Every finding on record at Windsor Nursing and Rehabilitation Center of Bastr

Based on observation, interview and record review the facility failed to ensure residents received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 7 of 12 residents (Residents #13 and 6 confidential residents) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature to the residents, on 09/09/2026.This failure could place residents who received meals from the food cart at risk for diminished or altered nutritional status and potential weight loss. Findings included: Record review of Resident #13's admission Record dated 09/08/2026 revealed an [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included Vascular Dementia, mild with mood disturbance(early stage of cognitive decline, (caused by reduced blood flow to brain), hyperlipidemia (high cholesterol, too many fats in blood), and chronic kidney disease (kidneys are damaged and cannot filter blood). Record review of Resident #13's Care Plan, dated 09/08/2026, revealed; Resident was on a regular diet with no added salt, and she was at risk for imbalanced nutritional deficits and at risk for unintended weight loss. Record review of the MDS assessment, dated 06/25/2026, revealed; Resident #13 had a BIMS score of 06, which indicates she has a severe problem with thinking and memory. MDS Section Functional Ability for eating indicated Resident # 13 required Supervision or touching assistance and Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes. Interview conducted on 09/08/2026 at 9:49 AM, Resident #13 stated her food was ice cold 60 percent of the time, other times [NAME]-warm. She stated sometimes the food was too salty and she was not supposed to have much salt. Resident #13 stated, the kitchen staff are nice to talk to but I rather have hotter food. Interview conducted on 09/09/2026 at 9:45 AM, a request was made to the DTM to provide 2 sample trays with regular and pureed meal items, same portions and resident set up. It was also requested that the sample trays would be the last tray served on Hall F. Observation conducted 09/09/2026 beginning at 12:30 PM, the State Survey Team participated in sampling and food temperature reading of the Lunch Meal which included 2 Test Trays (regular, and puree). The regular tray and pureed tray consisted of Pork and veggie stir-fry, steamed rice, roll, margarine, pears, tea, and water. The temperatures were Pork and Veggie Stir-fry temperature-123.6 degrees Fahrenheit for regular tray and 124 degrees Fahrenheit for pureed tray, Regular rice temperature was 112.1degress Fahrenheit and pureed rice was 123.8 degrees Fahrenheit. DTM advised of food temperatures. During a group confidential interview on an undisclosed date and time, six confidential residents stated that often meals were served cold, sometimes warm but not hot. One confidential resident stated she sits up front in the dining room, but she was one of the last to be served and her food was always cold. Additional Interview conducted on 09/10/2026 at 8:14 AM, Resident #13 stated her lunch the previous day was warm, she stated she didn't eat the stir-fry, she had a burger. Resident #13 stated her supper meal was cold and did not get served until after 6pm. Observation on 09/10/2016 at 10:55 AM, a heated food cart was observed in dining area by the door. Interview conducted on 09/10/2026 at 11:00 AM, [NAME] A stated she has worked for the facility for seven months but for the company for two years. [NAME] A stated that some residents have complained about receiving cold food. She stated that when that occurred, she would tell the residents they may return the food and receive a hot replacement meal. [NAME] A stated that food temperatures were checked in the kitchen before trays were sent to the dining rooms and the resident hallways. She stated that nursing staff sometimes take time to check and distribute the trays, and she believed this delay may have contributed to the food becoming cold before it reaches the residents. She stated the food was hot when it leaves the kitchen. When asked about the warming cart observed, [NAME] A stated that a warming cart was available in the facility; however, she stated that she had not seen it used since she began working at the facility. [NAME] A stated that if a resident receives cold food, the resident could potentially become dissatisfied and refuse to eat the meal. Interview conducted 09/10/2026 at 11:10 AM, the MTD stated the heated food cart worked. He stated there was some issues 4-5 months prior, but the cart was fixed, he stated it was a lot of money spent on the repair. Interview conducted on 09/10/2026 at 11:18 AM, the DTM stated food served in the dining room and hallways were checked twice during each meal service before the food was placed on trays. She stated she had received some complaints from residents regarding food being cold. The DTM stated the facility previously used one food cart but now they use two food carts to serve trays. She stated she had been waiting for the heated cart to be repaired. Surveyor informed DTM that the heated cart was fixed according to the MTD, she stated she was unaware that it was fixed. She stated that when food trays were placed on the carts, nursing staff then check the trays sometimes it may take a while for them to check the trays, which may result in the food becoming cold before it was served to residents. The Dietary Manager stated that serving cold food could result in a resident becoming sick. Interview conducted on 09/10/2026 at 3:06 PM, the ADM stated his expectations were for the residents to receive food at the temperature of their likings. He stated he has not had a pattern of concerns about cold food. He stated he doesn't know the breakdown of cold food; it could be the delivery time. He stated he does not choose to use the heated food cart. He stated it did not work when he first came to the facility. He stated afterwards it was fixed. He stated it heated the food more so than keeping it at temperature. He stated it affected some of the cold foods that were on the trays. He stated the potential effect on residents that received cold food was, they would not enjoy their meal. Record review of the facility's, Food Holding and Service Policy, dated 12/1/11, revealed: Policy: The consultant dietitian will monitor the holding and service of food to ensure that all food served by the facility is of good quality and safe for consumption. All food will be held and served according to the state and Federal Food Codes. See Section 6 for Quality Assurance Monitor forms and schedule. The following guidelines should be followed. Guidelines: All hot foods are served at a temperature of > 140 F and all cold food at < 40 F. The temperature is adjusted to account for the time the food will be held prior to service on the steam table and on the tray carts.Foods are held prior to service for less than one hour, maintaining the temperatures noted above. Foods are covered to maintain temperatures except for foods that will be served crispy.Food is placed on steam table no more than 30 minutes prior to meal service.If hot foods drop below 140 F, it is reheated to 165 F for a minimum of 15 seconds.

Based on observations and interviews, the facility failed to provide a private space for residents' monthly council meetings for 11 of 11 residents reviewed for resident council. The facility failed to provide the Resident Council with a private meeting area to conduct their meetings. This failure could place residents at risk of not being able to voice concerns due to a lack of privacy.Findings included: Interview conducted with the ACTD on 9/08/2026 at 10:55 AM. ACTD stated that the Resident Council Meeting met in the dining room. She reported that she had signs that would be posted. A confidential group interview and observation in facility dining room were conducted on 9/09/2026 at 3:00 PM with 11 residents. During this confidential group interview the meeting was interrupted several times by delivery men and facility staff: 3:05 PM- 2 delivery men came through the dining room doors3:06 PM, DTM came through dining doors3:09 PM, DTA D came in and out the dining doors3:11 PM, CNA H, talking to kitchen staff from the door in dining room leading to kitchen3:15 PM, DTA D came in and out the dining doors again3:19 PM, DTA D came in and out the dining doors a third time3:21 PM, DTA D came in and out the dining doors a fourth time, she was asked could she not open the door again until meeting was over3:23 PM, DTM came through a second time3:33 PM, DTM, opened the dining room door again while talking to persons in the hall, then she closed the door3:35 PM, DTA D, walked into the dining area a 5th time, and left outSeveral of the confidential residents stated interruptions have happened during their previous meetings.Interview conducted with DTA on 9/09/2026 at 3:45 PM., DTA D stated she has been employed with the facility for one year. She stated was not familiar with the facility's Resident Council protocols. She stated she was attempting to finish washing the dishes because another staff member was absent, which required her to go in and out of the dining room. When asked why she returned to the dining room after being asked if she could not open the door until the end of the meeting, DTA D stated her supervisor told her it was okay for her to enter and exit the dining room. DTA D stated she believed residents had the right to meet in private.Interview conducted with the DTM on 9/09/2026 at 3:52 PM, the DTM stated she has been trained in Resident Rights. The DTM stated she was familiar with the Resident Council protocol but understood that Resident Council generally consisted of residents meeting with individuals they invited. She reported that Resident Council meetings have been held in the dining room since she came to the facility over 2 years ago. When asked why she walked through the dining room three times during the Resident Council meeting, the DTM stated she was attempting to perform her job duties and prepare items for residents. She stated that, in the past, staff had only been instructed to keep the noise level down while residents were conducting a Resident Council meeting. She further stated that staff were free to move throughout the dining room during the meeting. When asked about the potential harm to residents when they were unable to meet privately, the dietary manager stated that, it could disrupt the residents' privacy.Interview conducted with the ACTD on 9/10/2026 at 2:18 PM, the ACTD stated she has worked at the facility for three years, come October 2026. She stated she has received training regarding resident rights, with her most recent training occurring approximately two months ago. The ACTD stated she had never seen a policy regarding Resident Council. She stated she was responsible for assisting residents with setting up Resident Council meetings and that the dining room was the only private area available at the facility for the meetings. She stated Resident Council meetings have always been held in the dining room during her time at the facility. The ACTD stated signs have always been placed on the dining room door to notify staff and others that a Resident Council meeting was in progress. She stated staff have walked into the meetings and that she has had to inform them that a Resident Council meeting was taking place and that the meeting should not be interrupted. In regard to the kitchen staff, the ACTD stated they had been asked to keep the conversations and music volume down while Resident Council meetings were being conducted. She stated she knows the residents do not like the noise and may feel disrespected. She stated residents have reported that they do not like the noise because they cannot hear what is being discussed during the meeting, and she stated she understood how they feel. The ACTD stated she has spoken with the administrator regarding the concern; however, she stated nothing has changed.Interview conducted with the ADM on 9/10/2026 at 2:52 PM., the ADM stated he has been at the facility for 15 months. He stated he was trained in Resident Rights, and he ultimately was responsible for training all the staff on Resident Rights. The ADM stated the facility did not have a policy for Resident Council but stated protocol was that the residents could have a Resident Council, run their own meeting, and could invite who they wanted to their meeting. The ADM stated the residents have not stressed to him meetings have been interrupted. He stated a year ago it was said that inside the kitchen was kind of noisy and they heard music. The ADM stated they implemented the practice of having the doors to the kitchen closed. The ADM stated he did not know how it made the residents feel about having uninvited people at their meetings, because no one has brought it to his attention. He stated the residents could possibly be annoyed by it. The ADM stated, unfortunately, due to the design of the building, we do not have another large meeting room or other entrance to the kitchen. Staff must get meals prepared. The ADM further stated, up to this point, they have held the meetings and put out signs. He stated that staff knew not to enter the dining room while a Resident Council meeting was being held. The ADM stated that they respectfully do the best they can with that space.No resident council policy was provided upon exit.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1.The facility failed to properly store, label, and date all food items located in the facility refrigerator, freezer and in the dry food pantry area on 09/08/2026, and 09/09/2026. 2.The facility failed to ensure a trash can was next to handwashing station.3. The facility failed to ensure DTA C wore a hairnet when she entered the kitchen on 09/08/2026.4. The facility failed to discard outdated food items located in the dry food area on 09/09/2026. 5. The facility failed to seal food items open to air in the freezers on 09/09/2026.These failures could place residents who received meals from the kitchen at risk of foodborne illnesses.Findings:Observation during the initial tour of the kitchen on 09/08/2026 beginning at 8:53 AM revealed the following:No trash can next to handwashing sinkRefrigerator:1 storage container, labeled mech soft ham,9/3, no discard date 1 storage container of apples in syrup, dated 9/7, no discard date1 pan, labeled puree beans, dated 9/7, no discard date 1 pan, labeled puree veggies, dated 9/7, no discard date 1 pan, labeled puree eggs, dated 9/8, no discard date 1 storage container labeled tuna, dated 9/6. no discard date 1 storage bag of brown liquid resembling gravy, no name, no date, no discard date1 storage container labeled pickles, dated 7/26, no discard date Freezer: 1 storage bag resembling waffle fries, no name, no open date, no discard date1 opened blue bag, appeared to look like vegetables inside, no name, no dates 1 storage bag of frozen green and brown substance, no name, no dates1 storage bag of brown balls, no name, open date of 9/3, no discard date Dry Food Pantry area:1 storage container, labeled rice crisp, dated 8/17, no discard date1 storage container labeled ff, dated 8/22, no discard date1 storage container labeled cheerios, dated 7/10 on one label, and prep date of 4/3 on other label1 storage container of approximately 10 bags out of original packaging, labeled pudding, dated 8/18, no discard dates1 storage container of approximately 10 bags of cake mixes, labeled cake mixes and brownies, no dates 1 storage container labeled brown sugar, dated 9/5, no discard date1 storage bag looked like tortillas, no name, no dates1 storage container labeled rice, dated 9/5, no discard date, lid not tight fitting 1 storage container labeled sugar, dated 4/24 and 8/11, no discard date, lid not tight fitting 1 opened bag of fan shaped pasta, dated 8/14, no discard date1 storage bag labeled couscous, dated 3/9, no discard date Observation on 09/08/2026 at 12:41 PM, observed DTA C walk into kitchen past food serving area without hairnet. Observation during the follow up tour of the kitchen on 09/09/2026 beginning at 10:42 AM, revealed the following: Refrigerator: 1 storage container labeled fruit, dated 9/8, no discard date1 storage container labeled pears, dated 9/9, no discard date1 storage container labeled vanilla pudding, dated 9/9, no discard date1 storage container, labeled mech soft ham,9/3, no discard date 1 storage container labeled tuna, dated 9/6. no discard date 1 storage container labeled ham, dated 8/26. no discard date Freezer: 1 opened bag of breaded pork patties, open to air, no dates 1 opened bag of sausage links, open to air, no open date 1 storage bag of brown balls, no name, open date of 9/3, no discard date1 opened packed of lasagna pasta sheets, open to air Dry Food Pantry area: 1 storage container, labeled fruit loops, dated 8/17, no discard date1 storage container labeled ff, dated 8/22, no discard date1 storage container labeled cheerios, dated 8/17, no discard date1 storage container of approximately 10 bags out of original packaging, labeled pudding, dated 8/18, no discard dates1 storage container of approximately 10 bags of cake mixes, labeled cake mixes and brownies, no dates 1 storage container labeled brown sugar, dated 9/5, no discard date1 package of tortillas, expiration date of 6/3/2026 1 storage container labeled rice, dated 9/5, no discard date, lid not tight fitting 1storage container labeled flour, dated 8/11, no discard date, lid not tight fitting1 storage bag labeled crisps, dated 8/20, no discard date 1 storage bag labeled couscous, dated 3/9, no discard date Interview conducted with DTA C on 09/08/2026 at 3:24 PM, DTA C stated she had worked at the facility for a year. She stated the hairnet protocol was to immediately go into the kitchen and put on a hairnet, then wash hands. DTA C was asked were hairnets required to be put on prior to entering the kitchen, she stated yes but the hairnets were not available on the outside of the kitchen. DTA C stated the other door entrance was blocked with trays being passed and she came in to help due to being short staffed. DTA C stated the potential harm to a resident if hair fell into the food could cause a resident to choke or become sick. Interview conducted with [NAME] A on 09/10/2026 at 10:54 AM, [NAME] A stated she has been employed at the facility for seven months. She stated she was trained by the DTM over kitchen protocols. She stated a foot operated trash can should be next to the handwashing station, she stated the area is small and the can was moved over the day surveyor came. [NAME] A stated her training included the labeling and dating process, she stated foods received from the delivery truck were marked with the date received. She stated cooked foods that were opened and placed in the refrigerator are stored in a storage bag or other container and labeled with the item name, preparation date, and discard date. [NAME] A stated items stored in the freezer were labeled with the item name and the date opened; however, a discard date was not placed on the items. She stated staff refer to a list provided by the Dietitian to determine the discard date for frozen items. [NAME] A further stated dry goods were labeled with the date they were opened but were not labeled with a discard or expiration date. When asked how staff determine the expiration date of dry goods removed from their original packaging, [NAME] A stated she had never been instructed to place an expiration date on dry goods. [NAME] A stated expired food items were discarded in the trash. She stated the potential harm to a resident who received expired food could include vomiting or diarrhea. [NAME] A further stated that any staff member who failed to discard expired food should be terminated. Interview conducted with DTM on 09/10/2026 at 11:11 AM, The DTM stated dry goods were labeled with the item name, date received, date opened, and discard date. She stated that dry goods were sometimes maintained in a sealed bag in their original packaging and, therefore, the expiration date was not transferred to another label. The DTM stated the freezer items were labeled with the date received and once opened, the date opened and an expiration or discard date. She stated opened bags were tied closed. The DTM stated food storage containers were supposed to have tight-fitting lids. She stated the facility had been having an issue with obtaining new containers due to budget limitations. The DTM stated expired food items were discarded. She stated trash cans were supposed to be located near the handwashing station. In regard to the hairnets, the DTM stated hairnets had been kept inside the kitchen since she began working at the facility. She stated the hairnets were moved yesterday outside the kitchen door after the raised concern. The DTM stated the potential harm to residents who consume expired food could include becoming sick. She further stated that if hair were to fall into food, a resident could potentially choke.Interview conducted on 09/10/2026 at 1:33 PM, [NAME] B stated she has worked at the facility for five years. [NAME] B stated the DTM trained her on kitchen protocols. She stated when labeling food items, the food was marked with the date, the name of the food and then they place it in the refrigerator. She stated they had not previously put discard dates until it was brought to their attention today and they were told today to label items with a discard date. [NAME] B said that they normally label items with the name and date and then place it in a container. [NAME] B was asked how they determine when the dry goods expire if it's out of the original package, she stated she does not know the expiration dates. [NAME] B stated a resident could become sick if they ate expired food, she stated moving forward she would be placing an end date on all stored food items. Record review 08/10/2026 of the facility's policy named Employee Sanitation, dated 12/01/11 reflected:3. Employee Cleanliness Requirements .b. Hair restraints, such as hats, hair coverings or nets, caps and beard/moustache restraints (snoods) or other effective hair restraints are worn to keep hair from contacting food and food-contact surfaces Record review 08/10/2026 of the facility's policy named Food Storage, dated 12/01/11 reflected: Policy: The consultant dietitian will monitor the storage of foods to ensure that all food served by the facility is of good quality and safe for consumption. All food will be stored according to the state and Federal Food Codes. The following guidelines should be followed. Guidelines: Dry storage roomsTo ensure freshness, opened and bulk items are stored in tightly covered containers. All containers are labeled and dated.Where possible, items are left in the original cartons placed with the date visible. The first-in, first-out (FIFO) rotation method is used. Packages are dated and new items are placed behind existing supplies, so that the older items are used first. Refrigerators a. All refrigerated foods are stored per state and federal guidelines. All refrigerated foods are dated, labeled and tightly sealed, including left overs, using clean, nonabsorbent, covered containers that are approved for food storage. All leftovers are used within 48 hours. Items that are over 48 hours old are discarded.Freezers.Frozen foods are stored in moisture-proof wrap or containers that are labeled and dated.

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 2 of 5 residents (Resident #32 and Resident #37) reviewed for infection control practices during medication pass. MA E failed to sanitize the blood pressure cuff during medication pass before and after using it on Resident #32 and Resident #37. These failures could place residents at risk for developing wounds, upper respiratory infections and risk for healthcare associated cross-contamination and infections. Findings include:Review of Resident #32's face sheet dated 9/10/2026 reflected a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses Unspecified Dementia (memory loss where cause is not determined), Contact with and Suspected exposure to other hazardous substances (being around toxic chemicals, mold, or heavy metals), Presence of Cardiac Defibrillator (surgically placed monitor that can shock your heart if rhythm is to fast) , Atherosclerotic Heart Disease of native coronary artery (plaque buildup restricting blood flow to the heart), and atrial fibrillation (irregular and rapid heart rhythm). Review of Resident #37's face sheet dated 9/10/2026 reflected an [AGE] year old male admitted to the facility on [DATE] with the following diagnoses of malignant neoplasm of unspecified kidney (tumor of the kidney), secondary malignant neoplasm of liver and intrahepatic bile duct (cancer of liver and duct), muscle wasting and atrophy (weakness and loss of muscle), chronic systolic heart failure (heart muscle is weak to pump blood out into the body), diabetes mellitus (body doesn't produce enough insulin and food cannot become energy) and pneumonia (lung infection caused by fluid buildup in the lungs).Observation on 09/9/2026 at 7:58 AM revealed MA E outside of Resident #32's room to prepare for medication administration. MA E grabbed the wrist blood pressure machine from her medication cart on the way to the room. MA E went into Resident #32's room and took his blood pressure without cleaning the blood pressure cuff.Observation on 09/09/2026 at 8:02 AM revealed MA E outside of Resident #37's room to prepare medications for administration. MA E using the same blood pressure machine used on Resident #32 entered Resident #37's room and took his blood pressure without cleaning the blood pressure cuff.In an interview on 09/09/2026 at 8:15 am MA B stated yes, I should have cleaned the blood pressure cuff prior to using it on Resident #32 and Resident #37. MA E stated, normally we use wipes and by not cleaning the blood pressure cuff between resident, it could cross contaminate the residents.In an interview on 09/09/2026 at 8:26 am LVN G stated if you don't wipe the BP cuff, it is an infection issue and can cause cross contamination of residents and their germs.In an interview with CMA F on 9/9/2026 at 8:30am, MA F said, we are always supposed to wipe any shared equipment before and/or after we use it on a resident, and if we don't it spreads things from room to room.In an interview on 09/10/2026 at 11:04 AM the DON and Nurse Consultant stated it was the facility's policy that any shared item is to be disinfected between residents. The DON said, I expected staff to clean any reusable equipment between residents to prevent cross contamination.In an interview on 9/10/2026 at 3:23pm, the Administrator stated staff were all trained on infection control. We have an infection control policy, and we should want to not spread stuff. If they did not clean cuff, it can increase risk of spreading infection to our residents. I think they did not clean it because of performance anxiety. In an interview on 9/10/26 at 3:35pm the ADON stated ADON is in charge and taken the role of infection preventionist. The ADON stated if we do not wipe things down it would cross contaminate our residents, anything we share should be wiped down. We monitor it and any equipment should be wiped down if shared between residentsRecord review of the facility's policy Infection Preventionist dated 10/24/2026 states all the principles of standard precautions (e.g., content on hand hygiene, personal protective equipment, injection safety, respiratory hygiene and cough etiquette, environmental cleaning and disinfection, and reprocessing reusable resident care equipment); is under the training and oversite of the Infection Control preventionist whose primary role is to coordinate and be actively accountable for the facility's infection prevention including all standard precautions is listed as being provided with all resident care activities (i.e., use and care of urinary catheters, wound care, incontinence care, skin care, performing fingerstick, medication administration, etc.)

Based on interview, observations and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 6 residents ( Resident #1) reviewed for pharmacy services. The facility failed to follow protocol of administering medications for Resident #1 resulting in postponing a surgical procedure. This failure could place residents at risk of not receiving the correct medications and a resident physical needs not being met. Findings included:Record review of Resident #1's face sheet, dated 6/30/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and, diagnoses included unspecified atrial fibrillation ( the specific type or duration of the irregular heartbeat was not documented, often because the episode was new or being evaluated), need for assistance with personal care ( support provided to individuals who cannot fully manage daily activities on their own, helping them maintain, hygiene, mobility, nutrition, and independence), and essential hypertension (high blood pressure with no identifiable secondary cause, often influenced by genetics, lifestyle, and age). Record review of Resident #1's admission MDS Assessment, dated 04/21/2026, reflected Resident #1 had a BIMS score of 8 which indicated his cognition was moderately impaired. Resident #1 did not have a feeding tube upon admission to the facility. Record review of Resident #1's Revised Care Plan, dated 06/29/2026 reflected as follows:*Resident #1 was on anticoagulant therapy ( a type of drug that prevents blood clots from forming or getting larger) related to atrial fibrillation. On 06/23/2026: order received to stop Eliquis 48 hours prior to surgery. Interventions: Administer medication as ordered by Physician. Monitor side effects and effectiveness every shift. *Resident #1 had a Medi-port ( a small device placed under the skin- usually on the upper chest. It connects to a flexible tube that leads directly to a large vein near the heart) inserted into the left subclavian ( a major blood vessel that branches directly off the aortic arch) related to upcoming chemotherapy ( a drug treatment used to destroy cancer cells, stop them from growing, or prevent them from spreading throughout the body). Interventions: Monitor Resident #1's Medi-port for 7 days ( redness, swelling, or pain). Update the Physician of any changes in tone , color , swelling or pain to the Medi-port. *Resident #1 required tube feeding related to diagnosis of squamous cell carcinoma ( the second most common form of skin cancer) with upcoming chemotherapy (a systemic drug treatment used to destroy cancer cells, stop them from growing, or prevent them from spreading throughout the body). Interventions: Provide local care to G-tube site as ordered and monitor for signs and symptoms of infection. Resident #1 needs assistance with tube feeding and water flushes. Record review of Resident #1's Physician Orders, dated 06/01/2026 thru 06/30/2026 reflected Resident #1 had an order of the following:Eliquis oral tablet of 5 MG give one table by mouth two times a day for atrial fibrillation with a start date of 04/17/2026 and an end date of 06/23/2026.2.Eliquis oral tablet of 5 MG give one table by mouth two times a day for atrial fibrillation with a start date of 06/25/2026 and an end date of 06/26/2026. Record review of Resident #1's Medication Administration Record ( MAR), start date 06/26/2026 10:00 p.m. and end date 06/29/2026 at 9:19 p.m. reflected Resident #1 was NPO ( nothing by mouth) on every shift. Surgery Monday ( 06/29/2026). Resident #1's medication Eliquis reflected:Eliquis oral tablet of 5 MG give one table by mouth two times a day for atrial fibrillation with a start date of 04/17/2026 and an end date of 06/23/2026.Eliquis oral tablet of 5 MG give one table by mouth two times a day for atrial fibrillation with a start date of 06/25/2026 and an end date of 06/26/2026. Record review of Resident #1's Nurses Practitioner Note, dated 06/17/2026, reflected Resident #1 was seen by Nurse Practitioner for monthly visit. This month he [Resident #1] had decided to undergo recommended treatment and a Porta Cath ( a small implanted medical device placed entirely under the skin. It provides long-term, reliable access for intravenous treatments and blood draws), so he [ Resident #1] can sustain nutrition and get chemo ( a medical treatment that uses powerful drugs to destroy cancer cells). Diagnosis: Squamous cell carcinoma of skin, scalp and the neck. Squamous cell carcinoma of the neck as Tonsillar mass (a type of throat cancer that originates in the thin, flat lining of your tonsils) as evidence by biopsy after hospitalization on 04/22/2026. Record review of Resident #1's Nurse Practitioner Note, dated 6/23/2026 reflected Stopped his [Resident #1's] Eliquis (a bioprecipitation oral blood thinner medication that prevents and treats dangerous blood clots) oral tablet 5 mg BID 48 hours prior to surgery. Will restart when he returns.Record review of Resident #1's Nurses Note, dated 6/23/2026, reflected new orders received to hold Eliquis, Vitamin D3, Vitamin B12, and AREDS (high dose vitamin and mineral formulations clinically proven to slow the progression of age-related macular degeneration-eye disease that damages the central, most sensitive part of the retina) for two days prior to feeding tube procedure. Resident andResponsible Party were notified and verbalized understanding of the treatment plan. Signed by LVN A.Record review of Resident #1's Nurses Note, dated 06/25/2026, reflected LVN B called Nurse Practitioner regarding Resident #1's Eliquis. LVN B received an order to restart Eliquis 5 mg. and Nurse Practitioner will discharge the Eliquis at a later time. Resident #1 will probably have procedure on Monday ( 6/29/2026). Signed by LVN BRecord review of Resident #1's Nurses Note, dated 06/28/2026, reflected Resident #1 had no adverse effect from discontinuing Eliquis on 06/26/2026. Will continue to monitor any side effects or changes in behavior. Signed by LVN C.Record review of Resident #1's Nurses Note, dated 06/29/2026, reflected Resident #1 continued on NPO (nothing by mouth) since 11:00 p.m. for pending surgery of G-tube ( a medical device surgically inserted through the abdomen directly to the stomach. It provides a direct channel to deliver nutrition, hydration, and medication to individuals who cannot eat or drink safely by mouth and Porta Cath. Signed by LVN C.Observation and interview on 06/30/2026 at 9:30 a.m. Resident #1 was lying in bed. Resident #1 stated I am not in any pain after I went to hospital yesterday [06/29/2026] for surgery. I had a tube placed in my stomach for feeding and something else called a catheter for me to get chemotherapy. I am tired and want to take a nap. He did not respond to any further questions.Interview on 06/30/2026 at 9:45 a.m. DON stated Resident #1 was scheduled to receive surgery on 06/26/2026 for a G-tube and a Porta Catheter. He stated the Nurse Practitioner discharged Resident #1's Eliquis for 6/24/2026 and 6/25/2026. He stated Resident #1 was to restart taking Eliquis once he returned from the procedure which was originally scheduled on 6/26/2026. DON stated Eliquis had been d/c from Resident #1's MAR on 06/23/2026. He stated Resident #1's Eliquis was not listed on the computer system the Nurses and Med-Aides use when administering medications. He stated Med-Aide D administered Eliquis on 06/24/2026 when the medication was to be held and had been d/c. DON stated during his investigation of why Resident #1 received Eliquis on 06/24/2026, it was determined Med-Aide D administered Eliquis to Resident #1 without reviewing the MAR in the computer system located on the medication cart. He stated if Med-Aide D had followed the medication administration protocol of the facilities policy, she would have known not to give Resident #1 his Eliquis. He stated it was the expectation and part of the medication administration to review the MAR and compare the medication on the MAR with the medications being administered to the resident. He stated this was the only medication Med-Aide D gave to Resident #1 when she made the medication error. Interview on 06/30/2026 at 10:30 a.m. Med-Aide D stated she did not review Resident #1's MAR on the computer system located on top of the medication cart prior to giving the medication Eliquis to Resident #1 on 06/24/2026. She stated she was expected to have the medication cart with her at residents room, Identify the resident, review the MAR and compare medications to the MAR, explain the medication to the resident, take blood pressure if needed, and observe Resident #1 swallow his medications. She stated Resident#1 was only to receive Eliquis at the time she administered the medication to him and she did not follow protocol. She stated if she had reviewed the MAR on the computer system she would have known the Eliquis had been discharged . Med-Aide D stated later she realized she made a mistake and contacted the DON and reported the med error to DON. She stated LVN A contacted the Nurse Practitioner, Resident #1, Resident #1's responsible party about giving him Eliquis. She stated the procedure to have G-tube and Porta Cath was postponed until Monday 06/29/2026. She stated Resident #1 was expected to have this procedure on Friday 06/26/2026, however, since he received the Eliquis by error the procedure had to be postponed. She stated she was inserviced and trained on medication administration prior to the med error and after the med error of given Eliquis to Resident #1 when the medication had been d/c. Interview on 06/30/2026 at 2:18 p.m. Nurse Practitioner stated Resident #1 did not have any adverse effects from his medication Eliquis. She stated there was no adverse effect from the surgical procedure of the G-tube and Porta Cath delayed from Friday 06/26/2026 until 06/29/2026. She stated he was doing great and currently there was no concerns about his G-tube , Porta Cath or any of his medications. Interview on 06/30/2026 at 2:30 p.m. The Administrator stated his expectations was all Med-Aides and Nurses to follow the facility policy and protocol when administering medications. He stated Med-Aide D did not follow the facility's protocol when she administered Eliquis to Resident #1. He stated Med-Aide D had been counseled, one-on-one in-service and training was completed with her and will continue training and observations of Med-Aide D administering medications. He stated all Med-Aides and Nurses received in-service on administering medications and following the facility's policy. The Administrator stated he was not a medical profession, and he could not answer any questions concerning the medication and any medical information. Record review of the Facility's Policy on Medication Administration, dated 10/24/2022 reflected the following: Policy:Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Policy Explanation and Compliance Guidelines: 10. Review MAR to identify medication to be administered. 14. Administer medication as ordered in accordance with manufacturer specifications. 20. Correct any discrepancies and report to nurse manager.

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to 1 of 3 medication carts (Medication Cart #1) reviewed for drug storage.The facility failed to ensure LVN A did not leave Medication Cart #1, unlocked leaving , medications unsecured, and accessible to other staff, residents, or visitors on 06/23/2026 at 6:49 a.m. and 7:30 a.m.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included Observation on 06/30/2026 at 12:56 a.m., revealed Medication Cart #1 was facing toward the open area between the med room and the nurses' station. There were not any staff in the hall or near the nurse's station. LVN A exited Hall E approximately 1:05 a.m. and walked toward the nurse's station to the observed unlocked medication cart.Interview with LVN A on 06/30/2026 at 1:09 a.m., stated she was trained on medication storage. She stated the nurse or medication aide who was working on the cart was responsible for locking the medication cart. LVN A stated if the staff left the medication cart unlocked and unattended a resident, staff or a visitor could get into the medication cart and take medication that did not belong to them. LVN A stated there was a possibility that a resident may have an allergic reaction if ingested medication ordered for another resident. She stated it was a possibility a resident may need to be transferred to emergency room for an evaluation. She stated she had been in-serviced on locking medication carts however; she did not recall the date or time. Interview with the Director of Nurses on 06/30/2026 at 3:00 p.m., he stated all medication carts were expected to be locked when the med-aide or nurse was not standing in front of the medication cart. He stated if the medication cart was left unlocked and unattended, a resident could get into the medication cart and take medications. He stated there was a possibility a resident may become severely ill such a low blood pressure if the resident ingested numerous blood pressure pills. He stated a resident may need to be admitted to hospital for further evaluation. He stated nurse leadership was to monitor by doing observations and in-service training. He stated she did not know why LVN A left the medication carts unlocked on 06/30/2026.Interview with the Administrator on 06/23/2026 at 9:45 a.m., stated the medication cart was to always be locked. He stated no matter what time of day the medication cart should be locked. He stated the nurse or medication aide who was on the medication cart were responsible for ensuring the medication cart was locked. The Administrator stated if the medication cart was left unlocked and unattended a resident could take medication that was harmful to them and the resident may need medical attention from the hospital. He stated he did not know why LVN A left the medication cart unlocked. He stated the staff had received in-services on locking medication cart. Record review of the Facility's Policy on Medication Carts and Supplies for Administering Meds, dated 10/01/2019 reflected Only a Licensed Nurse or Certified Medical Aide may carry keys to the medication cart. The medication cart is locked at all times when not in use.

Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one of five residents (Resident # 9) reviewed for activities.The facility failed to provide Resident #5 in room activities three times per week from May 2026 through June 18, 2026.This failure could place residents at risk for boredom, depression, and a diminished quality of life.Findings includeRecord review of Resident #5's face sheet, dated 06/30/2026, reflected an [AGE] year-old-female admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit (an impairment in communication skills caused by disrupted thinking and mental processes- such as attention and memory rather than a primary speech issue), panic disorder (intense rush of physical and mental fear even when there is no actual danger or obvious trigger present), and age-related cognitive decline (the gradual, natural slowing of the brain processing and memory recall that occurs as people grow older. It may take slightly longer to learn new skills or multitask). Record review of Resident #5's admission MDS Assessment, dated 05/13/2026, reflected Resident #5 had a BIMS score of 15, which indicated her cognition was intact. Resident #5's activity preferences that were very important to her were the following:Having books, newspapers, and magazines to readBe around animals such as pets.Keep up with the newsGo outside to get fresh air when the weather was good.Record review of Resident #5's Comprehensive Care Plan, revised on 06/02/2026 reflected Resident #5 enjoyed visiting with family and talking on the phone. Intervention: Resident #5 preferred the following television channels: cooking shows.Record review of Resident #5's Activity Assessment, dated 06/07/2026 reflected Resident #5 preferred not to participate in group activities. Resident #5 received one on one (in room activities) three times per week. She enjoyed reading, watching television, the news, and coloring. Signed by the Activity Director.Record review of the list of residents on the in-room activity program, not dated, reflected Resident #5 was to receive in-room activities. Record review of the in room activity participation binder reflected Resident #5 did not have an in room activity participation record.During an observation and interview on 06/30/2026 at 1:00 p.m., revealed Resident #5 was lying in her bed. She was watching a talk show on television. Resident #5 stated she currently did not prefer to be in a group with other people. She stated she becomes nervous (feeling worried or slightly afraid, often accompanied by physical tension in the body) sometimes when she is around other people. Resident #5 stated she preferred for someone to do come to her room and do activities instead of attending group activities. She stated she talked to someone when she first came to the facility and agreed on doing activities in her room. Resident #5 stated she has not seen that person anymore since she was admitted and did not recall the person name. She stated she thought the person worked with activities in the facility. Resident #5 stated she has not received activities in her room. She stated she would enjoy possibly doing an activity with someone outside just the two of them. Resident #5 also stated she would enjoy maybe playing a game in her room. She denied being depressed or lonely. Resident #5 stated she has not been depressed in a long time (she did not specify the length of time). She did not prefer to answer any further questions.In an interview on 06/30/2026 at 1:30 p.m., CNA E stated if a resident was not receiving any type of activities there was a possibility a resident may become bored or lonely. She stated she knew who Resident #5 was and she did not recall observing anyone in Resident #5's room assisting with activities. She stated she had been working at the facility a approximately a year.In an Interview on 06/30/2026 at 8:15 a.m., the Activity Director stated Resident #5 was on the in-room activity program. She stated Resident #5 did not receive in-room activities since her admission to the facility few months ago. The Activity Director stated she did not recall the month Resident #5 was admitted to the facility. She stated , I forgot Resident #5 was to receive in room activities. The Activity Director stated if a resident was not receiving in-room activities there was a possibility a resident may become bored, feel isolated, and may have a decline in their mental status. She stated she was responsible to ensure all residents received the activities they needed. The Activity Director stated she had been an employee as Activity Director since 10/2023. She stated, I do not recall the exact date I was hired. The Activity Director stated Resident #5 did not have attend group activities very often. She stated Resident #5 was asked about her activity preferences when Resident #5 was admitted to facility. She stated Resident #5 activity preference was to have in room activities. Interview on 06/30/2026 at 9:52 a.m., the Administrator stated it was very important for the residents unable to come out of their room or unable to participate in group activities to receive activities in their room. He stated the Activity Director was over the activity department and he was the Activity Director's supervisor. He stated there was a possibility that a resident may become lonely if they were not receiving activities in their room. The Administrator stated he expected all activities to be documented on every resident on a daily basis to capture who was attending group activities and what the residents were doing during in-room activities. The Administrator stated anytime a resident was assessed by the Activity Director to receive in-room activities his expectations were the Activity Director to begin the in-room activities immediately and follow the resident's activity preferences. Requested Activity Policy on 06/30/2026 at 9:02 via email to the Administrator. In an interview on 06/30/2026 at 3:00 p.m. The Administrator stated the facility did not have an Activity Programming or documentation policy they followed the job description for the Activity Director. Record review of the Activity Job Description ,signed on 10/09/2023, reflected The Activity Director will be responsible for planning, coordinating, and directing the resident's activity program and the maintenance of necessary documentation. Essential functions such as :Organize both individual and group activities based on the needs of the residents.Provide activities for residents that are bedfast and/or unable to participate in group activities ( one to one) and documents in the appropriate record.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of six residents (Resident # 5) reviewed for care plans. The facility failed to develop a comprehensive care plan to reflect Resident #5 needed in room activities. These failures could place residents at risk of not receiving appropriate interventions to meet their psychosocial needs. Findings include: 1. Record review of Resident #5's face sheet, dated 06/30/2026, reflected an [AGE] year-old-female admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit (an impairment in communication skills caused by disrupted thinking and mental processes- such as attention and memory rather than a primary speech issue), panic disorder (intense rush of physical and mental fear even when there is no actual danger or obvious trigger present), and age-related cognitive decline (the gradual, natural slowing of the brain processing and memory recall that occurs as people grow older. It may take slightly longer to learn new skills or multitask). Record review of Resident #5's admission MDS Assessment, dated 05/13/2026, reflected Resident #5 had a BIMS score of 15, which indicated her cognition was intact. Resident #5's activity preferences that were very important to her were the following:Having books, newspapers, and magazines to readBe around animals such as pets.Keep up with the newsGo outside to get fresh air when the weather was good. Record review of Resident #5's Comprehensive Care Plan, dated 5/25/2026 and revised on 06/02/2026 reflected Resident #5's activity care plan was not revised to meet her current activity preferences (receive in room activities).Record review of the list of residents on the in-room activity program, not dated, reflected Resident #5 was to receive in-room activities. During an observation and interview on 06/30/2026 at 1:00 p.m., revealed Resident #5 was lying in her bed. She was watching a talk show on television. Resident #5 stated she currently did not prefer to be in a group with other people. She stated she becomes nervous (feeling worried or slightly afraid, often accompanied by physical tension in the body) sometimes when she was around other people. Resident #5 stated she preferred for someone to come to her room and do activities instead of attending group activities. She stated she talked to someone when she first came to the facility and agreed on doing activities in her room. Resident #5 stated she has not seen that person anymore since she was admitted and did not recall the person name. She stated she thought the person worked with activities in the facility. Resident #5 stated she has not received activities in her room. She stated she would enjoy possibly doing an activity with someone outside just the two of them. Resident #5 also stated she would enjoy playing a game in her room. She denied being depressed or lonely. Resident #5 stated she has not been depressed in a long time. ( she did not specify the length of time). She did not prefer to answer any further questions.Interview on 06/30/2026 at 2:00 p.m., the Activity Director stated Resident #5 was on the in-room activity program. She stated all residents were expected to have their care plan revised to meet their activity preferences. The Activity Director stated she did not revise Resident #5's care plan to meet their current activity preferences of receiving in-room activities. She stated she did not realize she did not revise Resident #5's care plan. She stated, if a resident was feeling lonely, had behavior issues or was depressed the staff would not have the information of the activities to use to help the resident.In an interview on 06/04/2026 at 3:00 p.m., The MDS Coordinator stated if a resident had a change in their activity preference the activity care plan was expected to be revised. He stated the Activity Director was expected to discuss the changes with the interdisciplinary team. He stated it was very important to revise any changes with the resident to the care plan. He stated the staff would not know what type of care or activities to do with the resident if the care plan was not updated to meet their current needs and preferences. He stated in-room activities were not on Resident #5's current care plan.In an interview on 06/30/2026 at 2:30 p.m., the Administrator stated his expectations of care plans was the IDT discussed care of each resident and if there was a change with anything which included resident preferences the care plan was expected to be revised. He stated the IDT was expected to ensure the resident's information to give appropriate care to each resident was documented on the care plan whether it was physical, emotional, resident preference, activities, etc. Record review of the facility's Comprehensive Care Plan, dated 2022, reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS Assessment.

Based on interviews and record reviews, the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure processes were in place for accurate verification and reconciliation of physician orders and medications upon admission. The DON did not enter the complete medication allergy list into Resident #1's electronic medical record and the facility's NP prescribed an antibiotic that Resident # 1 had a known allergy to. This resulted in Resident #1 having an allergic reaction that led to significant rash over her body. Resident #1 was administered the medication Bactrim DS: Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) a total of 12 different times on: 12/24/2025 (1 time), 12/25/2025 (2 times), 12/26/2025 (2 times), 12/27/2025 (2 times), 12/28/2025 (2 times), 12/29/2025 (2 times), and 12/30/2025 (1 time). The physician order was to give 1 tablet by mouth every 12 hours for 10 days from 12/24/2025.The non-compliance was identified as past non-compliance. The deficient practice at the level of actual began on 12/24/2025 and ended on 12/30/2025. The facility had corrected the noncompliance prior to the start of the survey. The facility had implemented corrective actions and returned to compliance before the investigation began.This failure could place residents at risk of health decline, allergic reactions, hospitalization, and death.Review of the facility's Provider Investigation Report, dated 01/08/26, revealed, Resident #1 first admitted to the facility on [DATE]. On 12/24/2025[Resident #1] was noted with redness and warmth to left lower extremity-the same leg as the fracture. Provider notified and orders obtained for Tramadol for pain, and Bactrim DS for cellulitis. On 12/29/25 [Resident#1] was noted with a rash to back of neck and back. Lab order obtained for STAT WBC with differential. On 12/30/2025 approximately 1:00 PM [Resident#1] was noted with worsening of rash with inflamed pruritus (itchy skin) to the arms, thighs, back and stomach. Nurse practitioner informed and antibiotic was discontinued. NP noted in review of hospital records that resident had an allergy to sulfa medications that was not included in medical record.Record review of Resident #1's MDS Assessment, dated 12/29/25, reflected she was an [AGE] year-old female, admitted [DATE] with a BIMS score of 6, which indicated severe cognitive impairment characterized by loss of core information, inability to focus, and difficulty understanding spoken or written instructions. The resident's diagnoses included displaced comminuted fracture of shaft of left tibia (left shinbone where the bone has shattered into multiple pieces), coronary artery disease (main blood vessels that supply your heart struggle to send enough blood, oxygen, and nutrients to heart muscle, hyperlipidemia (too much fat like cholesterol or triglycerides in the blood, which can raise the risk of heart disease and stroke), and unspecified dementia (significant memory and thinking problems that interfere with daily life).Record review of Resident #1's facility's resident evaluation, dated 12/8/2025, uploaded to Resident #1's electronic file 12/23/25 at 3:54 PM reflected allergies: Pennicillin, Sulfa, Clindamycin Azithromycin.Record review of Resident #1's hospital discharge date d 12/23/25 and uploaded to Resident #1's electronic file 12/23/2025 at 3:54 PM reflected coded allergies: Penicillins (Severe, Swelling, Rash 01/15/21), Sulfa (Sulfonamide Antibiotics) (Severe, Swelling and Rash 01/15/21) azithromycin (Severe, Swelling, Rash 01/15/21) clindamycin (Severe, Swelling, Rash 01/15/21).Record review of Resident #1's electronic allergy profile reflected Penicillin, Clindamycin, Azithromycin were added on 12/23/2025. Sulfa Antibiotics and Bactrim were not added until 12/30/2025.Record review of Resident #1's Medication Administration Review (MAR), dated 12/01/2025 through 12/31/2025, reflected the resident was administered Bactrim DS: Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) on: 12/24/2025 (1 time), 12/25/2025 (2 times), 12/26/2025 (2 times), 12/27/2025 (2 times), 12/28/2025 (2 times), 12/29/2025 (2 times), and 12/30/2025 (1 time) which was a total of 12 times. Record review of Resident #1's progress note dated 12/29/2025 at 1:56 PM by LVN D reflected this nurse notified by res RP to come to resident room, Res RP concerned about red spots on the back of neck and her back. Red areas appear to look like petechiae(tiny, red, purple spots on skin). This nurse notified [NP] regarding issue and received an order for STAT CBC w/diff.Record review of Resident #1's progress note dated 12/30/2025 at 3:00 PM Change of Condition reflected: erythema(abnormal redness to skin) inflamed patches of redness/hives with pruritus to arms, thigh, back and stomach, started 12/29/2025, since started it has gotten: Worse.Interview conducted 2/05/2026 at 12:35 PM, ADM stated the admitting nurses for Resident #1 on 12/23/2025 was former DON and LVN B. ADM stated the facility did not have a policy named admission Procedures for Nurses.Interview conducted 2/05/2026 at 1:13 PM, former DON stated she worked for the facility since January 2023. She stated she stopped working for the facility on 1/13/2026. DON stated Resident #1 was admitted on [DATE] and the Quick ADT didn't get completed and it wasn't realized until the next day. DON stated they can put in information such as allergies, batch orders, crushed medications, and other standard items on a resident prior to their arrival when they are wait-listed. DON stated she started inputting Resident #1's allergy information and then State (HHSC) walked into the building on an investigation, and she stopped completing the information on Resident #1. DON stated she then passed the duty over to the charge nurse LVN A to finish inputting information. DON stated LVN B also worked on some of Resident #1's admission information and LVN C was the admitting nurse. DON stated they all were seasoned workers, and she did not know what happened. The DON stated that the nurse on duty was responsible for completing the admission process. This includes entering the admission note, completing the skin assessment, and confirming physician orders and medications. She stated that orders entered ahead of a resident's arrival must be confirmed against the orders provided by EMS to ensure they match. The DON further stated that the nurse accepting the resident is responsible for double-checking all allergies and entering on that day along with code status. She added that the nurse contacts and reviews the information with the NP.Interview conducted 2/05/2026 at 2:11 PM, LVN A stated she did not work on 12/23/2025. She stated she was not part of Resident #1's admission at all.Interview conducted 2/05/2026 at 2:26 PM, the RP stated her mother (Resident #1) was admitted to the facility at approximately 6:45 PM on 12/23/25. She reported that Resident #1's medical information was provided to the facility by EMS transport at the time of admission. The RP stated that when she visited Resident #1 on 12/29/25, she observed red hives on her. She reported the facility had washed Resident #1's hair, which she did not feel was necessary because her mother had recently had her hair braided. The RP further stated Resident #1's gown and bed sheets were wet, so she removed them. She reported after she removed the wet gown, she observed a rash covering Resident #1's body. The RP stated she reported her observations to CNA E, who suggested it might be related to something Resident #1 may have eaten. The RP also reported speaking with LVN D regarding the rash. According to the RP, the facility ordered laboratory work on 12/29/25. The RP stated that on 12/30/25 she asked the facility what medication had been administered to her mother and was told Resident #1 had received Bactrim. The RP reported she and her husband researched the medication and learned it contains sulfa. She stated she informed the facility that Resident #1 had a sulfa allergy. The RP stated the facility did not explain why Bactrim was administered despite the allergy and did not apologize. She reported that a nurse administered Benadryl to Resident #1 for the reaction. The RP stated that when she spoke with the DON, she was told the reaction could be generational. She also stated the NP had ordered Bactrim DS which was double strength on top of that. The RP further expressed concern that she felt Resident #1 was medically neglected by the facility.Interview conducted 2/05/2026 at 3:08 PM, LVN C stated on 12/23/2025 that he completed only the second page of the admission checklist. He reported that the DON completed the first page, which included the admitting medication orders and allergy information. LVN C stated he was not familiar with the facility's protocol for entering information into the electronic medical record. He also stated he did not know who was responsible for providing information to the NP. LVN C reported that Resident #1's allergies were listed on the intake the day of her admission. He further stated that the admission process should have been delegated to one nurse. LVN C indicated that the admission process was changed following the incident and that several in-services had been conducted since that time. He stated he no longer worked for the facility as of 1/09/2026. LVN C stated that failure to properly communicate a resident's allergies could result in an allergic reaction, which could negatively impact the resident.Interview conducted 2/05/2026 at 4:42 PM, LVN A stated in a follow-up interview that on 12/29/2025 she had an interaction with Resident #1's daughter. LVN A reported Resident#1 appeared to have raised hives on her skin. According to LVN A, the resident's daughter mentioned that the facility-provided soap had been used the previous day and questioned whether that soap was the cause of the rash. Additionally, LVN A stated she was unaware on 12/29/25 that the resident was allergic to Bactrim. She explained that the allergy was not listed at the time. LVN A reported that the former DON was responsible for electronically entering Resident #1's allergies on the day of admission along with the physician's orders. LVN A stated that the facility has since implemented a new checklist process due to the incident. This process includes a two-step verification in which a second nurse reviews the checklist for accuracy. She also stated that the admitting nurse reviews all orders with the physician or NP. LVN A acknowledged the potential harm to the resident, explaining that an allergic reaction could result in a rash or other delayed reaction. Interview conducted 2/05/2026 at 4:58 PM, NP stated resident's allergies are normally placed in the computer files. NP stated the nurse did not enter Resident #1's Sulfa or Bactrim allergy into the electronic medical record. The NP reported that NPs typically do not review the full resident chart within the first 24 hours of admission. She stated her usual practice was to have labs completed and then visit the resident at the facility. She indicated that all orders and allergies were normally communicated to her by the nurse. NP stated she ordered Bactrim for Resident #1's leg infection. She reported that LVN D initially informed her that Resident #1 had a rash that appeared to be petechiae. Later, she received a call from LVN E who stated the rash appeared more consistent with an adverse reaction. NP stated she then completed a FaceTime assessment with the resident and LVN E. Upon reviewing the hospital records, NP stated she identified that Resident #1 had a documented sulfa allergy. She stated that the following day she spoke with the DON, who responded, Oh crap, I didn't put all the allergies in. The NP emphasized that the facility should have someone double-checking charts as information is entered. According to the NP, she stopped seeing residents at the facility as of 1/16/2026.Interview conducted 2/05/2026 at 5:06 PM, LVN D stated that she and CNA F assisted Resident #1 with a shower on the 12/29/2025 and did not observe any skin issues at that time. She reported that when the resident's daughter visited later, she asked for a nurse to assess Resident #1's skin. LVN D stated that upon assessment, she observed a rash on the lower portion of the resident's back, which appeared to look like petechial in nature to her. She called and notified the NP. She further stated she was unaware at the time that Resident #1 had a Bactrim allergy until after the medication was discontinued, at which time the allergy was added to the medical record later. LVN D stated the hospital discharge paperwork had the resident's allergies listed on them. LVN D explained that if allergy information is not accurately entered into the medical record, potential harm to the resident could occur, such as allergic reactions including severe hives. She acknowledged that serious outcomes, including life-threatening reactions, could result.An interview conducted on 02/05/2026 at 5:41 PM, the ADM stated he has been employed at the facility for 9 months. He stated that the admitting nurse was responsible for entering new resident information upon admission, including obtaining discharge orders and relevant diagnoses for prompt entry into the electronic health record. He stated this task is generally assigned to the nurse designated to that resident's room on the day of admission. When questioned about the incomplete allergy profile for Resident #1, the ADM stated the information was missed and not accurately transcribed. He reported that the admitting nurse was expected to communicate all clinical information to the physician and NP. The ADM acknowledged that the former DON failed to complete the allergy portion of the ADT process. He stated that, ultimately, he holds responsibility for ensuring this process is completed. He reported having extensive discussions with the DON regarding the incident. The Administrator stated his expectation was that nurses thoroughly review all clinical information, accurately enter it into the electronic health record, and communicate all orders to the physician and NP. He indicated the facility has implemented a new protocol in which two nurses will complete the admission checklist, specifically the DON and a designated nurse. The Administrator further stated that failure to enter accurate allergy information could result in an allergic reaction and potential harm to a resident.Record review of facility policy Medication Administration revised 10/01/19 read: PolicyMedications are administered as prescribed in accordance with good nursing principles and practices andonly by persons legally authorized to do so. Personnel authorized to administer medications do so onlyafter they have been properly oriented to the medication management system in the facility. The facilityhas sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.Procedure1. PreparationA. Medications are prepared only by licensed nursing, medical, pharmacy or other personnelauthorized by state laws and regulations to prepare medications.D. 10 Rights of Medication Administration -Whenever you are preparing to give someone medication, it is important to understand the 10 rights of medication administration. Safety should be the first thing on your mind with medications. There is always a risk of giving the wrong pill, the wrong dose, or the wrongdeadly. While there has always been protocol for giving drugs, it is important for everyone to know the safety rules for medication. In the past, you may have heard of the 5 rights of Medication Administration: right patient, right drug, right route, right time, and right dose.Medical practices have changed to include a few more rights.1. Right Patient - Make sure you are giving the right medication to the right person. Check the name on the order and the patient. Use 2 identifiers. Always ask the patients name, check an ID band, pictures or whatever form of identification is being used and check the medication bottles/cards/tubes to compare before giving a medication.2. Right Medication-Check the medication supply and compare it to the doctor's order to make sure it is the right one.7. Right Education / Reason - Let your patient know what to expect from the medication:side-effects, benefits, and reactions that might happen. The patient has the right to knowexactly what they are taking and why. As the nurse, you need to know why- what is the reason this patient is taking this medication. What is the patient's history? Why is he/she taking this medication? Revisit the reasons for long-term medication use.10. Right Evaluation- Make sure you check for drug allergies and interactions between different medications. Doctors and pharmacists don't always catch them and we need to be a third set of eyes.Prior to the surveyor entry on 2/05/2026, the facility took the following steps to abate the actual harm tag:Review of facility in services dated 01/01/2026 revealed all nursing staff were re-educated on:Abuse Neglect and Exploitation prevention and reportingAdverse drug reaction reportingMedication AdministrationOrder transcription and verificationResident Assessment, change in conditionReview of Ad Hoc QAPI meeting held on 1/02/2026 revealed an QAPI meeting was held to discuss the abatement plan and action review.Review of allergy audit was completed on all current residents and Resident #1 with no additional updates required in the EMR.Review of Long-Term Care New admission Orders and Expectations Quiz revealed all staff passed the quiz to verify comprehension of in-services.Review of Medication Pass Competency Assessments revealed all nursing staff that administer medications completed the assessment. Interviews with facility staff on 02/05/2026 revealed they were educated on Residents, Abuse and Neglect, admission process of documentation of allergies and new orders verification system of being verified for accuracy by two nurses.

Based on observations, interviews 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 reviewed for storage, preparation and sanitation.The facility failed to ensure the kitchen dry pantry shelves were clean. The facility failed to ensure frozen foods were properly labeled and dated. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination.Findings included: Kitchen Observation on 07/15/2025 beginning at 10:12 AM revealed the following items in freezer were not dated, labeled or sealed : *4 bags of French toast stick, not labeled and dated;*2 bags of waffles, not labeled and dated;*1 opened bag of waffles, not labeled, dated and sealed Observation on 07/15/2025 at 10:10:17 AM in the facility kitchen revealed there was food debris on the dry storage shelf .Observation on 07/15/2025 at 10:12AM revealed cooked biscuits in a plastic bag, sitting on top of the can goods. During an interview on 07/18/2025 at 11:00 AM, [NAME] A, said she was in-serviced to label and date desserts and drinks before they were placed in the refrigerator or dry storage. He said all food items and drinks in the kitchen should be labeled and dated on the date the items were opened. She stated she began an in-service with her staff on labeling and dating. The risk of not labeling and dating items could have led to staff giving expired food to residents, and the residents could have gotten sick.During an interview on 07/18/2025 at 11:05AM, the Dietary Manager said the expectation was for all foods to be labeled, dated and all food items that had been opened should be labeled and dated. She stated it was every dietary staff responsibility to ensure food items was labeled. She stated on 07/16/2025 she had completed an in-service regarding all labeling and dating food items in the kitchen. She said the risk of storing unlabeled items could have led to food-borne illnesses in residents. During an interview on 07/18/2025 11:11AM, the administrator said his expectation was for all food items to be dated and labeled . He said the risks associated with unlabeled and undated food items in the refrigerator or the dry storage area could have led to infection and illness in residents.Record review of a facility policy and procedure dated 2018 and titled General Kitchen Sanitation reflected The facility recognizes that food borne illness has the potential to harm elderly and frail residents. All Nutrition and Food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure 1. Clean and sanitize all food preparation areas, food contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware and food contact surfaces of equipment, except cooking surfaces of equipment and pot and pans that are not used to hold or store food and are used solely for cooking purposes. 6. Clean nonfood contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, food particles and otherwise in a clean and sanitary condition. Record review of a facility policy and procedure dated 2018 and titled Food Storage reflected Policy: To ensure all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms. i. Do not use or store cleaning materials where they might contaminate foods. Store in locked area away from any food products. 2. Refrigerators a. Keep fresh meat, in the refrigerator at an internal temperature of 41 degrees F or less. d. Date, label and tightly seal all refrigerated foods. 3. Freezers i. Once frozen food has been thawed, it must be maintained at 41 degrees F or less prior to cooking.Record review of FDA Code dated 2022 revealed the following: Pathogens can contaminate and/or grow in food that is not stored properly.

Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. 1.The Regular diet kitchen test tray of the lunch meal foods were unappealing and lacked flavor. The regular diet lunch test tray revealed a tray with a Resident's adaptive aide ( spoon and fork) provided, and the food item of Arroz Con [NAME] which tasted mushy in texture, and salty in taste . The main ingredients in the dish could not be identified visually as it was formed in in round / ball shape on the plate. The plate provided was a divided plate with Arroz Con [NAME], broccoli and corn; however, the corn and broccoli was mixed together . The test tray did not have a dessert or a beverage. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings included: Observation on 7/16/25 at 12:20 PM revealed a lunch menu of Arroz Con [NAME], corn, seasoned broccoli, wheat roll, margarine, chilled pears , tea and coffee. The alternative meal was choice sandwich with chips and salad. The regular diet lunch test tray revealed a tray with a Resident's adaptive aide ( spoon and fork) provided, and the food item of Arroz Con [NAME] which tasted mushy in texture, and salty in taste . The main ingredients in the dish could not be identified visually as it was formed in in round / ball shape on the plate. The plate provided was a divided plate with Arroz Con [NAME], broccoli and corn; however, the corn and broccoli was mixed together . The test tray did not have a dessert or a beverage. During an observation and interview on 07/16/2025 at 12:30PM with Resident # 40 , her lunch tray was sitting by on her bedside table and the Arroz Con [NAME] had not been ate. She stated the food was not good and too salty and she did not know what it was. She stated she could have gotten an alternative meal (a sandwich), but it was always the same alternative meal. She stated she only ate her vegetables and desert. Resident #40 had not made a complaint and stated her family brought her snacks, it she was hungry. During an Interview on 07/17/25 at 11:00 AM with the Dietitian Consultant she stated she was new to the facility .She stated the cook is to follow the recipe, which tells them how to make each food item. She reviewed the food item (Arroz Con [NAME]) and stated the presentation did not look like it should. She stated if residents did not want the item on the menu, they are able to have an alternative meal (soup and salad . She stated she was new to the facility. The Dietitian Consultant stated a negative outcome of meals not being palatable and attractive was a Resident can have nutrition inadequacy. During an Interview on 07/17/2025 at 11:05 AM with the Dietary Manager she reflected awareness of lunch on 07/16/2025 not being attractive. She stated she would help the cook by giving her opinion and provide training; however, they should follow the recipe. She stated a negative impact to food not being attractive would-be Residents not eating and weight loss. During an interview on 07/17/2025 at 11:08 AM with the [NAME] she stated she was told to use shredded chicken instead of chicken cubes by her Dietary Manager. She stated she did follow the recipe, and she figured I did not turn out right because of the shredded chicken. She stated she understood if food was not appealing how, it could affect a Resident, and they would not eat and possible loss weight. During an interview on 07/17/2025 at 11:11AM with the Administrator, he stated his expectations was for meals to be appealing. He stated he was not pleased with the food (Arroz Con [NAME]) presentation. He stated all food served is to be palatable to ensure Residents are getting a nutritionist meal. Record review of facility test tray policy dated October 1, 20218 reflected, The facility recognizes the importance of routine quality assurance monitoring to ensure that its residents are provided food that is appealing, palatable and served at the correct temperatures. Routine test trays will be evaluated by the Nutrition & Foodservice Manager or designated employee.

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 and follow accepted national standards for one of five residents (Resident #48). reviewed for infection control practices. The facility failed to ensure that staff wore a gown during medication administration via g-tube (a tube inserted into the stomach) for Resident #48. This failure could place the resident at risk for cross contamination.Findings Included: Review of Resident #48's Face sheet reflected a [AGE] year-old female, admitted on [DATE]. Diagnoses included Huntington's Disease (a genetic condition affecting the brain's nerve cells, causing gradual loss of function and cell death), dysphagia (difficulty swallowing), aphasia (difficulty using or comprehending language), and Alzheimer's disease (dementia that damages the brain). Review of Resident #48's Annual MDS dated [DATE] reflected the resident is rarely or never understood. The Functional Abilities section reflected she is dependent for all care. For section K0520 Nutritional Approaches, it indicated she used a feeding tube only for nutrition at the time of the assessment. Review of Resident #48's Orders reflected at order dated 04/16/2025 for Place on Enhanced Barrier Protection. Review of Resident #48's Care Plan reflected a Problem initiated on 05/28/2024 stating, [Resident #48] has the need for Enhanced Barrier Precautions due to: g-tube. Is at risk for infection, depression, feelings of isolation, and decline in physical activity. The Interventions dated 05/28/2024 included, Place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures: Gown and gloves only for high-contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care). Observation of medication administration with LVN A on 07/16/2025 at 08:40AM, revealed LVN A did not wear a gown while administering medications via G-tube for Resident #48. In an interview with LVN A on 07/16/2025 at 08:54AM, she stated that she should have worn a gown to administer medications via g-tube for Resident #48. She stated that potential impact to the resident of not wearing a gown while administering medications via g-tube could be the potential spread of infection to the resident. In an interview with IP on 07/17/2025 at 11:32AM, she stated that she was the Infection Preventionist for the facility. She stated it was her responsibility to monitor and educate staff regarding EBP (Enhanced Barrier Precautions). She stated that it was her expectation that staff wear gowns and gloves when providing care to residents with PEG (type of g-tube) tubes, during wound care, and during medication administration. She stated that not wearing a gown and gloves during g-tube medication administration would put the resident at potential risk for infection. In an interview on 07/17/2025 at 12:56PM with the DON, she stated that staff are supposed to wear and gown and gloves during medication administration with a g-tube. She stated that the risk to the resident of not wearing a gown and gloves during medication administration with a g-tube is the potential to cause infection for the resident. In an interview on 07/17/2025 at 12:58PM with ADMIN, he stated it was his expectation that staff follow precautions per the signage on the door. He stated he would defer to nursing regarding the specific cares that require the precautions. He stated that not following EBP when indicated would increase the risk of infection for the resident receiving care. Review of facility Infection Control Program policy dated 05/13/2023 reflected, Policy: This facility has established and maintains 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 as per accepted national standards and guidelines.5. Isolation Protocol (Transmission-Based Precautions):a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Review of the CDC guidelines for Enhanced Barrier Precautions in Nursing Homes dated 05/20/2024 reflected, EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP.EBP should be used for any residents who meet the above criteria, wherever they reside in the facility.

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one(Resident #1) of 5 residents reviewed for care plans. The facility failed to revise Resident #1's care plan to reflect the most recent fall on 03/25/2025. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: Review of Resident #1's face sheet dated 03/28/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included essential primary hypertension(a condition characterized by persistently elevated blood pressure without an identifiable underlying cause), major depressive disorder (a common mental health condition characterized by persistent low mood, loss of interest or pleasure, and other symptoms that significantly interfere with daily functioning), delirium (a sudden change in mental state characterized by confusion, disorientation, and difficulty focusing), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicated she was moderate cognitive intact. Review of Resident #1 's care plan dated 03/28/2025, reflected date initiated 09/19/2024 and revised on 09/19/2024 Resident # 1 had an actual fall on 09/18/2024. Review of Resident #1's incident report dated 03/25/2025, reflected that Resident # 1 had slipped off the bed and it was unwitnessed. During an interview with the ADM on 03/30/2025 at 3:20 PM, the ADM stated that the MDS Coordinator was responsible for updating the care plans. The ADM stated it was expected for the MDS Coordinator to update the care plan so the needs of Resident # 1 would be met. During an interview with the MDS Coordinator on 03/30/2025 at 3:26 PM, the MDS Coordinator stated she was responsible for updating care plans. The MDS Coordinator stated she did not update the date of the most recent fall and only added Resident #1's intervention on 03/25/2025 of nonskid tape. MDS Coordinator stated when the care plan was not updated the resident's needs would not have been met. Review of the facility policy Care Plans Revisions Upon Status Change dated 10/24/2022 reflected The purpose of this procedure is to provide a consistent process for reviewing and revising the car plan for those experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.

Based on observations, interviews 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 reviewed for kitchen sanitation. The facility failed to ensure the kitchen floors, food preparation surfaces, pantry shelves and refrigerator shelves were clean. The facility failed to ensure frozen meat was thawed and stored properly prior to preparation. The facility failed to ensure stored foods were properly stored, labeled, and dated. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. Findings included: Observation on 06/09/2024 at 9:00 AM in the facility kitchen revealed there were spilled liquids and food debris on all areas of the kitchen floor. All of the food preparation countertops had food spills and food debris. The shelves under the area containing the hot food serving trays had food spills and debris on them. A lid to a hot food serving tray had food debris on it and was sitting on top of a dirty box under the counter. The dry pantry floor had loose food debris on it and one of the shelves had pieces of dry cereal on it. A mop head in a plastic bag was on located on top of the canned goods. Observation on 06/09/2024 at 9:05 AM revealed a 10-pound roll of hamburger meat sitting on the countertop. The meat was soft and warm at one end and cooler toward the other end. It did not feel frozen. Observation on 06/09/2024 at 9:08 AM revealed the refrigerator in the kitchen contained an undated box of moldy green peppers with holes in them. The refrigerator shelves had food debris on them. There was a large container of undated cooked rice. There was a quart size container of liquid egg whites that was opened and not dated with an open date. A bottle of ranch dressing was opened, and the opened date was illegible. In an interview on 06/09/2024 at 9:10 AM the [NAME] stated she had worked at the facility for one year. She stated the hamburger meat was frozen when she got it out at 5 am that morning and she had put it on the counter to make a meatloaf for later. She stated it should not be sitting out on the counter and it had to be at a specific temperature, but she did not know what that was. She removed the hamburger meat from the counter and placed it in a container in the sink under cold running water. She stated the mop head should not have been on top of the canned goods and she removed the bag containing it. She further stated she had been off of work for two days. She stated she only had one worker on the 1-8 PM shift and her manager would come in on the night shift to clean the floors. She further stated the facility maintenance person was supposed to power wash the floors, but the facility maintenance person had only been employed for three days. In an interview on 06/11/2024 at 2:03 PM the Dietary Manager stated he had worked at the facility for four months. He stated he expected routine cleaning in the kitchen. He stated the kitchen was a little understaffed and they were missing two dietary aides. He stated he worked the morning shift for breakfast and assisted with lunch shift. He stated he would take a break and then return to the facility to work as a dietary aide in the evenings. He stated they had ads out to hire more staff but getting staff to stay had been an issue. He stated cleaning the kitchen would fall on everyone employed there and if a staff member saw something they should do something about it. He stated he tried to in-service and educate the staff. He stated food should be dated with the opened date and the date should be legible. He stated spoiled food should have been discarded. He stated when staff arrived in the morning or left for the night kitchen cleanliness and food labeling should have been checked. He stated there was no checklist or way to ensure accountability, but he would have to implement a checklist or duty sheet. He stated the moldy peppers in the refrigerator should have been discarded. He stated if closing duties had been implemented they would have caught the issues noted in the morning. He stated the 10-pound roll of hamburger meat should not have been left out on the countertop. He stated the potential risk to the residents was being served spoiled food or hamburger meat then there could be a food poisoning, or a food borne illness. In an interview on 06/11/2024 at 3:45 PM the ADM in training stated the facility should ensure all food are was prepped in a safe and sanitary way. He stated all foods in the refrigerator should have been labeled and dated and all raw foods should have been handled per guidelines, either by being kept in the freezer, refrigerator or under cold running water. He further stated the potential risk was spoiled food could adversely affect the resident's health and lead to a food borne illness. Record review of a facility policy and procedure dated 2018 and titled General Kitchen Sanitation reflected The facility recognizes that food borne illness has the potential to harm elderly and frail residents. All Nutrition and Food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure 1. Clean and sanitize all food preparation areas, food contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware and food contact surfaces of equipment, except cooking surfaces of equipment and pot and pans that are not used to hold or store food and are used solely for cooking purposes. 6. Clean nonfood contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, food particles and otherwise in a clean and sanitary condition. Record review of a facility policy and procedure dated 2018 and titled Food Storage reflected Policy: To ensure all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms. i. Do not use or store cleaning materials where they might contaminate foods. Store in locked area away from any food products. 2. Refrigerators a. Keep fresh meat, in the refrigerator at an internal temperature of 41 degrees F or less. d. Date, label and tightly seal all refrigerated foods. 3. Freezers i. Once frozen food has been thawed, it must be maintained at 41 degrees F or less prior to cooking. Record review of fda.gov, FDA Food Code 2022, dated 2022 reflected: 3-501.13 Thawing. Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5 degrees C (41degrees F) or less Pf; or (B) Completely submerged under running water: (1) At a water temperature of 21degrees C (70degrees F) or below Pf, (2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5degrees C (41degrees F) Pf, or (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5oC (41degrees F), for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking Pf, or (b) The time it takes under refrigeration to lower the FOOD temperature to 5degrees C (41degrees F) Pf; 4-602.13 Nonfood-Contact Surfaces. Nonfood-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Based on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for 1 of 151 resident rooms (Resident # 38), and 1 of 1 dining rooms whose environment was reviewed. A) The facility failed to ensure Resident # 38's room was free of trash and debris on the floor on 06/09/2024 at 10:12 AM. B) The facility failed to ensure the dining room floor was free of dead and dying insects during the meal service on 06/09/2024 at 12:03 PM. These failures could place residents at risk of living in an unsanitary, uncomfortable environment, and lead to a diminished quality of life. Findings included: A) Record review of the undated Face Sheet for Resident #38 reflected he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Chronic Systolic (Congestive) Heart Failure (lifelong condition left ventricle of the heart becomes weak and cannot contract normally. This prevents the heart from pumping enough blood with enough force to circulate throughout the body). Record review of the MDS OSA dated 05/13/2024 for Resident #38 reflected he had a BIMS score of 11 indicating moderate cognitive impairment. Observation on 06/09/2024 at 10:12 AM in Resident # 38's room revealed there was loose trash and debris on the floor beside his bed. The floor appeared dingy and unclean. Resident # 38 was sleeping and not available for an interview . B) Observation on 06/09/2024 at 12:03 PM in the facility dining room during lunch service revealed one dead roach and another roach that was wiggling near the back of the dining room, in plain view of residents who were starting to receive their lunches. There were two dead crickets on the dining room floor. In an interview on 06/11/2024 at 1:35 PM LVN A stated she would expect dead bugs to be swept up in the dining room. In an interview on 06/11/2024 at 1:50 PM the DON stated her expectation was for there to be no pests in the facility and for the rooms to be clean. In an interview on 06/11/2024 at 3:50 PM the ADM in training stated his expectation was for the facility to maintain livable conditions and there should be daily rounds to ensure cleanliness. He stated roaches and other insects on the dining room floor could affect the dignity of the residents. Record review of an undated facility Policy and procedure titled General Housekeeping Policies : The facility provided sufficient housekeeping and maintenance personnel, equipment and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. All housekeeping personnel utilize the accepted practices and procedures to keep the facility free form offensive odors, accumulation of dirt, rubbish, dust, and hazards as well as participate in ongoing education and training to maintain their competency.

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 communicable diseases and infections for 1 (Resident #37) of 14 residents reviewed for infection control. LVN A failed to perform hand hygiene after removing her gloves and before putting on clean gloves while performing wound care to Resident #37 on 06/11/24. This failure could place residents at risk for cross contamination and the spread of infection. Findings included: Review of Resident #37's Significant change in status MDS assessment, dated 04/24/24, Section A (Identification Information) reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including cerebral infarction due to embolism (obstructed blood flow to the brain due to a clot causing brain tissue damage), hypertension (high blood pressure), peripheral arterial disease (narrowing of arteries which results in reduced blood flow to the legs), hemiplegia (paralysis of one side of the body), dysphagia (difficulty swallowing), schizophrenia (a mental health disorder characterized by delusions, hallucinations, and disorganized thoughts), legal blindness, and muscle wasting/atrophy( degeneration or shrinkage of muscle). Section C (Cognitive Patterns) reflected a BIMS score of 3 indicating severely impaired cognition. Review of Resident #37's comprehensive care plan, revised 06/09/24, reflected, The resident has actual impairment to skin integrity of right heel related to PAD . Resident's opening to her right heel will show signs of healing . Apply treatment per medical practitioner's orders . Another problem reflected, Resident has actual impairment to skin integrity of the left buttock . opening to left buttock will show signs of healing . assist with turning and repositioning every 2 hours and as needed . Subsequent problems reflected skin impairment to right buttock and coccyx. During an observation on 06/11/24 at 11:23 AM to 11:47 AM, revealed LVN A performed wound care on Resident #37. The ADON was present in the room and recorded the wound measurements. LVN A washed her hands and donned gloves. With the brief already removed and the buttocks exposed, she measured the wounds on the left buttock. She doffed the gloves and, without performing hand hygiene, donned a new pair of gloves. She measured the wound on the coccyx. She doffed the gloves and, without performing hand hygiene, donned a new pair of gloves. She measured the wound on the right buttock, doffed the gloves then washed her hands. She donned gloves and measured an area on the resident's knee. She removed the gloves and washed her hands. She donned gloves and cleansed the left buttock. She doffed the gloves, and without performing hand hygiene, donned new gloves. She used gauze to pat dry the area. She doffed her gloves and without performing hand hygiene, she donned new gloves. She applied ointment to the wound then doffed her gloves and, without hand hygiene donned new gloves. The same process continued for the wound on the coccyx and the wound on the left buttock. LVN A washed her hands then donned new gloves. She measured the wound on the right heel. LVN A doffed her gloves, and without performing hand hygiene, donned new gloves. She cleansed the heel wound. LVN A doffed her gloves, and without performing hand hygiene donned new gloves and used gauze to pat the wound dry. LVN A opened a package of a medicated gauze and placed the wrapper in the red trash bag (biohazard waste) touching the inside of the bag with her gloved hands. She proceeded to apply the dressing to the wound without changing her gloves. LVN A was observed changing her gloves 20 times throughout wound care process. LVN A was observed washing her hands 6 times throughout the process. During an interview on 06/11/24 at 1:52 PM, LVN A stated she had received training on wound care, hand hygiene, and infection control. LVN A stated she was supposed to change gloves when moving from one field to another. When asked if she was familiar with the facility policy on hand hygiene she stated, I am now because they just showed me. She stated she did not perform hand hygiene each time she changed gloves, but it should have been performed before donning gloves, at every glove change, and when doffing gloves. She stated not performing hand hygiene increased the potential for contamination. During an interview on 06/11/24 at 3:06 PM, the ADON stated hand hygiene should be completed with each glove change. She stated during her observation earlier of wound care, LVN A changed her gloves about 30 times during wound care but did not perform hand hygiene every time. She stated not performing hand hygiene when changing gloves increased the potential for infection. During an interview on 06/11/24 at 3:10 PM, the acting ADM stated had hygiene should be performed when hands or gloves are visibly soiled, when starting a new procedure, after toileting, and multiple other times. He stated LVN A had counted 20 glove changes but did not perform hand hygiene with each glove change. He stated not performing hand hygiene with each glove change had the potential to increase the risk of contamination or infection. Review of the facility policy, Hand Hygiene, implemented 10/24/22, reflected in part, Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water, or the use of an antiseptic had rub, also known as alcohol-based hand rub . 6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves

Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #23) 10 residents reviewed for pharmacy services. The facility failed to ensure Resident #23 had a stop date for PRN Ativan (a medicine used to treat the symptoms of anxiety). This failure could place residents at risk of being overmedicated or receiving unnecessary medications. Findings included: Review of Resident #23's annual MDS assessment, dated 04/03/24, Section A (Identification Information) reflected an [AGE] year-old female initially admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses that included Alzheimer's Disease (a type of dementia), cerebrovascular accident (stroke), arthritis (swelling and tenderness of joints), anxiety disorder (intense and excessive worry and fear), and depression (a mood disorder with persistent feeling of sadness and loss of interest). Section C (Cognitive Patterns) reflected a BIMS score of 00 indicating severely impaired cognition. Review of Resident #23's comprehensive care plan, revised 04/19/24, reflected the use of anti-anxiety medications and interventions to monitor for side effects. The care plan reflected the problem, [Resident #23] is at risk for digestive/bowel problems, headaches/migraines, rapid heartbeat, infections, substance misuse, insomnia, heart disease, isolation, frustration, and constant fear secondary to diagnosis of anxiety. Interventions included Administer medications as ordered. Behavioral health consults as needed. Monitor/record/report to MD prn mood patterns, signs and symptoms of depression, anxiety, sad mood . Review of Resident #23's physician's order dated 06/01/24 reflected, Ativan Oral Tablet 1 Mg (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety related to anxiety disorder. The order had no end date. Review of Resident #23's Medication Administration Record for June 2024, reflected Ativan 1 mg was administered on both 06/09/24 and 06/10/24. During an interview on 06/11/24 at 9:50 AM, the DON stated all their PRN psychotropic medication orders were limited to 14 days. She stated they did not use PRN antipsychotic medications. She stated it did not meet her expectations that there was a PRN Ativan order without an end or stop date. She stated she was responsible for monitoring psychotropic medications and she was responsible for ensuring follow up on the pharmacist's recommendations. During an interview on 06/11/24 at 3:06 PM, the ADON stated PRN psychotropic medications should be limited to 14 days to ensure the medications was still necessary. Review of the facility policy, Psychotropic Medication, dated 08/15/22, reflected in part, 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order

Based on observation, interview, and record review, the facility failed to post required nurse staffing information in a prominent place readily accessible to resident and visitors. The facility failed to ensure nurse staffing information was posted on 06/08/24 and 06/09/24. This failure could put residents, resident representatives, and visitors at risk of being unaware of actual staffing levels and available staff. Findings included: An observation on 06/09/24 at 10:29 AM revealed the posted staffing information was dated 06/07/24. During an interview on 06/11/24 at 9:50 AM, the DON stated the staffing information was to be posted daily and that she was responsible to post the papers. She stated the weekend charge nurse was responsible to ensure the posting was updated. She stated it did not meet her expectations that on 06/09/24, the document was dated 06/07/24. She stated there was no risk to the resident for not posting; the only risk was that the surveyor would cite them. Review of the facility policy, Nurse Staffing Posting Information, dated 10/24/22, reflected in part, It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time . 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. 44317

Based on interview, and record review the facility failed to ensure the required 80 square feet per resident for 47 of 47 rooms licensed for double occupancy. The facility failed to ensure resident rooms had the required 80 square feet per resident. This deficient practice placed residents at risk for having a diminished quality of life. Findings included: In an interview on 06/11/2024 at 10:53 AM the acting ADM stated all of the facility's double occupancy rooms measured less than 80 square feet per resident. He said the facility was not planning on changing anything as there was no possible way to make any changes. He stated a waiver was requested when the facility submitted the plan of correction from last year's citation and the plan of correction was accepted. He stated he wished to continue the room waiver and the health and safety of the residents would not be affected. He stated there was no room waiver policy. Record review of the facility map (undated) reflected 47 rooms did not have 80 square feet per resident. were of the smaller size . Record review of the Bed Classification form dated 06/10/2024 and signed by the acting ADM revealed all the resident rooms were licensed for double occupancy. Record review of the Room Size Waiver for Facilities form dated 06/10/2024 and signed by the acting ADM reflected the facility met all four criteria for a waiver including 1. The minimum square footage allowed for a waiver is 72 square feet per resident in multiple-use rooms. 2. Residents are ambulatory and have sufficient space to meet their needs and/or residents with physical disabilities have adequate space to meet accessibility standards. 3. The health and safety of the residents will not be adversely affected. 4. There is not impediment to the resident attaining the highest practicable well-being.

Based on observation, interview and record review, the facility failed to follow the menu for four (Resident #12, Resident #25, Resident #97, and Resident #9) of eight residents reviewed for menu accuracy. 1. The FSD failed to ensure the pureed recipe was accurately followed for Residents #12, #25, #97, and #9. 2. The Cook failed to use the correct scoop size to serve residents. This failure placed residents at risk of decreased intake and weight loss. Findings included: A record review of Resident #12's face sheet dated 4/27/2023 reflected an [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia (mental disorder), muscle wasting and atrophy (muscle loss), muscle weakness, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (acid reflux), protein-calorie malnutrition (undernutrition), vitamin deficiency, and hypertension (high blood pressure). A record review of Resident #12's MDS assessment dated [DATE] reflected a BIMS score of 99, which indicated he was unable to complete the interview. A record review of Resident #12's care plan last revised on 4/13/2023 reflected he was at risk for imbalanced nutrition, unintended weight loss, and received a pureed diet. A record review of Resident #12's physician order dated 3/11/2023 reflected he required a pureed diet. A record review of Resident #25's face sheet dated 4/27/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of dementia (mental disorder), muscle weakness, history of traumatic brain injury, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (acid reflux), and hypertension (high blood pressure). A record review of Resident #25's MDS assessment dated [DATE] reflected no BIMS score, which indicated the resident was not assessed for cognition. A record review of Resident #25's care plan last revised on 4/27/2023 reflected he was at risk for imbalanced nutrition, unintended weight loss secondary to CVA, and received a pureed diet. Resident #25's care plan reflected he received hospice services and was at risk for decline in nutritional status. A record review of Resident #25's physician order dated 11/23/2022 reflected he required a pureed diet. Resident #25's physician order dated 1/26/2023 reflected DC all weekly and monthly weights. Activity is too taxing for resident. A record review of Resident #97's face sheet dated 4/27/2023 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of urinary tract infection, hypertension (high blood pressure), atherosclerotic heart disease (narrowed arteries), and chronic obstructive pulmonary disease (lung disease). A record review of Resident #97's MDS assessment dated [DATE] did not reflect a BIMS score. A record review of Resident #97's BIMS assessment dated [DATE] reflected a score of 2, which indicated severely impaired cognition. A record review of Resident #97 care plan last revised on 4/26/2023 reflected she was at risk for imbalanced nutrition, unintended weight loss, and received a pureed diet. A record review of Resident #97's physician order dated 4/25/2023 reflected she required a pureed diet. A record review of Resident #9's face sheet dated 4/27/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (brain disorder), dysphagia (difficulty swallowing), muscle wasting and atrophy (muscle loss), obsessive-compulsive disorder (mental and behavioral disorder), gastro-esophageal reflux disorder (acid reflux), cerebral infarction (stroke), major depressive disorder (depression), hyperlipidemia (high cholesterol), deficiency of other vitamins and hypertension (high blood pressure). A record review of Resident #9's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. A record review of Resident #9's care plan last revised on 4/27/2023 reflected she was at risk for imbalanced nutrition, unintended weight loss, and received a pureed diet. A record review of Resident #9's physician order dated 4/06/2022 reflected she required a pureed diet. Observations on 4/25/2023 at 12:48 p.m. revealed Resident #12 and Resident #25 were in the dining room being fed pureed food by caregivers. Resident #25 had finished eating most of his food. Both Resident #12 and Resident #25 were non-interviewable. During an observation and interview on 4/26/2023 at 10:57 a.m., the FSD was pureeing lunch items for residents on a pureed diet. The FSD measured 15 scoops of turkey [NAME] using the grey (4 ounce) scoop and pureed it. The FSD stated there were 11 residents on a pureed diet and that she was preparing 15 servings. The recipe for turkey [NAME] was on the kitchen counter and it reflected instructions for pureeing the turkey [NAME] in increments of 5. It reflected that for 15 servings, 15- 8 ounce servings needed to be pureed. During an interview on 4/26/2023 at 11:25 a.m., the FSD stated she was finished with pureeing the food items for lunch. During an interview on 4/26/2023 at 11:28 a.m., when asked how she knew how much to puree for the turkey [NAME] dish, the FSD stated the recipe called for 15 grey (4 ounce) scoops and she pointed to the recipe which reflected it called for 15- 8 ounce portions to be pureed. The FSD stated the grey scoop (4 ounces) contained 8 ounces. When asked how she knew the grey scoop (4 ounces) contained 8 ounces, the FSD pointed to a chart posted on the refrigerator which reflected each scoop, its color, its size number, and the ounces it contained. The chart reflected the grey scoop held 4 ounces, not 8 ounces. When asked how many ounces a half cup (4 ounces) was, the FSD stated 8. When asked how she knew a half cup (4 ounces) was 8 ounces, the FSD consulted with the RDN, who was standing in the kitchen. An observation on 4/26/2023 at 11:30 a.m. revealed the RDN checked the diet spreadsheet, discovered the FSD had not pureed enough turkey [NAME], and instructed the FSD to puree 15 more grey (4 ounce) scoops of turkey [NAME]. The FSD then began pureeing additional servings of turkey [NAME]. An observation on 4/26/2023 at 11:56 a.m. revealed the Cook was serving lunch in the kitchen. As the Cook served pureed turkey [NAME] using a 4 ounce scoop, the FSD instructed the Cook by stating, remember it's two scoops of the 8 ounce. This indicated the FSD did not know how many ounces the scoop contained. Observations of the kitchen on 4/26/2023 at 12:04 p.m. revealed a portion control chart was posted on the refrigerator. This chart reflected different scoops, their color, size, and capacity. Menu extensions were available in a binder, however, they were not posted or dated. During an interview on 4/26/2023 at 12:06 p.m., the FSD stated she had completed in-services with staff on portion control and preparing puree food items. The FSD stated she received video trainings on those topics from the dietitians, including the RDN. During an observation and interview on 4/26/2023 at 1:45 p.m., the FSD stated the scoops had the number of ounces they contained written on the inside of the scoop. Observed the interior of the grey scoop (scoop #8/4 ounces) and it contained a #8 engraved on the inside of the scoop. FSD stated this was how many ounce it contained. An observation of the kitchen on 4/27/2023 at 11:33 a.m. revealed the service line was set up in preparation for lunch and scoops were in their respective steam pans. There were two steam pans of mashed potatoes-one larger one with a grey (4 ounce) scoop and one smaller one with a blue (2 ounce) scoop. The FSD stated both were mashed potatoes, both were the same, and that she had placed the smaller pan next to the pureed items for convenience of serving. During an interview on 4/27/2023 at 11:41 a.m., when asked why a blue (2 ounce) scoop was used to serve mashed potatoes to residents on a pureed diet whereas residents on a regular diet were to be served using a grey (4 ounce) scoop, the FSD stated they got a smaller scoop because that was what was on the diet spreadsheet. When asked why those residents received a smaller portion than other residents, the FSD stated she did not know but she would find out by asking the FSD, who was standing in the kitchen. An observation on 4/27/2023 at 11:42 a.m. revealed the Cook began serving lunch. The Cook did not check the diet spreadsheet prior to serving. The FSD was present in the kitchen and had not verified that scoop sizes were correct prior to the start of service. The Cook used a blue (2 ounce) scoop to serve mashed potatoes to a resident on a pureed diet. Observed the RDN check the diet spreadsheet and communicate to the FSD that the wrong scoop size had been used. The FSD then instructed the Cook to replace the blue (2 ounce) scoop with the grey (4 ounce) scoop. During an interview on 4/27/2023 at 12:17 p.m. the RDN stated he was covering at that facility because they had recently switched dietitians. The RDN stated his first time in the facility was the day prior (on 4/26/2023). When asked how the facility ensured residents on a pureed diet received enough to eat, the RDN stated they're supposed to follow the standardized recipes and when they use the recipes, they're supposed to refer to the dietary spreadsheet for the meal that day. When asked how the facility ensured kitchen staff used the correct scoop sizes, the RDN stated typically the cook will go through it and the FSD will go through the serving line and check. The RDN stated the Cook had been getting nervous all day with so many people in the kitchen and that caused her to get confused with the scoops at lunch that day so that was why she used the blue scoop for the mashed potatoes. When asked how staff had been trained on which scoop sizes to use, the RDN stated we do a roll out of in-services with dietary managers and stated the dietitians would review the new menus and diet spreadsheets with dietary managers. The RDN stated the FSD then shared this information with kitchen staff. The RDN stated the dietitians could provide further education if needed. When asked how kitchen staff had been trained on knowing the scoop numbers, colors, and how much each held, the RDN stated the cooks reviewed the menu extensions with the portions and stated they had a cheat sheet on the refrigerator so they knew which color matched the scoop # and how many ounces it held. When asked if kitchen staff had been trained on reading the diet spreadsheet, the RDN stated, I can't verify the names but stated the FSD had a sign in sheet for an in-service she completed with staff on portion sizes. The RDN stated the FSD as well as himself were responsible for training staff. The RDN stated he trained the FSD and the FSD trained kitchen staff. The RDN stated that since the FSD was in the facility every day, she was responsible for monitoring the kitchen to ensure staff used the correct scoops. When asked how staff were monitored to ensure compliance of the menu, the RDN stated the FSD reviewed the menu with cooks before they cooked the meal. The RDN stated when the cooks set up their service line, the FSD checked the service line. The FSD stated that day (4/27/2023), the FSD had a deadline to submit her food order so she went into the kitchen late. The FSD stated that without intervention, he was not sure whether the FSD would have caught that the Cook used the wrong scoop to serve mashed potatoes. When asked if he had observed the FSD checking the service line before meal service that day (4/27/2023), the RDN stated, no. The FSD stated he did not observe the FSD checking the service line prior to service the day before (4/26/2023) either but he stated he thought that she did. The RDN stated that after lunch on 4/26/2023, he reviewed the recipes with the FSD to see where the miscommunication was because there was a casserole (turkey [NAME]) that needed to be 8 ounces. The RDN stated it seemed as if the FSD did not see the number 2 in front of the scoop number listed as the portion size on the recipe for pureed turkey [NAME]. The RDN stated the FSD monitored portion sizes every month by completing a tray line check. When asked what a potential negative resident outcome could be if residents on a pureed diet received less food than they were supposed to, the RDN stated, they could slowly lose weight depending on the resident and depending on which serving it was and how many calories the resident needed, there could be a slow weight loss. An observation on 4/27/2023 at 12:10 p.m. revealed Resident #97 was eating a plate of pureed food in the dining room. Resident #97 was talking with family and unavailable for an interview. An observation on 4/27/2023 at 12:11 p.m. reveal Resident #9 was eating pureed food in the dining room. Resident #9 said the food was good. During an interview on 4/27/2023 at 2:27 p.m., when asked how the facility ensured residents got enough to eat, the ADM stated, we have the diets that we follow and the RDN checks off. The ADM stated she went into the kitchen to do random rounds. The ADM stated the majority of residents had gained weight since they had been in the facility and if residents had lost weight, they had medical issues. When asked what the facility's policy was on following menus, the ADM stated, they follow the recipes because it says on there what they're supposed to utilize. The ADM stated the FSD and the RDN were responsible for ensuring compliance of that policy. When asked how the RSD and RDN monitored, the ADM stated, I know they're in there watching and looking at recipes. When asked how staff were trained on using the correct scoop sizes, the ADM stated she believed there was visual training with the scoop chart posted on the refrigerator as a visual cue. The ADM stated the recipes reflected which scoops to use. The ADM stated kitchen staff had been trained on scoops sizes by the FSD and the RDN. When asked if the FSD was checking the service line before each meal, the ADM stated, she should be checking it. When asked what a potential negative resident impact could include if residents did not receive adequate portions, the ADM stated, I feel comfortable with the weight system and I think this was an isolated thing and she was nervous. The ADM stated she would make sure there was additional education and monitoring. A record review of the facility's Monthly Weight Report dated 4/25/2023 reflected the following: Resident #25 lost 7.8% of his body weight from October 2022 - January 2023, which is considered severe weight loss. Resident #25 had no recorded weights for February, March, or April of 2023. Resident #9 and Resident #12 had gained weight from January 2023 - April 2023. Resident #97 had no recorded weights. A record review of the facility's recipe for pureed turkey [NAME] reflected Portion Size: 2 #8 SCOOPS. A record review of the facility's recipe for pureed mashed potatoes reflected Portion Size: #8 SCOOP. A record review of the facility's Diet Spreadsheet reflected residents on a pureed diet were to receive 2 #8 scoops of turkey [NAME] for lunch on 4/26/2023. A record review of the facility's Diet Spreadsheet reflected residents on a pureed diet were to receive a #8 scoop of mashed potatoes for lunch on 4/27/2023. A record review of the facility's in-service dated 1/09/2023 reflected the FSD trained dietary staff on portion size breakdown and the recipes book. The Cook was listed on the sign in sheet. A record review of the facility's in-service dated 1/24/2023 reflected the FSD trained dietary cooks on following portion sizes. The Cook was listed on the sign in sheet. A record review of the facility's in-service dated 3/09/2023, 3/17/2023, 3/23/2023, 3/30/23 reflected the FSD was trained by the RDN on the Spring-Summer 2023 menu, menu extensions, texture instructions on recipes, menu guide textures and menu guide. A record review of the facility's in-service dated 3/17/2023 reflected dietary staff were trained on pureed diets. The Cook was listed on the sign in sheet. A record review of the facility's in-service dated 4/14/2023 reflected the FSD trained dietary staff on scoop sizes and chart reading breakdown to use the right size. A record review of the facility's policy titled Menu planning dated 6/01/2019 reflected the following: Policy: The facility believes that nutrition is an important part of maintaining the well-being and health of its residents and is committed to providing a menu that is well-balanced, nutritious and meets the preferences of the resident population. A standardized menu which meets the nutritional recommendations of the residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, Nationals Academy of Sciences will be used. Modification for resident population and preferences may be made as appropriate. Procedure: 1. Menus will be prepared for each facility by their food vendor. Menus are updated twice each year with Spring-Summer and Fall-Winter cycles and are updated intermittently based on resident preferences. The menus will be for a five-week cycle and will include a week-at-a-glance menu, alternates, diet extensions for all diets offered for each day, nutritional analysis, standardized recipes, a production guide and an order guide. Menus are available in paper form and web-based. A record review of the facility's policy titled Portion Control dated 10/01/2018 reflected the following: Policy: The facility will use standard portion control procedures and utensils to ensure that adequate portions are served to residents. Procedure: 1. Standardized recipes should be used to prevent over-production. Recipes should be adjusted as needed to provide the amount of servings required. Amounts may vary when various serving methods and menus are utilized. 2. A dated copy of the daily menu extensions with portion sizes should be posted in the kitchen near the preparation and serving areas. 3. Portions for each food item should follow the specific portion sizes listed on the menus. 4. Food items should be served using standard size ladles, scoops, spoodles and spoons. Standard scoop and ladle sizes are listed in the following tables: A record review of the facility's policy titled Portion Control dated 10/01/2018 reflected a table for scoop sizes. The following was reflected: A #8 scoop was 1/2 cup and 4 oz. A #10 scoop was 3/8 cup and 3-3 1/2 oz. A #12 scoop was 1/3 cup and 2 1/2 - 3 oz. A #16 scoop was 1/4 cup and 2-2 1/2 oz.

Based on interview, observation and record review, the facility failed to ensure the resident's rights to be free from abuse and neglect for 7 (#31, #24, #18, #36, #53, #29 and #55) of 28 residents reviewed for abuse and neglect. The facility failed to monitor residents and recognize abuse and neglect by CNA A who admitted to abusing residents on Halls E, A, B and C in that Residents #31, #24, #18, #36, #29, #53 and #55 made allegations against CNA The facility failed to ensure that residents felt safe to report abuse without fear of retaliation which resulted in psychosocial emotional harm as evidenced by residents expressing fear and not wanting to reveal identifying information to surveyors at the risk of further harm. The facility failed to ensure staff reported to the abuse coordinator all concerns reported to them by residents to include CNA A reportedly being rough when caring for residents. These failures resulted in an Immediate Jeopardy (IJ) situation on 03/02/2021 at 2:13 PM. While the IJ was removed on 03/08/2021, the facility remained out of compliance at a severity level of potential harm at a scope of pattern due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #31's face sheet dated 03/01/2022 reflected an [AGE] year-old woman admitted to the facility on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #31's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #31 had a BIMS score of 12 (cognitively intact) and needed limited to extensive assistance with ADL with one-person physical assists, the need for a wheelchair for mobility and the use of an indwelling catheter for occasional incontinence. The MDS indicated the Resident #31 had no behaviors but was at risk for developing pressure ulcers. Record review of Resident #31's Care Plan dated 01/30/2021 revealed that Resident #31 received one-person physical assists for bed transfers and extensive one-person physical assist for toileting. Care Plan stated Resident #31 was at moderate risk for falls due to spinal stenosis and contracture of her left foot. The Care Plan documented that on 08/23/21, the resident was found lying on the floor and on 09/05/2021, the resident slid out bed. Interventions included one-person physical assists for bed mobility, transfers, locomotion on and off unit and dressing. Extensive assistance needed for toilet use and personal hygiene. During an observation and interview on 02/28/2022 at 10:44 AM, Resident #31 stated there was an aide that would not pay attention to her and was rough with her. She went on to state this aide left bruises when she is through. She stated the aide also left red marks on her body. Resident showed on her own body (her wrists, and legs) where the bruises were left. Resident was not observed with any bruises during interview. She stated she can feel it in her bones. She stated the aide isn't personable and has said if you don't go know, I won't help you during the night shift. Resident stated she felt pressure to go to bed when she didn't want to. Resident stated she didn't want to say the name of the staff as she might get in trouble. She might not get assistance when she needed if she said the staff members name. She stated she had mentioned this to ADMIN but felt because the facility was short staffed, they continue to let this aide work here. She stated that the staff get mad if she turns her call light on and waits up to an hour for someone to come to aid her when call light was on. She talked about a day where she didn't get her medications and was told to go back to her room. She stated that had been an incident when her wound dressing had not been changed in a whole day, even though she requested it and had to do it herself . During an interview on 2/28/2022 at 02:38 PM, Resident #31 stated she told the ADMIN about the staff was rough with her. The ADMIN told Resident #31 that this wasn't the first time that she has heard this information. Resident #31 felt like the facility felt like it's better than nothing. She stated she didn't feel comfortable revealing the name of the resident because she might get into trouble. During an interview on 02/28/2022 at 05:09 PM, Resident #31 identified the staff member that she was afraid of revealing was staff member was CNA A. She stated she told the Resident Council and felt more comfortable saying it because other people also mention her by name. During an observation of Hallway B on 02/28/2022 at 05:09 PM, Surveyor overheard RN Q inside of Resident 31's room say, we've heard that from other residents as well. During an interview on 03/01/2022 at 01:28 PM with RN Q she has never had issues with CNA A. She stated that CNA A was a serious person and has been working at this facility for about two and a half years. She stated CNA only had a break in employment when positive for covid. She stated she wasn't aware of any abuse allegations involving CNA A and had no concerns with CNA A and other residents. Was asked why she stated I've heard that from other residents when the surveyor was discussing abuse allegations with Resident #31. She stated that she doesn't know what she was referring to. Record review of Resident #24's face sheet dated 03/01/2022 reflected a [AGE] year-old woman admitted to the facility on [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24 needed supervision for activities of daily living with set-up help only and was occasionally incontinent of bowel and bladder. Record review of Resident #24's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #24 had with a BIMS score of 12 (moderate cognitive impairment) and cognition skills for decision making and needed supervision or one-person assistance for activities of daily living. Resident #24 rejected care necessary to achieve goals of health and wellness one to three days. Record review of Resident #24' Care Plan dated 01/19/2019 revealed that Resident #24 participated in occupation therapy three times a week to increase functional mobility and self-care tasks. Resident #24 received one-person physical assists for locomotion on and off unit, extensive assistance for dressing and supervision for walking in her room and corridor. Resident #24 participated in care by allowing staff to perform incontinent care and showers. During an interview on 03/01/2022 at 2:45 PM, Resident #24 said that she doesn't like CNA A. When asked why, Resident stated CNA A told her to make her own bed. She stated that CNA A shoves Resident #18 into the bed when its bedtime even if Resident #18 doesn't want to go to bed. She stated Resident #18 has been wet, and CNA A made her take off all of her clothes and forced her (showed two hands up and a shove motion) into the bed. Stated she has told other staff about this. Record review of Resident #18's face sheet dated 03/01/2022 reflected a [AGE] year-old woman admitted to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #18's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #18 had a BIMS score of 9 (moderate cognitive impairment) and was able to understand others with no hallucinations or delusions. Resident #18 had issues with verbal behaviors directed towards others. Resident #18 needed extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene with one-person physical assistance. Resident #18 required a wheelchair for mobility and is always bowel and bladder incontinent. Record review of Resident #18's Care Plan dated 08/06/2021 revealed that Resident #18 was on a walking program to maintain functioning, an eating and swallowing program to reduce food spillage and extensive assistance for all activities of daily living. During an interview with Resident #18 at 02/28/2022 at 4:20 PM, Resident revealed her leg hurt when CNA H shoved her around and cussed. She revealed CNA H shoves her around when they get Resident up and out of bed. Resident #18 stated I don't want to say nothing to the CNA because she will tell me she's doing pericare you (Resident #18) should be quite. When asked if she has voiced concern and treatment to ADMIN, Resident stated the ADMIN don't care based on her actions. During an interview on 03/01/2022 at 2:54 PM with Resident #18 stated that CNA A has shoved her into her bed. Resident #18 was observed to be curled into a sitting fetal position when discussing how CNA A treated Resident #18. Resident #18's voice was audibly lower and shaky when discussing this mistreatment. She was wiping something wet from her eyes when discussing it with surveyor. Record review of Resident #29's face sheet dated 03/01/2022 reflected a [AGE] year-old-man admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #29's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 had a BIMS score of 2 (significant cognitive impairment) and required extensive assistance or limited assistance with activities of daily living with one- or two-person physical assistance and a wheelchair for mobility. Resident #24 was always bowel and bladder incontinent. Record review of Resident #29's Care Plan dated 10/01/2020 revealed that Resident #29 would have no less than two episodes of fecal matter on himself and would allow staff to help him complete his self-care tasks. Resident #29 received extensive assistance for dressing and personal hygiene with one-person personal assistance. During an interview on 03/01/2022 at 03:11 PM Resident #29 stated he knew who CNA A was. When asked if she was rough with his care he said, I don't want to get into that. When further questioned he stated, I don't want to talk about that. Record review of Resident #36's face sheet dated 03/01/2022 reflected a [AGE] year-old man admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #36's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #36 had a BIMS score of 12 (moderate cognitive impairment) and required extensive or limited assistance for activities of daily living with one-person physical assistance and a wheelchair for mobility. Record review of Resident #36's Care Plan dated 01/25/2022 revealed that Resident #36 maintained mobility by ambulating with a rolling walker for 200 feet, supervised by staff in the hallway. Resident required supervision and one-person assistance for toileting. Resident had falls on 07/19/2021, 08/18/2021, 09/19/2021, 09/23/2021 and was educated on risks of not calling for help after falling. During an interview on 03/01/2022 at 3:15 PM, Resident #36 stated his roommate when CNA A was assisting him he cries, says ow, you're hurting me. Resident #36 stated CNA A was rough with Resident #29's incontinent care and has heard her tell Resident #29, I'll do it how I want to. When Resident #36 asked CNA A for assistance transferring to from wheelchair to bed, she said, you need to be doing that by yourself and left him to transfer himself despite his history of falls per record review. Resident #36 stated I really still need the assistance, CNA A doesn't want to help me even though I feel better with the assistance because I had a fracture. Record review of Resident #53's face sheet dated 03/01/2022 revealed a [AGE] year-old woman admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #53's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #36 had a BIMS score of 15 (cognitively intact) and behavioral symptoms occurred one to three days including verbal symptoms directed at others and other behavioral symptoms not directed at others. Resident #53 needed supervision with one-person assistance for toilet use. During an interview on 02/28/2022 at 10:13 AM, Resident #53 stated she doesn't want retaliation from staff and was visibly distressed when talking to surveyor. She stated she's fighting a spiritual battle and the facility doesn't understand. Resident #53 stated every time she made a complaint the ADMIN talked to her within 12 hours and embarrassed her in front of the staff. Resident stated the facility was always on lockdown and she was stuck in her room During an interview on 02/28/2022 at 09:11 AM, Resident #55 revealed staff was slow to help when asked. Resident #55 revealed staff had made derogatory statements to her. She revealed the medications that was prescribed are not accurate and that administration listens to phone calls made to family. She also revealed the temperature in building gets too cold or too hot. During the Resident Council Meeting on 02/28/2022 at 2:00 PM, Resident #53 revealed that the facility has staff issues and feels as if staff will retaliate against her for complaining on the facility. She stated staff was listening in on phone calls and opened her mail. Resident #31 revealed she feels as if staff will retaliate against her for complaining. She revealed that CNA A was rough when she turned her over in bed, she does not have the personality to take care of elderly people. Resident #31 stated her bandages have not been changed today. During an observation on 02/28/2022 at 5:40 PM, revealed CNA A in the dining area assisting a resident with meal in a slow pace. CNA A was observed rolling her eyes during the meal service as she was holding a utensil to the resident's mouth. She appeared annoyed. During an interview on 03/01/2022 at 01:53 PM, CNA A stated the facility was very short staffed, and the CNAs had to do everything by themselves. She stated she has to turn the person over with one hand, wipe with the other hand, change the dry sheet with one hand and do the cleaning with one hand while holding the resident up alone. She stated the Residents won't help, causing her to be rougher with resident care. CNA A went on to state Residents #18 and #47 won't help her when she was assisting them. She stated she worked on Halls E, A, B and sometimes C providing care to those residents. She stated she's told the ADMIN that doing the care by herself was difficult, but the ADMIN won't do anything to help the situation. She stated Resident #29 was getting kinda stiff because he was not getting the correct assistance and she can't do Resident #29's care by herself. She stated she's told Nurses and the ADMIN about this, but they don't give her assistance. She stated she had residents say you're hurting me when there was nobody around to give CNA A assistance with tasks. She stated she warns the residents that it might hurt. CNA A denied ever leaving marks on a resident and stated she hasn't heard this from residents. She stated she has had an in-service about abuse neglect, had it last month. She went on to state that Resident #53 doesn't like her and accuses her of trying to poison Resident #53. CNA A stated she ignores Resident #53 when she complained and when Resident #53 said she was going to report CNA A to the state. CNA A stated, residents don't have respect for us when we are a few number. CNA A started crying and said it's so stressful when there are only two CNAs for the whole building. CNA A stated she tries to avoid residents that don't like her and went on to state that if the residents don't like her, she doesn't assist them. She stated when she's the only CNA on the hall during her shift, she doesn't know who cares for these residents who don't like her and who she doesn't assist. CNA A stated, I am kind of abusing them because we're not attending them. She stated, you're damned if you do and damned if you don't. She stated the results of leaving vulnerable residents alone could be injury, accidents and death. CNA A stated she has been here at the facility for three years and currently works the 2:00 PM to 10:00 PM shift. She stated she got her training at a facility in anther facility and has also been a CMA. During an interview on 03/01/2022 at 2:53 PM with CNA G stated she had not heard resident complaints of care by CNA A or a resident who had not received care. She stated she had not seen neglect of residents by CNA A. She stated she did not have resident complaints of rough treatment by CNA A. She stated Resident #53 would complain about CNA A attitude but not care provided. During an interview on 03/01/2022 at 03:26 PM, Resident #30 said about CNA A she's evil. She stated the diaper people are the ones getting hurt but CNA A isn't physically rough with Resident #30 but is rude. Resident #30 stated she felt the ADMIN needs people, it doesn't matter what happens. She has told the ADMIN about her concerns but fears of retaliation. During an interview on 03/02/2022 at 6:08 AM CNA H revealed that she had heard that CNA A could be a little rough with residents but had not observed any injuries or bruises on residents that have been cared for by CNA A. She stated she did not know if this had been reported to management. During an interview on 03/02/2022 at 6:20 AM with LVN B stated that she didn't work very much with CNA A and stated the residents complained more about her being rude and her attitude. She said she had not had complaints from residents that CNA A was rough with them or she would have reported it. She stated she didn't know if management knew about CNA A being rude or having a bad attitude, she had not told anyone. During an interview with the DON on 03/01/2022 at 4:33 PM, the DON stated he was not aware or told that CNA A was refusing to provide care to residents and neglecting the residents. The DON received no complaints from residents or other staff regarding CNA A treating them roughly or not providing care. The DON stated he had not been told by staff that CNA A was not providing care to residents. During an interview on 03/04/2022 at 9:14 AM, the DON stated the ADMIN handles the grievances by investigating, gathering facts, interviewing, then mediation. He stated the grievance was put on a concern form but was verbally given to staff then discussed to standup meetings. He stated t the resident forms were available but was verbally reported. He stated that with the reports of retaliation, the verbal report of complaints by residents might not be the best. He stated t he was thinking of ways to change the report using a different scale in order to implement change and help the residents feel more comfortable reporting. During an interview on 03/01/2022 at 5:00 PM the ADMIN stated she was not aware of any physical abuse or neglect allegations regarding CNA A. When informed of CNA A's admission she stated she had no idea that CAN A had been neglecting resident or had been rough with residents She stated CNA A had never come to her to let her know she felt overwhelmed or was having any problems. She stated there were protocols in place such as rotation or re-assignment if staff felt uncomfortable caring for any residents. The ADMIN stated she had never witnessed or overheard CNA A providing inappropriate care (abusive/neglectful) to residents nor was she aware CNA A was avoiding residents, hallways, etc. The ADMIN stated CNA A will be relieved of duty. The ADMIN stated they provided in-services for employees, utilized staffing agencies to ensure full staff, strategized for call in's or staff that was not available. The ADMIN stated it was bullshit that CNA A was not provided with additional help for incontinent care, lifts or other two person duties. The ADMIN stated CNA A had been a CMA but this seemed to be too much for her and was returned to the CNA title when she came back from Covid. The admin stated CNA A rarely worked extra shifts. During an interview on 03/03/2022 at 11:57 AM, Resident #24 stated that CNA A was rough with Resident #18's care. Resident #24 stated prior interview information. She stated that yesterday an aide told her that CNA A called another aide and told the aide that she didn't get fired, was suspended and would return to work when CNAs are shorthanded. Resident #24 stated she didn't want to give out no names because I might get in trouble. She said that when she gets in trouble the facility won't let her have visits with her family and locks me in my room and she doesn't get to associate with others. Resident #24 stated that CNA H was the aide that pushed Resident #18's her hurt leg causing additional pain to the resident. Record review of the facility's in-services revealed the following in-services: 01/31/2022-Understanding Abuse and Neglect, duration (1 hour), presented by ADMIN. Topics discussed were reporting Abuse and Neglect. 02/07/2022-Understanding Abuse and Neglect, duration (1 hour), presented by ADMIN. Topics discussed Abuse/Neglect guidelines. Record review on of the facility's Abuse and Neglect Protocols dated 07/2018 revealed, each Resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility does not allow involuntary seclusion. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator. The Administrator, DON, SVP and Regional Compliance Nurse was notified of the Immediate Jeopardy on 03/02/2022 at 2:13 PM and the IJ template was provided. The Plan of Removal was accepted on 03/08/2022 at 3:20 PM and included the following: Problem: Abuse/Neglect This plan serves as the alleged Immediate Jeopardy removal for F 600: Abuse and Neglect exploitation effective 3/2/2022 Facility failed to protect residents from an abusive staff member Facility did not create a culture of safety in which residents felt they could safely report abuse without fear of retaliation Identification of Others The Unit Coordinator, MDS Coordinator, Health Information Coordinator were directed to interview all interviewable residents one on one to ensure they are comfortable with the staff that is assigned to care for them this was completed on 3-4-22. No other concerns were identified. Unit Coordinator and Administrator verbally Informed the four [CONDITION(S)] residents/residents' representatives that from 3/3/22 ongoing they will be transported to and from [CONDITION(S)] using the centers van or a non- emergency medical van only. Documentation of this communication was recorded in each resident's medical record on 3/3/22 Medical Director was notified on 3-3-22 of abuse and neglect prohibition and reimplementation of ambassador program. Systemic Changes All Staff were re-educated on the centers Abuse and Neglect policy by the Unit Coordinator, NHA and DON, the education was completed on 3/3/22. Employees that were not at work were contacted via phone and educated on policy, completed 3/3/22. Ambassadors and designees were re-educated on the Concern/Grievance Resolution Process, to include location of Concern/Grievance forms and how to complete them. This education was completed on 3/3/22 by NHA, DON and Unit Coordinator. Employees that were not at work were contacted via phone and reeducated on process, completed 3/3/22. NHA/Designee reeducated ambassadors of the centers anonymous Compliance Hotline, which is a third-party managed service number to educate residents and inform them that they can anonymously call in any concern to a third-party person. Poster was placed next to resident use phone; the room has a door for privacy. This education included location of posters throughout the center and was completed on 3/3/22. For employees not at work they were contacted via phone and educated, completed 3/3/22. On 3-2-22 District Director of Clinical Services, Senior vice president of Operations, Nursing Home Administrator (NHA), Director of Nursing (DON) completed an ADHOC QAPI and developed the new [FACILITY] [CONDITION(S)] Transportation Process. Abuse and neglect prohibition policy and ambassador program to be reimplemented. Ambassador program utilizes key staff to round on each resident to ensure their needs are being met, concerns identified and addressed. The NHA/Designee will be the primary responsible person to implement and monitor the new process effective 3-2-22 and will be ongoing. Monitoring NHA/Designee will audit Ambassador rounds daily 5 days a week to validate that all residents are checked in on by their Ambassador started 3-3-22 and will be ongoing. Results of the audit will be reviewed in the monthly QAPI an ongoing. DON/Designee will monitor the Transportation Log daily to validate that all residents are being transported to and from [CONDITION(S)] started 3-3-22 and ongoing. Results of the audit will be reviewed in the monthly QAPI ongoing. NHA/Designee will audit new employee records daily to validate that all new employees have been trained on the new [CONDITION(S)] transportation process prior to working a shift on the floor started 3-3-22 ongoing. Results of the audit will be reviewed in the monthly QAPI ongoing. DON/Designee will audit all new admission daily that require transportation to hemo [CONDITION(S)], to validate that the resident and or resident's representative have been informed of the [CONDITION(S)] transportation process started 3-3-22 and ongoing. Audit results will be reviewed in the monthly QAPI ongoing. NHA will review the results of the monthly QAPI with the SVPO and DDCS monthly to determine compliance and any ongoing monitoring, or any plan changes this will be effective 3-2-22. This will be ongoing. Monitoring for the Plan of Removal was completed from 03/02/2022 through 03/08/2022 and consisted of: During an interview on 03/02/2022 at 08:54 AM, Resident #36 said that he was glad the CNA A was not going to come back to the facility. Has no other concerns with other staff members and feels safe with his care? During an interview on 03/02/2022 at 08:57 AM, Resident #29 stated that he was fine with CNA A not returning to the facility, people are hired and people are fired. He had no further concerns with other staff at the facility. During an interview on 03/02/2022 at 09:28 AM, Resident #18 repeated that CNA A shoved her in the bed and made her go to bed before she wanted to go. Resident stated that she was glad that CNA A was not returning to the facility. During an interview on 03/02/2022 at 09:29 AM, Resident #24 stated that she felt safe now that CNA A was not returning to the facility and didn't have further concerns for staff. During an interview on 03/02/2022 at 09:30 AM, Resident #53 stated she was comfortable that CNA A was not returning to the facility. She stated that CNA A was never physical with her. Staff interviews conducted and record review of staff and training logs revealed staff were re-educated on the centers Abuse and Neglect policy by the Unit Coordinator, NHA and DON, the education was completed on 03/03/2022. Ambassadors and designees were re-educated on the Concern/Grievance Resolution Process Resolution Process, in include location of Concern/Grievance forms and how to complete them. This education was completed on 03/03/2022 by NHA, DON and Unit Coordinator. Record review of Abuse and Neglect in-service training dated 03/03/2022 revealed staff were re-educated regarding Abuse and Neglect policies for Residents at the facility. Record review of Concern/Grievance Resolution Process dated 03/03/2022 revealed that staff were trained on the process and where to find the grievances forms should Residents have any concern that they want to report. An observation on 03/03/2022 at 5:30 PM reflected Anonymous Compliance Hotline sign which was posted in the beauty salon and was a third party managed service number to educate and inform residents of availability to call in anonymous concerns. These failures resulted in an Immediate Jeopardy (IJ) situation on 03/02/2022. While the IJ was removed on 03/08/2022, the facility remained out of compliance at a severity level of potential harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness.

Based on observation, interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for three (Resident #9, Resident #19 and Resident #22 ) of four residents reviewed for quality of care. The facility failed to provide safe and comfortable transportation for Resident #19, an [AGE] year-old female resident who was transported to [CONDITION(S)] in her wheelchair across a busy road in 28 degree Fahrenheit sleeting weather one day after being discharged from the hospital with COVID-19 pneumonia and subsequently had to wait outside the facility in the poor weather conditions for 15-20 minutes before being admitted to the facility. The facility failed to provide safe and comfortable transportation for Resident #9, Resident #19 and Resident #22 who were routinely transported to [CONDITION(S)] in their wheelchair across a busy road with no stop light or sign in all weather conditions and in the dark without safety equipment to prevent a collision with a vehicle. These failures resulted in an Immediate Jeopardy (IJ) situation on 03/02/2021 at 2:13 PM. While the IJ was removed on 03/08/2021, the facility remained out of compliance at a severity level of potential harm at a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for discomfort, serious injury, hospitalization , and death. Findings included: Record review of Resident #19 face sheet dated 03/01/2022 revealed Resident #19 to be an [AGE] year old female admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #19 quarterly MDS assessment dated [DATE] revealed Resident #19 to have a BIMS score of 15 to indicate Resident #19 was cognitively intact. The MDS assessment revealed Resident #19 to need one person assistance in ADL care. Record review of LVN C nursing progress note dated 02/18/2022 at 4:30 PM revealed resident care specialist reported to this nurse after returning from [CONDITION(S)] that Resident #19 was on oxygen and complained of chest pain. This nurse had not received any reports from [CONDITION(S)] nurse regarding resident condition. This nurse assessed resident vital signs and resident complained of chills, body aches, loss of appetite, and weakness. At 3:28 PM this nurse called 911. EMS instructed this nurse to administer 325mg aspirin due to complaints of chest pain. At 5:40 PM EMS arrived and at 5:49 PM resident left the building. Record review of Resident #19 hospital discharge paperwork dated 02/21/2022 revealed Resident #19 tested positive for COVID-19 on 02/18/2022 when brought to the ER in respiratory distress and returned to the facility on [DATE]. Resident #19 was diagnosed with COVID-19 pneumonia while hospitalized . Record review of Resident #19 [CONDITION(S)] record dated 03/04/2022 revealed Resident #19 had [CONDITION(S)] on 02/23/2022 after missing [CONDITION(S)] on 02/21/2022 due to hospitalization . Records indicated Resident #19's chair time was changed to 4:45 PM because Resident #19 was positive for COVID-19. Record review of LVN C charge nurse regarding resident chair time. [CONDITION(S)] nurse stated, Resident #19 must keep chair time of 4:45 PM Monday-Wednesday-Friday until Resident #19 tests negative for COVID-19. Record review of Resident #19 care plan dated 10/04/2021 revealed Resident #19 to needed hemodialysis related to [CONDITION(S)]. Interventions included staff were to check for bruit/thrill every shift, [CONDITION(S)] communication record was sent to [CONDITION(S)] center every treatment and staff were to ensure it was returned. Staff were to encourage Resident #19 to attend scheduled [CONDITION(S)] appointments and check resident vital signs every 24 hours. An observation on 02/28/2022 at 4:00 PM revealed Resident #19 to be in her wheelchair with CNA D prepared to take her across the street to [CONDITION(S)]. CNA D observed to be wearing a reflective green safety vest and carrying a stop sign. In an interview on 02/28/2022 at 9:51 AM Resident #19 stated the facility rolls her to the center across the street in the street in the snow, rain and cold. She stated it was really bad when it was cold. She said recently she had to wait outside of the [CONDITION(S)] center for up to twenty minutes because the [CONDITION(S)] clinic would not let her in due to her having COVID-19. She said she was extremely cold when this happened, but could not remember the exact date. She said the staff always take her to [CONDITION(S)] by walking her there in her wheelchair. She said they do not use the van to transport her to [CONDITION(S)]. In an interview on 03/02/2022 at 11:30 AM, the ADMIN stated she did not know why the nurse did not call her before transporting Resident #19 in poor weather conditions to [CONDITION(S)] across the street. She stated they would have made arrangements for the van driver to transport Resident #19. In an interview on 03/07/2022 at 11:06 AM SVP stated the facility failure regarding [CONDITION(S)] resident transport was a system failure related to culture of not making a change when a change was needed. He stated there was a change to Resident #19's schedule because of COVID-19 and staff did not think to change her transportation as well. He stated Resident #19 was going to [CONDITION(S)] in the middle of the day and then was changed. He stated there was a problem with free thinking in the staff and there needed to be some logic. He stated it would have been the expectation that instead of transporting Resident #19 at night in poor weather conditions, the staff should have called the van driver or ADMIN for help with transportation. He stated he felt the facility was missing a crucial piece of not having a social worker. He stated he felt a social worker would help provide oversight and logic in this situation. In an interview on 03/07/2022 at 11:18 am REG RN stated the systemic breakdown for that situation regarding [CONDITION(S)] patients points toward overall culture at the facility for example just because someplace else was doing does not mean staff should not routinely assess all situations for safety. She stated staff could have used better judgement before she transported Resident #19 across the road after being hospitalized for COVID-19 pneumonia in poor weather conditions. In an interview on 03/04/2022 at 10:22 AM Physician nurse stated she was not aware of the facility taking Resident #19 across road in a wheelchair for [CONDITION(S)]. She stated she had concerns for Resident #19's health related to her age and vulnerability if transported in inclement weather and safety concerns due to the busy nature of the road. Record review of Resident #9 face sheet dated 03/01/2022 revealed Resident #9 to be a [AGE] year old female admitted to the facility 06/26/2020 with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9 quarterly MDS assessment dated [DATE] revealed Resident #9 to have a BIMS score of 14 to indicate Resident #9 was cognitively intact. Resident #9 required one person or stand by assistance for ADL care. Record review of Resident #9 care plan dated 06/28/2020 revealed Resident #9 needed hemodialysis related to [CONDITION(S)] with interventions to include checking access for bruit/thrill and ensuring [CONDITION(S)] communication record was sent with resident each treatment and returned completed by the facility. In an interview on 02/28/2022 at 09:50 AM Resident #9 stated she was wheeled across the street to the [CONDITION(S)] center for treatment. She stated she was transported in the rain and she gets wet. She stated the facility takes them over to the [CONDITION(S)] in their wheelchair across the street no matter what the weather was like. In an interview on 03/02/2022 at 6:15 AM, CNA G stated Resident #9 did not go to [CONDITION(S)] by herself and was taken over in a wheelchair across the street by a staff member. She stated she did take them across the street but did not always use the reflective vest and stop sign. She stated the road could be very busy and they had to hurry across. She denied having any close calls of being hit by a car. She said they use an umbrella if its bad weather and bundle the residents up instead of using the van. She said she did not know why they did not take the residents in the van. She said they did not use a flashlight when crossing the crosswalk in the dark. Record review of Resident #22 face sheet dated 03/01/2022 revealed Resident #20 to be a [AGE] year old male admitted to the facility 12/25/2019 with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #22 quarterly MDS assessment dated [DATE] revealed Resident #22 to have a BIMS score of 15 to indicate Resident #20 was cognitively intact. Resident #22 required stand-by one person assistance for ADL care. Record review of Resident #22 care plan dated 05/20/2020 revealed Resident #20 to needed hemodialysis related to kidney failure with interventions to include checking access for bruit/thrill and ensuring [CONDITION(S)] communication record was sent with resident each treatment and returned completed by the facility. In addition, the staff were to encourage resident to go for the scheduled [CONDITION(S)] appointments. In an interview on 02/28/2022 at 4:30 PM Resident #22 stated the facility takes him to [CONDITION(S)] in a wheelchair across the street to the center. He did not know what happened if the weather was bad. In an interview on 03/03/2022 at 3:48 PM Nurse practitioner stated she was not aware Resident #22 was being wheeled across the street in all-weather types to participate in [CONDITION(S)]. She stated, she would have safety concerns, if she would have been aware of this situation. In an interview on 03/02/2022 at 6:20 AM Charge Nurse LVN B stated for residents on [CONDITION(S)] like Resident #9, she walked them across the street in their wheelchair in the morning. She stated this morning (approximately 5:30 AM) Resident #9 was pushed by her in a wheelchair (for her treatment time of 6:00 AM) and they hurried across because the cars on the road were going fast and it was dark outside. She denied there being close calls. She stated they had to walk them across in the morning because there was no one at the facility at that time in the morning who was certified to drive the van. She stated in bad weather they bundle them up or use an umbrella. She stated last week there was a day (02/23/2022) she worked the 2-10 pm shift and she had to walk Resident #19 across when the weather was cold, and it was sleeting outside. She said the van was not available because there was no one certified to drive the van at that time. She said Resident #19 had to go late in the day because she was positive for COVID and the [CONDITION(S)] center had to dialyze her alone after all of the other residents had left. She said they had to go in the back door and waited 6-7 minutes before they would let them inside. She said she called before taking her across the street and they said they were ready but then they were not ready. She said she had Resident #19 bundled up in two blankets, hat and scarf. She said they also took Resident #22 across the street too. She said she did not feel it was unsafe, but she always made sure she had plenty of time to cross with the residents. LVN B stated on the night Resident #19 had [CONDITION(S)] starting at 4:45 PM she had to walk across the street and pick her up from the clinic. She said it was dark outside and the van driver was not at work. She said there was no one at the clinic to pick Resident #19 up from the clinic in the van. She stated she did not have a flashlight but there was a light in the parking lot of the [CONDITION(S)] clinic to be able to see. In an interview on 03/02/2022 at 7:59 AM [CONDITION(S)] staff at the [CONDITION(S)] clinic across the street from nursing facility said Resident #19 was wheeled across the street by nursing facility staff to and from [CONDITION(S)]. She said that was the way all three [CONDITION(S)] residents were transported to and from the clinic. She said they will bring Resident #19 very late sometimes and they had to cut her treatment time. She said were late picking Resident #19 up from [CONDITION(S)] up to an hour sometimes. She said staff gave them a run around when they are late picking her up and say no one from [CONDITION(S)] called them. She said all three residents were picked up late sometimes. She said her main concern would be that they were crossing the busy street with the residents in the dark and did not have a flashlight and its not well lit. She said there was a parking lot light in front of their clinic but not a streetlight over the crosswalk. She said Resident #19 was currently on the COVID-19 shift in which all other non-COVID-19 positive patients had to be out of the building before the COVID-19 resident was admitted to the building. She stated they required COVID-19 positive patients to enter the building from the back entrance to prevent exposure to other patients. She stated Resident #19 likely had to wait outside for her treatment time after she was hospitalized because the COVID-19 negative residents were not all out of the building. An observation on 03/02/2022 at 9:00 AM reflected the distance between the nursing facility front door to the [CONDITION(S)] clinic front door was 285 feet. There was no streetlight observed over or near the crosswalk. In an interview on 02/28/2022 at 11:00 AM the ADMIN stated the residents that received [CONDITION(S)] across the street were transported across the street in their wheelchair by staff members. She stated they used the crosswalk, and this had been the way they transport residents for many years. She stated they use the facility van if the weather was bad to transport the residents. When asked if they use the van for rain, she said yes. In an interview on 03/04/22 at 1:45 PM DON stated DRIVER was the only certified van driver. He stated DRIVER would transport the [CONDITION(S)] residents on Saturday for their treatments. He stated they had attempted to have nurses and/or CNA's certified to drive the van. He stated none of the nurses or CNAs wanted to be trained and certified to drive the van. He stated there was not a back-up plan for [CONDITION(S)] transport in the past. In an interview 03/04/2022 at 1:55 PM DRIVER stated he took the [CONDITION(S)] via the van semi-frequently if the weather was bad. He stated there were times he was not available due to other resident appointments and the [CONDITION(S)] residents had to be transported across the street via wheelchair in bad weather. When he was in another city for an appointment, he could not get back for appointment for [CONDITION(S)] residents. He stated there was no one at facility that was a back-up for him. He stated maybe a CNA could be a back-up driver. Record review of Accommodation of Needs in-service dated 04/16/2021 revealed if weather is inclement, i.e. raining, for those residents who are going across the street to [CONDITION(S)], there are umbrellas, and rain gear in the med room for their use. There is also a stop sign available to help direct traffic. Please assist the residents with these items. Use crosswalk for safety. Record review of weather records for 02/23/2022 revealed the temperature at 5:00 PM was 28 degrees Fahrenheit and it was sleeting. Facility was unable to provide a [CONDITION(S)] resident transport policy or resident transport policy. These failures resulted in an Immediate Jeopardy (IJ) situation on 03/02/2022. While the IJ was removed on 03/08/2022, the facility remained out of compliance at a severity level of potential harm at a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The Administrator, DON, SVP and Regional Compliance Nurse were notified of the Immediate Jeopardy on 03/02/2022 at 2:13 PM and the IJ template was provided. The Plan of Removal was accepted on 03/08/2022 at 3:20 PM and included the following: Problem: Quality of Care Interventions: Identification of Others An audit of current residents was completed on 3/2/22 and identified a total of 4 residents that required transportation to and from the [CONDITION(S)] center. Unit Coordinator and Administrator verbally Informed the four [CONDITION(S)] residents/residents' representatives that from 3/3/22 ongoing they will be transported to and from [CONDITION(S)] using the centers van or a non- emergency medical van only. Documentation of this communication was recorded in each resident's medical record on 3/3/22 Medical Director was notified of new [CONDITION(S)] transport process on 3-3-22. Systemic Changes On 3-2-22 District Director of Clinical Services, Senior vice president of Operations, Nursing Home Administrator (NHA), Director of Nursing (DON) completed an ADHOC QAPI and developed the new [FACILITY] [CONDITION(S)] Transportation Process. The NHA/Designee will be the primary responsible person to implement and monitor the new process will be ongoing. The centers van will be the primary vehicle for transportation to and from [CONDITION(S)]. The Nursing Home Administrator (NHA) has secured a secondary non-emergency medical transport vehicle to use as a backup in case of a schedule conflict or if the center van is in for any repairs or is inoperable or unavailable for any other reason. This contract has been secured with [COMPANY] Non.-Emergency Medical Transportation. The contract was reviewed on 3/3/22 and is on file for review this will be ongoing. The facility van started being utilized on 3-2-22. On 3-2-22 a transportation log for [CONDITION(S)] residents was implemented and will be used ongoing and will be maintained, monitored and updated by Unit Coordinator and Director of Nurses. Facility Unit coordinators, Administrator, DON began educating all staff that was working on 3/2/22. The education was on that [FACILITY] has a new process to transport all residents requiring [CONDITION(S)] care. The new process will be, all residents requiring hemo-[CONDITION(S)] will be transported to and from [CONDITION(S)] using the facility vehicle transport and/or medical van transportation as per scheduled for their specific [CONDITION(S)] treatment. The education continued until all staff, full time, part time, as needed (PRN) and any staff that may have been out on leave. All staff in all departments received the education on the new [CONDITION(S)] transportation process. The education was completed on 3-3-22, employees that were not at work were contacted via phone to be educated, this was completed 3-3-22 and will be ongoing. All new hires will receive this education about [CONDITION(S)] transportation. This education will be included in the orientation of new hires prior to them working a shift on the floor. The Staffing Manager/designee will be responsible for new employee education on the new [CONDITION(S)] transportation process will be ongoing. This was started on 3-7-22 and will be ongoing. Resident Council meeting was completed on 3-3-22 to verbally inform residents/residents representative of new process for [CONDITION(S)] transportation by Unit Coordinator and Administrator All new residents requiring hemo-[CONDITION(S)], will be informed of the [CONDITION(S)] transportation process by the Care Transition Advisor (CTA)/designee upon admission to [FACILITY]. The NHA educated the CTA/designee of this step on 3/6/22 and this will be ongoing. All current residents were informed of new [CONDITION(S)] transport process on 3-2-22 and this will be ongoing. Monitoring NHA/Designee is primary person responsible for implementation and monitoring of all aspects of the new [FACILITY] [CONDITION(S)] Transportation Process started on 3-2-22 and will be ongoing. DON/Designee will monitor the Transportation Log daily to validate that all residents are being transported to and from [CONDITION(S)] was started on 3-3-22 and will be ongoing. Results of the audit will be reviewed in the monthly QAPI ongoing. NHA/Designee will audit new employee records daily to validate that all new employees have been trained on the new [CONDITION(S)] transportation process prior to working a shift on the floor, started on 3-3-22. Results of the audit will be reviewed in the monthly QAPI and ongoing. DON/Designee will audit all new admission daily that require transportation to hemo [CONDITION(S)], to validate that the resident and or resident's representative have been informed of the [CONDITION(S)] transportation process started on 3-3-22. Audit results will be reviewed in the monthly QAPI ongoing. NHA will review the results of the monthly QAPI with the SVPO and DDCS monthly ongoing. AdHoc QAPI completed on 3-2-22. The Survey team monitored the plan of removal as follows from 03/02/2022 - 03/08/2022: In an interview on 03/03/2022 at 10:13 AM Resident #19 stated the facility brought her back in the van from [CONDITION(S)] last night. She stated that using the van was more comfortable that being taken across the street in a wheelchair. In an interview on 03/03/2022 at 11:30 AM Resident #9 stated she was transported to [CONDITION(S)] this morning via the facility van. Staff interviews conducted revealed staff were trained regarding the new [CONDITION(S)] resident transport policy and that no residents should be transported in their wheelchair via the crosswalk. Staff stated residents should be transported in the facility van or using the facility transport company. Staff were trained to contact ADMIN if the van driver was not available, and the transport company was required to provide resident transportation to [CONDITION(S)]. Record review of [CONDITION(S)] Transport Log dated 03/03/2022 revealed Resident #19 was transported to and from [CONDITION(S)] on 03/02/2022 via the facility van. It further revealed Resident #9 was transported via the facility van on 03/03/2022. Record review of Non-Emergency Medical Transportation agreement dated 03/02/2022 revealed a signed agreement for [COMPANY] to provide transport for [CONDITION(S)] residents at the facility. Record review of New [CONDITION(S)] Transport Protocol training dated 03/02/2022 revealed staff were educated regarding the new procedure for residents transported to [CONDITION(S)] across the street in the facility van. If the van was not available, the transport company would be used. Record review of nursing progress notes dated 03/02/2022 revealed Resident #19 was educated that effective immediately we would no longer transport her to [CONDITION(S)] via wheelchair and that she would go to/from [CONDITION(S)] per facility van driven by Driver or designee, or another mode or transportation. Record review of nursing progress notes dated 03/02/2022 revealed Resident #9 was educated that effective immediately we would no longer transport her to [CONDITION(S)] via wheelchair and that she would go to/from [CONDITION(S)] per facility van driven by DRIVER or designee, or another mode of transportation.

Based on observation, interview and record review, the facility failed to ensure that all allegations of abuse or neglect were thoroughly investigated for two (2) of eight (8) residents (Resident #1 and #2) reviewed for abuse and neglect. A) The facility failed to thoroughly investigate an incident on 07/22/2019 when Resident #1 went outside for a supervised smoke break at 1:15 PM and was left outside without supervision until he was found at 4:29 PM (approximately three (3) and a half hours later), lethargic, with a temperature of 101 degrees and blisters on his skin. Resident #1 was sent to the emergency room and diagnosed with [REDACTED]. B) The facility failed to thoroughly investigate an altercation between Resident #2 and Resident #4 on 03/30/2019 which resulted in bruising to Resident #2's left eye. These failures resulted in an Immediate Jeopardy situation on 08/13/2019. While the IJ was removed on 08/13/2019, the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. The failure placed the facility's residents at risk for harm, decreased quality of life and abuse and neglect. The failure to invesitgated placed the residents at risk for repeated occurances of harm. The findings included: A) Review of Resident #1's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's Quarterly Minimum (MDS) data set [DATE] reflected Resident #1 was assessed to have a Brief Interview for Mental Status (BI[CONDITION]) score of 10 indicating moderate cognitive impairment. Resident #1 was further assessed to have no skin conditions. Resident #1 was assessed to require one-person physical assist with locomotion off unit. Review of Resident #1's Comprehensive Care Plan dated 3/07/18 reflected Resident #1 had an Activities of Daily living deficit related to impaired balance and required limited assist with transfers and observation for changes or decline in function. Record Review of Nursing Progress Notes reflected, an entry dated 07/22/2019 at 4:29 PM, (Resident #1) was found outside E Hall Door. (this is the door where Residents go out to smoke), sweating and nose running. Resident states he feels bad. Nauseated and lethargic. Keeps falling asleep. B/P (blood pressure) 168/70, Pulse (P) 104, Respirations (R.) 18 Oxygen on room air 99%, Temperature (T) 101.5. Wrapped in wet towel around Resident's neck. Placed two (2) icepacks under the arms. Gave Resident Fluids. Notified (Doctor) DR. and he said to send to emergency room (ER). Resident sent to ER. Record Review of emergency room Notes dated 07/22/19 reflected The patient is a [AGE] year-old male with a history of stroke who lives in a nursing home who presents to the emergency department with a chief complaint of heat exhaustion. He was outside smoking. He says that he kind of got overheated and when he got up to go into the facility, he got light headed and passed out .Apparently, he was outside for about two (2) hours before someone came and helped him. They found his temperature to be 101 and they started cooling measures. Paramedics found the patient to have normal vital signs and transported for further evaluation. Review of the website: accuweather.com reflected the temperature was 101 degrees on 07/22/2019 in [CITY]. Review of Resident #1's Nursing Progress Note dated 07/22/2019 at 7:03 PM reflected Returned from ER noted to have blisters on his abdomen, both arms and left ankle. ER did not give any orders for blisters, called MD and received orders for [MEDICATION NAME] cream to be applied daily. Review of Resident #1's Physician order [REDACTED]. Review of Physician order [REDACTED].#1), [MEDICATION NAME] Cream 1% apply to left ankle topically every day shift for wound, cleanse with pat dry apply [MEDICATION NAME] 1% cream cover with dry protective dressing every day shift. Sunscreens Aerosol apply to body topically as needed for sunburn prevention apply twice per day as needed while outside. Review of skin assessments dated 07/11/2019 and 07/18/2019 reflected, Skin integrity intact. In an interview on 07/29/2019 at 11:00 AM CNA #A stated, I saw (Resident #1) when he came in from outside and he had sweat all over him, his clothes were wet with sweat and (Resident #1) wasn't hardly moving he was exhausted from being outside and looked very weak couldn't keep his head from falling to side. Everyone was worried about (Resident #1). We knew he had been outside a very long time. (Resident #1) said he was out there since smoke break around 1:00 and it was around 4:00 when staff brought him in from outside. In an interview on 07/29/2019 at 1:30 P.M. with LVN B stated, (Resident #1) was found at the door end of E hall trying to enter facility from outside. (Resident #1) was lethargic, sweating and clothes were wet. We immediately applied wet towels and cold packs and gave him fluids. I don't know how long he had been outside. (Resident #1) said he been there since smoke break. He was found 07/22/2019 at 4:29 P.M. LVN B stated there was no smoke break after 1:15 PM the next smoke break would have started around 4:00 P.M. Observation of Resident #1's left arm and left ankle on 07/29/2019 at 2:00 PM revealed left upper arm, left hand, and abdomen with burn areas. Resident #1's left ankle had a large fluid filled blister. In an interview on 07/29/2019 at 2:00 PM Resident #1 stated, I was outside smoking after lunch the first smoke break around 1:00 PM or little after 1:00 PM and I wanted to stay outside. The people here (staff) didn't come see about me until I pushed myself to the door and got help. I can't remember who was the one out there when we smoked. I was hot and passed out. I was out there a long time it was almost time for us to go out and smoke again when they found me. Resident #1 stated the Van Driver took him to smoke right after lunch and after the smoke break he realized he was outside alone. Resident #1 stated he was trying to get inside and got very tired and stated he must of fallen asleep. Resident #1 stated It was hot out there, it was 107 degrees. When asked if his skin was exposed he stated he had a shirt and socks on but got burned through his shirt. Review of Designated Smoke Break Times provided by facility (no date) reflected: All times are approximate, breaks are approximately 15 minutes each. First Break 9:00 AM, Second Break 11:30 AM, Third Break 1:15 PM, Fourth Break 4:00 PM, Fifth Break 6:30 PM. In an interview on 07/29/2019 at 2:30 PM the Administrator stated, My main concern was to train the staff about checking Residents and making sure this didn't happen again. I asked (Resident #1) what happened, and I have a statement. I asked him when he returned from emergency room . I know my statement of when I talked to (Resident #1) is dated for 07/24/2019 this isn't the date he went to emergency room he went on 07/22/2019 I don't know why date is wrong I will just have to look at policy and see. No, I don't have any investigation I will need to look at the policy. I didn't report it to any agency I don't have to report what happened to (Resident #1). I will look at my policy and get back with you about it. In an interview on 07/30/2019 at 11:10 AM the Van Driver stated he did not take Resident #1 out to smoke that day even though he was assigned to take the residents out to smoke. The Van Driver stated he had an appointment with a resident and was not in the facility. In an interview on 07/30/2019 at 1:00 PM CNA A stated she worked on Resident #1's hall on 07/22/2019. CNA A stated she did not see who took Resident #1 outside to smoke that day. CNA A stated her shift ended at 2:00 PM and the smoke break is usually at 1:00 PM. In an interview on 07/30/2019 at 2:03 PM CNA D stated she worked on 07/22/2019 and came on shift at 2:00 PM. She stated she did not notice Resident #1 was outside. CNA D stated she saw the laundry lady pull Resident #1 in the building. CNA D stated Resident #1 usually does not sit outside after his smoke breaks. When asked what time the resident was found CNA D stated she was not sure, but it was well after her shift started. In an interview on 07/30/2019 at 3:38 PM the Wound Care doctor, after examining Resident #1's burns, stated the areas were from the sun and heat exposure. The Wound Care Doctor stated the areas did not appear infected. The Wound Care Doctor stated the facility needed to be careful with residents in the heat and they should not be left outside. Observation on 08/13/2019 at 6:15 PM revealed Resident #1 wheeling self-down the side walk after his smoke break. Resident #1 was able to get to the ramp at the door but required assist form the staff to get up the ramp and into the building. Review of the facility's policy of Nursing Rounds/Licensed Staff reflected Procedure: 1. Check the resident a minimum of every 2 hours or as indicated by Resident's assessment. 2. Observe Resident for privacy, dignity and safety .19. Report changes in the resident's condition to the charge nurse at once. B) Review of Resident #2's Face Sheet reflected an [AGE] year-old male admitted to facility on 0[DATE]17 with the following Diagnoses: [REDACTED]. Review of Resident #2's Quarterly Minimum (MDS) data set [DATE] reflected Resident #2 was assessed with [REDACTED]. Resident #2 was assessed to have behavior problems of rejecting care 1-3 days out of week. Review of Resident's #2's Comprehensive Care plan reflected a focus area dated 05/31/2017 has impaired cognitive function/ dementia impaired thought process. Has a communication problem related to dementia and has aggression toward staff or others. Review of Resident's #2's Nursing Progress Notes reflected an entry dated 03/30/2019 at 8:57 AM Resident was in line for coffee in the Dining Room when another Resident got impatient and hit Resident with his fist in his left eye. This nurse separated the two Residents applied ice pack to eye. No other injuries noted. Review of Resident #2's Nursing Progress Note dated 03/31/2019 reflected resident with bluing discoloration to left eye . Observation on 07/30/2019 at 1:30 PM revealed Resident #2 in his room in bed. Resident #2 was confused and did not communicate with surveyor. No bruising was noted. Review of Residents # 4's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Muscle Weakness, Major [MEDICAL CONDITION], Recurrent, Moderate. Review of Resident #4's Annual Minimum (MDS) data set [DATE] reflected, Resident #4 was assessed to have a Brief Interview for Mental Status score of nine (9) indicating moderate cognitive impairment. Resident #4 was further assessed to have Physical and Verbal Behavior Symptoms toward others. (Behavior occurred 1-3 times week). Resident #4 further assessed behaviors interfered with Resident #4's care and rejection of care. Resident #4's was further assessed behavior significantly interfered participating in activities or social interactions, significantly interfered living environment and significantly intrude on the privacy or activity of others. Review of Resident #4's Comprehensive Care Plan dated 07/04/2017 reflected Resident #4 a focus area of Depression. Interventions included to discuss with the resident/family/caregivers any concerns, fears, issues regarding health or other subjects as needed. Care Plan revised on 08/15/2018 reflected Resident #4 has ADL self-care performance deficit related to Aggressive Behavior, Dementia. Interventions Encourage Active participation in tasks. Review of Resident's #4's Comprehensive Care Plan printed on 07/29/2019 reflected, the following was not identified: behaviors toward others, rejection of care, behavior significantly interfered participating in activities or social interactions, significantly interfered living environment and significantly intrude on the privacy or activity of other Residents. In an interview dated on 07/29/2019 at 1:20 PM and on 07/30/2019 at 11:45 AM the Director of Nurses stated, Ask the administrator I don't know anything about reporting things. In an interview on 07/30/3019 at 12:05 PM with The Administrator stated, I am not discussing anything else I will read my policy and get back with you. In an interview on 07/30/2019 at 2:26 PM the Administrator stated, when asked about the Resident to Resident abuse for Resident #2 and #3, she did not investigate or report the incidents because of the Residents' dementia and BI[CONDITION] scores and did not feel the incidents meet the criteria for reporting. Review of the facility's Policy of Incident / Accident Reporting for Residents dated 02/2017 reflected: All incidents, accidents, and unusual occurrences involving a resident are investigated, documented and reported in accordance with Federal and State Law. Fundamental Information: Definitions: incidents, Accidents and Unusual Occurrences Any event not consistent with routine resident care; Any event reportable to Federal and State agencies in accordance with State and /or Federal law; and Any event involving a resident with negative or harmful results or outcomes. Adverse Event (Significant or Serious Incidents)[MEDICAL CONDITION] injuries resulting in significant/ serious harm Assaults/ Abuse (verbal, emotional, sexual, physical between any parties. Neglect . Review of the facility's policy Abuse and Neglect Prohibition states, Reporting and Response: 1. State reporting obligations: The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and Law Enforcement officials and adult protective agencies in accordance with Federal and State Law through established procedures. Timeline for reporting is as follows: A. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after the management staff becomes aware of the allegation; or B. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours after the management staff becomes aware of the allegation. Prevention . Facility Supervisors will immediately investigate and correct. Reported or identified situations in which abuse, neglect . On 08/13/2019 at 2:20 PM the Administrator, and DON, were notified the facility had an IJ situation for the above failures. The facility's first Plan of Removal (POR) was submitted by the Administrator on 08/13/2019 at 5:24 PM. The final POR was accepted by the survey team on 08/13/2019 at 7:21 PM. Review of the Facility's POR reflected Abatement 1. Resident#1 was sent toER on [DATE] after it was reported that he was outside and had an altered mental status. - Resident #1 returned on 07/22/19 and it was noted that he had blisters on his wrist, abdomen and ankle. -07/22/19 upon returning to Bastrop Nursing Center, the Administrator interviewed and provided education to Resident #1. -07/30/19 Facility reported this incident to DADS. 3613 completed and submitted on 08/06/19. - Incident on 03/30/19 Jones VS Johnson reported to DADS on 07/30/19 3613 completed with full investigation on 08/06/19. -8/13/19 Administrator will reopen an investigation on Resident #1 from the 7/22/19 incident. Administrator will utilize new knowledge on thorough investigations to include witness statements. Entirety of findings will be submitted to the DADS portal with completion of investigation. 2. All residents with potential to have been affected 3. Residents identified as smokers or who remain outdoors were given PRN orders for sunscreen, routine hydration procedures have been implemented, outdoor wellness checks initiated, door alarm monitoring, supervised smoking initiated. -07/22/19 Staff In-service on newly implemented protocols. -Administrator/ DON were In Serviced by District Nurse RN on 07/30/19 on reporting guidelines and received most current copy of guidelines. This training included completing full investigations with the completion of 3613 form and turning into state within 5 calendar days. -Incident and accident reports audited x 6months to ensure investigation were completed and reported as indicated. 4. Administrator/ DON will audit wellness and outdoor checks weekly. Administrator/ DON will review Incident and accident reports daily to ensure investigation and incidents are complete and reported if needed. Staff will call DON / Administrator with new incidents. Audits and findings will be reviewed for up to 2 months. District Director of Clinical Services in-serviced Administrator / DON with Vice President of Operations via teleconference 8/13/19 6:10pm on Investigation processes to include witness statements, resident interviews and staff interviews to formulate an appropriate finding and conduct an adequate investigation on incidents and accidents. Administrator provided with a witness statement form to outline the witness statement process. This training included investigating and reporting according to HHSC tac and code of federal regulations. Administrator/DON will identify any resident needing outdoor preventative measures during morning meeting and clinical meeting: changes in condition and progress note review. 5. Compliance date 8/13/19 Monitoring for the Plan of Removal began on 08/13/2019 at 7:21 PM. Staff were interviewed for understanding regarding the new procedure regarding resident safety when outside during the extreme heat and reporting all alleged allegation of abuse or neglect. All staff interviewed had a good understanding of the training. Approximately [AGE] % of the staff had received their training. On 08/13/2019 at 7:24 PM the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observation, interviews and record reviews the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents and hazards for one (1) of eight (8) residents reviewed for accidents and hazards The facility failed to provide adequate supervision and routine resident checks for Resident #1 when he went outside for a supervised smoke break at 1:15 PM and was left outside without supervision until he was found at 4:29 PM (approximately three (3) and a half hours later), lethargic, with a temperature of 101 degrees and blisters on his skin. Resident #1 was sent to the emergency room and diagnosed with [REDACTED]. These failures resulted in an Immediate Jeopardy situation on 08/13/2019. While the IJ was removed on 08/13/2019, the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. The deficient practice could place residents who spend time outside at risk for physical harm or death. Findings Include: Review of Resident #1's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's Quarterly Minimum (MDS) data set [DATE] reflected Resident #1 was assessed to have a Brief Interview for Mental Status (BI[CONDITION]) score of 10 indicating moderate cognitive impairment. Resident #1 was further assessed to have no skin conditions. Resident #1 was assessed to require one-person physical assist with locomotion off unit. Review of Resident #1's Comprehensive Care Plan dated 3/07/18 reflected Resident #1 had an Activities of Daily living deficit related to impaired balance and required limited assist with transfers and observation for changes or decline in function. Record Review of Nursing Progress Notes reflected, an entry dated 07/22/2019 at 4:29 PM, (Resident #1) was found outside E Hall Door. (this is the door where Residents go out to smoke), sweating and nose running. Resident states he feels bad. Nauseated and lethargic. Keeps falling asleep. B/P (blood pressure) 168/70, Pulse (P) 104, Respirations (R.) 18 Oxygen on room air 99%, Temperature (T) 101.5. Wrapped in wet towel around Resident's neck. Placed two (2) icepacks under the arms. Gave Resident Fluids. Notified (Doctor) DR. and he said to send to emergency room (ER). Resident sent to ER. Record Review of emergency room Notes dated 07/22/19 reflected The patient is a [AGE] year-old male with a history of stroke who lives in a nursing home who presents to the emergency department with a chief complaint of heat exhaustion. He was outside smoking. He says that he kind of got overheated and when he got up to go into the facility, he got light headed and passed out .Apparently, he was outside for about two (2) hours before someone came and helped him. They found his temperature to be 101 and they started cooling measures. Paramedics found the patient to have normal vital signs and transported for further evaluation. Review of the website: accuweather.com reflected the temperature was 101 degrees on 07/22/2019 in [CITY]. Review of Resident #1's Nursing Progress Note dated 07/22/2019 at 7:03 PM reflected Returned from ER noted to have blisters on abdomen both arms and left ankle. ER did not give any orders for blisters, called MD and received orders for [MEDICATION NAME] cream to be applied daily. Review of Resident #1's Physician order [REDACTED]. Review of Physician order [REDACTED].#1), [MEDICATION NAME] Cream 1% apply to left ankle topically every day shift for wound, cleanse with pat dry apply [MEDICATION NAME] 1% cream cover with dry protective dressing every day shift. Sunscreens Aerosol apply to body topically as needed for sunburn prevention apply twice per day as needed while outside. Record Review of skin assessments dated 07/11/2019 and 07/18/2019 reflected, Skin integrity intact. In an interview on 07/29/2019 at 11:00 AM CNA #A stated, I saw (Resident #1) when he came in from outside and he had sweat all over him, his clothes were wet with sweat and (Resident #1) wasn't hardly moving he was exhausted from being outside and looked very weak couldn't keep his head from falling to side. Everyone was worried about (Resident #1). We knew he had been outside a very long time. (Resident #1) said he was out there since smoke break around 1:00 and it was around 4:00 when staff brought him in from outside. In an interview on 07/29/2019 at 1:30 P.M. with LVN B stated, (Resident #1) was found at the door end of E hall trying to enter facility from outside. (Resident #1) was lethargic, sweating and clothes were wet. We immediately applied wet towels and cold packs and gave him fluids. I don't know how long he had been outside. (Resident #1) said he been there since smoke break. He was found 07/22/2019 at 4:29 P.M. LVN B stated there was no smoke break after 1:15 PM the next smoke break would have started around 4:00 P.M. Observation of Resident #1's left arm and left ankle on 07/29/2019 at 2:00 PM revealed left upper arm, left hand, and abdomen with burn areas. Resident #1's left ankle had a large fluid filled blister. In an interview on 07/29/2019 at 2:00 PM Resident #1 stated, I was outside smoking after lunch the first smoke break around 1:00 PM or little after 1:00 PM and I wanted to stay outside. The people here (staff) didn't come see about me until I pushed myself to the door and got help. I can't remember who was one out there when we smoked. I was hot and passed out. I was out there a long time it was almost time for us to go out and smoke again when they found me. Resident #1 stated the Van Driver took him to smoke right after lunch and after the smoke break he realized he was outside alone. Resident #1 stated he was trying to get inside and got very tired and stated he must of fell asleep. Resident #1 stated It was hot out there, it was 107 degrees. When asked if his skin was exposed he stated he had a shirt and socks on but got burned through his shirt. Review of Designated Smoke Break Times provided by facility (no date) reflected: All times are approximate, breaks are approximately 15 minutes each. First Break 9:00 AM, Second Break 11:30 AM, Third Break 1:15 PM, Fourth Break 4:00 PM, Fifth Break 6:30 PM. In an interview on 07/29/2019 at 2:30 PM the Administrator stated, My main concern was to train the staff about checking Residents and making sure this didn't happen again. I asked (Resident #1) what happened, and I have a statement. I asked him when he returned from emergency room . I know my statement of when I talked to (Resident #1) is dated for 07/24/2019 this isn't the date he went to emergency room he went on 07/22/2019 I don't know why date is wrong I will just have to look at policy and see. No, I don't have any investigation I will need to look at the policy. I didn't report it to any agency I don't have to report what happened to (Resident #1). I will look at my policy and get back with you about it. In an interview on 07/30/2019 at 11:10 AM the Van Driver stated he did not take Resident #1 out to smoke that day even though he was assigned to take the residents out to smoke. The Van Driver stated he had an appointment with a resident and was not in the facility. In an interview on 07/30/2019 at 1:00 PM CNA A stated she worked on Resident #1's hall on 07/22/2019. CNA A stated she did not see who took Resident #1 outside to smoke that day. CNA A stated her shift ended at 2:00 PM and the smoke break is usually at 1:00 PM. In an interview on 07/30/2019 at 2:03 PM CNA D stated she worked on 07/22/2019 and came on shift at 2:00 PM. She stated she did not notice Resident #1 was outside. CNA D stated she saw the laundry lady pull Resident #1 in the building. CNA D stated Resident #1 usually does not sit outside after his smoke breaks. When asked what time the resident was found CNA D stated she was not sure, but it was will after her shift started. In an interview on 07/30/2019 at 3:38 PM the Wound Care doctor after examining Resident #1'[MEDICAL CONDITION] the areas were from the sun and heat exposure. The Wound Care Doctor stated the areas did not appear infected. The Wound Care Doctor stated the facility needed to be careful with residents in the heat and they should not be left outside. Review of the facility's policy of Nursing Rounds/Licensed Staff reflected Procedure: 1. Check the resident a minimum of every 2 hours or as indicated by Resident's assessment. 2. Observe Resident for privacy, dignity and safety .19. Report changes in the resident's condition to the charge nurse at once. On 08/13/2019 at 2:20 PM the Administrator, and DON, were notified the facility had an IJ situation for the above failures. The facility's first Plan of Removal (POR) was submitted by the Administrator on 08/13/2019 at 5:24 PM. The final POR was accepted by the survey team on 08/13/2019 at 7:21 PM. Review of the Facility's POR reflected Abatement 1. Resident#1 was sent toER on [DATE] after it was reported that he was outside and had an altered mental status. - Resident #1 returned on 07/22/19 and it was noted that he had blisters on his wrist, abdomen and ankle. -07/22/19 upon returning to Bastrop Nursing Center, the Administrator interviewed and provided education to Resident #1. -07/30/19 Facility reported this incident to DADS. 3613 completed and submitted on 08/06/19. -8/13/19 Administrator will reopen an investigation on Resident #1 from the 7/22/19 incident. Administrator will utilize new knowledge on thorough investigations to include witness statements. Entirety of findings will be submitted to the DADS portal with completion of investigation. 2. All residents with potential to have been affected 3. Residents identified as smokers or who remain outdoors were given PRN orders for sunscreen, routine hydration procedures have been implemented, outdoor wellness checks initiated, door alarm monitoring, supervised smoking initiated. -07/22/19 Staff In-service on newly implemented protocols. -Administrator/ DON were In Serviced by District Nurse RN on 07/30/19 on reporting guidelines and received most current copy of guidelines. This training included completing full investigations with the completion of 3613 form and turning into state within 5 calendar days. -Incident and accident reports audited x 6months to ensure investigation were completed and reported as indicated. 4. Administrator/ DON will audit wellness and outdoor checks weekly. Administrator/ DON will review Incident and accident reports daily to ensure investigation and incidents are complete and reported if needed. Staff will call DON / Administrator with new incidents. Audits and findings will be reviewed for up to 2 months. District Director of Clinical Services in-serviced Administrator / DON with Vice President of Operations via teleconference 8/13/19 6:10pm on Investigation processes to include witness statements, resident interviews and staff interviews to formulate an appropriate finding and conduct an adequate investigation on incidents and accidents. Administrator provided with a witness statement form to outline the witness statement process. This training included investigating and reporting according to HHSC tac and code of federal regulations. Administrator/DON will identify any resident needing outdoor preventative measures during morning meeting and clinical meeting: changes in condition and progress note review. 5. Compliance date 8/13/19 Monitoring for the Plan of Removal began on 08/13/2019 at 7:21 PM. Staff were interviewed for understanding regarding the new procedure regarding resident safety when outside during the extreme heat and reporting all alleged allegation of abuse or neglect. All staff interviewed had a good understanding of the training. Approximately [AGE] % of the staff had received their training. On 08/13/2019 at 7:24 PM the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility requiring time to train all staff and monitor their plan of removal.

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, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (1) of four (4) residents reviewed for pain (Resident # 1). Resident #1 was found on the floor in her room on her left side by the bed on 11/06/16. Licensed staff failed to thoroughly assess for and identify Resident #1's acute left hip/leg pain until after surveyor intervention on 11/08/16, when x-rays of her pelvis and hip were ordered. The resident was diagnosed with [REDACTED]. This deficient practice could affect a facility census of 9 residents with [DIAGNOSES REDACTED]. The Findings Include: Review of a Face Sheet for Resident #1 reflected she was [AGE] years old and had an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated [DATE] for Resident #1, reflected the following: -Extensive assistance of two staff for transfers -Extensive assistance of one staff for bed mobility due to contractures of the lower legs -Incontinent of Bowel and Bladder -Pain- resident unable to answer questions for pain assessment -moderate to severe cognitvie impairment Review of a Care Plan for Resident #1 dated 08/01/16, reflected chronic pain due to polyarthitis. Assess every 4 hours and administer pain medications, if indicated. Review of physician orders [REDACTED]. [MEDICATION NAME] 325 mg give two tablets every 4 hours as needed for pain. Date 07/21/16 [MEDICATION NAME]-[MEDICATION NAME] 5-325mg give one tablet every 6 hours as needed for pain 07/21/16 [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg give two tablets every 4 hours as needed for pain 11/01/16 [MEDICATION NAME] 50 mg one tablet every 12 hours as needed for pain. There was no date on this order. Review of a facility incident report for Resident #1 dated 11/06/16 time 8:33 PM, reflected the following: -Entered Resident's room and found her lying on the floor with left arm under her. -Amended 11/09/16. Resident denied pain in any other location except left arm. The amendment was signed by the DON. In an interview on 11/07/16 at 10:00 AM during initial tour the facility, the RN Director of Resident Care stated Resident #1 had a fall over the weekend (11/06/16); but always had pain in her knees, due to contractures and resisted repositioning. In an observation of wound care for Resident #1 on 11/08/16 at 9:30 AM, the facility's treatment nurse, LVN B, stated Resident #1 had a skin tear on her left hip first identified on 10/23/16, a Stage II pressure sore on her right hip and a deep tissue injury on her left foot. During the care Resident #1 was moaning and saying it hurts, oh lord and telling staff to go slow with her when she was being turned and as she was reaching for the side rails. When the surveyor asked LVN B if the deep tissue injury on the left foot could be observed she stated yes and started to remove the protective boot that was in place. During the removal of the boot, as Resident #1's left leg was slightly abducted (moved laterally away from the body), she reached for her left leg, cried in pain, and stated I don't know what is going on. This is different, this is different! When Resident #1 was asked by LVN B if she could say where she was hurting she stated I don't know, it is different, I hurt all over. Resident #1 made these statements in an anxious manner. LVN B stated again she felt Resident #1's pain was at baseline even though she was medicated with [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 mg two tablets at 7:00 AM. In an observation on 11/08/16 at 11:30 AM, prior to entrance into Resident #1's room for incontinent care, Resident #1 was lying on her right side with her arms over the quarter rails. Resident #1 was moaning and crying out Someone please help me! Please help me! Resident #1's door was open and directly across from a room where staff was eating lunch with the door open. Resident #1 was on isolation precautions for an intestinal infection, and while the surveyor and CNA X were donning gowns and gloves, Resident #1 continued to cry out in pain. LVN B was in the room across the hall eating lunch and was informed by the surveyor of Resident #1's continued pain, to which she replied, it was too soon to give her any more pain medication. In an observation on 11/08/16 at 12:00 PM, CNA X was providing incontinent care for Resident #1, who had a large bowel movement. When Resident #1 was assisting CNA X to turn to her left side for care, she was reaching for the side rails and repeatedly cried out in pain that she was hurting. Resident #1 stated several times, This is different. Resident #1 attempted to reach for her left hip in a protective manner. In an interview during the incontinent care observation on 11/08/16 at 12:00 PM, CNA X stated she had been working at the facility for about two months and had cared for Resident #1 many times. CNA X stated Resident #1 always had pain with repositioning; but it seemed more intense during this care. CNA X was asked if she had been informed that Resident #1 fell on [DATE], and she stated she had not. Because of Resident #1's continued cries of pain, LVN B was asked to come to the room. On 11/08/16 at 12:00 PM , the treatment nurse came to Resident #1's room and observed the remainder of her incontinent care and her continued expressions of pain. LVN B stated she would check to see if Resident #1 could have more pain medication, but did not ask Resident #1 any pain assessment questions. LVN B did state it was not unusual for Resident #1 to cry out when moved, but wouldn't comment on the fact she was stating this is different. Review of nurses' notes for Resident #1 dated 11/08/16, reflected the following: 7:00 AM [MEDICATION NAME]-[MEDICATION NAME] 5-325mg two tablets for pain. 10:53 AM Follow up pain scale for [MEDICATION NAME]-[MEDICATION NAME] 5-325 2 tabs administration was 1 (the scale is 1-10. One meaning the least pain and 10 being the worst).The note was electronically signed by LVN C. 11:23 AM resident complained of pain during treatment this morning. Resident stated pain all over. Resident medicated for pain prior to treatment. The note was electronically signed by LVN B. 11:36 AM [MEDICATION NAME]-[MEDICATION NAME] 5-325 two tablets given for pain. 1:00 PM Follow up pain scale for [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. was 5. Administration was ineffective. The note was electronically signed by LVN A. In an interview on 11/08/16 at 3:00 PM, LVN A stated she was told by the treatment nurse there may be a concern with Resident #1's left hip and to call the mobile x-ray service for x-rays. LVN A stated she was the charge nurse for Resident #1, but she had not done a pain assessment on Resident #1 during her shift, other than to look in her room when she made rounds shortly after 6:00 AM. LVN A stated she had not done neuro checks that are required per policy for 72 hours post fall. LVN A stated when she does a pain assessment, she looks at the resident for any signs of injury; but does not ask them to try to move an extremity, if there is a question of pain or injury. LVN A also stated she had not informed the CNA on duty that Resident #1 had a fall on 11/08/16. When asked about the nurses' note documenting the [MEDICATION NAME]-[MEDICATION NAME] 5-325mg two tablets administration given at 11:36 AM being ineffective, LVN A stated she just asked Resident #1 if she was hurting. LVN A stated she did not follow up on the ineffective pain medication administration. Review of a portable X-ray report for Resident #1 dated 11/08/16 time 2:20 PM reflected the following: Examination: Hip Unilateral with pelvis 2-3 views Left Results: Subcapital fracture identified on the left. Cortical irregularity identified in the left humeral neck. Component of impaction at the fracture site. No definite acute right fracture. No definite acute pelvic fracture (a fracture at the head of the femur where it attaches to the hip socket). In an interview on 11/08/16 at 4:30 PM, Resident #1's physician stated he had been taking care of Resident #1 for approximately 2 years and he received a call earlier today from the facility stating Resident #1 was having increased pain in her left hip. Resident #1's physician went on to say the subcapital [MEDICAL CONDITION] hip happened when she fell on [DATE]. The physician stated the type of fracture Resident #1 sustained was due to an impact trauma. The physician was asked if he felt Resident #1's pain would have been assessed more thoroughly by the nurses, the acute pain vs. chronic pain would have been identified and the fracture have been identified sooner? The physician replied he felt a more experienced nurse or his nurse practitioner would have identified Resident #1's left hip pain with abduction faster than the facility nurses; but eventually they would have figured it out. Resident #1's physician stated she was not a candidate for surgical repair that would require a total hip replacement. Instead, the hip socket will make a pseudo socket from scar and cartilage tissues over the next six weeks. Resident #1's physician added he will write orders to continue the [MEDICATION NAME]-[MEDICATION NAME] 5-325mg, two tablets every 4 hours, or prior to any care; and will monitor her to see if Roxynol ([MEDICATION NAME] sulfate) sublingual may need to be added to manage her pain quickly and effectively. In an interview on 11/08/16 at 5:00 PM, LVN B was asked why she instructed LVN A to contact the mobile x-ray service for Resident #1 to order a left hip x-ray. LVN B stated she spoke with the DON after you (meaning the surveyor) were asking questions about her pain and if it was at baseline, and the DON stated maybe a hip x-ray was indicated. LVN B stated she continued to think Resident #1's pain was at baseline until the x-ray results identified a fracture. LVN B added sometimes it just takes a different set of eyes to see a resident differently than those of us who see them daily. In an interview on 11/09/16 at 2:15 PM, LVN D stated she was the charge nurse on duty when Resident #1 was found lying on her left side on the ground next to her bed on 11/06/16. LVN D stated Resident #1 stated she was trying to get out of bed. LVN D stated initially Resident #1 complained of left arm pain; so x-rays were ordered, but they were negative. LVN D stated she worked a double shift on 11/06/16, so she was on duty for 10 hours after Resident #1's fall. LVN D stated when she assessed Resident #1 after the fall and during the next shift, she did not assess her lower extremities for pain as part of the neuro assessment. LVN D stated she just felt Resident #1's pain was from her shoulder and her ongoing chronic knee pain, so she administered [MEDICATION NAME]-[MEDICATION NAME] 5-325 for pain. In an interview on 11/10/16 at 2:30 PM, the DON stated she had no idea how Resident #1 was able to fall out of bed, unless it was a sudden burst of energy. The DON added she didn't know if her staff would have picked up on Resident #1's acute pain because of her chronic issues. It is just hard to do. The DON stated the nurses did not follow policy on assessments for 72 hours after a fall; and it would have been appropriate to ask Resident #1 to attempt to move her lower extremities to elicit pain, rather than the nurses trying to move them. The DON stated when the treatment nurse came to her and stated there was a concern regarding generalized left side pain, she thought it would be a good idea to get x-rays. The DON stated the nurses are usually good at noticing pain; but agreed the post fall assessments weren't done after 11/07/16, and they were incomplete. The DON stated licensed staff should follow-up when a pain medication administration is identified as ineffective with another assessment and possible medications for breakthrough pain. The DON added she had instructed the CNAs to log roll Resident #1 when turning her to lessen the risk of moving her left leg/hip. The DON concluded with saying Resident #1 offers lots of complaints and it is hard with this particular resident. Review of the facility's undated Pain Assessment, long term care procedure reflected the following: Pain is commonly undertreated in residents with cognitive impairments such as dementia. Pain can be acute or chronic. Characteristics of acute pain are: -related to recent events -time limited less than three months -symptom of damaged tissue -visual signs of pain Assessing Pain. When performing a pain assessment assess the following specifics: -Location- what is the site or sites of pain -Intensity- What is the severity of the pain -Quality or type- throbbing, stabbing, or burning -Onset and duration- -Previous treatments- what makes it feel better -Associated Symptoms- what is happening when the pain starts -Objective assessment of resident's mood or behaviors Special Considerations: Keep in mind that residents with a decline in cognitive function are commonly under assessed and undertreated. The DON provided a facility census of 9 residents with chronic pain. -

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents when: A) One (1) of three (3) residents (Resident # 8) reviewed for requiring 2 person transfers with a mechanical lift was not transferred according to the plan of care when CNA T transferred Resident #8 alone and without using a mechanical lift. Resident #8 sustained pain and swelling in her left knee as a result of the improper transfer. This deficient practice affected Resident # 8 and placed eight (8) additional residents care planned for two person mechanical lift transfers by placing them at risk for injuries and pain. B) One (1) of two (2) shower rooms (Shower Room A) observed for safety was unlocked and contained razors and dangerous chemicals that would be harmful if swallowed. C) One (1) of three (3) housekeeping carts was left unlocked with hazardous chemicals present with the warning DO NOT DRINK. The cart was found in an unlocked room on Hall A (A-27) where an un-sampled resident was witnessed to wander. These deficient practices placed 2 residents known to wander in the facility at risk for injuries and ingestion of harmful chemicals which could lead to poisoning. The Findings Include: A) Review of a Face Sheet for Resident #8 reflected she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS Assessment for Resident #8 dated 05/15/15 and an Annual MDS dated [DATE], reflected Resident #8 was a two person mechanical lift for transfers, ambulated in her wheelchair with assistance required at times and had moderate cognitive impairment. Review of a Care Plan for Resident #8 dated 10/19/14 and most recently updated on 08/26/15 reflected: Transfers-Total Hoyer (mechanical lift) with two persons. Observation on 09/22/15 at 10:15 AM, revealed Resident #8 being transferred from her bed to the wheelchair by CNA T and CNA V. Resident #8 had a mesh sling under her in her bed. CNA T and CNA V attached the sling to the lift and began to raise the resident out of bed. When Resident #8's legs were being moved to align them for placing her in the wheelchair, she attempted to reach for her knee in a protective manner, and stated it hurt several times. CNA T and CNA V moved her legs and completed the transfer. In an interview immediately following the observation on 09/22/15 at 10:15 AM, CNA T was asked if Resident #8 complains of pain in her left knee often and CNA T stated no and she would notify the charge nurse. CNA T added, Resident #8 may seem confused, but she knows what is going on around her and can make her needs known. Review of a facility incident report for Resident #8 dated 09/23/15, reflected the following: Resident's left knee is swollen and resident complains of pain with movement, such as turning and repositioning, and transferring. States she feels like her knee got twisted upon a transfer from the wheelchair to the bed after dinner on 09/22/15 around 8:00 PM. The resident stated the crane (Hoyer) was not used during the transfer. Further review of the facility incident report dated 09/23/15 reflected: Resident #8 was transferred by 2-10 CNA (CNA T) after dinner from the wheelchair to the bed by having the resident attempt to stand and pivot instead of using the mechanical lift per resident. Resident #8 stated she told the CNA (CNA T) her left knee was twisting and the CNA went and got the Hoyer lift. Resident #8 added the pain in her knee happens with movement. An observation on 09/23/15 at 3:00 PM, revealed a mobile x-ray technician positioning Resident #8 for an x-ray of her left knee. Resident #8 was complaining of pain in her left knee and asked the technician to please be careful when moving her left leg. Resident #8's left knee was swollen to approximately twice the size of her right knee. Review of a mobile X-ray report for Resident #8 dated 09/23/15 , reflected the following: Results: Left knee two views reflected no fracture or dislocation. Moderate degenerative changes. A mild joint effusion (swelling) is seen. Review of MARs for Resident #8 for 07/2015, 08/2015 and through 09/24/15, reflected Resident #8 had not requested medication for pain until 09/23/15 and 09/24/15 and she had received three doses as of midday 09/24/15. There was a physician order on 09/23/15 for Tylenol 325 mg. two tablets every 6 hours as needed for pain. In an interview on 09/23/15 at 9:30 AM, CNA T stated she was off duty, but was waiting on transportation. CNA T stated she had worked a double shift on the 09/22/15 and Resident #8 was transferred to bed after dinner using the Hoyer left and that CNA U assisted her. CNA T stated she knew Resident #8 was to be transferred with two people using a Hoyer lift, and had not transferred her alone. In an interview on 09/24/15 at 2:20 PM, CNA U stated she worked the 2 PM-10 PM and was assigned to a different hall than the one Resident # 8 resides. CNA U stated when a resident needs to be transferred with the Hoyer lift two staff are required. CNA U added she is usually the go to person for CNA T when she needs assistance. CNA U stated that she did not assist CNA T transfer Resident #8 during her shift. In an interview on 09/23/15 at 3:30 PM, Resident #8 stated a CNA tried to transfer her alone without using that crane , from her wheelchair to the bed after dinner. Resident #8 stated when the CNA stood her up and tried to pivot her to the bed, she immediately felt pain in her left knee and told the CNA. Resident #8 stated the CNA placed back in her wheelchair, got the crane and then put her to bed using the lift without another CNA to assist her. When asked if she knew the name of the CNA that did the transfer Resident #8 stated she wasn ' t ' good with names, but gave a detailed description of CNA T. In an interview on 09/25/15 at 8:30 AM, LVN F stated she was the charge nurse on duty for Resident #8 on the night of 09/22/15 from 10:00 PM to 6:00 AM. LVN F went on to say that a night shift CNA, CNA W, came to her and reported that Resident #8 was complaining of left knee pain when they were positioning her for the Hoyer lift transfer. LVN F stated she went to assess Resident #8's left knee and found it was swollen twice the size of the right knee and she had pain with movement. LVN F stated she completed an incident report, notified the physician, and received orders for a mobile x-ray and as needed Tylenol every six hours. LVN F stated when she asked Resident #8 what happened she reported she was hurt by a CNA that attempted to transfer alone and without the mechanical lift. In an interview on 09/24/15 at 5:40 PM, LVN G stated she was a charge nurse on duty on 09/22/15 and none of the CNAs came to her to report Resident #8 was in pain, including CNA T. In an interview on 09/25/15 at 10:00 AM, the Administrator stated she had reported the transfer incident with Resident #8 to the state reporting agency and the facility's investigation did not reveal any staff that could collaborate CNA T's statement that she transferred Resident #8 with CNA U using a lift on the evening of 09/22/15. The Administrator added the facility was going to conclude their investigation and confirm Resident #8's statement of the incident. B) Observation on 09/21/15 at 6:37 PM, revealed the shower room located on Hall A was unlocked and unattended by staff. Inside the shower room was a cabinet with a pad lock opened and the doors open. Inside the cabinet were large plastic bins with disposable razors, liquid shampoo bottles, and liquid body wash. The liquid bottles had labels that read for external use only, do not swallow. In an interview on 09/21/15 at 7:00 PM, the DON stated the shower rooms and/or the cabinets inside them should be locked when staff is not using them to prevent any residents wandering in and taking items that may be harmful to them. C. Observation on 09/23/2015 at 8:27 AM, revealed one (1) housekeeping cart was left unlocked with hazardous chemicals present. All chemicals had warnings of do not drink and keep out of the reach of children. The cart was found in an unoccupied, unlocked room (A-27) on Hall A and readily accessible to residents. The hazardous chemicals were located in a lockable compartment of the cart with a working locking mechanism and they included two (2) spray bottles of air freshner with DO NOT DRINK on the labels, one (1) bottle of disinfectant cleaner with label reading Do not drink; hazard to human and domestic animals and one (1) bottle of toilet bowl cleaner with a label stating Keep out of reach of children - DANGER. Located directly below this lockable compartment was one (1) large bag of hand sanitizer with expiration date of 11/2013 and labeled Keep out of reach of children, and two (2) bags of liquid antibacterial soap labeled Keep out of reach of children. In an interview on 09/23/2015 at 8:45 AM, Housekeeper Z stated he had forgotten to lock his cart when he pushed it into this bedroom at approximately 8:02 AM because the breakfast trays were being served to residents. Housekeeper Z stated he usually locks his cart for safety and that it is policy but he was in a rush this morning. He stated the lock worked properly and he demonstrated with the key. In observations of an Unsampled Resident on 09/23/2015 at various times of the day revealed her wandering up and down Hall A and around the facility in her wheelchair including the following: · 11:18 AM - Unsampled Resident wandered down Hall A and was sitting outside Room #A-27. · 12:00 PM - Unsampled Resident wandered down Hall A and was sitting outside Room #A-27. · 12:05 PM - Unsampled Resident wandered down Hall A and was sitting outside Room #A-27. · 3:30 PM - Unsampled Resident was wheeling down the Hall A and went to Room #A-27. She opened the door, looked in briefly and closed it again then wandered over to Room #A-25. · 3:46 PM - Unsampled Resident wandered down Hall A and was sitting outside Room #A-27. In an interview on 09/25/2015 at 10:00 AM, the Administrator stated the housekeeping carts are not to be stored in rooms but are to be locked in the housekeepers' closet. The Administrator stated the employee had been counseled. Review of the facility policy Housekeeping Equipment Guide dated April 2005 reflected: 4. Never leave carts unattended with chemicals exposed for resident safety. Chemicals should be kept with the housekeeper, or placed in locked storage compartment. The DON stated there were nine (9) residents in the facility that required the Hoyer Lift for transfers. The DON stated there were two (2) confused residents that wander in the building.

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit neglect of residents for one (1) of three (3) residents reviewed for neglect (Resident #8) CNA T transferred Resident #8 alone, without using a mechanical lift, and not according to the care plan. Resident #8 sustained pain and swelling in her left knee as a result of the improper transfer. This deficient practice affected Resident #8 and placed an additional 8 residents care planned for two person mechanical lift transfers at risk for injuries and pain. The Findings Include: A) Review of a Face Sheet for Resident #8 reflected she was [AGE] years old and admitted to the facility on [DATE]. Review of a Quarterly MDS Assessment for Resident #8 dated 05/15/15 and an annual MDS dated [DATE], reflected Resident #8 was a two person mechanical lift for transfers, ambulated in her wheelchair with assistance required at times, and had moderate cognitive impairment. Review of a care plan for Resident #8 dated 10/19/14 and most recently updated on 08/26/15 for Resident #8 reflected: Transfers-Total Hoyer (mechanical lift) with two persons. Observation on 09/22/15 at 10:15 AM, revealed Resident #8 being transferred from her bed to the wheelchair by CNA T and CNA V. Resident #8 had a mesh sling under her in the bed. CNA T and CNA V attached the sling to the lift and began to raise the resident out of bed. When Resident #8's legs were being moved to align them for placing her in the wheelchair, she attempted to reach for her knee in a protective manner, and stated it hurt several times. CNA T and CNA V moved her legs and completed the transfer. In an interview immediately following the observation on 09/22/15 at 10:15 AM, CNA T stated Resident #8 does not complain of pain in her left knee often and she would notify the charge nurse. CNA T stated Resident #8 may seem confused, but she knows what is going on around her and can make her needs known. Review of Resident #8's facility incident report dated 09/23/15, reflected the following: Resident's left knee is swollen and resident complains of pain with movement, such as turning and repositioning, and transferring. States she feels like her knee got twisted upon a transfer from the wheelchair to the bed after dinner on 09/21/15 around 8:00 PM. The resident stated the crane (Hoyer) was not used during the transfer. Further review of the facility incident report dated 09/23/15 reflected: Resident #8 was transferred by 2-10 CNA (CNA T) after dinner from the wheelchair to the bed by having the resident attempt to stand and pivot instead of using the mechanical lift per resident. Resident #8 stated she told the CNA (CNA T) her left knee was twisting and the CNA went and got the Hoyer lift. Resident #8 added the pain in her knee happens with movement. An observation on 09/23/15 at 3:00 PM, revealed a mobile x-ray technician positioning Resident #8 for an x-ray of her left knee. Resident #8 was complaining of pain in her left knee and asked the technician to please be careful when moving her left leg. Resident #8's left knee was swollen to approximately twice the size of her right knee. Review of a mobile X-ray report for Resident #8 dated 09/23/15, reflected the following: Results: Left knee two views reflected no fracture or dislocation. Moderate [MEDICAL CONDITION] changes. A mild joint effusion (swelling) is seen. Review of MARs for Resident #8 for 07/2015, 08/2015 and through 09/24/15, reflected Resident #8 had not requested medication for pain until 09/23/15 and 09/24/15 and she had received three doses as of midday 09/24/15. There was a physician order [REDACTED]. two tablets every 6 hours as needed for pain. In an interview on 09/23/15 at 9:30 AM, CNA T stated she was off duty, but was waiting on transportation. CNA T stated she had worked a double shift on the 09/22/15 and Resident #8 was transferred to bed after dinner using the Hoyer lift and that CNA U assisted her. CNA T stated she knew Resident #8 was to be transferred with two people using a Hoyer lift, and had not transferred her alone. In an interview on 09/24/15 at 2:20 PM, CNA U stated she worked the 2 PM-10 PM and was assigned to a different hall than the one Resident #8 resides. CNA U stated when a resident needs to be transferred with the Hoyer lift two staff are required. CNA U added she is usually the go to person for CNA T when she needs assistance. CNA U stated that she did not assist CNA T transfer Resident #8 during her shift on the evening of 09/22/15. In an interview on 09/23/15 at 3:30 PM, Resident #8 stated a CNA tried to transfer her alone without using that crane, from her wheelchair to the bed after dinner. Resident #8 stated when the CNA stood her up and tried to pivot her to the bed, she immediately felt pain in her left knee and told the CNA. Resident #8 stated the CNA placed back in her wheelchair, got the crane and then put her to bed using the lift without another CNA to assist her. When asked if she knew the name of the CNA that did the transfer Resident #8 stated she wasn't good with names, but gave a detailed description of CNA T. In an interview on 09/25/15 at 8:30 AM, LVN F stated she was the charge nurse on duty for Resident #8 on the night of 09/22/15 from 10:00 PM to 6:00 AM. LVN F went on to say that a night shift CNA, (CNA W) came to her and reported that Resident #8 was complaining of left knee pain when they were positioning her for the Hoyer lift transfer prior to breakfast. LVN F stated she went to assess Resident #8's left knee and found it was swollen twice the size of the right knee and she had pain with movement. LVN F stated she completed an incident report, notified the physician, and received orders for a mobile x-ray and as needed Tylenol every six hours. LVN F stated when she asked Resident #8 what happened she reported she was hurt by a CNA that attempted to transfer alone and without the mechanical lift. In an interview on 09/24/15 at 5:40 PM, LVN G stated she was a charge nurse on duty on 09/22/15 and none of the CNAs came to her to report Resident #8 was in pain, including CNA T. In an interview on 09/25/15 at 10:00 AM, the Administrator stated she had reported the transfer incident with Resident #8 to the state reporting agency and the facility's investigation did not reveal any staff that could collaborate CNA T's statement that she transferred Resident #8 with CNA U using a lift on the evening of 09/22/15. The Administrator added the facility was going to conclude their investigation and confirm Resident #8's statement of the incident which would indicate neglect. Review of the facility's Abuse & Neglect Prohibition Policy dated 0/2012 reflected the following: Fundamental Information: Definitions- Neglect means failure to provide goods and services necessary to avoid physical harm . The DON reported there were nine (9) residents in the facility that required two (2) person mechanical lift transfers and two (2) confused residents wandered in the building.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for one (1) of three (3) residents reviewed for neglect (Resident #8) CNA T transferred Resident #8 alone, without using a mechanical lift, and not according to the care plan. Resident #8 sustained pain and swelling in her left knee as a result of the improper transfer. This deficient practice could affect nine (9) residents care planned for two (2) person mechanical lift transfers by placing them at risk for injuries and pain. The Findings Include: Review of the facility's Abuse & Neglect Prohibition Policy dated 0/2012 reflected the following: Fundamental Information: Definitions- Neglect means failure to provide goods and services necessary to avoid physical harm . Review of a Face Sheet for Resident #8 reflected she was [AGE] years old and admitted to the facility on [DATE]. Review of a Quarterly MDS for Resident #8 dated 05/15/15 and an annual MDS dated [DATE], reflected Resident #8 was a two person mechanical lift for transfers, ambulated in her wheelchair with assistance required at times and had moderate cognitive impairment. Review of a care plan for Resident #8 dated 10/19/14 and most recently updated on 08/26/15 for Resident #8 reflected: Transfers-Total Hoyer (mechanical lift) with two persons. Observation on 09/22/15 at 10:15 AM, revealed Resident #8 being transferred from her bed to the wheelchair by CNA T and CNA V. Resident #8 had a mesh sling under in her bed. CNA T and CNA V attached the sling to the lift and began to raise the resident out of bed. When Resident #8's legs were being moved to align them for placing her in the wheelchair, she attempted to reach for her knee in a protective manner, and stated it hurt several times. CNA T and CNA V moved her legs and completed the transfer. In an interview immediately following the observation on 09/22/15 at 10:15 AM, CNA T was asked if Resident #8 complains of pain in her left knee often and CNA T stated no and she would notify the charge nurse. CNA T added, Resident #8 may seem confused, but she knows what is going on around her and can make her needs known. Review of a facility incident report dated 09/23/15 reflected the following: Resident #8's left knee is swollen and resident complains of pain with movement, such as turning and repositioning, and transferring. States she feels like her knee got twisted upon a transfer from the wheelchair to the bed after dinner on 09/22/15 around 8:00 PM. The resident stated the crane (Hoyer) was not used during the transfer. Further review of the facility incident report dated 09/23/15 reflected: Resident #8 was transferred by 2-10 CNA (CNA T) after dinner from the wheelchair to the bed by having the resident attempt to stand and pivot instead of using the mechanical lift per resident. Resident #8 stated she told the CNA (CNA T) her left knee was twisting and the CNA went and got the Hoyer lift. Resident #8 added the pain in her knee happens with movement. An observation on 09/23/15 at 3:00 PM, revealed a mobile x-ray technician positioning Resident #8 for an x-ray of her left knee. Resident #8 was complaining of pain in her left knee and asked the technician to please be careful when moving her left leg. Resident #8's left knee was swollen to approximately twice the size of her right knee. Review of a mobile X-ray report for Resident #8 dated 09/23/15, reflected the following: Results: Left knee two views reflected no fracture or dislocation. Moderate [MEDICAL CONDITION] changes. A mild joint effusion (swelling) is seen. Review of MARs for Resident #8 for 07/2015, 08/2015 and through 09/24/15, reflected Resident #8 had not received medication for pain until 09/23/15 and 09/24/15 and she had received three doses as of midday 09/24/15. There was a physician order [REDACTED]. two tablets every 6 hours as needed for pain. In an interview on 09/23/15 at 9:30 AM, CNA T stated she was off duty and was waiting on transportation. CNA T stated she had worked a double shift on the 09/22/15 and Resident #8 was transferred to bed after dinner using the Hoyer left and that CNA U assisted her. CNA T stated she knew Resident #8 was to be transferred with two (2) people using a Hoyer lift, and had not transferred her alone. In an interview on 09/24/15 at 2:20 PM, CNA U stated she worked the 2 PM-10 PM and was assigned to a different hall than the one Resident #8 resides. CNA U stated when a resident needs to be transferred with the Hoyer lift two (2) staff are required. CNA U added she is usually the go to person for CNA T when she needs assistance. CNA U stated that she did not assist CNA T transfer Resident #8 during her shift on the evening of 09/22/15. In an interview on 09/23/15 at 3:30 PM, Resident #8 stated a CNA tried to transfer her alone without using that crane, from her wheelchair to the bed after dinner. Resident #8 stated when the CNA stood her up and tried to pivot her to the bed, she immediately felt pain in her left knee and told the CNA. Resident #8 stated the CNA placed back in her wheelchair, got the crane and then put her to bed using the lift without another CNA to assist her. When asked if she knew the name of the CNA that did the transfer Resident #8 stated she wasn't good with names, but gave a detailed description of CNA T. In an interview on 09/25/15 at 8:30 AM, LVN F stated she was the charge nurse on duty for Resident #8 on the night of 09/22/15 from 10:00 PM to 6:00 AM. LVN F went on to say that a night shift CNA, CNA W, came to her and reported that Resident #8 was complaining of left knee pain when they were positioning her for the Hoyer lift transfer. LVN F stated she went to assess Resident #8's left knee and found it was swollen twice the size of the right knee and she had pain with movement. LVN F stated she completed an incident report, notified the physician, and received orders for a mobile x-ray and as needed Tylenol every six hours. LVN F stated when she asked Resident #8 what happened she reported she was hurt by a CNA that attempted to transfer alone and without the mechanical lift. In an interview on 09/24/15 at 5:40 PM, LVN G stated she was a charge nurse on duty on 09/22/15 and none of the CNAs came to her to report Resident #8 was in pain, including CNA T. In an interview on 09/25/15 at 10:00 AM, the Administrator stated she had reported the transfer incident with Resident #8 to the state reporting agency and the facility's investigation did not reveal any staff that could collaborate CNA T's statement that she transferred Resident # 8 with CNA U using a lift on the evening of 09/22/15. The Administrator added the facility was going to conclude their investigation and confirm Resident # 8's statement of the incident which would indicate neglect. The DON reported there were 9 residents in the facility that required two person mechanical lift transfers and two (2) confused residents wandered in the building.

Based on observation, interview and record review the facility failed to ensure a resident having pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for one (1) of four (4) residents reviewed for pressure sores (Residents # 1). The facility failed to accurately identify, assess and consult with the Physician when Resident # 1 who was admitted without pressure sores developed a pressure sore that progressed to an unstageable pressure sore to the coccyx and a Stage II to the right buttocks resulting in hospitalization . This deficient practice placed 13 residents, who are at risk for pressure sores, identified in the facility with skin issues and the potential for skin issues at risk for delayed medical intervention, treatment, decreased skin integrity, severe life threatening infections and hospitalization . The Findings Include: Review of Resident # 1's Face Sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #1 was discharged to the hospital on [DATE] due to vomiting, diarrhea times 4, and diaphoresis (excessive perspiration). Review of Admission Minimum Data Set (MDS) for Resident # 1 dated 10/14/13 reflected her cognitive score was 5, no behaviors, moody, needed extensive assist of two people with transfers, dressing, and hygiene. Resident #1 needed one to assist with eating. She was incontinent of bowel and bladder. There were no skin issues identified on the 10/14/13 or 10/20/13 MDS. Review of Comprehensive Care Plan dated 10/14/13, corresponding to the Admission MDS, reflected Resident #1 was at risk for falls, had cognitive impairment, impaired decision making skills, requires the assistance of two staff for bed mobility, transfers, and toileting. and incontinent of bowel and bladder. A care plan was also included for Resident #1 [MEDICATION NAME](antibiotic) for a urinary tract infection. As of 11/01/13, a care plan was added for pressure sores. Interventions included pressure reduction mattress, pressure reduction cushion to chair or wheelchair, monitor lab values as ordered, weekly skin checks, turn and reposition in bed and chair frequently, referrals to registered dietitian, physical and occupational therapists, and zinc past Q shift. On 11/6/13, additional interventions included low-air loss mattress, and up for meals. Review of Resident # 1's Braden Scale for "Predicting Pressure Sore Risk" dated 10/07/13 Resident # 1 was a high risk for skin breakdown with a score of 16 (a score of 12 or less represents high risk). On 10/14/13 the score was 13. On 10/21/13 the score was 12 as well as 10/25/13. Review of the weekly skin assessment for Resident #1 on 10/09/13 skin intact, no skin issues, 10/13/13 skin intact, no skin issues, 10/16/13 skin intact, no skin issues, 10/30/13 skin intact no skin issues. Review of the "Weekly Pressure Ulcer Record" dated 11/01/13 "coccyx pressure sore, measured a Stage II 4.0 centimeters (cm) x 1.0 cm x less than 0.1 cm. Documentation of undermining was none, exudate type was none, exudate amount was none, and wound bed was pink normal for skin, surrounding skin color normal for skin, surrounding skin normal for skin and pain related to wound no. It was documented that family, physician and dietary were notified on 11/01/13. Other evaluation documentation included, fissure shape, broken-partial thickness, top layer of skin peeling. Pressure redistributing mattress in place. An actual air mattress was documented on 11/04/13. On 11/04/13 Stage II to the coccyx measuring 4.0 cm x 1.5 cm x less than 0.1 cm, skin pealing at end edge, Wound bed marked pink the rest of the documentation is the same as 11/01/13. On 11/11/13 unstageable coccyx, measuring 3.2 cm x 2.0 cm with questionable depth, Wound bed is yellow, surrounding skin color was pink, shallow crater - palatable, no complaint of pain with palpation, yellow shiny slough covered wound bed". The rest of the documentation is unchanged from 11/01/13. Review of the "Weekly Pressure Ulcer QA & A log" dated 11/5/13 reflected Resident #1's coccyx pressure sore (facility acquired) was identified as a Stage II measuring 4.0 cm x 1.5 cm and depth <1.0 cm with no odor or drainage. Treatment was indicated as "Z guard". An additional log dated 11/12/13 reflected Resident #1's coccyx pressure sore (facility acquired) was identified on 11/1/13 as unstageable - slough measuring 3.3 cm x 2.0 cm and depth was questionable. Treatment was indicated as "Z guard". Resident #1 was not documented on any of the previous "Weekly Pressure Ulcer QA & A logs" for October 2012. Review of the faxes sent to the physician: on 11/01/13 notification of Stage II pressure sore to the coccyx measuring 4 cm x 1 cm fissure shape, incontinent of bowel and bladder, poor appetite routinely eating less than 25% of meals. On pressure redistributing mattress and wheelchair cushion, turning/repositions every two hours. Apply Z guard (zinc protectant) by nurse per shift and CNA ' s with routine peri care every two hours. There was no response to this fax from the physician. He was out of the country. There were faxes sent on 11/06/13 which was not signed by the physician until 11/13/13. Treatment were written as telephone orders and treatments followed without the physician recognizing the order until two weeks later. No one else was contacted for orders. The 11/06/13 fax added dietary supplements without treatment change. This fax was not acknowledged by the physician until 11/13/13 when he returned to work. On 11/12/13 the treatment nurse LVN B changed the treatment to the pressure sore to Santyl [MEDICATION NAME] twice a day to wound bed cover with occlusive dressing. This was okayed by the physician on 11/13/13. Wound culture was requested by LVN B on 11/14/13 and this was phoned to the physician after a mix up in whether it was for a UA (urine)with C (Culture) & S (Sensitivity) or a Wound culture with C & S and asking for antibiotics. There was a wound culture collected to the coccyx on 11/14/13 finding returned after Resident #1 was sent to the hospital. The results were 4+ Proteus mirabilis, 2+ Pseudomonas aeruginosa and 4+ [MEDICATION NAME] species (bacteria normal to the intestinal tract) which was faxed to the hospital. In an interview on 11/21/13 at 9:40 AM Licensed Vocational Nurse (LVN) B, treatment nurse, stated she does as many skin checks as she can in the mornings and on scheduled shower days. She stated the nurse aides contact her with any skin issues and as does the shower aides. She stated they page her or it goes through the head set they use. In an interview on 11/21/13 at 9:50 AM LVN B, stated Resident #1 did not eat very well when she was admitted to the facility and she had diarrhea and was incontinent of bowel and bladder. She stated the nurse aides were continuously putting on barrier cream to protect her bottom. LVN B stated there was a persistent red line on Resident #1 ' s coccyx they were putting barrier cream on. She stated last week she noticed a foul odor from Resident #1 ' s pressure sore on her coccyx and she had contacted the physician for an order for [REDACTED]. LVN B stated she used Santyl on the wound and working with the PA (physician assistant). She stated the doctor was out of the country. LVN B stated they were in the process of getting a contract with a wound specialist to assist with wounds. In an interview on 11/21/13 at 12:00 PM the Director of Nurses (DON) stated Resident #1 was on a BRAT (banana, rice, applesauce and toast) diet for diarrhea and vomiting. In an interview on 11/21/13 at 12:10 PM the DON stated the emergency services supervisor had questioned her about Resident #1 ' s wounds. He stated her pressure sores were not identified on the transfer record. The DON stated there was a square there to mark and it was marked. There was no other information regarding the pressure sore. The DON stated the emergency services supervisor had stated his crew was to do a head to toe exam before they transport and they did not. She stated the emergency room doctor had called her with concerns regarding Resident #1 ' s pressure sores. She told him Resident #1 was receiving supplements and the doctor was being contacted with updates of the pressure sores. In an interview on 11/21/13 at 1:00 PM a family member for Resident #1 stated the family member stated another family member pointed out the pressure sores and asked for a culture. The family stated the resident was not eating and lethargic. The family member stated they were concerned as they believed no physician had looked at the pressure sores. The family was told Resident #1 was dehydrated and had a wound infection when she arrived at the hospital. In an interview on 11/21/13 at 2:00 PM LVN B stated Resident #1 had no open areas on her skin until 11/01/13. She stated she faxed the physician on 11/02/13 about the pressure sore and spoke with the PA on 11/06/13 and discussed the pressure sore on Resident #1 ' s coccyx. LVN B stated she did not know if the PA saw Resident #1 and her pressure sore or not. In an interview on 11/21/13 at approximately 12:15 PM the Social Worker at the local hospital stated when Resident #1 arrived at the hospital it was felt Resident #1 had been neglected. There was odor from pressure sores, and the severity of the pressure sores caused concern. The social worker stated she spoke with a family member who had stated she had asked the nursing home about the blisters she noted on Resident #1 and she was told the facility was putting antibiotic cream on them. In an interview on 11/21/13 at 12:40 PM the hospital physician stated Resident #1 came in to the hospital with unstageable pressure sores to the sacral/coccyx area and bilateral buttocks. He stated infection was likely. The physician stated there was no record of a pressure sores upon Resident #1 ' s last admission. (Resident #1 was admitted to the facility on [DATE] from the hospital). Review of hospital admission documentation dated 11/17/13 reflected a [DIAGNOSES REDACTED]. Hospice recommended. Review of hospital documentation dated 11/18/13 reflected Resident #1 is "septic most likely source is wound. Left lower lobe pneumonia, [MEDICAL CONDITIONS], altered mental status, sacral decubitus unstageable, significant leukocytosis, [MEDICAL CONDITION] severe." Resident #1's White Blood Cell (WBC) count on admission was 50K. "Source sacral wound and no [MEDICAL CONDITION] Resistent Staphylococcus Aeureus (MRSA). " Review of the wound specialist report dated 11/18/13 at the hospital reflected " a wound to the sacrum, unstageable pressure ulcer in which the base of the ulcer is covered with 100% black eschar and the wound depth cannot be identified. Size is 3.5 cm x 1.6 cm x 100% unstable eschar. Left Gluteal unstageable pressure ulcer in which the base of the ulcer is covered with 100% black eschar and the wound depth cannot be identified. Size is 3 cm x 2.4 cm x 100 % unstable eschar. Right gluteal wound shearing and friction damage to the tissue. Partial thickness loss of skin involving the epidermis and the dermis. The ulcer is superficial and present clinically as a shallow crater. Size 3.4 cm x 3.2 cm x less than .1 cm. Stage I pressure ulcer noted to the sacrum, area of periwound with decreased amount of subcutaneous tissue. " In an interview on 11/21/13 at 2:50 PM the Physician's Assistance (PA) stated she never saw the pressure sores on Resident #1. She stated the doctor is out of the country and she was never told of the pressure sores to Resident #1. She stated if she had been told she would have evaluated them. She stated the faxes go to the doctor ' s office and she is there one day a week on Tuesdays as she teaches college. She stated the doctor for Resident #1 manages all the nursing home residents and she sees them occasionally. She stated there was a doctor on call for Resident #1 ' s doctor while he was unavailable. The PA stated staff can call her or the doctor if there are specific issues and not fax them. She stated she did receive a fax for a urine culture and she gave that okay; however she was not aware she was okaying a wound (of the pressure sore) culture as she thought it was just the urine culture. She stated again she was not told of the pressure sores to Resident #1 or she would have looked at them. In an interview on 11/21/13 at 6:50 PM a family member stated another family member had noticed blisters to Resident #1 ' s bottom when they were in the facility. He stated the family member did bring it to the attention of the nurse. He would have that family member call the investigator. In an interview on 11/21/13 at 7:20 PM another family member called and stated on October 26th she had an aide help Resident #1 to the bathroom. At this time the family member stated she saw blisters between Resident #1 ' s buttock cheeks and at the top crease of the buttocks. The family member stated she saw them because as the resident was being transferred from the wheelchair to the toilet by Certified Nurse Aide (CNA) F, Resident #1 ' s brief fell off. The family member stated she told the treatment nurse (LVN B) to be sure and record the information in Resident #1 ' s file. On 0ctober 29th the family member wanted Resident #1 changed and CNA E took off her brief and blisters had burst and down each side of Resident #1 ' s buttock crease was deep red. The nurse aide placed cream on the bottom. She notified RN A to come and see Resident #1 ' s buttocks. The nurse told the family member the open areas did not look infected but just irritated. The family member and RN A walked to the nurses' station to look at documentation of the blistered area and nothing was documented in the treatment book or nurses notes nor was there documentation on October 30th. The family member saw Resident #1 November 1st and spoke with the treatment nurse twice with questions regarding Resident #1 ' s buttocks. LVN B stated the buttocks were not infected. The family member felt there were Stage II ' s to Resident #1 ' s bottom. The staff just lathered her bottom with some type of cream. On approximately November 15th the family member told LVN B the areas on Resident #1 ' s bottom did not look like they were healing and LVN B stated there was a culture of the wound being done. The family member stated the doctor had stated when she was admitted to the facility Resident #1 still had a WBC of 16,000 and a urinary culture was done. The family member explained the area of the pressure sores from the tailbone, each side of the cheeks of the buttocks where the cheeks start to fill out into the buttock was reddish purple in color. It looked like a big angry bruise. Then half to three quarter of the way down the buttock crease, tapering off around the rectum area also was red in color. On October 30th it wounds looked differently as they looked like Resident #1 ' s bottom looked like it had been scalded. The family member stated her sister was scalded when she was little and Resident #1 ' s bottom looked just like that. The family member stated it looked like a bad sun burn with raw skin and a texture change. LVN B stated to her that she was using an enzyme of some kind on Resident #1 ' s bottom and that she had slipped an antibiotic cream on her. She felt Resident #1 was not put on an air mattress until about a week prior to last Friday (approximately 8th or 9th of November). In an interview on 11/22/13 at 9:50 AM LVN B stated all their mattress in the facility are pressure redistributing mattress. She stated depending on the Braden scale for each resident they may be placed on an air mattress. LVN B stated she remembered talking with the PA about Resident #1 ' s pressure sore. LVN B stated the PA is in and out alot when the doctor is out of town. LVN B stated she had not looked at the pressure sore with the PA. She stated prior to 11/01/13 Resident #1 had mild excoriation to the buttocks. LVN B stated " if it looks like good peri care will heal the excoriation then she does not notify the physician." She stated " it did not impress her as being an issue. I thought it would heal. " LVN B stated the cream that is used is Z guard (zinc based barrier cream). She stated the nurse aides can apply the cream and charge nurses do treatments when she is not there. She stated she works Monday through Friday and is off on weekends. LVN B stated the nurses would contact the physician on the weekends. LVN B stated " I have been doing this for a long time. " She stated she does not have standing orders for treatments. She faxes the physician with what she wants to do for a treatment and he will give her the go ahead. She stated she faxes the physician and if there is no response she will fax again or call. She stated she thought someone in the office would respond. She stated she did not address the red, excoriation to the buttocks of Resident #1 on her weekly skin sheets and knew nothing of the other pressure sores other than the coccyx area. In an interview on 11/22/13 at 10:00 AM CNA F stated Resident #1 had redness to her buttocks and she had been putting Z guard on her buttocks and the top of the buttocks. CNA F stated " I believe somewhere mid-October when I was taking Resident #1 to the bathroom with the family member present and I only saw one blister at the top of the butt crack, tailbone area. " CNA F stated " I reported it to LVN B, the treatment nurse. LVN B came to look at Resident #1 buttock and told her to just put Z guard on it. " In an interview on 11/22/13 at 10:22 AM RN A stated a family member did come to her about Resident #1. She stated she was not the nurse for that hall but she went to look at the skin issues as the family member asked. RN A stated Resident #1 had a red buttocks and a crack in the skin at the coccyx area. She stated she left a note for LVN B and then told her the next day she worked. She could not be sure of the dates. She stated it was somewhere around the first of November or just before. The family member wanted to be sure that LVN B knew about it. RN A stated she had the nurse aide put cream (Z guard) on the area. In an interview on 11/22/13 at 10:24 AM the Administrator stated LVN B has taken the wound care course (for pressure sore treatment and care) to be certified and just needed to take the test. In an interview on 11/22/13 at 11:07 AM the DON stated she expected the nurses to call the physician with a follow up phone call if there has been no response to faxes. Also to call when it is important and not wait for a fax to return. The DON stated that blisters should be addressed on the non-pressure sore log or the pressure ulcer log. She stated the blister or any open area should be documented on the weekly skin sheet. The DON stated she was concerned that the pressure sore that the hospital is saying Resident #1 has is from shearing and could have happened during emergency service (EMS) transport from the facility to the hospital. She stated the condition could have exacerbated while waiting in the hospital. She stated the EMS did not do their head to toe assessment like their supervisor stated they were supposed to do. The DON stated LVN C sent Resident #1 to the hospital. The DON stated she was not aware of pressure sores with eschar on Resident #1. She stated she did not understand how eschar was on the wound and to speak with LVN C as she sent Resident #1 to the hospital. The DON stated they do not have standing orders for any type of wound care. In an interview on 11/22/13 at 11:35 AM CNA E stated Resident #1 ' s coccyx area was red but not real red when she assisted the family member. She stated that LVN B was made aware. She stated she did not remember the area looking like a bruise. CNA E stated she is a restorative aide in the facility. CNA E stated she did not see blister, or anything that looked like a blister or one that had burst. In an interview on 11/22/13 at 11:55 AM the DON stated " I only saw the one area to Resident #1 ' s coccyx early on and again later. Never saw anything more than that. " In an interaview on 11/22/13 at 12:40 PM LVN C stated EMS picked Resident #1 up about 9:45 PM. She stated the resident had a mushy stool and she was trying to clean her up. Resident #1 had a derma dressing on her coccyx so she did not see it the pressure sore. She stated she did not notice any other open areas or redness. She stated she just glanced at the bottom and if there was anything black she would have noticed it. LVN C stated, " I was more concerned with Resident #1 ' s heart rate. I was just thinking of heart rate and not butt." In an interview on 11/22/13 at 12:45 PM LVN B stated Resident #1 ' s buttock looked superficial/macerated on October 26th. She stated she did not see blisters. She stated she had never seen deep tissue like bruises. She stated the buttock was fleshy. She stated the dietitian saw Resident #1 because she was not eating well. LVN B stated Resident #1 had left side redness and swelling to the buttocks and that was why she asked for an antibiotic. She stated the treatments were being done twice a day. In an interview on 11/22/13 at 1:20 PM the physician for Resident #1 stated he did not physically look at Resident #1 ' s pressure sores. He stated he was waiting to put Resident #1 on antibiotic when she was admitted as she was already on them. He stated the CBC done after admission on 10/09/13 for Resident #1 he was not aware of the results of the WBC of 16.8 He stated it was a hard call to make to say whether the pressure sores on Resident #1 was unavoidable or not. He stated he had been out of the country for three weeks but there was a doctor on call for him and the PA. He stated when he got back to the office on 11/13/13 there were faxes about antibiotics for wounds and urine culture. This was a mess up as the antibiotics were Okayed by the PA for the urine culture but did not include the pressure sore. The physician stated he was not aware of the pressure sore but the PA would have seen them. When he was told the PA was not told the physician stated, " Then someone should have called to ensure the areas were evaluated. " The facility provided Skin Management information dated 2010 SavaSeniorCare Administrative Services and Clinical Practice Standards for Changes of Resident Condition dated 2005 SavaSeniorCare Administrative Services. Neither of the documents have policy/procedures. On the Changes in Resident Condition there is a statement that " The resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and caregivers is also important to ensure that consistency and continuity are maintain for resident benefit. Under 1. The resident, attending physician and legal representative or designated family member are notified when there is (under c. a need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.) The Skin Management documentation addresses references and guidelines only on management of tissue loads, measuring pressure ulcers, suggested interventions for Stage I, II, III and Stage IV. Also addresses clean dressing changes. The facility did not provide specific information, policy and procedures for notification of wound care changes, how often to notify the physician and how to contact the physician as to faxes verses phone calls for discussion. The Treatment Nurse provided a list of 13 residents at risk for pressure sores.

Based on observation, interview and record review the facility failed to consult with the Physician when there was a significant change in the Resident's pressure sore and a need to alter treatment significantly for one (1) of three (4) residents (Residents # 1) reviewed for pressure sores. The facility failed to consult and discuss with the Physician Resident # 1's pressure sore and treatment which resulted in hospitalization for an unstageable pressure sore to the coccyx, and unstageable pressure sore to the left buttocks and a stage II pressure sore to the right buttocks. This deficient practice placed 13 residents in the facility, identified for risk for pressure sore development at risk for progression, worsening and infection of pressure sores and possible hospitalization when there is a delay in appropriate medical treatment and interventions. The Findings Include: Review of Resident # 1's Face Sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #1 was discharged to the hospital on [DATE] due to vomiting, diarrhea times 4, and diaphoresis (profuse perspiration). Review of Admission Minimum Data Set (MDS) for Resident # 1 dated 10/14/13 reflected her cognitive score was 5, no behaviors, moody, needed extensive assist of two people with transfers, dressing, and hygiene. Resident #1 needed one to assist with eating. She was incontinent of bowel and bladder. There were no skin issues identified. Review of Comprehensive Care Plan corresponding to the Admission MDS for Resident # 1's reflected her choice of activities, risk for falls, cognitive deficits, impaired decision making skills, full code, Activities of Daily Living skills, [MEDICAL CONDITION] Fibrillation, Incontinent of bowel and bladder, [MEDICATION NAME](antibiotic) for a urinary tract infection, and potential for weight loss. As of 11/01/13 pressure sore care plan was added with low air loss mattress. Review of Resident # 1's Braden Scale for Predicting Pressure Sore Risk dated 10/07/13 Resident # 1 was a low risk for skin breakdown with a score of 16 (a score of 12 or less represents high risk). On 10/14/13 the score was 13. On 10/21/13 the score was 12 as well as 10/25/13. Review of the weekly skin assessment for Resident #1 on 10/09/13 skin intact, no skin issues, 10/16/13 skin intact, no skin issues, 10/13/13 skin intact, no skin issues, 10/30/13 skin intact no skin issues. Review of the "Weekly Pressure Ulcer Record" dated 11/01/13 coccyx, measured a Stage II 4.0 cm (centimeter) x 1.0 cm x less than 0.1 cm. Documentation of undermining was none, exudate type was none, exudate amount was none, and wound bed was pink normal for skin, surrounding skin color normal for skin, surrounding skin normal for skin and pain related to wound no. It was documented that family, physician and dietary was notified on 11/01/13. Other evaluation documentation included, would fissure shape, broken-partial thick, top layer of skin peeling. Pressure redistributing mattress in place. An actual air mattress was documented on 11/04/13. On 11/04/13 Stage II pressure sore to the coccyx measuring 4.0 cm x 1.5 cm x less than 0.1 cm, skin pealing at end edge, Wound bed marked pink the rest of the documentation is the same as 11/01/13. On 11/11/13 unstageable pressure sore to the coccyx, measuring 3.2 cm x 2.0 cm with questionable depth, Wound bed is yellow, surrounding skin color was pink, shallow crater - palatable, no complaint of pain with palpation, yellow shiny slough covered wound bed. The rest of the documentation is unchanged from 11/01/13. Review of the "Weekly Pressure Ulcer QA &A log" only identified the coccyx wound (pressure sore) to Resident #1 at 11/12/13 as unstageable slough measuring 3.3 cm x 2.0 cm and depth questionable. Z guard (zinc barrier type cream) used and wound identified on 11/01/13. Then there is another QA & A log dated 11/05/13 that identified a Stage II pressure sore to coccyx measuring 4.0 cm x 1.5 cm x less than .01 cm identified on 11/01/13. There was no other "Weekly Pressure Ulcer QA & A log" provided. Review of the faxes sent to the physician: on 11/01/13 notification of Stage II pressure sore to the coccyx measuring 4cm x 1cm fissure shape, incontinent of bowel and bladder, poor appetite routinely eating less than 25% of meals, On pressure redistributing mattress and wheelchair cushion, turning/repositions every two hours. Apply Z guard zinc protectant by nurse per shift and CNA ' s with routine peri care every two hours. There was no response to this fax from the physician. He was out of the country. There were faxes sent on 11/06/13 which was not signed by the physician until 11/13/13. Treatments were written as telephone orders and treatments followed without the physician recognizing the order until two weeks later. No one else was contacted for orders. The 11/06/13 fax added dietary supplements without treatment change. This fax was not acknowledged by the physician until 11/13/13 when he returned to work from his vacation. On 11/12/13 the treatment nurse LVN B changed the treatment to the wound to Santyl [MEDICATION NAME] twice a day to wound bed cover with occlusive dressing. This was okayed by the physician on 11/13/13. Wound culture was requested by LVN B on 11/14/13 and this was phoned to the physician after a mix up in whether it was for a UA (urine) with C (Culture) & S (Sensitivity) or a Wound culture with C & S and asking for antibiotics. There was a wound culture collected to the coccyx on 11/14/13 finding returned after Resident #1 was sent to the hospital. The results were 4+ Proteus mirabilis, 2+ Pseudomonas aeruginosa and 4+ [MEDICATION NAME] species (bacteria normal to the intestinal tract) which was faxed to the hospital. In an interview on 11/21/13 at 9:50 AM Licensed vocational Nurse (LVN B), stated Resident #1 did not eat very well when she got to the facility she had diarrhea and was incontinent of bowel and bladder. She stated the nurse aides were continuously putting on barrier cream to protect her bottom. LVN B stated there was a persistent red line on Resident #1 ' s coccyx they were putting barrier cream on. She stated last week she noticed a foul odor from Resident #1 ' s pressure sore on her coccyx and she had contacted the physician for an order for [REDACTED]. LVN B stated she used Santyl on the pressure sore and working with the PA (physician assistant). She stated the doctor was out of the country. LVN B stated they were in the process of getting a contract with a wound specialist to assist with wounds. In an interview on 11/21/13 at 1:00 PM a family member for Resident #1 stated Resident #1 was not eating well enough and she was lethargic. The family member stated another family member pointed out the pressure sore and asked for a culture. The family member stated they were concerned as they believed no physician had looked at the pressure sore. The family was told Resident #1 was dehydrated and had a wound (pressure sore) infection when she arrived at the hospital. In an interview on 11/21/13 at 2:00 PM LVN B stated Resident #1 had no open areas on her skin until 11/01/13. She stated she faxed the physician on 11/02/13 about the wound (pressure sore) and spoke with the PA on 11/06/13 and discussed the wound (pressure sore) wound on Resident #1 ' s coccyx. LVN B stated she did not know if the PA saw Resident #1 and her wound (pressure sore) or not. Review of hospital documentation dated 11/18/13 reflected Resident #1 is septic most likely source is wound. Left lower lobe pneumonia, [MEDICAL CONDITIONS], altered mental status, sacral decubitus unstageable, significant leukocytosis, [MEDICAL CONDITION] severe.Resident #1's WBC count on admission was 50K. Source sacral wound and [MEDICAL CONDITION]." Review of the wound specialist report dated 11/18/13 at the hospital reflects " a wound to the sacrum, unstageable pressure ulcer in which the base of the ulcer is covered with 100% black eschar and the wound depth cannot be identified. Size is 3.5 cm x 1.6 cm x 100% unstable eschar. Left Gluteal unstageable pressure ulcer in which the base of the ulcer is covered with 100% black eschar and the wound depth cannot be identified. Size is 3 cm x 2.4 cm x 100 % unstable eschar. Right gluteal wound shearing and friction damage to the tissue. Partial thickness loss of skin involving the epidermis and the dermis. The ulcer is superficial and present clinically as a shallow crater. Size 3.4 cm x 3.2 cm x less than .1 cm. Stage I pressure ulcer noted to the sacrum, area of periwound with decreased amount of subcutaneous tissue. " In an interview on 11/21/13 at 2:50 PM the Physician Assistant (PA) stated she never saw the pressure sores on Resident #1. She stated the doctor is out of the country and she was never told of the pressure sores to Resident #1. She stated if she had been told she would have evaluated them. She stated the faxes go to the doctor ' s office and she is there one day a week on Tuesdays as she teaches college. She stated the doctor for Resident #1 manages all the nursing home residents and she sees them occasionally. She stated there was a doctor on call for Resident #1 ' s doctor while he was out of the country. The PA stated staff can call her or the doctor if there are specific issues and not fax them. She stated she did receive a fax for a urine culture and she gave that okay; however she was not aware she was okaying a wound culture as she thought it was just the urine culture. She stated again she was not told of the pressure sores to Resident #1 or she would have looked at them. In an interview on 11/22/13 at 9:50 AM LVN B stated all their mattresses in the facility are pressure redistributing mattresses. She stated depending on the Braden scale for each resident they may be placed on an air mattress. LVN B stated she remembered talking with the PA about Resident #1 ' s pressure sore. LVN B stated the PA is in and out a lot when the doctor is out of town. LVN B stated she had not looked at the pressure sore with the PA. She stated prior to 11/01/13 Resident #1 had mild excoriation to the buttocks. LVN B stated "if it looks like good peri care will heal the excoriation then she does not notify the physician." She stated" it did not impress her as being an issue. I thought it would heal. " LVN B stated the cream that is used is Z guard (zinc based barrier cream). She stated the nurse aides can apply the cream and charge nurses do treatments when she is not there. She stated she works Monday through Friday and is off on weekends. LVN B stated the nurses would contact the physician on the weekends. LVN B stated " I have been doing this for a long time." She stated she does not have standing orders for treatments. She faxes the physician with what she wants to do for a treatment and he will give her the go ahead. She stated she faxes the physician and if there is no response she will fax again or call. She stated she thought someone in the office would respond. She stated she did not address the red, excoriation to the buttocks of Resident #1 on her weekly skin sheets and knew nothing of the other pressure sores other than the coccyx area. In an interview on 11/22/13 at 11:07 AM the DON stated she expected the nurses to call the physician with a follow up phone call if there has been no response to faxes. Also to call when it is important and not wait for a fax to return. In an interview on 11/22/13 at 11:55 AM the DON stated " I only saw the one area to Resident #1 ' s coccyx early on and again later. Never saw anything more than that. " In an interview on 11/22/13 at 1:20 PM the physician for Resident #1 stated he did not physically look at Resident #1 ' s wounds or pressure sores. He stated he was waiting to put Resident #1 on antibiotic when she was admitted as she was already on them. He stated the CBC done after admission on 10/09/13 for Resident #1 he was not aware of the results of the WBC of 16.8 He stated it was a hard call to make to say whether the pressure sores on Resident #1 was unavoidable or not. He stated he had been out of the country for three weeks but there was a doctor on call for him and the PA. He stated when he got back to the office on 11/13/13 there were faxes about antibiotics for wounds and urine culture. This was a mess up as the antibiotics were Okayed by the PA for the urine culture but did not include the pressure sore. The physician stated he was not aware of the pressure sore but the PA would have seen them. When he was told the PA was not told the physician stated, " Then someone should have called to ensure the areas were evaluated. " The facility provided Skin Management information dated 2010 SavaSeniorCare Administrative Services and Clinical Practice Standards for Changes of Resident Condition dated 2005 SavaSeniorCare Administrative Services. Neither of the documents have policy/procedures. On the Changes in Resident Condition there is a statement that " The resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and caregivers is also important to ensure that consistency and continuity are maintained for resident benefit. Under 1. The resident, attending physician and legal representative or designated family member are notified when there is (under c. a need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.) The Skin Management documentation addresses references and guidelines only on management of tissue loads, measuring pressure sores, suggested interventions for Stage I, II, III and Stage IV. Also addresses clean dressing changes. The facility did not provide specific information, policy and procedures for notification of wound care changes, how often to notify the physician and how to contact the physician as to faxes verses phone calls for discussion. The Treatment Nurse provided a list of 13 residents at risk for pressure sores. .