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

Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for two residents (#8 and #94) of thirty-two residents reviewed for MDSs. 1. Facility failed to note on Resident #8's annual MDS, dated [DATE], the resident was taking CPAP (Continuous Positive Airway Pressure) at hours of sleep. 2. Facility failed to note on Resident #94's annual MDS, dated [DATE], she was taking a hypoglycemic medication. This deficient practice affects residents who receive care and could result in missed or inappropriate care. The findings included: 1. Record review of Resident #8's face sheet, dated 07/31/2025, revealed the resident was a [AGE] year old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with the diagnoses of type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), cirrhosis of liver (chronic liver damage from a variety of causes leading to scarring and liver failure), hypertension (high blood pressures), atherosclerotic heart disease of native coronary artery (plaque and blood clots can reduce blood flow through an artery), muscle wasting and atrophy (loss of skeletal muscle mass), and sleep apnea (breathing repeatedly stops and starts at night's sleep). Record review of Resident #8's annual MDS assessment, dated 06/20/2025, revealed the resident's BIMS was 12 out of 15 indicated the resident had moderate cognitive impairment, and the resident required supervision or touching assistance (Helper provides verbal cues and/or touching assistance), such as sit to stand, chair to bed, and toilet transfer. Further record review of the MDS assessment revealed regarding the question of Non-invasive Mechanical Ventilator in Section O (Special care), the answered was coded No. Record cord review of Resident #8's comprehensive care plan, dated 05/19/2025, revealed the resident had the care plan of [Resident #8] has an order for CPAP (Continuous Positive Airway Pressure) for sleep apnea. For intervention – change CPAP (Continuous Positive Airway Pressure) tubing and setting it as ordered. Record review of Resident #8's physician order, dated 05/15/2025, revealed the resident had the order of CPAP (Continuous Positive Airway Pressure) settings: CPAP (Continuous Positive Airway Pressure) 11CMH2O (Centimeters of water) at HS (hours of sleep) and prn (as needed) at bedtime. During an interview on 07/31/2025 at 1:20 p.m. with MDS nurse stated Resident #8 was taking CPAP (Continuous Positive Airway Pressure) at night as ordered, and the MDS nurse thought CPAP (Continuous Positive Airway Pressure) was not Non-invasive Mechanical Ventilator. Further interview with the MDS nurse said she called the company's regional MDS coordinator, and the regional MDS coordinator said per RAI guidelines, if a resident had CPAP (Continuous Positive Airway Pressure), the answer of Non-invasive Mechanical Ventilator in Section O (Special care) should be coded Yes. The MDS nurse said it was her mistake, and it should have been coded Yes because the resident was taking CPAP (Continuous Positive Airway Pressure). During an interview on 07/31/2025 at 3:00 p.m. with DON said Resident #8's annual MDS was inaccurate regarding the question of Non-invasive Mechanical Ventilator in Section O (Special care), and the answered should have been coded Yes because the resident was taking CPAP (Continuous Positive Airway Pressure) as ordered. The DON stated an inaccurate MDS assessment could result in a resident not being provided needed care which could result in poor health issues. 2. Record review of Resident #94's electronic face sheet dated 07/28/2025 reflected she was an [AGE] year-old-female admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (a progressive neurodegenerative disorder (a group of disorders characterized by the progressive degeneration and loss of nerve cells in the brain and central nervous system) that is the most common cause of dementia (a syndrome characterized by a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment, that interfere with daily functioning and social relationships)), type 2 diabetes mellitus (a chronic condition where the body either does not produce enough insulin or cannot properly use the insulin it produces, leading to elevated blood sugar levels) with diabetic neuropathy (kidney disease that develops a complication of diabetes), hypokalemia (condition characterized by low levels of potassium in the blood) and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest, and other symptoms that significantly interfere with daily life). Record review of Resident #94's annual MDS assessment dated [DATE] reflected she was usually understood and usually was able to understand. She scored a ninety-nine on her BIMS which indicated she was unable to complete the interview. Diabetes mellitus was noted under active diagnoses. Under Section N - Medications, reflected Resident #94 received insulin injections daily. Under section N0415. High-Risk Drug Classes: Use and Indication, J. Hypoglycemic (including insulin) was not noted on either 1. Is taking, or 2. Indication noted. Record review of Resident #94's comprehensive care plan revised date of 07/06/23 reflected Problem, has diabetes, Interventions, administer medications as ordered. Record review of Resident #94's Active Orders as of: 07/28/2025 reflected Toujeo Solostar's subcutaneous (under the skin) solution pen-injector 300 units/ml (insulin Glargine) inject 5 units subcutaneously one time a day related to type 2 diabetes mellitus with a start date of 07/12/25. She had insulin ordered as needed which started on 01/29/2025. During an interview on 07/31/2025 at 1:36 pm with the MDS nurse, she stated she missed noting Resident #94's high risk hypoglycemic area on her annual MDS assessment dated [DATE]. She stated she did not know how it was missed, and that the MDS needed to be accurate to reflect the type of care a resident had and needed or the care might be missed or the wrong care provided which could result in health issues. During an interview on 07/31/2025 at 1:45 pm with the DON, she stated she was not aware Resident #94's annual MDS was inaccurate, and she would have to audit from then on to ensure MDS accuracy. She stated an inaccurate MDS assessment could result in a resident not being provided needed care which could result in poor health issues. Record review of CMS's RAI version 3.0 Manual, dated 10/2024, revealed For Non-invasive Mechanical Ventilator, code any type of CPAP (Continuous Positive Airway Pressure) and BiPAP (bi-level positive airway pressure) respiratory support devices that prevent airway from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle. Record review of the CMS RAI Version MDS 3.0 Manual dated October 2024 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident.

Based on interviews and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 1 of 8 residents (Resident #55) whose records were reviewed for PASRR services. The facility failed to recognize on the Level I PASRR screening that Resident #55 had the mental illness diagnoses of depression, delusional disorder and bipolar disorder which would qualify Resident #55 for a PASRR evaluation. This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses. The findings included: Record review of Resident #55's face sheet, dated 07/30/2025, revealed she was admitted on [DATE] with diagnoses which included: depression, delusional disorders and bipolar disorder, unspecified. Record review of resident #55's Quarterly MDS assessment, dated 05/30/2025, revealed the resident's BIMS score 99 noting resident was unable to complete the interview. Quarterly MDS assessment revealed with diagnoses of bipolar disorder and psychotic disorder (other than schizophrenia). Record review of Resident #55's care plan, initiated date 03/10/2025, revealed Resident #55 had a problem of [resident name] has a mood problem r/t depression, bipolar disease, delusional disorders. Record review of Resident #55's PASRR screening dated 02/20/2025, noted an answer of 0 (No) in section C0100 Mental Illness in response to the question, Is there evidence or an indicator this is an individual with a Mental Illness? During an interview and observation on 07/30/2025 at 12:57 p.m. the CMC stated Resident #55 came in from the community based off what they were provided from the community she did not trigger positive but triggered negative for mental illness on the 1 PASRR. The CMC reviewed Resident #55's PASRR dated 02/20/2025 along with her EMR then stated at the time she did not have any positive mental illness listed on her history paperwork at all. The CMC further stated Resident #55 should have been reassessed and a new 1 PASRR completed when the mental illness diagnoses were noted. The CMC stated she did not know why Resident #55 wasn't reassessed. The CMC stated a new 1 PASRR should have been completed. The CMC further stated it was her responsibility to ensure a new 1 PASRR assessment was completed. The CMC stated with the quarterly assessment they should have been reviewing the diagnoses codes and updating the diagnoses in case it was missed. During an interview on 07/30/2025 at 2:29 p.m. the RCS stated the facility did not have a policy but follows the THHSC Guidelines and provided a copy of the guidelines. During an interview on 07/31/2025 at 12:34 p.m. the DON stated the 1 PASRR was usually received once they got a referral for admission, and it was normally received from whatever entity they were receiving the resident from. The DON stated a new 1 PASRR should have been completed for Resident #55 so they could have initiated services for her, and so the local authority would have come out and assessed her. The DON stated the purpose of an accurate 1 PASRR was to ensure the resident had the opportunity for services. During an interview on 07/31/2025 at 12:43 p.m. the Administrator stated the admission team would ensure they received the 1 PASRRs and then admissions would input it into the EMR and then the MDS nurses (CMC) review them to make sure they were accurate.Record review of Texas Health and Human Services (THHSC)'s Detailed Item by Item Guide for Local Authorities and Nursing Facilities to Complete the PASRR Level 1 Screening Form guidelines, dated June 2023, read, Section C.1: PASRR Screening: Steps for Assessment: 1. Identify diagnoses: Review the medical record, if available, for an MI, ID, and/or DD/RC diagnoses. Medical record sources can include but are not limited to: verbal interview with the individual, family members or LAR, observation, progress notes, annual physical exam, the most recent History and Physical, hospital discharge summaries or diagnosis list. 2. If you cannot locate a diagnosis, but suspect that an individual does have an MI, ID, and/or DD/RC, then document that information in this section of the form. C0100 Mental Illness-Is there evidence or an indicator this is an individual that has Mental Illness? 0. No 1. Yes. Examples of MI diagnoses are: Schizophrenia, Mood Disorder (Bipolar Disorder, Major Depressive Disorder or other mood disorder) .

Based on interviews and record review, the facility failed to review and revise resident care plans after each assessment for 1 of 26 residents (Resident #8) reviewed for care plan revision/timing. The facility failed to ensure Resident #8's care plan addressed changes in his smoking status regarding the resident did not need a smoking apron while smoking because he was very safe smoker after smoking assessment, dated 06/20/2025. This deficient practice could affect residents' care and services and may cause a delay in treatment and/or decline in health. Findings included: Record review of Resident #8's face sheet, dated 07/31/2025, revealed the resident was a [AGE] year old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with the diagnoses of type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), cirrhosis of liver (chronic liver damage from a variety of causes leading to scarring and liver failure), hypertension (high blood pressures), atherosclerotic heart disease of native coronary artery (plaque and blood clots can reduce blood flow through an artery), muscle wasting and atrophy (loss of skeletal muscle mass), and sleep apnea (breathing repeatedly stops and starts at night's sleep). Record review of Resident #8's annual MDS assessment, dated 06/20/2025, revealed the resident's BIMS was 12 out of 15 indicated the resident had moderate cognitive impairment, and the resident required supervision or touching assistance (Helper provides verbal cues and/or touching assistance), such as sit to stand, chair to bed, and toilet transfer. Further record review of the MDS assessment revealed regarding the question of tobacco use, the answered was coded Yes. Record review of Resident #8's comprehensive care plan, dated 06/17/2025, revealed the resident had the care plan of [Resident #8] is a smoker. The resident requires a smoking apron while smoking. Record review of Resident #8's smoking assessment, dated 07/17/2024, revealed the resident needed a smoking apron while smoking. Further record review of the resident's smoking assessment, dated 06/20/2025, revealed the resident did not need a smoking apron while smoking because the resident was a safe smoker. Interview on 07/31/2025 at 12:00 p.m. with Resident #8 said the resident did not wear a smoking apron while smoking anymore because he was a very safe smoker. Interview on 07/30/2025 at 4:00 p.m. with care management coordinator stated Resident #8 was a safe smoker, so the resident did not need a smoking apron anymore. The current care plan was inaccurate, and it should have been revised after smoking assessment dated [DATE] to reflect current resident status. During an interview on 07/31/2025 at 3:00 p.m. with DON said Resident #8's current care plan was inaccurate regarding a smoking apron, and the care plan should have been revised after smoking assessment dated [DATE], and not updating care plan could result in a resident not being provided needed care which could result in safety issues. Record review of the facility policy, titled Care Plan Revisions Upon Status Change, dated 10/24/2022, revealed The comprehensive care plan will be revised, and revised as necessary, when a resident experiences a status change.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #90) of 7 residents reviewed for infection control practices during medication administrations. MA-D did not sanitize or wash her hands and did not clean a blood pressure cuff when administering medications and measuring blood pressure to Resident #90. This deficient practice could place residents at risk for cross contamination and infections. The findings included: Record review of Resident #90's face sheet, dated 07/31/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with the diagnoses of vascular dementia (memory loss due to stoke), atherosclerotic heart disease of native coronary artery (plaque and blood clots can reduce blood flow through an artery), muscle wasting and atrophy (loss of skeletal muscle mass), difficulty in walking, and saddle embolus of pulmonary artery (a large blood clot that gets stuck where the main artery in the lungs, called the pulmonary artery, branches left and right to bring blood to each lung). Record review of Resident #90's quarterly MDS, dated [DATE], revealed the resident's BIMS was 13 out of 15 indicated the resident's cognitive was intact, and the resident required setup or clean-up assistance (Helper sets up or cleans up) to sit to stand, chair to bed, and toilet transfer. Record review of Resident #90's comprehensive care plan, dated 04/05/2024, revealed [Resident #90] is at risk for deterioration of medical condition related to possible exposure to other covid-19 individuals. For intervention - Assist resident in practicing hand hygiene and educate staff on use of personal protective equipment and provide instruction on proper donning, doffing, and disposal of items used. Observation on 07/29/2025 at 5:02 p.m. revealed MA-D prepared Resident #90's evening medications at the 500-hallway to administer evening medication to the resident. MA-D did not sanitize or wash her hands when preparing the resident's medications. Further observation revealed the MA-D took a blood pressure cuff, entered Resident #90's room, and measured the resident's blood pressure before giving the evening medications without cleaning the blood pressure cuff, then came out from the room and gave all evening medication to Resident #90 without sanitizing or washing MA-D's hands and cleaning the blood pressure cuff. During an interview on 07/29/2025 at 5:23 p.m. with MA-D stated she did not sanitize or wash her hands during medication administration to Resident #90 and did not clean a blood pressure cuff when measuring blood pressure to the resident. Further interview with MA-D said she should have sanitized or washed her hands and cleaned the blood pressure cuff to prevent possible infection during medication administration. MA-D said she was very nervous so forgot cleaning her hands and blood pressure cuff. During an interview on 07/31/2025 at 4:00 p.m. with DON said MA-D should have cleaned her hands and blood pressure cuff during medication administration to prevent possible infection. Record review of the facility policy, titled Medication Administration, revised on 10/01/2019, revealed . B. Handwashing and hand sanitization: the person administering medications adheres to good had hygiene, which includes washing hands thoroughly before beginning a mediation pass, prior to handling any mediation, after coming into direct contact with a resident and before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparation and medication s given via enteral tube. Record review of the facility policy, titled Infection Prevention and Control Program, dated 05/13/2023, revealed . 10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedure governing the cleaning d sterilization of soiled or contaminated equipment.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure the Robot Coupe that was being used to prepare altered texture diets was clean and free from contaminates prior to using. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation of the facility kitchen on 07/30/2025 at 10:06 AM revealed the cook was in the process of preparing pureed rice. The cook was observed setting up the robot coupe by placing the bowl and blade on the base with the lid sitting on the prep table. Small bits of debris, yellow in color, were observed on the lid, on the inside of the bowl and on the blade. The cook then pureed rice in the robot coupe. Interview with The [NAME] on 07/30/2025 at 10:50 AM revealed she had worked at the facility in the kitchen for 34 years. The [NAME] stated that the robot coupe needed to be cleaned prior to preparing altered textured foods for the residents. The [NAME] stated the process was to ensure all equipment was clean before using and then cleaned in between each food item that was prepared. The [NAME] stated she had prepared mechanical soft corn, cleaned the robot coupe and then set the robot coupe up to puree the rice. The cook stated it was the responsibility of all staff in the kitchen to ensure equipment was clean and free from debris prior to use. The [NAME] stated she did not see the debris prior to preparing the puree rice. The [NAME] stated by not ensuring equipment was free from debris it could cause food born illness in those that receive food from the kitchen. Interview with the Dietary Manager on 07/31/2025 at 1:13 PM revealed equipment should be clean prior to use. The Dietary Manager stated it was the responsibility of all staff to ensure equipment should be clean prior it being used. The Dietary Manager stated if staff use dirty equipment, it could cause food born illness. Interview with DON on 07/31/2025 at 2:05 PM revealed the kitchen staff should ensure equipment was cleaned prior to it being used. DON stated if dirty equipment was used in the kitchen, it placed the residents at risk for food born illness. DON stated no residents had recent signs or symptoms of food born illness. Interview with Administrator on 07/31/2025 at 2:11 PM revealed equipment should be clean prior to it being used to prepare food. The Administrator stated all kitchen staff were responsible to ensure equipment was clean before using it. The Administrator stated if equipment is not properly cleaned prior to use it could place the resident's at risk for food born illness. Record review of the facility policy named Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment, dated October 1, 2018, revealed 3. Rinse or scrape equipment and utensils and, when necessary, soak to remove gross food particles and soil prior to being washed. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for 2 (north nursing cart and south nursing cart) of 3 med carts and 1 (Resident #11) of 26 residents reviewed for pharmacy services. 1. There was one individual pack of Remedy - Intensive skin therapy Hydragurd-D dimethicone cream to protect skin from the drying effects that expired 05/2025 found in north nursing cart and seven individual packs found in south nursing cart on 07/30/2025. 2. Resident #11's insulin Flasp (Insulin aspart) for diabetes had open date of 06/26/2025, found inside the south nursing cart on 07/30/2025. Per the label of the insulin said, Discard 28 days after date opened, which was on 07/24/2025. This failure could place residents at risk of not receiving appropriate therapeutic effects of medication. The findings included: 1. Observation on 07/30/2025 at 11:38 a.m. revealed one individual pack of Remedy - Intensive skin therapy Hydragurd-D dimethicone cream to protect skin from the drying effects that expired 05/2025 (0.14 ounce) found in north nursing cart. Further observation on 07/30/2025 at 11:52 p.m. revealed seven individual packs of Remedy - Intensive skin therapy Hydragurd-D dimethicone cream to protect skin from the drying effects that expired 05/2025 (0.14 ounce) found in south nursing cart. During an interview on 07/30/2025 at 12:06 p.m. with ADON-C she acknowledged one individual pack of Remedy - Intensive skin therapy Hydragurd-D dimethicone cream to protect skin from the drying effects that expired 05/2025 found in north nursing cart and seven individual packs in south nursing cart. ADON-C said she did not know what reason these skin barrier creams were stored in north and south nursing carts. All expired medications and biologicals should have been removed from med carts. Expired medications and biologicals might not reach therapeutic effects. 2. Record review of Resident #11's face sheet, dated 07/31/2025, revealed Resident #11 was a [AGE] year-old female and admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), spinal stenosis (the spaces inside the bones of the spine get too small), paraplegia (the inability to voluntarily move the lower parts of the body), muscle weakness, and anemia (the blood does not have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body). Record review of Resident #11's annual MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. Record review of Resident #11's physician's order, dated 05/29/2025, revealed the resident had the order of Flasp Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 200 = 0 units; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units Administer 10 units and Notify Medical Doctor if Blood Sugars >400, subcutaneously before meals related to TYPE 2 DIABETES MELLITUS. Record review of Resident #11's medication administration record, dated from 07/01/2025 to 07/31/2025, revealed the resident was receiving Insulin Flasp (Aspart) subcutaneous solution 100 unit/ml - inject subcutaneously for type 2 diabetes mellitus at 7:30 am 11:00 am, and 4:00 pm. Observation on 07/30/2025 at 11:52 a.m. revealed Resident #11's insulin Flasp (Aspart) for diabetes with open dated 06/26/2025 inside the south nursing cart. Further observation revealed the resident's insulin had the box, and the box had label indicated Discard 28 days after date opened. During an interview on 07/30/2025 at 12:06 p.m. ADON-C stated Resident #11's insulin Flasp (Aspart) for diabetes with open date on 06/26/2025 was inside the south nursing cart, and the label on the insulin box indicated Discard 28 days after date opened. Further interview, ADON-C said Resident #11's insulin Flasp (Aspart) for diabetes should have been discarded 28 days after opening on 06/26/2025 per the label, which should have been discarded on 07/24/2025. However, ADON-C did not know what reason nurses did not discard the insulin and still used it on 07/30/2025. Resident #11 did not have any negative outcome related to blood sugars, but it might affect not reaching therapeutic effects. During an interview on 07/31/2025 at 4:00 p.m. DON said the facility nurses should have discarded Resident #11's Flasp (insulin Aspart) on 07/24/2025 because it was opened on 06/26/2025 and got 28 days after opened per the label of the insulin box. DON said Resident #11's insulin might not have therapeutic effects, and it was nurses' responsibility, and DON and ADON sometimes reviewed nursing carts, but they did not know what reason nurses did not discard the insulin. Further interview with the DON said the facility did not have specific policy regarding insulin but followed general guidelines and labels on medications. Record review of facility policy, titled medication Storage and disposal, revised 10/01/2019, revealed Drugs, which have been dispensed for individual residents, are not to be used beyond the expiration date indicated by the manufacturer, by the pharmacy, or based on the following criteria. The facility is to be strictly adhere to the expiration dating.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #7) of 4 residents reviewed for incontinence care. CNA A after he retracted Resident #7's foreskin of his penis did not pull it forward after incontinent care and CNA B did not clean the left buttock and scrotal area of Resident #7 when they turned him over to complete his incontinent care. This failure could place residents who required incontinence care at risk for cross contamination and the development of urinary tract infections. The findings included: Record review of Resident #7's electronic face sheet dated 07/30/2025 reflected he was an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: Alzheimer's disease (progressive brain disorder that gradually impairs memory, thinking, and the ability to carry out simple tasks), senile degeneration of brain (age-related cognitive decline, particularly memory loss), atrial fibrillation (a heart condition characterized by an irregular and often rapid heartbeat) and dementia (loss of cognitive functioning-thinking, remembering and reasoning-to such an extent it interferes with a person's daily life and activities). Record review of Resident #7's quarterly MDS assessment dated [DATE] reflected he rarely understands others and was rarely understood. He was not a candidate for a BIMS which indicated he was severely cognitively impaired. He was dependent for care with his ADLs. He was always incontinent of bowel and bladder. Record review of Resident #7's comprehensive care plan revised date 10/19/24 reflected Problem, has bladder and bowel incontinence r/t dementia, Interventions, clean peri-area with each incontinent episode. Observation on 07/30/2025 at 11:22 am of CNA A and CNA B perform incontinent care for Resident #7 revealed CNA A retracted Resident #7's foreskin to clean the resident's penis, and did not pull the foreskin back upon completion of peri care. CNA A cleaned the right buttock of Resident #7, and then Resident #7 was turned over to his left side, and instead of cleaning Resident #7's left buttock area, CNA B proceeded to pull the clean linen and brief through Resident #7's crotch area to initiate the completion of peri care. The surveyor prompted CNA A to pull Resident #7's foreskin back to the original position. During an interview on 07/30/25 at 11:40 CNA A and CNA B, they both stated they were trained to clean both sides of the buttocks and to pull the foreskin back in place after retracting it to clean the penis. They both stated it could cause pain and could result in infection or swelling.During an interview on 07/31/2025 at 1:45 pm with the DON, she stated CNA A and CNA B were trained to provide proper incontinent care and not putting the male foreskin back could result in pain and swelling. She stated not cleaning Resident #7's buttocks and scrotal area completely could result in cross contamination and infection. Record review of facility Incontinent Care Skills Checklist for CNA B dated 01/02/2025 reflect she met 5. Gently grasp shaft of penis and if uncircumcised retract foreskin, 6., Unretract foreskin of uncircumcised male, 10. With new wipe or cloth, cleanse the entire buttock area and surrounding hip area. Turn over surface of wipe to cleanse other side of buttock. Record review of the facility policy and procedure titled: Perineal Care dated 10/24/2022 reflected It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown, 12. Males, j. Turn the resident on his side, k. Clean and dry the bottom the scrotum and anal area.

Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 10 residents (Resident #29) reviewed for quality of care. On 05/17/2024, Resident #29 suffered a broken ankle when CNA C and CNA I used a sheet to transfer Resident #29 from a shower chair to a wheelchair. This failure could place residents at risk for serious injuries. The findings included: A record review of Resident #29's admission record dated 05/23/2024, revealed an admitted [DATE] with diagnoses which included disorder of bone density and structure, pain in knees, and muscle weakness. A record review of Resident #29's annual MDS assessment dated [DATE], revealed Resident #29 was an [AGE] year-old female admitted for long term care and assessed with an ability to hear, make herself understood with clear speech, and had impaired vision without eyeglasses. Resident #29 was assessed with a BIMS score of 09 out of a possible 15 which indicated moderate cognitive impairment. Resident #29 was assessed as Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for the following activities of daily life: toileting, bathing / showering, chair to bed transfers, and tub / shower transfers. A record review of Resident #29's care plan dated 05/21/2024 revealed Resident #29 was a 2-person assist for transfers and bathing / showering. A record review of Resident #29's Occupational Therapy Evaluation and Plan of treatment certification period 04/17/2024 - 05/15/2024, dated 05/14/2024, revealed Resident #29's PLOF (prior level of functioning) was total dependence with bathing, toileting, lower body dressing, functional mobility during ADLs (activities of daily living) and required maximum assistance with a Hoyer lift (a mechanical lift). Resident #29 was assessed as having pain with movement: intensity = 09/10 due to severe arthritis in joints .location bilateral knees . Resident #29 was assessed with risk factors, due to the documented physical impairments and associated functional deficits, the patient is at risk for: falls, further decline in function, muscle atrophy, decreased participation with functional tasks and decreased ability to return to prior living environment A record review of Resident #29's Facility's Investigation report dated 05/28/2024, revealed the Administrator investigated and concluded CNA C and CNA I on the evening of 05/17/2024 assisted Resident with a shower and when Resident #29 was transferred back into her wheelchair when her legs were under her and the wheelchair and thus felt pain which was assessed as an ankle fracture. During an interview on 05/21/2024 at 03:10 PM, Resident #29 stated she was bed bound and had pain in her knees. Resident #29 stated she preferred to be showered in a shower chair and CNA C and CNA I would transfer her with a bed sheet from her bed to her wheelchair and then to the shower room where she would be transferred from the wheelchair to a shower chair. Resident #29 stated she preferred the bed sheet transfer and would refuse to be transferred any other way. Resident #29 stated the Hoyer lift was uncomfortable. Resident #29 stated on 05/17/2024 when CNA C and CNA I transferred her from the shower chair to the wheelchair using a draw sheet, and she was put in the wheelchair while her legs went under her and felt pain to her right foot . Resident #29 stated she was assessed with a broken ankle; the x-ray showed my broken foot. Interview on 05/22/2024 at 01:30 PM with Resident #29 revealed she could not place weight on her feet. She stated the staff were good to her at the facility and what happened with her ankle was an accident. She stated the staff took her from the shower chair and placed her into the wheelchair, where her knee buckled, and she started sliding out of the chair and landed on her ankle. She stated she did not like the mechanical lift or gait belt, and the staff transferred her with a draw sheet which did not hurt her like the mechanical lift. During a joint interview on 05/23/24 at 03:32 PM CNA C and CNA I stated Resident #29 was not able to stand or walk and needed the assistance of 2 staff to transfer from a bed to a wheelchair. CNA C and CNA I stated Resident #29 would refuse transfer assistance with a Hoyer lift and would also usually refuse a bed bath. CNA C and CNA I stated Resident #29 preferred a shower in the shower chair and over the last months they had developed a rapport with Resident #29 and successfully transferred Resident #29 with a 2 person assist bed sheet transfer. CNA C and CNA I stated they used a bed sheet as a draw sheet and would place the sheet under Resident #29 then they would grasp the sheet and pick Resident #29 above the bed and over to the wheelchair. CNA C and CNA I stated on 05/17/2024 they transferred Resident #29, with the draw sheet from her bed to her wheelchair, to the shower room, to the shower chair, and afterwards transferred Resident #29 from the shower chair to the wheelchair. CNA C and CNA I stated when they used the draw sheet to pick up Resident #29 and transferred her to the wheelchair, they had not seen Resident #29 bend her knees and tucked them under her while they sat her down and thus Resident called out in pain. CNA C stated she used her strength to pick up the front wheels of Resident #29's wheelchair to allow Resident #29 to extend her legs from under the wheelchair. CNA C and CNA I stated Resident #29 was assessed by the nurse and then sent to the hospital where she was assessed with a broken right ankle. CNA C and CNA I stated Resident #29 had always had her legs extended straight out and they had never known Resident #29 had the ability to bend her knees therefore they never expected Resident #29 could bend her legs and have them under the wheelchair. During an interview on 05/23/24 at 04:30 PM, ADON K stated Resident #29 often preferred to stay in bed and was assessed as a 2 person assist for transfers. ADON K stated Resident #29 would refuse to be transferred with a gait belt and or a Hoyer mechanical lift . ADON K stated CNA C and CNA I were Resident #29's preferred staff and had developed a rapport and technique to transfer Resident #29 with a draw sheet. On 05/24/2024 at 10:00 AM, a facility policy regarding transfers was requested from the facility and a policy regarding Activities of Daily living was provided. A record review of the facility's Activities of Daily Living policy dated 05/26/2023 revealed, the facility will, based on the Resident's comprehensive assessment and consistent with the Resident's needs and choices, ensure a Resident's ability in activities of daily life do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: bathing, dressing, grooming, and oral care; transfer and ambulation; toileting

Based on observation, interview and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 6.9%, based on 2 errors out of 29 opportunities which involved 2 of 6 residents (Resident #16 and #53) reviewed for medication administration and medication errors. 1. Medication Aide J administered Resident #16's clonazepam, a drug used to treat panic disorder, 17 minutes late. 2. Medication Aide J administered Resident #53's gabapentin, a drug used to treat nerve pain, 30 minutes late. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: A record review of Resident #16's admission record dated 5/24/2024 revealed an admitted [DATE] with diagnoses which included anxiety, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and malignant neoplasm of brain (brain cancer). A record review of Resident #16's admission MDS dated [DATE] revealed Resident #16 was a [AGE] year-old female admitted for long term care and was assessed with medically complex conditions which included non-traumatic brain dysfunction and cancer. Resident #16 was assessed with a BIMS score of 11 out of a possible 15 which indicated intact cognition. A record review of Resident #16's care plan dated 05/04/2024 revealed, (Resident #16) will exhibit indicators of depression, anxiety, or sad mood less than daily by review date .Administer medications as ordered. Monitor/document for side effects and effectiveness A record review of Resident #16's physician's orders dated 05/24/2024 revealed the physician prescribed Resident #16 clonazepam tablet 0.5mg three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, related to anxiety disorder. During an observation on 05/23/2024 at 09:17 AM revealed Med Aide J prepared and administered to Resident #16's her clonazepam. A record review of Resident #53's admission record revealed an admitted [DATE] with diagnoses which included type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic polyneuropathy (many nerves in pain). A record review of Resident #53's quarterly MDS assessment dated [DATE], revealed Resident #53 was a [AGE] year-old female admitted for long term care and assessed with medically complex diagnoses which included diabetes, and a BIMS score of 05 out of a possible of 15 which indicated severe cognitive impairment. A record review of Resident #53's physician's orders dated 05/24/2024 revealed Resident #53 was prescribed Gabapentin 100mg 1 capsule three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, for diabetic polyneuropathy. A record review of Resident #53's care plan revealed Resident #53 had nerve pain related to the diabetes, (Resident #53) receives scheduled medications and has PRN (as needed) meds available as well During an observation on 05/23/2024 at 09:30 AM revealed Medication Aide J prepared and administered to Resident #53 her gabapentin. During an observation on 05/23/2024 at 09:35 AM Medication Aide J stated she administered Resident #16's clonazepam a few minutes late and administered Resident 53's gabapentin 30 minutes late. Medication Aide J stated she was running a little late due to preparing residents for their physicians' appointments earlier in the morning. Medication Aide J stated she had not reported to her supervisor she had a potential for administering medications late. During an interview on 05/24/2024 at 09:17 AM the DON stated nursing staff should administer medications on time as prescribed and staff are expected to communicate with their supervisor and or the DON if they have a potential to administer medications late. A record review of the facility's Medication Administration policy dated 10/01/2019, revealed, Policy: medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . the facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions .Procedure: . 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 wrong person's medication. If this happens, harm to the person can occur and some reactions can be deadly . In the past, you may have heard of the five 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 . right time- the time a medication is given is important. check the frequency of the ordered medication. double check that you are giving the ordered dose at the correct time. confirm when the last dose was given A record review of The Institute for Safe Medication Practices website, Guidelines for Timely Administration of Scheduled Medications (Acute) | Institute For Safe Medication Practices (ismp.org) , accessed 05/24/2024, titled, Guidelines for Timely Administration of Scheduled Medications revealed, .How to Use the Guidelines: These guidelines are applicable ONLY to scheduled medications (see definition section) . Definitions: 1. Scheduled medications include all maintenance doses administered according to a standard, repeated cycle of frequency (e.g., q4h, QID, TID, BID, daily, weekly, monthly, annually) . 2. Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time A record review of the National Library of Medicine's website, Nursing Rights of Medication Administration - StatPearls - NCBI Bookshelf (nih.gov) , accessed 05/24/2024 titled Nursing Rights of Medication Administration updated 09/04/2023, revealed, Definition/Introduction: Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.[1] It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. These 'rights' came into being during an era in medicine in which the precedent was that an error committed by a provider was that provider's sole responsibility and patients did not have as much involvement in their own care.[2]; The five traditional rights in the traditional sequence include: . 'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 residents (Residents #3, #102 and #308) of 24 residents reviewed for infection control. 1.Resident #3 had an opened wound and received treatment but was not on EBP. 2. Resident #102's urinary drainage bag was on the floor wedged between the low bed frame and the floor. 3. Resident #308 had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) to her sacrum, received treatment and was not on EBP. These deficient practices affect residents who require assistance treatments and indwelling catheters and could place residents at risk for cross contamination and infections. The findings included: 1. Record review of Resident #3's electronic face sheet dated 05/22/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (a type of dementia that affects memory, thinking and behaviors), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine) and anxiety (a feeling of worry, nervousness and unease). Record review of Resident #3's annual MDS assessment with an ARD of 05/03/2024 reflected she scored a 03 out of 15 on her BIMS which signified she was severely cognitively impaired. She was dependent on staff for ADLs, and had an open cancerous lesion. Record review of Resident #3's comprehensive person-centered care plan dated revised on 03/05/2024 reflected Resident's left lateral breast has an area of hardness and has some clear drainage noted, Interventions, clean with skin wound cleanser and apply triple antibiotic ointment and cover with a nonstick dressing QD until resolved. Further review reflected, has an open wound #2 to the medial aspect of the left breast 05/07/2024 merged into one wound, Interventions, clean with skin wound cleanser and apply triple antibiotic ointment and cover with nonstick dressing QD until resolved. Record review of Resident #3's Active Orders as of: 05/23/2024 reflected Wound to left breast each day shift cleanse with skin wound cleanser and apply triple antibiotic ointment and cover with nonstick dressing until resolved, start date 05/17/2024. During an interview on 05/23/2024 at 10:30 AM with the Treatment Nurse, she stated Resident #3 had breast cancer and her lesions were open and received treatment each day. Record review of facility training titled Enhanced Barrier Precautions dated 04/29/2024 revealed 35 staff members were signed off as trained. Record review of the EBP sign on Residents doors who were identified to need EBP reflected STOP, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Wear gloves and a gown for the following High-Contact Resident Care Activities .Changing briefs and assisting with toileting .Wound Care: Any skin opening requiring a dressing. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated Resident #3 had an open wound area and should have been placed on EBP. She stated it was important to reduce the potential of cross contamination and infection and to reduce transmission of multidrug-resistant organisms. She stated staff were trained on EBP and residents would get EBP in their physician orders. 2. Record review of Resident #102's electronic face sheet dated 05/23/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the tissues in the body), diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord, or nerve problems) and dysphagia (difficulty or discomfort in swallowing). Record review of Resident #102's significant change MDS assessment dated [DATE] reflected he was not a candidate for a BIMS which signified he was severely cognitively impaired. He could usually understand and usually be understood. He was dependent on staff for his ADL care. He had an indwelling urinary catheter. Record review of Resident #102's comprehensive person-centered care plan revised 05/22/2024 reflected Problem, has a need for Enhanced Barrier Precautions due to foley catheter, G-tube status, Interventions place on Enhanced Barrier Precautions. Observation on 05/23/2024 at 03:15 PM of MA G and CNA H perform catheter care for Resident #102 reflected they gowned, sanitized hands, and put on clean gloves. Resident #102's bed was in a low position, to the floor, and his indwelling urinary catheter bag was lying on the floor wedged between the floor and the bed frame. In an interview on 05/23/2024 at 3:20 PM with CNA H, she stated Resident #102's drainage bag was in a basin earlier and not on the floor. She stated someone must have placed his bed in the low position. She stated the drainage bag should not be on the floor because of cross contamination. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated Resident #102's urinary drainage bag should not have been on the floor, but in a basin. She stated cross contamination could occur and give the resident an infection. 3. Record review of Resident #308's electronic face sheet dated 05/21/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: hydrocephalus (fluid accumulates in the brain, enlarging the head and sometimes causing brain damage), severe protein-calorie malnutrition (significant muscle wasting and loss of subcutaneous fat), Down syndrome (genetic disorder caused when abnormal cell division results in extra genetic material from chromosome 21 and causes a distinct facial appearance, intellectual disability, and developmental delays), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #308's admission MDS assessment dated [DATE] reflected she was not a candidate for BIMS which signified she was severely cognitively impaired. She could usually understand and usually be understood. She was dependent on staff for her ADL care. She had a Stage II pressure ulcer. Record review of Resident #308's comprehensive person-centered care plan revised 05/16/2024 reflected Problem, has a stage II pressure injury to the sacrum. Always stays on back while in bed with head of bed up, over scar tissue. Record review of Resident #308's Wound Care Notes dated 04/25/2024 reflected Assessments: 1. Pressure ulcer of sacral region, Stage II. Record review of Resident #308's Wound Care Notes dated 05/08/2024 reflected Assessments: 1. Pressure ulcer of sacral region, Stage II. Record review of Resident #308's weekly skin assessments dated 04/22/2024, 04/29/2024, 5/11/2024 and 5/13/2024 reflected she had a Stage II pressure injury to her sacrum. Observation on 05/23/2024 at 11:09 a.m. of the Treatment Nurse provide incontinent care and wound care for Resident #308 reflected she had a Stage II pressure sore which was open to her sacral area. She was not on EBP. Interview on 05/23/2024 at 11:20 a.m. with the Treatment Nurse, she stated Resident #308's stage II pressure sore was recurring and she had the open sore now for weeks. When asked why Resident #308 was not on EBP, she stated she did not know, but the resident should have been. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated Resident #308 had an open pressure sore and should have been placed on EBP. She stated it was important to reduce the potential of cross contamination and infection and to reduce transmission of multidrug-resistant organisms. She stated staff were trained on EBP and residents would get EBP in their physician orders. Record review of the facility's policy and procedure titled Enhanced Barrier Precautions dated 04/05/2024 reflected An order for Enhanced Barrier Precautions will be obtained for residents with any of the following, wounds, diabetic foot ulcers, unhealed surgical wounds, chronic venous stasis ulcers). Record review of CDC presentation titled Indwelling Urinary Catheter Insertion and Maintenance undated https://www.cdc.gov/infection-control/media/pdfs/Strive-CAUTI104-508.pdf reflected Maintain Unobstructed Urine Flow .Keep the urine bag off the floor.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to ensure pre-packaged chicken salad was discarded after the use by date. 2. The facility failed to ensure beverage machines dispenser gun with dispenser buttons was clean and properly stored. 3. The facility failed to ensure staff with facial hair was covered by a hair restraint. 4. The facility failed to ensure refrigerated items were dated and properly sealed. 5. The facility failed to ensure puree carrots were prepared in a sanitary fashion. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on [DATE] at 9:46 a.m. during the initial tour of the kitchen walk in refrigerator revealed pre-packaged chicken salad in producer container with less than ,d+[DATE] of the container left, dated use by [DATE] and received date [DATE]. The beverage machine dispenser guns with dispenser buttons were hanging down over the side of the counter with beverage build up on them. During an interview on [DATE] at 10:00 a.m. the DM stated the beverage machine dispenser guns should have been placed in the holders next to the machine and needed to be cleaned due to risk of cross contamination. The DM further stated the chicken salad had last been used to make sandwiches for residents on Monday ([DATE]). The DM stated the chicken salad was expired and it should have been thrown out. The DM further stated the chicken salad could have made the resident's sick due to possibility of being spoiled. Observation on [DATE] at 10:20 a.m. DA L was observed with a mustache and thin beard not wearing a facial hair restraint while washing dishes and using the dish washing machine. Observation and interview on [DATE] at 11:27 a.m. DA L was observed to still be washing dishes with a mustache and thin beard not restrained by facial hair restraint. DA L stated he had just started 3 days ago and did not believe he needed to wear a beard restrain in the dish room, but knew he was supposed to wear one when handling food. During an interview on [DATE] at 11:33 a.m. the dietician stated DA L should have been wearing a facial hair restraint to his beard. The dietician further stated by wearing the restraint it would prevent hair from getting in the food and contaminating it. The dietician then instructed DA L to get a hair net and use it over his beard and mustache. Observation on [DATE] at 11:07 a.m. the walk- in refrigerator revealed a tray of cranberry juices, and a tray of milk covered but not dated, along with a tray with 8 glasses of apple juice not covered or dated. During an interview on [DATE] at 11:12 a.m. DA A stated the apple juices should have been covered so nothing could fall in them and dated so staff would know when they were prepared. During an interview on [DATE] at 11:14 a.m. DA B stated she had put the juices and milk in the fridge and had forgotten to date them. DA B further stated it was important to date drinks so staff would know how long they had been in the fridge. DA B stated she did not want to give someone something old they could get sick. Observation on [DATE] at 3:20 p.m. the Cook was observed during puree prep of carrots. When she finished completing the puree of the carrots, she grabbed the spatula from the counter by the spatula side not the handle with her bare hand she had been using to push buttons on food processor, worn oven mitts, and handled the pans. The Cook then proceeded to scrape the carrots from the processor into the pan. The Cook covered the carrots and placed carrots in oven to warm. During an interview on [DATE] at 3:23 p.m. the Cook stated by touching the spatula end instead of the handle she could have caused the food to be contaminated. During an interview on [DATE] at 3:28 p.m. the DM stated when items were stored in the refrigerator they should covered to prevent bugs and things from getting in them to avoid cross contamination. The DM further stated items stored in the refrigerator should have been dated so items were not stored in the refrigerator too long. The DM stated the pre-poured drinks should have been used the same day. The DM stated the Cook should have washed the spatula prior to using it after she grabbed the wrong end due to by her touching it with her hand, she caused it to be contaminated. The DM further stated by touching the spatula with her hand and using it in the food it could cause the residents to get sick. Review of facility's policy Food Storage, date approved [DATE] and revised [DATE], read Policy: 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, federal and US Food Codes and HACCP guidelines., Procedure: 2. Refrigerators: d. Date, label and tightly seal all refrigerated foods using clean, non-absorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Review of facility's policy Employee Sanitation, date approved [DATE], read Policy: The Nutrition & Food service employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness., Procedure: 3. Employee Cleanliness Requirements, b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Review of the Food Code , U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, ,d+[DATE].11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, ,d+[DATE] Hair Restraints, ,d+[DATE].11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 medication cart and 1 Treatment cart of 2 carts observed for secure biologicals and drugs. 1.LVN F left the medication cart unsecured on 200 Hallway while administering medications. 2.The Treatment Nurse left the treatment cart unsecured on 05/22/2024 on the 100 Hallway, and on 05/23/2024 on the 300 Hallway prior to wound care for a resident. These deficient practices could place residents at risk for misappropriation, misuse or tampering of medications. The findings included: Observation on 05/22/2024 at 08:29 a.m. on the 200 Hall revealed the medication cart was left unattended and not locked. During an interview on 05/22/2024 at 08:30 with LVN F, who returned to the unlocked cart from a resident's room, she stated she had not left the medication cart unlocked before and did not know why she did. She stated she was focused on checking a resident and did not secure the cart. She stated she knew she should have secured the medication cart because there were resident medications on the cart to include insulin. She stated misappropriation, misuse, and harm could happen if someone were to get into the cart and acquire something they should not have. Observation on 05/24/2024 at 08:40 am on 100 Hall revealed the treatment cart was left unlocked and unattended. Inside were solutions and ointments for wound care, dressings, and other supplies. During an interview on 05/24/2024 at 08:45 a.m. with the Treatment Nurse, she stated she had never left the cart unlocked and unattended. She stated residents and others could have access to the cart, take items, or use them and be harmed. Observation on 05/24/2024 at 11:09 a.m., before going to observe a treatment for a resident, the Treatment Nurse gathered her supplies and went into the resident's room. She motioned for the surveyor to follow. The treatment cart was left unlocked. The surveyor lingered to see if the Treatment Nurse would come back to the cart, but she did not. The surveyor stepped inside the resident's room halfway and motioned for the Treatment Nurse to check her cart. During an interview on 05/24/2024 at 11:15 a.m. with the Treatment Nurse, she stated she could not believe she left the treatment cart unlocked and unattended again. She stated she did not know why she left the cart unlocked twice in one morning. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated LVN F and the Treatment Nurse were two of her nurses who had worked at the facility the longest, and she could not understand how both could have forgotten to lock the carts. She stated nurses and medication aides were trained to keep the medication carts secure when not in use because of the potential of misappropriation and harm if someone took medications they were not prescribed. Record review of the facility's policy and procedure titled Medication Carts and Supplies for Administering Meds revised 10/01/19 reflected The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. The mobile medication cart will be used to facilitate administration of medications to residents. The purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications. Procedure, 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, do not leave the medication cart unlocked or unattended in the resident care areas.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for 3 of 6 residents (Residents #31, #34, and #104) reviewed for significant medication errors. 1. On 05/23/2024 at 09:42 AM, Medication Aide J administered sodium chloride (salt; is an important mineral that helps balance the amount of fluid (water) in your body. It also helps your nerves and muscles to work properly. When the salt level in your blood is too low, extra water moves into your cells and makes them swell. This can be dangerous, especially in the brain where there is not a lot of room to expand) to Resident #104 late by 42 minutes. 2. On 05/23/2024 at 09:43 AM, Medication Aide J administered buspirone (primarily used to treat generalized anxiety) 10 mg to Resident #31 late by 43 minutes. 3. On 05/23/2024 at 09:48 AM, Medication Aide J administered carbidopa- levodopa (a combination medications used to treat symptoms of Parkinson's disease or Parkinson-like symptoms, such as: shakiness, stiffness, and difficulty moving) to Resident #34 late by 48 minutes. These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings include: 1. A record review of Resident #104's admission record dated 5/24/2024 revealed an admitted [DATE] with diagnoses which included cerebral infarction (stroke) and hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia (a condition that occurs when the level of sodium in the blood is too low). A record review of Resident #104's MDS assessment dated [DATE] revealed Resident #104 was a [AGE] year-old male admitted for long term care and was assessed with medically complex conditions which included low blood sodium. Resident #104 was assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognition impairment. A record review of Resident #104's care plan dated 05/04/2024 revealed, (Resident #104) has had a cerebral vascular accident, causing weakness, aphasia (difficulty speaking), dysphagia (difficulty swallowing), and impaired cognition .Give medications as ordered by the physician. Monitor/document side effects and effectiveness A record review of Resident #104's physician's orders dated 05/24/2024 revealed the physician prescribed Resident #104 sodium chloride 1 gram, three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, related to low salt in his blood. A record review of Resident #104's Medication Adim Audit Report dated 05/24/2024 revealed Medication Aide J administered to Resident #104 his sodium at 09:42 AM when it was scheduled at 08:00 AM, 42 minutes late. 2. A record review of Resident #31's admission record dated 05/24/2024 revealed an admitted [DATE] with diagnoses which included generalized anxiety disorder. A record review of Resident #31's quarterly MDS assessment dated [DATE], revealed Resident #31 was a [AGE] year-old female admitted for long term care and assessed with medically complex diagnoses which included generalized anxiety and a BIMS score of 07 out of a possible of 15 which indicated severe cognitive impairment. A record review of Resident #31's care plan revealed, (Resident #31) uses anti-anxiety medications r/t (related to) anxiety . Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every shift) A record review of Resident #31's physician's orders dated 05/24/2024 revealed Resident #31 was prescribed buspirone 10mg three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, for generalized anxiety. A record review of Resident #31's Medication Adimn Audit Report dated 05/24/2024 revealed Medication Aide J administered to Resident #31 her buspirone at 09:43 AM when it was scheduled at 08:00 AM, 43 minutes late. 3. A record review of Resident #34's admission record dated 05/24/2024 revealed an admitted [DATE] with diagnoses which included dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A record review of Resident #34's quarterly MDS assessment dated [DATE], revealed Resident #34 was a [AGE] year-old male admitted for long term care and assessed with medically complex diagnoses which included Parkinson's disease and a BIMS score of 08 out of a possible of 15 which indicated moderate cognitive impairment. A record review of Resident #34's physician's orders dated 05/24/2024 revealed Resident #34 was prescribed carbidopa-levodopa 10-100mg three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, for Parkinson's disease. A record review of Resident #34's care plan revealed, (Resident #34) is at risk for pain r/t Parkinson's disease . Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain A record review of Resident #34's Medication Adimn Audit Report dated 05/24/2024 revealed Medication Aide J administered to Resident #34 his carbidopa-levodopa at 09:48 AM when it was scheduled at 08:00 AM, 48 minutes late. During an observation and interview on 05/23/2024 at 09:35 AM revealed Med Aide J at her medication cart with the electronic medication administration record displayed which revealed a red highlighted medication for Resident 31, Resident #34, and Resident #104. Medication Aide J stated she had yet to administer 08:00 AM scheduled medications for residents #31, #34, and #104 due to her running a little late earlier in the morning. Medication Aide J stated she had to assist a couple of residents prepare for their physicians' appointments. Medication Aide J stated she had not reported the potential late medication administrations to her supervisor or the DON. During an interview on 05/24/2024 at 09:17 AM the DON stated nursing staff should administer medications on time as prescribed and staff were expected to communicate with their supervisor and or the DON if they had a potential to administer medications late. A record review of the facility's Medication Administration policy dated 10/01/2019, revealed, Policy: medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . the facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions .Procedure: . 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 wrong person's medication. If this happens, harm to the person can occur and some reactions can be deadly . In the past, you may have heard of the five 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 . right time- the time a medication is given is important. check the frequency of the ordered medication. double check that you are giving the ordered dose at the correct time. confirm when the last dose was given A record review of The Institute for Safe Medication Practices website, Guidelines for Timely Administration of Scheduled Medications (Acute) | Institute For Safe Medication Practices (ismp.org) , accessed 05/24/2024, titled, Guidelines for Timely Administration of Scheduled Medications revealed, .How to Use the Guidelines: These guidelines are applicable ONLY to scheduled medications (see definition section) . Definitions: 1. Scheduled medications include all maintenance doses administered according to a standard, repeated cycle of frequency (e.g., q4h, QID, TID, BID, daily, weekly, monthly, annually) . 2. Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time A record review of the National Library of Medicine's website, Nursing Rights of Medication Administration - StatPearls - NCBI Bookshelf (nih.gov) , accessed 05/24/2024 titled Nursing Rights of Medication Administration updated 09/04/2023, revealed, Definition/Introduction: Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.[1] It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. These 'rights' came into being during an era in medicine in which the precedent was that an error committed by a provider was that provider's sole responsibility and patients did not have as much involvement in their own care.[2]; The five traditional rights in the traditional sequence include: . 'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time

Based on interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 (Residents #22 and #64) of 24 residents reviewed for care plans. 1.Resident #22's comprehensive person-centered care plan was not revised after her quarterly MDS assessment with an ARD of 05/09/24 to reflect she was incontinent of bladder. 2.Resident #64's comprehensive person-centered care plan was not revised after his quarterly MDS assessment with an ARD of 04/09/2024 to reflect he was always incontinent of bowel and bladder. This deficient practice affects residents who require assistance with ADL's and could place residents at risk of missing required care. The findings included: 1.Record review of Resident #22's electronic face sheet dated 05/22/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), dysphagia (difficulty swallowing), asthma (inflamed airways, producing mucous which makes it difficult to breath), vascular dementia (brain damage caused by multiple strokes), and cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area). Record review of Resident #22's quarterly MDS assessment with an ARD of 05/09/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She sometimes could understand, but rarely could be understood. She was dependent on staff for her ADL care and was always incontinent of bowel and bladder. Record review of Resident #22's comprehensive person-centered care plan revision date of 05/08/2023 reflected has bowel incontinence r/t CVA. The care plan did not address she was always incontinent of bladder. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated Resident #22 was always incontinent of bowel and bladder and that information needed to be reflected on the person-centered care plan. She stated revisions of care plans are completed after the MDS assessment and this one must have been missed, and she did not know why. She stated proper care for a resident was communicated through the care plan and care could be missed. During an interview on 05/24/2024 at 2:50 PM with the MDS nurse she stated Resident #22 was always incontinent of bladder and somehow she missed putting that information into her care plan revision. She stated the importance of updating and revising care plans to keep information of care accurate and current to meet the resident's needs. During an interview on 05/24/2024 at 03:06 PM with CNA C revealed, she worked on Resident #22's hall and Resident #22 was always incontinent of bowel and bladder. 2. Record review of Resident #64's electronic face sheet dated 05/22/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: Alzheimer's disease (a type of dementia that affects memory, thinking and behaviors), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), end stage renal disease (the final permanent stage of chronic kidney disease) and malignant neoplasm of prostate (prostate cancer that can grow and spread to other parts of the body). Record review of Resident #64's quarterly MDS assessment with an ARD of 04/09/2024 reflected he scored a 03 out of 15 on his BIMS which signified he was severely cognitively impaired. He could be understood and usually could understand. He required moderate to extensive assistance with his ADL's. He was always incontinent of bowel and bladder. Observation on 05/23/2024 at 2:22 PM of CNA D and CNA E perform incontinent care for Resident #64 revealed he was incontinent of bowel and bladder. Record review of Resident #64's comprehensive person-centered care plan revised on 01/31/2022 reflected has an ADL self-care performance deficit r/t Alzheimer's disease, Interventions, TOILET USE: The resident requires limited to extensive assistance x1-2 staff for toileting. Resident will need staff assistance on and off toilet and with peri care brief changes daily and as needed. The care plan did not reflect he was always incontinent of bowel and bladder. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated Resident #64 was incontinent of bowel and bladder and that information needed to be updated in his care plan for him to receive the appropriate care needed. During an interview on 05/24/2024 at 2:50 PM with the MDS nurse she stated Resident #64 was always incontinent of bowel and bladder and she did not know why she missed updating the information in his care plan. She stated the care plan reflected the care required for residents. During an interview on 05/24/2024 at 03:06 PM with CNA C revealed, she worked on Resident #64's hall and stated he was always incontinent of bowel and bladder. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time limits and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care.

Based on observation, 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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 24 residents (Residents #3) reviewed for care plans. Resident #3 had compression stockings ordered to be on in AM and off in PM which was not reflected in her person-centered care plan. This deficient practice affected residents who require assistance with ADL's and could result in missed or inadequate care. The findings included: Record review of Resident #3's electronic face sheet dated 05/22/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (a type of dementia that affects memory, thinking and behaviors), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine) and anxiety (a feeling of worry, nervousness and unease). Record review of Resident #3's annual assessment with an ARD of 05/03/2024 reflected she scored a 03 out of 15 on her BIMS which signified she was severely cognitively impaired. She was dependent on staff for ADLs. Record review of Resident #3's comprehensive person-centered care plan dated revised on 07/06/2023 reflected Resident has an ADL self-care performance deficit, Interventions, able to help pull clothes down at times but relies on extensive assistance x1 from staff to lift arms/legs into clothes. Record review of Resident #3's Active Orders as of: 05/23/2024 reflected KNEE HIGH COMPRESSION STOCKINGS 15-20 MMHG at bedtime for EDEMA APPLY IN THE MORNING AND REMOVE AT BEDTIME Verbal Active 09/08/2022 Observation on 05/23/2024 at 08:15 a.m. of Resident #3 revealed she was lying in bed and she did not have knee high compression stockings on her lower legs. Record review of Resident #3's EMAR dated 05/01/2024 to 05/31/2024 reflected she refused the Knee-High Compression Stockings daily. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated she would look at the order to see if Resident #3 still required the stockings, and if not she would get the order discontinued. She stated a daily treatment for the resident should have been in the resident's comprehensive person-centered care plan as a part of her care. She stated care could be missed and the stockings may be care she no longer required. During an interview on 05/24/2024 at 2:50 PM with the MDS Nurse she stated Resident #3's compression stockings needed to be in her comprehensive plan of care. She stated Resident #3 had the stockings ordered for daily, so they must have been an important part of care to reduce swelling in her legs. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time limits and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care.

Based on observation, interviews and record reviews, the facility failed to ensure the MDS assessment must accurately reflect the resident's status for 1 (Resident #3) of 24 residents reviewed for assessments. Resident #3 was ordered an RCS diet with pureed texture and fortified foods, and her annual MDS assessment with an ARD of 05/03/2024 did not reflect she was on a therapeutic diet. This deficient practice affects residents with specialized care and could result in inaccurate or missed care. The findings included: Record review of Resident #3's electronic face sheet dated 05/22/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (a type of dementia that affects memory, thinking and behaviors), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine) and anxiety (a feeling of worry, nervousness and unease). Record review of Resident #3's annual assessment with an ARD of 05/03/2024 reflected she scored a 03 out of 15 on her BIMS which signified her cognition was severely impaired. She was dependent on staff for ADLs, and she was prescribed a mechanically altered diet and not therapeutic. Record review of Resident #3's comprehensive person-centered care plan revised on 04/05/2024 reflected on a reduced concentrated sweets diet, pureed texture, regular liquids. Record review of Resident #3's Active Orders as of: 05/23/2024 reflected Diet, Reduced Concentrated Sweets Diet Pureed Texture, regular liquids consistency, start date, 08/27/2023. Observation on 05/23/2024 at 08:15 a.m. of Resident #3 revealed she was lying in bed with her food tray on her bedside table. Her food was of a pureed texture. Record review on 05/23/2024 at 08:15 a.m. of Resident #3's meal ticket, it read RCS, pureed, regular liquid diet. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated reduced concentrated sweets was a therapeutic diet and should have been indicated on Resident #3's annual MDS assessment. She stated the accuracy of the MDS assessment was important because it communicated the type of care a resident required. During an interview on 05/24/2024 at 2:50 PM with the MDS nurse she stated Resident #3 was on an RCS diet which was therapeutic and she did not know how it was missed on her 05/23/2024 MDS assessment, but that the assessment was inaccurate. She stated accuracy of the MDS assessment was important for communication about care for a resident and the care could be missed or inaccurately provided. She stated she was accountable for the MDS accuracy. During an interview on 05/24/2024 at 03:06 PM with CNA C revealed, she worked on Resident #3's hall and delivered her meal trays often. She stated Resident #3 was on an RCS, pureed diet with regular liquids. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status.

Based on observations and interviews, the facility failed to post, in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility for 1 of 1 facility reviewed for resident rights. The facility did not have the survey results available and accessible to residents and visitors without having to ask for them on 5/21/24, 5/22/24, and 5/23/24 during the survey period. This failure resulted in residents, family members, and legal representatives of residents having a lack of knowledge of the facility's past inspections, violating resident rights. The findings were: In an observation on 05/21/24 at 9:09 a.m., there was no sign indicating where the survey results were located and no survey results were observed at the entrance, lobby area, or at the nursing station. In an observation on 5/22/24 at 8:50 a.m., there was no sign indicating where the survey results were located and no survey results were observed at the entrance, lobby area, or at the nursing station. In the resident council group meeting on 5/22/24 at 10:00 a.m. the residents stated they were not aware of being able to read previous survey results and denied knowledge of a sign indicating where the survey results were or a binder or book in the facility or an area where they could read the previous survey results. The residents stated they were not aware they could read the results and would like to be able to. In an observation and interview on 5/23/24 at 1:15 p.m., the DON stated the results used to be in the lobby area and she was unsure of where the sign was regarding the survey results or where the survey results were located and would check with the Administrator. The Administrator was able to show surveyor an approximately 4-inch x 8-inch piece of paper behind a framed glass case hanging on the wall at the entrance that was typed and indicated the survey results were available for viewing behind the receptionist area and to please see a staff member for assistance. The Administrator stated the reason for them to ask a staff member for assistance to access and read the results was on several occasions pages were torn out and were missing so they were placed behind the receptionist area as a solution but were still available upon request. In an observation on 5/23/24 at 6:00 p.m., the survey results were in a binder clearly marked on a conversation table between two chairs in the entrance/lobby area and readily accessible to anyone wishing to view them. In an interview on 5/24/24 at 11:05 a.m., the Administrator stated he was unsure of when the survey results had been placed behind the receptionist area. The Administrator stated the consequences could be a knowledge deficit for people who wanted to view them. On 5/24/24 at 2:16 p.m., the DON stated they did not have a policy on survey results being readily accessible.

Based on observation, interview and record review the facility failed to ensure the resident environment was as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 9 residents (Residents #1 and #2) reviewed for accidents and hazards. 1. The facility failed to ensure Resident #1 did not elope from the facility. Resident #1 eloped to a busy street on 12/18/23. 2. The facility failed to ensure staff were adequately trained on the elopement process, which included not training the therapy department after 12/18/23 elopement incident. 3. The facility failed to ensure interventions for elopement were updated and appropriate to prevent elopements for Resident #1 and #2. Resident #1 successfully eloped 12/18/23. An Immediate Jeopardy (IJ) situation was identified on 04/19/24 at 03:28 PM. While the IJ was removed on 04/20/2024, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm that was an Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm, severe injury, and possible death to residents who require supervision to prevent elopement. The findings were: 1. Record review of Resident #1's admission record, dated 04/17/24, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (loss of cognitive function that interferes with daily life and activities), age relative cognitive decline, alcohol abuse and difficulty in walking. Record Review of the facility's Investigation report, dated 12/26/23, reflected On 12/18/23 at approximately 10:45 AM, [Admissions Director] noted Resident #1 was attempting to leave the premises via the front entrance. [Admissions Director] had attempted to redirect [Resident #1] back into the main portion of the building, but the resident became verbally and physically aggressive. [Admissions Director] did not have any way to flag down assistance and after numerous attempts to call for help failed and with the resident becoming more agitated, she sought help from someone in the facility to come and help her redirect the resident back into the facility. The facility social worker was the first person she was able to call for help and he was the first on the scene to attempt to redirect the resident back to the facility. The social worker was unable to determine which way the resident exited; the facility called for an immediate search from all available staff members. The staff members were able to locate the resident walking on the sidewalk approximately 100 yards from the facility grounds. The search for the resident lasted less than 5 minutes from the time the resident was unable to be redirected to the time the resident was assisted safely back inside the building. The resident was given a head-to-toe assessment, and no abnormal findings were noted. The resident's physician and family were notified and an order as well as a consent for the resident to admit to the facility unit were obtained. The resident now resides in the facility secure unit . The resident will continue to be monitored and the facility will continue to monitor the resident and make changes to the plan of care as necessary. Record review of Resident #1's Social Services-Wandering Evaluation- V 1, dated 11/13/23, reflected Resident #1 had a moderate risk score for elopement. Record review of Resident #1's the Nurse Note, dated 09/05/23, authored by LVN B, reflected Resident with exit seeing behaviors. Trying to open exit front doors setting alarm off. Resident yelling at staff and difficult to redirect. Record review of Resident #1's Nurse Note, dated 10/25/23, authored by LVN A, reflected .Resident then self-propelled in w/c to front door of facility and repeated set off the exit alarms. Nurses x 3 attempted to stop and redirect. Not effective. Resident states that he is just going to leave facility Observation on 04/17/24 to 04/21/24 revealed a busy street less than 50 yards away from the front entrance of the facility with a speed limit of 20 mph. Attempted interview with Resident #1 on 04/17/24 at 03:11 PM denied leaving the facility. During an interview on 04/17/24 at 03:18 PM, LVN A revealed Resident #1 previously tried to elope before he was successful on 12/18/23. She revealed she told the Administrator about this incident before 12/18/23 and she was unsure if interventions were care planned for Resident #1's exit seeking behavior. LVN A further revealed she was not present at the facility on the day of Resident #1's elopement. During an interview on 04/17/24 at 04:08 PM, the Administrator revealed elopement risk was care planned on a case-by-case basis. He further revealed he would not care plan if a resident set off the exit door alarm but would care plan if the resident was pushing the doors and tried to exit the facility. During an interview on 04/17/24 at 04:59 PM, MDS Nurse C stated Resident #1 was a moderate risk for elopement on 11/13/23 and this should have been care planned. She further revealed it was care planned on 11/27/24 that Resident #1 had adjustment issues to the facility, but not that he was an elopement risk. During an interview on 04/17/24 at 05:10 PM, the Administrator could not recall if he knew of Resident #1 triggering the exit doors and vocalizing that he wanted to exit prior to the 12/18/23 incident, but this would have been mentioned in the morning meeting and care planned appropriately. During an interview on 04/18/24 at 10:53 AM, the Admissions Director revealed she was not able to redirect Resident #1 from trying to exit the front doors. She further revealed she was looking out for Resident #1's safety and did not want him to hit her and be evicted from the facility. She revealed Resident #1's safety was impacted either way because he eloped. She further revealed she should have stayed with Resident #1 as he was eloping. She further revealed there were no other staff around and she had to run to get another staff member for help. During an interview on 04/18/24 at 12:20 PM, the Social Worker revealed Resident #1 should have had interventions in his care plan to prevent his elopement on 12/18/23. Attempted interview with LVN B on 04/18/24 at 1:49 PM was unsuccessful. A voicemail was left for LVN B . 2. During an interview on 04/18/24 at 09:23 AM, CNA D revealed he was trained on elopement last month. He revealed he was not aware of what to do when a resident left the facility or when a resident was heading to the exit door. During an interview on 04/18/24 at 10:15 AM, the Administrator revealed if the in-service sign in sheets were missing signatures, it may have been the therapy department because the facility did not train the therapy department. During an interview on 04/18/24 at 10:18 AM, the Director of Rehab revealed she did not specifically train her staff on elopement, but it was the facility that would come to her department and train her staff members. She further revealed if her staff were trained, they would have signed the in-service sign in sheet. During an interview on 04/18/24 at 11:35 AM, the Maintenance Director revealed he was not sure if he needed to accompany the residents when they were in the process of eloping, but he would let a nurse know and get some help. During an interview on 04/18/24 at 02:13 PM, the Director of Rehab provided documentation of the therapy department receiving training for elopement, but they did not have any documentation for training for the facility policy for elopement. Observation on 04/18/24 revealed the therapy department was located to left side of the front entrance before walking out of the facility. Record review of the facility's, undated, In-Service training Report for Elopement reflected all departments were trained, however, no one in the therapy department singed the in-service sign in sheet. 3. Record review of Resident #2's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Alzheimer's (degenerative brain disorder causing problems with memory, thinking, and behavior), difficulty in walking, and cerebral infarction (condition that results in the death of brain tissue due to lack of blood and oxygen supply). Record review of Resident #2's care plan reflected problem [Resident #2] scored 6 or above on wandering assessment is at risk for elopement., dated 12/19/23 with interventions complete wandering risk tool and fall risk assessment. Record review of Resident #2's quarterly MDS assessment, dated 03/01/24, reflected the resident was not a wanderer. Resident #2 had a BIMS score of 03/15, which indicated severe cognitive impairment. Record review of Resident #2's Social Services-Wandering Evaluation- V 1, dated 03/01/24, reflected Resident #2 had a moderate risk score for elopement. Resident #2 had not had any elopements in the facility. Record review of Resident #2's Psychiatric Services note, dated 02/09/24, reflected Resident #2 had a diagnosis of Dementia . with other behavioral disturbance [unsafe wandering, exit-seeking] .Resident frequently says she needs to go home . poor safety awareness. During an interview on 04/18/24 at 12:20 PM, the Social Worker revealed Resident #2 had interventions to be distracted to not elope, but this was not care planned and should be care planned. During an interview on 04/19/24 at 09:38 AM, LVN F revealed if a resident was exit seeking, she would have to look at that specific resident's care plan for interventions. During an interview on 04/19/24 at 10:13 AM, Resident #2's RP did not have any concerns with Resident #2 trying to leave the facility, but every time the RP left, she made sure to tell the nurses what to do in order to prevent Resident #2 from trying to exit the facility, which included re-direct her and don't let her go past the nurse's desk. She further revealed she expected the nurses to prevent Resident #2 from trying to head to the exit doors. During an interview on 04/19/24 at 11:05 AM, ADON E revealed there was no policy or procedure to follow for when residents were transitioned from the secure unit to other hallways in the facility. She further revealed there was no documentation other than signing a consent form for transitioning out of the secure unit. She confirmed there were no specific interventions for Resident #2 to prevent her from eloping and there should be specific interventions for any resident transitioning out of the secure unit. She was able to verbalize what interventions she does do for Resident #2 even though they were not documented on Resident #2's care plan. During an interview on 04/19/24 at 12:55 PM, the DON revealed she was not aware if there were any policies for residents who moved from the secure unit to other hallways in the facility. She further revealed she knew they did a trial run for residents who moved out of the secure unit and the family was involved. During an interview on 04/19/24 at 12:45 PM, ADON G revealed when a resident came off the secure unit, the nursing staff would communicate through nurse's report and verbally but was not aware of any policies to follow for this transition. During an interview and record review on 04/19/24 at 01:30 PM, the ADON E revealed there were no progress notes documented when Resident #2 transitioned from the secure unit to the 400-hallway. She further revealed Resident #2 moved to 400-hallway from the secure unit 04/01/2023. Record review of nursing notes from 02/2023 to 05/2023 reflected no nursing note of the resident transitioning from the secure unit to 400 hallways. During an interview on 04/19/24 at 02:15 PM, the Administrator revealed he did not have a policy to take residents out of the secure unit to put them in the other hallways in the facility. He revealed there was discussion with the IDT when a resident left the secure unit, in order to reside in another hallway in the facility. He revealed his expectation was for documentation at least once a day for resident's adjustment and it's the nurse's standard of practice to check on residents frequently. He revealed care plans should be as person-centered as possible. During an interview on 04/18/24 at 03:24 PM, ADON E revealed the interventions listed for Resident #2's problem of being at risk for elopement (completing tool and doing fall risk assessment) would not be an appropriate intervention to prevent Resident #2 from eloping. She further revealed appropriate interventions were needed so the CNA and nurses knew about resident care and how to keep the resident safe. She knew some interventions for Resident #2 could be re-direction and distracting her with activities. She further revealed Resident #2 packed her bags and stated she was leaving the facility frequently. During an interview on 04/18/24 at 03:49 PM, MDS nurse C revealed she reviewed residents' care plans and there could be a more personalized intervention to prevent elopement. During an interview and observation on 04/18/24 at 04:13 PM, Resident #2's roommate revealed Resident #2's clothing were stacked on her bed because Resident #2 frequently stated she was going to go home. She further revealed Resident #2 had not attempted to exit facility yet. During an interview on 04/20/24 at 06:41 PM, NP Y (on call NP for the facility) revealed if resident was exit-seeking, the expectation was for the facility to protect the resident and keep them safe. She revealed the residents of the facility could run into the car because of the street in front of the facility. She further revealed the interventions in the care plan, for those at risk for elopement, should be to prevent elopements. She suggested some interventions could include psychiatric evaluation, redirect resident, or keep them busy with activities. When looking at Resident #2's interventions due to being at risk for elopement, she revealed fall risk assessment was not an intervention for elopement and any assessment was not enough to stop an elopement from happening. She further revealed care plan interventions should be individualized because every resident was different. Record review of the facility's policy Elopements and Wandering Residents, dated 11/21/22, reflected the following: The facility shall establish and utilize systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff 6. Procedure Post-Elopement e. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. This was determined to be an Immediate Jeopardy (IJ) on 04/19/24 at 3:28 PM. The facility Administrator and the DON were notified. The Administrator was provided with the IJ template on 4/19/24 at 3:28 PM. The following Plan of Removal submitted by the facility was accepted on 04/19/24 at 7:43 AM: Windsor Nursing and Rehabilitation Center of [NAME] Issue: F689 Free of Accident Hazards/ Supervision/ Devices For Residents Involved: Resident #1: 4/19/24, wandering/ elopement risk evaluation completed by Social Services Director 4/19/24, care plan for wandering evaluation was reviewed and revised 4/19/24, exit seeking behavior added to the Medication Administration Record to track every shift behavior 12/18/23, wandering evaluation completed by Social Services Director 12/18/23, Resident #1 was transferred to the secure unit. M.D. and RP notified 12/18/23 12/18/23, Resident #1's care plan was completed for wandering behavior and placement on secure unit. Resident #2: 4/19/24, wandering evaluation completed by Social Services Director 4/19/24, care plan for wandering evaluation was reviewed and revised 4/19/24, exit seeking behavior added to the Medication Administration Record to track every shift behavior To Identify Any Other Residents to Have the Potential: The Director of Nursing and/ or designee is reviewing that all current residents have a current wandering/elopement risk evaluation. 4/19/24 The Director of Nursing and/ or designee will review those with moderate risk or above are being reviewed for care plan interventions 4/19/24 The Director of Nursing and/ or designee will ensure those with exit seeking behavior have that on the Medication Administration Record for every shift documentation. 4/19/24 The Director of Nursing and/ or designee will review residents admitted in the last 30 days to ensure that wandering evaluations are complete and if have wandering risk will have care plans reviewed to ensure interventions are care planned. 4/19/24 Education/ System Change: All staff including Therapy will be reeducated by the Director of Nursing and/ or designee on the following topics: 4/19/24 Abuse and Neglect Wandering/ Elopement Policy to include what to do if a resident displays exit seeking behavior Adding exit seeking behavior to the Medication Administration Record to track behavior each shift for number of times Care plan development and interventions to prevent wandering behavior/ exit seeking To complete Interdisciplinary Team documentation as to evaluation to remove a resident from the secure unit To update care plan when removing a resident from secure unit Re-education will continue for all staff until 100% of staff have completed the education. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Employee roster will be used to validate completion. Monitoring: The Director of Nursing or designee will review the 24- hour report in the morning clinical meeting to ensure that changes of condition such as those with wandering/ exit seeking behavior that are documented in the clinical record are identified and care planned interventions are in place. The Director of Nursing or designee will ensure new admissions have wandering evaluations completed and that interventions are care planned if exit seeking. The Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the admissions and the 24-hour report in the morning clinical meeting. An AdHoc QAPI was conducted on April 19, 2024, by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning F 689 and to develop the above-mentioned plan of care. We respectfully submit this action plan for removal of Immediate Jeopardy. Monitoring of the POR was as follows: Observation on 4/20/2024 at 12:29 PM in the facility's locked unit, Resident #1 was in the dining area eating lunch. Record review of Resident #1 Wandering Evaluation, dated 4/19/2024, reflected he scored a 10- moderate risk signed by the Social Worker (4.) SW stated on Wandering Evaluation [Resident #1] was reassessed today, he scored severely impaired cognitively. He has a dx of dementia, disoriented to year and day of the week. He continues to benefit from residing in the the facility's locked unit. Record review of Resident #1's care plan, dated updated on 4/19/2024, reflected Resident #1 scored a 6 or above on his wandering assessment r/t disoriented x 2, independent no assist, taking antidepressant and antianxiety, known wanderer/history of wandering, is an elopement risk/wanderer r/t dementia, currently resides in Generations Unit for structured environment. Interventions-Asses for fall risk, becomes easily agitated when he is hungry, will be easily redirected with snacks and drinks, Complete wandering evaluation tool, Monitor for fatigue and weight loss Resident #1 placed in Generations Secure unit, Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, Staff to redirect Resident #1 as needed/Engage Resident #1 in social activities, provide alternate task/Admit to generations unit for exit seeking behaviors. Record review of Resident #'s 1 consolidated orders reflected Resident #1 was admitted to the facility's secure unit on 12/18/2023 for a structured environment. An order, dated 4/19/2024, document the number of times Resident #1 was exit seeking on current shift. Record review of Resident #1's consent for the Generations Unit placement, dated 12/18/2024, reflected via phone by family. Record review of Resident #1's MAR was reflected document the number of times Resident #1 was exit seeking on current shift. No times xd as exit seeking. Record review of Resident #1's progress notes, dated 12/18/2023, reflected 11:30 a.m. Informed resident's RP of exit seeking behavior with verbal consent given via telephone for placement in Generation's Unit for Structured Environment. Care ongoing. Record review of Resident #1's care plan dated 2/22/2024 revealed Resident #1- is an elopement risk/wanderer r/t dementia, currently resides in the Generations Unit for structured environment, scored 6 or above on wandering assessment. Interventions were Assess for fall, risk, Complete wandering evaluation too, Monitor for fatigue and weight loss, Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, Resident placed in Generations Secure Unit and Staff to redirect resident as needed/Engage resident in social activities, provide alternate task/Admit to generations unit for exit seeking behaviors. Observation on 4/20/2024 at 12:33 PM in the main dining room, Resident #2 was sitting in wheelchair with family. Record review of Resident #2 Wandering Evaluation, dated 4/19/2024, reflected the resident scored a 9, which meant Moderate risk. This was signed by the Social Worker. The Social Worker documented Resident #2 was apt to wander within the facility. She did pack her personal belongings and made statements of wanting to go home. Her family members do not believe she would attempt to leave the facility. She was redirected by reminding her that she was staying at the facility and her family members knew. She could call her family members at any time if verbal redirection did not work or if she just wanted to talk to them. She is not exhibiting exit seeking behaviors. Record review of Resident #2's care plan, updated on 4/19/2024, reflected Resident #2 had scored 6 or above on the wandering assessment r/t disoriented x 3, forgetfulness, short attention span, independent with aide, Alzheimer's disease, taking antidepressant medication. Has a history of wandering. She was not exhibiting any exit seeking behaviors. Interventions were Complete wandering assessment quarterly and as needed. Resident #2 was easily redirected by calling her family members at any time of the day or night. Staff to let Resident #2 pack personal items as desired and staff would help unpack items at her discretion. Resident #2 stayed in bed once staff assisted her into bed. When Resident #2 made statements about going home, she was easily redirected with reminding her that she lived in the facility and her family members were aware she was there. Record review of Resident #2's consolidated orders reflected an order to document the number of times resident was exit seeking on current shift (ordered on 4/19/2024). Record review of Resident #2's MAR reflected document the number of times Resident #2 was exit seeking on current shift. No times xd as exit seeking. Interview and record review on 04/20/24 at 07:14 PM, Regional Clinical Specialist X and the DON revealed: 1. 107 out of 107 residents had a wandering/elopement risk evaluation done 4/19/24. 61 out of 107 residents scored moderate to high risk of wandering/elopement. 2. Sample of 10 out of 61 residents reflected care plan interventions. 3. Every calendar day the charge nurse will Document the number of times resident is exit seeking on current shift. Every shift. The DON or designee will mark every calendar day that they reviewed each resident's MAR that is exit seeking. 4. 107 out of 107 residents had a wandering/elopement risk evaluation done 4/19/24, including residents admitted in the last 30 days. Observation on 04/20/24 at 06:15 PM revealed a sign on the front door of the facility which stated ATTENTION VISITORS. Please check with a facility team member before assisting a patient/resident outdoors. Interview on 04/20/24 at 7:14 PM, Regional Clinical Specialist X and the DON revealed all departments were trained on ANE and Wandering/Elopement Policy. Staff who were not interviewed would be interviewed before they worked the floor. Record review of all staff were trained on 04/19/24 on topic Elopement Prevention with summary including, Preventing, identifying, and reporting abuse and neglect; Wandering/Elopement Policy; Identifying and responding to behaviors/triggers to prevent elopement; Evaluation and identifying exit seeking/wandering risk for all new admissions/readmissions/quarterly/change in condition. Interviews with the following staff included: 3 out of 6 MAs 6 out of 28 CNAs 1 out of 10 Dietary Department 3 out of 10 Therapy Department 1 out of 5 Housekeepers 3 out of 13 LVNs 1 out of 5 RNs Shift breakdown was as follows: 6 AM- 2 PM: 11 out of 39 2 PM- 10 PM: 12 out of 20 10 PM- 6 AM: 4 out 16 8 AM- 5 PM: 7 out of 21 The interviews below were separated into shifts: All shifts (6 AM-2 PM, 2 PM-10 PM, 10 PM-6 AM) Interview on 04/20/224 at 01:05 PM with CNA J revealed CNA worked for 1 year and worked all shifts. She revealed she attended in-services on Elopement and ANE. Interview on 04/20/24 at 01:25 PM with LVN L revealed LVN has worked at the facility for [AGE] years and worked all shifts. She further revealed she was in-serviced on ANE, elopement process, and change of condition. Interview on 04/20/24 at 03:24 PM with CMA/CNA/Medical record P revealed she worked for [AGE] years and worked all shifts. She revealed she was in-serviced on elopement, change of condition and ANE. Shifts 6 AM-2 PM and 2 PM-10 PM Interview on 4/20/2024 at 12:47 PM with MA H revealed she worked at the facility for [AGE] years and worked the 6 AM-2 PM and 2 PM-10 PM. She further revealed she was in-serviced on Abuse and Elopement. She further revealed if she saw possible abuse, she would try to separate resident and perpetrator, keep resident safe, notify nurse, and report to Administrator. She further revealed in elopement training, she learned she would stay with resident and re-direct resident as needed. Interview on 4/20/2024 at 01:18 PM, Laundry Aid K stated she worked for 1.5 years. and worked 2 PM-10PM, then 6 AM -2 PM. She revealed she was in-serviced on elopement and ANE. She learned if resident left the building, she needed to follow the resident and not leave them alone. She would call someone for help and she notified the Administrator. Interview on 4/20/2024 at 01:38 PM with CNA M revealed she worked for 41 yrs. and worked the 6 AM-2 PM, 2 PM-10 PM. She revealed she was in-serviced on ANE and Elopement. Interview on 4/20/2024 at 03:18 PM with CNA/Central Supply staff member O worked for [AGE] years. She revealed she was in-serviced Elopement, notifications of changes and ANE. She learned if sees any abuse, she would notify the administrator. Interview on at 01:57 PM with LVN A revealed she worked for 4 years for the 6 AM-2 PM, 2 PM-10 PM shifts. She revealed she was in-serviced on ANE and Elopement and change of condition. She further revealed if a resident had a change of condition, she would notify MD, SBAR, ADON/DON and family. Interview on 4/20/2024 at 3:55 PM with CNA S revealed she worked for 5 months for 6 AM-2 PM and 2 PM-10 PM shift. She further revealed she was in-serviced on ANE and elopement. She revealed she would call the Administrator if she observed ANE with a resident. Shift: 6 AM-2 PM Interview on 04/20/24 at 12:56 PM, HSK I stated she worked for 8-9 years and 6 AM-2 PM shift. She revealed she was in-serviced on Elopement and ANE. She identified examples of abuse and revealed reporting ANE and the elopement process. Interview on 04/20/24 at 01:46 PM, RN N revealed she worked for 1 year. She further revealed she was in-serviced on Elopement and ANE reporting. She reviewed ANE reporting and the elopement process. Shift: 8 AM- 5 PM Interview on 04/20/24 at 01:11 PM, the Maintenance Director worked for 2 years and worked 7:30 AM -4 PM shift. He further revealed he was in-serviced on the elopement process including staying He further revealed he was trained on ANE including reporting to the administrator as soon as possible. Interview on 04/20/24 at 04:10 PM with Food Service Supervisor reveal she worked for 2 years and worked the 8 AM-5 PM shift. She further revealed she was in-serviced on the Elopement and ANE process. She revealed different examples of ANE and the elopement process. Interview on 04/20/24 at 04:44 PM with PTA V revealed they worked for [AGE] years. They were in-serviced on the elopement process and ANE. They gave examples of ANE and would report to Administrator as soon as possible. They revealed the elopement process. Interview on 04/20/24 at 04:48 PM with ST W revealed they worked for [AGE] years and shift 7 AM-4 PM). They revealed they were in-serviced on the elopement process and ANE. She reviewed the facility's elopement and ANE reporting process. Shift: 2 PM-10 PM Interview on 04/20/24 at 03:48 PM with MA R revealed they worked for 1 year and on the 2 PM-10 PM shift. They further revealed they were in-serviced on the elopement process and ANE. She revealed the elopement process and reporting ANE to the administrator. Shift 2 PM-10 PM and 10 PM-6 AM Interview on 04/20/24 at 04:36 PM with CNA U revealed they worked for [AGE] years for the shifts: 10 PM-6 AM and 2 PM-10 PM. They revealed they were in-serviced on the elopement process and ANE. They revealed how to prevent elopement and examples of ANE. Interview on 04/20/24 at 03:34 PM with LVN T revealed they worked for 3 years and worked shifts: 10 PM-6 AM, 2 PM-10 PM. They further revealed they were in-serviced on ANE, the elopement process, and change of condition. They reviewed these policies. Observation on 4/20/2024 at 10:30 AM of DON calling the Director of Rehab via phone and In-serviced her on ANE, change of condition/behaviors, and the elopement process. Record review of 61 out of 61 residents with exit seeking behaviors were added to the MAR to track behaviors each shift. Interview on 04/20/24 at 07:14 PM, Regional clinical specialist X and DON revealed the DON will initial on each day of a calend [TRUNCATED]

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 3 of 12 residents (Residents #2, #4 and #5) reviewed for care plans. The facility failed to develop person-centered care plan to include interventions to prevent elopement for Residents #2, #4 and #5. This failure could place residents at risk of not having their needs met. The findings include: 1. Record review of Resident #2's admission record, dated 04/18/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Alzheimer's (degenerative brain disorder causing problems with memory, thinking, and behavior), difficulty in walking and cerebral infarction (condition that results in the death of brain tissue due to lack of blood and oxygen supply). Record review of Resident #2's care plan, undated, reflected problem [Resident #2] scored 6 or above on wandering assessment is at risk for elopement., dated 12/19/23 with interventions complete wandering risk tool and fall risk assessment. Record review of Resident #2's quarterly MDS assessment, dated 03/01/24, reflected the resident was not a wanderer and had a BIMS score of 03/15, which indicated severe cognitive impairment. Record review of 03/01/24 Social Services-Wandering Evaluation- V 1 reflected Resident #2 had a moderate risk score for elopement. Record review of Resident #2's Psychiatric Services note, dated 02/09/24, reflected Resident #2 had a diagnosis of Dementia . with other behavioral disturbance [unsafe wandering, exit-seeking] .Resident frequently says she needs to go home . poor safety awareness. 2. Record review of Resident #4's admission record reflected a [AGE] year-old male initially admitted to the facility on [DATE]. Resident #4 had diagnoses which included dementia (group of symptoms that affects memory, thinking and interferes with daily life), major depressive disorder, alcohol abuse, and paranoid schizophrenia (serious mental disorder in which people interpret reality abnormally). Record review of Resident #4's care plan reflected problem [Resident #4] scored 6 or above on wandering assessment is at risk for elopement., dated 12/19/23 with interventions complete wandering risk tool and fall risk assessment. Record Review of Resident #4's quarterly MDS assessment, dated 02/28/24, reflected the resident was not a wanderer and had a BIMS score of 10/15, which indicated moderate cognitive impairment. Record Review of Resident #4's SOCIAL SERVICES-Wandering Evaluation- V 1 dated 02/28/24 reflected Resident #4 had a moderate risk score for elopement. 3. Record Review of Resident #5's admission record reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #5 had diagnoses which included Alzheimer's (degenerative brain disorder causing problems with memory, thinking, and behavior), impulsiveness, mild cognitive impairment and generalized anxiety disorder. Record review of Resident #5's care plan reflected problem [Resident #5] scored 6 or above on wandering assessment is at risk for elopement., dated 12/20/23 with interventions complete wandering risk tool and fall risk assessment. Record review of Resident #5's quarterly MDS assessment, dated 01/26/24 reflected the resident had wandering behavior in the last 1 to 3 days and had a BIMS score of 03/15, which indicated severe cognitive impairment. Record review of Resident #5's social services-Wandering Evaluation- V 1, dated 01/26/24, reflected Resident #5 had a moderate risk score for elopement. During an interview on 04/18/24 at 12:20 PM, the Social Worker revealed Resident #2 had interventions to be distracted to not elope, but this was not care planned and should be care planned to prevent elopement. He did not mention who should care plan this but it should be care planned. During an interview on 04/19/24 at 09:38 AM, LVN F revealed if a resident was exit seeking, she would have to look at the specific resident's care plan for interventions to keep the resident safe. During an interview on 04/19/24 at 10:13 AM, Resident #2's RP did not have any concerns with Resident #2 trying to leave the facility, but every time the RP left she made sure to tell the nurses what to do in order to prevent Resident #2 from trying to exit the facility, which included re-direct her and don't let her go past the nurse's desk. She further revealed she expected the nurses to prevent Resident #2 from trying to head to the exit doors. During an interview on 04/19/24 at 11:05 AM, ADON E revealed there was no policy or procedure to follow for when residents were transitioned from the secure unit to other hallways in the facility. She further revealed there was no documentation other than signing a consent form for transitioning out of the secure unit. She stated there were no specific interventions for Resident #2 to prevent her from eloping and there should be specific interventions for any resident transitioning out of the secure unit. She was able to verbalize what interventions she did for Resident #2 even though they were not documented on Resident #2's care plan. During an interview on 04/19/24 at 12:55 PM, the DON revealed she was not aware if there were any policies for residents that move from the secure unit to other hallways in the facility. She further revealed she knew they did a trial run for residents that moved out of the secure unit and family was involved. During an interview on 04/19/24 at 12:45 PM, ADON G revealed when a resident came off the secure unit, the nursing staff will communicate through nurse's report and verbally but was not aware of any policies to follow for this transition. During an interview and record review on 04/19/24 at 01:30 PM, the ADON E revealed there were no progress notes documented when Resident #2 transitioned from the secure unit to the 400-hallway. She further revealed Resident #2 moved to 400-hallway from the secure unit 04/01/2023. Record review of the nursing notes from 02/2023 to 05/2023 revealed no nursing note of the resident transitioning from secure unit to 400 hallway. During an interview on 04/19/24 at 02:15 PM, the Administrator revealed he did not have a policy to take residents out of the secure unit to put them in the other hallways in the facility. He revealed there was discussion with the IDT when a resident left the secure unit to reside in another hallway in the facility. He revealed his expectation was for documentation at least once a day for the resident's adjustment and it's the nurse's standard of practice to check on residents frequently. He revealed care plans should be as person-centered as possible. He further revealed interventions would be discussed in morning meetings as an IDT and care plans updated accordingly. During an interview on 04/18/24 at 03:24 PM, ADON E revealed the interventions listed for Resident #2's problem of being at risk for elopement (completing tool and doing fall risk assessment) would not be an appropriate intervention to prevent Resident #2 from eloping. She further revealed appropriate interventions were needed so CNA and nurses knew about resident care and how to keep the resident safe. She knew some interventions for Resident #2 could be re-direction and distracting her with activities. She further revealed Resident #2 packed her bags and stated she was leaving the facility frequently. During an interview on 04/18/24 at 03:49 PM, MDS nurse C revealed she reviewed residents' care plans and there could be a more personalized intervention to prevent elopement. During an interview on 04/19/24 at 09:38 AM, CNA D revealed he was unsure if Residents #4 and #5 were at risk for elopement and he was unaware of any interventions to do to prevent elopement for these residents. He further revealed Resident #2 was at risk for elopement, however he was not aware of interventions for Resident #2 and would go to the nurse for help. During an interview on 04/20/24 at 06:41 PM, NP Y (on call NP for the facility) revealed if a resident was exit-seeking, the expectation was for the facility to protect the resident and keep them safe. She revealed the residents of the facility could run into the car because of the street in front of the facility. She further revealed the interventions in the care plan, for those at risk for elopement, should be to prevent elopements. She suggested some interventions could include psychiatric evaluation, redirect resident, or keep them busy with activities. When looking at Resident #2's interventions due to being at risk for elopement, she revealed fall risk assessment was not an intervention for elopement and any assessment was not enough to stop an elopement from happening. She further revealed care plan interventions should be individualized because every resident was different. Record review of the facility's policy Comprehensive Care Plans, dated 10/24/22, reflected The comprehensive care plan will describe, at a minimum .The services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being Resident specific interventions that reflect the resident's needs and preferences. Record review of the facility's policy Elopements and Wandering Residents, dated 11/21/22, reflected, The facility shall establish and utilize systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff.

Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but no later than 2 hours after the allegation was made, in events that caused the allegation involved abuse or resulted in serious bodily injury to the Administrator of the facility and other officials, which included to the State Survey Agency, for 1 of 9 residents (Resident #3) reviewed for reporting abuse and neglect. LVN F failed to report to the administrator and HHSC an allegation of sexual abuse made by Resident #3 on 02/05/24. This failure could place residents at risk for harm to include neglect, a diminished quality of life, and possible death. Findings include: Record review of Resident #3's admission record reflected a [AGE] year-old male initially admitted to the facility on [DATE]. Resident #3 had diagnoses which included Alzheimer's (degenerative brain disorder causing problems with memory, thinking, and behavior), dementia (group of symptoms that affects memory, thinking and interferes with daily life) and schizoaffective disorder (a mental disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Record Review of Resident #3's care plan reflected problem [Resident #3] has a behavior problem . [Resident #3] is apt to hear voices in his head, he will call his [RP] to leave voicemails about the FBI and working for the mafia, he says he is 'losing his mind' . [Resident #3] is apt to make delusions allegations reaching out to attorneys and government officials . [Resident #3] will make false claims against staff members. Record Review of Resident #3's MDS assessment, dated 02/22/24, reflected a BIMS score of 11/15, which indicated moderate cognitive impairment. Record review of Nurse note, dated 02/05/24 at 02:35 PM, authored by LVN F, reflected, resident was on resident phone south station I heard resident talking stating that [the DON] came to him wanting to have sex . During an interview on 04/18/24 at 03:24 PM, ADON E revealed Resident #3 was always making accusations. She further revealed he would use the phone frequently trying to report accusations, but there was not truth to these accusations due to history of hallucinations. She further revealed this was care planned. During an interview on 04/19/24 at 12:24 PM, the Administrator revealed Resident #3 would make inappropriate comments to staff members, his RP and providers. During an interview on 04/19/24 at 12:55 PM, the DON revealed Resident #3 did not bring up any abuse allegations. She noted the resident had inappropriate behaviors. During an interview on 04/19/24 at 02:10 PM, the Administrator revealed he could not recall any allegations made by Resident #3. He read the nursing note, dated 02/05/24 at 02:35 PM, and revealed he would not report this to the state agency but would do an internal investigation to see if the allegation was valid. He further revealed the resident was allowed to have sexual relations with anyone he chooses. He revealed he would report if the resident had an allegation of abuse after internal investigation, but he was not aware of this nursing note. During an interview on 04/19/24 at 02:46 PM, the DON was doing some medication changes and behaviors were escalating. She further revealed she did not recall LVN F reporting this allegation of sexual abuse to her. The DON tried to review nursing notes daily but did not recall this specific nursing note. She further revealed had she known about this allegation she would speak with the Administrator and the team. She would have asked the Social Worker to interview the resident and kept her distance. When asked if the DON would report this to the state, she did not say yes. Attempted interview on 04/19/24 at 03:52 PM with LVN F was unsuccessful. A voicemail was left. No call back. During an interview on 04/19/24 at 02:03 PM, ADON E revealed she reported Resident #3's abuse allegations to the appropriate nursing staff and the Administrator. She further revealed she expected the Administrator to report these allegations to the state agency and do an appropriate investigation. She revealed this needed to be investigated to ensure resident's safety. During an interview on 4/19/2024 at 2:30 PM, the SW stated he would report the nurse note on 02/05/24 at 02:35 PM that mentioned the DON, to the Administrator as an alleged sexual abuse. Attempted interview with Resident #3's RP was unsuccessful. A voicemail left on 04/19/24 at 01:47 PM. No call back. Record review of the facility's policy Abuse, Neglect and Exploitation, dated 08/15/22, reflected the following: IV. Identification of Abuse, Neglect and Exploitation B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse . VII. Reporting/Response A. The facility will have written procedures that include: 1. Report of all alleged violations to the Administrator, state agency . a. Immediately, but not later than 2 hours after the allegation is made; if the events that cause the allegation involve abuse or result in serious bodily injury

Based on observations, record reviews and interviews the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 22 residents (Resident #1) reviewed for care, in that: 1. a. The facility failed to document or implement interventions for Resident # 1, who they were aware had a history of [REDACTED]. Resident # 1 choked on [DATE], [DATE] and again on [DATE] and subsequently died . b. The facility failed to identify residents who took and ate food from other residents' plates and were at-risk for choking, provide supervision to those residents, and for ensuring inappropriately textured food was not within residents' reach. These failures resulted in identification of Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk of choking. These deficient practices affected residents in the facility who were at-risk of choking, and placed them at-risk for harm, choking or death. The findings were: Record review of Resident #1's face sheet, dated [DATE] revealed an admission date of [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change MDS dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment for daily decision-making skills. Further review under Functional Status revealed Resident #1 required extensive assistance with eating and one person physical assistance. Review of Resident #1's Care Plan, revised on [DATE], revealed her care plan indicated she was on a pureed diet, but did not reflect her history of choking or behavior of grabbing other resident's food. Review of Resident #1's Physician Order Summary for [DATE] revealed an order for [REDACTED]. Resident #1's diet order further revealed the original revision to pureed texture was on [DATE]. Review of Resident #1's Progress Notes revealed two previous choking incidents documented on [DATE] and [DATE]. Review of Resident #1's Modified [MEDICATION NAME] Swallowing Study, dated [DATE], revealed overall dysphagia severity is severe. Strategies - We recommend the following actions regarding the patient's feedings: Small Bites/Sips - Monitor PO Intake Rate - Positioned Upright - Supervised PO Feeding - Cueing for Strategies - Aspiration Precautions - Monitor [MEDICAL CONDITION] Status. Review of Resident #1's Speech Therapy Discharge Summary, dated [DATE], revealed to facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: general swallow techniques/precautions, alternation of liquid/solids and bolus size modifications. Use of adaptive cup to prevent spills secondary to tremors. Review of Resident #1's progress note, dated [DATE], revealed resident sitting up in chair in dining room, color pale, resident gasping for air. [MEDICATION NAME] maneuver done resident bringing up large amounts of solid food. Further review of the progress note revealed Resident #1 returned from the hospital with no new orders. Review of Resident #1's ER visit note, dated [DATE], revealed Choking episode. Review of the facility's incident reports for Resident #1 revealed an incident report was not completed for Resident #1's choking incident on [DATE] and [DATE]. There was no documentation of an assessment or interventions after Resident #1's choking episode on [DATE]. Review of Resident #1's progress note, dated [DATE], revealed Resident started choking on food she grabbed from another resident's plate with no RR (respiratory rate) and pale to color, proceeded to look for obstruction in throat and could not see or feel when finger swiping. Started [MEDICATION NAME] maneuver and did [MEDICATION NAME] for 5 minutes while resident had food running out of mouth but not yet unobstructed. I then felt for pulse and there was no pulse so that I started CPR until EMS came and was finally able to get a pulse after 20 minutes of working on her themselves. Resident sent to local hospital. Review of Resident #1's local hospital records, dated [DATE]- [DATE] revealed Resident #1 had a [MEDICAL CONDITION] after choking on her dinner. Resident #1 expired on [DATE]. An interview on [DATE] at 9:37 a.m. with the DON revealed Resident #1 had grabbed food from another resident's plate. Resident #1 was on pureed diet and the other resident had mechanical soft diet, except vegetables. The DON further revealed Resident #1 expired Saturday morning ([DATE]) from [MEDICAL CONDITION] and respiratory distress due to choking. An interview on [DATE] at 10:45 a.m. with CNA B revealed she and CNA C were on the Generations (memory care) unit gathering residents for dinner. Resident #1 started to grab other resident's trays. Resident #1 was redirected out of the dining room. After the trays were served, Resident #1 was brought back. CNA B further revealed she then went to assist Resident #5 with eating in his room, leaving only CNA C in the dining room on the Generations unit. CNA B stated she heard CNA C yell that Resident #1 was choking. Resident #1 was already discolored when CNA B arrived at Resident #1's side. CNA B stated she started the [MEDICATION NAME] on Resident #1 while CNA C went to get LVN D. CNA B confirmed Resident #1 had the behavior to grab other resident's food and that this was her third choking incident. An interview on [DATE] at 11:20 a.m. with CNA C revealed before dinner had started Resident #1 was already reaching out for other resident's food on their trays. We had to physically remove her because she was trying to get other resident's food. CNA C further revealed Resident #1 was brought back and given her tray after the other residents were served. CNA B went to assist Resident #5 and CNA C revealed she was feeding Resident #4 in the dining room. CNA C stated she was sitting caddy corner, so she could feed Resident #4 and look around to keep an eye on the other residents. CNA C stated, after feeding Resident #4, she walked by Resident #1 who had a spoon in her mouth. When CNA C picked up a tray she saw Resident #1 grab a cup and noticed the resident was shaking. CNA C stated she hit Resident #1 on the back and food came out. She then yelled for CNA B who performed the [MEDICATION NAME] on Resident #1 while she went to get the nurse. CNA C confirmed Resident #1 had the behavior to grab other resident's food and that she had choked before when she was on a regular diet. An interview on [DATE] at 12:58 p.m., LVD D revealed she had already passed trays on the Generations unit and was in the South dining room. CNA C came out of the Generations unit and stated that Resident #1 was choking. LVN D stated she ran to the Generations unit and took over doing the [MEDICATION NAME]. Another nurse tried to finger swipe and could not get the food. We got the crash cart when I checked, and she had no pulse. LVN D revealed she started CPR on Resident #1 and continued until EMS arrived and took over. LVN D confirmed that Resident #1 should not have been at the same table with a resident that had mechanical soft meat and that Resident #1 had choking episodes in the past. An interview on [DATE] at 3:41 p.m. with the Speech Therapist confirmed that Resident #1 needed supervision if she grabbed other resident's food. An interview on [DATE] at 3:55 p.m. with Case Management Specialist E confirmed Resident #1's choking episodes and behavior of grabbing other resident's food should have been care planned and it was not. An interview on [DATE] at 4:01 p.m. with the DON confirmed that Resident #1's behavior and risk of choking should have definitely been care planned. The DON revealed she was not aware of the extent of Resident #1's behavior of grabbing other resident's food. The DON further revealed she would not have placed Resident #1 with Resident #2 who had the mechanical soft meat. An interview on [DATE] at 4:31 p.m. with the Administrator and DON revealed they monitored and supervised staff through their department heads and nursing management following current or new protocols. They stated that in-services are held to provide training to the staff. An interview on [DATE] at 10:30 a.m. with the Administrator revealed he was aware of the choking incident in October and because there was no an adverse effect on her health, it was not reported. It was Resident #1's impulsivity and not following cues to swallow that caused the incident in October. The Administrator confirmed he was notified about Resident #1's current choking incident on Friday ([DATE]) at 6:20 p.m. The Administrator further confirmed he found out Resident #1 passed away on [DATE] at 12:15 p.m. The Administrator revealed he could not say this incident with Resident #1 was neglect because it was one incident that could have been prevented. Observation of noon meal service at 12:16 p.m. on [DATE] revealed four staff members present in the Generations unit dining room. Observation on [DATE] at 12:55 p.m. on the Generations unit revealed Resident #3 stood up from his chair and reached over with his fork to Resident #2's plate and took a fork full of sweet potatoes. Resident #3 ate the sweet potatoes before LVN B could intervene. Record review of care plans for Resident #2, #3, #4, #6, #7, #8, #10, #11, #12, #13, #14, #16, and #17 on the Generations unit revealed their behaviors of grabbing other resident's food, giving food and drinks to other residents, sitting in another residents seating area and eating their food, picking at other resident's food, and risk for choking was not updated until [DATE] and [DATE]. An interview on [DATE] at 10:45 a.m. with CNA B revealed usual staffing was two CNAs on the Generations unit during meals with twenty-something residents with behaviors. One CNA stayed in the dining room and the other went to assist Resident #5. CNA B further revealed all of the residents on the unit required redirecting at times. They were not able to provided one on one supervision and the nurse was not on the unit during meals. We had to clear the tables and we were constantly redirecting. CNA B stated they had to clean their own dining room while constantly redirecting residents and getting them ready for bed. CNA B confirmed everyone was aware of Resident #1's behavior to grab other resident's food. An interview on [DATE] at 11:11 a.m. with CNA F revealed Resident #1 had behaviors of wanting to get other people's food. When Resident #1 was done eating her food, she would go to different tables and take other resident's food. An interview on [DATE] at 11:20 a.m. with CNA C revealed there was one aide in the Generations unit dining room and one feeding Resident #5 in his room. CNA C further revealed that the nurse did not stay on the Generations unit the whole time during the meals. An interview on [DATE] at 12:37 p.m. with CNA F confirmed there were usually only 2 CNAs on the Generations unit during meal service. CNA F stated that the nurse would check the meal tickets and leave. CNA F confirmed during the current meal service that there were never that many staff members present on the Generations unit. An interview on [DATE] at 1:51 p.m. with LVN G revealed she checked the trays on the Generations unit and would have to go to the South dining room to check those trays and sometimes assist in feeding residents in that dining room. An interview on [DATE] at 4:01 p.m. with the DON stated staff needed to be present in the Generations unit dining room to provide assistance with feeding, monitoring if residents were eating and assist if someone choked. The DON confirmed that there definitely needed to be another staff member present in the Generations unit dining room if there was a resident grabbing other resident's food. An interview on [DATE] at 12:23 p.m. during lunch meal service on the Generations unit, the spouse of Resident #6 revealed there was never that many staff members present during lunch as there were now and he would come daily at this time. The spouse further revealed that there were only two staff present during lunch when he would come to see his wife. An interview on [DATE] at 3:55 p.m., the DON revealed they did not have a current list of residents with behaviors during meals or at risk for choking until yesterday evening ([DATE]). An interview on [DATE] at 4:30 p.m., the DON revealed any resident on a special or alternate diet was at risk for choking. An interview on [DATE] at 5:19 p.m., Case Management Specialist H revealed care plans were updated on [DATE] and [DATE] for all residents who had behaviors during meals and residents who were at risk for choking. Review of the facility policy titled Assistance with Meals dated [DATE] revealed Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. An interview on [DATE] at 11:06 a.m. the Administrator confirmed the facility did not have a policy on supervision during meals or choking. On [DATE] at 4:31 p.m. the Administrator and DON was notified of an Immediate Jeopardy (IJ) situation for the above failures, a completed IJ template was provided and a Plan of Removal was requested. On [DATE] at 12:27 p.m. the facility's Plan of Removal was approved. The facility's Plan of Removal included the following steps to be taken by the facility: 1. On [DATE] an audit was completed on all residents who have a propensity to choke or have a behavior which could lead to a choking episode. Residents who were identified to display these behaviors care plans were updated as necessary. 2. Effective [DATE] staff will be educated 5 times a week for 4 weeks on care plan changes that relate to diet changes as well as behaviors that could affect meal service of the resident. 3. On [DATE] new seating arrangements for residents with pureed diets were implemented for the South Dining and Generations Dining Rooms. Residents who are on a pureed diet will be sat together during mealtime. In an effort to ensure resident rights, residents how wish to not sit at the recommended table will be educated by licensed staff on the risks of possible harm to the resident's health and safety. 4. Effective [DATE] staffing will be adjusted in the Generations Unit and South Dining Rooms to include, 2 CNAs monitoring and assisting at all times during the entire meal service. A licensed staff will also be assigned to monitor residents and assist as necessary during the entire meal service. 5. On [DATE] staff were re-educated to dispose of remaining portions of food and remove trays immediately after each resident has completed their respective meal. 6. Effective [DATE] departments heads will conduct meal monitoring services for all meals 5 times a week for 4 weeks to ensure new facility protocol is being followed. 7. Re-education of the staff, to include nursing, therapy, dietary, maintenance, administrative and housekeeping was completed on [DATE] to ensure the staff members were educated regarding new dietary procedures to ensure adequate supervision during mealtimes. The surveyor verification of the Plan of Removal on [DATE] was as follows: Reviewed the audit completed by the facility on all residents who had a propensity to choke or had a behavior which could lead to a choking episode. Care plans reviewed for the residents(#2, #3, #4, #6, #7, #8, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35) identified in the audit to ensure the care plans were updated to include behavioral issues and the risk of choking. Reviewed and verified the daily education that would be provided to staff five times a week for four weeks that included resident's behaviors and care plan changes. Observed noon meal service on [DATE] on the Generations unit for new implementation of seating arrangements and how staff handled any residents that did not want to move. Observed noon meal service on [DATE] on the Generations unit for additional staff members in the dining rooms to include 2 CNAs and 1 LVN were present. In-service sign-in sheets and material covered by the in-services was reviewed onsite on [DATE] included the new seating arrangements, resident's diets, resident rights, number of staff present in the dining rooms, clearer trays as soon as the resident was done eating, supervision, and neglect. New scheduled for departments heads and documentation they must complete was reviewed onsite on [DATE]. Observed noon meals service on [DATE] for department heads presence and meal monitoring in the dining rooms. Staff interviews were conducted on 4 separate halls on 2 different shifts. Staff interviews were conducted of department heads regarding new responsibilities in the dining rooms. Interviews occurred on [DATE] from 2:00 p.m. - 5:20 p.m. with CNA B, CNA, C, CNA I, CNA J, CNA K, CNA M, CNA N, MA P, NA R, CNA S, PTA T, and Cook Q. All stated that they had received an in-service regarding which residents were at risk for choking and had behaviors during meals, the new seating arrangements and what to do if the resident did not want to sit at their designated table, the new requirements for staff needed in the dining rooms, and to dispose of leftover food/plates when a resident has completed their meal. Interviews occurred on [DATE] from 2:00 p.m. - 5:20 p.m. with LVN G, LVN L, RN O, the Maintenance Supervisor, the Social Worker, the Housekeeping Supervisor, the Activity Director, Case Management Specialist E & H, and the DON. All stated that they had received an in-service regarding which residents were at risk for choking and had behaviors during meals, the new seating arrangements and their responsibility as charge nurses or department heads on how to handle the situation if the resident did not want to sit at their designated table, the new requirements for staff needed in the dining rooms, to dispose of leftover food/plates when a resident has completed their meal, and the department heads new responsibilities during meal service. On [DATE] at 6:00 p.m., the Administrator, DON, the Director of Clinical Operations, and the Regional Vice-President of Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all staff were in-serviced.

Based on observations, record reviews and interviews, the facility failed to ensure that residents had the right to be free from neglect for 1 of 22 residents (Resident #1) whose care was reviewed for neglect, in that: 1. a. The facility failed to document or implement interventions for Resident # 1, who they were aware had a history of [REDACTED]. Resident # 1 choked on [DATE], [DATE] and again on [DATE] and subsequently died . b. The facility failed to identify residents who took and ate food from other residents' plates and were at-risk for choking, provide supervision to those residents, and for ensuring inappropriately textured food was not within residents' reach. These failures resulted in identification of Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk for choking and had behaviors during meal times, staff were in-serviced, and increased supervision was provided in the dining rooms. These deficient practices affected residents in the facility who were at risk of choking and behaviors during meals, and placed them at risk for harm, choking or death. The findings were: Review of the facility policy titled Assistance with Meals dated [DATE] revealed Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Review of the facility policy titled Abuse Prevention Program, dated [DATE] revealed Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Under the section titled Policy Interpretation and Implementation 3. j. The implementation of changes to prevent future occurrences of abuse. Under Reporting of Alleged Abuse to Facility Management 2. f. 'Neglect' is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An interview on [DATE] at 11:06 a.m. the Administrator confirmed the facility did not have a policy on supervision during meals or choking. Record review of Resident #1's face sheet, dated [DATE] revealed an admission date of [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change MDS dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment for daily decision-making skills. Further review under Functional Status revealed Resident #1 required extensive assistance with eating and one person physical assistance. Review of Resident #1's Care Plan, revised on [DATE], revealed her care plan indicated she was on a pureed diet, but did not reflect her history of choking or behavior of grabbing other resident's food. Review of Resident #1's Physician Order Summary for [DATE] revealed an order for [REDACTED]. Resident #1's diet order further revealed the original revision to pureed texture was on [DATE]. Review of Resident #1's Progress Notes revealed two previous choking incidents documented on [DATE] and [DATE]. Review of Resident #1's Modified [MEDICATION NAME] Swallowing Study, dated [DATE], revealed overall dysphagia severity is severe. Strategies - We recommend the following actions regarding the patient's feedings: Small Bites/Sips - Monitor PO Intake Rate - Positioned Upright - Supervised PO Feeding - Cueing for Strategies - Aspiration Precautions - Monitor [MEDICAL CONDITION] Status. Review of Resident #1's Speech Therapy Discharge Summary, dated [DATE], revealed to facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: general swallow techniques/precautions, alternation of liquid/solids and bolus size modifications. Use of adaptive cup to prevent spills secondary to tremors. Review of Resident #1's progress note, dated [DATE], revealed resident sitting up in chair in dining room, color pale, resident gasping for air. [MEDICATION NAME] maneuver done resident bringing up large amounts of solid food. Further review of the progress note revealed Resident #1 returned from the hospital with no new orders. Review of Resident #1's ER visit note, dated [DATE], revealed Choking episode. Review of the facility's incident reports for Resident #1 revealed an incident report was not completed for Resident #1's choking incident on [DATE] and [DATE]. There was no documentation of an assessment or interventions after Resident #1's choking episode on [DATE]. Review of Resident #1's progress note, dated [DATE], revealed Resident started choking on food she grabbed from another resident's plate with no RR (respiratory rate) and pale to color, proceeded to look for obstruction in throat and could not see or feel when finger swiping. Started [MEDICATION NAME] maneuver and did [MEDICATION NAME] for 5 minutes while resident had food running out of mouth but not yet unobstructed. I then felt for pulse and there was no pulse so that I started CPR until EMS came and was finally able to get a pulse after 20 minutes of working on her themselves. Resident sent to local hospital. Review of Resident #1's local hospital records, dated [DATE]- [DATE] revealed Resident #1 had a [MEDICAL CONDITION] after choking on her dinner. Resident #1 expired on [DATE]. An interview on [DATE] at 9:37 a.m. with the DON revealed Resident #1 had grabbed food from another resident's plate. Resident #1 was on pureed diet and the other resident had mechanical soft diet, except vegetables. The DON further revealed Resident #1 expired Saturday morning ([DATE]) from [MEDICAL CONDITION] and respiratory distress due to choking. An interview on [DATE] at 10:45 a.m. with CNA B revealed she and CNA C were on the Generations (memory care) unit gathering residents for dinner. Resident #1 started to grab other resident's trays. Resident #1 was redirected out of the dining room. After the trays were served, Resident #1 was brought back. CNA B further revealed she then went to assist Resident #5 with eating in his room, leaving only CNA C in the dining room on the Generations unit. CNA B stated she heard CNA C yell that Resident #1 was choking. Resident #1 was already discolored when CNA B arrived at Resident #1's side. CNA B stated she started the [MEDICATION NAME] on Resident #1 while CNA C went to get LVN D. CNA B confirmed Resident #1 had the behavior to grab other resident's food and that this was her third choking incident. An interview on [DATE] at 11:20 a.m. with CNA C revealed before dinner had started Resident #1 was already reaching out for other resident's food on their trays. We had to physically remove her because she was trying to get other resident's food. CNA C further revealed Resident #1 was brought back and given her tray after the other residents were served. CNA B went to assist Resident #5 and CNA C revealed she was feeding Resident #4 in the dining room. CNA C stated she was sitting caddy corner, so she could feed Resident #4 and look around to keep an eye on the other residents. CNA C stated, after feeding Resident #4, she walked by Resident #1 who had a spoon in her mouth. When CNA C picked up a tray she saw Resident #1 grab a cup and noticed the resident was shaking. CNA C stated she hit Resident #1 on the back and food came out. She then yelled for CNA B who performed the [MEDICATION NAME] on Resident #1 while she went to get the nurse. CNA C confirmed Resident #1 had the behavior to grab other resident's food and that she had choked before when she was on a regular diet. An interview on [DATE] at 12:58 p.m., LVD D revealed she had already passed trays on the Generations unit and was in the South dining room. CNA C came out of the Generations unit and stated that Resident #1 was choking. LVN D stated she ran to the Generations unit and took over doing the [MEDICATION NAME]. Another nurse tried to finger swipe and could not get the food. We got the crash cart when I checked, and she had no pulse. LVN D revealed she started CPR on Resident #1 and continued until EMS arrived and took over. LVN D confirmed that Resident #1 should not have been at the same table with a resident that had mechanical soft meat and that Resident #1 had choking episodes in the past. An interview on [DATE] at 3:41 p.m. with the Speech Therapist confirmed that Resident #1 needed supervision if she grabbed other resident's food. An interview on [DATE] at 3:55 p.m. with Case Management Specialist E confirmed Resident #1's choking episodes and behavior of grabbing other resident's food should have been care planned and it was not. An interview on [DATE] at 4:01 p.m. with the DON confirmed that Resident #1's behavior and risk of choking should have definitely been care planned. The DON revealed she was not aware of the extent of Resident #1's behavior of grabbing other resident's food. The DON further revealed she would not have placed Resident #1 with Resident #2 who had the mechanical soft meat. An interview on [DATE] at 4:31 p.m. with the Administrator and DON revealed they monitored and supervised staff through their department heads and nursing management following current or new protocols. They stated that in-services are held to provide training to the staff. An interview on [DATE] at 10:30 a.m. with the Administrator revealed he was aware of the choking incident in October and because there was no an adverse effect on her health, it was not reported. It was Resident #1's impulsivity and not following cues to swallow that caused the incident in October. The Administrator confirmed he was notified about Resident #1's current choking incident on Friday ([DATE]) at 6:20 p.m. The Administrator further confirmed he found out Resident #1 passed away on [DATE] at 12:15 p.m. The Administrator revealed he could not say this incident with Resident #1 was neglect because it was one incident that could have been prevented. Observation of noon meal service at 12:16 p.m. on [DATE] revealed four staff members present in the Generations unit dining room. Observation on [DATE] at 12:55 p.m. on the Generations unit revealed Resident #3 stood up from his chair and reached over with his fork to Resident #2's plate and took a fork full of sweet potatoes. Resident #3 ate the sweet potatoes before LVN B could intervene. Record review of care plans for Resident #2, #3, #4, #6, #7, #8, #10, #11, #12, #13, #14, #16, and #17 on the Generations unit revealed their behaviors of grabbing other resident's food, giving food and drinks to other residents, sitting in another residents seating area and eating their food, picking at other resident's food, and risk for choking was not updated until [DATE] and [DATE]. An interview on [DATE] at 10:45 a.m. with CNA B revealed usual staffing was two CNAs on the Generations unit during meals with twenty-something residents with behaviors. One CNA stayed in the dining room and the other went to assist Resident #5. CNA B further revealed all of the residents on the unit required redirecting at times. They were not able to provided one on one supervision and the nurse was not on the unit during meals. We had to clear the tables and we were constantly redirecting. CNA B stated they had to clean their own dining room while constantly redirecting residents and getting them ready for bed. CNA B confirmed everyone was aware of Resident #1's behavior to grab other resident's food. An interview on [DATE] at 11:11 a.m. with CNA F revealed Resident #1 had behaviors of wanting to get other people's food. When Resident #1 was done eating her food, she would go to different tables and take other resident's food. An interview on [DATE] at 11:20 a.m. with CNA C revealed there was one aide in the Generations unit dining room and one feeding Resident #5 in his room. CNA C further revealed that the nurse did not stay on the Generations unit the whole time during the meals. An interview on [DATE] at 12:37 p.m. with CNA F confirmed there were usually only 2 CNAs on the Generations unit during meal service. CNA F stated that the nurse would check the meal tickets and leave. CNA F confirmed during the current meal service that there were never that many staff members present on the Generations unit. An interview on [DATE] at 1:51 p.m. with LVN G revealed she checked the trays on the Generations unit and would have to go to the South dining room to check those trays and sometimes assist in feeding residents in that dining room. An interview on [DATE] at 4:01 p.m. with the DON stated staff needed to be present in the Generations unit dining room to provide assistance with feeding, monitoring if residents were eating and assist if someone choked. The DON confirmed that there definitely needed to be another staff member present in the Generations unit dining room if there was a resident grabbing other resident's food. An interview on [DATE] at 12:23 p.m. during lunch meal service on the Generations unit, the spouse of Resident #6 revealed there was never that many staff members present during lunch as there were now and he would come daily at this time. The spouse further revealed that there were only two staff present during lunch when he would come to see his wife. An interview on [DATE] at 3:55 p.m., the DON revealed they did not have a current list of residents with behaviors during meals or at risk for choking until yesterday evening ([DATE]). An interview on [DATE] at 4:30 p.m., the DON revealed any resident on a special or alternate diet was at risk for choking. An interview on [DATE] at 5:19 p.m., Case Management Specialist H revealed care plans were updated on [DATE] and [DATE] for all residents who had behaviors during meals and residents who were at risk for choking. On [DATE] at 4:31 p.m. the Administrator and DON was notified of an Immediate Jeopardy (IJ) situation for the above failures, a completed IJ template was provided and a Plan of Removal was requested. On [DATE] at 12:27 p.m. the facility's Plan of Removal was approved. The facility's Plan of Removal included the following steps to be taken by the facility: 1. On [DATE] staff re-education was provided to available staff on abuse, neglect and exploitation regarding resident supervision during mealtimes. Staff were re-educated to ensure the new facility policy on providing adequate supervision in the dining room was implemented. 2. Effective [DATE] staffing will be adjusted in the Generations unit and south Dining Rooms to include, 2 CNAs monitoring and assisting at all times during the entire meal service. A licensed staff will also be assigned to monitor residents and assist as necessary during the entire meal service. 3. On [DATE] staff were re-educated to dispose of remaining portions of food and remove trays immediately after each resident has completed their respective meals. 4. Effective [DATE] staff were re-educated on monitoring of meals, residents who are noted to have behaviors that pose a risk will be assessed by the interdisciplinary healthcare team and the care plan will be updated as necessary. The surveyor verification of the Plan of Removal on [DATE] was as follows: Care plans reviewed the residents (#2, #3, #4, #6, #7, #8, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35) identified to ensure the care plans were updated to include behavioral issues and the risk of choking. Observed noon meal service on [DATE] for additional staff members in the dining rooms to include 2 CNAs and 1 LVN were present. In-service sign-in sheets and material covered by the in-services was reviewed onsite on [DATE] included the new seating arrangements, resident's diets, resident rights, number of staff present in the dining rooms, clearer trays as soon as the resident was done eating, supervision, and neglect. Staff interviews were conducted on 4 separate halls on 2 different shifts. Interviews occurred on [DATE] from 2:00 p.m. - 5:20 p.m. with CNA B, CNA, C, CNA I, CNA J, CNA K, CNA M, CNA N, MA P, NA R, CNA S, PTA T, and Cook Q. All stated that they had received in-services regarding adequate supervision to prevent abuse, neglect, and exploitation; an in-service regarding which residents were noted to have behaviors that posed a risk, the new requirements for staff needed in the dining room, and to dispose of leftover food/plates when a resident has completed their meal. Interviews occurred on [DATE] from 2:00 p.m. - 5:20 p.m. with LVN G, LVN L, RN O, the Maintenance Supervisor, the Social Worker, the Housekeeping Supervisor, the Activity Director, Case Management Specialist E & H, and the DON. All stated that they had received in-services regarding adequate supervision to prevent abuse, neglect, and exploitation; an in-service regarding which residents were noted to have behaviors that posed a risk, the new requirements for staff needed in the dining room, and to dispose of leftover food/plates when a resident has completed their meal. On [DATE] at 6:00 p.m., the Administrator, DON, the Director of Clinical Operations, and the Regional Vice-President of Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all staff were in-serviced.

Based on observations, record reviews and interviews, the facility failed to ensure that residents had the right to be free from neglect for 1 of 22 residents (Resident #1) whose care was reviewed for neglect, in that: The facility's structure to prevent neglect were not implemented when: 1. a. The facility failed to document or implement interventions for Resident # 1, who they were aware had a history of [REDACTED]. Resident # 1 choked on [DATE], [DATE] and again on [DATE] and subsequently died . b. The facility failed to identify residents who took and ate food from other residents' plates and were at-risk for choking, provide supervision to those residents, and for ensuring inappropriately textured food was not within residents' reach. These failures resulted in identification of Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk for choking and had behaviors during meal times, staff were in-serviced, and increased supervision was provided in the dining rooms. These deficient practices affected residents in the facility who were at-risk of choking and behaviors during meals, and placed them at-risk for harm, choking or death. The findings were: Record review of Resident #1's face sheet, dated [DATE] revealed an admission date of [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change MDS dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment for daily decision-making skills. Further review under Functional Status revealed Resident #1 required extensive assistance with eating and one person physical assistance. Review of Resident #1's Care Plan, revised on [DATE], revealed her care plan indicated she was on a pureed diet, but did not reflect her history of choking or behavior of grabbing other resident's food. Review of Resident #1's Physician Order Summary for [DATE] revealed an order for [REDACTED]. Resident #1's diet order further revealed the original revision to pureed texture was on [DATE]. Review of Resident #1's Progress Notes revealed two previous choking incidents documented on [DATE] and [DATE]. Review of Resident #1's Modified [MEDICATION NAME] Swallowing Study, dated [DATE], revealed overall dysphagia severity is severe. Strategies - We recommend the following actions regarding the patient's feedings: Small Bites/Sips - Monitor PO Intake Rate - Positioned Upright - Supervised PO Feeding - Cueing for Strategies - Aspiration Precautions - Monitor [MEDICAL CONDITION] Status. Review of Resident #1's Speech Therapy Discharge Summary, dated [DATE], revealed to facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: general swallow techniques/precautions, alternation of liquid/solids and bolus size modifications. Use of adaptive cup to prevent spills secondary to tremors. Review of Resident #1's progress note, dated [DATE], revealed resident sitting up in chair in dining room, color pale, resident gasping for air. [MEDICATION NAME] maneuver done resident bringing up large amounts of solid food. Further review of the progress note revealed Resident #1 returned from the hospital with no new orders. Review of Resident #1's ER visit note, dated [DATE], revealed Choking episode. Review of the facility's incident reports for Resident #1 revealed an incident report was not completed for Resident #1's choking incident on [DATE] and [DATE]. There was no documentation of an assessment or interventions after Resident #1's choking episode on [DATE]. Review of Resident #1's progress note, dated [DATE], revealed Resident started choking on food she grabbed from another resident's plate with no RR (respiratory rate) and pale to color, proceeded to look for obstruction in throat and could not see or feel when finger swiping. Started [MEDICATION NAME] maneuver and did [MEDICATION NAME] for 5 minutes while resident had food running out of mouth but not yet unobstructed. I then felt for pulse and there was no pulse so that I started CPR until EMS came and was finally able to get a pulse after 20 minutes of working on her themselves. Resident sent to local hospital. Review of Resident #1's local hospital records, dated [DATE]- [DATE] revealed Resident #1 had a [MEDICAL CONDITION] after choking on her dinner. Resident #1 expired on [DATE]. An interview on [DATE] at 9:37 a.m. with the DON revealed Resident #1 had grabbed food from another resident's plate. Resident #1 was on pureed diet and the other resident had mechanical soft diet, except vegetables. The DON further revealed Resident #1 expired Saturday morning ([DATE]) from [MEDICAL CONDITION] and respiratory distress due to choking. An interview on [DATE] at 10:45 a.m. with CNA B revealed she and CNA C were on the Generations (memory care) unit gathering residents for dinner. Resident #1 started to grab other resident's trays. Resident #1 was redirected out of the dining room. After the trays were served, Resident #1 was brought back. CNA B further revealed she then went to assist Resident #5 with eating in his room, leaving only CNA C in the dining room on the Generations unit. CNA B stated she heard CNA C yell that Resident #1 was choking. Resident #1 was already discolored when CNA B arrived at Resident #1's side. CNA B stated she started the [MEDICATION NAME] on Resident #1 while CNA C went to get LVN D. CNA B confirmed Resident #1 had the behavior to grab other resident's food and that this was her third choking incident. An interview on [DATE] at 11:20 a.m. with CNA C revealed before dinner had started Resident #1 was already reaching out for other resident's food on their trays. We had to physically remove her because she was trying to get other resident's food. CNA C further revealed Resident #1 was brought back and given her tray after the other residents were served. CNA B went to assist Resident #5 and CNA C revealed she was feeding Resident #4 in the dining room. CNA C stated she was sitting caddy corner, so she could feed Resident #4 and look around to keep an eye on the other residents. CNA C stated, after feeding Resident #4, she walked by Resident #1 who had a spoon in her mouth. When CNA C picked up a tray she saw Resident #1 grab a cup and noticed the resident was shaking. CNA C stated she hit Resident #1 on the back and food came out. She then yelled for CNA B who performed the [MEDICATION NAME] on Resident #1 while she went to get the nurse. CNA C confirmed Resident #1 had the behavior to grab other resident's food and that she had choked before when she was on a regular diet. An interview on [DATE] at 12:58 p.m., LVD D revealed she had already passed trays on the Generations unit and was in the South dining room. CNA C came out of the Generations unit and stated that Resident #1 was choking. LVN D stated she ran to the Generations unit and took over doing the [MEDICATION NAME]. Another nurse tried to finger swipe and could not get the food. We got the crash cart when I checked, and she had no pulse. LVN D revealed she started CPR on Resident #1 and continued until EMS arrived and took over. LVN D confirmed that Resident #1 should not have been at the same table with a resident that had mechanical soft meat and that Resident #1 had choking episodes in the past. An interview on [DATE] at 3:41 p.m. with the Speech Therapist confirmed that Resident #1 needed supervision if she grabbed other resident's food. An interview on [DATE] at 3:55 p.m. with Case Management Specialist E confirmed Resident #1's choking episodes and behavior of grabbing other resident's food should have been care planned and it was not. An interview on [DATE] at 4:01 p.m. with the DON confirmed that Resident #1's behavior and risk of choking should have definitely been care planned. The DON revealed she was not aware of the extent of Resident #1's behavior of grabbing other resident's food. The DON further revealed she would not have placed Resident #1 with Resident #2 who had the mechanical soft meat. An interview on [DATE] at 4:31 p.m. with the Administrator and DON revealed they monitored and supervised staff through their department heads and nursing management following current or new protocols. They stated that in-services are held to provide training to the staff. An interview on [DATE] at 10:30 a.m. with the Administrator revealed he was aware of the choking incident in October and because there was no an adverse effect on her health, it was not reported. It was Resident #1's impulsivity and not following cues to swallow that caused the incident in October. The Administrator confirmed he was notified about Resident #1's current choking incident on Friday ([DATE]) at 6:20 p.m. The Administrator further confirmed he found out Resident #1 passed away on [DATE] at 12:15 p.m. The Administrator revealed he could not say this incident with Resident #1 was neglect because it was one incident that could have been prevented. Observation of noon meal service at 12:16 p.m. on [DATE] revealed four staff members present in the Generations unit dining room. Observation on [DATE] at 12:55 p.m. on the Generations unit revealed Resident #3 stood up from his chair and reached over with his fork to Resident #2's plate and took a fork full of sweet potatoes. Resident #3 ate the sweet potatoes before LVN B could intervene. Record review of care plans for Resident #2, #3, #4, #6, #7, #8, #10, #11, #12, #13, #14, #16, and #17 on the Generations unit revealed their behaviors of grabbing other resident's food, giving food and drinks to other residents, sitting in another residents seating area and eating their food, picking at other resident's food, and risk for choking was not updated until [DATE] and [DATE]. An interview on [DATE] at 10:45 a.m. with CNA B revealed usual staffing was two CNAs on the Generations unit during meals with twenty-something residents with behaviors. One CNA stayed in the dining room and the other went to assist Resident #5. CNA B further revealed all of the residents on the unit required redirecting at times. They were not able to provided one on one supervision and the nurse was not on the unit during meals. We had to clear the tables and we were constantly redirecting. CNA B stated they had to clean their own dining room while constantly redirecting residents and getting them ready for bed. CNA B confirmed everyone was aware of Resident #1's behavior to grab other resident's food. An interview on [DATE] at 11:11 a.m. with CNA F revealed Resident #1 had behaviors of wanting to get other people's food. When Resident #1 was done eating her food, she would go to different tables and take other resident's food. An interview on [DATE] at 11:20 a.m. with CNA C revealed there was one aide in the Generations unit dining room and one feeding Resident #5 in his room. CNA C further revealed that the nurse did not stay on the Generations unit the whole time during the meals. An interview on [DATE] at 12:37 p.m. with CNA F confirmed there were usually only 2 CNAs on the Generations unit during meal service. CNA F stated that the nurse would check the meal tickets and leave. CNA F confirmed during the current meal service that there were never that many staff members present on the Generations unit. An interview on [DATE] at 1:51 p.m. with LVN G revealed she checked the trays on the Generations unit and would have to go to the South dining room to check those trays and sometimes assist in feeding residents in that dining room. An interview on [DATE] at 4:01 p.m. with the DON stated staff needed to be present in the Generations unit dining room to provide assistance with feeding, monitoring if residents were eating and assist if someone choked. The DON confirmed that there definitely needed to be another staff member present in the Generations unit dining room if there was a resident grabbing other resident's food. An interview on [DATE] at 12:23 p.m. during lunch meal service on the Generations unit, the spouse of Resident #6 revealed there was never that many staff members present during lunch as there were now and he would come daily at this time. The spouse further revealed that there were only two staff present during lunch when he would come to see his wife. An interview on [DATE] at 3:55 p.m., the DON revealed they did not have a current list of residents with behaviors during meals or at risk for choking until yesterday evening ([DATE]). An interview on [DATE] at 4:30 p.m., the DON revealed any resident on a special or alternate diet was at risk for choking. An interview on [DATE] at 5:19 p.m., Case Management Specialist H revealed care plans were updated on [DATE] and [DATE] for all residents who had behaviors during meals and residents who were at risk for choking. Review of the facility policy titled Assistance with Meals dated [DATE] revealed Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Review of the facility policy titled Abuse Prevention Program, dated [DATE] revealed Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Under the section titled Policy Interpretation and Implementation 3. j. The implementation of changes to prevent future occurrences of abuse. Under Reporting of Alleged Abuse to Facility Management 2. f. 'Neglect' is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An interview on [DATE] at 11:06 a.m. the Administrator confirmed the facility did not have a policy on supervision during meals or choking. On [DATE] at 4:31 p.m. the Administrator and DON was notified of an Immediate Jeopardy (IJ) situation for the above failures, a completed IJ template was provided and a Plan of Removal was requested. On [DATE] at 12:27 p.m. the facility's Plan of Removal was approved. The facility's Plan of Removal included the following steps to be taken by the facility: 1. On [DATE] staff re-education was provided to available staff on abuse, neglect and exploitation regarding resident supervision during mealtimes. Staff were re-educated to ensure the new facility policy on providing adequate supervision in the dining room was implemented. 2. Effective [DATE] staffing will be adjusted in the Generations unit and south Dining Rooms to include, 2 CNAs monitoring and assisting at all times during the entire meal service. A licensed staff will also be assigned to monitor residents and assist as necessary during the entire meal service. 3. On [DATE] staff were re-educated to dispose of remaining portions of food and remove trays immediately after each resident has completed their respective meals. 4. Effective [DATE] staff were re-educated on monitoring of meals, residents who are noted to have behaviors that pose a risk will be assessed by the interdisciplinary healthcare team and the care plan will be updated as necessary. The surveyor verification of the Plan of Removal on [DATE] was as follows: Care plans reviewed the residents (#2, #3, #4, #6, #7, #8, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35) identified to ensure the care plans were updated to include behavioral issues and the risk of choking. Observed noon meal service on [DATE] for additional staff members in the dining rooms to include 2 CNAs and 1 LVN were present. In-service sign-in sheets and material covered by the in-services was reviewed onsite on [DATE] included the new seating arrangements, resident's diets, resident rights, number of staff present in the dining rooms, clearer trays as soon as the resident was done eating, supervision, and neglect. Staff interviews were conducted on 4 separate halls on 2 different shifts. Interviews occurred on [DATE] from 2:00 p.m. - 5:20 p.m. with CNA B, CNA, C, CNA I, CNA J, CNA K, CNA M, CNA N, MA P, NA R, CNA S, PTA T, and Cook Q. All stated that they had received in-services regarding adequate supervision to prevent abuse, neglect, and exploitation; an in-service regarding which residents were noted to have behaviors that posed a risk, the new requirements for staff needed in the dining room, and to dispose of leftover food/plates when a resident has completed their meal. Interviews occurred on [DATE] from 2:00 p.m. - 5:20 p.m. with LVN G, LVN L, RN O, the Maintenance Supervisor, the Social Worker, the Housekeeping Supervisor, the Activity Director, Case Management Specialist E & H, and the DON. All stated that they had received in-services regarding adequate supervision to prevent abuse, neglect, and exploitation; an in-service regarding which residents were noted to have behaviors that posed a risk, the new requirements for staff needed in the dining room, and to dispose of leftover food/plates when a resident has completed their meal. On [DATE] at 6:00 p.m., the Administrator, DON, the Director of Clinical Operations, and the Regional Vice-President of Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all staff were in-serviced.

Based on observations, record reviews and interviews, the facility failed to ensure that all alleged violations involving abuse and neglect are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 22 residents (Resident #1) whose care was reviewed for neglect, in that: The facility failed to report Resident # 1's episode of choking on [DATE] that resulted in resident being sent to the hospital then later died within a 2 hour period. These deficient practice could affect residents in the facility who are at risk of choking and place them at risk for abuse and neglect. The findings were: Record review of Resident #1's face sheet, dated [DATE] revealed an admission date of [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change MDS dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment for daily decision making skills. Further review under Functional Status revealed Resident #1 required extensive assistance with eating and one person physical assistance. Review of Resident #1's Care Plan, revised on [DATE], revealed her care plan indicated she was on a pureed diet, but did not reflect her history of choking or behavior of grabbing other resident's food. Review of Resident #1's physician's orders [REDACTED]. Resident #1's diet order further revealed the original revision to pureed texture was on [DATE]. Review of Resident #1's progress note, dated [DATE], revealed Resident started choking on food she grabbed from another resident's plate with no RR and pale to color, proceeded to look for obstruction in throat and could not see or feel when finger swiping. Started [MEDICATION NAME] maneuver and did [MEDICATION NAME] for 5 minutes while resident had food running out of mouth but not yet unobstructed. I then felt for pulse and there was no pulse so that I started CPR until EMS came and was finally able to get a pulse after 20 minutes of working on her themselves. Resident sent to local hospital. Review of Resident #1's local hospital records, dated [DATE]- [DATE] revealed Resident #1 had a [MEDICAL CONDITION] after choking on her dinner. Resident #1 expired on [DATE]. An interview on [DATE] at 9:37 a.m. with the DON revealed Resident #1 had grabbed food from another resident's plate. Resident #1 was on pureed diet and the other resident had mechanical soft diet, except vegetables. The DON further revealed Resident #1 expired Saturday morning ([DATE]) from [MEDICAL CONDITION] and respiratory distress due to choking. An interview on [DATE] at 10:45 a.m. with CNA B revealed she and CNA C were on the Generations (memory care) unit gathering residents for dinner. Resident #1 started to grab other resident's trays. Resident #1 was redirected out of the dining room. After the trays were served, Resident #1 was brought back. CNA B further revealed she then went to assist Resident #5 with eating in his room, leaving only CNA C in the dining room on the Generations unit. CNA B stated she heard CNA C yell that Resident #1 was choking. Resident #1 was already discolored when CNA B arrived at Resident #1's side. CNA B stated she started the [MEDICATION NAME] on Resident #1 while CNA C went to get LVN D. CNA B confirmed Resident #1 had the behavior to grab other resident's food and that this was her third choking incident. An interview on [DATE] at 11:20 a.m. with CNA C revealed before dinner had started Resident #1 was already reaching out for other resident's food on their trays. We had to physically remove her because she was trying to get other resident's food. CNA C further revealed Resident #1 was brought back and given her tray after the other residents were served. CNA B went to assist Resident #5 and CNA C revealed she was feeding Resident #4 in the dining room. CNA C stated she was sitting caddy corner, so she could feed Resident #4 and look around to keep an eye on the other residents. CNA C stated, after feeding Resident #4, she walked by Resident #1 who had a spoon in her mouth. When CNA C picked up a tray she saw Resident #1 grab a cup and noticed the resident was shaking. CNA C stated she hit Resident #1 on the back and food came out. She then yelled for CNA B who performed the [MEDICATION NAME] on Resident #1 while she went to get the nurse. CNA C confirmed Resident #1 had the behavior to grab other resident's food and that she had choked before when she was on a regular diet. An interview on [DATE] at 12:58 p.m., LVD D revealed she had already passed trays on the Generations unit and was in the South dining room. CNA C came out of the Generations unit and stated that Resident #1 was choking. LVN D stated she ran to the Generations unit and took over doing the [MEDICATION NAME]. Another nurse tried to finger swipe and could not get the food. We got the crash cart when I checked, and she had no pulse. LVN D revealed she started CPR on Resident #1 and continued until EMS arrived and took over. LVN D confirmed that Resident #1 should not have been at the same table with a resident that had mechanical soft meat and that Resident #1 had choking episodes in the past. An interview on [DATE] at 3:41 p.m. with the Speech Therapist confirmed that Resident #1 needed supervision if she grabbed other resident's food. An interview on [DATE] at 10:30 a.m. with the Administrator confirmed he was notified about Resident #1's current choking incident on Friday ([DATE]) at 6:20 p.m. The Administrator further confirmed he found out Resident #1 passed away on [DATE] at 12:15 p.m. The Aministrator revealed he could not say it was neglect because it was one incident that could have been prevented. The Aministrator further revealed he was under the impression that only abuse had to be reported within the two hour window. An interview on [DATE] at 10:45 a.m. with CNA B revealed usual staffing was two CNAs on the Generations unit during meals with twenty-something residents with behaviors. One CNA stayed in the dining room and the other went to assist Resident #5. CNA B further revealed all of the residents on the unit required redirecting at times. They were not able to provided one on one supervision and the nurse was not on the unit during meals. We had to clear the tables and we were constantly redirecting. CNA B stated they had to clean their own dining room while constantly redirecting residents and getting them ready for bed. CNA B confirmed everyone was aware of Resident #1's behavior to grab other resident's food. Review of Provider Letter No. ,[DATE] titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property, and Other Incidents that Must Be Reported to the Texas Department of Aging an Disability Services dated [DATE] revealed 2. Neglect: A certified NF must ensure that all alleged violations of neglect are reported to the NF administrator and to other officials in accordance with Texas law no later than two hours after the allegation is made, if the events that cause the allegation results in serious bodily injury.

Based on observation, interview and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan for 1 of 5 residents (Resident #3) reviewed for pain in that; The facility did not revise Resident #3's pain management plan of care when the current plan of care was not effective. Resident #3's pain level resulted in decreased mobility as she had significant pain with movement during care. This deficient practice could affect 9 residents in the 200 hall who had prn pain medication and could result in decreased quality of life. The findings were: Review of Resident #3's face sheet dated 5/17/17 revealed Resident #3 was admitted on [DATE]. Further review of the same document revealed Resident #3's [DIAGNOSES REDACTED]. Review of Resident #3's Care Plan dated 3/29/17 revealed Resident #3 had a history of [REDACTED]. Further review of the same document under interventions revealed to monitor Resident #3 for complaints of or signs and symptoms of pain, give prn medication per MD orders, monitor for effectiveness of prn medications, and notify MD/RP if medication isn't effective in relieving pain or in pain increases in frequency or intensity. Review of Resident #3's Admission MDS dated [DATE] revealed long and short-term memory loss with moderately impaired decision-making skills. Further review of the same document revealed Resident #3 had indications of pain or possible indications of pain observed 1-2 days (in the assessment look back period last 5 days). Review of Resident #3's April 2017 Consolidated Physician Orders revealed [MEDICATION NAME] 500 mg tablet give 2 tablets to equal 1000 mg by mouth three times a day for pain with a start date of 3/29/17, Tylenol 325 mg tablet give 2 tablets to equal 650 mg by mouth every 4 hours as needed for pain with a start date of 3/29/17, [MEDICATION NAME] HCL 50 mg tablet give 1 tablet by mouth every 4 hours as needed for pain with a start date of 3/30/17 and [MEDICATION NAME] HCL 50 mg tablet give 1 tablet by mouth every 8 hours as needed for pain with a start date of 3/31/17. Review of Resident #3's clinical record revealed a pain evaluation was completed on 3/28/17, 4/3/17, 4/10/17 and 5/23/17. Review of Resident #3's Pain Evaluation dated 3/28/17 revealed Resident #3 had bilateral knee pain that was sharp and frequent. Further review of this document revealed Resident #3 had facial grimacing as a nonverbal sign of pain. Further review of this same document revealed under Conclusion pain issues, changes needed. Further review of this same document revealed Resident #3's doctor was called and routine Tylenol was ordered three times a day. Review of Resident #3's Pain Evaluation dated 4/3/17 revealed facial grimacing relieved by pain medication. Further review of this same document revealed no pain, no intervention needed as the conclusion of the assessment. Review of Resident #3's Pain Evaluation dated 4/10/17 revealed under Conclusion Resident #3 had no pain, no intervention needed. Review of Resident #3's Pain Evaluation dated 5/23/17 revealed pain management is effective and that Resident is on routine pain medication. Review of Resident #3's Nursing Note dated 4/12/17 revealed Resident yelling in pain grabbing her knee prn [MEDICATION NAME] (treats pain) and [MEDICATION NAME] (treats anxiety) given, CNA states that everytime we try to change her she screams that she is hurting, will continue to monitor, call light in reach. Review of Resident #3's Controlled Drug Record revealed administration of [MEDICATION NAME] on 4/12/17 at 2:00 p.m., 6:00 p.m., and 10:00 p.m. Review of Resident #3's Nursing Notes dated 4/17/17 revealed Therapist brought her to nurses station informed me that resident stated she was in to much pain to work with her, resident was moaning and crying out it hurts lay me down, gave her prn [MEDICATION NAME] and laid her down in bed. Review of Resident #3's Physician Telephone Order with a date of 3/30/17 revealed [MEDICATION NAME] 50 mg 1 tablet by mouth every 4 hours as needed for pain. Further review of this same order revealed it was signed by Resident #3's Nurse Practitioner on 4/30/17 and included this change: every 4 hours was crossed out and every 8 hours three times a day was added and this change was initialed. Review of Resident #3's Consolidated Physician Orders for May 2017 revealed [MEDICATION NAME] 1000 mg po TID for pain with a start date of 3/29/17, Tylenol 650 mg by mouth every 4 hours prn for pain with a start date of 3/29/17, [MEDICATION NAME] 50 mg every 4 hours prn pain with a start date of 3/30/17 and [MEDICATION NAME] 50 every 8 hours prn pain with a start date of 3/31/17. Review of Resident #3's MAR for May 2017 revealed [MEDICATION NAME] 50 mg was not initialed as administered from 5/1/17-5/17/17. Further review of the same document revealed Tylenol 650 mg PRN not initialed as administered 5/1/17-5/17/17. Review of Resident #3's Controlled Drug Record for [MEDICATION NAME] 50 mg tab 1 tablet by mouth every 4 hours as needed for pain from 5/1/17-5/17/17 revealed signatures for administration of [MEDICATION NAME] from 1 to 4 times a day except for 5/3/17 and 5/9/17 when Resident #3 did not receive any dose of [MEDICATION NAME]. Observation of Resident #3 on 5/17/17 at 9:10 a.m. revealed Resident #3 was lying in bed for wound care on her feet. Resident #3 began crying, screaming, crying out with any movement of her body, particularly of her legs, feet, knees and hips. When the wound care nurse gently wiped the top of Resident #3's foot with skin prep, Resident #3 screamed in pain. Resident #3 stated she hurt all over her body. During an interview on 5/17/17 at 9:10 a.m. with LVN G, LVN G stated that Resident #3's responsible party does not like her medicated because she becomes out of it. During an interview on 5/17/17 at approximately 9:10 a.m., with Resident #3's family member, she indicated a preference for minimal use of prn pain medication. Review of Resident #3's Nursing Notes dated 5/17/17 at 2:33 p.m. revealed, PT was medicated for pain early this AM 930 with [MEDICATION NAME] 50mg with effective noted. PT C/O pain or discomfort when turning or repositioning, did call Dr. office left message re this awaiting call back (after surveyors intervention). During an interview on 5/17/17 at 2:43 p.m., CNA D revealed Resident #3 would experience pain with movement, indicating Resident #3 would cry out in pain when she moved her. Observation of resident #3 on 5/17/17 at 2:43 p.m. with the DON revealed Resident #3 began crying when CNA D told Resident #3 that she was going to reposition her. Resident #3 cried No, no, no as CNA D gently pulled on draw sheet to position for turn to left side. Resident #3 began screaming and crying as CNA D rolled Resident #3 to her left side at which point the DON walked out of the room. Review of Resident #3's Nursing Note dated 5/17/17 at 4:46 p.m. revealed, Late entry for 345PM pt c/o legs hurting [MEDICATION NAME] 50mg 1tab po was given with effectiveness now noted resting easily at present. During an interview with the DON on 5/17/17 at 2:47 p.m. and 2:56 p.m. she stated, I've seen enough. The DON confirmed a problem with Resident #3's pain control. The DON indicated Resident #3 had been medicated with prn [MEDICATION NAME], but indicated the pain medication might not be effective. The DON further indicated Resident #3's family did not want the resident heavily medicated for pain. Review of Resident #3's Nursing Note dated 5/17/17 at 4:32 p.m. revealed, Received a new order for [MEDICATION NAME] Patch 5% to bilaterl (bilateral) thighs from Dr ., family aware, want staff to utilize routine Tylenol and [MEDICATION NAME]es before giving her prn [MEDICATION NAME] . (This was after surveyor's intervention). Observation on 6/1/17 at 5:32 p.m. of Resident #3 with LVN J revealed when LVN J flexed Resident #3's right foot slightly and moved leg approximately 3-4 inches sideways on the bed Resident #3 stated no, no, no, no. LVN J stopped the movement and Resident denied pain without movement only with movement. LVN J indicated Resident #3's pain was better with the [MEDICATION NAME]es that were recently started. LVN J further indicated with the [MEDICATION NAME] and [MEDICATION NAME] given together the pain control was much better. Observation on 6/1/17 at 7:40 p.m. with LVN J of Resident #3, revealed when LVN J removed Resident #3's socks Resident #3 displayed no outward appearance of pain. LVN J lifted up Resident #3's right and left leg and Resident #3 did grimace but did not scream or cry. LVN J indicated Resident #3 had been given [MEDICATION NAME] at 4:00 p.m. When LVN J asked Resident #3 if Resident #3 had pain Resident #3 put her hand on her right hip but did not cry or grimace. LVN J further indicated Resident #3 was eating better since starting the [MEDICATION NAME]es and that Resident #3 was doing better in therapy. Observation on 6/1/17 at 8:25 p.m. of Resident #3 with CNA D revealed CNA D in Resident #3's room to do pericare and Resident #3 grimaced slightly as HOB was lowered. Resident #3 stated ow, ow, ow when CNA D very slightly abducted hips. Resident #3 placed hands on her right hip to indicate pain in hip. CNA D used the draw sheet to turn Resident #3 to left side and Resident #3 had tears in her eyes and grimace while being turned. CNA D lifted Resident #3's legs to place folded blanket beneath the ankles. Resident #3 cried out briefly and then stopped when her legs were on the bed. CNA D indicated the [MEDICATION NAME]es had made a lot of difference in pain control for the resident. CNA D indicated she had noticed a big difference for Resident #3 in the last 10 days since the [MEDICATION NAME] started. CNA D also indicated Resident #3 normally had two [MEDICATION NAME]es on, one on each leg and tonight Resident #3 only had one patch on. The [MEDICATION NAME] was observed to be on Resident #3's right inner thigh. CNA D further indicated Resident #3 was moving around a lot more now that pain was better controlled. CNA D further indicated evening shift rarely, if ever, transferred Resident #3 out of bed, as family preferred to have her up only when they were present because of pain issues. Interview on 6/2/17 at 6:41 p.m. with LVN K revealed Resident #3's pain was triggered with movement and said Resident #3 was more alert since Resident #3 had started on pain patches and was eating more and was doing better since the pain patches. Interview on 6/2/17 at 6:03 p.m. with Physician L revealed he had asked Resident #3 if she had pain and she had denied pain but he was not moving Resident #3. Physician L further indicated the facility had contacted him on 5/17/17 regarding Resident #3's pain and he did not have any other documentation of any other conversations regarding Resident #3's pain. Review of the facility policy on Pain Assessment with a revision date of 11/15 revealed Pain should be evaluated and documented when present and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is in line with the resident's established goals. Evaluate residents for pain indicators during routine interactions. If pain present, establish intensity and intervene as appropriate. Review of the information provided by the facility on 5/17/17 revealed there were 9 residents with prn pain medication on 200 hall.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent neglectfor 1 of 4 residents (Resident #3) reviewed for neglect in that; The facility did not revise Resident #3's pain management plan of care when the current plan of care was not effective. Resident #3's pain level resulted in decreased mobility as she had significant pain with movement during care. This deficient practice could affect 9 residents in the 200 hall who had prn pain medication and could result in decreased quality of life. The findings were: Review of the facility policy and procedure on Abuse Prevention Program dated November 2016 revealed Our residents have the right to be free from abuse/neglect/misappropriation of resident property/corporal punishment and involuntary seclusion. Review of the facility policy on Pain Assessment with a revision date of 11/15 revealed Pain should be evaluated and documented when present and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is in line with the resident's established goals. Evaluate residents for pain indicators during routine interactions. If pain present, establish intensity and intervene as appropriate. Review of Resident #3's face sheet dated 5/17/17 revealed Resident #3 was admitted on [DATE]. Further review of the same document revealed Resident #3's [DIAGNOSES REDACTED]. Review of Resident #3's Care Plan dated 3/29/17 revealed Resident #3 had a history of [REDACTED]. Further review of the same document under interventions revealed to monitor Resident #3 for complaints of or signs and symptoms of pain, give prn medication per MD orders, monitor for effectiveness of prn medications, and notify MD/RP if medication isn't effective in relieving pain or in pain increases in frequency or intensity. Review of Resident #3's Admission MDS dated [DATE] revealed long and short-term memory loss with moderately impaired decision-making skills. Further review of the same document revealed Resident #3 had indications of pain or possible indications of pain observed 1-2 days (in the assessment look back period last 5 days). Review of Resident #3's April 2017 Consolidated Physician Orders revealed [MEDICATION NAME] 500 mg tablet give 2 tablets to equal 1000 mg by mouth three times a day for pain with a start date of 3/29/17, Tylenol 325 mg tablet give 2 tablets to equal 650 mg by mouth every 4 hours as needed for pain with a start date of 3/29/17, [MEDICATION NAME] HCL 50 mg tablet give 1 tablet by mouth every 4 hours as needed for pain with a start date of 3/30/17 and [MEDICATION NAME] HCL 50 mg tablet give 1 tablet by mouth every 8 hours as needed for pain with a start date of 3/31/17. Review of Resident #3's clinical record revealed a pain evaluation was completed on 3/28/17, 4/3/17, 4/10/17 and 5/23/17. Review of Resident #3's Pain Evaluation dated 3/28/17 revealed Resident #3 had bilateral knee pain that was sharp and frequent. Further review of this document revealed Resident #3 had facial grimacing as a nonverbal sign of pain. Further review of this same document revealed under Conclusion pain issues, changes needed. Further review of this same document revealed Resident #3's doctor was called and routine Tylenol was ordered three times a day. Review of Resident #3's Pain Evaluation dated 4/3/17 revealed facial grimacing relieved by pain medication. Further review of this same document revealed no pain, no intervention needed as the conclusion of the assessment. Review of Resident #3's Pain Evaluation dated 4/10/17 revealed under Conclusion Resident #3 had no pain, no intervention needed. Review of Resident #3's Pain Evaluation dated 5/23/17 revealed pain management is effective and that Resident is on routine pain medication. Review of Resident #3's Nursing Note dated 4/12/17 revealed Resident yelling in pain grabbing her knee prn [MEDICATION NAME] (treats pain) and [MEDICATION NAME] (treats anxiety) given, CNA states that everytime we try to change her she screams that she is hurting, will continue to monitor, call light in reach. Review of Resident #3's Controlled Drug Record revealed administration of [MEDICATION NAME] on 4/12/17 at 2:00 p.m., 6:00 p.m., and 10:00 p.m. Review of Resident #3's Nursing Notes dated 4/17/17 revealed Therapist brought her to nurses station informed me that resident stated she was in to much pain to work with her, resident was moaning and crying out it hurts lay me down, gave her prn [MEDICATION NAME] and laid her down in bed. Review of Resident #3's Physician Telephone Order with a date of 3/30/17 revealed [MEDICATION NAME] 50 mg 1 tablet by mouth every 4 hours as needed for pain. Further review of this same order revealed it was signed by Resident #3's Nurse Practitioner on 4/30/17 and included this change: every 4 hours was crossed out and every 8 hours three times a day was added and this change was initialed. Review of Resident #3's Consolidated Physician Orders for May 2017 revealed [MEDICATION NAME] 1000 mg po TID for pain with a start date of 3/29/17, Tylenol 650 mg by mouth every 4 hours prn for pain with a start date of 3/29/17, [MEDICATION NAME] 50 mg every 4 hours prn pain with a start date of 3/30/17 and [MEDICATION NAME] 50 every 8 hours prn pain with a start date of 3/31/17. Review of Resident #3's MAR for May 2017 revealed [MEDICATION NAME] 50 mg was not initialed as administered from 5/1/17-5/17/17. Further review of the same document revealed Tylenol 650 mg PRN not initialed as administered 5/1/17-5/17/17. Review of Resident #3's Controlled Drug Record for [MEDICATION NAME] 50 mg tab 1 tablet by mouth every 4 hours as needed for pain from 5/1/17-5/17/17 revealed signatures for administration of [MEDICATION NAME] from 1 to 4 times a day except for 5/3/17 and 5/9/17 when Resident #3 did not receive any dose of [MEDICATION NAME]. Observation of Resident #3 on 5/17/17 at 9:10 a.m. revealed Resident #3 was lying in bed for wound care on her feet. Resident #3 began crying, screaming, crying out with any movement of her body, particularly of her legs, feet, knees and hips. When the wound care nurse gently wiped the top of Resident #3's foot with skin prep, Resident #3 screamed in pain. Resident #3 stated she hurt all over her body. During an interview on 5/17/17 at 9:10 a.m. with LVN G, LVN G stated that Resident #3's responsible party does not like her medicated because she becomes out of it. During an interview on 5/17/17 at approximately 9:10 a.m., with Resident #3's family member, she indicated a preference for minimal use of prn pain medication. Review of Resident #3's Nursing Notes dated 5/17/17 at 2:33 p.m. revealed, PT was medicated for pain early this AM 930 with [MEDICATION NAME] 50mg with effective noted. PT C/O pain or discomfort when turning or repositioning, did call Dr. office left message re this awaiting call back (after surveyors intervention). During an interview on 5/17/17 at 2:43 p.m., CNA D revealed Resident #3 would experience pain with movement, indicating Resident #3 would cry out in pain when she moved her. Observation of resident #3 on 5/17/17 at 2:43 p.m. with the DON revealed Resident #3 began crying when CNA D told Resident #3 that she was going to reposition her. Resident #3 cried No, no, no as CNA D gently pulled on draw sheet to position for turn to left side. Resident #3 began screaming and crying as CNA D rolled Resident #3 to her left side at which point the DON walked out of the room. Review of Resident #3's Nursing Note dated 5/17/17 at 4:46 p.m. revealed, Late entry for 345PM pt c/o legs hurting [MEDICATION NAME] 50mg 1tab po was given with effectiveness now noted resting easily at present. During an interview with the DON on 5/17/17 at 2:47 p.m. and 2:56 p.m. she stated, I've seen enough. The DON confirmed a problem with Resident #3's pain control. The DON indicated Resident #3 had been medicated with prn [MEDICATION NAME], but indicated the pain medication might not be effective. The DON further indicated Resident #3's family did not want the resident heavily medicated for pain. Review of Resident #3's Nursing Note dated 5/17/17 at 4:32 p.m. revealed, Received a new order for [MEDICATION NAME] Patch 5% to bilaterl (bilateral) thighs from Dr ., family aware, want staff to utilize routine Tylenol and [MEDICATION NAME]es before giving her prn [MEDICATION NAME] . (This was after surveyor's intervention). Observation on 6/1/17 at 5:32 p.m. of Resident #3 with LVN J revealed when LVN J flexed Resident #3's right foot slightly and moved leg approximately 3-4 inches sideways on the bed Resident #3 stated no, no, no, no. LVN J stopped the movement and Resident denied pain without movement only with movement. LVN J indicated Resident #3's pain was better with the [MEDICATION NAME]es that were recently started. LVN J further indicated with the [MEDICATION NAME] and [MEDICATION NAME] given together the pain control was much better. Observation on 6/1/17 at 7:40 p.m. with LVN J of Resident #3, revealed when LVN J removed Resident #3's socks Resident #3 displayed no outward appearance of pain. LVN J lifted up Resident #3's right and left leg and Resident #3 did grimace but did not scream or cry. LVN J indicated Resident #3 had been given [MEDICATION NAME] at 4:00 p.m. When LVN J asked Resident #3 if Resident #3 had pain Resident #3 put her hand on her right hip but did not cry or grimace. LVN J further indicated Resident #3 was eating better since starting the [MEDICATION NAME]es and that Resident #3 was doing better in therapy. Observation on 6/1/17 at 8:25 p.m. of Resident #3 with CNA D revealed CNA D in Resident #3's room to do pericare and Resident #3 grimaced slightly as HOB was lowered. Resident #3 stated ow, ow, ow when CNA D very slightly abducted hips. Resident #3 placed hands on her right hip to indicate pain in hip. CNA D used the draw sheet to turn Resident #3 to left side and Resident #3 had tears in her eyes and grimace while being turned. CNA D lifted Resident #3's legs to place folded blanket beneath the ankles. Resident #3 cried out briefly and then stopped when her legs were on the bed. CNA D indicated the [MEDICATION NAME]es had made a lot of difference in pain control for the resident. CNA D indicated she had noticed a big difference for Resident #3 in the last 10 days since the [MEDICATION NAME] started. CNA D also indicated Resident #3 normally had two [MEDICATION NAME]es on, one on each leg and tonight Resident #3 only had one patch on. The [MEDICATION NAME] was observed to be on Resident #3's right inner thigh. CNA D further indicated Resident #3 was moving around a lot more now that pain was better controlled. CNA D further indicated evening shift rarely, if ever, transferred Resident #3 out of bed, as family preferred to have her up only when they were present because of pain issues. Interview on 6/2/17 at 6:41 p.m. with LVN K revealed Resident #3's pain was triggered with movement and said Resident #3 was more alert since Resident #3 had started on pain patches and was eating more and was doing better since the pain patches. Interview on 6/2/17 at 6:03 p.m. with Physician L revealed he had asked Resident #3 if she had pain and she had denied pain but he was not moving Resident #3. Physician L further indicated the facility had contacted him on 5/17/17 regarding Resident #3's pain and he did not have any other documentation of any other conversations regarding Resident #3's pain. Review of the information provided by the facility on 5/17/17 revealed there were 9 residents with prn pain medication on 200 hall.

Based on observation, interview and record review the facility failed to ensure residents have the right to be free from neglect for 1 of 4 residents (Resident #3) reviewed for neglect in that; The facility did not revise Resident #3's pain management plan of care when the current plan of care was not effective. Resident #3's pain level resulted in decreased mobility as she had significant pain with movement during care. This deficient practice could affect 9 residents in the 200 hall who had prn pain medication and could result in decreased quality of life. The findings were: Review of Resident #3's face sheet dated 5/17/17 revealed Resident #3 was admitted on [DATE]. Further review of the same document revealed Resident #3's [DIAGNOSES REDACTED]. Review of Resident #3's Care Plan dated 3/29/17 revealed Resident #3 had a history of [REDACTED]. Further review of the same document under interventions revealed to monitor Resident #3 for complaints of or signs and symptoms of pain, give prn medication per MD orders, monitor for effectiveness of prn medications, and notify MD/RP if medication isn't effective in relieving pain or in pain increases in frequency or intensity. Review of Resident #3's Admission MDS dated [DATE] revealed long and short-term memory loss with moderately impaired decision-making skills. Further review of the same document revealed Resident #3 had indications of pain or possible indications of pain observed 1-2 days (in the assessment look back period last 5 days). Review of Resident #3's April 2017 Consolidated Physician Orders revealed [MEDICATION NAME] 500 mg tablet give 2 tablets to equal 1000 mg by mouth three times a day for pain with a start date of 3/29/17, Tylenol 325 mg tablet give 2 tablets to equal 650 mg by mouth every 4 hours as needed for pain with a start date of 3/29/17, [MEDICATION NAME] HCL 50 mg tablet give 1 tablet by mouth every 4 hours as needed for pain with a start date of 3/30/17 and [MEDICATION NAME] HCL 50 mg tablet give 1 tablet by mouth every 8 hours as needed for pain with a start date of 3/31/17. Review of Resident #3's clinical record revealed a pain evaluation was completed on 3/28/17, 4/3/17, 4/10/17 and 5/23/17. Review of Resident #3's Pain Evaluation dated 3/28/17 revealed Resident #3 had bilateral knee pain that was sharp and frequent. Further review of this document revealed Resident #3 had facial grimacing as a nonverbal sign of pain. Further review of this same document revealed under Conclusion pain issues, changes needed. Further review of this same document revealed Resident #3's doctor was called and routine Tylenol was ordered three times a day. Review of Resident #3's Pain Evaluation dated 4/3/17 revealed facial grimacing relieved by pain medication. Further review of this same document revealed no pain, no intervention needed as the conclusion of the assessment. Review of Resident #3's Pain Evaluation dated 4/10/17 revealed under Conclusion Resident #3 had no pain, no intervention needed. Review of Resident #3's Pain Evaluation dated 5/23/17 revealed pain management is effective and that Resident is on routine pain medication. Review of Resident #3's Nursing Note dated 4/12/17 revealed Resident yelling in pain grabbing her knee prn [MEDICATION NAME] (treats pain) and [MEDICATION NAME] (treats anxiety) given, CNA states that everytime we try to change her she screams that she is hurting, will continue to monitor, call light in reach. Review of Resident #3's Controlled Drug Record revealed administration of [MEDICATION NAME] on 4/12/17 at 2:00 p.m., 6:00 p.m., and 10:00 p.m. Review of Resident #3's Nursing Notes dated 4/17/17 revealed Therapist brought her to nurses station informed me that resident stated she was in to much pain to work with her, resident was moaning and crying out it hurts lay me down, gave her prn [MEDICATION NAME] and laid her down in bed. Review of Resident #3's Physician Telephone Order with a date of 3/30/17 revealed [MEDICATION NAME] 50 mg 1 tablet by mouth every 4 hours as needed for pain. Further review of this same order revealed it was signed by Resident #3's Nurse Practitioner on 4/30/17 and included this change: every 4 hours was crossed out and every 8 hours three times a day was added and this change was initialed. Review of Resident #3's Consolidated Physician Orders for May 2017 revealed [MEDICATION NAME] 1000 mg po TID for pain with a start date of 3/29/17, Tylenol 650 mg by mouth every 4 hours prn for pain with a start date of 3/29/17, [MEDICATION NAME] 50 mg every 4 hours prn pain with a start date of 3/30/17 and [MEDICATION NAME] 50 every 8 hours prn pain with a start date of 3/31/17. Review of Resident #3's MAR for May 2017 revealed [MEDICATION NAME] 50 mg was not initialed as administered from 5/1/17-5/17/17. Further review of the same document revealed Tylenol 650 mg PRN not initialed as administered 5/1/17-5/17/17. Review of Resident #3's Controlled Drug Record for [MEDICATION NAME] 50 mg tab 1 tablet by mouth every 4 hours as needed for pain from 5/1/17-5/17/17 revealed signatures for administration of [MEDICATION NAME] from 1 to 4 times a day except for 5/3/17 and 5/9/17 when Resident #3 did not receive any dose of [MEDICATION NAME]. Observation of Resident #3 on 5/17/17 at 9:10 a.m. revealed Resident #3 was lying in bed for wound care on her feet. Resident #3 began crying, screaming, crying out with any movement of her body, particularly of her legs, feet, knees and hips. When the wound care nurse gently wiped the top of Resident #3's foot with skin prep, Resident #3 screamed in pain. Resident #3 stated she hurt all over her body. During an interview on 5/17/17 at 9:10 a.m. with LVN G, LVN G stated that Resident #3's responsible party does not like her medicated because she becomes out of it. During an interview on 5/17/17 at approximately 9:10 a.m., with Resident #3's family member, she indicated a preference for minimal use of prn pain medication. Review of Resident #3's Nursing Notes dated 5/17/17 at 2:33 p.m. revealed, PT was medicated for pain early this AM 930 with [MEDICATION NAME] 50mg with effective noted. PT C/O pain or discomfort when turning or repositioning, did call Dr. office left message re this awaiting call back (after surveyors intervention). During an interview on 5/17/17 at 2:43 p.m., CNA D revealed Resident #3 would experience pain with movement, indicating Resident #3 would cry out in pain when she moved her. Observation of resident #3 on 5/17/17 at 2:43 p.m. with the DON revealed Resident #3 began crying when CNA D told Resident #3 that she was going to reposition her. Resident #3 cried No, no, no as CNA D gently pulled on draw sheet to position for turn to left side. Resident #3 began screaming and crying as CNA D rolled Resident #3 to her left side at which point the DON walked out of the room. Review of Resident #3's Nursing Note dated 5/17/17 at 4:46 p.m. revealed, Late entry for 345PM pt c/o legs hurting [MEDICATION NAME] 50mg 1tab po was given with effectiveness now noted resting easily at present. During an interview with the DON on 5/17/17 at 2:47 p.m. and 2:56 p.m. she stated, I've seen enough. The DON confirmed a problem with Resident #3's pain control. The DON indicated Resident #3 had been medicated with prn [MEDICATION NAME], but indicated the pain medication might not be effective. The DON further indicated Resident #3's family did not want the resident heavily medicated for pain. Review of Resident #3's Nursing Note dated 5/17/17 at 4:32 p.m. revealed, Received a new order for [MEDICATION NAME] Patch 5% to bilaterl (bilateral) thighs from Dr ., family aware, want staff to utilize routine Tylenol and [MEDICATION NAME]es before giving her prn [MEDICATION NAME] . (This was after surveyor's intervention). Observation on 6/1/17 at 5:32 p.m. of Resident #3 with LVN J revealed when LVN J flexed Resident #3's right foot slightly and moved leg approximately 3-4 inches sideways on the bed Resident #3 stated no, no, no, no. LVN J stopped the movement and Resident denied pain without movement only with movement. LVN J indicated Resident #3's pain was better with the [MEDICATION NAME]es that were recently started. LVN J further indicated with the [MEDICATION NAME] and [MEDICATION NAME] given together the pain control was much better. Observation on 6/1/17 at 7:40 p.m. with LVN J of Resident #3, revealed when LVN J removed Resident #3's socks Resident #3 displayed no outward appearance of pain. LVN J lifted up Resident #3's right and left leg and Resident #3 did grimace but did not scream or cry. LVN J indicated Resident #3 had been given [MEDICATION NAME] at 4:00 p.m. When LVN J asked Resident #3 if Resident #3 had pain Resident #3 put her hand on her right hip but did not cry or grimace. LVN J further indicated Resident #3 was eating better since starting the [MEDICATION NAME]es and that Resident #3 was doing better in therapy. Observation on 6/1/17 at 8:25 p.m. of Resident #3 with CNA D revealed CNA D in Resident #3's room to do pericare and Resident #3 grimaced slightly as HOB was lowered. Resident #3 stated ow, ow, ow when CNA D very slightly abducted hips. Resident #3 placed hands on her right hip to indicate pain in hip. CNA D used the draw sheet to turn Resident #3 to left side and Resident #3 had tears in her eyes and grimace while being turned. CNA D lifted Resident #3's legs to place folded blanket beneath the ankles. Resident #3 cried out briefly and then stopped when her legs were on the bed. CNA D indicated the [MEDICATION NAME]es had made a lot of difference in pain control for the resident. CNA D indicated she had noticed a big difference for Resident #3 in the last 10 days since the [MEDICATION NAME] started. CNA D also indicated Resident #3 normally had two [MEDICATION NAME]es on, one on each leg and tonight Resident #3 only had one patch on. The [MEDICATION NAME] was observed to be on Resident #3's right inner thigh. CNA D further indicated Resident #3 was moving around a lot more now that pain was better controlled. CNA D further indicated evening shift rarely, if ever, transferred Resident #3 out of bed, as family preferred to have her up only when they were present because of pain issues. Interview on 6/2/17 at 6:41 p.m. with LVN K revealed Resident #3's pain was triggered with movement and said Resident #3 was more alert since Resident #3 had started on pain patches and was eating more and was doing better since the pain patches. Interview on 6/2/17 at 6:03 p.m. with Physician L revealed he had asked Resident #3 if she had pain and she had denied pain but he was not moving Resident #3. Physician L further indicated the facility had contacted him on 5/17/17 regarding Resident #3's pain and he did not have any other documentation of any other conversations regarding Resident #3's pain. Review of the facility policy on Pain Assessment with a revision date of 11/15 revealed Pain should be evaluated and documented when present and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is in line with the resident's established goals. Evaluate residents for pain indicators during routine interactions. If pain present, establish intensity and intervene as appropriate. Review of the facility policy and procedure on Abuse Prevention Program dated November 2016 revealed Our residents have the right to be free from abuse/neglect/misappropriation of resident property/corporal punishment and involuntary seclusion. Review of the information provided by the facility on 5/17/17 revealed there were 9 residents with prn pain medication on 200 hall.