices were in place. During a second interview on [DATE] at 3:10 pm, LVN A stated that she had not been instructed to initial the TAR regarding side rails and pads by the facility administration (DON) , but understood that the instructions were "in the works." In response to a question, LVN A stated that the facility's system should include that all side rails, restraints, residents in bed be checked by the charge nurse every shift and that the observation be charted on the MAR. She stated that the system was not in place yet. Review of an incident report dated [DATE] revealed that the recording nurse was called to Resident #2's room by the Treatment Nurse (LVN A) and "observed pt. between bed and rail head with pt. on floor with blood drop on face and floor." LVN A, documented in a witness statement that a ,[DATE] rail was in an up position and was not padded. "Noted resident on the floor. (R) side with head wedged between bed and side rail. Blood from mouth with some on the floor. Resident was pale and hands and legs mottled and cold to touch. Yelled for charge nurse. Resident was not breathing." Review of the Medical Director's progress note, [DATE], documented that the resident had "no purposeful response, un-intellible speech. Able to sit up. Legs/arms stiff and resistant to ROM." Review of the Medical Director's progress note on [DATE] revealed that the physician had been called by the facility administrator. "Pt. found deceased - 2100 (9:00 pm) - with her head entrapped b/t side-rail and mattress. I auscultated (listening to the internal sounds of the body, usually using a stethoscope) pt. 2 minutes of no audible heart sounds, no visible or audible breath sounds/effort. Time of death 2202 (10:02 pm). Investigation pending. Addendum: 2310 (11:10 pm). Strongly suspect accidental death." During interview by phone on [DATE] at 12:40 pm, the Medical Director stated that he had been in the facility and observed the resident a few minutes after being found on [DATE]. The resident's head was still wedged between the side rail and mattress and the body was still lying on the floor. The side rail pad was under the bed and a personal alarm which attaches to the resident's clothing was hanging on the side rail with the cord still attached to the device. The physician stated that he did not believe the resident had a convulsion and that the resident slid down in bed and was pulled to the floor by the weight of her body. He stated that the bed in use did not belong to the facility and that he observed that the railing had approximately 7 inches of play (movement) between the mattress and side rail. He stated that if the side pads were in place, the resident would not have become entrapped in the railing. He stated that the use of this particular bed and side rail delivered to the facility by the hospice agency was not "a good idea." He stated that the incident was QA'd with the Administrator and DON the next day. During interview on [DATE] at 10:10 am, the DON stated that the LVN A had contacted her upon finding the resident and she instructed LVN A to call the Administrator and Medical Director. Based on the information provided by LVN A, both the DON and LVN A assumed the resident had expired. During interview on [DATE] at 10:20 am, the Administrator stated that she was called by facility staff on the evening of [DATE] and entered the facility within 5 minutes of the call. The Medical Director also arrived at the same time and Resident #1's head was wedged between the side rail and mattress. The Medical Director then assess the reident and determined that the resident had expired. The Administrator also stated that 2 police officers arrived and entered the room while the resident was still wedged between the side rail and mattres shortly afterwards followed by the local JP and a detective. The Administrator stated that the resident had been in the Secured Unit at one time and was transferred to the main floor when her care needs increased. She stated that the resident was placed on hospice services due to gradual weight loss requiring the staff to feed the resident and that the resident required total care. During interview on [DATE] at 10:30 am, LVN A stated that she entered Resident #1's room at 9:29 pm and found the resident on the floor with her head trapped between the side rail and bed and that the resident's eyes were closed. The arms, legs and hips were lying on the floor. She stated that she called for help and checked the resident's pulse. The resident was not removed from the side rail because the resident's skin appeared mottled; the resident had no pulse and was "obviously dead." The resident was a DNR and no interventions were initiated. She stated that the resident was not disengaged from the side rail so that the police could observe that the resident's death was "caused by an accident." During interview at the office of the local JP on [DATE] at 11:00 am, the JP reported that the cause of death was due to "accidental death by mechanical asphyxiation." The JP provided copies pictures of the death scene he had taken and it was verified that the resident's arms, legs and hips were on the floor, the head was trapped between the mattress and side rail and that the side rail pad was under the bed. There was no bolster pad on the bed and a mat was on the floor. He stated that he observed the personal alarm device attached to the side rail with the pull cord still attached to the device. Review of a draft copy of the ME's "Cause and Manner of Death" dated [DATE] and examined on [DATE] revealed that the manner of death was "accident" and the cause of death was "mechanical asphyxia." The draft copy did not have document a time of death. Review of Picture #1 revealed Resident #1 with her head between the mattress and side rail. Picture #2 revealed the resident's full body lying on the floor partially on top of a floor mat, arms crossed and the entire trunk, hips and legs were resting on the floor. No bolster is noted and the rail was without a pad. A personal alarm with a cord device was attached to the railing. Picture #3 revealed that the left cheek was compressed against the railing and the back of the head was resting on the mattress and the jaw was between the up and down bar and was resting on the cross bar. During interview on [DATE] at 12:10 pm, CNA B reported that she was working on the hall of Resident #1 and was assigned to provide direct care. CNA B reported that the placement of a bolster pad and side rail pad was not listed on her assignment sheet. She stated that she had placed the resident in bed after the dinner meal on [DATE] at approximately 6:35 pm. The resident was placed on her left side with her face directed to the wall. The resident's bed was pushed up against the wall and CNA B pulled the side rail up into position. The personal alarm was not attached to the resident's clothing, because the alarm was not on the assignment sheet. CNA B stated that she went on lunch break from 7:45 to 8:15 pm and then returned to the floor. She checked on Resident #1 and the resident was still on her left side and facing the wall. She stated that when the resident was found at 9:29 pm by LVN A, she responded and found the resident on the floor with her head trapped in the railing. She stated that LVN A would not allow anyone to touch the resident and insisted that the resident was already dead, was a DNR and that the police would need to see the body. CNA B stated that the accident could have been prevented if the side rail pad was in place and that she would have put the pad in place if instructed to do so on her assignment sheet. During interview on [DATE] at 7:30 pm, CNA C stated that he worked the evening shift and had been assigned to provide direct care to Resident #1 on 2 other dates ([DATE] and [DATE]) and on [DATE] had transferred Resident #1 from the bed to the wheelchair for the evening meal. He stated that the side rail pad and bolster were not in place, but that the personal alarm was attached to the resident's clothing while in bed. He stated that the side rail pad and bolster were not used on the 2 days he took care of the resident. He stated on [DATE] at 2:30 pm that he was providing direct care to Resident #5 on [DATE] when Resident #1 was found dead in her room. He stated that on the 2 days he provided care to Resident #1 no pads were on the bed and that he had hooked up the personal alarm and attached the pull cord to the resident's clothing while in bed. He stated that all side rails in the building were changed after the incident with Resident #1. During interview on [DATE] at 3:10 pm, LVN A stated that she had not been instructed by the facility administration to initial the TARS regarding side rails and pads, but understood that those instructions were "in the works," since the Surveyor's intervention. In response to a question, LVN A stated that the facility's system should include that all side rails, restraints, residents in bed be checked by the charged nurse every shift and that the observation be charted on the MAR. She stated that the system was not in place yet. Observations on [DATE] from 5:15 to 6:00 pm revealed that no other resident in the facility had a bed with a side rail that had caused Resident #1 to be entrapped and asphyxiated. Forty-four beds were observed and none of the beds had wobbly, loose side rails. During interview on [DATE] at 10:12 am, the DON reported that the nursing staff had called her on the evening of [DATE] when Resident #1 was found in her room entrapped in the side rail. Based on the description of the resident, the DON instructed the staff to leave the resident in place, because there would be a police inquest. When asked why the resident was not disengaged from the side rail, assessed and provided CPR, the DON stated that the resident was dead. The physician saw her soon after being found and confirmed the death. The DON stated that there was no protocol established within the facility to instruct the nursing staff on what steps to follow in the event a resident becomes entrapped in a side rail. During interview on [DATE] at 10:30 am, the Administrator confirmed that a protocol was not in place on responding to emergency situations such as hanging or strangulation by side rails. During interview on [DATE] at 11:00 am, the Maintenance Supervisor reported that he had tightened the railing on Resident #1's bed on [DATE]th at the request of the charge nurse. (He could not remember who the nurse was.) The Supervisor stated that he informed the charge nurse at that time to call the hospice agency and have the bed and side rail replaced. He stated that the side rail was changed on [DATE]th and that he had assessed the equipment for safety. During interview on [DATE] at 1:45 pm, Hospice Supply Staff D reported by phone that the agency did not receive a call to have the bed Resident #1 was in to be replaced. A side rail change was requested on [DATE] and a ,[DATE] rail was delivered on [DATE]. According to a fax listing a history report of deliveries sent to the facility on the Surveyor's entrace date ([DATE]), no changes of equipment occurred during the month of July. A side rail pad was delivered to the facility which was to be used with the side rail. The pad had Velcro straps to wrap around the side rail bars. Review of the hospice agency's order and delivery history report for Resident #1 revealed that a bed with full side rails was ordered and delivered on [DATE]. On [DATE], Hospice RN F assessed the bed and side rails and ordered the full side rails changed to half side rails. The side rail pad was also delivered on [DATE]. During interview on [DATE] at 2:30 pm, LVN E stated that she had provided supervision and direct care to Resident #1 during the month of June and July and ensured that the bolster pad was in place to prevent the resident from sliding out of bed. She stated that there was a side rail pad with Velcro straps that wrapped around the side rail and covered the openings. She stated that she had "fussed" with the hospice aides to tighten the side rail to the bed. She stated that she contacted the hospice agency to report the side rail and by the time Hospice RN F came out to the facility, the railing had been tightened. LVN E stated that she had the Maintenance Supervisor tighten the side rail. Interview with LVN G, charge nurse, on [DATE] at 12:30 pm by phone confirmed that she had signed for the side rail and side rail pad and were necessary for Resident #1 due to involuntary movements. LVN G confirmed that the side rail without the pad placed Resident #1 at risk for "getting caught in the side rail." During interview on [DATE] at 2:10 pm, Hospice RN F, Case Manager, stated that he had observed Resident #1 in a wheelchair and in bed and was aware of an issue regarding a side rail and the side rail was replaced. He stated that the side rail was needed due to the resident's history of seizures. He stated that a long side rail pad with Velcro straps was delivered to the facility and that he had seen the pad on the bed during visits to the facility. B. Review of Resident #5's clinical record revealed an admission face sheet ([DATE]) documenting that the [AGE] year old resident was admitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. On [DATE], a fax was sent to the Medical Director informing him that Resident #5 had stuck her right leg through the ,[DATE] side rail and a red mark was noted to the outer aspect of the leg, which could bruise and the physician responded with the following TPO's: . [DATE], the facility received a TPO for a blue foam mat (to be placed) next to the bed and ,[DATE] side rails x 1 with a sensor pad to the w/c. . [DATE], a TPO by the Medical Director, ordered ,[DATE] side rail padded. . [DATE], the TPO was clarified as ,[DATE] side rail padded as "enabler". On [DATE] the facility received a physician's telephone order to place an air mattress on the bed for "wound healing." A TAR for [DATE] listed a padded side rail ,[DATE] x 2 as enabler; drop seat to w/c; sensor pad to bed; blue floor mat next to the bed; and self-releasing alarm belt to w/c. None of the columns for these items on the TAR were initialed initialed to indicate the nurse had observed the items in place. The consolidated physician orders [REDACTED]. Review of nursing notes for [DATE] revealed that at 10:34 pm, the "resident's alarm went off" and the resident was found on the floor. The Incident Report also dated [DATE] documented that the side rail and pads were not in place to prevent the resident from rolling out of bed. On [DATE] nursing notes documented that the resident was found at 4:15 am with a leg in the railing. The Incident Report for [DATE] documented that the right leg had been "stuck through the ,[DATE] rail" and had caused a red mark to the leg. The resident was "confused, speaks Spanish." Side rail pads were not documented in place. Observation at 2:30 pm on [DATE] revealed that the resident was in bed with ,[DATE] side rails up. There was no pad attached to the side rail. A pad was positioned between the mattress and the wall. There was no side rail on that side. There was no floor mat in place and the resident was in bed speaking incoherently. A blue floor mat was observed leaning against the bureau and between the roommate's bed (the resident's spouse). During inteview at 5:30 pm on [DATE], the Administrator and DON were informed that Resident #5 was in an unsafe bed in a high position, 1 side rail unpadded and the floor mat not on the floor. Observation, accompannied by LVN A, was conducted on [DATE] at 12:30 pm of Resident #5 to determine whether the resident's environment was free of hazards. The resident's bed had been changed and now was on the floor with a floor mat. An approximately 10 inch gap was created between the head of the bed and the bedside table. A small refrigerator was on the other side of the bedside table. The 10 inch gap was sufficient to entrap the resident's head if the resident rolled off the bed onto the floor mat. LVN A verified that the changed set up now created an unsafe gap for the resident. LVN A moved the side table to the other side of the room. The removal of the bedside table then created more space (approximately shoulder width a part) to prevent entrapment of the head. C. The Immediate Jeopardy was removed on [DATE] after the third submission of the POR. A review of the facility's Quality Assurance Committee's POA, [DATE], revealed the corrective action was insufficient to ensure the safety of the residents. After a third submission, the POR provided sufficient evidence of an on-going process by the facility in identifying unsafe practices and hazards in the residents' environments and in assuring that adequate supervision of residents utilizing side rails. This included: . Supervisors utilizing a "Daily Care Guide," to check on resident utilizing side rails during rounds. . Establishment of a protocol instruct the nursing staff on how to respond to residents encountered in emergent circumstances such as hanging, choking and trauama, regardless of their DNR status. . In-servcing the nursing staff on a one-on-one basis on the new protocol.. Convening of an IDT on [DATE] to assess the cognitive capabilities and needs of each resident in the facility relative to the use of side rails. At 4:00 pm on [DATE], the IJ was removed. The facility reported on [DATE] that 44 residents had been identified as using side rails attached to their beds as safety precautions due to poor safety awareness and/or as enablers to enhance resident bed mobility.

Based on record review, interviews and observations, the facility failed to implement the facility's written policies and procedures that prohibited neglect in the use of side rails and to provide interventions to prevent 2 of 6 residents (#1 & 5) from falling out of bed and becoming entrapped in a side rail. After regional administrative review, the surveyor reentered the facility on [DATE] to gather more information. 1. Resident #1: A side rail pad and bolster (a long, often cylindrical, cushion or pillow for a bed, sofa) were not in place as ordered by the physician ([DATE]) to prevent the resident from sliding off the bed onto the floor and the resident's head and jaw became entrapped between the side rail and mattress. The bed in use did not belong to the facility and the railing had approximately 7 inches of play (movement) between the mattress and side rail. Due to the excessive play, the resident's head and jaw became trapped between the mattress and the side rail resulting in mechanical asphyxiation (death) by accidental strangulation. 2. Resident #2: The side rail and pad were not in place to prevent the resident from falling out of bed; the side rail pad was not in place to prevent the prevent the resident from getting the right leg stuck in the side rail; and when the bed was changed for a low bed without a side rail, a 10 inch wide gap was created between the bed and bedside table placing the resident at risk for becoming trapped between the bed and table. This failure resulted in an Immediate Jeopardy which was identified on [DATE] and the facility remained out of compliance at a severity level of actual harm and isolated until [DATE]. All residents were not evaluated by an Interdisciplinary Team for the use of side rails; not all staff was in-serviced to evaluate unsafe use of side rails and hazards; and the nursing staff had not been in-serviced on documenting observations of compliance with physician orders [REDACTED]. This deficient practice could affect 44 residents who were identified by the facility as using side rails attached to their beds as safety precautions due to poor safety awareness and/or as enablers to enhance resident bed mobility. The findings were: A. Review of the facility Abuse Prevention policy dated [DATE] revealed that it was the facility's intent to ensure the residents' right to be free from physical abuse and neglect. The policy's purpose was to ensure residents were protected by providing a method for the prevention any type of alleged abuse through analysis: . of the physical environment that make abuse or neglect more likely to occur; . of the supervision of staff providing direct care; . of the assessment, care planning and monitoring of residents with needs and behaviors which might lead to neglect or injury; . of residents who require heavy nursing care and/or are totally dependent on staff. . of ensuring care giving staff are aware of all interventions required to protect the residents. Based on observations, interviews and record review, the facility failed to follow its own abuse prevention policy. Review of Resident #1's clinical record revealed a face sheet documenting the [AGE] year old resident's initial admission to the facility on [DATE] with [DIAGNOSES REDACTED]. The "Provider Investigation Report" dated [DATE] documented that Resident #1 was found on [DATE] at 9:29 pm on the floor of her room with her head between the side rail and bed mattress. The resident was "pale and cold to touch, unresponsive and no pulse present." The resident's arms and entire body were lying on the floor and the Resident's "legs, hands and arms were (sic.) modeled." (Mottled skin is a condition in which the skin becomes discolored in irregular patches, especially on the hands and feet and may look blue and blotchy due to slow blood circulation.) The "Provider Report" also documented that the resident's most recent fall was on [DATE] from bed to floor and that the resident had experienced 2 recent incidents of [MEDICAL CONDITION] ([DATE] and [DATE]). The "Provider Report" documented that the resident's movement in the bed on [DATE] may have been caused by a convulsion. Review of the "Provider Investigation Report," [DATE], revealed the facility self-reported the death of Resident #1 on [DATE] due to mechanical asphyxiation on the resident's side rail. Review of the facility's Quality Assurance Committee conducted on [DATE], which included the Medical Director, Administrator and DON) revealed a Plan of Action (POA) to prevent further accidental deaths. The POA included inspecting all side rails in use and appropriateness, in-servicing staff regarding the use of safety devices; requesting hospice providers to check delivered equipment for safety and ensuring maintenance staff inspect all side rails for safety. The POA did not include the development of a comprehensive system to ensure the safety of all the residents in the facility and had not implemented the facility's policy in assessing all residents for the use of side rails. The facility remained out of compliance at a severity level of Immediate Jeopardy to Resident Health and Safety at a Patterned level. Review of the facility's policy on "Side Rail Assessment Tool," dated [DATE] indicated that a team would assess each resident's functional and cognitive capacity to ascertain the "least restrictive intervention" in the use of side rails. The tool instructed the staff to ask the following questions: "Caution: Can resident's extremities or head become wedged between side rails and mattress? Residents under 100 lbs. or 5'0" have increased risk. Check for appropriate mattress size and eliminated spaces between mattress and side rails." The "Tool" also instructed the staff to conduct "ongoing evaluation of the risks and benefits of any device in use will be part of the process." No record that the "Tool" had been used in assessing Resident #1's safety while in the bed provided by the hospice agency prior to the accident on [DATE] was found. Review of an incident report for the accident on [DATE] revealed that the recording nurse was called to Resident #1's room by the Treatment Nurse (LVN A) and "observed pt. between bed and rail head with pt. on floor with blood drop on face and floor." LVN A, documented on a witness statement that a ,[DATE] rail was in an up position and was not padded. "Noted resident on the floor. (R) side with head wedged between bed and side rail. Blood from mouth with some on the floor. Resident was pale and hands and legs mottled and cold to touch. Yelled for charge nurse. Resident was not breathing." Review of nursing notes for Resident #1 revealed documentation of recent [MEDICAL CONDITION] activity: On [DATE] the resident had a convulsion that lasted between ,[DATE] seconds during the breakfast meal at 9:44 am. The resident became "somewhat pale...pt. tightened her lip and would not open her mouth." On [DATE], a nurse documented that at 8:45 am the resident was observed having "[MEDICAL CONDITION] activity, jerking intermittently, focus stare, no loss of B/B no drooling noted." The resident was given [MEDICATION NAME] (anti-anxiety) 0.5 mg SL. At 12:30 pm on [DATE] the resident was up in a recliner for lunch and "began jerking and shaking again, focus stare again." [MEDICATION NAME] 0.5.mg SL was administered. An incident report documented that on [DATE] at 11:00 pm, the resident was found to have a bruise to the right hand, 2nd knuckle. It was not determined how the injury occurred. However, the facility's assessment process documented that the side rails were up but not the side rail pad. Review of Resident #1's recent MDS assessment dated [DATE] indicated that the resident's cognitive level was not assessable due to the resident's unresponsiveness. Care plans documented a problem onset of falls/fall risk related to dx of dementia beginning on [DATE]: . [DATE] adding a pad alarm while in bed and a personal belt alarm to the wheelchair; . [DATE] being trapped between a mattress and side rail was on [DATE]due to a gap between the side rail and mattress; having a cord to the personal alarm being too long to set off the alarm in the event of a fall; attaching a magnetic alarm and tilt w/c 30 degrees while up in w/c for personal safety; and being found on floor by bed. A mat was placed in front of bed. . [DATE] finding a bruise to the right hand and 2nd knuckle area. Approaches included: "Implement appropriate measure (s) to prevent further occurrences (e.g. padded side rails....)." Review of CPO for [DATE], for Resident #1 revealed an order beginning on [DATE] for "padded side rails x1 for restlessness and skin extremity protection and beginning on [DATE] for side rails ,[DATE] w/bolster at foot of bed and floor mat. Review of a care plan dated [DATE] documented a second fall risk on [DATE] and the approaches included placing a floor mat next to the bed. A care plan for dated [DATE] assessed the resident requiring extensive assistance (1 to 2 persons) to assist with bed mobility, etc. The approach included assisting the resident in bed mobility such as moving to and from lying position, turning side to side, using both side rails for mobility and positions body while in bed. Review of TARS for June and [DATE] revealed that the nursing staff was not initialing the document indicating that the side rails and/or side rail safety pads were in place. Listed on the TARS was the following: "Side rails ,[DATE] with bolster at foot of bed and floor mat." The column was not initialed. "Padded side rails x1 for restlessness and skin and extremity protection." The column was not initialed. "Hi/Low electric bed w/mat to floor and continued triangle wedge to foot of bed." The column was not initialed. During interview on [DATE] at 1:30 pm, LVN A (who found the resident in her room on [DATE]) stated that the devices were listed on the TARS and MARS for the nurses' FYI and the columns did not have to be initialed. LVN A stated that nurses entered the residents' rooms at some point in the shift and were to observe that the devices were in place. During a second interview on [DATE] at 3:10 pm, LVN A stated that she had not been instructed to initial the TAR regarding side rails and pads by the facility administration (DON), but understood that the instructions were "in the works." In response to a question, LVN A stated that the facility's system should include that all side rails, restraints, residents in bed be checked by the charge nurse every shift and that the observation be charted on the MAR. She stated that the system was not in place yet. Review of a physician's progress note written by the Medical Director on [DATE] revealed that the resident had: "no purposeful response; unintellible speech. Able to sit up. Legs/arms stiff and resistant to ROM." Review of a physician's progress note by the Medical Director dated [DATE] revealed that he was called by the facility administrator on [DATE] and he "found (resident) deceased - 2100 (9:00 pm) - with her head entrapped b/t side-rail and mattress. I auscultated (listening to the internal sounds of the body, usually using a stethoscope) pt. 2 minutes of no audible heart sounds, no visible or audible breath sounds/effort. Time of death 2202 (10:02 pm). Investigation pending. The physician also wrote on [DATE]: "Addendum: 2310 (11:10 pm). Strongly suspect accidental death." During interview by phone on [DATE] at 12:40 pm, the Medical Director stated that he had been in the facility and observed the resident a few minutes after being found on [DATE]. The resident's head was still attached to the side rail and the body was still lying on the floor. The side rail pad was under the bed and a personal alarm which attaches to the resident's clothing was hanging on the side rail with the cord still attached to the device. The physician stated that he did not believe the resident had a convulsion and supposed that the resident had slid down in bed and was pulled to the floor by the weight of her body. (The resident weighed approximately 148 pounds) He stated that the bed in use did not belong to the facility and that he observed the railing have approximately 7 inches of play (movement) between the mattress and side rail. He stated that if the side rail pads were in place, the resident would not have become entrapped in the railing. He stated that the use of this particular bed and side rail delivered to the facility by the hospice agency was not "a good idea." He stated that the incident was QA'd with the Administrator and DON the next day. During interview on [DATE] at 10:10 am, the DON stated that LVN A had contacted her upon finding the resident on [DATE] and she instructed LVN A to call the Administrator and Medical Director. Based on the information provided by LVN A, the resident was assumed dead by both LVN A and the DON. The DON stated that the bed that Resident #1 was in came from a hospice agency and was not the type used in the facility. During interview on [DATE] at 10:20 am, the Administrator stated that she was called by facility staff on the evening of [DATE] and she entered the facility within 5 minutes of the call. The Medical Director also arrived at the same time, because he was either in the building or the parking lot, and Resident #1 was still in the same position found by LVN A at 9:29 pm on [DATE]. The physician examined the resident and assessed the resident dead. The Administrator stated that the local police had also been contacted and arrived at the facility. The Justice of the Peace accompanied by a detective entered the facility and observed the resident while entrapped in the side rail. The Administrator stated that the resident had been a resident in the Secured Unit and was transferred to the main floor when her care needs changed. She stated that the resident was placed on hospice services due to gradual weight loss requiring the staff to feed the resident and that the resident required total care. During interview on [DATE] at 10:30 am, LVN A stated that she entered Resident #1's room at 9:29 am and found the resident on the floor with her head trapped in the side rail and bed and that the resident's eyes were closed. The arms, legs and hips were lying on the floor. She stated that she called for help and checked the resident's pulse. The resident was not removed from the side rail because the resident's skin appeared mottled; the resident had no pulse and was obviously dead. The resident was a DNR and no interventions were initiated. She stated that the resident was not disengaged from the side rail so that the police could determine that the resident's death was caused by an accident. During interview on [DATE] at 11:00 am, the JP reported that the cause of death was due to "accidental death by mechanical asphyxiation." The JP provided a draft copy of the ME's report and pictures of the death scene. The pictures verified that the resident's arms, legs and hips were on the floor, the head was trapped between the mattress and side rail and that the side rail pad was under the bed. There was no bolster pad and a mat was on the floor. Review of a draft copy of the ME's "Cause and Manner of Death" dated [DATE] and examined on [DATE] revealed that the manner of death was "accident" and the cause of death was "mechanical asphyxia." Review of Picture #1 revealed Resident #1 with her head between the mattress and side rail. Picture #2 revealed the resident's full body was lying on the floor partially on top of a floor mat, arms crossed and entire trunk, hips and legs were resting on the floor. No bolster was noted and the rail was without a pad. A personal alarm with a cord device was attached to the railing. Picture #3 revealed that the left cheek was compressed against the railing, the back of the head was resting on the mattress and the jaw was between the up and down bar and was resting on the cross bar. During interview on [DATE] at 12:10 pm, CNA B reported that she was working on the hall of Resident #1 and was assigned to provide direct care. CNA B reported that the placement of a bolster pad and side rail pad was not listed on her assignment sheet. She stated that she had placed the resident in bed after the dinner meal on [DATE] at approximately 6:35 pm. The resident was placed on her left side with her face directed to the wall. The resident's bed was pushed up against the wall and CNA B pulled the side rail up into position. The personal alarm was not attached to the resident's clothing, because the alarm was not on the assignment sheet. CNA B stated that she went on lunch break from 7:45 to 8:15 pm and then returned to the floor. She checked on Resident #1 and the resident was still on her left side and facing the wall. She stated that when the resident was found at 9:29 pm by LVN A, she responded and found the resident on the floor with her head trapped in the railing. She stated that LVN A would not allow anyone to touch the resident and insisted that the resident was already dead, was a DNR and that the police would need to see the body. CNA B stated that the accident could have been prevented if the side rail pad was in place and that she would have put the pad in place if instructed to do so on her assignment sheet. During interview on [DATE] at 7:30 pm, CNA C stated that he worked the evening shift and had been assigned to provide direct care to Resident #1 on 2 other dates ([DATE] and [DATE]) and on [DATE] had transferred Resident #1 from the bed to the wheelchair for the evening meal. He stated that the side rail pad and bolster were not in place, but that the personal alarm was attached to the resident's clothing while in bed. He stated that the side rail pad and bolster were not used on the 2 days he took care of the resident. He stated on [DATE] at 2:30 pm that he was providing direct care to Resident #5 on [DATE] when Resident #1 was found dead in her room. He stated that on the 2 days he provided care to Resident #1 no pads were on the bed and that he had hooked up the personal alarm and attached the pull cord to the resident's clothing while in bed. He stated that all side rails in the building were changed after the incident with Resident #1. Observation on [DATE] from 5:15 to 6:00 pm of beds in the rooms throughout the facility revealed that there were no other beds with a side rail like the one used by Resident #1 at the time of her death. Forty-four beds were observed and none of the beds had wobbly, loose side rails. During interview on [DATE] at 10:12 am, the DON reported that the nursing staff had called her on the evening of [DATE] when Resident #1 was found in her room entrapped in the side rail. Based on the description of the resident, the DON instructed the staff to leave the resident in place, because there would be a police inquest. When asked why the resident was not disengaged from the side rail, assessed and provided CPR, the DON stated that the resident was dead. The physician saw her soon after being found and confirmed the death. The DON stated that there was no protocol established within the facility to instruct the nursing staff on what steps to follow in the event a resident becomes entrapped in a side rail. During interview on [DATE] at 10:30 am, the Administrator confirmed that a protocol was not in place on responding to emergency situations such as hanging or strangulation by side rails. During interview on [DATE] at 11:00 am, the Maintenance Supervisor reported that he had tightened the railing on Resident #1's bed on [DATE]th at the request of the charge nurse. (He could not remember who the nurse was.) The Supervisor stated that he informed the charge nurse at that time to call the hospice agency and have the bed and side rail replaced. He stated that the side rail was changed on [DATE]th and that he had assessed the side rail for safety. During interview on [DATE] at 1:45 pm, Hospice Staff D reported by phone that the agency did not receive a call to have the bed Resident #1 was in to be replaced. A side rail change was requested on [DATE] and a ,[DATE] rail was delivered on [DATE]. No changes of equipment occurred in the month of July. A side rail pad was delivered to the facility which was to be used with the side rail. The pad had Velcro straps to wrap around the side rail bars. During interview on [DATE] at 2:30 pm, LVN E stated that she had provided supervision and direct care to Resident #1 during the month of June and ensured that the bolster pad was in place to prevent the resident from sliding out of bed. She stated that there was a side rail pad with Velcro straps that wrapped around the side rail and covered the openings. She stated that she had "fussed" with the hospice aides to tighten the side rail to the bed. She stated that she contacted the hospice agency and by the time the hospice RN came out to the facility, the railing had been tightened. LVN E stated that she had the maintenance supervisor tighten the side rail. Review of the hospice agency's order history (provided by the hospice agency by fax) for Resident #1 revealed that a bed with full side rails was ordered and delivered on [DATE]. On [DATE], Hospice RN F assessed the bed and side rails and ordered the full side rails changed to half side rails. The side rail pad was also delivered on [DATE]. Interview with LVN G, charge nurse, on [DATE] at 12:30 pm by phone confirmed that she had signed a receipt for the side rail and side rail pads and were necessary for Resident #1 due to involuntary movements. LVN G confirmed that the side rail without the side rail pad placed Resident #1 at risk for "getting caught in the side rail." During interview on [DATE] at 2:10 pm, Hospice RN F, Case Manager, stated that he had observed Resident #1 in a wheelchair and in bed and was aware of an issue regarding a side rail and the side rail was replaced. He stated that the side rail was needed due to the resident's history of [MEDICAL CONDITION]. He stated that a long side rail pad with Velcro straps was delivered to the facility and that he had seen the pad on the bed during visits to the facility. B. Review of Resident #5's clinical record revealed an admission face sheet ([DATE]) documenting that the resident was admitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. On [DATE], a fax was sent to the Medical Director informing him that the resident had stuck the right leg through the ,[DATE] side rail and a red mark was noted to the outer aspect of the leg, which could bruise. On [DATE], the facility received a TPO for a blue foam mat (to be placed) next to the bed and ,[DATE] side rails x1 with a sensor pad to the w/c. On [DATE], a TPO by the Medical Director, ordered ,[DATE] side rail padded. On [DATE], the TPO was clarified as ,[DATE] side rail padded as "enabler". On [DATE] the facility received a physician's telephone order to place an air mattress on the bed for "wound healing." A TAR for [DATE] revealed a padded side rail ,[DATE] x2 as enabler listed and not initialed as being observed on the bed. The consolidated physician orders [REDACTED]." Review of nursing notes for [DATE] revealed that at 10:34 pm, the "resident's alarm went off" and the resident was found on the floor. The Incident Report documented that the side rail and pads were not in place to prevent the resident from rolling out of bed. On [DATE] nursing notes documented that the resident was found at 4:15 am with a leg in the railing. The Incident Report for [DATE] documented that the right leg had been "stuck through the ,[DATE] rail" and had caused a red mark to the leg. The resident was "confused, speaks Spanish." Side rail pads were not documented as in place. Observation at 2:30 pm on [DATE] revealed that the resident was in bed with ,[DATE] side rails up. There was no pad attached to the side rail. A pad was positioned between the mattress and the wall. There was no side rail on that side. There was no floor mat in place and the resident was in bed speaking incoherently. A blue floor mat was observed positioned at the end of the roommate's bed frame and the stand-up bureau. During the exit at 5:30 pm on [DATE], the Administrator and DON were informed that Resident #5 was in an unsafe position with the bed in a high position, 1 side rail unpadded and the floor mat not on the floor. Observation on [DATE] at 12:30 pm was made of Resident #5 with LVN A to determine whether the resident's environment was free of hazards. The resident's bed had been changed and now was on the floor with a floor mat. An approximately 10 inch gap was created between the head of the bed and the bedside table. A small refrigerator was on the other side of the bedside table. The 10 inch gap was sufficient to entrap the resident's head if the resident rolled off the bed onto the floor mat. LVN A agreed with the Surveyor's assessment of the set up and confirmed the gap was unsafe for the resident. LVN A moved the side table to the other side of the room. The removal of the bedside table then created more space (approximately shoulder width a part) to prevent entrapment of the head. B. Review of Resident #5's clinical record revealed an admission face sheet ([DATE]) documenting that the resident was admitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. On [DATE], a fax was sent to the Medical Director informing him that the resident had stuck the right leg through the ,[DATE] side rail and a red mark was noted to the outer aspect of the leg, which could bruise. On [DATE], the facility received a TPO for a blue foam mat (to be placed) next to the bed and ,[DATE] side rails x1 with a sensor pad to the w/c. On [DATE], a TPO by the Medical Director, ordered ,[DATE] side rail padded. On [DATE], the TPO was clarified as ,[DATE] side rail padded as "enabler". On [DATE] the facility received a physician's telephone order to place an air mattress on the bed for "wound healing." A TAR for [DATE] revealed a padded side rail ,[DATE] x2 as enabler listed and not initialed as being observed on the bed. The consolidated physician orders [REDACTED]." Review of nursing notes for [DATE] revealed that at 10:34 pm, the "resident's alarm went off" and the resident was found on the floor. The Incident Report, [DATE], documented that the side rail and pads were not in place to prevent the resident from rolling out of bed. The resident's spouse, who occupied the second bed in the room, reported that the resident had rolled out of bed. Four days later on [DATE], nursing notes documented that the resident was found at 4:15 am with a leg in the railing. The Incident Report for [DATE] documented that the right leg had been "stuck through the ,[DATE] rail" and had caused a red mark to the leg. The resident was "confused, speaks Spanish." Side rail pads were not documented as in place. Observation at 2:30 pm on [DATE] revealed that the resident was in bed with ,[DATE] side rails in an up position. There was no pad attached to the side rail. A pad was folded up between the mattress and the wall. There was no side rail on that side. There was no floor mat in place and the resident was in bed speaking incoherently. A blue floor mat was observed standing up and wedged between of the roommate's bed (spouse) and the dress bureau. During interview at 5:30 pm on [DATE], the Administrator and DON were informed that Resident #5 was in an unsafe bed in a high position, 1 side rail unpadded and the floor mat not on the floor. Observation, accompanied by LVN A, was conducted on [DATE] at 12:30 pm of Resident #5 to determine whether the resident's environment was free of hazards. The resident's bed had been changed and now was on the floor with a floor mat. An approximately 10 inch gap was created between the head of the bed and the bedside table. A small refrigerator was on the other side of the bedside table. The 10 inch gap was sufficient to entrap the resident's head if the resident rolled off the bed onto the floor mat. LVN A verified that the changed set up now created an unsafe gap for the resident. LVN A moved the side table to the other side of the room. The removal of the bedside table then created more space (approximately shoulder width a part) to prevent entrapment of the head. The Immediate Jeopardy was removed on [DATE] after the third submission of the POR. A review on [DATE] of the facility's Quality Assurance Committee's POA, [DATE], revealed the corrective action was insufficient to ensure the safety of the residents within the facility. After a third submission on [DATE], and regional administration review, it was determined that the POR provided sufficient evidence of an on-going process by the facility in identifying unsafe practices and hazards in the residents' environments and in assuring adequate supervision of residents utilizing side rails and supervision of direct care staff. This included: . Continuous evaluation for appropriateness of side rails once per quarter and as needed to include assessments by IDT prior to side rails being placed and updated quarterly or as needed. (Several assessment forms were reviewed upon their completion.) . Inspection of all side rails in use and prior to use for appropriateness and malfunction. Immediate assessment of danger will be immediately reported to the administrator. (Done on [DATE] by maintenance) . all staff was in-serviced (Reviewed in-services forms and lesson plan. Staff interviewed) . Supervisors utilizing a "Daily Care Guide," to check on resident utilizing side rails during rounds. (Copy of Guide was provided to the Surveyor.) . Establishment of a protocol instructing the nursing staff on how to respond to residents encountered in emergent circumstances such as hanging, choking and trauma, regardless of their DNR status. (Was being prepared). . In-servicing the nursing staff on a one-on-one basis on the new protocol. (Was in progress) . Convening of an IDT on [DATE] to assess the cognitive capabilities and needs of each resident in the facility relative to the use of side rails. (Was being held prior to the exit.) Through observations, review of resident IDT assessments and interviews, it was determined that the POA had been initiated and at 4:00 pm on [DATE], the IJ was removed. The facility reported on [DATE] that 44 residents had been identified as using side rails attached to their beds as safety precautions due to poor safety awareness and/or as enablers to enhance resident bed mobility.

Based on record review, interviews and observations, the facility failed to implement the facility's policies and procedures that prohibited neglect in the use of side rails and to provide interventions to prevent 2 of 6 residents (#1 & 5) from falling out of bed and becoming entrapped in a side rail. After regional administrative review, the surveyor reentered the facility on [DATE] to gather more information. 1. Resident #1: A side rail pad and bolster (a long, often cylindrical, cushion or pillow for a bed, sofa) were not in place as ordered by the physician ([DATE]) to prevent the resident from sliding off the bed onto the floor and the resident's head and jaw became entrapped between the side rail and mattress. The bed in use did not belong to the facility and the railing had approximately 7 inches of play (movement) between the mattress and side rail. Due to the excessive play, the resident's head and jaw became trapped between the mattress and the side rail resulting in mechanical asphyxiation (death) by accidental strangulation. 2. Resident #2: The side rail and pad were not in place to prevent the resident from falling out of bed; the side rail pad was not in place to prevent the prevent the resident from getting the right leg stuck in the side rail; and when the bed was changed for a low bed without a side rail, a 10 inch wide gap was created between the bed and bedside table placing the resident at risk for becoming trapped between the bed and table. This failure resulted in an Immediate Jeopardy which was identified on [DATE] and the facility remained out of compliance at a severity level of actual harm and isolated until [DATE]. All residents were not evaluated by an Interdisciplinary Team for the use of side rails; not all staff was in-serviced to evaluate unsafe use of side rails and hazards; and the nursing staff had not been in-serviced on documenting observations of compliance with physician orders [REDACTED]. This deficient practice could affect 44 residents who were identified by the facility as using side rails attached to their beds as safety precautions due to poor safety awareness and/or as enablers to enhance resident bed mobility. The findings were: A. Review of Resident #1's clinical record revealed a face sheet documenting the [AGE] year old resident's initial admission to the facility on [DATE] with [DIAGNOSES REDACTED]. The "Provider Investigation Report" dated [DATE] documented that Resident #1 was found on [DATE] at 9:29 pm on the floor of her room with her head between the side rail and bed mattress. The resident was "pale and cold to touch, unresponsive and no pulse present." The resident's arms and entire body were lying on the floor and the Resident's "legs, hands and arms were (sic.) modeled." (Mottled skin is a condition in which the skin becomes discolored in irregular patches, especially on the hands and feet and may look blue and blotchy due to slow blood circulation.) The "Provider Report" also documented that the resident's most recent fall was on [DATE] from bed to floor and that the resident had experienced 2 recent incidents of [MEDICAL CONDITION] ([DATE] and [DATE]). The "Provider Report" documented that the resident's movement in the bed on [DATE] may have been caused by a convulsion. Review of the "Provider Investigation Report," [DATE], revealed the facility self-reported the death of Resident #1 on [DATE] due to mechanical asphyxiation on the resident's side rail. Review of the facility's Quality Assurance Committee conducted on [DATE], which included the Medical Director, Administrator and DON) revealed a Plan of Action (POA) to prevent further accidental deaths. The POA included inspecting all side rails in use and appropriateness, in-servicing staff regarding the use of safety devices; requesting hospice providers to check delivered equipment for safety and ensuring maintenance staff inspect all side rails for safety. The POA did not include the development of a comprehensive system to ensure the safety of all the residents in the facility and had not implemented the facility's policy in assessing all residents for the use of side rails. The facility remained out of compliance at a severity level of Immediate Jeopardy to Resident Health and Safety at a Patterned level. Review of the facility's policy on "Side Rail Assessment Tool," dated [DATE] indicated that a team would assess each resident's functional and cognitive capacity to ascertain the "least restrictive intervention" in the use of side rails. The tool instructed the staff to ask the following questions: "Caution: Can resident's extremities or head become wedged between side rails and mattress? Residents under 100 lbs. or 5'0" have increased risk. Check for appropriate mattress size and eliminated spaces between mattress and side rails." The "Tool" also instructed the staff to conduct "ongoing evaluation of the risks and benefits of any device in use will be part of the process." No record that the "Tool" had been used in assessing Resident #1's safety while in the bed provided by the hospice agency prior to the accident on [DATE] was found. Review of an incident report for the accident on [DATE] revealed that the recording nurse was called to Resident #1's room by the Treatment Nurse (LVN A) and "observed pt. between bed and rail head with pt. on floor with blood drop on face and floor." LVN A, documented on a witness statement that a ,[DATE] rail was in an up position and was not padded. "Noted resident on the floor. (R) side with head wedged between bed and side rail. Blood from mouth with some on the floor. Resident was pale and hands and legs mottled and cold to touch. Yelled for charge nurse. Resident was not breathing." Review of nursing notes for Resident #1 revealed documentation of recent [MEDICAL CONDITION] activity: On [DATE] the resident had a convulsion that lasted between ,[DATE] seconds during the breakfast meal at 9:44 am. The resident became "somewhat pale...pt. tightened her lip and would not open her mouth." On [DATE], a nurse documented that at 8:45 am the resident was observed having "[MEDICAL CONDITION] activity, jerking intermittently, focus stare, no loss of B/B no drooling noted." The resident was given [MEDICATION NAME] (anti-anxiety) 0.5 mg SL. At 12:30 pm on [DATE] the resident was up in a recliner for lunch and "began jerking and shaking again, focus stare again." [MEDICATION NAME] 0.5.mg SL was administered. An incident report documented that on [DATE] at 11:00 pm, the resident was found to have a bruise to the right hand, 2nd knuckle. It was not determined how the injury occurred. However, the facility's assessment process documented that the side rails were up but not the side rail pad. Review of Resident #1's recent MDS assessment dated [DATE] indicated that the resident's cognitive level was not assessable due to the resident's unresponsiveness. Care plans documented a problem onset of falls/fall risk related to dx of dementia beginning on [DATE]: . [DATE] adding a pad alarm while in bed and a personal belt alarm to the wheelchair; . [DATE] being trapped between a mattress and side rail was on [DATE]due to a gap between the side rail and mattress; having a cord to the personal alarm being too long to set off the alarm in the event of a fall; attaching a magnetic alarm and tilt w/c 30 degrees while up in w/c for personal safety; and being found on floor by bed. A mat was placed in front of bed. . [DATE] finding a bruise to the right hand and 2nd knuckle area. Approaches included: "Implement appropriate measure (s) to prevent further occurrences (e.g. padded side rails....)." Review of CPO for [DATE], for Resident #1 revealed an order beginning on [DATE] for "padded side rails x1 for restlessness and skin extremity protection and beginning on [DATE] for side rails ,[DATE] w/bolster at foot of bed and floor mat. Review of a care plan dated [DATE] documented a second fall risk on [DATE] and the approaches included placing a floor mat next to the bed. A care plan for dated [DATE] assessed the resident requiring extensive assistance (1 to 2 persons) to assist with bed mobility, etc. The approach included assisting the resident in bed mobility such as moving to and from lying position, turning side to side, using both side rails for mobility and positions body while in bed. Review of TARS for June and [DATE] revealed that the nursing staff was not initialing the document indicating that the side rails and/or side rail safety pads were in place. Listed on the TARS was the following: "Side rails ,[DATE] with bolster at foot of bed and floor mat." The column was not initialed. "Padded side rails x1 for restlessness and skin and extremity protection." The column was not initialed. "Hi/Low electric bed w/mat to floor and continued triangle wedge to foot of bed." The column was not initialed. During interview on [DATE] at 1:30 pm, LVN A (who found the resident in her room on [DATE]) stated that the devices were listed on the TARS and MARS for the nurses' FYI and the columns did not have to be initialed. LVN A stated that nurses entered the residents' rooms at some point in the shift and were to observe that the devices were in place. During a second interview on [DATE] at 3:10 pm, LVN A stated that she had not been instructed to initial the TAR regarding side rails and pads by the facility administration (DON), but understood that the instructions were "in the works." In response to a question, LVN A stated that the facility's system should include that all side rails, restraints, residents in bed be checked by the charge nurse every shift and that the observation be charted on the MAR. She stated that the system was not in place yet. Review of a physician's progress note written by the Medical Director on [DATE] revealed that the resident had: "no purposeful response; unintellible speech. Able to sit up. Legs/arms stiff and resistant to ROM." Review of a physician's progress note by the Medical Director dated [DATE] revealed that he was called by the facility administrator on [DATE] and he "found (resident) deceased - 2100 (9:00 pm) - with her head entrapped b/t side-rail and mattress. I auscultated (listening to the internal sounds of the body, usually using a stethoscope) pt. 2 minutes of no audible heart sounds, no visible or audible breath sounds/effort. Time of death 2202 (10:02 pm). Investigation pending. The physician also wrote on [DATE]: "Addendum: 2310 (11:10 pm). Strongly suspect accidental death." During interview by phone on [DATE] at 12:40 pm, the Medical Director stated that he had been in the facility and observed the resident a few minutes after being found on [DATE]. The resident's head was still attached to the side rail and the body was still lying on the floor. The side rail pad was under the bed and a personal alarm which attaches to the resident's clothing was hanging on the side rail with the cord still attached to the device. The physician stated that he did not believe the resident had a convulsion and supposed that the resident had slid down in bed and was pulled to the floor by the weight of her body. (The resident weighed approximately 148 pounds) He stated that the bed in use did not belong to the facility and that he observed the railing have approximately 7 inches of play (movement) between the mattress and side rail. He stated that if the side rail pads were in place, the resident would not have become entrapped in the railing. He stated that the use of this particular bed and side rail delivered to the facility by the hospice agency was not "a good idea." He stated that the incident was QA'd with the Administrator and DON the next day. During interview on [DATE] at 10:10 am, the DON stated that LVN A had contacted her upon finding the resident on [DATE] and she instructed LVN A to call the Administrator and Medical Director. Based on the information provided by LVN A, the resident was assumed dead by both LVN A and the DON. The DON stated that the bed that Resident #1 was in came from a hospice agency and was not the type used in the facility. During interview on [DATE] at 10:20 am, the Administrator stated that she was called by facility staff on the evening of [DATE] and she entered the facility within 5 minutes of the call. The Medical Director also arrived at the same time, because he was either in the building or the parking lot, and Resident #1 was still in the same position found by LVN A at 9:29 pm on [DATE]. The physician examined the resident and assessed the resident dead. The Administrator stated that the local police had also been contacted and arrived at the facility. The Justice of the Peace accompanied by a detective entered the facility and observed the resident while entrapped in the side rail. The Administrator stated that the resident had been a resident in the Secured Unit and was transferred to the main floor when her care needs changed. She stated that the resident was placed on hospice services due to gradual weight loss requiring the staff to feed the resident and that the resident required total care. During interview on [DATE] at 10:30 am, LVN A stated that she entered Resident #1's room at 9:29 am and found the resident on the floor with her head trapped in the side rail and bed and that the resident's eyes were closed. The arms, legs and hips were lying on the floor. She stated that she called for help and checked the resident's pulse. The resident was not removed from the side rail because the resident's skin appeared mottled; the resident had no pulse and was obviously dead. The resident was a DNR and no interventions were initiated. She stated that the resident was not disengaged from the side rail so that the police could determine that the resident's death was caused by an accident. During interview on [DATE] at 11:00 am, the JP reported that the cause of death was due to "accidental death by mechanical asphyxiation." The JP provided a draft copy of the ME's report and pictures of the death scene. The pictures verified that the resident's arms, legs and hips were on the floor, the head was trapped between the mattress and side rail and that the side rail pad was under the bed. There was no bolster pad and a mat was on the floor. Review of a draft copy of the ME's "Cause and Manner of Death" dated [DATE] and examined on [DATE] revealed that the manner of death was "accident" and the cause of death was "mechanical asphyxia." Review of Picture #1 revealed Resident #1 with her head between the mattress and side rail. Picture #2 revealed the resident's full body was lying on the floor partially on top of a floor mat, arms crossed and entire trunk, hips and legs were resting on the floor. No bolster was noted and the rail was without a pad. A personal alarm with a cord device was attached to the railing. Picture #3 revealed that the left cheek was compressed against the railing, the back of the head was resting on the mattress and the jaw was between the up and down bar and was resting on the cross bar. During interview on [DATE] at 12:10 pm, CNA B reported that she was working on the hall of Resident #1 and was assigned to provide direct care. CNA B reported that the placement of a bolster pad and side rail pad was not listed on her assignment sheet. She stated that she had placed the resident in bed after the dinner meal on [DATE] at approximately 6:35 pm. The resident was placed on her left side with her face directed to the wall. The resident's bed was pushed up against the wall and CNA B pulled the side rail up into position. The personal alarm was not attached to the resident's clothing, because the alarm was not on the assignment sheet. CNA B stated that she went on lunch break from 7:45 to 8:15 pm and then returned to the floor. She checked on Resident #1 and the resident was still on her left side and facing the wall. She stated that when the resident was found at 9:29 pm by LVN A, she responded and found the resident on the floor with her head trapped in the railing. She stated that LVN A would not allow anyone to touch the resident and insisted that the resident was already dead, was a DNR and that the police would need to see the body. CNA B stated that the accident could have been prevented if the side rail pad was in place and that she would have put the pad in place if instructed to do so on her assignment sheet. During interview on [DATE] at 7:30 pm, CNA C stated that he worked the evening shift and had been assigned to provide direct care to Resident #1 on 2 other dates ([DATE] and [DATE]) and on [DATE] had transferred Resident #1 from the bed to the wheelchair for the evening meal. He stated that the side rail pad and bolster were not in place, but that the personal alarm was attached to the resident's clothing while in bed. He stated that the side rail pad and bolster were not used on the 2 days he took care of the resident. He stated on [DATE] at 2:30 pm that he was providing direct care to Resident #5 on [DATE] when Resident #1 was found dead in her room. He stated that on the 2 days he provided care to Resident #1 no pads were on the bed and that he had hooked up the personal alarm and attached the pull cord to the resident's clothing while in bed. He stated that all side rails in the building were changed after the incident with Resident #1. Observation on [DATE] from 5:15 to 6:00 pm of beds in the rooms throughout the facility revealed that there were no other beds with a side rail like the one used by Resident #1 at the time of her death. Forty-four beds were observed and none of the beds had wobbly, loose side rails. During interview on [DATE] at 10:12 am, the DON reported that the nursing staff had called her on the evening of [DATE] when Resident #1 was found in her room entrapped in the side rail. Based on the description of the resident, the DON instructed the staff to leave the resident in place, because there would be a police inquest. When asked why the resident was not disengaged from the side rail, assessed and provided CPR, the DON stated that the resident was dead. The physician saw her soon after being found and confirmed the death. The DON stated that there was no protocol established within the facility to instruct the nursing staff on what steps to follow in the event a resident becomes entrapped in a side rail. During interview on [DATE] at 10:30 am, the Administrator confirmed that a protocol was not in place on responding to emergency situations such as hanging or strangulation by side rails. During interview on [DATE] at 11:00 am, the Maintenance Supervisor reported that he had tightened the railing on Resident #1's bed on [DATE]th at the request of the charge nurse. (He could not remember who the nurse was.) The Supervisor stated that he informed the charge nurse at that time to call the hospice agency and have the bed and side rail replaced. He stated that the side rail was changed on [DATE]th and that he had assessed the side rail for safety. During interview on [DATE] at 1:45 pm, Hospice Staff D reported by phone that the agency did not receive a call to have the bed Resident #1 was in to be replaced. A side rail change was requested on [DATE] and a ,[DATE] rail was delivered on [DATE]. No changes of equipment occurred in the month of July. A side rail pad was delivered to the facility which was to be used with the side rail. The pad had Velcro straps to wrap around the side rail bars. During interview on [DATE] at 2:30 pm, LVN E stated that she had provided supervision and direct care to Resident #1 during the month of June and ensured that the bolster pad was in place to prevent the resident from sliding out of bed. She stated that there was a side rail pad with Velcro straps that wrapped around the side rail and covered the openings. She stated that she had "fussed" with the hospice aides to tighten the side rail to the bed. She stated that she contacted the hospice agency and by the time the hospice RN came out to the facility, the railing had been tightened. LVN E stated that she had the maintenance supervisor tighten the side rail. Review of the hospice agency's order history (provided by the hospice agency by fax) for Resident #1 revealed that a bed with full side rails was ordered and delivered on [DATE]. On [DATE], Hospice RN F assessed the bed and side rails and ordered the full side rails changed to half side rails. The side rail pad was also delivered on [DATE]. Interview with LVN G, charge nurse, on [DATE] at 12:30 pm by phone confirmed that she had signed a receipt for the side rail and side rail pads and were necessary for Resident #1 due to involuntary movements. LVN G confirmed that the side rail without the side rail pad placed Resident #1 at risk for "getting caught in the side rail." During interview on [DATE] at 2:10 pm, Hospice RN F, Case Manager, stated that he had observed Resident #1 in a wheelchair and in bed and was aware of an issue regarding a side rail and the side rail was replaced. He stated that the side rail was needed due to the resident's history of [MEDICAL CONDITION]. He stated that a long side rail pad with Velcro straps was delivered to the facility and that he had seen the pad on the bed during visits to the facility. B. Review of Resident #5's clinical record revealed an admission face sheet ([DATE]) documenting that the resident was admitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. On [DATE], a fax was sent to the Medical Director informing him that the resident had stuck the right leg through the ,[DATE] side rail and a red mark was noted to the outer aspect of the leg, which could bruise. On [DATE], the facility received a TPO for a blue foam mat (to be placed) next to the bed and ,[DATE] side rails x1 with a sensor pad to the w/c. On [DATE], a TPO by the Medical Director, ordered ,[DATE] side rail padded. On [DATE], the TPO was clarified as ,[DATE] side rail padded as "enabler". On [DATE] the facility received a physician's telephone order to place an air mattress on the bed for "wound healing." A TAR for [DATE] revealed a padded side rail ,[DATE] x2 as enabler listed and not initialed as being observed on the bed. The consolidated physician orders [REDACTED]." Review of nursing notes for [DATE] revealed that at 10:34 pm, the "resident's alarm went off" and the resident was found on the floor. The Incident Report documented that the side rail and pads were not in place to prevent the resident from rolling out of bed. On [DATE] nursing notes documented that the resident was found at 4:15 am with a leg in the railing. The Incident Report for [DATE] documented that the right leg had been "stuck through the ,[DATE] rail" and had caused a red mark to the leg. The resident was "confused, speaks Spanish." Side rail pads were not documented as in place. Observation at 2:30 pm on [DATE] revealed that the resident was in bed with ,[DATE] side rails up. There was no pad attached to the side rail. A pad was positioned between the mattress and the wall. There was no side rail on that side. There was no floor mat in place and the resident was in bed speaking incoherently. A blue floor mat was observed positioned at the end of the roommate's bed frame and the stand-up bureau. During the exit at 5:30 pm on [DATE], the Administrator and DON were informed that Resident #5 was in an unsafe position with the bed in a high position, 1 side rail unpadded and the floor mat not on the floor. Observation on [DATE] at 12:30 pm was made of Resident #5 with LVN A to determine whether the resident's environment was free of hazards. The resident's bed had been changed and now was on the floor with a floor mat. An approximately 10 inch gap was created between the head of the bed and the bedside table. A small refrigerator was on the other side of the bedside table. The 10 inch gap was sufficient to entrap the resident's head if the resident rolled off the bed onto the floor mat. LVN A agreed with the Surveyor's assessment of the set up and confirmed the gap was unsafe for the resident. LVN A moved the side table to the other side of the room. The removal of the bedside table then created more space (approximately shoulder width a part) to prevent entrapment of the head. B. Review of Resident #5's clinical record revealed an admission face sheet ([DATE]) documenting that the resident was admitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. On [DATE], a fax was sent to the Medical Director informing him that the resident had stuck the right leg through the ,[DATE] side rail and a red mark was noted to the outer aspect of the leg, which could bruise. On [DATE], the facility received a TPO for a blue foam mat (to be placed) next to the bed and ,[DATE] side rails x1 with a sensor pad to the w/c. On [DATE], a TPO by the Medical Director, ordered ,[DATE] side rail padded. On [DATE], the TPO was clarified as ,[DATE] side rail padded as "enabler". On [DATE] the facility received a physician's telephone order to place an air mattress on the bed for "wound healing." A TAR for [DATE] revealed a padded side rail ,[DATE] x2 as enabler listed and not initialed as being observed on the bed. The consolidated physician orders [REDACTED]." Review of nursing notes for [DATE] revealed that at 10:34 pm, the "resident's alarm went off" and the resident was found on the floor. The Incident Report, [DATE], documented that the side rail and pads were not in place to prevent the resident from rolling out of bed. The resident's spouse, who occupied the second bed in the room, reported that the resident had rolled out of bed. Four days later on [DATE], nursing notes documented that the resident was found at 4:15 am with a leg in the railing. The Incident Report for [DATE] documented that the right leg had been "stuck through the ,[DATE] rail" and had caused a red mark to the leg. The resident was "confused, speaks Spanish." Side rail pads were not documented as in place. Observation at 2:30 pm on [DATE] revealed that the resident was in bed with ,[DATE] side rails in an up position. There was no pad attached to the side rail. A pad was folded up between the mattress and the wall. There was no side rail on that side. There was no floor mat in place and the resident was in bed speaking incoherently. A blue floor mat was observed standing up and wedged between of the roommate's bed (spouse) and the dress bureau. During interview at 5:30 pm on [DATE], the Administrator and DON were informed that Resident #5 was in an unsafe bed in a high position, 1 side rail unpadded and the floor mat not on the floor. Observation, accompanied by LVN A, was conducted on [DATE] at 12:30 pm of Resident #5 to determine whether the resident's environment was free of hazards. The resident's bed had been changed and now was on the floor with a floor mat. An approximately 10 inch gap was created between the head of the bed and the bedside table. A small refrigerator was on the other side of the bedside table. The 10 inch gap was sufficient to entrap the resident's head if the resident rolled off the bed onto the floor mat. LVN A verified that the changed set up now created an unsafe gap for the resident. LVN A moved the side table to the other side of the room. The removal of the bedside table then created more space (approximately shoulder width a part) to prevent entrapment of the head. Review of the facility Abuse Prevention policy dated [DATE] revealed that it was the facility's intent to ensure the residents' right to be free from physical abuse and neglect. The policy's purpose was to ensure residents were protected by providing a method for the prevention any type of alleged abuse through analysis: . of the physical environment that make abuse or neglect more likely to occur; . of the supervision of staff providing direct care; . of the assessment, care planning and monitoring of residents with needs and behaviors which might lead to neglect or injury; . of residents who require heavy nursing care and/or are totally dependent on staff. . of ensuring care giving staff are aware of all interventions required to protect the residents. Based on observations, interviews and record review, the facility failed to follow its own abuse prevention policy. The Immediate Jeopardy was removed on [DATE] after the third submission of the POR. A review on [DATE] of the facility's Quality Assurance Committee's POA, [DATE], revealed the corrective action was insufficient to ensure the safety of the residents within the facility. After a third submission on [DATE], and regional administration review, it was determined that the POR provided sufficient evidence of an on-going process by the facility in identifying unsafe practices and hazards in the residents' environments and in assuring adequate supervision of residents utilizing side rails and supervision of direct care staff. This included: . Continuous evaluation for appropriateness of side rails once per quarter and as needed to include assessments by IDT prior to side rails being placed and updated quarterly or as needed. (Several assessment forms were reviewed upon their completion.) . Inspection of all side rails in use and prior to use for appropriateness and malfunction. Immediate assessment of danger will be immediately reported to the administrator. (Done on [DATE] by maintenance) . all staff was in-serviced (Reviewed in-services forms and lesson plan) . Supervisors utilizing a "Daily Care Guide," to check on resident utilizing side rails during rounds. (Copy of Guide was provided to the Surveyor.) . Establishment of a protocol instructing the nursing staff on how to respond to residents encountered in emergent circumstances such as hanging, choking and trauma, regardless of their DNR status. (Was being prepared). . In-servicing the nursing staff on a one-on-one basis on the new protocol. (Was in progress) . Convening of an IDT on [DATE] to assess the cognitive capabilities and needs of each resident in the facility relative to the use of side rails. (Was being held prior to the exit.) Through observations, review of resident IDT assessments and interviews, it was determined that the POA had been initiated and at 4:00 pm on [DATE], the IJ was removed. The facility reported on [DATE] that 44 residents had been identified as using side rails attached to their beds as safety precautions due to poor safety awareness and/or as enablers to enhance resident bed mobility.