Every finding on record at University Park Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen, in that: The facility failed to ensure food items in the large standing refrigerator and dry seasonings with expired used by dates were disposed of properly These failures could place residents at risk for decline in nutritional health status and foodborne illness.The findings included: In an observation of the kitchen on 08/10/2026 at 6:10 am there were the following expired foods inside the 2nd large standing refrigerator. 1- 13.6-ounce plastic container of Demi-[NAME] Sauce with expiration date of 30 July 20261 - 1-gallon plastic container of Dill Pickle Aioli with expiration date of 15 July 20251 - 5-pound plastic container of Cottage Cheese with expiration date of 07/24/2026 In an observation of the kitchen on 08/10/2026 at 6:15am there was the following expired dry seasonings sitting on a silver wire metal shelf;1 12-ounce plastic container labeled Poultry Seasoning with an expiration date of 03/19/2026.1 21-ounce plastic container labeled Everything Bagel Seasoning with an expiration date of 4/2/2026.1 16-ounce plastic container labeled Rubbed Sage with an expiration date of 3/19/2026.1 16-ounce plastic container labeled Ground Nutmeg with an expiration date of 11/15/2025 In an interview on 08/10/2026 at 6:18am, [NAME] A stated it was everyone's responsibility to check the expiration dates on all foods and spices. She stated the expectation was to not have anything expired in the kitchen and that a negative outcome could be a resident becomes ill. In an interview on 08/10/2026 at 6:25am, Dietary Aide B stated it was all kitchen staff's responsibility to make sure all expired food items and seasonings are discarded on or before the expiration date. She stated that was the expectation and that a negative outcome could be a resident develops stomach issues or becomes sick from eating things that have expired. In an interview on 8/11/2026 at 11:45am, DM it was the expectation that all staff were responsible to make sure expired food and other items are discarded by the expiration date if not used. She stated a negative outcome for residents could be that serving expired foods could make the residents sick or not feel well. The DM stated that she was ultimately responsible for making sure expired food and items were discarded and was very surprised there was some found. She stated that going through the refrigerators and freezers looking for expired foods was not currently on their cleaning logs. In an interview on 08/12/2026 at 10:15am, the DON stated the expectation was for all leftover foods and opened containers to be labeled and dated when it was received, when it was opened, and the expiration date to stay in compliance. She stated an adverse outcome could be the residents becoming sick or having stomach upset. She also stated it was the responsibility of all dietary workers to review the dates of items used in the kitchen daily, and that the DM should be supervising them to make sure it was done. In an interview on 08/12/2026 at 10:22am, the ADMN stated it was the dietary staff and DM's responsibility to ensure all expired foods and spices are discarded on or before the expiration dates. She stated it was her expectation that staff would label and date all left-over food items and opened containers with received by and opened date. She stated that with leftover foods, once it was opened it was to be dated and used within a few days. She stated that stock, once dated, was rotated to use the oldest first and the dates should be checked anytime a staff member uses an item. She stated an adverse outcome could be making a resident feel sick or stomach upset from eating it. Record review of policy titled Cleaning the Refrigerator dated 2012, revealed [in part];Refrigerators are maintained in a clean, sanitary condition free of offensive odors. Cleaning of reach in refrigerator will be done on a daily or as needed basis.Procedure:Remove all leftover food from the shelves. Check with the Dietary Service Manager and sort out and throw away all that is not usable.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1.The facility failed to ensure that spoiled food items were disposed of properly. 2.The facility failed to ensure foods were labeled properly. These failures could place residents at risk for food borne illnesses. Findings include: During an observation on 06/16/25 between 10:15 AM and 11:00 AM of kitchen revealed the following: Dry Storage: 1. 5 individual bowls of bran flake cereal with [NAME] not labeled with food description or a use by date. 2. 2 individual bowls of bran flake cereal with [NAME] not labeled with food description or a use by date. 3. 3 bags of fruit loop cereal out of the original container not labeled with food description or a use by date. 4. 3 bags of tortilla chips out of the original container not labeled with food description or a use by date. 5. A plastic container, with a lid, contained pinto beans out of the original package labeled without a use by date. Refrigerator #1 1. 20 individual glasses filled with liquid that were not labeled with a food description, open date, or a use by date. 2. A metal pan that contained Jello with fruit, that was uncovered, and did not have a label with a description, or use by date. Refrigerator #2 1. 1 open container of thickened cranberry juice with manufacture details that stated use within 7 days of opening; that was not labeled with an open date. 2. 1 open container of thickened sweet tea with manufacture details that stated use within 7 days of opening; that was not labeled with an open date. 3. 1 open container of thickened dairy beverage with manufacture details that stated use within 4 days of opening; that was not labeled with an open date. 4. 1 open container of thickened orange juice with manufacture details that stated use within 7 days of opening; that was labeled with an open date of 06/02. During an interview on 06/19/2025 at 11:00 AM DS B stated he was the weekend supervisor. DS B stated he was responsible for unloading truck weekly and labeling the food items. DS B stated someone else had unloaded the truck this week because had to cover another shift. DS B stated food items should have been labeled with a food description, open date a use by dated. DS B stated if the manufacture label stated to discard after a specific time frame, then items should have been disposed of within the time frame. During an interview on 06/19/2025 at 10:29 AM the DM stated her expectation was food be labeled with an open and use by date. The DM stated items were stored out of original container then they needed to be labeled with a food description, open date and an use by date. The DM stated all dietary staff were responsible to ensure food was labeled correctly and disposed of when needed. The DM stated she was responsible to monitor the kitchen staff. The DM stated she monitored by doing spot checks. The DM stated the effect on residents could have been residents received food that was spoiled or past its freshness. The DM stated what led to failure was staff being nervous, and not being thorough. During an interview on 06/19/2025 at 11:13 AM the RRN stated her expectation was for staff to follow policy. The RRN stated the dietary staff were responsible to ensure that food was labeled correctly and disposed of when needed. The RRN stated the DM was responsible to monitor kitchen staff by making rounds and ensuring food labeled appropriately. The RRN stated the effect on residents could have been residents receive food that was expired or loss of quality. The RRN stated what led to failure was lack of education or staff needed to be reeducated. Record review of facility policy titled, Food Storage and Supplies dated 2012, revealed: foods are still dated when received if they do not have an expiration date and once opened .Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or best by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated . discard within time frame. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 06/19/2025 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers .(B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 5 residents (Resident #15) reviewed for meals. The facility failed to ensure that Resident #15 was served pureed vegetables that were the proper texture. This deficient practice could affect residents by placing them at risk for choking and weight loss. The findings were: Record review of Resident #15's face sheet dated 06/19/2025 revealed [AGE] year-old female admitted on [DATE] with the following diagnoses Dementia, pulmonary embolism and heart disease. Record review of Resident #15's Quarterly MDS dated [DATE] revealed the following: * Section C Cognitive Patterns revealed Resident #15 had a BIMS score of 0(meaning interview was not conducted due to resident was rarely/never understood); *Section K Swallowing/Nutritional Status revealed Resident #15 did not have weight loss in the previous 6 months and had a mechanically altered diet. Record review of Resident #15's Dietary Profile dated 04/14/2025 revealed Resident #15 received purred texture food and honey thickened fluids. During an observation on 06/16/2025 between 11:25 AM to 12:30 PM [NAME] C pureed the zucchini puree. [NAME] C did not add thickener to the vegetable. The zucchini appeared to be a thin liquid that did not hold shape. The ADMN came into the kitchen and told the DM the puree did not look correct. The DM then re-pureed food for the lunch meal. The re-pureed food by the DM appeared to be the correct pudding like consistency. During an observation and interview on 06/16/2025 at 12:49 PM in the dining room Resident #15 was sitting at table with CNA D. CNA D had assisted Resident #15 with eating her meal. Resident # 15 did not appear to be choking on her meal or coughing. During an interview on 06/16/2025 at 1:45 PM [NAME] C he stated he had his food handlers and stated DS B had trained him. [NAME] C stated he was nervous and forgot to look at recipes. During an interview on 06/19/2025 at 10:29 AM the DM stated her expectation was food should be cooked and served according to the recipe. The DM stated puree food should be a smooth pudding like texture and not runny. The DM stated the cook was responsible to ensure recipes were followed and pureed food was the correct texture. The DM stated she was responsible to monitor the kitchen staff. The DM stated she monitored by doing spot checks. The DM stated the effect on residents could have choked because the puree was not the correct texture. The DM stated what led to failure was [NAME] C was trained by previous Dietary Manager, and he was nervous. During an interview on 06/19/2025 at 11:13 AM the RRN stated her expectation was for staff to follow policy. The RRN stated the DM was responsible to ensure pureed food was served at the correct texture. The RRN stated the DM and the ADMN should have been making daily rounds to ensure residents received food was prepared appropriately and the correct texture. The RRN stated the effect on residents could have been residents could have choked due to food not being the correct texture. The RRN stated what led to failure was lack of education or staff needed to be reeducated. Record review of facility policy titled, Pureed Diet dated 2025 revealed, The pureed recipes are followed for regular diet items so that the consistency of pureed foods is that of a semi-solid rather that a semi-liquid, with minimal separation of the liquid from the solid. If placed on a fork, it may drip but it does not flow continuously through the prongs. Pureed food should hold its shape on the plate and be the consistency of applesauce or pudding to mashed potato consistency. Record review of puree recipe for Zucchini dated 06/16/2025 revealed, If needed, gradually add thickener .Desired thickness should be mashed potato or pudding texture.

Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 2 of 18 residents (Resident #10 and Resident #26) reviewed for nutritive value, flavor, and appearance. The facility failed to provide palatable food served that was palatable and attractive to Residents #10 and Resident #26 for the lunch meal on 06/16/2025. This failure could affect the residents by placing them at risk of poor food intake and/or dissatisfaction of the meals served. The findings included: Resident #10 Record review of Resident #10's face sheet dated 06/19/2025 revealed [AGE] year-old male admitted on [DATE] with most recent readmission of 05/28/2025 with the following diagnoses Type 2 Diabetes, Leukemia (blood cancer that begins is bone marrow), and protein calorie malnutrition. Record review of Resident #10's Significant Change MDS dated [DATE] revealed: Section C Cognitive Patterns revealed Resident #10 had a BIMS score of 11(meaning moderate cognitive impairment); Section K Swallowing/Nutritional Status- revealed Resident #10 did not have weight loss in the previous 6 months. Observation and interview on 06/16/2025 at 4:10 PM Resident #10 was sitting on his bed in his room. Resident #10's lunch tray was sitting on the counter, by the sink, and appeared to not have been touched. Resident #10 stated he did not attempt to eat his lunch because his food did not look appealing, the manicotti looked over cooked. Resident #26 Record review of Resident #26's face sheet dated 06/19/2025 revealed [AGE] year-old male admitted on [DATE] with most recent readmission of 03/27/2025 with the following diagnoses Multiple Sclerosis, heart failure and paraplegia (impairment in motor or sensory function of lower extremities). Record review of Resident #26's Significant Change MDS dated [DATE] revealed the following: *Section C Cognitive Patterns revealed Resident #26 had a BIMS score of 9(meaning moderate cognitive impairment); *Section K Swallowing/Nutritional Status-revealed Resident #26 did not have weight loss in the previous 6 months. Observation and interview on 06/17/2025 at 10:13 AM Resident #26 was lying in his bed in his room. Resident #26 stated he did not eat the manicotti served at lunch yesterday because it looked horrible, it was dry and had black burnt ends. Observation and interview on 06/16/2025 at 1:21 PM DS B joined to taste and take the temperature of the test tray. The Manicotti appeared to be dry, no marinara on top, and ends appeared to have black crusty ends. DS B stated the plate did not appear to be appealing, the manicotti looked to dry and overcooked. DS B took the temperature of the manicotti and it was at 100 degrees. DS B stated the manicotti tasted lukewarm, that it was not hot, and appeared to be overcooked. During an interview on 06/19/2025 at 10:29 AM the DM stated her expectation was food should be cooked and served according to the recipe and be appealing to the residents. The DM stated the cook was responsible to ensure recipes were followed and the food was served warm and appealing. The DM stated she was responsible to monitor the kitchen staff. The DM stated she monitored by doing spot checks. The DM stated the effect on residents could have been weight loss because residents might not eat food if it did not look appetizing. The DM stated what led to failure was staff being nervous and not being thorough. During an interview on 06/19/2025 at 11:13 AM the RRN stated her expectation was for staff to follow policy. The RRN stated the DM and the ADMN are responsible to ensure residents were served meals that were appealing. The RRN stated the DM and the ADMN should have been making daily rounds to ensure residents received food that was appealing. The RRN stated the effect on residents could have been residents' dissatisfaction of food and not eating the food. The RRN stated what led to failure was lack of education or staff needed to be reeducated. Record review of facility policy titled Resident Rights dated 2003 revealed each resident has a right to a dignified existence, self -determination. ?

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 18 residents (Resident #10) reviewed for food and nutrition services. The facility failed to ensure Resident #10 received items listed on his lunch meal ticket on 6/05/2025. This failure could place residents at risk of poor intake, chemical imbalance, and/or weight loss. Findings included: Record review of Resident #10's face sheet dated 06/19/2025 revealed [AGE] year-old male admitted on [DATE] with most recent readmission of 05/28/2025 with the following diagnoses Type 2 Diabetes, Leukemia (blood cancer that begins is bone marrow), and protein calorie malnutrition. Record review of Resident #10's Significant Change MDS dated [DATE] indicated the following: *Section C Cognitive Patterns revealed Resident #10 had a BIMS score of 11(meaning moderate cognitive impairment); *Section K Swallowing/Nutritional Status-revealed Resident #10 did not have weight loss in the last 6 months. Record review of Resident #10's lunch meal ticket dated 06/16/2025 revealed the resident was to receive the following items: *2 Cheese Manicotti with Marinara, *½ cu Sauteed Zucchini, *1 slice garlic bread, *½ c smooth yogurt, and *Special Notes: fruit only for dessert (per resident request). Observation and interview on 06/16/2025 at 4:10 PM Resident #10 was sitting on his bed in his room. Resident #10's lunch tray was sitting on the counter, by the sink, and appeared to not have been touched. The manicotti appeared to be dry and the ends were burnt ends on the manicotti. Resident #10 stated he did not attempt to eat his lunch because his food did not look appealing, the manicotti looked dry and over cooked. Resident #10 stated he did not want dessert and had requested to get fruit to replace dessert was supposed to get yogurt with his lunch meal. Resident #10's lunch tray contained 1 manicotti without marinara sauce, zucchini, garlic bread, vanilla pudding with chocolate cookie on top. Resident #10's tray did not have a serving of fruit or a serving of yogurt. Resident #10 stated the kitchen forgets to send his fruit and yogurt often. Resident #10 stated he had snacks in his room. During an interview on 06/19/2025 at 10:29 AM the DM stated her expectation was Resident's meal tickets should have been followed. The DM stated the meal tickets reflected each resident's preference or dietary needs and was the menu for each resident. The DM stated the Dietary Aide, the cook, and the nurse were responsible to ensure meal tickets were followed. The DM stated she was responsible to monitor the kitchen staff. The DM stated she monitored by doing spot checks. The DM stated the affect on residents not getting what was on their meal ticket could have been weight loss because residents were not getting what they were supposed to get. The DM stated what led to failure was staff being nervous and not being thorough. During an interview on 06/19/2025 at 11:13 AM the RRN stated her expectation was for staff to follow policy. The RRN stated the DM and the ADMN are responsible to ensure residents were served the appropriate meals. The RRN stated the DM and the ADMN should have been making daily rounds to ensure residents received the appropriate meals. The RRN stated the effect on residents could have been residents' dissatisfaction of food and not eating the food. The RRN stated what led to failure was lack of education or staff needed to be reeducated. Record review of facility policy titled Resident Rights dated 2003 revealed each resident has a right to a dignified existence, self -determination, and communication with and access to persons and services inside and outside our facility.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for nutrition services. 1. The facility failed to ensure opened food were sealed in the nonperishable food storage room. 2. The facility failed to ensure temperature logs were kept for the refrigerator and freezer. 3. The facility failed to ensure the refrigerator had an internal thermometer. 4. The facility failed to ensure dishwashing logs were kept. 5. The facility failed to ensure staff followed proper hygiene during food prep and distribution. These failures could place residents at risk for decline in nutritional health status and foodborne illness. The findings include: In an observation and interview on 05/14/24 at 08:45 AM, during the initial tour of the kitchen, revealed the following: Trash can had a lid that did not fit, and hands had to be used to remove lid. There was a large, concentrated bag of orange Juice in a box on top of trash can lid. Dietary Aide G did not have all of her hair inside her hairnet. The temperature logs for two freezers had no temperature checks since 5/7/24 recorded. The refrigerator did not have a thermometer inside refrigerator and there was no log on the fridge. Cook E looked for an internal thermometer in the fridge and she could not find one. She said, there should be a thermometer inside the refrigerator and the temperature log should be hanging on the side of fridge. Dry Food Storage Pantry 1 bag of elbow macaroni which was opened in the dry pantry and was not sealed. Vienna [NAME] on the floor. Dish washing Machine Area dishwashing machine had no record of chemical usage checks. Cook E said there was no dishwashing machine checklist , and there should have been a log hanging on the wall next to the dishwasher. Above the dish machine was a vent in the ceiling with thick white paint peeling and dropping down above the dishwasher. A cart for clean trays was dirty with food and had dried grime particles on the top self which held clean plates. Stove Area The stove had food and residue dried and caked onto the burners and grill. The vent a hood above the stove had a thick looking dark grease caked on. In an observation and interview of kitchen on 05/14/24 10:21 revealed: Food and grime caked on the counter that held clean dishes. Dietary Aide H pulled cups from clean side of dish washing machine that were full of discolored water, then dumped the fluid from the cups, then stacked them in the clean area. Dietary Aide I put the utensils that were stacked on each other and pulled the tray to the dirty side of dishwashing area that had pink residue sitting on all parts of sink next to dishwasher. In an interview on 05/14/24 at 10:25 AM, the Regional Dietician stated the facility had a new dietary manager who started that day. She explained they were in the process of addressing numerous kitchen issues. In an interview on 5/14/24 at 10:26AM, Dietary Aide I stated she thought she was responsible for checking breakfast and lunch dishwashing chemicals on the machine when she worked. In an observation on 5/14/24 at 11:00 AM revealed Dietary Aide G got supplies to serve lunch and there were food particles and grime dried on the clean rolling cart where clean utensils were being held. In an observation and interview on 5/16/24 at 11:15 AM , a cart behind the prep table where the puree was being processed had clean ladles on the cart which had food and grime dried on shelves and sides. The Dietary Manager said they were not meeting cleaning requirements and the cart holding the clean items was not considered clean . 05/16/24 11:20 AM in an interview with the Dietary Manager said the dish machine should be checked for sanitation chemicals before and after each meal. In an observation and interview on 5/16/24 at 11:30 AM , a daily cleaning schedule hanging on wall not signed for past week. Dietary Manager said the cleaning schedule did not have day or month and had not been signed since last dietary manager was let go 1 week ago. Dietary Manager did not consider the serving cart clean. She also said they had not been doing kitchen cleaning according to schedule that is on the wall. In an observation on 05/16/24 at 12:38 PM Dietary Aide H pulled her cell phone out of her pocket and put it back in her pocket. Dietary Aide H did not wash her hands. Dietary Aide H started serving trays without gloves. In an observation on 05/16/24 at 12:40 PM revealed Dietary Aide G was handling food and utensils and had extremely long painted acrylic nails and did not wear gloves. In an observation on 05/16/24 at 12:48 PM revealed Dietary Aide H touched her nose and continued preparing trays and utensils with her bare hands without performing hand hygiene . In an interview on 05/16/24 at 12:50 PM with Dietary Manager, She said hand sanitation should always be performed after touching contaminated surfaces. In an observation on 05/16/24 at 12:53 PM Cook D lost her hair net which was slipping off over a 10-minute period. She picked the hair net up off floor and placed it on her head. Cook D did not perform hand hygiene and continued making sandwiches at prep table. In an observation on 05/16/24 at 12:57 PM revealed Dietary Aide H removed her gloves after washing dishes and did not perform hand hygiene and continued preparing meals for the halls. In an observation on 5/16/24 at 1:00 PM Cook D removed her gloves and placed them on the prep table. Cook D went into the walk-in fridge grabbed some supplies and re-gloved, while her last set of soiled gloves laid in the prep area. Cook D did not perform hand hygiene and was preparing sandwiches. In an observation on 5/16/24 at 1:03 PM revealed Dietary Aide H scratched her face and got applesauce. She wiped sauce that had gotten onto her hand onto her pants . In an observation on 05/16/24 at 1:16 PM revealed Dietary Aide H scratched her face and continued working without performing hand hygiene . In an interview on 5/16/24 at 01:35 PM with the Regional CDM, she said, If dietary staff have acrylic nails, they must be short. Nails were not to have polish on them She said They must wear gloves. Her expectation was that when gloves were removed, they should be placed in the trash and hand hygiene should follow. In an interview on 5/17/24 at 11:15 AM, DON said there had been an ongoing dietary issue. In an interview on 5/17/24 at 11:30 AM, the RN Compliance Nurse said hand hygiene should be performed when touching surfaces that were not clean including touching their face. In an interview on 05/17/24 at 03:45 PM, with the Administrator revealed hand hygiene for kitchen staff . should be common sense. She said At minimum when going from resident to resident, touching dirty areas and when changing gloves. In a record review of the facility's Dietary Services Policy & Procedure Manual 2012 Under Food Storage and Supplies (I-C 00-8.0) reflected [in-part]: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. Procedure: 4. Open packages of food are stored in closed containers with covers or in sealed bags. Equipment Sanitation (IC 00-6.0) [in-part]: We Will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. Procedure: 1. Thermometers must be available in refrigerators . 2. Food carts will be cleaned and sanitized after each meal. 3. Grease filters should be cleansed routinely with detergent as needed to remove obvious grime. 4. Pots and pans: c. Effective concentration of a suitable detergent shall be used. e. All equipment and utensils shall be thoroughly rinsed free of detergent solution. 7. Facilities shall use an approved test kit to measure the parts per million of the chemicals . Records of test results should be kept on the temperature/chemical log. 8. Blenders and food processor bowls should be inverted after cleaning to drain dry on shelves or trays with vented slots or bar netting. Record review of facility policy labeled Hand Hygiene, not dated, [in-part]: 1. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infection. When to perform hand hygiene . After blowing or wiping nose. . After touching garbage

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 7 residents (Residents #5, #15 and #50) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident # 5's MDS accurately reflected the resident's weight gain. 2. The facility failed to ensure Resident # 15's MDS accurately reflected her weight loss or that she received hemo dialysis 3 times a week. 3. The facility failed to ensure Resident #50's MDS accurately reflected her weight loss. These failures could place residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life. The findings include: 1. Record review of Resident #5's admission profile, dated 5/17/24, reflected a [AGE] year-old female who's most recent admitted was 06/16/21. Resident #5 had diagnoses which included: abnormal weight loss, edema (a condition in which fluid collects in the tissues of the body), and hypertension (high blood pressure). Record review of Resident #5's Quarterly MDS, dated [DATE], Section K reflected Resident #5 did not have a significant weight loss or gain of 5% in the last 30 days, or a 10% weight loss of gain within the last 180 days. Record review of Resident #5's care plan reflected the resident had the potential for unplanned weight loss or gain. The problem start date was 3/3/21, and a revision date of 9/6/23. Interventions included: monitor weight per facility protocol. Record review of Resident #5's weights reflected: On 10/03/2023, the resident weighed 134.6 lbs. On 04/01/2024, the resident weighed 147.4 pounds which was a 9.51 % Gain. Record review of nurse's progress notes dated 5/1/24 at 4:43 PM, reflected the following: Resident has weight gain since receiving dental work, resident currently on Lasix 40 mg of Lasix daily with 2+ edema noted to BLE. (Bilateral lower extremities) MD (physician) notified. No new orders. In an interview on 5/17/24 at 12:27 PM, MDS Coordinator B stated she did a Significant Change MDS on 5/16/24 for a weight gain of 13.8 pounds. She stated she must have made an error on the 4/1/24 Quarterly MDS because she just missed the weight change. MDS LVN B stated weight loss or change was communicated to her weekly by the Unit Manager and the DON through a written summary of the Standards Of Care Meeting. She stated she attended the Standards of Care meetings, but normally left the meeting after about 30 minutes into it because she had to go and supervise the smokers. She stated she did not feel her leaving the meeting had anything to do with the failure. She stated failure to document a weight loss or gain could result in the resident not receiving care. 2. Record review of Resident # 15's physician orders dated 5/16/24reflected a [AGE] year-old female who's most recent admitted was 6/9/23. Resident #15 had diagnoses which included: chronic kidney disease, end stage renal disease (condition in which the kidneys are not functioning properly and fail to filter waste and excess fluid from the body), and hypertensive heart disease (high blood pressure). Record review of Resident # 15's Quarterly MDS, dated [DATE], Section K reflected Resident # 15 did not have a significant weight loss or gain of 5% in the last 30 days, or a 10% weight loss of gain within the last 180 days. Section O reflected the resident did not receive hemodialysis or peritoneal dialysis. Record review reflected on 2/2/24, the resident weighed 179.8 lbs. On 3/5/24, the resident weighed 163.8 pounds which is a -8.90 % Loss. Record review of Resident #15's physician orders, dated 4/1/24, reflected: dialysis 3 times a week (3/5/24) and check shunt to left arm for signs and symptoms of infection, bleeding, bruising pulsation, or aneurysm (start date 3/1/24), weekly weight for weight loss (start date 2/29/24). Record review of Resident #15's care plan reflected the following: hemodialysis. Problem initiated 6/27/23. Intervention encourage resident to go for scheduled dialysis treatments. In an interview on 05/17/24 at 03:51 PM, MDS Coordinator B stated I cannot capture dialysis on the MDS without proof from dialysis center, and they will not provide documentation. She stated, We send a binder but 9 times out of 10 there is nothing there. She stated a Significant Change MDS was completed on 3/12/24 for Resident #15 for weight loss, but she should have caught the weight loss on 3/6/24. 3. Record review of Resident #50's admission profile, dated 5/17/24, reflected a [AGE] year-old female who's most recent admitted was 06/16/21. Resident # 5 had diagnoses which included: hypertension (high blood pressure), Protein calorie malnutrition and liver transplant. Record review of Resident #50's Quarterly MDS, dated [DATE], Section K reflected Resident #50 did not have a significant weight loss or gain of 5% in the last 30 days or a 10% weight loss of gain within the last 180 days. Record review of Resident #50's weights reflected: On 11/01/2023, the resident weighed 127.8 lbs. On 05/01/2024, the resident weighed 113.6 pounds which is a -11.11 % loss. Record review of Resident 50's physician orders, dated 5/17/24, reflected an order for Med Pass 2.0 (dietary caloric supplement) 60 cc three times a day. Order 12/29/23. Regular pureed diet pudding consistency 3 times a day. Record review of Resident #50's care plan reflected the following: potential nutritional problem related to dysphagia( difficulty swallowing) initiated 3/18/24. Problem initiated 6/27/23. Intervention monitor resident for signs and symptoms malnutrition, report weight loss or gain of more than 5 percent in one month, 7.5 percent in 3 months, and 10 percent in 6 months (initiated 3/18/24 . Last revised 3/18/24). In an interview on 5/16/24 at 1:00 PM Resident #50's family member stated she had trouble swallowing and was going to see the physician this week to see about getting a peg tube for nutrition. He stated she lost a lot of weight. Record review of the facility's, undated, policy titled MDS Data Accuracy Policy, reflected the following [in part]: The MDS coordinator will receive training to ensure competence in completing the assessment. Federal law requires the assessment accurately reflects the resident's status. Each individual responsible for a portion of the MDS must sign and certify their section of the assessment is accurate and complete. 50133

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 2 residents (Residents #19 and #183) reviewed for respiratory care. 1. The facility failed to ensure Residents #19 and #183's oxygen tubing was changed weekly. 2. The facility failed to ensure Residents #19 and #183's nasal cannula and nebulizer were kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. The findings include: 1. Record review of Resident #19's face sheet, dated 05/17/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #19 had diagnoses which included Hypertension (high blood pressure), Shortness of breath, Depression, Anxiety , chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe). Record review of Resident #19's MDS admission assessment, dated 05/17/2024, reflected a BIMS score of 06, which indicated severe cognitive impairment. Section I: Active diagnosis reflected chronic pulmonary disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. Record review of Resident #19's Physician Orders, dated 05/17/2024, reflected an order for Oxygen at 3 - 4 liters per minute via nasal cannula and nebulizer treatments two times daily. Change oxygen and nebulizer tubing weekly on Sunday. Record review of Resident #19's quarterly Care Plan, 05/09/2024 , reflected a care plan for has COPD (obstructive pulmonary disease) - Oxygen at 2- 4 liters per minute continuously to keep oxygen saturation above 92%. The Care Plan did not have an intervention regarding when oxygen tubing needed to be changed. In an observation on 05/15/2024 at 11:30 AM revealed Resident #19 was sitting in the dayroom in her wheelchair. Her nasal cannula was uncovered and hanging over the bed rail in her room with the nose prongs on floor . 2. Record review of Resident # 183's face sheet, dated 05/17/2024, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #183 had diagnoses which included dementia (memory loss), Hypertension (high blood pressure), Pneumonia (Inflammation of the air sacs in the lungs), Muscle wasting, Shortness of breath, Depression,(a group of conditions associated with the elevation or lowering of a person's mood) Anxiety , (A feeling of fear, dread, and uneasiness) chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe). Record review of Resident #183's MDS admission assessment, dated 05/17/2024, reflected a BIMS score of 99, which indicated severe cognitive impairment. Section I: Active diagnosis reflected chronic pulmonary disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. Record review of Resident #183's Physician Orders dated 05/17/2024 revealed an order for Oxygen at 2 liters per minute via nasal cannula and nebulizer treatments three times daily. Change oxygen and nebulizer tubing weekly on Sunday. Record review of Resident #183's admission Care Plan, dated 05/17/2024, reflected a care plan for [Resident #183] has COPD (obstructive pulmonary disease) - Oxygen at 2- 4 liters per minute continuously to keep oxygen saturation above 92%. The Care Plan did not have an intervention regarding when oxygen tubing needed to be changed. In an observation and interview on 05/14/2024 at 09:45 AM, during initial rounds, Resident #183 was lying in his bed receiving oxygen via nasal cannula at 2 liters per minute. His nebulizer was sitting on the nightstand uncovered. He could not recall when the oxygen tubing was last changed . 41944

Based on observation, interview, and record reviews , the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for one of one meal reviewed for palatable meals and preferred temperatures. The facility failed to ensure that the food was appetizing temperature, flavor, and texture. The deficient practice could affect the residents who received their meals from the kitchen by contributing to poor intake of nutrition, weight loss, and illness. This finding include: In an observation on 5/16/24 at 11:50 AM the holding food temperatures were as follows: Chicken corn casserole -154 F. Rice -158 F. Beans -148 F. Kool-aide with melted ice, a temperature was not obtained. In an observation on 05/16/24 at 01:27 PM of a sample test tray with Cook E present, revealed the following: Chicken corn casserole was at 110 degrees F, The warmth of the casserole was room temperature and not appetizing. The rice was gummy and not flavorful . The rice was difficult to swallow due to the texture. Kool-aide was room temperature and with melted ice. In an interview on 5/16/24 at 1:30 PM, Cook E said she had trouble with residents not liking the Kool-aide if the ice had melted and the drinks were watered down. In an interview on 05/14/24 at 10:04 AM, MDS Nurse B stated she had been working at the facility for [AGE] years. She said the food was consistently cold that was served down the halls. She said it had been an ongoing problem. In an interview on 05/17/24 at 11:15 AM with the DON she said the cold food and kitchen issues had been an ongoing issue and they were implementing things to improve cold food. In an interview on 5/17/24 at 11:30 AM, the Regional Compliance Nurse said they have known about the problems with the food. She said this was addressed in the Resident Council and with other residents on the halls. She said they completed a training about using plate warmers and she said they needed to be more efficient during mealtimes. In an interview on 05/17/24 at 03:45 PM with the Administrator, she revealed the cold food was an ongoing issue. She stated she tried changing the order the hall meal tray carts were being sent from the kitchen so the Hall 400 residents would not feel they always came last. The Administrator mentioned in the Resident Council meetings the food was frequently a concern. In a record review of the facility's Dietary Services & Policy & Procedure Manual 2012: FP 00-10.0 reflected the following [in part]: Under section 4. Every attempt will be made to honor resident food preferences . Under section 8. The menu will reflect the needs of the resident population as well as input from residents and resident groups.

Based on interview and record review the facility failed to provide advance notice of change in services and charges not covered under Medicare for 1 of 3 residents (Residents #45) reviewed for Medicaid and Medicare Coverage Liability Notices. The facility failed to ensure Resident #45's representative was given a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN Form CMS-10055) when he was discharged from skilled services. This failure could place residents and their representatives at risk of not being fully informed about services covered by Medicare. The findings included: Record review of Resident #45's Admission Record, dated 5/17/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #45 had diagnoses which included: congestive heart failure (impairment in the heart's ability to fill with and pump blood); hypertension (high blood pressure); polycythemia vera (rare blood cancer with increased red blood cells that thicken the blood and increase risk for blood clots); anemia; hyperlipidemia (high cholesterol); cerebrovascular disease (condition affecting blood flow and blood vessels in the brain); neuropathy (nerve damage causing weakness, numbness, and pain in hands and feet); chronic atrial fibrillation (irregular heartbeat); hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left sided weakness following a stroke); and joint pain. Record review of Resident #45's electronic health record census report reflected he was hospitalized from 1/28/2024 to 1/31/2024. Record review of the SNF Beneficiary Protection Notification Review worksheet for Resident #45 revealed he received Medicare Part A Services from 1/31/2024 through 2/19/2024. The resident remained in the facility. The form documented the resident's discharge from Medicare Part A services when benefit days were not exhausted had been voluntary. A SNF ABN, Form CMS-1005 was not provided. A hand-written note documented Resident is private pay and didn't want to go into co-pay days. In an interview on 5/15/24 at 9:51 AM, MDS Coordinator C stated she used the NOMNC and SNF ABN forms for notifying the residents and their responsible parties when skilled care services would end. She stated an IDT meeting was held to determine if skilled care was still needed and a resident's discharge from skilled services needed to be approved by the corporate office. She stated sometimes residents chose to be discharged from skilled services or chose hospice. In an interview on 5/17/24 at 10:57 AM, MDS Coordinator C stated Resident #45 was private pay and had used 20 days of Medicare Part A for skilled nursing care. She stated Resident #45's family member did not want to pay the copay for continued skilled care. She stated she did not have documentation from the conversation with Resident #45's family member. MDS Coordinator C stated she used the beneficiary notice guidelines from AAPACN decision tree. She stated the guidelines did not specify the use of the SNF ABN form when the resident initiated discharge from services and chose to remain in the facility. MDS Coordinator C stated she did not provide a SNF ABN to Resident #45 or his family member. She stated she would contact the corporate regional reimbursement nurse and ask if there was a policy and procedure for determining when and which notification form should be used. During an interview and record review on 5/17/24 at 2:13 PM, MDS Coordinator C stated her corporate regional reimbursement nurse said there was not a policy and procedure for use of the SNF ABN form, just the NOMNC form. She provided a company policy and procedure for NOMNC, which was not dated. The policy and procedure did not include information regarding the SNF ABN form. In an interview on 5/17/24 at 3:18 PM, MDS Coordinator B provided a copy of a policy and procedure for Advanced Beneficiary Notice NOMNC. She stated she was told to give it to the State Surveyor to review. In an interview on 5/17/24 at 3:21 PM, Resident #45 stated he received therapy services earlier this year. He stated the money ran out and he was told he had to stop services. Resident #45 stated he did not really want to stop therapy at that time. Record review of the facility's policy and procedure Advance Beneficiary Notice NOMNC, dated as revised 05/2024, reflected [in part]: ABN Notices are issued under the following circumstances: Part A only CMS 10055 1. On admission to SNF, the beneficiary has a 3-day hospital stay but does not require skilled care. 2. Part A stay will end because, SNF determines the beneficiary no longer requires daily skilled services. Resident has days remaining in benefit period. Resident will remain in facility (custodial care) . The above notices are to be delivered in writing far enough in advance to enable residents to make an informed decision.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #60) reviewed for infection control. 1. The facility failed to ensure CNA A washed or sanitized her hands before feeding Resident #60. 2. The facility failed to ensure CNA A did not make contact with her own face, hair, and other objects while feeding Resident #60. These failures could place residents at risk of infections. The findings include: Record review of Resident #60's face sheet, dated 5/20/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #60 had diagnoses which included: cerebral palsy (a condition present a birth which leads to poor coordination, and stiff, loose or weak muscles), protein calorie malnutrition (a state in which a decrease in nutrients, proteins and calories leads to changes in body composition and function), intellectual disability (a term used to describe a person with certain limitations in cognitive functioning and other skills) and dysphagia (difficulty swallowing). Record review of Resident #60's MDS assessment, dated 2/8/2024, reflected in Section GG the resident was dependent with meals (helper does ALL of the effort. Resident does none of the effort to complete the activity.) During an observation on 05/14/24 at 12:26 PM revealed Resident #60 was sitting at the assisted feeding table and needed assistance with meal intake. CNA A was asked by the DON to feed Resident #60; CNA A did not perform hand hygiene. CNA A rubbed her nose and face before and during feeding Resident # 60, and never performed hand hygiene. CNA A grabbed her own hair and pulled it out of her face and continued to feed Resident #60 after she picked a napkin up off the table and wiped his mouth. During an interview on 05/14/24 at 12:40 PM, CNA A stated she washed her hands before feeding Resident #60, and she did not know of anything she did wrong while feeding the resident. She stated she did not know what negative outcome for the resident could occur if hand hygiene was not performed after touching her hair or face. She also stated she did not know when the last in-service on hand washing, or infection control was. She stated she did not normally carry or use sanitizer when feeding. During an interview on 05/14/24 at 12:45 PM, the DON stated her expectation was that hand sanitizer be used by all personnel as part of infection control when feeding and after touching faces, hair or other objects. She stated failure to do so could cause infection. Record review of the facility's policy titled Fundamentals of Infection Control Precautions, dated as revised 03/24, reflected the following [in part]: Hand hygiene continues to be the primary means of preventing the transmission of infection. Hand hygiene should be used in the following situations - before and after assisting a resident with meals, after blowing or wiping your nose, after handling soiled equipment or utensils, after performing your hand hygiene, after contact with resident's mucus membranes, after coming in contact with a resident's intact skin

Based on observation, interview, and record review, the facility failed to ensure the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of two residents reviewed for infection control practices. CNA C and CNA D failed to perform hand hygiene and change their gloves at the appropriate times while providing incontinence care for Resident #1. These failures placed residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet, dated 01/30/24, revealed the resident was a 90- year- old male admitted to the facility on [DATE] with diagnoses of urinary tract infections, constipation, and benign prostatic hyperplasia (enlarged prostate). Review of Resident #1's MDS assessment, dated 01/17/24, revealed Resident #1 required extensive assistance with most ADLs and one person assist. Resident #1 was always incontinent of bowel and bladder. Review of Resident #1's care plan, dated 12/27/23, revealed the resident was care planned for bowel but not bladder incontinence. Observation of incontinence care for Resident #1 on 01/29/24 at 2:38 p.m. revealed CNA C and CNA D did not wash their hands or perform hand hygiene before the start of care. Both CNAs donned gloves. CNA C wiped Resident #1 from front to back making 5 strokes of clean with same soiled wipe. Resident #1's brief was soiled with urine and fecal matter. CNA C picked up the clean brief and placed it on the trash bag where the dirty wipes were kept. Her gloves were visibly soiled but she continued to clean the resident with it. CNA C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. She placed the clean brief on the resident and fastened it. Meanwhile, CNA D was assisting CNA C to provide care to Resident #1. CNA D wore the same gloves while repositioning and putting back the resident clean sheets and pillows. She also walked out of the room without washing hands and returned without performing hand hygiene and assisted in putting Resident #1 clothes on. CNA C and CNA D doffed their gloves, picked up the trash and left the room without washing their hands or performing hand hygiene. In an interview on 01/29/24 at 2:54p.m. with CNA C she stated she had been employed at the facility for about 1 month. She worked for the facility previously for 7 months. CNA C said she did not receive infection control training during her orientation. She stated cross contamination meant mixing clean with dirty. CNA C noted she should have washed hands and changed gloves at the appropriate times while providing care. She stated Resident #1 could get an infection for not using good infection control practice. Interview with CNA D on 01/30/24 at 1:42 p.m. revealed she had been employed at the facility for about 7 months. She stated she received infection control training from the facility 2 months ago. She stated cross contamination was transferring germs from one place to another. CNA D noted she should have changed her gloves and washed her hands after repositioning resident and changing her clean sheets. During an interview with the DON on 01/30/24 at 4:17 p.m. she acknowledged she was aware of some of the concerns raised about infection control. She stated the aides were expected to follow standard precautions to include appropriate hand washing and hand hygiene when providing incontinent care. The facility's infection control policy manual 2019 revealed, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1) Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene.: a) When coming on duty: b) When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . c) Before and after assisting a resident with personal care .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for 2 staff (CNA A, CNA B) of 5 staff reviewed for infection control, in that: 1. CNA A entered a COVID-19 Red Zone (COVID positive zone) room, without eye protection (face shield or goggles) on and proceeded to care for and speak with a resident that was unmasked, while the resident's door was open. 2. CNA B entered a COVID-19 Red Zone (COVID positive zone) room, without eye protection (face shield or goggles), a gown, or a N95 mask or respirator and proceeded to clean the COVID positive room. These failures could place residents at risk for contamination and infection. The findings included: Observation on 12/06/2023 at 10:20 AM, CNA A was in Resident #2's room performing resident care on Resident #2, a COVID-19 positive resident, without an eye shield (goggles or face shield). Resident #2 did not have a face mask on, and CNA A was near the resident. The resident's door was left open while CNA A was going in and out of the resident's room. Observation on 12/06/2023 at 10:22 AM there was a posting on Resident #2's door, revealed the resident was on aerosol precautions. A sign was posted on the door that read STOP- Aerosol Contact Precautions, only essential personnel should enter this room. The instructions below revealed the following: EVERYONE MUST: 1) Clean hands when entering and leaving room. 2) Use approved N95 or equivalent respirator especially during aerosolizing procedures, 3) Mask- Face mask is acceptable if respirator is not available and for visitors. 4) Wear eye protection- Face Shield and Goggles. 5) KEEP DOOR CLOSED Interview on 12/06/2023 at 10:25 AM, CNA A stated that she knew she was supposed to have goggles on, but she forgot. She said that she has received training on the Covid policy and that she just forgot to wear eye protection when in the resident's room or when she makes direct contact with the resident. She stated that she saw the postings on the resident's door. Observation on 12/06/2023 at 10:30 AM, CNA B was in Resident #3's room, a COVID positive resident without an eye shield (goggles or face shield), a gown, and a N95 mask, while his door was open. CNA B was changing Resident #3's bedding while coming in direct contact with the bedding that was touching CNA B's scrubs in the front. CNA B proceeded to gather Resident #3's dirty clothes while it touched her scrubs in the front. Interview and observation on 12/06/2023 at 10:35 AM, CNA B stated that she should have followed the PPE postings that were on the outside of the resident's door. She stated that she was trying to hurry and clean the resident's room while he was in the shower. She stated that she knew that her scrubs were touching his dirty bedding and that she should have had a gown on to cover her. She stated that she knew she should have worn an N95 mask and eye protection. She revealed this failure could place residents at risk for cross contamination. CNA B left the resident's room and did not change from her contaminated scrubs that shift. Interview on 12/06/2023 at 11:00 AM, the Administrator revealed that the postings should be followed exactly as posted and that all employees have been thoroughly in-serviced on infection control and COVID. Record review of the Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures Policy not dated: stated, Patient Placement: Place a patient with suspected or confirmed COVID infection in a single-person room. The door should be kept closed (if safe to do so). Personal Protection Equipment: HCP (Health Care Provider) who enters the room of a patient with suspected or confirmed COVID infection should adhere to standard precautions and use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection) goggles or a face shield that covers the front and side of the face). Record review of the CDC (Centers for Disease Control) Guidelines Recommendation dated Sept. 27, 2022, When COVID Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients.

Based on interview, and record review, the facility failed to accurately assess each resident's status for 1 of 5 (Resident #1) reviewed for assessment accuracy in that: Resident #1's Quarterly MDS assessment records, was not coded yes for weight gain of 5% or more in the last month or gain of 10% or more in last 6 months. This failure could place residents at risk of not receiving the proper care and services due to inaccurate assessment records. Finding included: Record review of Resident #1's Face Sheet, dated 12/07/2023, revealed a [AGE] year-old female, admitted to the facility on [DATE] with an admitting diagnosis of Dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), protein calorie malnutrition (inadequate intake of food such as protein, calories and other essential nutrients) and bipolar (periods of depression and periods of abnormally elevated mood that last from weeks to days). Record review of Resident #1's Admission MDS assessment, dated 04/14/2023, revealed the following: Section D (Mood) showed a score of 08. Section K (Weight) Showed a weight of 130 pounds. Section K (Weight gain)- No, weight gain of 5% or more in the last month or weight gain of 10% or more in last 6 months, resident not a physician prescribed weight regimen. Section G (Functional Status)- Required Extensive assistance for bed mobility and limited assistance for transfers. Record review of Resident #1's Quarterly MDS assessment, dated 06/27/2023, revealed the following: Section D (Mood) showed a score of 03. Section K (Weight)- Showed a weight of 142 pounds. Section K (Weight gain)- No, weight gain of 5% or more in the last month or weight gain of 10% or more in last 6 months, resident not a physician prescribed weight regimen. Section G (Functional Status)- Required no assistance with Bed Mobility and transfers. Record review of Resident #1's Quarterly MDS assessment, dated 09/22/2023, revealed the following: Section D (Mood) showed a score of 03. Section K (Weight)- Showed a weight of 151 pounds. Section K (Weight gain)- No, weight gain of 5% or more in the last month or weight gain of 10% or more in last 6 months, resident not a physician prescribed weight regimen. Section G (Functional Status)- Required no assistance with Bed Mobility and transfers. Record review of Resident #1's weight and vital summary revealed the following weights and dates: 08/31/2023- 151.4lbs- wheelchair 08/08/2023- 143lbs- wheelchair 04/06/2023- 130lbs- wheelchair In an interview on 12/06/2023 at 12:05 PM, the MDS coordinator revealed the resident had a significant weight gain of more than 10% in the month of August 2023. She revealed that the resident was admitted into the facility on [DATE] weighing 130lbs and in August she weighed 151 after they started snacks BID (twice daily) to increase the weight. She revealed that on the resident's Quarterly MDS assessment dated [DATE] she should have coded yes; the resident had a weight gain that was not physician prescribed in section K. She revealed that this failure could cause the resident to miss care areas not being identified and care planned accurately. In an interview on 12/06/2023 at approximately 1:30 PM, the DON revealed that it was the MDS Coordinator's responsibility to complete the MDS assessment accurately. She revealed that the resident had a significant weight gain, after the resident adjusted to being in the facility. Record review of the facility's policy covering MDS inaccuracies was requested to the MDS coordinator on 12/07/2023 and not received at the time of exit.

Based on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 2 medication carts reviewed for pharmacy services. The facility did not ensure medications carts were secured and locked. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings included: During an observation on 12/06/2023 at 3:30 PM, LVN A left a prescription IV medication of Vancomycin on top of the cart 2, unsecured and out of LVN A's sight, while she was in another resident's room. There was not any other staff in visual sight of the medication, and there was a resident that was within 3 feet of the medication cart. Surveyor was unsure where the nurse went and took the medication to the Administrator's office without LVN A realizing it was gone. During an interview on 12/06/2023 at 3:35 PM, LVN A said that she walked away to go into a resident's room to help him. She said that she should have locked the medication up before she left it unattended with residents around it. She said that this could cause a patient to get into it or take the medication. During an interview on 11/06/2023 at 12:45 PM, the DON said that her expectations were for medications to be locked up anytime a nurse walks away from it. She said that staff are all trained on medication expectations and know not to leave medications out or unattended. A policy and procedure titled Storage of Medication was requested on 12/07/2023 and was not received at the time of exit.

Based on interviews, and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 4 residents (Residents #1) whose records were reviewed for assessments. The facility failed to recognize and re-assess Resident #1 after an improvement in mood, significant weight gain, and an improvement in ADL function. This failure placed residents at risk for not developing interventions to meet their needs for care assistance and treatments. Findings include: Record review of Resident #1's Face Sheet, dated 12/07/2023, revealed a [AGE] year-old female, admitted to the facility on [DATE] with an admitting diagnosis of Dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), protein calorie malnutrition (inadequate intake of food such as protein, calories and other essential nutrients) and bipolar (periods of depression and periods of abnormally elevated mood that last from weeks to days). Record review of Resident #1's Admission MDS assessment, dated 04/14/2023, revealed the following: Section D (Mood) showed a score of 08. Section K (Weight) Showed a weight of 130 pounds. Section K (Weight gain)- No, weight gain of 5% or more in the last month or weight gain of 10% or more in last 6 months, resident not a physician prescribed weight regimen. Section G (Functional Status)- Required Extensive assistance for bed mobility and limited assistance for transfers. Record review of Resident #1's Quarterly MDS assessment, dated 06/27/2023, revealed the following: Section D (Mood) showed a score of 03. Section K (Weight)- Showed a weight of 142 pounds. Section K (Weight gain)- No, weight gain of 5% or more in the last month or weight gain of 10% or more in last 6 months, resident not a physician prescribed weight regimen. Section G (Functional Status)- Required no assistance with Bed Mobility and transfers. Record review of Resident #1's Quarterly MDS assessment, dated 09/22/2023, revealed the following: Section D (Mood) showed a score of 03. Section K (Weight)- Showed a weight of 151 pounds. Section K (Weight gain)- No, weight gain of 5% or more in the last month or weight gain of 10% or more in last 6 months, resident not a physician prescribed weight regimen. Section G (Functional Status)- Required no assistance with Bed Mobility and transfers. Record review of Resident #1's MDS assessments revealed there was no MDS Significant Change Assessments. Record review of Resident #1's Care Plan, last revised on 08/15/2023, revealed care plans for: Problem: Weight loss- has nutritional potential problem with weight loss due to Terminal prognosis related to multiple CVA'S (cerebral vascular accident). Goal: will maintain adequate nutritional status as evidenced by maintaining weight, no signs, or symptoms of malnutrition, and consuming at least 50% of at least three meals a day. In an interview on 12/06/2023 at 12:05 PM, the MDS coordinator revealed Resident #1 had a significant weight gain of more than 10%, her mood improved, and her functional status all improved since her Admission assessment. She revealed that she should have completed a significant Change MDS Assessment on June 27, 2023, instead of completed a Quarterly Assessment. She revealed that the resident was admitted into the facility on [DATE] weighing 130lbs and in August she weighed 151 after they started snacks BID (twice daily) to increase the weight. She revealed that since the resident's Annual Admission the resident has had an improvement in her ADL's, and that she was triggering as Independent in ADL areas. She revealed that this failure could cause the resident to miss care areas not being identified and/or a comprehensive care plan being completed. In an interview on 12/06/2023 at approximately 1:30 PM, the DON revealed that it was the MDS coordinator's responsibility to complete the MDS assessment accurately, which include the Significant Change Assessments. She revealed that the resident had adjusted and that her mood has improved since her admission. She revealed Resident #1 had a significant weight gain, after the resident adjusted to being admitted into the facility. Record review of the facility's policy covering MDS inaccuracies was requested to the MDS coordinator on 12/07/2023 and was not provided at the time of exit.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. The dietary staff did not operate the low temperature dish machine and check the chlorine sanitizer content to ensure it was operating correctly to clean and sanitize the dishes consistently each meal. 2. Dietary Aide C did not use disposable gloves while handling soiled dishes and did not wash or sanitize his hands before handling the clean dishes. 3. Food items in the non-perishable food storage areas were not stored in sealed containers or resealable storage bags after the manufacturer's package seal was opened. 4. Floors were soiled throughout the kitchen food preparation area. 5. The deep fryer unit was soiled with dried fried food crumbs and contained dark colored cooking oil. 6. The reach-in freezer unit #2 interior temperature was not maintained at zero degrees F or lower and foods stored in the unit were not frozen solid. The facility's failure placed residents at risk for foodborne illness and a decline in health status. The findings included: Observation on 4/02/23 at 9:25 AM, during the initial tour of the facility kitchen revealed the hand washing sink was located by the door to the short hallway that led to the nurses' station. There was not another hand washing sink in the kitchen or dish washing room. Interview and observation on 4/02/23 at 9:30 AM revealed Dietary Aide C was washing dishes in the low temperature dish machine. He was not wearing gloves when handling the soiled dishes. He stated he had worked in facility for about 1 month. Review of the dish machine temperature log form, dated April 2023, revealed columns to document wash and rinse water temperatures and sanitizer levels 3 times daily. No entries were documented on the form for 4/01/23 or breakfast 4/02/23. Observation on 4/02/23 at 9:35 AM revealed Dietary Aide C operated the dish machine. He started to record temperatures for breakfast on 4/01/23, then scratched them out when reminded today was 4/02/23. When Dietary Aide C checked the chlorine sanitizer content, the test strip did not react when dipped in the dish machine water. He primed the sanitizer and ran the dish machine again. No sanitizer was observed in the tube that emptied into the dish machine. Dietary Aide C checked the one-gallon sanitizer bottle, which was almost full. He removed the bottle cap which was connected to tubing and observed the siphon device was stuck down in the neck of the bottle and did not reach the cap. He stated he would go to the storage room and get another bottle of sanitizer. In an interview and observation on 4/02/23 at 9:40 AM, after returning to the kitchen, Dietary Aide C stated he could not find another bottle of sanitizer. He stated he was not going to wash dishes by hand and stated he might as well go home. He removed the cap to the sanitizer bottle and was able to pry the siphon device to the top of the bottle neck with a knife. He replaced the bottle cap with the tubing, primed the dish machine again and ran the machine. Chlorine sanitizer was observed flowing through the tubing and emptying into the dish machine. He tested the sanitizer and measured a level of 200 ppm. Observation of the low temperature dish machine manufacturer's recommendations revealed wash and rinse water temperatures at a minimum of 120 degrees F and a sanitizer level minimum of 50 ppm. When asked about the procedure for handling soiled and clean dishes, Dietary Aide C stated he put the dirty dishes in the racks, ran them through the dish machine, and then stacked the clean dishes. Inquired if he washed or sanitized his hands between touching the soiled and clean dishes, as he was not using disposable gloves, and he stated no. A two-compartment sink for rinsing dishes was in the dish room, but there was no hand soap, paper towel dispenser, or hand sanitizer in the room. Dietary Aide C stated he would start using gloves when handling dirty dishes. He got gloves from a box in the kitchen and put them on his hands. Observation and interview on 4/02/23 at 10:00 AM, during the initial tour of the facility kitchen revealed the following: - The reach-in refrigerator unit contained a rectangular pan covered with foil which was not labeled or dated. Cook D removed the pan from refrigerator and placed the pan on the stove top. She lifted the foil and stated it looked like a roast. The piece of meat had been cooked as a whole piece of meat (not sliced) and was surrounded by white colored cold grease/fat. Cook D stated she did not know when it had been cooked. - The reach-in freezer unit #2 had an interior thermometer with a temperature of 25 degrees F. The freezer was filled with unevenly stacked cardboard boxes, dated 3/29/23, which contained sweet dough and beef steak fritters (meat patties) which were not frozen solid. - The exterior surfaces of the stainless steel reach-in refrigerator and freezer units were soiled with dried food splatters. - The storage room for storing bread items on shelf rack had an open bag with potato chips rolled closed and dated 3/28/23. The potato chips were not in a sealed container or resealable bag. - The non-perishable food storage room had wire rack shelf units for storing dry food items. A large plastic bag containing flake coconut, dated 3/23/22, was rolled closed and had a trombone paper clip; a 5-pound bag with pecan pieces, dated 3/08/23, was rolled closed and had a trombone paper clip. The coconut and pecans were not in sealed containers or resealable bags. - The deep fryer unit top surface was covered with a large rectangular baking sheet and was not in use. The pan was moved to the side and dark colored cooking oil and fried food crumbs on the interior surface were observed. - The floor was soiled with food throughout the kitchen. In an interview on 4/02/23 at 10:10 AM, Cook D stated the food on the floor was from breakfast that morning and she had not yet swept the floor. She stated she sweeps the floor two times during her shift. In an observation and interview on 4/02/23 at 3:04 PM, a chest freezer was located in a storage room located in the short hallway outside the kitchen. A thermometer was not observed inside the freezer, but the food was frozen solid. The DSM stated she would place a thermometer in the chest freezer. A thermometer was observed on the wire rack shelf unit located to the left of the freezer. The DSM stated it probably belonged in the chest freezer. The DSM stated the roast in the reach-in refrigerator this morning was from last Wednesday, 3/29/23. She stated it should have been labeled and dated. When asked about the supply of chlorine sanitizer for the low temperature dish machine, she stated she had more in storage. She stated the new bottle of sanitizer must have been defective. In and interview and observation on 4/04/23 at 11:10 AM, the DSM stated she had gone to the store and had bought dinner rolls for the lunch meal today, due to throwing away the sweet dough that had not been frozen solid in freezer unit #2 on 4/02/23. She gave the frozen dinner rolls to an unidentified dietary staff member, who proceeded to place the frozen dinner roll dough on baking sheets and put them in the oven to bake. In an interview on 4/04/23 at 11:35 AM, the DSM stated she had worked as a dietary aide and dishwasher for the morning shift on Saturday, 4/01/23. When asked if she had changed the bottle of chlorine sanitizer for the dish machine that day, she stated no and she did not recall doing it. The DSM stated the evening shift dietary aide would have switched the sanitizer bottle with a new one. She did not recall checking the wash and rinse water temperatures and chlorine sanitizer for the Saturday 4/01/23 breakfast and lunch meals. When asked about the April 2023 dish machine temperature and sanitizer log not having any documented entries for 4/01/23, she stated she had not checked them. Review of the facility's policy and procedure for Dishwashing Preparation and Dishwashing, included in the Dietary Services Policy and Procedure Manual 2012 , revealed the following [in part]: The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils. Procedure: 2. Automatic dishwasher: Low temperature machine . d. Prior to washing the soiled dishes after a meal, the dish machine should be tested for proper temperature and PPM of sanitizing solution. The dish machine may need to be run empty for a few cycles to ensure the proper temperature is attained, and no dishes will be washed prior to achieving this standard. e. Hands should be sanitized before touching clean items and use care in removing utensils from conveyors in order not to contaminate clean items . Review of the facility's policy and procedure for Food Storage and Supplies, included in Dietary Services Policy and Procedure Manual 2012, revealed the following [in part]: All facility storage areas will be maintained in and orderly manner that preserves the condition of food and supplies. Will ensure storage areas are clean, organized, dry and protected from vermin and insects. Procedure: 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened. 5. Storeroom floors should be swept and mopped to be maintained in a sanitary manner to prevent vermin or pest infestation . Review of the U.S. Food and Drug Administration, 2017 Food Code, specified [in part]: Food storage/labelling 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. 6-501.12 Cleaning, Frequency and Restrictions. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared.

Based on observation, interview, and record review, the facility failed to ensure the maintenance of mechanical and electrical equipment in safe operating condition in 1 of 1 kitchen, in that: One of two reach-in freezers was not maintained at an interior temperature of zero degrees or below and food stored in the freezer was not frozen solid. This failure placed the residents at risk for foodborne illness from being served food that had not been stored at the proper temperature. The findings included: Observation on 4/02/23 at 10:00 AM revealed a row with one reach-in refrigerator unit and two reach-in freezer units. Observation of reach-in freezer unit #1 revealed an interior thermometer with a temperature of -4 degrees F. Freezer unit #1 contained vegetables in clear plastic bags and the vegetables were frozen solid. Observation of reach-in freezer unit #2 revealed an interior thermometer with a temperature of +25 degrees F. Freezer unit #2 contained cardboard boxes dated 3/29/23. The boxes were unevenly stacked to the ceiling of the freezer. A box contained sweet dough, which was thawed and soft, and a box contained beef steak fritters (meat patties) which were not frozen solid. In an interview on 4/02/23 at 10:02 AM, Cook D stated grocery delivery was received one time weekly on Wednesdays. She stated the grocery boxes dated 3/29/23 were from the delivery last week. The Cook left the kitchen through the door to the short hallway that led to the nurses' station. In an interview on 4/02/23 at 10:05 AM, Cook D stated she had called the DSM and she had not answered. She stated the DSM was good about calling back. Cook stated D stated she had talked with the nurses about the reach-in freezer unit, and they would try to reach the maintenance man. In an interview on 4/02/23 at 2:43 PM, the Administrator stated the Maintenance Director was trying to repair the reach-in freezer. In an interview on 4/02/23 at 2:48 PM, the DSM stated there had not been a problem with the end reach-in freezer unit #2 and it must have started during the past few days. She stated she would take all the food from the end freezer unit #2 and place it in the middle freezer unit #1 and in the chest freezer in the hallway storage room. The DSM stated she would defrost freezer unit #2. She stated if the freezer unit did not work after that it would need to be serviced. She stated the freezer was not older than 2 years. In an interview on 4/02/23 at 2:52 PM, the Maintenance Director stated the boxes of food in the reach-in freezer #2 were stacked too close together and too high and were blocking the fan. He stated the food needed to be removed and the freezer needed to be defrosted and then it should work ok. Observation and interview on 4/02/23 at 3:04 PM revealed a chest freezer was in the storage room located in the short hallway leading from the kitchen. The chest freezer had space for additional food from freezer unit #2 in the kitchen. A thermometer was not found inside freezer, but the food was frozen solid. The DSM stated she would place a thermometer in the chest freezer. A thermometer was observed on the wire rack shelf unit located to the left of the freezer. The DSM stated it probably belonged in the chest freezer. Observation on 4/03/23 at 9:43 AM revealed all food items had been removed from the reach-in freezer unit #2 and the unit had been defrosted. The fan blades in the interior ceiling had not yet been covered. Observation on 04/03/2023 at 9:43 AM of the reach-in freezer unit #1 revealed it contained food items, including the beef steak fritters, that had been removed from freezer unit #2. Observation and interview on 4/04/23 at 8:35 AM revealed reach-in freezer unit #2 was running and the interior thermometer temperature was 12 degrees F. The freezer remained empty at that time. The Maintenance Director stated he needed to replace the cover for the fan in the ceiling of the unit. In and interview and observation on 4/04/23 at 11:10 AM, the DSM stated she had gone to the store and had bought dinner rolls for the lunch meal today, due to throwing away the sweet dough that had not been frozen solid in freezer unit #2 on 4/02/23. She gave the frozen dinner rolls to an unidentified dietary staff member, who proceeded to place the frozen dinner roll dough on baking sheets and put them in the oven to bake. In an interview on 4/04/23 at 1:55 PM, the DSM stated she had 3 freezers, the 2 reach-in freezers in the kitchen and the chest freezer in the supply room. She stated freezer unit #2 was only about 2 years old. She stated she never had problems with reach-in freezer #1, and it was the oldest unit. She stated daily freezer temperatures were documented on the temperature log form. She stated she would look for a policy and procedure for maintenance of equipment and temperatures. Review of the daily freezer temperature log forms revealed columns for documenting temperatures 2 times daily, in the morning and in the evening. Review of the March 2023 daily temperature log for Freezer #1 revealed a temperature of -10 degrees F was consistently documented daily in the morning and the evening. Review of the March 2023 daily temperature log for freezer unit #2 revealed the documented morning and evening temperatures were above zero and ranged from 6 degrees F to 24 degrees F, except on 3/28/23 which documented -10 degrees F for both the morning and evening (possibly a documentation error). The documented morning temperature on 3/29/23 was 10 degrees, on 3/30/23 was 8 degrees, and on 3/31/23 was 11 degrees. No temperatures were documented for the evening on 3/29/23, 3/30/23, and 3/31/23. A policy and procedure for maintaining essential kitchen equipment, including checking and documenting refrigerator and freezer temperatures, was not provided as requested prior to exit.

Based on observation, interview, and record review, the facility failed to notify the state mental health authority promptly for resident review after a significant change in mental condition for two residents (Residents #21 and #55) with the PASRR screening and resident review (PASRR) program, of resident assessments reviewed for PASRR evaluations. The facility did not update the PASRR Level 1 forms for Resident #21 and Resident #55. This failure placed the residents at risk for not being evaluated for psychiatric conditions and not receiving needed PASRR specialized services for which they may be eligible. The findings included: Resident #21 Review of Resident #21's Face Sheet dated 04/02/2023 revealed she was admitted to the facility on [DATE] with Admitting diagnosis of schizoaffective disorder (mental disorder with abnormal thought process) and generalized anxiety disorder (persistent anxiety). Resident #21's additional diagnoses were added on 08/25/2022 and included Post traumatic stress disorder (behavioral disorder that develops after exposure to trauma). Review of Resident #21's Physician Orders dated 04/28/2022 revealed orders for Risperdal 0.5mg for bipolar and schizoaffective disorder. Review of Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #21 could understand others and was usually understood by others; had a mild cognitive impairment with a BIMS score of 8 out of 15. Review of Resident #21's Care Plan dated 03/23/2023 revealed complications associated with psychotropic medications and to monitor for target behaviors. Resident had behavioral problems and mood problems. Review of Resident #21's PASRR Level One Screening Forms dated 05/17/2021 revealed Resident #21 had a diagnosis and was positive for mental illness. An updated PL1 was not completed after a diagnosis of post-traumatic stress disorder was added on 08/25/2022. An updated PL1 was completed and resubmitted on 04/02/2023. Resident #55 Review of Resident #55's Face Sheet dated 04/02/2023 revealed she was admitted to the facility on [DATE] with Admitting diagnosis of generalized anxiety disorder (persistent anxiety). Resident #55's additional diagnoses were added on 08/25/2022 included psychotic disorder with delusions (mental disorder with paranoid delusions). Review of Resident #55's Physician Orders dated 04/28/2022 revealed orders for Seroquel 25 mg two times a day for psychotic disorder with delusions. Review of Annual MDS dated [DATE] revealed Resident #55 could usually understand others and was usually understood by others and had mild cognitive impairment with a BIMS score of 8 out of 15. Review of Resident #55's Care Plan dated 02/22/2023 revealed complications associated with psychotropic medications and to monitor for target behaviors. Resident had behavioral problems and mood problems. Review of Resident #55's PASRR Level One Screening Forms dated 07/10/2021 revealed Resident #55 had a diagnosis and was positive for mental illness. An updated PL1 was not completed after Seroquel was ordered for psychotic disorder with delusions. An updated PL1 was completed and resubmitted on 04/02/2023. In an interview on 04/02/2022 at 10:05 AM, the MDS Coordinator said that she thought she did not have to update a PL1 when the resident's condition changed. She stated she contacted her regional manager, and she informed her that it was to be updated if the resident's condition changed. Review of the facility's PASRR Policy and Procedures, dated 10/30/2017, revealed the following [in part]: Significant Change in status: If the resident's status has changed significantly enough from the initial reviewed status, they must have a new PASRR Level 1 to determine if they now are eligible for PASRR specialized services.

Based on observation, interview, and record review, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 4 residents (Residents #39) whose records were reviewed for assessments. 1) The facility failed to recognize and assess Resident #39's weight loss, IV medications while in the facility, decline in ADL's and a decline in Bowel and Bladder function. This failure placed residents at risk for not being assessed for a change in condition and the need to revise their care plans to address changes in condition and develop interventions to meet their needs for care assistance and treatments. The findings included: Review of Resident #39's Face Sheet, dated 04/04/2023, reflected Resident #39 was a [AGE] year-old female readmitted to the facility on [DATE]. The resident had Acute Respiratory Failure with Hypoxia (impaired gas exchange between the lungs and blood), Bacterial Infection (infection by microorganisms that invade the tissue), and malnutrition (lack of proper nutrition). Review of Resident #39's MDS assessments showed significant changes from her Quarterly MDS Assessment 10/09/2022 to her Quarterly MDS Assessment 11/29/2022 as follow: 1) The Quarterly MDS dated [DATE] section G revealed the resident had extensive assistance in dressing and was not steady but able to stabilize with staff assistance while moving from seated to standing position, was not steady but able to stabilize with staff assistance in walking, was not steady but able to stabilize with staff assistance in turning around, was not steady but able to stabilize with staff assistance in moving on and off toilet and was not steady but able to stabilize with staff assistance in surface to surface transfers. A wheelchair was used for mobility devices. The Quarterly MDS dated [DATE] section G revealed the resident had total dependance in dressing, activity did not occur in transfers, activity did not occur while moving from seated to standing position, activity did not occur in walking, activity did not occur in turning around, activity did not occur in moving on and off toilet and activity did not occur in surface-to-surface transfers. None of the above was used for mobility devices. 2) Resident had a significant weight loss from 10/09/2022 to 11/29/2022. The Quarterly MDS dated [DATE] section K revealed the resident weighed 195 with no significant weight loss or weigh gain coded. The Quarterly MDS dated [DATE] section K revealed the resident weighed 171 with no significant weight loss or weight gain coded. 3) Review of the MDS Quarterly assessment dated [DATE] revealed in Section O in treatments that the resident was not receiving IV Medications while in the facility and was receiving Oxygen Therapy while in the facility. Section N in medications revealed the resident received 0 days of Antibiotics, 7 days of Antidepressants and 7 days of Antianxiety. The MDS Quarterly assessment dated [DATE] revealed in Section O in treatments that the resident received IV Medications while in the facility and was not receiving Oxygen Therapy while in the facility. Section N in medications revealed the resident received 7 days of Antibiotics, 0 days of Antidepressants and 0 days of Antianxiety. Observation and interview on 04/02/2023 at 10:30 AM revealed Resident #39 was alone in her room lying in her bed. She stated that she had been doing much better after her recent hospitalization . In an interview on 04/02/2023 at 3:15 PM, the MDS Coordinator said that Resident #39 had a significant change and that a significant change assessment should have been completed within 14 days after the change. She said failure to do a significant change assessment could result in inadequate care areas and an appropriate care plan not being established. She said she did not know that she needed to complete a Significant Change Assessment with some of these areas and she had not realized she had more than one care area where the resident declined. She stated she knew the resident had a weight loss and she forgot to code it. She said that she was the one responsible for completing and the assessment and ensuring it was done accurately. Review of the facility's policy and procedure for Resident Assessment, dated 2003, revealed the following [in part]: A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument in (RAI). The assessment will include at least the following: Medically defined conditions and prior medical history Medical status measurement Physical and mental functional status Nutritional status and requirements Special treatments or procedures Drug therapy RAI assessments must be conducted within 14 days after the date of admission, probably after a significant change in the residence physical or mental condition as soon as the resident stabilizes at a new functional are cognitive level or within two weeks, whichever is earlier The results of the assessment are used to develop, review, and revise the residence comprehensive plan of care. Any individual who willing play knowingly certifies or causes another individual to certify immaterial and false statement in a resident assessment will be terminated in a septic to civil many penalties.

Based on interview and observation record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for 1 (Resident #1) of 6 resident reviewed for pain management. 1) The facility failed to ensure an ordered medication was given timely. Resident did not get pain medication for more than 24 hours. Resident #1 passed away shortly after the surveyor left the faciity on [DATE]. 2) There was no documented pain assessment after resident complained of pain in the presence of the surveyor. 3) There was no care plan for Resident #1 related to pain management. 4) The pain management section of his electronic clinical record was blank. There was no documentation of any kind reflecting pain status. 5) There was no record of Resident #1 change of condition after he complained of generalized pain on 01/03/2022; And the Responsible Party (RP) was not notified of Resident #1 pain issues or treatment. 6) Resident #1's facility physician was not contacted to prescribe needed pain medication after resident complained of pain. These failures could place residents on pain management at risk for unnecessary pain, discomfort and decreased quality of life. Findings include: Record review of a Resident #1 progress notes dated 01/04/22 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #1 understood others and made himself understood. The MDS indicated Resident #1 did have cognitive impairment (BIMS of 02). There were no behavioral issues noted. The MDS further indicated Resident #1 required extensive assistance with most ADL's including bed mobility, transfers, dressing, toilet use and personal hygiene. He was frequently incontinent of bladder and always incontinent of bowel. The MDS also indicated Resident #1 staff assessment for pain was blank denoting no pain. Record review of the MAR for Resident #1 dated 01/01/22 through 01/04/22 revealed no documentation or receipt of pain medication by Resident #1. There were as following: Aspirin 81 mg tablet-Give 1 tablet by mouth one time a day [MEDICATION(S)] tablet 25 mg-Give 0.5 tablet by mouth once a day. [MEDICATION(S)] Tablet 80 mg-Give 1 tablet by mouth at bedtime. [MEDICATION(S)] tablet 250 mg-Give 250 mg by mouth one time a day for pneumonia for 4 days. [MEDICATION(S)] tablet 500 mg-Give 500 mg by mouth one time a day for pneumonia for i day. [MEDICATION(S)] capsule 25 mcg (1000 UT)-Give 1 capsule by mouth one time a day. [MEDICATION(S)] tablet 75 mg by mouth daily [MEDICATION(S)] tablet 1000 mcg-Give 1 tablet by mouth one time a day. Daily multivitamins/Min tablet (multiple Vitamins -Minerals)-Give 1 tablet by mouth one time a day for supplement. [MEDICATION(S)] Sulfate Tablet delayed Release 325 mg (65FE) mg-Give 1 tablet by mouth once a day. [MEDICATION(S)] tablet 20 mg-Give 2 tablets by mouth one time a day. [MEDICATION(S)] Tablet 15 mg -Give 1 tablet by mouth at bedtime. [MEDICATION(S)] Tablet 25 mg ([MEDICATION(S)])-Give 1 tablet by mouth at bedtime related to paranoid. [MEDICATION(S)] Tablet 100 mg ([MEDICATION(S)] HCL)-Give 1 tablet by mouth one time a day related [CONDITION(S)]. [MEDICATION(S)] Tablet 50 mg ([MEDICATION(S)] HCL)-Give 1 tablet by mouth one time a day related [CONDITION(S)]. [MEDICATION(S)] tablet 500 mg-Give 1 tablet by mouth two times a day for pneumonia for 1 day. Prostat AWC-Give 30 ml two times a day for weight loss. MedPass 2.0-Give 120 ml three times a day for weight loss. [MEDICATION(S)]-[MEDICATION(S)] Tablet 25-100 mg-Give 1 tablet by mouth four times a day related to [CONDITION(S)] disease [MEDICATION(S)] Tablet 0.5 mg (lorazepam)-Give 1 tablet by mouth every 24 hours as needed for Anxiety: Agitation for 14 day These 2 medications were documented and given after Surveyor made facility away of Resident #1 pain condition. [MEDICATION(S)] Sulfate (concentrated) Solution 20 mg/ml-Give 1 ml by mouth every 2 hours as needed for severe pain/SOB. Tylenol with [MEDICATION(S)] #3 Tablet 300-30 mg (Acetaminophen-[MEDICATION(S)])-Give 1 tablet by mouth every 4 hours as needed for Pain until [MEDICATION(S)] comes. Review of Resident #1's care plan dated 01/04/22 revealed no pain assessment reflected. Record review of progress notes for Resident #1 on 01/03/22 revealed, he did not receive pain medication after he complained of pain. He was observed with signs of pain including facial grimacing, moaning, crying, restlessness, constant shifting in bed, and confirmed his pain condition to LVN A and the surveyor. On Observations on 01/03/22 at 10:49a.m, surveyor entered Resident #1 room to check on his condition based on report of possible fall incident. He was found with lacerations on his left shin. Resident #1 was covering his pelvic areas with his hands. He was grimacing, crying, moaning, restless, agitated, and constantly shifting in bed to avoid LVN A touching. Resident #1 said he was in pain. Surveyor asked the resident the location of the pain. He said it was all over-generalized pain. LVN A stated Resident #1 was on hospice and they would get his pain medication. Meanwhile, surveyor called the DON to report the state of resident pain condition. She came to the Resident #1's room to see his restlessness due to pain. He did not calm down. Observations on 01/04/22 at 11:20a.m. Surveyor entered Resident #1's room (a day after initial contact), he was still in pain, grimacing, restless, moaning and agitated. He verbalized generalized pain. Review of MAR and Nurse's notes dated 01/03/22 revealed Resident #1 did not get pain medication. Resident #1 has gone more than 24 hours without pain relief according to his MAR. There was no documented non-pharma logical pain management or relief documented. Interview with LVN C on 01/04/2021 at 11:53a.m, revealed she was from an agency working in the facility for the first time. She said she was responsible for Resident #1's care today. She was asked if she was informed of Resident #1's pain condition during the change of shift. LVN C said she was not told. She stated the outgoing nurse informed her Resident #1 was receiving antibiotics for pneumonia and had a skin tear on the elbow. She explained there was no mention of pain. She said the resident was not complaining of pain when she gave him his morning medications. In an interview with RN F on 01/04/22 at 1:54p.m, she said she was the MDS nurse. She stated she was not aware of Resident #1 pain status until surveyor raised the issue. RN F said after encounter with the surveyor, she went to talk to LVN A. She informed LVN A that a pain assessment was needed to be done on Resident #1. LVN A told RN F she was going to call RNE (hospice nurse). During an interview with CNA B on 01/04/22 at 2:04p.m, she said she was familiar and takes care of Resident #1 during the evening shifts. She explained Resident #1 had been in a lot of pain and appears to be declining. She said he will ask you to get him up out of bed and the next few minutes wants to get back to it. The aide said, when asked, that the nurses were aware of his pain because she told them each time the resident complained of pain. She was asked to be specific on who she told about Resident #1 pain condition. She explained that the facility has been using agency nurses, a different one every day. She said she thought resident was receiving pain medication. She was asked how long Resident #1 had been complaining of pain? She stated about 3-4 months and his condition has been progressively worse including having problem breathing. She stated tells the resident's charge nurse to give breathing treatment when he has problems. The aide was asked what she was doing to help Resident #1 with pain. She said, she tried to reposition the resident as much as possible. The aide said the resident was walking when he was first admitted to the facility. He almost always takes smoke breaks. He started using wheelchair and now requires total assistance with most Activity of daily living (ADLs). CNA B was told by surveyor that Resident #1 has not been receiving pain medications according his medication administration record (MAR). She said she was surprise he had not been receiving pain medication all this time. In an interview with LVN A on 01/04/22 at 1:52p.m, she said she did not know that Resident #1 was in pain. She knew when she came to the resident's room with surveyor. She said Resident #1 said his pain was all over. She explained she was told by the DON to call the hospice nurse (RN E) for pain medication. She called RN E who said she was going to call the Doctor. She made another call to RN E. RN E informed her she was waiting on the hospice physician to call back. LVNA was asked if resident had an ordered pain medication, she said he did not. During interview with RNE on 01/04/22 at 2:11p.m, she said she was the hospice nurse for Resident #1. RN F explained LVN A called her on 01/03/22 at 2:10p.m requesting stronger pain medication to be ordered because the Tylenol was not working. RN E was asked if she ordered pain medication for Resident #1 prior to LVNA's recent call. RN E explained she received a verbal order of extra strength Tylenol (every 8 hours as needed) on 12/31/21 which she gave to LVN A. She said the resident should have be getting the Tylenol when told by surveyor there was no such orders in Resident #1's MAR. RN E said she was waiting to hear from the Hospice physician for pain medication of [MEDICATION(S)] and [MEDICATION(S)]. On further interview with LVN A on 01/06/22 at 11:11a.m, she acknowledged Resident #1 had complained of pain a few days before surveyor made an entrance to the facility. This was contrary to what she told the surveyor on 01/03/22 at 1:52p.m. She was asked why she did not give Resident #1 the extra strength Tylenol ordered by RN E. LVN A said she did not put the order on the MAR and forgot to give it. She said she did not think the hospice would take too long to order the stronger pain medication. LVN A acknowledged she should have called the facility doctor, PH Z, for an order and retrieve the pain medication from the emergency kit. During interview with the Responsible Party (RP) on 01/06/22 at 10:42a.m, she said she was a family of Resident #1. She stated she did not know Resident #1 was in pain and was not notified by the facility. RP explained the facility called on several fall incidents but not for the pain condition. In an interview with the facility physician, PH Z, on 01/06/22 at 10:58 a.m., he said he was the facility doctor for Resident #1. He stated the facility did not call him to order pain medication. The doctor explained Resident #1 was placed on hospice and the agency was in control of his treatment. He said Resident #1 had multiple terminal illnesses including chronic obstructive pulmonary disease ([CONDITION(S)]). During interview with PH Y on 01/10/22 at 11:55a.m, she said she was the hospice doctor for Resident #1. She stated she ordered extra strength Tylenol for the resident and RN E stated it was adequate to manage his pain according to LVN A. She received a call to order a stronger medication which she did. PH Y was asked the timeline of when she gave the medication orders. She said she did not have that information, but would call the Director of Hospice to call me. On 01/11/22 at 10:50 a.m., the Director of the Hospice agency called back. She explained PH Y ordered extra strength Tylenol on 12/31/22 and LVN A stated it was controlling the pain. LVN A notified the facility on 1/03/22 that she did not know how long the Tylenol will sustained Resident #1 and needs stronger pain medication. PH Y ordered [MEDICATION(S)] and RN E went to see Resident #1 on 01/04/22. Resident #1 passed away shortly after RNE visit. During interview with DON on 01/04/22 at 12:32p.m, she acknowledged the surveyor notified her about the Resident #1's complains of pain. She explained she told LVN A to get the resident some medication for pain. The DON was asked the facility protocol on pain management of residents. She explained when a resident complains of pain, the charge nurse assesses the resident. The resident is given the medication if it was already ordered. The physician is called, and order received for the pain medication. The nurse retrieves the medication from the emergency kit if not available. She said LVNA failed to follow the facility policy. The DON was told that RN E gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she was not aware until the surveyor informed her. Review of the facility policy on pain management revised May 25,2016 revealed the following: Policy Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Procedure 1. Assess resident's physical symptoms of pain, physical complaints, and daily activities. Pain questions based on a resident's communication ability ware included in the Admission/Readmission and Weekly Nursing Summary. If a resident is verbal, the new questions will be identical to the questions asked on the MDS. If a resident is non-verbal, the questions will be a PAINAD assessment. If the MDS QM Pain criteria is met, a Pain SBAR will be triggered. There is no QM criteria for a resident who is non-verbal. If a resident scores 7-10 on the PAINAD scale, then a PAIND SBAR will be triggered. It is directed toward residents who are non-verbal or cannot communicate. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects. PRN - if the resident complains of pain the nurse will assess, implement relief measures as ordered and/or care planned. 2. Perform comfort measures to promote relaxation. 3. Plan activities with the resident to provide distraction, such as reading, crafts, television, or visits, to help resident focus on non-pain related matters. 4. Manipulate the environment to promote periods of uninterrupted rest as much as possible. This promotes health, well-being, and increased energy level important to pain relief. 5. Apply heat or cold as ordered (specify) to minimize or relieve pain.

Based on observation, interview, and record review the facility failed to provided adequate supervision and assistance to prevent accidents for 1 of 8 residents (ID #1) reviewed for accidents and supervision of devices, by failing to ensure: A. 1 of 1 CNAs (CNA B) used the Hoyer lift in accordance with the manufacturer's operating instructions and the facility policy when assisting resident ID #1 out of a wheelchair. Resident ID# 1 sustained a fall during the transfer on 1/28/2017 and was transported to the hospital for an evaluation and found to have sustained a right subdural hematoma. The facility's failure resulted in harm for Resident #1 and could affect any of the 12 residents requiring the Hoyer by placing them at risk for avoidable injury, hospitalization and even death. The findings included: Resident ID #1 Record review of resident ID #1's February Physician Orders, dated 02/01/2017 through 02/28/2017 documented she was an [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The physician's orders [REDACTED]. Record review of resident ID #1s Quarterly MDS Assessment, dated 12/03/2016, documented the following: She scored 9/15 (moderately impaired) for cognitive status; extensive assistance with the support of one persons for bed mobility, total dependence with 2 staff for transfers; activity did not occur for ambulation. Record review of resident ID #1's Comprehensive Plan of Care for risk for alteration in mobility, dated 12/07/2016, documented she required the Hoyer lift for transfers. Record review of the facility's Provider Investigation report, dated 01/31/2017, documented the following (in part): Incident date 01/28/2017 at 8:00 pm, Summary: Resident was being transferred via Hoyer lift by CNA B. Sling strap ripped in a straight line across causing the resident to fall and hit head causing hematoma to left back of head and skin tear to left forearm and right lower leg. Assessment: vitals and neurochecks within normal limits. Resident sent to emergency room per MD. The report contained a witness statement from CNA B and documented the following statement: CNA B walked into resident ID #1's room at 8:00 PM. Alerted another CNA to help transfer resident onto the bed. CNA B hooked the Hoyer pad to lift and raised resident a couple of centimeters from her chair and stopped to wait for help. The wheelchair rolled back. The Hoyer pad strap ripped and CNA B tried to catch the fall. Resident ID #1 fell and hit her head. Statement was signed by CNA B. Record review of the Facility's Accident/Incident Report documented by RN A, dated 01/28/2017. The incident occurred at 8:00 PM involved resident ID #1 and the use of a Hoyer lift. The report documented during transfer with Hoyer lift, Hoyer pad strap broke and resident fell to ground. Resident was alert and no loss of consciousness. Resident was assessed for injury and vital signs taken. Injury to scalp, left forearm and right lower leg. Physician and family notified. Measures were put in place to in-service all staff on proper transfer techniques with Hoyer lift policy and procedure. Record review of resident ID #1's Progress Notes, dated 01/28/2017, documented the following (in part): CNA B notified nurse resident fell during transfer using Hoyer lift. Upon entering resident room, observed resident on floor sitting on buttocks. Skin tear to left forearm, to right lower leg and baseball size hematoma to left back occipital region. Skin tear to left forearm and right leg cleaned with normal saline and dressed with gauze. Neurochecks initiated and vital signs taken. Physician notified and orders to send to emergency room . Record review of resident ID #1's January Physician Order, dated 01/28/2017, documented an order to send resident to the emergency room for evaluation. Record review of resident ID #1's hospital History and Physical, dated 01/28/2017, documented the following (in part): [AGE] year-old female status [REDACTED]. CT brain shows small right subdural hematoma. She is on Plavix for history of cerebral vascular accident. Assessment to hold Plavix for at least two weeks and admit for observation. Record review of resident ID #1's hospital CT brain scan, dated 01/28/2017, documented the following (in part): Left posterior parietal scalp hematoma. No mass effect, edema, midline shift or acute intracranial hemorrhage. The osseous structures are intact. Follow up CT brain scan dated 01/29/2017, documented stable posterior left scalp hematoma. In an observation and interview on 02/11/2017 at 9:10 AM, Resident ID #1 was sitting in her wheelchair with a Hoyer pad under her. She had red/purple bruising on the left side of her head from the hair line, behind her left ear and on her neck. She had a dressing to her left forearm and a small abrasion noted to her right leg. Resident ID #1 stated she sustained bruising to her head, neck and skin tears from a fall from a Hoyer lift. She stated she was sitting in the wheelchair on the Hoyer pad and wanted to go to bed. CNA B hooked the pad to the lift and left the room to get help. She stated when she returned to the room she told the CNA she could put her to bed by herself. CNA B lifted resident ID #1 up out of the wheelchair and the strap broke and she fell to the floor landing on her left side. She stated she was not unconscious but her head hurt. She stated the nurse came in and they sent her to the hospital. She stated that was the first time one staff operated the lift. In an interview on 02/11/2017 at 10:45 AM, the DON stated when she questioned CNA B what happened, CNA B told her she was assisting resident ID #1 for bed and left the room to get another staff for help. She stated CNA B told her she hooked the pad to the lift and raised the resident out of the wheelchair a few inches and the sling broke and the resident fell to the floor. She stated CNA B then stated she may have raised the resident a little higher. She stated she questioned CNA B on policy of two staff required to use Hoyer lift and CNA B stated I know and do not know why I didn't wait for help. She stated CNA B was suspended for not following facility policy and then terminated after the facility conducted the investigation. The DON stated the strap broke from the Hoyer pad; the break was a clean break and did not have frayed edges. She stated they threw the pad away. She stated she did not have any record of how often the Hoyer pads are checked but staff and laundry staff let her know when there was a pad that looks defective. The DON stated all staff were in-serviced on how to use the Hoyer lift when hired, annually and always if there was a concern with transfers. In a telephone interview on 02/11/2017 at 1:00 PM, CNA B stated she went to get an aide to assist with putting resident ID #1 to bed. She stated the aide was busy with another resident and would be there in a minute. She stated she went back into resident ID #1's room and hooked the Hoyer pad to the lift. She stated resident ID #1 was getting agitated and wanted to go to bed so she thought if she lifted the resident up just a little out of her wheelchair resident ID #1 would calm until the staff came to help. She stated when she raised the resident up and the strap broke, the wheelchair was not locked and started to roll away. CNA B stated she tried to stop the wheelchair from rolling and the resident went over the back of the wheelchair and hit the floor. CNA B stated she was in-serviced on how to operate the Hoyer lift when she was hired at the facility. She stated she was hired August of 2016. She stated she knew 2 staff were required to operate Hoyer lift and she should have waited for help. In an interview on 02/21/2017 at 2:20 PM, RN A stated she was not aware CNA B was in resident ID #1's room until she came and told her resident ID #1 had fallen. She stated resident ID #1 sustained a hematoma to the back left side of her head, skin tear to the left forearm and skin tear to the left leg. She stated the physician was notified and orders to transport resident ID #1 to the hospital for a evaluation. Record review of In-service records titled Initial Nurse Aide Performance Review, dated 08/31/2016, documented CNA B's name on the mechanical lift training skills check off sheet. In-service record titled Proper transfer technique, policy for Hoyer lift, dated 12/26/2016, documented always use 2 people for Hoyer lift and CNA B's name was documented in attendance to the in-service. Record review of the facility's accident/incident reports from the past year did not identify any Hoyer lift incidents prior to resident ID #1's incident involving the Hoyer lift. Record review of the Facility's policy titled Mechanical Lift, dated 06/2012, documented the following (in part): It is the policy of this home to utilize the Hoyer (or similar) lift when it is necessary to safely transfer a resident due to body weight or physical condition. The specific product utilized may vary according to the manufacturer's recommendations. Lifting a resident with a mechanical lift is always a two person procedure. The policy also documented to position wheelchair and lock brakes. Manufacturer's operating instructions for the Hoyer lift, not dated, documented the following (in part): Always check slings before use. If the patient is in a wheelchair, secure the wheel locks in place to prevent the chair from moving forwards or backwards. Wheelchair wheel MUST be in a locked position. When elevated a few inches off the surface of the stationary object (wheelchair or be) and before moving the patient, check again to make sure threat the sling is properly connected. If any attachments are not properly in place, lower the patient back onto the stationary object and correct this problem. Bleached, torn, cut frayed or broken slings are unsafe and could result in serious injury or death. Discard immediately. Regular maintenance of patient lifts and accessories is necessary to assure proper operation. The operating instructions documented recommends two assistants be used for all lifting and transferring procedures. Record review of the facility Resident Bed List Report, dated 02/11/2017, documented 12 residents currently requiring the Hoyer lift for transfers.

Based on observation, interview, and record review the faciltiy failed to immediately consult with the resident's physician; and notify the resident's legal representative or an interested family member when there was a change of condition and need to alter treatment for 2 (resident # 1 and # 3) of 7 residents reviewed for blood sugar monitoring and diabetic care. Residents # 1 had seriously low, under 6o, BBG results on repeated occasions during October and November 2014, without the physician being notified, according the physicians order, or the facility policy; with resident # 1 continuing to receive routinely ordered insulin, oral hypoglycemic's and the physician-ordered amounts of sliding scale insulin. Resident # 1 became unresponsive to verbal stimuli on 11/29/14 then her BBG dropped to 20 during her transfer to the emergency room where she continued in serious condition on a ventilator. Resident # 3 had elevated BBG results without the physician being notified, according to facility policy, placing resident # 3 at risk for hyperglycemic coma and other serious effects of [MEDICAL CONDITION] including death. LVN A, who conducted the BBG tests and documented the low results for resident # 1 did not notify resident # 1's physician, family or the facility DON of the low readings. An Immediate Jeopardy (IJ) was identified on 12/05/14. While the IJ was removed on 12/08/14, the facility remained out of compliance at a level of isolated actual harm that is not IJ because the facility administrative staff had not had time to implement policies and procedures and, the facility was still in-servicing staff as part of the implementation of the Plan of Removal. These failures to ensure diabetic residents with abnormal blood sugar levels were being reported to their physicians and properly re-assessed placed the facility's 20 insulin receiving diabetics at risk for a decline in their health and well-being without properly reporting hyper/[DIAGNOSES REDACTED] and being treated accordingly, which could then result in [MEDICAL CONDITION], coma, brain and organ damage and death (www.medscape.com/multispecialy). The findings included: Resident # 1: Record review of the physicians orders dated 11/01/14 - 11/30/14 documented resident # 1 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the physicians orders dated 11/01/14 - 11/30/14 documented resident # 1 was to have her blood sugar checked 4 times a day and the physician was to be notified of any values less than 60 or greater than 400. The physicians orders documented resident # 1 was to receive [MEDICATION NAME] (long acting) insulin 20 units subcutaneous daily, [MEDICATION NAME] R (fast acting) insulin 4 times a day per sliding scale, the dose was dependent on results of the BBG's. Resident # 1 also received [MEDICATION NAME] (oral hypoglycemic) 1000 mg by mouth daily. Record review of the Quarterly MDS dated [DATE] for resident # 1 documented in section C resident # 1 was rarely or never understood. Section G documented resident # 1 was totally dependent with 2 person assistance for most of her ADL care, she required limited assistance with 1 person assisting her with eating. Record review of the careplan dated 9/25/14 documented resident # 1 had diabetes mellitus that required blood sugar monitoring as ordered and PRN with physician notification as indicated. Observation of resident # 1 on 12/04/14 at 12:00 PM, at a local hospital revealed she was in bed, on a ventilator. Her daughter was present. Interview on 12/04/14 at 12:00 PM resident # 1's daughter said resident # 1 had been a diabetic for several years, she had been more controlled until lately, she now was less controlled and required more insulin. Resident # 1's daughter said the facility had been good to call her about resident # 1's needs, resident # 1 had been wheelchair bound, requiring 2 persons to help her transfer and toilet. She sat at the assisted feeding table. Resident # 1 did not ea dinner the day she was hospitalized , the facility had let her lay down, knowing how severe her diabetes was. They called her at exactly 7:49 PM because resident # 1 was being sent to the hospital, the hospital social worker said resident # 1's blood sugar was 16 when she arrived. {Normal BBG (finger stick blood sugar) per local hospital lab is 60 -130 mg/dl} Clinical record review of the nurses notes dated 11/29/14 at: - 9:00 AM documented resident # 1 was given a pain medication for her complaint of leg pain. - 1:00 PM the notes documented her the medication was effective. - 5:00 PM resident # 1 was documented to be responsive to tactile stimuli, she had increased drooling, her BBG was 104, B/P 94/58, pulse 72. - 7:30 PM LVN "B" documented she went to check resident # 1's BBG, resident # 1 was not responsive to verbal/tactile stimuli, breath was short, shallow with stridor present bilateral upper lobes. B/P was 162/89, pulse 67, temperature 98.2, respiration 12, O 2 was 91%. The on call doctor was paged. - 7:45 PM the doctor returned the call and ordered resident # 1 be sent to the emergency room , the ambulance was called and a message was left for the family. - 8:00 PM ambulance arrived and resident was transported to the hospital. - 8:15 PM residents daughter returned call. Record review of the MAR indicated [REDACTED]. At 12:30 PM the MAR indicated [REDACTED]. The blood sugars were circled for 5:30 PM and 8:00 PM. The back of the MAR indicated [REDACTED]. Continued review of the BBG record for resident # 1 documented abnormal findings of BBG of: - 27 on 11/28/14 at 7:15 AM with 30 grams of carbs and breakfast being given and a recheck at 8:30 BBG was 142. No physician notification was documented. - 30 on 11/25/14 at 7:30 AM with 30 grams of carbs and breakfast being given and a recheck at 8:30 BBG was 134. No physician notification was documented. - 31 on 11/22/14 at 7:15 AM with 30 grams of carbs and breakfast being given and a recheck at 8:30 BBG was 144. No physician notification was documented. - 30 on 11/18/14 at 7:30 AM with 30 grams of carbs and breakfast being given and no recheck value was documented. No physician notification was documented. - 26 on 11/14/14 at 7:30 AM with 30 grams of carbs and breakfast being given and a recheck at 8:30 BBG was 151. No physician notification was documented. - 52 on 11/12/14 at 7:15 AM with 30 grams of carbs and breakfast being given and no recheck value was documented. No physician notification was documented. - 29 on 11/04/14 at 7:30 AM with 30 grams of carbs and breakfast being given and a recheck at 8:30 BBG was 79. No physician notification was documented. - 28 on 10/30/14 at 7:30 AM with 30 grams of carbs and breakfast being given and a recheck at 7:15 BBG was 42, an additional 15 grams of carbs was given, the BBG at 8:10 AM was 110. No physician notification was documented. - 25 on 10/24/14 at 7:30 AM with 30 grams of carbs and breakfast being given. There was no documentation of a recheck or physician notification. - 52 on 10/21/14 at 7:30 AM with 15 grams of carbs and breakfast being given. There was no documentation of a recheck or physician notification. - 26 on 10/11/14 at 12:30 AM there was no documentation of intervention or physician notification. - 38 on 10/06/14 at 7:30 AM with 30 grams of carbs and breakfast being given. There was no documentation of a recheck or physician notification. - 46 on 10/05/14 at 7:30 AM with 30 grams of carbs and breakfast being given. No physician notification was documented. - 60 on 10/02/14 at 7:30 AM there was no documentation of intervention or physician notification. Continued review of the BBG's for resident # 1 also documented abnormal high values for resident # 1 of 450 on 11/14/14 at 12:30 PM and a value of 446 was documented on 11/21/14 at 8:00 PM no documentation of physician notification. Clinical record review of the physicians notes and nurses notes did not document any physician notification of the abnormal BBG values for resident # 1 during the months of October and November 2014. In a telephone interview on 12/05/14 at 1:27 PM resident # 1's physician said he had not been made aware of any abnormal BBG's for resident # 1, he said the facility nurses did not communicate residents needs, the nurse just says no concerns; he makes his rounds and the nurse tells him there are no new concerns. Resident # 1's physician said he could not treat if he was not made aware of problem. Record review of the physicians progress note dated 10/30/14 documented resident # 1 was seen by her physician that day, resident # 1 was documented to be a poor historian. The nurse reported resident # 1 was doing well with no concerns. The physician documented resident # 1 had left lower limb [MEDICAL CONDITION] and she was to be sent to the ER to rule out [MEDICAL CONDITION] and resident # 1 was to start physical therapy. The physician progress notes [REDACTED].# 1 was seen by her physician, the note documented resident # 1's case was discussed with the nurse who did not have any questions or concerns. Interview on 12/04/14 at 2:40 PM CNA "F" said resident # 1's blood sugar got low a lot, the staff were trained to report changes in condition. Interview on 12/05/14 at 11:15 AM CNA "E" said resident # 1 had to be fed that day (11/29/14), she usually fed herself and resident # 1 had not been normal for a few days, she had reported it to the charge nurse. CNA "E" said it was normal for resident # 1 to lay down after lunch and if she was fussy they would get her back up. Interview on 12/05/14 at 11:35 AM PM "D" said resident # 1 was unresponsive when they arrived, the facility reported her last BBG was 72, she had a BBG of 20 on the ambulance; it had been extremely hard to get an IV started on resident # 1. Record review of the ambulance transfer notes documented resident # 1 was unresponsive when they arrived, the nursing staff reported a BBG of 72. The report documented the facility staff reported resident # 1 had moist lung sounds, she did not eat supper, and she have possible aspirated; her oxygen saturation level was 84%. The report documented at 7:52 PM a BBG of 20. The report documented difficulty starting an IV. Interview on 12/05/14 at 12:35 PM LVN "C" said on 11/29/14 resident # 1's BBG was 104 at suppertime, resident # 1 was drowsy, she had [MEDICATION NAME] and [MEDICATION NAME] earlier, and they put resident 1 to bed. Resident # 1 did not eat supper, they kept her tray to reheat and feed her later because resident # 1 would not eat. Resident # 1's BBG was then decreased to 84. At 7:30 PM resident # 1's BBG was around 73 when she found resident # 1 unresponsive. LVN "C" said she assessed resident # 1, called her doctor and had the staff get her ready to go to the hospital. Interview on 12/05/14 at 12:35 PM CNA "B" said resident # 1 gets out of bed in the mornings, she brushes her own teeth and drinks coffee. The day she went to the hospital she didn't do any of that, she would rouse but she was much quieter. Resident # 1 would usually help them move her but that day she was just dead weight. Resident # 1 had snacks in her room, she always got snacks; she ate sugar free pudding at 10:00 AM that morning. CNA "B" said resident # 1 ate breakfast that day and someone attempted to feed resident # 1 lunch, then she was put to bed. CNA "B" said she reported to the nurse, stating it may have been LVN "A", that resident # 1 had not voided that day and the nurses did not always take them seriously. Interview on 12/05/14 at 12:35 PM LVN "C" said on 11/29/14 resident # 1's BBG was 104 at suppertime, resident # 1 was drowsy, she had [MEDICATION NAME] (anti-anxiety medication) and [MEDICATION NAME] (pain medication) earlier, and they put resident # 1 to bed. Resident # 1 did not eat supper, they kept her tray to reheat and feed her later because resident # 1 would not eat. Resident # 1's BBG was then decreased to 84. At 7:30 PM resident # 1's BBG was around 73 when she found resident # 1 unresponsive. LVN "C" said she assessed resident # 1, called her doctor and had the staff get her ready to go to the hospital. In a telephone interview on 12/05/14 at 1:59 PM LVN "A" said she did notify resident # 1's physician when resident # 1's BBG was too low. LVN "A" said she would fax the doctor and she called. The physician would not respond, one time he asked if the blood sugar came up. LVN "A" said no, she did not document contacting the physician and the facility did not keep faxes that were sent to the physician, if orders were received they would write the orders on a phone order sheet and throw away the fax copy. LVN "A" said she did not make the Medical Director aware of the concerns with resident # 1's blood sugar. Record review of the facility policy dated 1/2008 for Nursing Care of Diabetic Residents documented the residents physician was to be notified of finger stick blood sugars (BBG's) greater than 300 or less than 70, unless the physician ordered specific parameters for the individual resident. In a telephone interview on 12/06/14 at 4:30 PM resident # 1's daughter said she had never been made aware of resident # 1's blood sugar falling too low, the facility contacted her about falls and those things but never about blood sugars. Interview on 12/08/14 at 10:40 AM the DON said she had not been made aware of the low blood sugars resident # 1 had been experiencing. Resident # 3: Record review of the physicians orders dated 11/01/14 - 11/30/14 documented resident # 3 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The orders documented resident # 3 received [MEDICATION NAME]13 units subcutaneous daily at 8:00 AM and Humalog Insulin subcutaneous daily: 6 units at 7:30 AM, 8 units at 12:30 PM, 9 units at 5:30 PM with additional doses of the Humalog insulin to be given 4 times a day per sliding scale. with additional BBG's to be done at 12:00 and 3:00 AM. There were no orders for parameters on the BBG's. Record review of the BBG log for resident # 3 documented he had the following elevated blood sugars: - 458 on 11/02/14 at 7:30 AM, 430 at 5:30 PM - 470 on 11/03/14 at 12:30 PM - 411 on 11/05/14 at 5:30 PM - 489 on 11/09/14 at 8:00 PM - 414 on 11/10/14 at 12:30 PM - 435 on 11/11/14 at 12:30 PM - 487 on 11/15/14 at 5:30 PM, 491 at 8:00 PM - 451 on 11/16/14 at 12:30 PM, 474 at 8:00 PM - 484 on 11/17/14 at 8:00 PM - 450 on 11/22/14 at 5:30 PM - 458 on 11/26/14 at 12:30 PM - 457 on 11/27/14 at 5:30 PM - 454 on 11/28/14 at 5:30 PM Clinical record review for resident # 3 of the November nurse notes, physician orders and progress notes did not document any physician notification of the high blood sugar reading for resident # 3. Observation and interview on 11/05/14 at 11:30 AM resident # 3 was in his wheel chair, in his room, he was alert and oriented and self propelled his wheel chair. Resident # 3 said his blood sugars were checked before each meal and at bedtime, the nurses were very good to explain to him what his sugar was and how much insulin he was getting. Record review of the Quarterly MDS dated [DATE] for resident # 3 documented in section C resident # 3 was alert and oriented with a BIMS score of 09. Section G documented he required 1 person assistance with his ADL's. This was determined to be Immediate Jeopardy (IJ) on 12/05/14 at 2:30 PM, the Administrator and the DON were notified at that time. The following Plan of Removal for the Immediate Jeopardy was accepted on 12/08/14 at 12:30 PM Issues identified: Failure to notify physician of a change in residents condition. 1. The facility Medical Director was notified of the Immediate Jeopardy of the home on 12/05/2014 at 3:15 PM. 2. The DON/designee immediately audited all diabetic residents glucose log to determine if all residents testing high or low were reported to the physicians. 3. All glucometers were calibrated by the DON/designee and the nightly checks were ongoing on the 10 - 6 shift to determine if the unit was functioning properly. 4. All nursing staff on duty were educated immediately by the DON on the following: - Notification of the the physician for a change of condition to include hypoglycemic and hyperglycemic events. Employees not working will be educated prior to working their next shift. - Observation and identification of change of condition with reporting on the 24 hour report. - Licensed nurses were instructed to document changes of condition in the clinical record in addition to documenting on the 2 hour report communication tool, i.e. falls, GI distress, respiratory distress, blood sugar changes,etc.. Nurses were being inserviced on when to call the physician and when it was appropriate to fax. All communication with the physician was to be charted. - All CNA's were educated immediately by the DON to: report all changes in condition to the DON as well as the charge nurse. On Monday 12/08/14 at 12:30 PM the plan of removal was accepted and the IJ was removed; the facility remained at a level of isolated actual harm that is not IJ because the facility administrative staff had not had time to implement policies and procedures and monitor the effectiveness outlined in their Plan of Removal. In an interview on 12/08/14 at 11:00 AM the DON said there were 20 insulin dependent residents living in the facility.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for two (Residents # 1, #3) of 8 residents reviewed for assessments related to blood sugar results. Residents # 1 had low, under 60, BBG results on repeated occasions during October and November 2014, without the physician being notified, according the physicians order, or the facility policy; with resident # 1 continuing to receive routinely ordered insulin, oral hypoglycemic's and the physician-ordered amounts of sliding scale insulin. Resident # 1 became unresponsive to verbal stimuli on 11/29/14 then her BBG dropped to 20 during her transfer to the emergency room where she continued in serious condition on a ventilator. Resident # 3 had elevated BBG results without the physician being notified, according to facility policy. LVN A, who conducted the BBG tests and documented the low results for resident # 1 did not notify resident # 1's physician, family or the facility DON of the low readings. An Immediate Jeopardy (IJ) was identified on 12/05/14 at 2:30 PM. While the IJ was removed on 12/08/14 at 12:30 PM, the facility remained out of compliance at a level of isolated actual harm that is not IJ because the facility administrative staff had not had time to implement policies and procedures and, the facility was still in-servicing staff as part of the implementation of the Plan of Removal. These failures to ensure diabetic residents with abnormal blood sugar levels were being reported to their physicians and properly re-assessed placed the facility's 20 insulin receiving diabetics at risk for a decline in their health and well-being without properly reporting hyper/[DIAGNOSES REDACTED] and being treated accordingly, which could then result in coma, brain and organ damage and death. The findings included: Resident # 1: Record review of the physicians orders dated 11/01/14 - 11/30/14 documented resident # 1 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the Quarterly MDS dated [DATE] for resident # 1 documented in section C resident # 1 was rarely or never understood. Section G documented resident # 1 was totally dependent with 2 person assistance for most of her ADL care, she required limited assistance with 1 person assisting her with eating. Record review of the careplan dated 9/25/14 documented resident # 1 had diabetes mellitus that required blood sugar monitoring as ordered and PRN with physician notification as indicated. Record review of the physicians orders dated 11/01/14 - 11/30/14 documented resident # 1 was to have her blood sugar checked 4 times a day and the physician was to be notified of any values less than 60 or greater than 400. The physicians orders documented resident # 1 was to receive [MEDICATION NAME] (long acting) insulin 20 units subcutaneous daily, [MEDICATION NAME] R (fast acting) insulin 4 times a day per sliding scale, the dose was dependent on results of the BBG's. Resident # 1 also received [MEDICATION NAME] (oral hypoglycemic) 1000 mg by mouth daily. Observation of resident # 1 on 12/04/14 at 12:00 PM, at a local hospital revealed she was in bed, on a ventilator, resident # 1 appeared comfortable. Her daughter was present. Resident # 1 would open her eyes and look at her daughter. Interview on 12/04/14 at 12:00 PM resident # 1's daughter said resident # 1 had been a diabetic for several years, she had been more controlled then, she now was less controlled and required more insulin. Resident # 1's daughter said the facility had been good to call her about resident # 1's needs, resident # 1 had been wheelchair bound, requiring 2 persons to help her transfer and toilet. She sat at the assisted feeding table. Resident # 1 did not eat dinner the day she was hospitalized , the facility had let her lay down, knowing how severe her diabetes was. They called her at exactly 7:49 PM because resident # 1 was being sent to the hospital, the hospital social worker said resident # 1's blood sugar was 16 when she arrived. {Normal BBG (finger stick blood sugar) per local hospital lab is 60 -130 mg/dl} A hypoglycemic episode can lead to [MEDICAL CONDITION], coma, [MEDICAL CONDITION] and death. (www.medscape.com/multispecialy) Resident # 1's daughter said the hospital staff attempted to decrease the vent use the night before, the hospital recommended placement of a vent and/or comfort care. Clinical record review of the nurses notes dated 11/29/14 at: - 9:00 AM documented resident # 1 was given a pain medication for her complaint of leg pain. - 1:00 PM the notes documented her the medication was effective. - 5:00 PM resident # 1 was documented to be responsive to tactile stimuli, she had increased drooling, her BBG was 104, B/P 94/58, pulse 72. - 7:30 PM LVN "B" documented she went to check resident # 1's BBG, resident # 1 was not responsive to verbal/tactile stimuli, breath was short, shallow with stridor present bilateral upper lobes. B/P was 162/89, pulse 67, temperature 98.2, respiration 12, O 2 was 91%. The on call doctor was paged. The nurses note did not document a BBG, Review of the MAR indicated [REDACTED] - 7:45 PM the doctor returned the call and ordered resident # 1 be sent to the emergency room , the ambulance was called and a message was left for the family. - 8:00 PM ambulance arrived and resident was transported to the hospital. - 8:15 PM residents daughter returned call. Record review of the MAR indicated [REDACTED]. At 12:30 PM the MAR indicated [REDACTED]. The blood sugars were circled for 5:30 PM and 8:00 PM. The back of the MAR indicated [REDACTED]. Continued review of the BBG record for resident # 1 documented abnormal findings of BBG of: - 27 on 11/28/14 at 7:15 AM with 30 grams of carbs and breakfast being given and a recheck at 8:30 BBG was 142. No physician notification was documented. - 30 on 11/25/14 at 7:30 AM with 30 grams of carbs and breakfast being given and a recheck at 8:30 BBG was 134. No physician notification was documented. - 31 on 11/22/14 at 7:15 AM with 30 grams of carbs and breakfast being given and a recheck at 8:30 BBG was 144. No physician notification was documented. - 30 on 11/18/14 at 7:30 AM with 30 grams of carbs and breakfast being given and no recheck value was documented. No physician notification was documented. - 26 on 11/14/14 at 7:30 AM with 30 grams of carbs and breakfast being given and a recheck at 8:30 BBG was 151. No physician notification was documented. - 52 on 11/12/14 at 7:15 AM with 30 grams of carbs and breakfast being given and no recheck value was documented. No physician notification was documented. - 29 on 11/04/14 at 7:30 AM with 30 grams of carbs and breakfast being given and a recheck at 8:30 BBG was 79. No physician notification was documented. - 28 on 10/30/14 at 7:30 AM with 30 grams of carbs and breakfast being given and a recheck at 7:15 BBG was 42, an additional 15 grams of carbs was given, the BBG at 8:10 AM was 110. No physician notification was documented. - 25 on 10/24/14 at 7:30 AM with 30 grams of carbs and breakfast being given. There was no documentation of a recheck or physician notification. - 52 on 10/21/14 at 7:30 AM with 15 grams of carbs and breakfast being given. There was no documentation of a recheck or physician notification. - 26 on 10/11/14 at 12:30 AM there was no documentation of intervention or physician notification. - 38 on 10/06/14 at 7:30 AM with 30 grams of carbs and breakfast being given. There was no documentation of a recheck or physician notification. - 46 on 10/05/14 at 7:30 AM with 30 grams of carbs and breakfast being given. No physician notification was documented. - 60 on 10/02/14 at 7:30 AM there was no documentation of intervention or physician notification. Record review of the November 2014 MAR indicated [REDACTED]. Clinical record review of the physicians notes and nurses notes did not document any physician notification of the abnormal BBG values for resident # 1 during the months of October and November 2014. The nurses notes did not have a physical assessment documented for the abnormal blood sugars listed. In a telephone interview on 12/05/14 at 1:27 PM resident # 1's physician said he had not been made aware of any abnormal BBG's for resident # 1, he said the facility nurses did not communicate residents needs, nurse just says no concerns; he makes his rounds and the nurse tells him there are no new concerns. Resident # 1's physician said he could not treat if he was not made aware of problem. In an interview on 12/08/14 at 11:00 AM the DON said the documented 30 grams of carbs must have been the nurses intervention, She should have notified the doctor and followed up. Record review of the physicians progress note dated 10/30/14 documented resident # 1 was seen by her physician that day, resident # 1 was documented to be a poor historian. The nurse reported resident # 1 was doing well with no concerns. The physician documented resident # 1 had left lower limb [MEDICAL CONDITION] and she was to be sent to the ER to rule out [MEDICAL CONDITION] and resident # 1 was to start physical therapy. The physician progress notes [REDACTED].# 1 was seen by her physician, the note documented resident # 1's case was discussed with the nurse who did not have any questions or concerns. Interview on 12/04/14 at 2:40 PM CNA "F" said resident # 1's blood sugar got low a lot, the staff were trained to report changes in condition. Interview on 12/05/14 at 11:15 AM CNA "E" said resident # 1 had to be fed that day (11/29/14), she usually fed herself and resident # 1 had not been normal for a few days, she had reported it to the charge nurse. CNA "E" said it was normal for resident # 1 to lay down after lunch and if she was fussy they would get her back up. Interview on 12/05/14 at 11:35 AM PM "D" said resident # 1 was unresponsive when they arrived, the facility reported her last BBG was 72, she had a BBG of 20 on the ambulance; it had been extremely hard to get an IV started on resident # 1. Record review of the ambulance transfer notes, dated 11/29/14, documented resident # 1 was unresponsive when they arrived, the nursing staff reported a BBG of 72. The report documented the facility staff reported resident # 1 had moist lung sounds, she did not eat supper, and she have possible aspirated; her oxygen saturation level was 84%. The report documented at 7:52 PM a BBG of 20. The report documented difficulty starting an IV. Interview on 12/05/14 at 12:35 PM LVN "C" said on 11/29/14 resident # 1's BBG was 104 at suppertime, resident # 1 was drowsy, she had [MEDICATION NAME] (anti-anxiety medication) and [MEDICATION NAME] (pain medication) earlier, and they put resident # 1 to bed. Resident # 1 did not eat supper, they kept her tray to reheat and feed her later because resident # 1 would not eat. Resident # 1's BBG was then decreased to 84. At 7:30 PM resident # 1's BBG was around 73 when she found resident # 1 unresponsive. LVN "C" said she assessed resident # 1, called her doctor and had the staff get her ready to go to the hospital. Interview on 12/05/14 at 12:35 PM CNA "B" said resident # 1 gets out of bed in the mornings, she brushes her own teeth and drinks coffee. The day she went to the hospital she didn't do any of that, she would rouse but she was much quieter. Resident # 1 would usually help them move her but that day she was just dead weight. Resident # 1 had snacks in her room, she always got snacks; she ate sugar free pudding at 10:00 AM that morning. CNA "B" said resident # 1 ate breakfast that day and someone attempted to feed resident # 1 lunch, then she was put to bed. CNA "B" said she reported to the nurse, stating it may have been LVN "A", that resident # 1 had not voided that day and the nurses did not always take them seriously. Interview on 12/05/14 at 1:10 PM LVN "C" said resident # 1 usually went to bed after lunch then gout up for the 4:00 PM smoke break; that day she was alert but drowsy, she had some trouble swallowing so they laid her back down and saved her tray. Resident # 1 had [MEDICATION NAME] and [MEDICATION NAME] earlier, it would make her drowsy, and she would come out later in the evening and eat, the CNA's usually tried to get her to eat again. The staff had reported her increased drowsiness that day, and resident # 1 had not voided. LVN "C" said she went to check resident # 1's BBG first because she expected her to have a low reading but it was normal. In a telephone interview on 12/05/14 at 1:59 PM LVN "A" said she did notify resident # 1's physician when resident # 1's BBG was too low. LVN "A" said she would fax the doctor and she called. The physician would not respond, one time he ask if the blood sugar came up. LVN "A" said no, she did not document contacting the physician and the facility did not keep faxes that were sent to the physician, if orders were received they would write the orders on a phone order sheet and throw away the fax copy. LVN "A" said she did not make the Medical Director aware of the concerns with resident # 1's blood sugar. Record review of the facility policy dated 1/2008 for Nursing Care of Diabetic Residents documented the residents physician was to be notified of finger stick blood sugars (BBG's) greater than 300 or less than 70, unless the physician ordered specific parameters for the individual resident. In a telephone interview on 12/06/14 at 4:30 PM resident # 1's daughter said she had never been made aware of resident # 1's blood sugar falling to low, the facility contacted her about falls and those things but never about blood sugars. Resident # 3: Record review of the physicians orders dated 11/01/14 - 11/30/14 documented resident # 3 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The orders documented resident # 3 received [MEDICATION NAME]13 units subcutaneous daily at 8:00 AM and Humalog Insulin subcutaneous daily: 6 units at 7:30 AM, 8 units at 12:30 PM, 9 units at 5:30 PM with additional doses of the Humalog insulin to be given 4 times a day per sliding scale. with additional BBG's to be done at 12:00 and 3:00 AM. There were no orders for parameters on the BBG's. Record review of the BBG log for resident # 3 documented he had the following elevated blood sugars: - 458 on 11/02/14 at 7:30 AM, 430 at 5:30 PM - 470 on 11/03/14 at 12:30 PM - 411 on 11/05/14 at 5:30 PM - 489 on 11/09/14 at 8:00 PM - 414 on 11/10/14 at 12:30 PM - 435 on 11/11/14 at 12:30 PM - 487 on 11/15/14 at 5:30 PM, 491 at 8:00 PM - 451 on 11/16/14 at 12:30 PM, 474 at 8:00 PM - 484 on 11/17/14 at 8:00 PM - 450 on 11/22/14 at 5:30 PM - 458 on 11/26/14 at 12:30 PM - 457 on 11/27/14 at 5:30 PM - 454 on 11/28/14 at 5:30 PM Clinical record review for resident # 3 of the November nurse notes, physician orders and progress notes did not document any physician notification of the high blood sugar reading for resident # 3. Observation and interview on 11/05/14 at 11:30 Am resident # 3 was in his wheel chair, in his room, he was alert and oriented and self propelled his wheel chair. Resident # 3 said his blood sugars were checked before each meal and at bedtime, the nurses were very good to explain to him what his sugar was and how much insulin he was getting. Record review of the Quarterly MDS dated [DATE] for resident # 3 documented in section C resident # 3 was alert and oriented with a BIMS score of 09. Section G documented he required 1 person assistance with his ADL's. This was determined to be Immediate Jeopardy (IJ) on 12/05/14 at 2:30 PM, the Administrator and the DON were notified at that time. The following Plan of Removal for the Immediate Jeopardy was accepted on 12/08/14 at 12:30 PM Issues identified: Failure to notify physician of a change in residents condition. 1. The facility Medical Director was notified of the Immediate Jeopardy of the home on 12/05/2014 at 3:15 PM. 2. The DON/designee immediately audited all diabetic residents glucose log to determine if all residents testing high or low were reported to the physicians. 3. All glucometers were calibrated by the DON/designee and the nightly checks were ongoing on the 10 - 6 shift to determine if the unit was functioning properly. 4. All nursing staff on duty were educated immediately by the DON on the following: - Notification of the the physician for a change of condition to include hypoglycemic and hyperglycemic events. Employees not working will be educated prior to working their next shift. - Observation and identification of change of condition with reporting on the 24 hour report. - Licensed nurses were instructed to document changes of condition in the clinical record in addition to documenting on the 2 hour report communication tool, i.e. falls, GI distress, respiratory distress, blood sugar changes,etc.. Nurses were being inserviced on when to call the physician and when it was appropriate to fax. All communication with the physician was to be charted. - All CNA's were educated immediately by the DON to: report all changes in condition to the DON as well as the charge nurse. On Monday 12/08/14 at 12:30 PM the plan of removal was accepted and the IJ was removed; the facility remained at a level of isolated actual harm that is not IJ because the facility administrative staff had not had time to implement policies and procedures and monitor the effectiveness outlined in their Plan of Removal. In an interview on 12/08/14 at 11:00 AM the DON said there were 20 insulin dependent residents living in the facility.

Based on observation, interview and record review the facility failed to ensure 3 residents (# 1, # 7 and # 8) of 5 residents, documented to be unsafe to smoke unsupervised, and reviewed for smoking safety received adequate supervision and safety devices to prevent accidents. The facility failed to: 1) ensure staff supervision and the use of safety devices (smoking apron)were in place to protect Resident # 1, who the facility assesed to be unsafe to smoke independently, from unsupervised smoking, cigarette related burns to his clothing and 30 % of his body, and his subsequent death. 2) ensure staff supervision and the use of safety devices (smoking apron)were in place to prevent Resident # 7 and # 8 from smoking unsupervised and 3) ensure Resident # 7 returned all her cigarettes and lighters when she returned to the facility from outings. This deficient practice resulted in an Immediate Jeopardy (IJ) on 6/06/13. While the IJ was removed on 6/07/13, the facility remained out of compliance at a Severity level of Actual Harm with a Scope of Isolated related to continued need by the facility to monitor their plan for effectiveness. These failures could place 2 residents (# 7 and 8) identified by the facility as a non-compliant smoker at risk for cigarette related burns, fires and/or death. The findings included: Resident # 1: Review of the physicians orders dated 6/01/13 documented resident # 1 was a [AGE] year old male admitted to the facility on [DATE]. Resident # 1 ' s [DIAGNOSES REDACTED]. Review of the annual MDS (Minimum Data Set- tool used for resident assessment and care screening) dated 3/18/13, for resident # 1 documented in sections: B - Hearing Speech and Vision: - B0600 speech clarity was coded as (2) had no speech, - B0700 making self-understood, was coded as (2) sometimes he was understood. C - Cognitive Patterns: - C0700 short term memory, was coded as (1) memory problem, - C0800 long term memory problem, was coded as (1) memory problem, - C1000 cognitive skills for daily decision making was coded as (2) moderately impaired - decisions poor, cues/supervision required. E - Behavior: - E0200 other behavioral symptoms not directed toward others was coded in subsection C as a (3) behavior occurred daily, - E0500 did the identified symptoms put resident at risk for physical illness or injury was coded as (1) yes. G - Functional status: - G0110: B. transfers - subsection 1. coded as (2) limited assistance and subsection 2. coded as (2) requires assistance of 1 person; F. locomotion off unit - subsection 1. coded as (0) independent and 2. coded as (1) setup help only. - G0300: Balance during transitions and walking - subsection A. (move from sitting to standing position) - coded as (1) Not steady and able to stabilize without staff assistance, B. - (walking) coded as (2) not steady, only able to stabilize with staff assistance. V - Care area assessment summary: -V0200 CAA results: 02. Cognitive loss - short term memory problem with impaired decision making, 04. Communication - aphasic, able to make needs known by gestures, 05. ADL function - requires extensive to total assistance with activities of daily living, 09. Behavior - Refused ADL care daily-showers, incontinent care. The clinical record contained smoking assessments dated 8/07/12, 12/10/12, 2/27/13 and 5/20/13 documenting resident # 1 was deemed unsafe and must be supervised. The assessment documented on each date resident # 1 was not able to make himself understood, dropped ashes, did not comply with facility smoking regulations and did not follow the rules regarding keeping smoking paraphernalia on self or in the room. The assessment documented all residents must keep all smoking materials at the nursing station, and at no time were residents allowed to keep an ignition device. A careplan dated 7/16/12 documented resident # 1 ' s wife (also his Power of Attorney) signature acknowledging his non-compliance with smoking and leaving the facility without signing out. Continued record review for resident # 1 documented a careplan dated 3/24/13 documented resident # 1 was non-compliant with the facility smoking policy. The interventions included: - re-enforcement of the facility policy PRN (as needed), - verbal re-direction as needed, - document non-compliance, - facility staff were not to furnish non-allowable items to the resident. The careplan contained a note documenting resident # 1 ' s wife was aware of his non-compliance and her indication of her approval for resident # 1 to go without signing out. Review of the nurse's notes dated 6/03/13 at 10:00 am documented resident # 1 had right sided paralysis was mobile in a wheel chair and wheeled himself. The note documented resident # 1 refused ADL s and was non-compliant with smoking rules. At 1:00 pm on 6/03/13, the nursing note documented a visitor stated resident # 1 was on fire outside. The notes documented resident # 1 had a fire blanket on and the fire was extinguished with an extinguisher, 911 was called, oxygen was applied, wife was notified and resident # 1 was placed on a stretcher and the emergency room was notified. Review of the facility investigation report, dated 6/03/13 at 1:15 pm, documented resident # 1 was found outside on fire by a visitor and the fire was reported to the facility by a visitor. A statement signed by LVN " A " documented resident # 1 was sitting in his wheelchair at the corner of Fairway and Coronado at 11:00 am when LVN " A " went to lunch. A statement written by staff member "B" documented he had returned from lunch at approximately 12:10 pm, resident # 1 was sitting on the porch and staff "B" had held the door open for resident # 1 to come back into the facility. A statement given by the DON documented she saw resident # 1 go by the nurses ' station at approximately 12:15 pm. The statement documented the DON asked resident # 1 if he was going outside and resident # 1 shook his head yes and waved. Observation of the site on 6/04/13 at 5:02 pm where resident # 1 was sitting when the fire occurred revealed he was not in the smoking area, he was in front of the facility, on the side walk, under a tree and he was not in full sight of the facility as a wall in the entrance area blocked vision. Review of the facility smoking policy dated 10/2011 and signed with an " X " by resident # 1 documented the policy stating smoking would be permitted in designated safe areas only and residents not complying with the home ' s smoking policy may be discharged from the home. Procedure # 5 of the policy documented all residents, whom were not deemed capable to smoke, unsupervised, would be given the opportunity to smoke with supervision at the designated smoking times. Procedure # 6 documented all smoking materials were to be kept at the nursing station. The designated smoking area was the hall # porch. In an interview on 6/04/13 at 2:40 pm the Administrator said resident # 1 had passed away shortly after midnight, the night he was burned. The burns were severe and he had lung damage from the fire. Resident # 1 had been in the building 5 minutes before the incident, he had not signed out. A visitor had seen resident # 1 on fire, threw water on him and sent her daughter into the facility to notify the staff. Someone threw a blanket on resident # 1 to extinguish the fire. The fire department was called and resident # 1 was sent to the hospital. The Administrator said resident # 1 had a stroke, and would not sign out; resident # 1 ' s wife was aware and had signed the careplan. Resident # 1 did not usually smoke unattended; he had been non-compliant with smoking rules in the past. He would go to a local convenience store and purchase cigarettes, the staff would confiscate them, and there had not been a problem with resident # 1's non-compliance the last few months to her knowledge. In an interview on 6/04/13 at 3:55 pm the visitor said she was leaving the facility and saw a man in wheelchair, on fire. He was sitting outside the facility, by the facility sign. She sent her daughter in to get the nurses and poured water on him, a partially lit cigarette was laying on the ground, she turned to go get more water and heard a pop. Then she saw a cigarette lighter fall to the ground from resident # 1 ' s lap. The lighter was burned and in pieces. There was not any type covering on resident # 1 ' s clothing until a neighbor brought a blanket to smother the fire. In a telephone interview on 6/04/13 at 4:32 pm resident # 1 s wife said resident # 1 had a stroke and was paralyzed on the right side and it affected his speech. He had a wheelchair with a special hand pump, he came and went as he pleased. He would sneak out at times to smoke and was non-compliant. Resident # 1 would get a cigarette any way he could. Resident # 1's wife said she would not allow the facility to restrain resident # 1 to prevent his non-compliance. Resident # 1 had not burned himself before. In an interview on 6/05/13 at 12:50 pm the DON said resident # 1 made his own decisions (although the MDS documented poor decision making skills), communicated with hand gestures and had not burned himself before. He would go the local store and buy cigarettes. The staff would confiscate the cigarettes and lighter. The DON said she was not aware of any non-compliance in the last couple months. Resident # 1 ' s wife had signed his careplan but she had not signed any actual releases. The DON said she had discussed using a wander guard with resident # 1's wife and the wife had refused. An elopement assessment was done and he was not an elopement risk, he was alert and knew where he was going. Resident # 1 would get a cigarette any way he could, it was not known where he got one. The convenience store clerk was interviewed on 6/05/13 at 1:25 pm and said there had not been any resident in the store the morning of the fire. Resident # 7: Review of the physicians orders dated 6/01/13 for resident # 7 documented she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the smoking assessment dated [DATE], 10/05/12, 12/17/12 and 3/05/13 documented resident # 7 dropped ashes, identifying her as an unsafe smoker. Record review of the MDS dated [DATE] documented in section G: functional status: - resident # 7 required supervision and cueing for transfers off the unit. The CAA documented resident # 7 had short term memory loss with impaired decision making, required assistance with her ADLs and had a potential for falls due to her balance being unsteady. Review of the careplan dated 12/26/12 documented resident # 7 required supervised smoking. In an interview on 6/06/13 at 4:34 pm CNA " D " said resident # 7 would go out to smoke alone. Observation of resident # 7 on 6/06/13 at 4:34 pm, during her supervised smoke break revealed she was in a wheelchair. In an interview on 6/06/13 at 4:44 pm resident # 7 said she did go out to smoke alone. Resident # 7 said she had not gone out alone since resident # 1 ' s accident. She would go out and buy cigarettes and lighters when she was signed out and would not turn them in. In a confidential interview on 6/07/13 at 3:58 pm it was said resident # 7 did go out and smoke unattended. Resident # 7 would sit outside on the front porch and threw her cigarette butts in the flower bed. Resident # 7 would buy cigarettes and not turn them in; resident # 7 would leave the cigarettes in her neck pouch, barely visible and make sure resident # 8 saw them so he would become upset. Resident # 7 would turn in a few cigarettes and hide the others. Observation of the flower beds in the front of the facility on 6/07/13 at 4:00 pm revealed there were cigarette butts in the flower bed. Resident # 8: Review of the physician's orders [REDACTED]. His [DIAGNOSES REDACTED]. Review of the smoking assessment for resident # 8 dated 1/08/13 and 4/07/13 documented resident # 8 was unsafe and additional measures were required. Review of the MDS dated [DATE] for resident # 8 identified in section: V - Care area assessment summary: -V0200 CAA results - cognitive deficit related to head injury, fall risk and behavioral problems. In an interview on 6/04/13 at 3:04 pm resident # 8 said he goes out alone to smoke if he gets a chance to. They were not supposed to and they were supposed to sign out if they went out, but he doesn ' t do it. In an observation on 6/06/13 at 4:32 pm the alarm sounded on the exit door to the smoking area as the investigator went out the door. Residents were outside for their supervised smoke break. Resident # 8 got up from his wheelchair and put the code in to turn off the alarm. Facility staff was present. In an interview on 6/06/13 at 4:34 pm CNA " D " said resident # 8 did go out to smoke unsupervised but he had not in the last few months. In an interview on 6/06/13 at 12:06 pm RN "C" said the cigarettes are kept locked up, and the facility has a smoking schedule; the schedule is in the admission packets and posted. Residents smoke in area off Hall 3. Residents check their cigarettes out and turn cigarettes in when they return from signing out. Review of the cigarette sign out log on 6/06/13 documented the log did not provide a means to identify when cigarettes were turned in. In an interview on 6/06/13 at 12:10 pm CNA "E" said she had seen resident # 1 and # 11 smoke unattended, she had heard resident # 7 did but had not seen her. In an interview on 6/06/13 at 12:32 pm the DON said resident # 8 was non-compliant with smoking rules in the past, he had not been recently due to his declining condition. Resident # 7 signs her cigarettes out when she goes to the day program, resident # 7 sits outside and waits for the bus, resident # 7 had not been reported smoking unattended. Resident # 1 was the only non-compliant resident in the last 3 - 4 months. She did discuss the alarm with resident # 1' s wife and probably did not document it. Not able to find any documentation. The Administrator, D.O.N. and A.D.O.N. and Corporate staff were informed of the IJ situation on 6/06/13 at 6:25 pm in the area of accident hazards and supervision to prevent accidents. The facility submitted a plan of removal with completion dates documented 6/06/13, except for inservice and discharging non-compliant residents, which would be on-going until 100% completion. The plan included: A. Identification of the 2 residents who had smoked unsupervised (ID #'s 7, & 8). B. Administrator will check all non-compliant residents including resident # 7 for smoking materials now. C. Inservice all staff on smoking policy and reporting. D. Notify, in writing, any resident if they were found to be non-compliant with facility ' s smoking policy that they would be discharged if they continued to be non-compliant. E. Discharge any resident if they continued to be non-compliant. F. Implement the wander guard (monitoring system) on resident # 7 & 8. G. Change wander guard door system code. F. Change the door alarm code to the smoke patio. The IJ was removed 6/07/13 at 10:08 am after Surveyors verified the above actions were completed through observations, interviews and record reviews. The facility had identified 2 of 21 smokers (resident # 7 & 8) to be a risk for non-compliance with the facility smoking policy. The facility remained out of compliance at a level of Severity level of Actual Harm that was not IJ with a Scope of Isolated, because the facility had not yet in-serviced all employees and had not made the arrangements for the discharge of residents. The facility census list identified 21 residents that smoked.

Based on observation, interview and record review the Administrator and Director of Nursing (DON) failed to implement the facility smoking ploicy and utilize facility resources effectively to ensure resident were smoking safely, to prevent unsupervised smoking and potential smoking related accidents for 3 residents (# 1, # 7 and # 8) of 5 residents, indentified as unsafe smokers, who were reviewed for smoking safety. The Administrator and DON failed to implement the facility's smoking policy by failing to: 1) ensure staff supervision and the use of safety devices (smoking apron)were in place to protect Resident # 1, who the facility assessed to be unsafe to smoke independently, from unsupervised smoking, cigarette [MEDICAL CONDITION] his clothing and 30 % of his body, and his subsequent death. 2) ensure staff supervision and the use of safety devices (smoking apron)were in place to prevent Resident # 7 and # 8 from smoking unsupervised and 3) ensure Resident # 7 returned all her cigarettes and lighters when she returned to the facility from outings. This deficient practice resulted in an Immediate Jeopardy (IJ) on 6/06/13. While the IJ was removed on 6/07/13, the facility remained out of compliance at a Severity level of Actual Harm that was not IJ with a Scope of Isolated related to continued need by the facility to monitor their plan for effectiveness. These failures had the potential to place 2 residents (# 7 and 8) identified by the facility as a non-compliant smoker at risk for cigarette related burns, fires and/or death. The findings included: Resident # 1: Review of the physicians orders dated 6/01/13 documented resident # 1 was a [AGE] year old male admitted to the facility on [DATE]. Resident # 1 ' s [DIAGNOSES REDACTED]. Review of the annual MDS (Minimum Data Set- tool used for resident assessment and care screening) dated 3/18/13, for resident # 1 documented in sections: B - Hearing Speech and Vision: - B0600 speech clarity was coded as (2) had no speech, - B0700 making self-understood, was coded as (2) sometimes he was understood. C - Cognitive Patterns: - C0700 short term memory, was coded as (1) memory problem, - C0800 long term memory problem, was coded as (1) memory problem, - C1000 cognitive skills for daily decision making was coded as (2) moderately impaired - decisions poor, cues/supervision required. E - Behavior: - E0200 other behavioral symptoms not directed toward others was coded in subsection C as a (3) behavior occurred daily, - E0500 did the identified symptoms put resident at risk for physical illness or injury was coded as (1) yes. G - Functional status: - G0110: B. transfers - subsection 1. coded as (2) limited assistance and subsection 2. coded as (2) requires assistance of 1 person; F. locomotion off unit - subsection 1. coded as (0) independent and 2. coded as (1) setup help only. - G0300: Balance during transitions and walking - subsection A. (move from sitting to standing position) - coded as (1) Not steady and able to stabilize without staff assistance, B. - (walking) coded as (2) not steady, only able to stabilize with staff assistance. V - Care area assessment summary: -V0200 CAA results: 02. Cognitive loss - short term memory problem with impaired decision making, 04. Communication - aphasic, able to make needs known by gestures, 05. ADL function - requires extensive to total assistance with activities of daily living, 09. Behavior - Refused ADL care daily-showers, incontinent care. The clinical record contained smoking assessments dated 8/07/12, 12/10/12, 2/27/13 and 5/20/13 documenting resident # 1 was deemed unsafe and must be supervised. The assessment documented on each date resident # 1 was not able to make himself understood, dropped ashes, did not comply with facility smoking regulations and did not follow the rules regarding keeping smoking paraphernalia on self or in the room. The assessment documented all residents must keep all smoking materials at the nursing station, and at no time were residents allowed to keep an ignition device. A careplan dated 7/16/12 documented resident # 1 ' s wife (also his Power of Attorney) signature acknowledging his non-compliance with smoking and leaving the facility without signing out. Continued record review for resident # 1 documented a careplan dated 3/24/13 documented resident # 1 was non-compliant with the facility smoking policy. The interventions included: - re-enforcement of the facility policy PRN (as needed), - verbal re-direction as needed, - document non-compliance, - facility staff were not to furnish non-allowable items to the resident. The careplan contained a note documenting resident # 1 ' s wife was aware of his non-compliance and her indication of her approval for resident # 1 to go without signing out. Review of the nurse's notes dated 6/03/13 at 10:00 am documented resident # 1 had right sided paralysis was mobile in a wheel chair and wheeled himself. The note documented resident # 1 refused ADL s and was non-compliant with smoking rules. At 1:00 pm on 6/03/13, the nursing note documented a visitor stated resident # 1 was on fire outside. The notes documented resident # 1 had a fire blanket on and the fire was extinguished with an extinguisher, 911 was called, oxygen was applied, wife was notified and resident # 1 was placed on a stretcher and the emergency room was notified. Review of the facility investigation report, dated 6/03/13 at 1:15 pm, documented resident # 1 was found outside on fire by a visitor and the fire was reported to the facility by a visitor. A statement signed by LVN " A " documented resident # 1 was sitting in his wheelchair at the corner of Fairway and Coronado at 11:00 am when LVN " A " went to lunch. A statement written by staff member "B" documented he had returned from lunch at approximately 12:10 pm, resident # 1 was sitting on the porch and staff "B" had held the door open for resident # 1 to come back into the facility. A statement given by the DON documented she saw resident # 1 go by the nurses ' station at approximately 12:15 pm. The statement documented the DON asked resident # 1 if he was going outside and resident # 1 shook his head yes and waved. Observation of the site on 6/04/13 at 5:02 pm where resident # 1 was sitting when the fire occurred revealed he was not in the smoking area, he was in front of the facility, on the side walk, under a tree and he was not in full sight of the facility as a wall in the entrance area blocked vision. Review of the facility smoking policy dated 10/2011 and signed with an " X " by resident # 1 documented the policy stating smoking would be permitted in designated safe areas only and residents not complying with the home ' s smoking policy may be discharged from the home. Procedure # 5 of the policy documented all residents, whom were not deemed capable to smoke, unsupervised, would be given the opportunity to smoke with supervision at the designated smoking times. Procedure # 6 documented all smoking materials were to be kept at the nursing station. The designated smoking area was the hall # porch. In an interview on 6/04/13 at 2:40 pm the Administrator said resident # 1 had passed away shortly after midnight, the night he was burned. [MEDICAL CONDITION] severe and he had lung damage from the fire. Resident # 1 had been in the building 5 minutes before the incident, he had not signed out. A visitor had seen resident # 1 on fire, threw water on him and sent her daughter into the facility to notify the staff. Someone threw a blanket on resident # 1 to extinguish the fire. The fire department was called and resident # 1 was sent to the hospital. The Administrator said resident # 1 had a stroke, and would not sign out; resident # 1 ' s wife was aware and had signed the careplan. Resident # 1 did not usually smoke unattended; he had been non-compliant with smoking rules in the past. He would go to a local convenience store and purchase cigarettes, the staff would confiscate them, and there had not been a problem with resident # 1's non-compliance the last few months to her knowledge. In an interview on 6/04/13 at 3:55 pm the visitor said she was leaving the facility and saw a man in wheelchair, on fire. He was sitting outside the facility, by the facility sign. She sent her daughter in to get the nurses and poured water on him, a partially lit cigarette was laying on the ground, she turned to go get more water and heard a pop. Then she saw a cigarette lighter fall to the ground from resident # 1 ' s lap. The lighter was burned and in pieces. There was not any type covering on resident # 1 ' s clothing until a neighbor brought a blanket to smother the fire. In a telephone interview on 6/04/13 at 4:32 pm resident # 1 s wife said resident # 1 had a stroke and was paralyzed on the right side and it affected his speech. He had a wheelchair with a special hand pump, he came and went as he pleased. He would sneak out at times to smoke and was non-compliant. Resident # 1 would get a cigarette any way he could. Resident # 1's wife said she would not allow the facility to restrain resident # 1 to prevent his non-compliance. Resident # 1 had not burned himself before. In an interview on 6/05/13 at 12:50 pm the DON said resident # 1 made his own decisions (although the MDS documented poor decision making skills), communicated with hand gestures and had not burned himself before. He would go the local store and buy cigarettes. The staff would confiscate the cigarettes and lighter. The DON said she was not aware of any non-compliance in the last couple months. Resident # 1 ' s wife had signed his careplan but she had not signed any actual releases. The DON said she had discussed using a wander guard with resident # 1's wife and the wife had refused. An elopement assessment was done and he was not an elopement risk, he was alert and knew where he was going. Resident # 1 would get a cigarette any way he could, it was not known where he got one. The convenience store clerk was interviewed on 6/05/13 at 1:25 pm and said there had not been any resident in the store the morning of the fire. Resident # 7: Review of the physicians orders dated 6/01/13 for resident # 7 documented she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the smoking assessment dated [DATE], 10/05/12, 12/17/12 and 3/05/13 documented resident # 7 dropped ashes, identifying her as an unsafe smoker. Record review of the MDS dated [DATE] documented in section G: functional status: - resident # 7 required supervision and cueing for transfers off the unit. The CAA documented resident # 7 had short term memory loss with impaired decision making, required assistance with her ADLs and had a potential for falls due to her balance being unsteady. Review of the careplan dated 12/26/12 documented resident # 7 required supervised smoking. In an interview on 6/06/13 at 4:34 pm CNA " D " said resident # 7 would go out to smoke alone. Observation of resident # 7 on 6/06/13 at 4:34 pm, during her supervised smoke break revealed she was in a wheelchair. In an interview on 6/06/13 at 4:44 pm resident # 7 said she did go out to smoke alone. Resident # 7 said she had not gone out alone since resident # 1 ' s accident. She would go out and buy cigarettes and lighters when she was signed out and would not turn them in. In a confidential interview on 6/07/13 at 3:58 pm it was said resident # 7 did go out and smoke unattended. Resident # 7 would sit outside on the front porch and threw her cigarette butts in the flower bed. Resident # 7 would buy cigarettes and not turn them in; resident # 7 would leave the cigarettes in her neck pouch, barely visible and make sure resident # 8 saw them so he would become upset. Resident # 7 would turn in a few cigarettes and hide the others. Observation of the flower beds in the front of the facility on 6/07/13 at 4:00 pm revealed there were cigarette butts in the flower bed. Resident # 8: Review of the physician's orders [REDACTED]. His [DIAGNOSES REDACTED]. Review of the smoking assessment for resident # 8 dated 1/08/13 and 4/07/13 documented resident # 8 was unsafe and additional measures were required. Review of the MDS dated [DATE] for resident # 8 identified in section: V - Care area assessment summary: -V0200 CAA results - cognitive deficit related to head injury, fall risk and behavioral problems. In an interview on 6/04/13 at 3:04 pm resident # 8 said he goes out alone to smoke if he gets a chance to. They were not supposed to and they were supposed to sign out if they went out, but he doesn ' t do it. In an observation on 6/06/13 at 4:32 pm the alarm sounded on the exit door to the smoking area as the investigator went out the door. Residents were outside for their supervised smoke break. Resident # 8 got up from his wheelchair and put the code in to turn off the alarm. Facility staff was present. In an interview on 6/06/13 at 4:34 pm CNA " D " said resident # 8 did go out to smoke unsupervised but he had not in the last few months. In an interview on 6/06/13 at 12:06 pm RN "C" said the cigarettes are kept locked up, and the facility has a smoking schedule; the schedule is in the admission packets and posted. Residents smoke in area off Hall 3. Residents check their cigarettes out and turn cigarettes in when they return from signing out. Review of the cigarette sign out log on 6/06/13 documented the log did not provide a means to identify when cigarettes were turned in. In an interview on 6/06/13 at 12:10 pm CNA "E" said she had seen resident # 1 and # 11 smoke unattended, she had heard resident # 7 did but had not seen her. In an interview on 6/06/13 at 12:32 pm the DON said resident # 8 was non-compliant with smoking rules in the past, he had not been recently due to his declining condition. Resident # 7 signs her cigarettes out when she goes to the day program, resident # 7 sits outside and waits for the bus, resident # 7 had not been reported smoking unattended. Resident # 1 was the only non-compliant resident in the last 3 - 4 months. She did discuss the alarm with resident # 1' s wife and probably did not document it. Not able to find any documentation. The Administrator, D.O.N. and A.D.O.N. and Corporate staff were informed of the IJ situation on 6/06/13 at 6:25 pm in the area of accident hazards and supervision to prevent accidents. The facility submitted a plan of removal with completion dates documented 6/06/13, except for inservice and discharging non-compliant residents, which would be on-going until 100% completion. The plan included: A. Identification of the 2 residents who had smoked unsupervised (ID #'s 7, & 8). B. Administrator will check all non-compliant residents including resident # 7 for smoking materials now. C. Inservice all staff on smoking policy and reporting. D. Notify, in writing, any resident if they were found to be non-compliant with facility ' s smoking policy that they would be discharged if they continued to be non-compliant. E. Discharge any resident if they continued to be non-compliant. F. Implement the wander guard (monitoring system) on resident # 7 & 8. G. Change wander guard door system code. F. Change the door alarm code to the smoke patio. The IJ was removed 6/07/13 at 10:08 am after Surveyors verified the above actions were completed through observations, interviews and record reviews. The facility had identified 2 of 21 smokers (resident # 7 & 8) to be a risk for non-compliance with the facility smoking policy. The facility remained out of compliance at a level of Severity level of Actual Harm that was not IJ with a Scope of Isolated, because the facility had not yet in-serviced all employees and had not made the arrangements for the discharge of residents. The facility census list identified 21 residents that smoked.