Every finding on record at Woodlands Rehabilitation and Healthcare Center

Based on interview, record review, and facility policy review, the facility failed to implement physician ordered treatments for one (1) of eight (8) residents sampled residents. Resident #2.Findings include:A record review of the facility policy titled Medication Orders, revised 11/2014, revealed the purpose of the procedure is to establish uniform guidelines for receiving and recording all medication and treatment orders. The policy further revealed treatment orders are to specify the treatment, frequency, and duration of the treatment.On 7/1/26 at 12:52 PM, during a phone interview, Resident #2's Patient Advocate stated Resident #2 never received ice to her surgical site during her stay despite being instructed it was to be provided following surgery.On 7/1/26 at 1:35 PM, during an interview, the Director of Nursing (DON) stated medical records staff enter hospital discharge orders into the electronic medical record and the admitting nurse reviews the orders.On 7/1/26 at 2:30 PM, during an interview, Licensed Practical Nurse #1 stated she enters hospital discharge medication orders into the system but wound care orders are entered by the treatment nurse or admitting nurse.On 7/1/26 at 2:36 PM, during an interview, Registered Nurse #1 stated medical records staff enter medication orders and the wound care nurse enters treatment orders.On 7/1/26 at 2:50 PM, during an interview, the DON confirmed the physician order for ice therapy had been missed and should have been entered into the system. She acknowledged the omission could result in postoperative discomfort at the surgical site and stated staff are expected to provide quality care to all residents.A record review of the hospital discharge orders dated 6/5/26 revealed an order, Ice to the operative area 20 minutes on then 20 minutes off as needed for post-operative swelling and pain. A record review of Resident #2's June 2026 electronic Treatment Record (TAR), June 2026 electronic Medication Administration Record (MAR), and Order Summary Report with active orders as of 6/5/26 revealed the physician ordered ice treatment was not entered into the facility's TAR, MAR or on the physician orders.A record review of Resident #2's admission Record revealed an admission date of 6/5/26 with diagnoses including aftercare following joint replacement surgery and presence of a right artificial knee joint.Record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 6/10/26 revealed a Brief Interview for Mental Status (BIMS) score of (15) indicating the resident was cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to provide appropriate perineal care by thoroughly cleansing the perineal area following an incontinent episode for one (1) of three (3) residents observed receiving incontinent care. Resident #6.Findings include:A record review of the facility policy titled Perineal Care, revised 3/3/26, revealed the purpose of the procedure is to provide cleanliness and comfort, prevent infection and skin irritation, and observe the resident's skin condition. The policy further revealed that for female residents staff are to separate the labia and cleanse from front to back.On 7/1/26 at 9:40 AM, Certified Nursing Assistant (CNA) #1 was observed providing incontinent care to Resident #6. The resident's brief contained feces. CNA #1 cleansed the perineal area multiple times but did not separate the labia while cleansing. After completing care and applying a clean brief, the State Agency staff requested the CNA reassess the resident's cleanliness. Upon removal of the clean brief, feces remained on the resident's vaginal and anal areas. CNA #1 required six additional cleansing wipes before the perineal area was free of fecal material.On 7/1/26 at 9:56 AM, during an interview, CNA #1 confirmed feces remained on the resident after she completed incontinent care. She stated, I guess I did not wipe good enough. She acknowledged the resident could develop skin irritation, pressure injuries, or a urinary tract infection if feces remained on the skin and confirmed she should have continued cleansing until the wipes were free of fecal material.On 7/1/26 at 3:00 PM, during an interview, the Director of Nursing confirmed CNA #1 should have continued cleansing until no fecal material remained on the wipes. She stated leaving feces on the resident's skin could result in skin breakdown and confirmed staff are expected to provide quality care to all residents.A record review of Resident #6's admission Record revealed an admission date of 11/13/24 with diagnoses including vascular dementia, anxiety, and dysphagia.A record review of Resident #6's Minimum Data Set with an Assessment Reference Date of 4/20/26 revealed a Brief Interview for Mental Status (BIMS) score of six (6), indicating severe cognitive impairment. Section GG revealed the resident was dependent on staff for personal hygiene.

Based on observation, interview, record review, and skills checklist review the facility failed to ensure a call light was maintained within reach for one (1) of three (3) residents. Resident #2.Findings Included:Record review of the facility policy document titled, Skills Checklist: Feeding a Resident (undated) revealed Procedure Step 21 Leaves call light within resident's reach . The facility was unable to provide a call light policy.On 4/28/26 at 2:15 PM, observation and interview revealed Resident #2 was awake and resting in bed with his lunch tray on the over the bed table in front of him. The resident's call light was lying on the floor under the head of his bed. He stated that he could use his call light but did not know where it was.On 4/29/26 at 12:00 PM, observation revealed that Resident #2 was resting in bed with his lunch tray on the over the bed table in front of him. The resident's call light was behind the head of his bed, hanging behind the mattress and out of the resident's sight and reach. He stated that he could use her call light but did not know where it was. The Director of Nurses (DON) retrieved the call light and placed it within reach of the resident.On 4/29/26 at 2:15 PM, during an interview Certified Nursing Assistant (CNA) #1 said that call lights were to be within the reach of residents. She confirmed that she had received in-service training and passed competency checked off on regarding feeding/serving resident meals and leaving their call lights within reach. On 4/29/26 at 3:00 PM, an interview with CNA #2 confirmed that call lights were to be within the reach of residents and that the facility provided in-service training on resident rights and call lights at least monthly. During an interview on 4/29/26 at 3:15 PM, Licensed Practical Nurse (LPN) #1 stated nurses make rounds throughout the day and use direct observation to ensure call lights are answered in a timely manner, which requires call lights to be within the reach of residents. On 4/29/26 at 3:12 PM, an interview with the DON revealed that she expected call lights to be left within reach of residents and answered in a timely manner. She confirmed that Resident #2 was unable to find or reach his call light at 12:00 PM on 4/29/26.During an interview on 4/29/26 at 4:10 PM, the Administrator stated she expects call lights to be left within the reach of residents and answered in a timely manner. She confirmed the facility does not have a specific policy regarding call light placement. Record review of the admission Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included epilepsy, infection of the skin and subcutaneous tissue, open wound of left upper arm, and gastrostomy status.Record review of the Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 3/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 11, which revealed moderate cognitive impairment.

Based on observation, record review, facility policy review, and interviews the facility failed to provide treatment and care in accordance with professional standards of practice to prevent urinary tract infections for one (1) of three (3) sampled residents who required incontinent care. Resident #2Findings Included:Record review of the facility policy/procedure titled, Peri Care-Incontinent Care with revision Date 1-2023 (January 2023) revealed the procedure stated, FOR MALE RESIDENTS: For a male resident: a. Wet washcloth/cleaning wipes and apply soap or skin cleansing agent. b. Wash perineal area starting with urethra and working outward.c. Retract foreskin of the uncircumcised male. d. Wash and rinse urethral area using a circular motion. e. Continue to wash the perineal area including the penis, scrotum, and inner thighs. F. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth/cleaning wipes. G. Gently dry perineum following same sequence.On 4/28/26 at 12:55 PM, observation revealed Certified Nursing Assistant (CNA) #1 provided incontinent care for Resident #2. CNA #1 removed Resident #2's wet brief, assisted the resident to turn onto his right side, loosened the fitted sheet, tucked the sheet under the resident, replaced the fitted sheet with a clean one on the left side of his bed, walked to the right side of the bed, assisted him to turn onto his left side and adjusted and secured the fitted sheet and replaced his incontinent brief with a clean, dry brief without cleansing the resident's perineal area front or back. On 4/29/26 at 2:15 PM, during an interview CNA #1 confirmed that she was aware and had completed in-service training and competency check offs for perineal cleansing during incontinent care. She confirmed that on 4/28/26 at 12:55 PM she provided incontinent care for Resident #2, whose incontinence brief was wet with urine, without cleansing his perineal area. She stated that she was nervous but had received training and knew that she was supposed to cleanse the resident's perineal area in addition to replacing his wet brief with a dry one. On 4/29/26 at 3:00 PM, during an interview CNA#2, (the CNA Supervisor and Schedular) revealed she provided in-service training upon hire and during orientation and competency checks-offs for new CNAs and employees during orientation and then annually to ensure skills competency using the Peri- care/ Incontinent Care Skills Checklist. She confirmed that the procedure for incontinent care included cleansing the perineal area, front and back in addition to removal of wet briefs and replacement with a clean dry brief. On 4/29/26 at 2:45 PM, an interview with Licensed Practical Nurse (LPN) #1 confirmed that nursing staff received in-service training using the Peri Care-Incontinent Care Skills Checklist. She confirmed that incontinent care included cleansing the perineal area, front and back. On 4/29/26 at 3:12 PM, during an interview the Director of Nursing (DON) stated the facility provided in-service training that included provision of incontinent care and toileting hygiene for all incontinent residents as needed with orientation and annual competency check offs for CNA s. She confirmed that incontinent care included cleansing the perineal area, front and back. On 4/29/26 at 4:10 PM, an interview with the Administrator revealed that she expected CNA s to provide cleansing the perineal area, front and back along with brief changes for incontinent care.Record review of the admission Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included epilepsy, infection of the skin and subcutaneous tissue, open wound of left upper arm, and gastrostomy status.Record review of the Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 3/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 11, which revealed moderate cognitive impairment. Section GG revealed the facility assessed Resident #2 was dependent for toilet hygiene.

Based on observation, interview, record review, and facility policy review the facility failed to ensure residents were treated with respect and dignity during the provision of care for two (2) of three (3) sampled residents. Resident #2 and Resident #3. Findings Included:Record review of the facility policy, Nursing Facility Resident Rights dated 3/06/26 revealed, The following rights are guaranteed to residents.To be treated with dignity, courtesy and respect.To privacy during personal care, visits, and phone calls .Record review of the facility document titled, Skills Checklist: Feeding a Resident (undated) revealed Procedure Step 11. Stated, Sits facing resident. Sits at resident's eye level. Sits on the stronger side if resident has one-sided weakness. Record review of the facility document titled, Peri care-Incontinent Care revised 1-2023 revealed the procedure indicated .Provide privacy (draw curtain from foot of bed to side up to wall, pull window curtain) .Resident #2On 4/28/26 at 12:55 PM, during an observation Certified Nursing Assistant (CNA) #1 provided incontinent care for Resident #2 without closing the door to the resident's room and with the privacy curtain partially drawn. The State Agency (SA) was at the bottom right corner of the resident's bed and able to see out into the hallway and watch the procedure during which the resident was uncovered and exposed.On 4/29/26 at 2:15 PM, during an interview CNA#1 confirmed that she was aware that assistance with incontinence care required provision of privacy and that she had received training from the facility and passed a competency check-off for incontinent care that included provision of privacy. She confirmed that in-service training included provision of privacy for respectful care and dignity which was each resident's right. On 4/29/26 at 2:15 PM, during an interview CNA#1 confirmed that she was aware that assistance with incontinence care required provision of privacy and that she had received training from the facility and passed a competency check-off for incontinence care that included provision of privacy. She confirmed that in-service training included provision of privacy for respectful care and dignity which was each resident's right. Record review of the admission Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included epilepsy, infection of the skin and subcutaneous tissue, open wound of left upper arm, and gastrostomy status. Record review of the admission Record for Resident #2 revealed the facility admitted him on 12/11/23 and he had diagnoses of epilepsy, infection of the skin and subcutaneous tissue, open wound of left upper arm, and gastrostomy status.Record review of the Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 3/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 11, which revealed moderate cognitive impairment. Section GG revealed the facility assessed Resident #2 was dependent for toilet hygiene.Resident #3On 4/29/26 at 12:15 PM, during an observation CNA #3 assisted Resident #3 to eat lunch while standing over the resident. The Director of Nursing (DON) instructed CNA #3 that staff were to sit next to residents while assisting with eating. On 4/29/26 at 12:20 PM, during an interview CNA #3 revealed that she forgot to sit beside the resident while assisting with eating.On 4/29/26 at 3:00 PM, during an interview CNA #2 revealed that she was the CNA Supervisor and Scheduler and provided orientation and competency checks-offs for new CNAs and would observe the new CNA s to complete the skills check offs ensure competency during orientation and at least annually using the Skills Checklist: Feeding a Resident and the Peri care-Incontinent Care Skills Checklist. She confirmed that nursing staff (nurses and CNAs) received in-service training on residents' rights and treating residents and providing care in a respectful and dignified manner at least monthly. CNA#2 confirmed that provided training included provision of privacy for incontinent care and that staff were to sit beside residents while assisting with eating to provide respectful and dignified care.On 4/29/26 at 2:45 PM, during an interview with Licensed Practical Nurse (LPN)#1, confirmed that nursing staff (nurses and CNA s) received in-service training on residents rights and treating residents and providing care in a respectful and dignified manner at least monthly and that CNAs competency was assessed through competency checks during orientation upon hire and annually using the Skills Checklist: Feeding a Resident and the Peri care-Incontinent Care Skills Checklist (among others that addressed specific skills/procedures). She confirmed that in-service training, resident rights and competency check offs included ensuring respectful care during each procedure and resident interaction, which included provision of privacy, especially for any procedure that involved exposure of residents and sitting beside residents while assisting them to eat.On 4/29/26 at 3:12 PM, during an interview the Director of Nursing (DON) stated the facility provided in-service training that included provision of privacy for all procedures that involved exposure of residents and sitting next to residents while assisting with eating to ensure respectful and dignified care in accordance with Residents' Rights. She confirmed that she observed CNA #2 standing over Resident #3 while assisting her to eat lunch on 4/29/26. On 4/29/26 at 4:10 PM, during an interview with the Administrator revealed that she expected call lights to be left within reach of residents and answered in a timely manner. She confirmed that she expected residents' rights to be protected and promoted for all residents as instructed through monthly facility provided in-service training. She confirmed that the Residents' Rights to dignified and respectful treatment included staff be seated while assisting residents to eat and provision of privacy for incontinence care. Record review of the admission Record for Resident #3 revealed the facility admitted the resident on 4/27/26 and she had diagnoses of cerebral infarction (stroke), anemia, hemiplegia and hemiparesis affecting right dominant side.Record review of the Baseline Care Plan for Resident #3 revealed .A.1. Eating.01 Dependent.

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain an infection prevention and control program to help prevent the possible development and transmission of communicable diseases and infections for three (3) of 26 sampled residents, as evidenced by failing to conduct hand hygiene between glove changes (Resident #5 and Resident #115) and failing to adhere to Enhanced Barrier Precautions (EBP) during care (Resident #32).Findings Include: Review of the facility’s policy, “Infection Prevention and Control Program” with a revision date of 6/30/25 revealed “Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection…” Review of the facility’s “Non-Sterile Dressing Change Skills Checklist”, dated 6/27/25, revealed, “…Step 10 Remove gloves, place in plastic bag Step 11 Wash hands (or hand sanitizer) & put on gloves…” Review of the facility’s “Handwashing/Hand Hygiene Residents” with a revision date of 6/30/25 revealed “Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections…” Review of the facility’s “Enhanced Barrier Precaution” dated 6/30/25 revealed, “… EBP refer to infection control interventions designed to reduce transmission of multidrug-resistant organism that employ targeted gown, and gloves use during high contact residents care activities…” Resident # 5 On 8/13/25 at 1:03 PM, during an observation of wound care for Resident #5’s left foot, Registered Nurse (RN) #3 removed and changed gloves a total of five (5) times throughout the procedure without performing hand hygiene between glove changes. On 8/13/25 at 1:23 PM, during an interview with Registered Nurse (RN) #3, he explained that he was not aware hand hygiene should be performed between glove changes. He acknowledged that failing to do so was an infection control issue with the potential to spread infection to Resident #5’s wound. He further stated that he had previously received training on infection control. On 8/13/25 at 5:10 PM, during an interview with the Director of Nursing (DON), she explained that Registered Nurse (RN) #3 should have performed hand hygiene with either soap and water or hand sanitizer between each glove change. She stated that by not doing so, RN #3 placed the resident at risk for infection during wound care. A record review of the admission Record revealed the facility admitted Resident #5 on 5/30/23 with current diagnoses including Pressure Ulcers. A record review of the “Order Summary Report” revealed Resident #5 had a Physician’s Order, dated 8/7/25, for wound care to the 5th toe on the left foot. A record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/4/25 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Resident # 115 On 08/13/2025 at 1:58 PM, in an observation of Resident #115 receiving perineal care by Certified Nursing Assistant (CNA) #2, the CNA applied gloves but did not place a gown on. She removed the front of the resident’s brief, which was heavily soiled, and then used pre moistened perineal wipes from a package, pulling out two to three wipes at a time while continuing to wear dirty gloves. Throughout the care, she removed soiled gloves and applied clean gloves a total of four times but never performed hand hygiene with soap and water or hand sanitizer between glove changes. There was signage on the resident’s door indicating Enhanced Barrier Precautions. On 08/13/2025 at 2:16 PM, in an interview with Certified Nursing Assistant (CNA) #2, she confirmed she did not wear a gown while providing perineal care and did not perform hand hygiene during the care for Resident #115. She stated she was supposed to apply a gown before starting perineal care. She acknowledged she forgot to wash her hands and apply a gown. She explained she had received training on hand hygiene and Enhanced Barrier Precautions. She stated she also forgot to place a barrier on the table and to remove all needed wipes from the package before starting care. She acknowledged she was not supposed to pull wipes out of the package with dirty gloves on. She stated Resident #115 was placed at risk for infection due to her not following Enhanced Barrier Precautions, not performing hand hygiene, and pulling wipes out of the package with contaminated gloves. On 08/13/2025 at 5:13 PM, in an interview with the Director of Nursing (DON), she explained that CNA #2 should have placed a barrier on the table and gathered all needed supplies, including pulling wipes out of package, before beginning care for Resident #115. She stated the CNA should have washed her hands and donned (put on) a gown prior to starting perineal care. She further stated that CNA #2 placed the residents at risk of infection by not following the facility’s Enhanced Barrier Precautions policy during care. Record review of the “admission Record” revealed the facility admitted Resident #115 on 9/29/20 with diagnosis including of Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease. Record review of the Comprehensive Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/24/25 revealed Resident #115 had a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Resident #32 On 8/13/2025 at 9:00 AM, during an observation of Percutaneous Endoscopic Gastrostomy (PEG) site care performed by Licensed Practical Nurse (LPN) #2, a protective gown was not worn during the procedure. A record review of the “admission Record” revealed the facility admitted Resident #32 on 3/13/20 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction. A record review of the Quarterly MDS with an ARD of 5/11/25, revealed Resident #32 had a BIMS of 00, which indicated severe cognitive impairment. A record review of the “Order Details” revealed a physician’s order, dated 7/29/24, for PEG site care. On 8/13/2025 at 3:15 PM, during an interview with the Director of Nursing (DON) with the Administrator present, the DON confirmed that a gown should be worn during care identified for EBP and stated she would conduct additional staff training. On 8/13/2025 at 4:02 PM, during an interview, LPN #2 acknowledged that she did not wear a gown during the procedures and agreed this was an infection control issue.

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain a medication error rate below five (5) percent (%), for two (2) of 31 medication opportunities observed, resulting in a 6.45 % medication error rate. Included was Resident #3, who was not instructed to rinse with water following administration of a steroid inhaler, and Resident #141, for whom the nurse prepared an incorrect dosage of Thiamine.Findings include:Record review of facility Medication Administration policy, reviewed and revised June 2025, revealed Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident right, right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #3On 8/13/2025 at 8:33 AM, during an observation of medication administration, Licensed Practical Nurse (LPN) # 5 administered Symbicort Inhalation Aerosol to Resident #3. LPN #5 did not rinse Resident #3's mouth after administering the inhalation medication. LPN# 5 explained that she forgot and acknowledged that mouth rinsing should occur because it can cause thrush, and reported she would go back and do it.On 8/12/2025 at 11:30 AM, during an interview with the Director of Nursing (DON), explained that a resident's mouth should be rinsed with water following administration of an inhaled corticosteroid, such as Symbicort, to prevent oral thrush.A record review of Order Summary Report with active orders as of 8/14/25 revealed an order dated 7/18/25 Symbicort Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate), two (2) puffs inhaled orally every morning and at bedtime for wheezing.A record review of the admission Record for Resident #3 revealed the facility admitted the resident on 7/18/2025 with diagnoses that included Toxic Encephalopathy.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/2025 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of (14), indicating the resident was cognitively intact.A record review of the Quick Guide to Using Your Symbicort Inhaler, dated 2018, revealed, .After you finish taking Symbicort.rinse your mouth with water. Spit out the water.Resident #141On 8/12/2025 at 8:14 AM, during an observation of medication administration, LPN #6 prepared medications for Resident #141. She prepared Thiamine 100 mg and placed it in the medication cup with the resident's other medications to be administered. The resident's physician orders indicated the correct dosage as Thiamine 50 mg. On 8/12/2025 at 8:30 AM, during an interview with LPN #6, she confirmed she intended to administer the medications to Resident #141, however, when she reviewed the Thiamine medication label, she confirmed the dosage was listed as Thiamine 100 milligrams (mg). She removed the 100 mg tablet and explained that it was what they had available.On 8/12/2025 at 10:15 AM, during an interview the DON, explained that administering an incorrect dose could result in negative outcomes and that medications must be administered in accordance with physician orders. A record review of the admission Record revealed the facility admitted Resident #141 on 8/5/2025 with diagnoses including Fracture of Shaft of Humerus.A record review of the Medication Administration Record (MAR) for August 2025 revealed Resident #141 had a Physician's Order, dated 8/12/25, for Thiamine HCl Oral Tablet 50 mg to be given by mouth every morning as a supplement.

Based on interview and record review, the facility failed to ensure that one (1) of (26) sampled residents (Resident #46) receiving dialysis treatment was transported in a timely manner to receive the full duration of the prescribed treatment. This resulted in multiple shortened dialysis sessions over the previous month and placed the resident at risk for adverse health outcomes, including hyperkalemia, gastrointestinal distress, and other dialysis-related complications.Findings included:On 08/12/2025 at 10:58 AM, during an interview, Resident #46 reported that she had been consistently arriving late to her scheduled dialysis appointments and stated, I'm supposed to be there by 11:00, but I've been getting there around 12:00. She further stated that her dialysis sessions had been shortened as a result.On 08/14/2025 at 11:46 AM, during an interview with the dialysis Nurse Manager, they explained that Resident #46 had arrived more than 15 minutes late to her appointments on five separate occasions in the last month: 07/25/2025, 07/28/2025, 08/08/2025, 08/11/2025, and 08/13/2025. The dialysis Nurse Manager stated that the resident's scheduled chair time was 11:30 AM to 3:00 PM, and her average arrival time had been 12:16 PM. She stated the resident's late arrivals had caused the clinic to reschedule her chair time to 11:55 AM to 3:25 PM effective 08/15/2025, making her the last patient of the day and resulting in early removal from dialysis on late arrival days because the clinic closes at 5:00 PM. The dialysis Nurse Manager reported that shortened dialysis sessions result in incomplete treatment, and complications associated with inadequate dialysis include hyperkalemia (high potassium), nausea, vomiting, and itching. On 08/14/2025 at 12:05 PM, during an interview Director of Nursing (DON), explained that they had contacted the dialysis clinic and were told the resident had only been late a few times and only by about ten minutes. The DON stated that the chair time had been adjusted effective 08/12/2025, which may have contributed to the resident's tardiness on that date.On 08/14/2025 at 2:29 PM, during an interview with Driver# 1, explained that the dialysis clinic had informed him of a chair time of 11:50 AM, which was later changed to 11:55 AM effective 08/12/2025. He stated the resident was only late on 08/13/2025 due to that change. He acknowledged that the dialysis clinic had made multiple chair time changes without clearly communicating them and that one of the facility's vans was currently out of service, causing occasional delays in transportation. However, he confirmed that dialysis patients were treated as a transport priority.A review of the dialysis attendance log and interview documentation confirmed that the resident had repeatedly arrived late, leading to shortened treatment durations and increasing the risk of adverse medical outcomes due to incomplete dialysis sessions.On 8/14/25 at 5:30 PM, in an interview with Resident #46, she stated that it is frustrating and inconvenient the fact that her chair time is being changed to later in the day because her body is used to the time already. She doesn't understand why the facility can't just take her early and drop her off at the dialysis facility so she doesn't miss getting her whole treatment she started and wondered why the facility can't get her there on time. On 08/15/2025 at 1:00 PM, In an interview with the Administrator, she stated that the company had two vans go down one due to the air conditioning being out on one and the other due to car wreck damage. This led to the facility using the only service for transport in town to cover more appointments, however this provider had a past history of being late for dialysis, so the facility van drivers are responsible for getting residents to and from dialysis and it is her expectation that residents be transported in a timely manner to their appointment and follow policy and doctor's orders.Record review of the admission Record revealed Resident #46 was admitted on [DATE] with diagnoses that included End Stage Renal Disease.Record review of the Order Summary Report with active orders as of 8/14/25 revealed a physician order dated 7/25/25 Resident to receive hemodialysis three (3) days a week on M/W/F (Monday, Wednesday, Friday) at (Proper name of dialysis center) .Chair Time: 11:30 AM.

Based on observation, interview, record review, and policy review, the facility failed to ensure medications were securely stored and monitored to maintain safety and integrity for one (1) of five (5) residents reviewed for medication administration and storage, Resident #62. Findings included: Record review of facility storage and medication policy dated July 2024 review 6/24/2025 reveal the facility stores all drugs and biologicals in a safe secure and orderly manner On 08/13/2025 at 11:32 AM, during an observation, a medication prescribed to Resident #62 was noted sitting unattended on the bedside table. The medication was Dulera Inhalation Aerosol 100-5 MCG/ACT (Mometasone Furoate–Formoterol Fumarate Dihydrate). The label included resident-identifying information and dosage instructions: “2 puffs orally, twice daily”. The medication was not secured in a medication cart or locked storage area, and no staff were present in the room. Record review of the “Order Details” revealed a physician order dated 8/8/25 for “Dulera Inhalation Aerosol…related to Acute and Chronic Respiratory failure with hypoxia.” A review of the resident’s August 2025 Medication Administration Record (MAR) revealed Dulera was ordered for treatment of acute and chronic respiratory failure with hypoxia. A review of the admission Record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia. A review of the resident’s most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/28/2025 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. On 08/13/2025 at 11:32 AM, during an interview, the Director of Nursing (DON) stated that nurses were not supposed to leave medications in residents’ rooms. She stated that Resident #62 would not be able to self-administer the inhaler. The DON removed the medication from the room.

Based on staff interview, record review, and facility policy review, the facility failed to ensure that a resident was informed of their right to formulate an advance directive (AD) and was provided assistance to do so for one (1) of (26) sampled residents (Resident #22).Findings Include:A review of the facility's policy, Resident Rights, undated, revealed, .Facility must protect and promote the rights of each resident, including each of the following rights . 5. Advance Directives .a. Facility will inform and provide written information to Resident concerning the right to accept or refuse medical or surgical treatment and, at the Resident's option, formulate an advance directive.A record review of Resident #22's clinical record revealed there was no documentation indicating whether the resident had been informed of ADs or was offered assistance by the facility in formulating one.On 8/12/25 at 8:00 AM, during an interview and concurrent observation of the electronic health record (EHR), Licensed Practical Nurse (LPN) #1 in Medical Records confirmed that Resident #22 had no documentation indicating the resident had been informed or was offered assistance in formulating an AD. LPN #1 explained that if it was not scanned into the system, then it was not present in the building, and verified that the resident's entire chart had been scanned into the new system.On 8/12/25 at 1:26 PM, during an interview with the Administrator, she confirmed that Resident #22's AD had lived in the facility for several years. She acknowledged that a care plan conference was held on 8/6/25 with the resident, at which time it was identified that the resident had no Power of Attorney (POA) or AD in place. However, the Administrator confirmed that, since that time, the facility had taken no steps to ensure the resident was informed of their right to formulate an AD or offered assistance in doing so.A record review of the admission Record revealed Resident #22 was initially admitted by the facility on 6/17/16 with diagnoses including Unspecified Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/28/25 revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.A record review of the Care Plan Conference document, dated 8/6/25, revealed interdisciplinary team (IDT) discussion that Resident #22 did not have an AD plan.

Based on observation, record review, facility policy review, and interview, the facility failed to implement care plan interventions related to Enhanced Barrier Precautions for one (1) of 26 sampled residents (Resident #115). Findings included: Review of the facility’s policy “Care Plans Comprehensive Person-Centered”, with a review date of 6/2/25, revealed, “A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical psychological and functional needs is developed and implemented for each resident…” Record review of the “Care Plan Report” for Resident #115 revealed a “Focus” of “Resident requires Enhanced Barrier Precautions r/t (related to) Feeding tube” with “Interventions/Tasks” including “EBP…used during high-contact resident care activities as applicable such as…Changing briefs…” On 08/13/2025 at 1:58 PM, in an observation of Resident #115 receiving perineal revealed Certified Nursing Assistant (CNA) #2 did not wear a protective gown. On 08/13/2025 at 2:16 PM, in an interview with CNA #2 confirmed that she did not wear a gown doing peri care or washing hands doing care. She stated she was supposed to put on a gown before starting peri care. She stated she forgot to put on the gown. She stated she has had training on Enhanced Barrier Precautions. (EBP). On 08/14/25 at 11:36 AM, in an interview with Registered Nurse (RN)/Minimum Data Set (MDS)/Care plan nurse stated CNA #2 did not follow the comprehensive care plan. She stated the purpose of the care plan is to help staff take care of the Resident. She stated she expects the staff to follow the care plan. She stated CNA #2 should have worn a gown while providing care. Record review of the “admission Record” revealed the facility admitted Resident #115 on 9/29/20 with diagnosis including of Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease.

Based on observation, interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident #140) received supervision and assistance during activities of daily living (ADL) bathing to prevent accidents or injury. The facility failed to ensure staff followed the resident's functional status, used appropriate transfer assistance, and sought help when the resident displayed signs of weakness during a shower transfer. Findings included:On 08/13/2025 at 11:44 AM, during an observation, Certified Nursing Assistant (CNA)# 3 was observed providing shower care to Resident #140. The resident was seated on a rolling shower chair and required transfer back to his wheelchair. CNA #3 instructed Resident #140 to stand twice to be dried and dressed. The resident was visibly weak and unsafe while standing both times. During the second attempt, the resident's arms were noted to shake while holding himself upright. No other staff were present during the bathing process, and CNA#3 did not request assistance.On 08/13/2025 at 2:01 PM, during an interview CNA #3, explained it was their first time caring for Resident #140. When asked how a CNA would know how to safely transfer a resident, they stated, It's usually in the care plan, but I can usually look in a room at a resident and decide if they can walk . I can tell if they need two people or not if I see a lift pad or other things in the room. CNA #3 reported they had assistance transferring the resident to the wheelchair earlier but did not think help was needed in the bathroom because he had done so well in the room. When asked why assistance was not sought during the observed episode of weakness, CNA#3 stated they did not want to leave the resident alone and chose not to call using the call light because they didn't think anyone would answer it and the surveyor was present. CNA #3 acknowledged the resident's arms were visibly shaking but stated they did not want to place the resident back in the shower chair because it had been soiled with stool. They admitted in hindsight that it would have been safer. When asked whether it was within a CNA's scope to determine transfer needs by observation alone, they responded, No, and acknowledged that improper transferring could lead to resident falls and injury.On 08/13/2025 at 5:10 PM, during an interview the Director of Nursing (DON), explained the resident was listed as a one-person assist upon admission assessment. The DON stated that CNA #3 should have sought help or sat the resident back down when he became visibly unstable. The DON confirmed that both the care plan and CNA Point of Care Kardex contain transfer status guidance. The DON stated that failure to follow proper transfer protocols or making assumptions about resident ability based solely on appearance, places the resident and staff at risk for injury.A record review of the admission Assessment - Functional Abilities, dated 08/08/2025, section GG of the Minimum Data Set (MDS), revealed the resident was coded as 01 - Dependent, meaning the helper does all of the effort, or that two or more helpers are required to complete the activity.A review of the admission Record revealed Resident #140 was admitted on [DATE] with a diagnosis of Syncope and Collapse, a condition that may contribute to weakness or fainting.

Based on staff interview, record review, and facility policy review, the facility failed to maintain a complete and accurate medical record by not documenting whether a resident had an advance directive (AD) in place, declined to complete one, or was offered assistance to formulate one for one (1) of (26) sampled residents (Resident #22).Findings Include:A record review of Resident #22's clinical record revealed there was no documentation indicating whether the resident had an AD in place, declined to complete one, or had been offered assistance by the facility in formulating one.During an interview and concurrent observation of the electronic health record (EHR), on 8/12/25 at 8:00 AM, Licensed Practical Nurse (LPN) #1 in Medical Records confirmed that Resident #22 had no documentation indicating the resident did or did not have an AD. The LPN verified Resident #22's entire chart had been scanned into the new system and commented that if the information was not scanned into the system, then it was not present in the building. During an interview on 8/12/25 at 1:26 PM, the Administrator, confirmed that Resident #22's information regarding an AD was not readily available in the medical record. The Administrator reported that the resident had lived for several years in the facility and acknowledged that a care plan conference was held on 8/6/25 with the resident, at which time it was identified that the resident had no Power of Attorney (POA) or AD in place. However, the Administrator confirmed that, since that time, the facility had taken no steps to ensure documentation of the resident's AD status in the medical record.A record review of the admission Record revealed Resident #22 was initially admitted by the facility on 6/17/16 with diagnoses including Unspecified Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/28/25 revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.A record review of the Care Plan Conference document, dated 8/6/25, revealed interdisciplinary team (IDT) discussion that Resident #22 did not have an AD plan.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to maintain a medication error rate below 5 percent (%) during an annual recertification survey on 4/11/24 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of nine (9) deficiencies cited. (F759)Findings Include: Review of the facility's policy Quality Assurance Performance Improvement (QAPI) Program, reviewed 6/25, revealed, .The purpose of Quality Assurance Performance Improvement committee is to create a system for improving the care for our residents.Record review of the Provider History Profile revealed the facility received a citation for F759 - Free of Medication Error Rates 5 Percent or More.Record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 4/11/24, revealed the facility received a citation for F759, .Based on observations, interviews, record review, and facility policy review, the facility failed to maintain less than a 5% medication error administration rate for two (2) errors of 25 medication administration opportunities. This observation resulted in an 8% medication error rate.During the current recertification survey, the facility failed to maintain a medication error rate below five (5) percent (%), for two (2) of 31 medication opportunities observed, resulting in a 6.45 % medication error rate. This included Resident #2, who was not instructed to rinse with water following administration of a steroid inhaler, and Resident #141, for whom the nurse prepared an incorrect dosage of Thiamine. On 8/15/25 at 2:20 PM, during an interview with the Nursing Home Administrator (NHA), she explained the Quality Assurance Committee meets quarterly and all members attend. She acknowledged awareness of previous citations and reported that the facility plans to increase education and provide one-on-one training. She explained that additional monitoring will be implemented by the Assistant Director of Nursing (ADON) and Director of Nursing (DON). She stated spot checks will be conducted, and pharmacy staff will provide additional oversight.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1, a vulnerable resident, from leaving the facility premises unsupervised for one (1) of six (6) residents reviewed. Resident #1. On 3/22/25 at 8:17 AM, Resident #1, who has a Brief Interview for Mental Status (BIMS) score of 7, left the facility unsupervised. The facility's transportation aide let the resident out of the front door to sit on the porch. Licensed Practical Nurse (LPN) #1 encountered Resident #1 in the facility parking lot and attempted to redirect the resident back to the facility. She left the resident unsupervised to get help from additional staff. When staff returned, the resident had moved further off-site, and was across the street in a daycare parking lot, approximately one-fourth (1/4) of a mile from the facility. The resident was out of sight and unsupervised for approximately 13 minutes. The facility's failure to adequately supervise Resident #1, a vulnerable resident, put this resident and all other vulnerable residents at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 3/22/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 3/28/25 at 10:55 AM and provided an IJ Template. Based on the facility's implementation of corrective actions on 3/25/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 3/26/25, prior to the SA's entrance on 3/27/25. Findings Included: A review of the facility's policy, Wanderer Management, Monitoring System & (and) Resident Elopement Protocol, reviewed 01/2023, revealed, .It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible .All staff is responsible to ensure resident safety . On 3/27/25 at 8:17 AM, an observation revealed the street where the facility was located on a two-way roadway with 18 inches of cement along the edge of both sides of the street between the asphalt. There were no crosswalks and the curbs were approximately eight (8) inches high. The speed limit was posted as 25 miles per hour (mph). There was a wooded area across from the facility and a local business comprised of two separate buildings with a fenced-in playground between the buildings that were across the street and to the right of the facility. There were three (3) vehicles observed on the roadway during a five-minute observation. The facility driveway was one-fourth (1/4) mile from the facility's portico (front entrance) to the street at the lower driveway entrance. It was one-half (0.5) mile from the lower driveway entrance to the parking lot of the second building of the local business across the street from the facility. Observation included that the front entrance of the facility was locked and required a code to be entered into a wall-mounted keypad beside the door on the outside or depression of a button at the front desk in the entranceway. Record review of the Admission Record revealed the facility admitted Resident #1 on 11/19/2024 and he had current diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 2/21/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated he his cognition was severely impaired. Record review of the facility's investigation, dated 3/27/25, revealed on 3/22/25, Resident #1 exited through the front door and was observed by LPN #1 while she was leaving the facility at approximately 8:30 AM. LPN #1 went to the resident and tried to assist the resident back to the facility without success and had to reenter the facility for assistance. According to the Facility Investigation, LPN #1 and other staff located Resident #1 across the street in a local business parking lot, approximately one quarter mile from the facility upper driveway and assisted the resident back into the facility at 8:43 AM. Record review of the historical weather information on Wunderground.com, the local weather on 3/22/25 at 8:00 AM had zero (0) precipitation and the temperature was fifty (50) degrees Fahrenheit. On 2/27/25 at 8:35 AM, an interview with the Administrator revealed that on 3/22/25 she was notified of the elopement of Resident #1 by Registered Nurse (RN) #1 at approximately 8:30 AM. She reported that SA was notified, and thorough investigation initiated. She stated that based on security camera footage and interview with RN #1 and LPN #2 it was determined that the resident exited the facility through the front entrance, opened by the Transportation Aide (TA). She said that according to the security camera footage the resident walked down the driveway towards the lower driveway entrance. She stated that LPN #1 was driving out of the parking lot and observed Resident #1 walking up the street towards the upper driveway entrance, parked her car and walked up the street with the resident and attempted to return him to the facility. When Resident #1 refused, LPN #1 went for assistance, returned with other staff and located the resident across the street approximately 1,320 feet from the facility and assisted to return to the facility. The Administrator confirmed that the Quality Assurance (QA) committee met and determined that the root cause of the incident was that resident had been permitted to sit outside in front of the facility near the driveway and street unaccompanied and during a QA meeting on 3/24/25 made recommendations for change of procedure which was presented to the Resident Council on 3/24/25. She confirmed that the resident remained at a behavioral unit with plans for him to return to the facility following assessment and treatment. On 3/27/25 at 2:50 PM, an interview with Certified Nursing Assistant (CNA) #1 revealed she arrived at the facility at 7:00 AM on 3/22/25 and responded to request for assistance at approximately 8:30 AM outside the facility front entrance and she observed Resident #1 across the street in the (local business) parking lot and that the staff assisted the resident to return to the facility. On 3/27/25 at 2:56 PM an interview with the TA revealed that he had opened the door for Resident #1 at approximately 8:17 AM, whom he recognized as a resident who liked to sit outside. The TA said that when he was made aware of the elopement at approximately 8:30 AM he went outside and assisted nursing staff to return the resident to the facility. On 3/27/25 at 4:30 PM an interview with CNA #2 revealed that she was working from 7:00 AM to 7:00 PM on 3/22/25 and was made aware of the elopement per intercom announcement at approximately 8:30 AM and went outside and assisted in returning the resident to the facility. On 3/28/25 at 11:00 AM, during a telephone interview with LPN #2, she reported that she was on duty 7:00 AM through 3:00 PM on 3/22/25 and assigned to the care of Resident #1, with whom she was familiar. At approximately 8:30 AM, she heard an overhead announcement and reported to the Unit 1 Nurses Station where she was notified by LPN #1 that the resident was outside and refused to return to the facility. She confirmed that she and other staff went to assist the resident who had walked a little way up the street and crossed over into the parking lot of a local business that was closed due to it being Saturday. She said following return to his room, Resident #1 refused a body audit but allowed incontinent care during which she was able to observe for signs of injury and observed none. On 3/28/25 at 2:00 PM, an interview with the Director of Nursing (DON) revealed she reported that LPN #1 made her aware of the elopement via telephone on 3/22/25 at approximately 8:30 AM. She stated she was responsible for referrals to behavioral units and securing placement with Resident #1's Representative (RR) consent at a behavioral unit for assessment and treatment due to behavioral chances. She confirmed that she conducted a new Wander/Elopement Assessment and reviewed and updated the resident's care plan and facility elopement binders on 3/22/25. She said that Resident #1 had never exhibited exit seeking or aggressive behaviors prior to 3/22/25. On 3/28/25 at 2:30 PM an interview with the Administrator revealed she stated, The facility could not anticipate that the resident's normal behavior would change. She said that Resident #1's BIMS score indicated cognitive impairment, but he had never exhibited exit seeking or aggressive behaviors prior to 3/22/25. The Administrator confirmed that all steps on the facility's Corrective Action Plan had been completed as of 3/24/25. The facility submitted a corrective action plan as follows: On March 28, 2025, at 10:55 AM -State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). The State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. Facility respectfully submits this corrective action plan. Brief Summary of Events On 03/22/2025 at approximately 8:17 AM it was discovered that Resident #1 exited the building through the front entrance with assistance by the facility Transportation Aide #1. Resident #1 was not deemed a wander risk on wander assessment completed 02/2l/2025 and never exhibited wandering behaviors while in the facility. The facility failed to provide supervision to prevent the elopement of Resident# 1, who left the facility unattended. This failure allowed Resident# I to be away from the facility unnoticed and unsupervised on 03/22/2025 from 08:17 AM until 08:30 AM, when the facility nurse noted resident outside in front of the facility. This was approximately 13 minutes after Resident# l was last observed in the facility by Van Driver #1. Corrective Actions On 03/22/2025 at 8:30 AM, LPN (Licensed Practical Nurse) #1 was exiting the facility grounds when she noticed resident#1 pushing his wheelchair and at 8:36 A.M. along with additional staff assisted the resident to return to the facility On 03/22/2025, at approximately 08:40 AM, the Administrator was notified by RN (Registered Nurse)#1 of Resident#1 exited the building without supervision and was back in the building. On 03/22/2025 at approximately 08:45 AM, resident#1 was placed on 1:1 monitoring. On 03/22/2025 at approximately 08:50 AM, Resident#1 Responsible Party was notified by the DON that Resident#1 exited and had been returned to the facility. On 03/22/2025 Nurse Practitioner (NP)#1 was notified by the Director of Nursing of Resident#1 exit of facility and return along with behaviors. NP#1 placed an order for behavioral unit evaluation of Resident#1 for inpatient stay. On 03/22/2025 at approximately 8:55 AM DON contacted Behavior facility with a referral for resident#1 for further evaluation. On 03/22/2025 at approximately 9 AM, Resident# 1 refused a head-to- toe assessment but LPN #2 was able to visually inspect resident#1 during incontinence care. No injuries were noted. On 03/22/2025 at approximately 2:43 PM Resident#1 exited the facility with Behavioral Unit for inpatient stay. On 03/23/2025 at 8:14 PM the State Agency (SA) was notified by the Director of Nurses of the incident. On 03/24/2025 at approximately 9:30 AM, the SOC initiated a 100%, mandatory In-service Training which was completed on 03/25/2025 for elopement (including facility policy review) and the care of residents with difficult behaviors, to be continued for all new hires going forward. No staff are allowed to work until in service completed. On 03/24/2025 at 4:53 PM, the DON completed a post Elopement wander evaluation on Resident #1 and changed to high risk for Elopement, and the care plan was updated to reflect this. On 03/24/2025 at approximately 12:00 PM, DON reviewed the wander and elopement binders to ensure all were up to date. On 03/24/2025 at approximately 2:00 PM, a Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction; policies were reviewed with no revisions. The facility procedure for residents sitting outdoors was updated. On 03/24/2025 at approximately 5:00 PM, the Director of Nursing audited current high-risk wander patients to review orders and care plans for accuracy. There was currently one (1) wander patient. And the Administrator performed an elopement drill on 03/25/2025 at 6:30 AM. On 03/24/2025 at 2:48 PM and 03/24/2025 at 5:40 PM the Maintenance director performed elopement drills with staff to review and educate on policies and procedures on elopement. On 03/24/2025 at approximately 9 am a Staff quiz was initiated by the CNA # 2 with all staff on knowledge of the elopement policy. On 03/25/2025 at approximately 10 am Resident council meeting was held by the Administrator to include the President and 19 members to notify of current events and procedure changes to outdoor sitting with supervision in ungated areas. On 03/25/25 at 10 am new procedures were implemented by the Administrator related to residents prohibited from sitting in ungated areas without supervision. On 03/25/25 at approximately 10:10 am new procedures were placed in the new hire orientation package by the Administrator for implementation of the procedure change of residents prohibited from sitting in ungated areas without supervision. On 03/25/25 at approximately PM Wander evaluations were audited by the Director of Nursing on all current residents reveals six residents requiring schedule adjustments. The Director of Nursing will monitor current residents for potential risks through incident report reviews, observation and communication with staff for three (3) months; the Maintenance Director will conduct elopement drills monthly (with rotating shifts until all shifts completed) for three (3) months. The Administrator will present incident report reviews and documentation of drills for review to QA team weekly to monitor compliance with the plan for three (3) months then quarterly. The facility alleges that all corrective actions were completed as of 3/25/25 and the IJ removed 3/26/25 prior to the SA entry on 3/27/25. Validation: The SA validated through interview and record review view, that all corrective actions had been implemented as of 3/25/25, and the facility was in compliance as of 3/26/25, prior to the SA's entrance on 3/27/25.

Based on interviews, record review, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse from a staff member for one (1) of five (5) sampled residents. Resident #1 Resident #1 was physically and emotionally abused on 12/25/24 when Certified Nursing Aide (CNA) #1 handled him roughly, sprayed cold water on his face, and turned out the lights in the shower room, while laughing. The facility's failure to protect resulted in Resident #1 reporting he felt sad, taken advantage of, and a little afraid. Additionally, the facility's failure to immediately remove CNA #1 from the facility placed this resident and other residents in a situation that was likely to result in ongoing serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The State Agency (SA) notified the Administrator of the IJ and SQC on 2/3/25 at 2:40 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 12/31/24, the SA determined the IJ and SQC to be Past-Non-Compliance (PNC) and the IJ was removed on 1/1/25 prior to the SA's entrance on 1/23/25. Findings include: A review of the facility's, Abuse Prohibition Policy dated 5/17/24, revealed, Intent: This protocol was intended to assist in the prevention of abuse .Policy:1. The facility will prohibit neglect, mental or physical abuse . A record review of the Admission Record revealed the facility admitted Resident #1 on 8/22/24 with diagnoses including Hypertension and Depression. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact. A record review of the facility's investigation, dated 1/2/25, revealed that on 12/30/24, the Director of Nursing (DON) received notification that a CNA had handled a resident roughly during activities of daily living (ADL) care, which included spraying a resident in the face with cold water and turning the light off in the shower room prior to exiting the room, leaving another employee and the resident in darkness. The incident occurred on 12/25/24. A review of the corrective actions revealed the facility put immediate actions in place including suspending and terminating the perpetrator and the facility's Administrator. The resident was provided support and reassurance, a body audit was conducted, and the allegation was reported, and appropriate notifications, including law enforcement were made. Life Satisfactions Rounds and Peer reviews were initiated, and Trauma Assessment was performed on Resident #1. A Quality Assurance Performance Improvement (QAPI) committee meeting was held on 12/31/24. In-services were completed on abuse, resident rights, and vulnerable the adult act. A record review of the Witness Statement, completed by Licensed Practical Nurse (LPN) #1 and signed on 12/26/24, revealed, I, (Proper Name of LPN #1), witnessed CNA (name not provided) cause emotional abuse to resident (Proper Name of Resident #1). While giving the resident a shower, CNA turned on the shower and sprayed the resident in the face with the water. Resident hollered out loudly, telling CNA to stop. Writer also told CNA not to do it anymore. CNA roughly wiped the resident's body parts. Resident started crying for CNA to stop and please let her (writer) do my shower. Writer told CNA she would take over with the shower. Writer asked CNA to just spray the soap off. CNA then turned the water from warm to cold and began spraying the resident. Resident began to scream, telling CNA the water is too cold. CNA only laughed and told the resident he will be ok. CNA began to shake the resident's bed side to side roughly. Resident began to scream 'stop.' Writer also told CNA to stop and that the resident could fall off the shower bed. CNA replied, 'it's your wheels screeching.' Also, while writer was drying the resident off, CNA went and turned the lights off, causing darkness. Both writer and the resident screamed, telling CNA to stop. CNA just laughed it off. When writer got done dressing the resident, I asked CNA how he would transfer the resident back to bed without a sling because he wet the previously one up, he replied, 'watch this, he's going to roll and go for a ride.' CNA put the shower bed beside the resident's bed and told resident, 'your about to roll on your stomach then to your back' and proceeded to push the resident from the shower bed to his bed. Writer walked out. A record review of the timecard for CNA #1 revealed he worked at the facility from 6:30 AM to 7:00 PM on 12/25/24 and 12/26/24. He also worked from 6:30 AM to 4:45 PM on 12/30/24, which was after the abuse occurred on 12/25/24. On 1/23/25 at 9:46 AM, during an interview with Resident #1, he recalled the incident in the shower and explained CNA #1 roughly handled him roughly and sprayed cold water on his face. He stated that he told CNA #1 it was cold, and CNA #1 laughed in response. Later, when CNA #1 began drying him off, it hurt and at that point, the nurse intervened and took over, which felt much better to him. He expressed that he was not afraid or upset, but the incident did make him feel sad that he was taken advantage of. CNA #1 did not take care of him anymore after that. At 11:18 AM on 1/23/25, during a phone interview with LPN #1, she recalled the incident involving CNA #1, where she witnessed as he began to get the resident from the bed. As he did so, he placed both his hands on the sides of the bed and shook it from side to side. She told him to stop because the resident could fall off the bed. He complied, but in response, CNA #1 thought it was funny and stated, He will be alright. After that, CNA #1 wheeled the resident out to the shower room and into the stall and she was there to assist as well. At that time, he took off the resident's gown, turned on the water, and sprayed the resident in the face with the shower sprayer. LPN#1 yelled, What are you doing? The water is still cold! She observed Resident #1's face grimace as if he was in pain, and he then stated, It's cold, it's cold. She asked CNA #1 why he did that, but he shrugged her off and waited until the water warmed up. LPN#1 began to lather the resident's body with body wash while CNA #1 sprayed him down with warm water. After CNA #1 finished, he grabbed a towel and began to wipe the resident down roughly. The resident said, It hurts, so she commanded CNA#1 to stop, and let her handle it. She then took the towel and began to wipe the resident gently. She indicated that CNA #1 continued to laugh it off, and turned the lights off, she and the resident screamed, and he turned them back on. On 1/23/25 at 12:02 PM in an interview with the current Administrator, she revealed the incident occurred with the previous Administrator, but she was aware of the situation. During the investigation, the facility determined that the event occurred and terminated CNA #1 and the Administrator. On 1/23/25 at 1:12 PM, during a phone interview, CNA #1 revealed that he has worked at the facility for the past two years. He explained that he is aware but does not know the source of the allegations regarding Resident #1. He confirmed that a nurse he does not know and claims to have never seen before assisted him while he was showering the resident. He stated that he does not recall spraying cold water on the resident's face, adding that all he remembers is the resident saying the water was too hot. He reiterated, I did not do anything to the resident. CNA #1 further explains that the Administrator never spoke with him about anything. All he knows is that on 12/30/24, he was told to go home because an investigation had been opened regarding him. He stated that he did not ask what it was about nor was he informed, and a few days later, someone from Human Resources called him and told him he was fired. On 1/23/25, at 1:36 PM, during an interview with the DON, she revealed that the incident occurred on 12/25/24, however, she did not learn about it until Monday, 12/30/24. She immediately suspended CNA#1 and began inservicing staff as the they were not allowed to work until in serviced on abuse and neglect. The Administrator was on vacation at the time. She indicated that she could not readily remember if CNA #1 had been written up for similar actions and was surprised that he would be accused of such behavior. She noted that he had been working with the same group of men for at least three (3) or four (4) months and that during her interviews after the event, the men spoke fondly of him, although she did add that he plays a lot. On 1/23/25 at 2:57 PM, in a phone interview with the previous Administrator, she explained that she worked on 12/26/24 and 12/27/24, which were on Thursday and Friday, and then she was off for vacation. During that time, LPN #1 came to talk with her and informed her about the incident with CNA #1 and Resident #1, mentioning that the CNA had the water set too cold during the shower. The former Administrator explained that was all LPN #1 said about the situation, so she instructed the nurse to write a statement and put it in her box. Afterward, she went to interview Resident #1 while he was sitting outside his door, and he denied that anything had happened to him other than the shower being cold. She asked him if someone had hurt him, and he specifically said No. She then told the resident that she would speak with the CNA anyway, and the resident seemed concerned, asking, What are you going to talk with him about? She reassured the resident that there was nothing to worry about. The Administrator stated she then attempted to interview CNA #1 by calling him on the phone, but he did not answer and was not scheduled to work that day. She noted that the written statement by LPN #1 was completely different from what she had verbally reported. She stated she was surprised to be suspended and later terminated regarding this event. On 2/3/25 at 10:00 AM, in a follow up interview with Resident #1, he recalled being a little afraid when CNA #1 was shaking the shower bed because he could have fallen. He acknowledged that he was sprayed in the face but was most upset about being wiped and handled roughly. Resident #1 confirmed that he did cry out during the shower for CNA #1 to stop and that it was several days before anyone at the facility asked him any questions about it. On 2/3/25 at 10:18 AM in a follow-up interview with LPN #1, she stated that the event occurred on 12/25/24 in the afternoon, and she thought it may have been after 3:00 PM. She explained both she and CNA #1 were working a 12 hour shift that day. She stated that CNA #1's behavior in the shower room scared her because it seemed odd to her. LPN #1 could not recall if CNA#1 was in the resident's room after the shower when she left the room, but she immediately reported what had happened to Registered Nurse (RN) #1 who was the charge nurse. She explained RN #1 was at the nurses station when she reported the abuse and there were other staff members that were there and may have heard her report. She reported everything that happened in the shower room to the charge nurse. LPN #1 further explained that on the following day, 12/26/24, she was working at the facility and the Administrator was there. She reported the CNA's abusive behavior to the Administrator at that time, who instructed her to write a statement. She wrote the statement and handed it directly to the Administrator and did not put it in a box. She said the Administrator did not ask her any questions about it. On 2/3/25 at 10:53 AM, in a phone interview with LPN #2, she stated that on 12/25/24, she walked up on RN #1 and LPN #1 as they were discussing the incident that occurred in the shower room with Resident #1 and CNA #1. She explained that LPN #1 was upset, but she was not sure of everything that was said because she was passing by and just heard part of the conversation. LPN #2 was unsure of how many days CNA #1 worked after 12/25/24. On 2/3/25 at 11:33 AM, in a phone interview with CNA #2, she stated that she was working on 12/25/24. She explained that she worked close to the shower room and recalled hearing noises and hollering from the shower room. She described it as kind of unusual but that CNA #1 always talked loudly. She stated that she saw LPN #1 and RN #1 talking but did not hear much of the conversation. She said that LPN #1 was upset and was saying she couldn't believe what was happening. On 2/3/25 at 11:45 AM, in an interview with RN #1, she stated that she left the faciity on [DATE] around 1:30 PM to 2:00 PM and denied being at the facility when the event occurred. She stated she did not hear about it until the next day (12/26/24) when LPN #1 told her about it and said she was going to report it to the Administrator. She said that the nurse did not go in detail, but said she was uncomfortable with what had happened. On 2/3/25 at 1:00 PM, in an interview with the current Administrator and the DON, they confirmed the CNA continued to work his shift on 12/25/24 and he also worked on 12/26/24 and until around 4:00 PM on 12/30/24. The DON stated she received the call from corporate around 4:00 PM inquiring if the allegation was reported to the SA. She was unaware of the incident because she was off the week of Christmas. The DON and Administrator stated that as part of their investigation they conducted interviews regarding the nurse's inaction. The nurse (LPN #1) said that she reported the incident immediately, but when they interviewed the charge nurse, she denied this. They felt like it was a she said, she said situation and was unable to find out where the breakdown occurred. They said they interviewed the staff that worked on 12/25/24, but none of them stated they heard LPN #1 telling the charge nurse about the abuse. Based on the implementation of the facility's corrective actions on 12/31/2024, the deficient practice was determined to be past noncompliance, and the facility was found in compliance effective 1/1/25. Validation: The SA validated on 1/23/2025, through interview and record review that all corrective actions had been implemented as of 12/31/24, and the facility was in compliance as of 1/1/25, prior to the SA's entrance on 1/23/2025.

Based on interviews, record review, and facility policy review, the facility failed to report an allegation of abuse within the required two (2) hour timeframe for one (1) of five (5) sampled residents. Resident #1 Licensed Practical Nurse (LPN) #1 witnessed physical and emotional abuse of Resident #1 on 12/25/24, however, the facility did not report it to the State Agency (SA) until 12/30/24, delaying the facility's ability to protect the resident from further harm. The facility's failure to ensure immediate reporting increased the risk of further harm which left Resident #1 and other residents in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The State Agency (SA) notified the Administrator of the IJ and SQC on 2/3/25 at 2:40 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 12/31/24, the SA determined the IJ and SQC to be Past-Non-Compliance (PNC) and the IJ was removed on 1/1/25 prior to the SA's entrance on 1/23/25. Findings include: A review of the facility policy, Abuse Prohibition revised 5/17/24, reveals on page 7 .2. The facility will report all allegations and substantiated occurrences of abuse .to the state agency and to all other agencies as required by law .The Abuse Coordinator will report all allegations of abuse .immediately or within two hours of the allegation . A record review of the Admission Record revealed the facility admitted Resident #1 on 8/22/24 with diagnoses including Hypertension and Depression. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact. A record review of the facility's investigation, dated 1/2/25, revealed that on 12/30/24, the Director of Nursing (DON) received notification that a Certified Nursing Assistant (CNA) had handled a resident roughly during activities of daily living (ADL) care, which included spraying a resident in the face with cold water and turning the light off in the shower room prior to exiting the room, leaving another employee and the resident in darkness. The incident occurred on 12/25/24. A review of the corrective actions revealed the facility put immediate actions in place including suspending and terminating the perpetrator and the facility's Administrator. The resident was provided support and reassurance, a body audit was conducted, and the allegation was reported, and appropriate notifications were made, including law enforcement. Life Satisfactions Rounds and Peer reviews were initiated, and Trauma Assessment was performed on Resident #1. A Quality Assurance Performance Improvement (QAPI) committee meeting was held on 12/31/24. In-services were completed on abuse, resident rights, and vulnerable the adult act. A record review of the Witness Statement, completed by Licensed Practical Nurse (LPN) #1 and signed on 12/26/24, revealed, I, (Proper Name of LPN #1), witnessed CNA (name not provided) cause emotional abuse to resident (Proper Name of Resident #1). While giving the resident a shower, CNA turned on the shower and sprayed the resident in the face with the water. Resident hollered out loudly, telling CNA to stop. Writer also told CNA not to do it anymore. CNA roughly wiped the resident's body parts. Resident started crying for CNA to stop and please let her (writer) do my shower. Writer told CNA she would take over with the shower. Writer asked CNA to just spray the soap off. CNA then turned the water from warm to cold and began spraying the resident. Resident began to scream, telling CNA the water is too cold. CNA only laughed and told the resident he will be ok. CNA began to shake the resident's bed side to side roughly. Resident began to scream 'stop.' Writer also told CNA to stop and that the resident could fall off the shower bed. CNA replied, 'it's your wheels screeching.' Also, while writer was drying the resident off, CNA went and turned the lights off, causing darkness. Both writer and the resident screamed, telling CNA to stop. CNA just laughed it off. When writer got done dressing the resident, I asked CNA how he would transfer the resident back to bed without a sling because he wet the previously one up, he replied, 'watch this, he's going to roll and go for a ride.' CNA put the shower bed beside the resident's bed and told resident, 'you're about to roll on your stomach then to your back' and proceeded to push the resident from the shower bed to his bed. Writer walked out. During an interview on 1/23/25, at 1:36 PM, the DON revealed that the incident occurred on 12/25/24, however, she did not learn about it until Monday, 12/30/24. She immediately suspended the CNA and began educating staff as the they were not allowed to work until in-serviced on abuse and neglect. The Administrator was on vacation at the time. During a phone interview on 1/23/25 at 2:57 PM, the previous Administrator explained that she worked on 12/26/24 and 12/27/24, which were on Thursday and Friday, and then she was off for vacation. During that time, LPN #1 came to talk with her and informed her about the incident with CNA #1 and Resident #1, mentioning that the CNA had the water set too cold during the shower. The former Administrator explained that was all LPN #1 said about the situation, so she instructed the nurse to write a statement and put it in her box. She noted that the written statement by LPN #1 was completely different from what she had verbally reported. During a follow-up interview on 2/3/25 at 10:18 AM, LPN #1 she stated that the event occurred on 12/25/24 in the afternoon, and she thought it may have been after 3:00 PM. She explained she immediately reported what had happened to Registered Nurse (RN) #1 who was the charge nurse on 12/25/24. She explained RN #1 was at the nurses' station when she reported the abuse and there were other staff members that were there and may have heard her report. She reported everything that happened in the shower room to the charge nurse. LPN #1 further explained that on the following day, 12/26/24, she was working at the facility and the Administrator was there. She reported CNA #1's abusive behavior to the Administrator at that time, who instructed her to write a statement. She wrote the statement and handed it directly to the Administrator and did not put it in a box. She said the Administrator did not ask her any questions about it. During a phone interview on 2/3/25 at 10:53 AM, LPN #2 stated that on 12/25/24, she walked up on RN #1 and LPN #1 as they were discussing the incident that occurred in the shower room with Resident #1 and the CNA #1. She explained that LPN #1 was upset, but she was not sure of everything that was said because she was passing by and just heard part of the conversation. During a phone interview on 2/3/25 at 11:33 AM, CNA #2 stated that she was working on 12/25/24. She stated that she saw LPN #1 and RN #1 talking but did not hear much of the conversation. She said that LPN #1 was upset and was saying she couldn't believe what was happening. During an interview on 2/3/25 at 11:45 AM, RN #1 stated that she left the faciity on [DATE] around 1:30 PM to 2:00 PM and denied being at the facility when the event occurred. She stated she did not hear about it until the next day (12/26/24) when LPN #1 told her about it and said she was going to report it to the Administrator. She said that LPN#1 did not go in detail, but said she was uncomfortable with what had happened. During an interview on 2/3/25 at 1:00 PM, with the current Administrator and the DON, the DON stated she received the call from corporate around 4:00 PM on 12/30/24 inquiring if the allegation was reported to the state agency. She was unaware of the incident because she was off the week of Christmas. The nurse (LPN #1) said that she reported the incident immediately, but when they interviewed the charge nurse, she denied this. They also reported they had interviewed the staff that worked on 12/25/24, but none of them stated they heard LPN #1 telling the charge nurse about the abuse. Based on the implementation of the facility's corrective actions on 12/31/2024, the deficient practice was determined to be past noncompliance, and the facility was found in compliance effective 1/1/25. Validation: The SA validated on 1/23/2025, through interview and record review that all corrective actions had been implemented as of 12/31/24, and the facility was in compliance as of 1/1/25, prior to the SA's entrance on 1/23/2025.

Based on observations, interviews, facility policy review, and record review, the facility failed to ensure a clean, homelike environment for three (3) of five (5) sampled residents, Residents #2, #3, and #4. Findings Include: A review of the facility's policy titled Homelike Environment, revised February 2021, revealed Residents are provided with a safe, clean, comfortable, and homelike environment .1. Staff provides person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include: a. clean, sanitary, and orderly environment .f. pleasant, neutral scents . On 09/23/24 at 1:25 PM, during an observation of Resident #2's room, an extremely strong urine odor was noted. A wet incontinence brief was found in a plastic bag inside the room's trash can. On 09/23/24 at 1:30 PM, during an interview, Licensed Practical Nurse (LPN) #1 agreed Resident #2's room had a very strong odor of urine. On 09/23/24 at 2:05 PM, during an interview, Certified Nursing Assistant (CNA) #1 stated that she had noticed the strong urine odor before 11:00 AM but had not located the source or notified housekeeping. The room continued to have a pungent urine smell throughout the day. On 09/23/24 at 2:35 PM, during an interview with the Assistant Housekeeping Supervisor, she confirmed that she smelled the strong odor of urine in the room of Resident #2. On 09/23/24 at 3:20 PM, an observation of Resident #3 and Resident #4 in their shared room revealed both residents seated on their beds with an extremely strong urine odor in the room. A urinal and a pool of spilled urine was noted under the bed of Resident #3. On 09/23/24 at 4:10 PM, during an observation and interview, CNA #2 assisted Resident #3 to stand, revealing a non-disposable incontinence pad. The pad was white around three edges but yellowed on one side, with brown streaks and stains in the middle. The pad emitted a strong odor of urine and feces. CNA #2 stated, It's soaking wet under there, the sheet is wet too. It looks like he's just been sitting there letting it go. She reported that she had not entered the room since 1:00 PM. On 09/24/24 at 2:50 PM, during an interview with the Housekeeping Supervisor, she stated that the floor in the room of Resident #3 and Resident #4 needed to be stripped, waxed, and possibly have the tiles replaced. She described the room as smelling like hot pee. On 09/25/24 at 12:05 PM, during an interview with the Director of Nursing (DON), she confirmed that CNAs could summon housekeeping services at any time or provide cleaning of urine or bodily fluids themselves to maintain a clean and safe environment for residents. A record review of Resident #2's Admission Record revealed that the facility admitted the resident on 03/24/2020, The resident had diagnoses that included Cerebral Infarction (Stroke), Repeated Falls, and Malignant Neoplasm of the Bladder. A record review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated no cognitive impairment. Section GG indicated Resident #2 required moderate assistance for toileting hygiene. Section H indicated Resident #2 was frequently incontinent of bowel and bladder. A record review of Resident #3's Admission Record revealed that the facility admitted the resident on 11/29/21. The resident had diagnoses that included Stage 3 Chronic Kidney Disease, Psychotic Disorder, and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. A record review of Resident #3's Quarterly MDS with an ARD of 08/17/24, in Section C revealed a BIMS score of thirteen (13), which indicated Resident #3 was cognitively intact. Section GG indicated revealed the resident required substantial assistance for personal hygiene and supervision for toileting. A record review of Resident #4's Admission Record revealed that the facility admitted the resident on 10/30/23 with diagnoses of Cerebral Infarction (Stroke) and Cognitive, Social or Emotional Deficit following Cerebral Infarction. A record review of Resident #4's Quarterly MDS with an ARD of 07/26/24 revealed a BIMS score of 99, indicating the resident was unable to participate in the interview.

Based on observations, interviews, and record review, the facility failed to ensure that timely incontinent care was provided two (2) of five (5) sampled residents. Residents #2 and #3 Findings Include: Resident #2 On 09/23/24 at 1:25 PM, during an observation and interview, Resident #2 was found kneeling on a bedside mat with his upper torso resting on the mattress. He was wearing a saturated incontinence brief that had sagged down to his lower thighs. On 09/23/24 at 2:05 PM, during an interview, Certified Nursing Assistant (CNA) #1 stated that she last checked Resident #2 for incontinence care before 11:00 AM on 09/23/24. CNA #1 confirmed that Resident #2's care instructions included incontinence care every two (2) hours and as needed. CNA #1 returned from lunch at 1:29 PM and found the resident on the floor but had not provided care between 11:00 AM and 1:29 PM. A record review of Resident #2's Admission Record revealed that the facility admitted the resident on 03/24/2020, The resident had diagnoses that included Cerebral Infarction (Stroke), Repeated Falls, and Malignant Neoplasm of the Bladder. A record review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated no cognitive impairment. Section GG indicated Resident #2 required moderate assistance for toileting hygiene. Section H indicated Resident #2 was frequently incontinent of bowel and bladder. Resident #3 During an observation of incontinence care and interview on 09/23/24 at 4:10 PM, revealed CNA #2 began providing incontinence care to Resident #3. The incontinence pad was soaked with urine and feces. CNA #2 confirmed that she had last checked Resident #3's urinal and incontinence pad around 1:00 PM and had not provided care between 1:00 PM and 3:47 PM. A record review of Resident #3's Admission Record revealed that the facility admitted the resident on 11/29/21. The resident had diagnoses that included Stage 3 Chronic Kidney Disease, Psychotic Disorder, and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. A record review of Resident #3's Quarterly MDS with an ARD of 08/17/24, in Section C revealed a BIMS score of thirteen (13), which indicated Resident #3 was cognitively intact. Section GG indicated revealed the resident required substantial assistance for personal hygiene and supervision for toileting. During an interview on 09/23/24 at 4:35 PM, Registered Nurse (RN) #1 stated that CNAs were expected to make rounds every two (2) hours and provide incontinence care as needed. During an interview on 09/24/24 at 12:41 PM, the Risk Management Nurse confirmed that CNAs were expected to make rounds every two (2) hours to ensure residents' needs were met and call lights were within reach. During an interview on 09/25/24 at 12:05 PM, the Director of Nursing (DON) confirmed that CNAs were responsible for making rounds every two (2) hours and as needed. She stated that all residents' care instructions were documented in the Kardex within the facility's documentation software,' and CNAs had access to these instructions.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the Comprehensive Care Plan interventions were implemented for two (2) of five (5) sampled residents. Residents #2, and #3 Findings Include: A review of the facility policy titled Care Plans Comprehensive Person-Centered, reviewed January 2023, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . Resident #2 A record review of the comprehensive care plan for Resident #2 with a date initiated of 3/25/2020 revealed Focus: The resident has an ADL (activities of daily living) self-care performance deficit .Interventions/Task .Personal Hygiene: The resident requires ext (extensive) assistance x 1 staff with personal hygiene and oral care. Record review of the comprehensive care plan for Resident #2 with a date initiated of 3/7/2022 revealed Focus: The resident has a communication problem .Interventions/Task .Anticipate and meet needs. Record review of the comprehensive care plan with a date initiated of 3/25/2020 revealed Focus: The resident is at risk for falls .Interventions/Task .Anticipate and meet the resident's needs . Record review of the comprehensive care plan revealed with a date initiated of 3/25/2020 revealed The resident has .impairment to skin integrity .Interventions/Task .Provide peri care with each incontinent episode .anticipate and meet the resident's needs and ensure the resident's call light was within reach. On 9/23/24 at 1:25 PM, an observation of Resident #2 revealed the resident was kneeling at his bedside wearing a saturated incontinence brief that had sagged down to his lower thighs. On 9/23/24 at 2:05 PM, during an interview, Certified Nursing Assistant (CNA) #1 stated that she last checked Resident #2 for incontinence care before 11:00 AM. CNA #1 confirmed that Resident #2's care plan required incontinence with every incontinent episode, to prevent skin breakdown. CNA #1 stated that she returned from lunch at 1:29 PM but had not checked on Resident #2 until 1:50 PM. A record review of Resident #2's Admission Record revealed that the facility admitted the resident on 3/24/2020, The resident had diagnoses that included Cerebral Infarction (Stroke), Repeated Falls, and Malignant Neoplasm of the Bladder. A record review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/24 revealed in Section C, a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated Resident #2 was cognitively intact. Section GG indicated Resident #2 required moderate assistance for toileting hygiene. Section H indicated Resident #2 was frequently incontinent of bowel and bladder. Resident #3 A record review of the comprehensive care plan, undated, revealed Focus: .Prefers to have his urinal on his bedside table .Interventions: Assist with emptying urinal as needed . A record review of the comprehensive care plan, undated, revealed Focus: The resident is at risk for falls r/t (related to) weakness .Interventions .Anticipate and meet the resident's needs . A record review of the comprehensive care plan, undated revealed Focus: The resident has potential/actual impairment to skin integrity . Interventions .Provide peri-care every 2 hrs (hours) and prn (as needed). On 9/23/24 at 3:20 PM, an observation of Residents #3 revealed his room had a strong urine odor. Resident #3 was sitting up in bed on a saturated incontinence pad. There was a urinal and a pool of urine under the resident's bed. On 09/23/24 at 4:10 PM, as CNA #2 provided incontinence care to Resident #3, an observation revealed the incontinence pad was soaked with urine and feces. CNA #2 confirmed that she had last checked Resident #3's urinal and incontinence pad around 1:00 PM and had not provided care since then. A record review of Resident #3's Admission Record revealed that the facility admitted the resident on 11/29/21. The resident had diagnoses that included Stage 3 Chronic Kidney Disease, Psychotic Disorder, and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. A record review of Resident #3's Quarterly MDS with an ARD of 08/17/24, in Section C revealed a BIMS score of thirteen (13), which indicated Resident #3 was cognitively intact. Section GG indicated revealed the resident required substantial assistance for personal hygiene and supervision for toileting. On 9/25/24 at 12:05 PM, during an interview, the Director of Nursing (DON) confirmed that it was crucial for staff to follow each resident's care plan interventions and care instructions. The DON explained that all care plans were accessible via the facility's documentation software, generating care instructions available to CNAs through the Kardex. On 9/25/24 at 1:50 PM, the Minimum Data Set (MDS) Coordinator emphasized that following the care plan was essential, as it detailed the instructions for providing individualized care to each resident. She stated that if staff did not follow care-planned instructions for an incontinent resident, it could result in falls or skin damage.

Based on record review, resident and staff interview, and facility policy review the facility failed to notify the physician of a resident's severe pain rated initially at a ten (10) on a pain scale of (0-10) with 10 being the most severe for one (1) of four (4) sampled residents. Resident #2. Findings include: Record review of the facility policy titled Medication Policies, revised 10/1/19, revealed, .Procedure .12. When contacting the attending physician regarding a change in condition where it is likely the physician will order a medication, the nurse is to inform the physician of the availability of remote medications in the facility (i.e. the contents of the remote drug supply). This will facilitate timely drug administration . During a telephone interview on 6/6/24 at 12:20 PM, Resident #2 revealed that upon arrival/admission at the facility, she reported severe pain in her right hip. She reported that she did not receive any medication for pain until later in the evening. The resident was unable to recall the exact time but reported that it was hours after her arrival. She stated that the nursing staff was not responsive to her reports of pain. Record review of the Progress Notes dated 5/8/24 at 5:05 PM, revealed Resident transferred to facility .at 3:00 PM .due to right hip fracture .Resident is alert .oriented x (times) 4 .Resident reports pain 9 out of 10 on pain scale during assessment .Narcotic script .faxed to pharmacy . standing order for Acetaminophen 325 MG (milligrams) two (2) tablets every six (6) hours as needed . Record review of the Baseline Care Plan-V-2 revealed .B. Communication: 1. Can the resident communicate easily with staff? . Yes .2. Cognitive status: Cognitively intact .E. Pain: 5/08/24 at 4:58 PM .Most recent pain level: 10 . Resident admitted to facility for skilled services .aftercare following joint replacement surgery . Record review of the facility's electronic Medication Administration Record (eMAR) revealed Resident #2 received (1) tablet of Oxycodone-Acetaminophen 7.5-325 MG on 5/8/24 at 8:35 PM, (2) tablets of Acetaminophen 325 MG on 5/9/24 at 12:47 AM, (1) tablet of Oxycodone-Acetaminophen 7.5-325 MG on 5/9/24 at 2:55 AM and again at 8:56 AM. During an interview on 6/6/24 at 3:40 PM, Registered Nurse (RN) #1 confirmed that on 5/08/24 she had been on duty from 7:00 AM to approximately 5:15 PM. The nurse stated that at approximately 3:00 PM, Resident #2 had arrived at the facility, and she had conducted a pain assessment. RN #1 confirmed that Resident #2 had reported pain rated 9 on a 0-10 pain scale during her initial admission assessment. RN #1 confirmed that she had not administered any pain medication to Resident #2 on 5/08/24. She confirmed that the facility had a policy and procedure in place that addressed pain management which included reporting to the resident's primary healthcare provider for direction and informing the physician of the availability of remote medications in the facility. She confirmed that she had not notified the resident's primary healthcare provider regarding the resident's pain. During an interview on 6/6/24 at 6:11 PM, the Director of Nurses (DON) confirmed that in case pain was unrelieved by a resident's current pain regimen, the resident's nurse could notify the primary healthcare provider and report the resident's description of pain and make the provider aware of pain medications readily available. She confirmed that there was no documentation or indication of any report of unrelieved pain to the primary healthcare provider. During an interview on 6/06/24 at 6:20 PM, the Administrator confirmed that according to the documentation the resident complained of unrelieved pain not reported to the resident's primary healthcare provider on 5/08/24. Record review of the Admission Record for Resident #2 revealed the facility admitted the resident on 5/08/24, with diagnoses that included Aftercare Following Joint Replacement, Pain in right Hip, and Presence of Right Artificial Hip Joint.

Based on staff and resident interview, record review and facility policy review, the facility failed to respond and administer pain medication timely for a resident's complaint of severe pain rated initially at a ten (10) on a pain scale of (0-10) with 10 being the most severe for one (1) of four (4) sampled residents. Resident #2. Findings Include: Record review of the facility policy titled, Pain Management Program Policy, revised 10/22, revealed, The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management . Monitoring . 5. If a resident is experiencing pain during that shift, then pain medication and or alternative therapies should be administered as ordered . Additional Guidance . If pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated . Record review of the facility policy titled Medication Policies, revised 10/1/19, revealed, Subsection: Ordering and Receiving Medications from Pharmacy Subject: Remote Medication Kits (Emergency Kits) and Controlled (Narcotic) Kits or Safe, .An initial or STAT supply of medications for first dose and continued doses until next regular, scheduled delivery, is maintained in the facility in limited quantities by the provider pharmacy in a portable, sealed containers per state and federal regulations. Procedure .12. When contacting the attending physician regarding a change in condition where it is likely the physician will order a medication, the nurse is to inform the physician of the availability of remote medications in the facility (i.e. the contents of the remote drug supply). This will facilitate timely drug administration . On 6/6/24 at 12:20 PM, a telephone interview with Resident #2 revealed that upon arrival/admission at the facility, she reported severe pain in her right hip. She reported that she did not receive any medication for pain until later in the evening. The resident was unable to recall the exact time but reported that it was hours after her arrival. She stated that the nursing staff was not responsive to her reports of pain. Record review of the New Admit/Readmits Hospital Report Sheet, dated 5/8/24 regarding a Nurse-to-Nurse Phone Report, revealed the facility was made aware that Resident #2 had Pain issues prior to admission to the facility. The nursing staff was made aware that the last pain medication Resident #2 received prior to admission to the facility was on 5/8/24 at 12:15 PM. Record review of the hospital History and Physical dated 5/07/24 revealed that Resident #2 had right total hip arthroplasty (hip replacement) on 5/06/24. Record review of the Progress Notes dated 5/8/24 at 5:05 PM, revealed Resident transferred to facility .at 3:00 PM .due to right hip fracture .Resident is alert .oriented x (times) 4 .Resident reports pain 9 out of 10 on pain scale during assessment .Narcotic script .faxed to pharmacy . standing order for Acetaminophen 325 MG (milligrams) two (2) tablets every six (6) hours as needed . Record review of the Baseline Care Plan-V-2 revealed .B. Communication: 1. Can the resident communicate easily with staff? . Yes .2. Cognitive status: Cognitively intact .E. Pain: 5/08/24 at 4:58 PM .Most recent pain level: 10 . Resident admitted to facility for skilled services .aftercare following joint replacement surgery . Record review of the Order Summary Report, with active orders as of 5/8/24, revealed an order dated 5/8/24 Oxycodone-Acetaminophen Tablet 7.5-325 MG Give 1 (one) tablet by mouth every 6 (six) hours as needed for pain for 7 (seven) days. An additional order dated 5/8/24 revealed Acetaminophen Oral Tablet 325 MG . Give 2 (two) tablet by mouth every 6 hours as needed for pain. Record review of the facility's electronic Medication Administration Record (eMAR) revealed Resident #2 received (1) tablet of Oxycodone-Acetaminophen 7.5-325 MG on 5/8/24 at 8:35 PM, (2) tablets of Acetaminophen 325 MG on 5/9/24 at 12:47 AM, (1) tablet of Oxycodone-Acetaminophen 7.5-325 MG on 5/9/24 at 2:55 AM and again at 8:56 AM. On 6/6/24 at 3:15 PM, during an interview with Licensed Practical Nurse (LPN) #1 she confirmed that she was on duty on 5/08/24, when Resident #2 was admitted by the facility. She confirmed that she had not administered any pain medication to Resident #2 during her shift on 5/08/24. LPN #1 stated that she did not remember the resident's report of pain or an assessment regarding the resident's pain. LPN #1 revealed that pharmacy deliveries were usually made after 7:00 PM each evening. On 6/6/24 at 3:40 PM, an interview with Registered Nurse (RN) #1 confirmed that on 5/08/24 she had been on duty from 7:00 AM to approximately 5:15 PM. The nurse stated that at approximately 3:00 PM, Resident #2 had arrived at the facility, and she had conducted a pain assessment. She confirmed that the resident had a written physician's prescription with her upon arrival for Oxycodone/Acetaminophen 7.5-325 MG one (1) tablet by mouth every 6 hours as needed for pain and she had faxed the prescription to the facility pharmacy. RN #1 confirmed that Resident #2 had reported pain rated 9 on a 0-10 pain scale during her initial admission assessment. She stated that Resident #2 also had physician orders for Acetaminophen 325 MG two (2) tablets by mouth every six (6) hours as needed for pain. RN #1 confirmed that she had not administered any pain medication to Resident #2 on 5/08/24, as she was the RN Supervisor, not the resident's medication nurse. She confirmed that the facility had a policy and procedure in place that addressed pain management which included reporting to the resident's primary healthcare provider for direction and informing the physician of the availability of remote medications in the facility, although she said she was not sure which medications were in the emergency medication kit. She confirmed that she had not notified the resident's primary healthcare provider regarding the resident's pain. On 6/6/24 at 6:11 PM, an interview with the Director of Nurses (DON) and record review of the New Admit/Readmits Hospital Report Sheet, for Resident #2 revealed that the DON had taken the telephone report from a nurse at the hospital regarding discharge and history and physical for Resident #2. She indicated that she had recorded that the hospital nurse had reported the last pain medication (medication name not included) administration at the hospital was at 12:15 PM on 5/08/24. The DON confirmed that based on her notes the resident could have Oxycodone-Acetaminophen 7.5-325 MG at 6:30 PM on 5/08/24. She confirmed that in case pain was unrelieved by a resident's current pain regimen, the resident's nurse could notify the primary healthcare provider and report the resident's description of pain and make the provider aware of pain medications readily available. She confirmed that there was no documentation or indication of any report of unrelieved pain to the primary healthcare provider. The DON confirmed that the resident had a total hip replacement surgery on 5/06/24. She confirmed that there was documentation of a report of pain rated 9 on a 0-10 pain scale during initial assessment and no documentation of administration of pharmacological or non-pharmacological pain management interventions for Resident #2 from 3:00 PM until 8:35 PM on 5/08/24. She confirmed that the facility had a policy and procedure for pain management which included notification of the resident's primary healthcare provider who could call in a prescription in accordance with the provider's determination of need and if available the medication could be retrieved from the emergency medication kit or delivered to the facility by the pharmacy. On 6/06/24 at 6:20 PM, an interview with the Administrator revealed that nurses were responsible for pain assessments for new and existing residents. She said she was not aware that Resident #2's physician orders for Oxycodone-Acetaminophen 7.5-325 MG was not administered per orders at 6:15 PM on 5/08/24. She confirmed that the facility had procedures in place to obtain medications for new residents to be administered in a timely manner according to physician's orders. She confirmed that according to the documentation the resident complained of unrelieved pain not reported to the resident's primary healthcare provider on 5/08/24. Record review of the contents of the facility's EDK (Emergency Drug Kit) revealed the kit contained Oxycodone-Acetaminophen 5-325 mg and Oxycodone-Acetaminophen 10-325 mg. Record review of the Admission Record for Resident #2 revealed the facility admitted the resident on 5/08/24, with diagnoses that included Aftercare Following Joint Replacement, Pain in right Hip, and Presence of Right Artificial Hip Joint.

CI MS # Based on record review, policy/procedure review, and interview, the facility failed to ensure that the Therapeutic Diet care plan was followed for one (1) of 10 residents, Resident #1, as evidenced by on 6/22/18, Resident #1, who had orders and a care plan for nothing by mouth (NPO), was served and fed a breakfast meal by Certified Nursing Assistant (CNA) #1. Resident #1 choked on the food and required the [MEDICATION NAME] maneuver to clear her airway to prevent Asphyxiation. She also required medical intervention of antibiotics for Aspiration Pneumonia. The failure to ensure the care plan was followed to keep a resident NPO, per physician's orders [REDACTED]. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 6/22/18, when Resident #1 was fed a meal tray and had orders and a care plan for nothing by mouth. The facility's Administrator was notified of the IJ and SQC on 7/12/18. The facility submitted a credible Allegation of Compliance (AoC) on 7/13/18, in which the facility alleged all corrective actions to remove the IJ were completed on 7/12/18, and the IJ removed as of 7/13/18. The State Agency validated the facility's AoC and determined all corrective actions were completed by the facility on 7/12/18, and the IJ was removed, prior to exit. Therefore, the scope and severity for the IJ at CFR 483.21 (b)(1), F656; Comprehensive Care Plans, was lowered to a D while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. FINDINGS INCLUDE: Review of the facility's Care Plan policy, not dated, revealed, The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. Review of the Nurse Aide's Information Sheet, also named the CNA Care Card, documented that Resident #1 was NPO and tube fed. Review of Resident #1's Baseline Nursing Care Plan, dated 6/20/18, documented the resident's dietary orders included NPO and a tube feeder. Record review revealed that Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of the facility's 6/22/18 incident report and investigation revealed that on 6/22/18, at approximately 7:45 AM, CNA #1 delivered a meal tray to Resident #1, who had orders to be NPO. CNA #1 assisted Resident #1 in eating and Resident #1 began to choke. CNA #1 notified RN #1, who entered Resident #1's room and initiated the [MEDICATION NAME] maneuver until Resident #1 expelled the food particles. RN #1 and CNA #1 stated that there was not a tray card on the tray identifying whose tray it belonged to; rather there was a card on the tray that read, Begin new cart. Review of Resident #1's medical record revealed a Chest X-Ray ordered on [DATE], after the choking incident for Resident #1 was reported to Nurse Practitioner (NP) #1. The results of this X-Ray revealed, Conclusion: Modest right upper lobe density, possibly infectious process. The Physician ordered [MEDICATION NAME] 500 milligram (mg) for seven (7) days. Review of NP #2's documented assessment, dated 6/23/18, revealed she reviewed the Chest X-Ray and documented an Aspiration Pneumonia diagnosis. She discontinued the [MEDICATION NAME] antibiotic and ordered [MEDICATION NAME] 300 mg by mouth (PO) two (2) times a day (BID) for 10 days, Metranidazole 500 mg PO every (Q) eight (8) hours for 10 days, O2 at two (2) liters by nasal cannula, and hold therapy until Monday. Interview with CNA #1 on 7/11/18 at 11:20 AM, revealed she was trained on matching the menu card to the resident, looking at the menu card, where to find the resident room number, and if it is a door bed or window bed. She stated that she was trained on Care Cards before starting to work with residents on the floor. She stated that there was a menu card on the meal tray she fed Resident #1 on 6/22/18, but the nurse went back and couldn't find it. She stated the name on the card was (name belonged to no resident in the facility). CNA #1 stated that the menu card was for Resident #1's bed and room number. CNA #1 stated the meal was grits, eggs, and a cinnamon roll and the roll was not pureed. She stated she was positive it was a cinnamon roll. CNA #1 stated she didn't think she had done anything wrong because she had read the menu card that was on that tray. She stated, I just matched the bed and room number. She stated that was the first time working with Resident #1. CNA #1 stated that the meal wasn't pureed but there were thickened liquids in cartons on the tray. She stated that she started to feed the resident and the resident began coughing and didn't stop once patted on the back, so she got the nurse. CNA #1 stated food came out of the resident's mouth after the nurse performed the [MEDICATION NAME]. CNA #1 did not acknowledge reviewing the Care Card prior to feeding the resident, only the menu card that had the resident's room and bed number. Interview with the Director of Nursing (DON) on 7/11/18 at 9:40 AM, revealed that prior to Resident #1's choking incident on 6/22/18, the CNA Care Card was how CNA's would know if any resident was NPO. The DON stated, Part of initial CNA training is to pull the Care Card of a Resident if not certain of a diet. She stated that CNAs are trained to not deliver a meal tray that does not have a meal/menu card on it. The DON stated, The CNA Care Card is the CNA Care Plan. Interview with the DON on 7/11/18 at 10:08 AM, revealed, Nurses update the CNA Care Cards. They are updated when changes are ordered. CNA Care Cards are started on admission for each resident. Further interview with the DON on 7/11/18 at 3:10 PM, revealed that prior to this incident the only therapeutic diets listed on the CNA care cards were NPO, Peg Tube Fed, and Thickened Liquids. She stated that CNA's relied on menu/tray cards or nurses to know any other type of therapeutic diet for other residents. Interview with the DON on 7/22/18 at 4:00 PM, revealed she expected the CNA to review the Care Card prior to beginning the shift, in case there were any changes in care. She stated that CNA #1 had admitted she didn't review Resident #1's Care Card prior to serving her breakfast meal on 6/22/18. Interview with Risk Manager #1 on 7/11/18 at 2:28 PM, revealed that CNA Care Cards are reviewed with new CNA's during their training on hire; it covers where to find each resident's care information on the Care Card. Interview with Minimum Data Set Nurse #1 (MDS) on 7/11/18 at 2:45 PM, revealed, We do a baseline care plan on admit and a comprehensive in five (5) days. She stated if there is a care plan intervention change, they are updated on the computer; floor nurses up-date Care Cards with changes. The MDS Nurse stated that any order changes are then discussed in standup and changes made in the computer, if not done already. The facility provided an Allegation of Compliance (AoC) on 7/13/18: At Approximately 11:20 AM on (MONTH) 12, (YEAR), the Administrator was notified by the surveyor that an immediate jeopardy was being called. The facility respectfully submits this allegation of compliance (A[NAME]). 1. On (MONTH) 22, (YEAR), at approximately 7:45 AM, CNA #1 delivered a tray to Resident #1 with an order to be NPO. CNA #1 proceeded to assist Resident #1 in eating. Resident #1 began to choke. CNA #1 notified RN #1 and RN #1 entered Resident #1's room and initiated the [MEDICATION NAME] maneuver for approximately twenty seconds until Resident #1 expelled the food particles. RN #1 and CNA #1 stated that there was not a tray card on the tray identifying whose tray it belonged to; rather there was a tray card that stated, Begin new cart. 2. On (MONTH) 22, (YEAR), at approximately 8:00 AM, RN #1 notified Nurse Practitioner #1, who was on site, of the incident and an order for [REDACTED].#1 was notified on (MONTH) 22, (YEAR) at approximately 8:30 AM, and Vital Stem treatment for [REDACTED]. The conclusion of the Chest X-Ray read, Modest infiltrate in the right upper lobe, possibly infectious process. Upon result of the chest X-Ray on (MONTH) 22, (YEAR), at approximately 1:32 PM, Physician #1, who is also Medical Director #1, was notified of the incident. At that time, he ordered [MEDICATION NAME] 500 mg for 7 days via peg tube beginning on (MONTH) 22, (YEAR), and ordered a repeat Chest X-Ray to be completed on (MONTH) 26, (YEAR). On (MONTH) 23, (YEAR) at approximately 10:00 AM, NP #2 assessed Resident. NP #2 discontinued the order for [MEDICATION NAME] and gave the following new orders: [MEDICATION NAME] 1 cap BID X 10 days, [MEDICATION NAME], O2 at 2L (two liters) via nasal cannula, PRN monitoring of O2 Saturation with parameters to notify MD if O2 saturations drop below 90% and to hold therapy until (MONTH) 25, (YEAR). 3. Five (5) unsuccessful attempts were made by DON #1 to notify the Responsible Party. The second contact, who is the grandson and is actively involved, was notified on (MONTH) 22, (YEAR), at approximately 4:30 PM, by DON #1. 4. A Repeat Chest X-Ray was completed on (MONTH) 26, (YEAR) and at approximately 12:18 PM, results concluded that there was no acute findings in the chest and finding improved from (MONTH) 22, (YEAR). Due to a history of Resident #1 requesting food and water while being on an NPO diet, as well as her psychiatric diagnosis, the Psychiatric NP #1 assessed resident on (MONTH) 29, (YEAR). 5. On (MONTH) 22, (YEAR), at approximately 4:54 PM, an audit of C.N.A. care cards versus diet orders was initiated for 100% of census. (Care cards are the care plan for Certified Nursing Assistants). Risk Manager #1 completed the audit. Residents who were NPO (Nothing by Mouth) had NPO diet listed on their care cards already, however all other diet orders were not listed. All diet orders were added to C.N.A. care cards by Risk Manager #1 on (MONTH) 22, (YEAR) by handwriting them on the paper C.N.A. care cards. 6. On (MONTH) 22, (YEAR), at approximately 4:46 PM, an audit of care plans for residents with NPO diet orders confirmed that NPO diets were care planned. Audit was completed by MDS #1. 7. On (MONTH) 22, (YEAR), at approximately 4:54 PM, an initial tray card versus diet order versus actual food served audit was initiated by Risk Manager #1 and Staff Development Coordinator #1 during the evening delivery of meal trays to ensure that residents received the appropriate diet. Findings of the audit included six (6) diet order discrepancies that were corrected at the time of finding and placed on care cards. 8. On (MONTH) 22, (YEAR), at approximately 8:15 PM, all new admission diet orders from (MONTH) 20, (YEAR) to (MONTH) 22, (YEAR) were checked for accuracy with no adverse findings. Audit was completed by ADON #1. 9. On (MONTH) 22, (YEAR), at approximately 7:13 PM, a new process of using orange circular stickers used to visually identify residents with a diet order of NPO was initiated. These orange circular stickers were placed on the outside of the residents rooms by the name tag for six (6) of six (6) residents who had an order for [REDACTED].#1 applied the stickers. 10. On (MONTH) 22, (YEAR), at approximately 5:19 PM, Staff Development Coordinator #1 initiated an in-service titled, Education on Diet for Residents with Nursing, Activity, Social Services, and Administrative departments. Education material included excerpts from Chapter 17, Assisting with Nutrition, of the How to Be a Nurse Assistant, Integrating Excellence in Training with Quality of Care manual, as well as protocol related to the orange circular sticker visually identifying residents with an NPO order. Upon initiation of in-service, staff was notified that each had to receive the information prior to returning to work their next scheduled shift. 139 of 176 employees have been in-serviced. 36 of those employees had not worked after the incident and were terminated. One (1) employee has not been in-serviced and will not be allowed to return to work until the in-service is completed. 11. On (MONTH) 22, (YEAR) at approximately 9:30 AM, Cook #1 completed an in-service on the process of comparing tray tickets to the diets being loaded on the cart on (MONTH) 22, (YEAR) with five (5) of 14 dietary employees. 12. An audit was completed by Dietary Manager #1 and Dietary Employee #1 on (MONTH) 23, (YEAR) at 4:18 PM, of the Meal Tracker diet order system to facility's Diet Orders in Point Click Care electronic health care record system. Summary of audit findings: Seven (7) residents' diet orders were clarified between nursing and dietary systems. The findings were added to the care card. 13. A Quality Assurance (QA) meeting was held with Medical Director #1, Director of Nursing #1, Administrator #1, risk Manager #1, and Staff Development Coordinator #1 on (MONTH) 22, (YEAR) at 5:53 PM. During this QA meeting, the incident and initial investigation findings were discussed. There were no new policy changes, however a new protocol was adopted on (MONTH) 22, (YEAR), regarding implementing a system to identify Residents that are NPO. An action plan was developed including: 100% audit of Resident's Diet order to Care Cards to be completed (MONTH) 22, (YEAR) by Risk Manager #1 and again (MONTH) 24, (YEAR) by Risk Manager #1 and RN #2; Care Plans for Residents with an NPO order to be reviewed and revised on (MONTH) 22, (YEAR) by MDS #1, 100% audit of tray cards to diet order on the evening meal of (MONTH) 22, (YEAR) by Risk Manager #1 and RN #2; and an audit of resident diet orders to tray tickets on (MONTH) 23, (YEAR) to be completed by Dietary Manager #1. Meal tray audits of tray tickets to diet orders were scheduled once a day for seven (7) days beginning on (MONTH) 22, (YEAR); Review of the initiation of education with Nursing, Activity, Social Services, and Administrative Departments regarding the new system to identify residents that are NPO, importance of verifying tray cards, verifying care cards, risks of aspiration pneumonia and how to respond in and emergent situation. Dietary employees were to begin an initial in-service on the process of comparing tray tickets to diets being loaded into cart. Five (5) Dietary Employees of 14 total Dietary Employees were in-serviced on (MONTH) 22, (YEAR) by Cook #1. In-service was continued by Dietary Manager #1 on (MONTH) 10, (YEAR) with 12 Dietary employees of 14 total Dietary employees. On (MONTH) 12, (YEAR), 11 of 14 dietary employees were re-trained on this information by Registered Dietician #1 with subsequent test that all 11 employees passed. The three (3) remaining employees will not return until training is received and they pass the test. 14. A Quality Assurance meeting was held with Medical Director #1, Administrator #1, Director of Nursing #1, Social Services Director #1, Social Services Assistant #1, Dietary Manager #1, Activity Director #1, director of Rehabilitation #1, Staff Development Coordinator #1, Maintenance Director #1, Business Office Manager #1, Business Office Assistant #1, Housekeeping Director #1, MDS #1, Medical Records Director #1, ADON #1, Risk Manager #1, ADON #2, Case Manager #1, Assistant Administrator #1, Human Resources #1 on (MONTH) 12, (YEAR) at 12:03 PM. During this QA meeting the incident (for Resident #1) was reviewed. The team was notified that an Immediate Jeopardy had been issued. Additional education was planned for Dietary department. An audit schedule of tray tickets to diet orders in the dietary department was completed on (MONTH) 12, (YEAR) by Registered Dietician #1. On (MONTH) 9, (YEAR), Administrator #1 completed an audit of the orange stickers to identify three (3) of three (3) residents' with order for NPO. 15. On (MONTH) 22, (YEAR), at approximately 11:30 AM, CNA #1 received a verbal warning by DON #1 and Case Manager #1 regarding failure to verify a tray card prior to feeding a resident resulting in a choking episode. CNA #1 was contacted by Administrator #1, DON #1 and Risk Manager #1 on (MONTH) 22, (YEAR) at approximately 5:15 PM, for further interview. At the end of the interview, CNA #1 was suspended pending investigation by the Administrator #1. Upon completion of the facility investigation, it was determined that it was an isolated incident, in which CNA #1 of her own accord, failed to verify the tray card prior to delivering and assisting a meal tray to a resident. CNA #1's employment was terminated by Administrator #1 and DON #1 on (MONTH) 25, (YEAR), at approximately 4:45 PM. 16. Incident was called in by Director of Nursing #1 to the Mississippi State Department of Health Licensure and certification on (MONTH) 22, (YEAR) at 9:00 PM. The incident was reported to the Office of the Attorney General on (MONTH) 22, (YEAR), at 10:20 PM. On (MONTH) 25, (YEAR), the written report was submitted by the Administrator to the Mississippi State Department of Health at approximately 5:55 PM and to the Office of the Attorney General at approximately 5:57 PM. 17. Registered Dietician #1 was in-serviced by Risk Manager #1 on in-service material discussed during (MONTH) 12, (YEAR) QA. Registered Dietician #1 in turn in-serviced 11 of 14 Dietary employees on, Tray line assembly, orange dot for NPO residents, diet requisitions for residents, diet changes/discharges. The remaining three (3) employees who have not been in-serviced on the material will not be allowed to return to work until they do. 18. An audit of Tray Card to Diet Orders to actual food served was completed on the following date, per action plan schedule, by Administrator #1, Director of Nursing #1, Risk Manager #1, and Staff Development Coordinator #1: (MONTH) 22, (YEAR); (MONTH) 23, (YEAR); (MONTH) 24, (YEAR); (MONTH) 25, (YEAR); (MONTH) 26, (YEAR); (MONTH) 27, (YEAR), (MONTH) 28, (YEAR); (MONTH) 3, (YEAR); (MONTH) 5, (YEAR); (MONTH) 6, (YEAR); (MONTH) 10, (YEAR). The areas that were identified throughout the audits include discharged residents trays being sent out, diet type order clarifications needed, and tray card room numbers. Issues identified were corrected and findings reported to the QA Committee on (MONTH) 12, (YEAR). 19. Facility is alleging that all activities to remove the immediate jeopardy were completed as of (MONTH) 12, (YEAR), and the Immediate Jeopardy was removed as of (MONTH) 13, (YEAR). VALIDATION of the Allegation of Compliance: 1. The State Agency (SA) validated through record review and staff interviews that on (MONTH) 22, (YEAR), at approximately 7:45 AM, CNA #1 delivered a meal tray to Resident #1, who had orders to be NPO. CNA #1 assisted Resident #1 in eating. Resident #1 began to choke, CNA #1 notified RN #1 and RN #1 initiated the [MEDICATION NAME] maneuver until Resident #1 expelled the food particles. RN #1 and CNA #1 initially reported that there was not a tray card on the tray identifying whose tray it belonged to; rather there was a tray card that stated, Begin new cart. 2. Through interview and record review, the SA validated that on (MONTH) 22, (YEAR), RN #1 notified Nurse Practitioner #1, of the incident and an order for [REDACTED].#1 was notified on (MONTH) 22, (YEAR) and Vital Stem treatment for [REDACTED]. Record review revealed the Chest X-Ray read, Modest infiltrate in the right upper lobe, possibly infectious process. Upon result of the chest X-Ray on (MONTH) 22, (YEAR), Physician #1, who is also Medical Director #1, was notified of the incident and he ordered [MEDICATION NAME] 500 milligram (mg) for seven (7) days via feeding tube beginning on (MONTH) 22, (YEAR), and ordered a repeat Chest X-Ray to be completed on (MONTH) 26, (YEAR). On (MONTH) 23, (YEAR) NP #2 assessed Resident and discontinued the order for [MEDICATION NAME] and gave the following new orders: [MEDICATION NAME] 1 cap BID X 10 days, [MEDICATION NAME], O2 at 2L via nasal cannula, PRN monitoring of O2 Saturation with parameters to notify MD if O2 saturations drop below 90% and to hold therapy until (MONTH) 25, (YEAR). 3. The SA validated through record review and interview that there five (5) unsuccessful attempts were made by DON #1 to notify the Responsible Party. The second contact was notified on (MONTH) 22, (YEAR), by DON #1. 4. Through record review and interviews, the SA validated that a repeat Chest X-Ray was completed on (MONTH) 26, (YEAR), and results concluded that there was no acute findings in the chest and finding improved from (MONTH) 22, (YEAR). Due to a history of Resident #1 requesting food and water while being on an NPO diet, as well as her psychiatric diagnosis, Psychiatric NP #1 assessed resident on (MONTH) 29, (YEAR). 5. The SA validated through interviews and record review that on (MONTH) 22, (YEAR), an audit of CNA Care Cards versus diet orders was initiated for 100% of the census by Risk Manager #1. All diet orders were added to CNA Care Cards by Risk Manager #1 on (MONTH) 22, (YEAR) by handwriting them on the paper CNA Care Cards. 6. Through record review and interviews, the SA validated that on (MONTH) 22, an audit of care plans for residents with NPO diet orders confirmed that all NPO diets were care planned. Audit was completed by MDS #1. No problems were identified during survey with current Care Cards. 7. The SA validated through interviews and record review that on (MONTH) 22, (YEAR), an initial tray card versus diet order versus actual food served audit was initiated by Risk Manager #1 and Staff Development Coordinator #1 during the evening delivery of meal trays to ensure that residents received the appropriate diet. Findings of the audit included six (6) diet order discrepancies that were corrected at the time of finding and place on care cards. No discrepancies were noted during survey during observation and record review. 8. Through record review and interview, the SA validated that on (MONTH) 22, (YEAR), all new admissions diet orders from (MONTH) 20, (YEAR) to (MONTH) 22, (YEAR) were checked for accuracy with no adverse findings. Audit was completed by ADON #1. Review of two (2) new admission records, since survey, revealed diets and care cards and care plans were congruent. 9. The SA validated through record review, interviews and observation that on (MONTH) 22, (YEAR), a new process of using orange circular stickers used to visually identify residents with a diet order of NPO was initiated. These orange circular stickers were placed on the outside of the residents rooms by the name tag for six (6) of six (6) residents who had an order for [REDACTED].#1 applied the stickers. Observation revealed all residents with NPO orders had orange stickers on the name tag of resident doors and on the Care Cards. 10. The SA validated through interviews and record review that on (MONTH) 22, (YEAR), the Staff Development Coordinator #1 initiated an in-service titled, Education on Diet for Residents with Nursing, Activity, Social Services, and Administrative departments. Education material included excerpts from Chapter 17, Assisting with Nutrition, of the How to Be a Nurse Assistant, Integrating Excellence in Training with Quality of Care manual, as well as protocol related to the orange circular sticker visually identifying residents with an NPO order. Upon initiation of in-service, staff was notified that each had to receive the information prior to returning to work their next scheduled shift. 139 of 176 employees have been in-serviced. Thirty six of those employees had not worked after the incident and were terminated. One (1) employee had not been in-serviced and was not allowed to return to work until the in-service was completed. 11. Through record review and interview, the SA validated that on (MONTH) 22, (YEAR), Cook #1 completed an in-service on the process of comparing tray tickets to the diets being loaded on the cart on (MONTH) 22, (YEAR) with five (5) of 14 dietary employees. 12. Through record review and interview, the SA validated that an audit was completed by Dietary Manager #1 and Dietary Employee #1 on (MONTH) 23, (YEAR) of the Meal Tracker diet order system to facility's Diet Orders in Point Click Care electronic health care record system. Summary of audit findings: seven (7) residents' diet orders were clarified between nursing and dietary systems. The findings were added to the Care Card. No concern was noted/observed during survey. 13. The SA validated through record review and interviews that a Quality Assurance (QA) meeting was held with Medical Director #1, Director of Nursing #1, Administrator #1, risk Manager #1, and Staff Development Coordinator #1 on (MONTH) 22, (YEAR) at 5:53 PM. During this QA meeting, the incident and initial investigation findings were discussed. There were no new policy changes, but a new protocol was adopted on (MONTH) 22, (YEAR), regarding implementing a system to identify Residents that are NPO. An action plan was developed including: 100% audit of Resident's Diet order to Care Cards to be completed (MONTH) 22, (YEAR) by Risk Manager #1 and again (MONTH) 24, (YEAR) by Risk Manager #1 and RN #2; Care Plans for Residents with an NPO order to be reviewed and revised on (MONTH) 22, (YEAR) by MDS #1, 100% audit of tray cards to diet order on the evening meal of (MONTH) 22, (YEAR) by Risk Manager #1 and RN #2; and an audit of resident diet orders to tray tickets on (MONTH) 23, (YEAR) to be completed by Dietary Manager #1. Meal tray audits of tray tickets to diet orders were scheduled once a day for seven (7) days beginning on (MONTH) 22, (YEAR); Review of the initiation of education with Nursing, Activity, Social Services, and Administrative Departments regarding the new system to identify residents that are NPO, Importance of verifying tray cards, verifying Care Cards, risks of Aspiration Pneumonia and how to respond in and emergent situation; Dietary employees were to begin an initial in-service on the process of comparing tray tickets to diets being loaded into cart. Five (5) Dietary Employees of 14 total Dietary Employees were in-serviced on (MONTH) 22, (YEAR), and 12 Dietary employees of 14 total Dietary employees were in-service by the Dietary Manager on (MONTH) 10, (YEAR). On (MONTH) 12, (YEAR), documentation showed that 11 of 14 dietary employees were re-trained on this information by Registered Dietician #1 with a subsequent test that all 11 employees passed. The three (3) remaining employees did not return until training was received and they passed the test. 14. Through record review and interviews, the SA validated that a Quality Assurance meeting was held with Medical Director #1, Administrator #1, director of Nursing #1, Social Services Director #1, Social Services Assistant #1, Dietary Manager #1, Activity Director #1, director of Rehabilitation #1, Staff Development Coordinator #1, Maintenance Director #1, Business Office Manager #1, Business Office Assistant #1, Housekeeping Director #1, MDS #1, Medical Records Director #1, ADON #1, Risk Manager #1, ADON #2, Case Manager #1, Assistant Administrator #1, Human Resources #1 on (MONTH) 12, (YEAR) at 12:03 PM. During this QA meeting the choking incident was reviewed. The team was notified that an Immediate Jeopardy had been issued. Additional education was planned for the Dietary department. An audit schedule of tray tickets to diet orders in the dietary department was completed on (MONTH) 12, (YEAR) by Registered Dietician #1. On (MONTH) 9, (YEAR), Administrator #1 completed an audit of the orange stickers and identified three (3) of three (3) residents' with an order for [REDACTED].>15. Through record review and interviews, the SA confirmed that on (MONTH) 22, (YEAR), CNA #1 received a verbal warning by DON #1 and Case Manager #1 regarding failure to verify a tray card prior to feeding a resident, resulting in a choking episode. CNA #1 was contacted by Administrator #1, DON #1 and Risk Manager #1 on (MONTH) 22, (YEAR), for further interview. At the end of the interview, CNA #1 was suspended pending investigation by Administrator #1. Upon completion of the facility investigation, it was determined that it was an isolated incident, in which CNA #1 of her own accord, failed to verify the tray card and Care Card, prior to delivering and assisting a meal tray to a resident. CNA #1's employment was terminated by Administrator #1 and DON #1 on (MONTH) 25, (YEAR). 16. The SA validated through record review and interviews that the choking incident for Resident #1 was called in by Director of Nursing #1 to the Mississippi State Department of Health Licensure and certification on (MONTH) 22, (YEAR) at 9:00 PM, with a written report on 6/25/18. The SA validated through record review and interview that the incident was reported to the Office of the Attorney General on (MONTH) 22, (YEAR), at 10:20 PM, with a written report on (MONTH) 25, (YEAR). 17. The SA validated through record review and interview that the Registered Dietician #1 was in-serviced by Risk Manager #1 on in-service material discussed during (MONTH) 12, (YEAR) QA. Registered Dietician #1 in turn in-serviced 11 of 14 Dietary employees on, Tray line assembly, orange dot for NPO residents, diet requisitions for residents, diet changes/discharges. The SA validated through record review and interview that the remaining three (3) employees, who had not been in-serviced on the material, was not allowed to return to work until they received training. 18. Through record review and interviews, the SA validated that an audit of Tray Card to Diet Orders to actual food served was completed on the following dates, per action plan schedule, by Administrator #1, Director of Nursing #1, Risk Manager #1, and Staff Development Coordinator #1: (MONTH) 22, (YEAR); (MONTH) 23, (YEAR); (MONTH) 24, (YEAR); (MONTH) 25, (YEAR); (MONTH) 26, (YEAR); (MONTH) 27, (YEAR), (MONTH) 28, (YEAR); (MONTH) 3, (YEAR); (MONTH) 5, (YEAR); (MONTH) 6, (YEAR); (MONTH) 10, (YEAR). the areas that were identified throughout the audits include discharged residents trays being sent out, diet type order clarifications needed, and tray card room numbers. The SA validated through record review and interviews that Issues identified were corrected and findings reported to the QA Committee on (MONTH) 12, (YEAR). 19. The SA validated through interview and record review that the facility completed all activities to remove the Immediate Jeopardy as of (MONTH) 12, (YEAR) and the IJ was removed as of (MONTH) 13, (YEAR). The SA interviews for validation included one (1) RN DON, one (1) RN Assistant DON, one (1) RN Risk Manager, 15 Certified Nursing Assistants, eight (8) Licensed practical Nurses, one (1) LPN Medical Records Nurse, four (4) Registered Nurses, two (2) MDS Registered Nurses, two (2) MDS Licensed Practical Nurses, one (1) Social Service, two (2) Activity employees, and eight (8) Dietary employees.

CI MS # Based on observation, interview, record review, and policy/procedure review, the facility failed to ensure a resident with Nothing by Mouth (NPO) orders was not served a diet, in any form, for one (1) of 10 residents reviewed, Resident #1. On 6/22/18, Resident #1, who had orders for NPO, was served and fed portions of a breakfast meal by Certified Nursing Assistant (CNA) #1 and the resident choked, resulting in Aspiration Pneumonia and antibiotic treatment. Resident #1 had a therapeutic diet of [MEDICATION NAME] 1.2 per Percutaneous Endoscopic Gastrostomy (PEG) tube only, and was to receive nothing by mouth due to a history Dysphagia. The failure to ensure a resident with NPO status did not get a meal tray had caused, or was likely to cause, this resident or other residents with NPO status, serious injury, harm, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 6/22/18, when Resident #1 was fed a meal tray and had orders for nothing by mouth, resulting in the resident choking, requiring medical intervention. The facility's Administrator was notified of the IJ and SQC on 7/12/18. The facility submitted a credible Allegation of Compliance (AoC) on 7/13/18, in which the facility alleged all corrective actions to remove the IJ were completed on 7/12/18, and the IJ removed as of 7/13/18. The State Agency validated the facility's AoC and determined all corrective actions were completed by the facility on 7/12/18, and the IJ was removed, prior to exit. Therefore, the scope and severity for the IJ at CFR 483.25 (g) (1) - (3), F692, Assisted Nutrition and Hydration; was lowered to a D while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. FINDINGS INCLUDE: Review of the facility's Therapeutic Diets policy/procedure, undated, revealed, All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. One (1) of the documented purposes of the therapeutic diet is to provide food that a resident can eat. Procedure: 2. The licensed Nurse completes and signs the Diet Requisition Form, including the full diet order, food allergies and specific food preference requests. 3. Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care. (This would include tube feeding and NPO diets.) Review of documentation on facility letterhead, and signed by the Director of Nursing, dated 7/23/18, revealed the facility did not have a specific policy to address NPO status of residents. Record review revealed that Resident #1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the 6/22/18 facility incident report, facility investigative report, and written report to the State Agency revealed that on (MONTH) 22, (YEAR), at approximately 7:45 AM, CNA #1 delivered a meal tray to Resident #1, who had an order to be NPO. CNA #1 fed the resident a bite of grits and eggs and then a piece of cinnamon roll. Resident #1 began to choke. CNA #1 notified RN #1, who entered Resident #1's room and initiated the [MEDICATION NAME] maneuver until Resident #1 expelled the food particles. The resident received a chest X-ray, which revealed Aspiration Pneumonia, and was prescribed Antibiotics and Oxygen (O2). RN #1 and CNA #1 initially reported that there was not a tray card identifying who was to receive the meal tray; rather there was a card that stated, Begin new cart. CNA #1 was terminated on 6/25/18, for poor work performance. Record review of the menu for 6/22/18, at breakfast, revealed the food was Scrambled Eggs, Bacon, and Cinnamon Roll. Review of the Hospital discharge orders, dated 6/20/18, documented Resident #1 was NPO until therapy evaluation, and was PEG tube fed. Review of the physician's orders [REDACTED].#1 was to have a diet of nothing by mouth (NPO). Orders were for a tube feeding of [MEDICATION NAME] 1.2 at 45 cubic centimeters (cc) per hour for 22 hours daily. Review of the Nurse Aide's Information Sheet also named the CNA Care Card, documented that Resident #1 was NPO and tube fed. Review of a Diet Requisition form, dated 6/20/18, documented, New Admission and Resident #1's correct room number and bed number. It did not have the name of Resident #1 under the Resident Name section. Under the Comments section, documentation included, NPO-Peg Tube. Review of Resident #1's medical record revealed a STAT (immediate) Chest X-Ray ordered on [DATE], after the choking incident for Resident #1 was reported to Nurse Practitioner (NP) #1. The results of this X-Ray revealed, Conclusion: Modest right upper lobe density, possibly infectious process. The physician was notified of the incident and ordered [MEDICATION NAME] 500 milligram (mg) for seven (7) days. Review of NP #2's documented assessment, dated 6/23/18, revealed she reviewed the Chest X-Ray and gave the [DIAGNOSES REDACTED]. She discontinued the [MEDICATION NAME] antibiotic order and ordered [MEDICATION NAME] 300 mg by mouth (PO) two (2) times a day (BID) for 10 days, Metranidazole 500 mg PO every (Q) eight (8) hours for 10 days, O2 at two (2) liters by nasal cannula, and hold therapy until Monday. Interview and observation of Resident #1 on 7/10/18 at 7:45 AM, revealed the resident was alert and asked for water each time a question was asked. [MEDICATION NAME] 1.2 infused at 45 cc per hour per pump. No food tray was in the resident's room. Interview with CNA #1 on 7/11/18 at 11:20 AM, revealed she was trained on matching the menu card to the resident, looking at the menu card, where to find the resident room number, and if it is a door bed or window bed. She stated that she was trained on Care Cards before starting to work with residents on the floor. She stated she had been thinking about everything and recalled reading the menu card that was on the tray that she fed Resident #1 (on 6/22/18). She stated that there was a menu card on that tray, but the nurse went back and couldn't find the card. CNA #1 stated that the menu card was for Resident #1's bed and room number. CNA #1 stated the meal was grits, eggs, and a cinnamon roll and the roll was not pureed. She stated she was positive it was a cinnamon roll. CNA #1 stated she didn't think she had done anything wrong because she had read the menu card that was on that meal tray. She stated, I just matched the bed and room number. She stated that was the first time working with that resident. CNA #1 stated that the meal wasn't pureed, but the tray did have thickened liquids in cartons. She stated that she started to feed the resident, just one (1) small bite, and Resident #1 started choking. CNA #1 stated that she patted the resident on the back but the resident kept coughing so she went to get the nurse. CNA #1 stated the resident didn't cough anything up until the nurse did the [MEDICATION NAME] maneuver. CNA #1 stated that she didn't know where the tray went. She stated she thought the name on the menu ticket was (gave a name that didn't match Resident #1 or any resident in the facility). Review of the previous resident who lived in the room, prior to Resident #1's admission, didn't match the name CNA #1 mentioned. Review of CNA #1's personnel file revealed she was hired 6/4/18, and her New Hire Checklist, dated 6/4/18, revealed she was trained on Dietary Meals and the Nurse Aide Information Sheet (Care Cards). Interview with the Risk Manager #1 on 7/11/18 at 2:28 PM, revealed that CNA Care Cards are reviewed with new CNA's during their training on hire and they covered where to find each resident's care information on the Care Card. Interview with RN #1 at 10:45 AM on 7/10/18, revealed an unknown CNA came to her and said that Resident #1 would not stop coughing, but she did not say she was feeding her. RN #1 stated she saw a breakfast tray on the resident's bedside table, and food was noticeably missing. She stated she saw grits and eggs, but didn't recall seeing a meat. RN #1 stated that the CNA said Resident #1 was talking the whole time she fed her. RN #1 stated when she went into the room and saw the tray, she asked what the tray was doing there, and the CNA stated said she thought the tray was for Resident #1. RN #1 stated when she checked for the meal ticket, she saw a documented, Meal Cart and one (1) other word she couldn't recall. RN #1 said the tray did not have any resident's name on it. RN #1 stated that Resident #1 was red-faced, with no forcible air with her cough, could not speak, and didn't have anything in her mouth. RN #1 stated that she did five (5) abdominal thrusts and brought up grits and eggs that drooled out of the resident's mouth and the resident could speak then. RN #1 stated that the NP was in the house and ordered a Stat chest X-ray. RN #1 stated that she never saw a meal card on that tray with anyone's name on it. RN #1 stated that she called the Dietary Department and talked to Cook #1 and asked why they sent Resident #1 a tray, and the Cook said they didn't, that the tray was supposed to be for Resident #4. RN #1 stated that Resident #1 received the same kind of tray prior to being hospitalized and readmitted . RN #1 stated that Resident #1 always asks for water and there was nothing to indicate for visitors that Resident #1 is NPO. She stated, Something, a note that says see the nurses before feeding, is needed. Interview with Licensed Practical Nurse (LPN) #1 on 7/10/18 at 10:20 AM, revealed she was Resident #1's Medication Nurse on 6/22/18. LPN #1 stated that RN #1 came to her and said Resident #1 choked on some breakfast, to which she responded that Resident #1 was NPO. LPN #1 stated that she didn't see a menu card on the tray, only a Start new cart card on it. LPN #1 stated that she saw eggs, grits and biscuit on the tray, and it was pureed, but didn't pay attention to the liquids. She stated, They are not supposed to take a tray with no ticket into a resident's room. LPN #1 stated it was CNA #1's first day to work with Resident #1 and she assumed the tray was Resident #1's since she'd taken the roommate's tray in just prior, the tray was next in line, and Resident #1 didn't have a tray. Interview with Cook #1 on 7/10/18 at 9:15 AM, revealed if a resident is NPO there is not a menu card printed out because there's no tray to send. Cook #1 stated she went to the hall when she was notified that Resident #1 choked on 6/22/18, and the nurse showed her the meal tray that was served. Cook #1 stated there wasn't a menu ticket on the tray, however, she identified the tray as Resident #4's, due to the double portions and thickened liquids; no one else in the facility received thickened liquids at the time. Cook #1 stated she saw the Begin New Cart ticket, which is placed on top of the first tray of every cart when a new cart goes out of the kitchen. She stated she explained this to the nurse who asked her what it meant. Cook #1 stated she knew there was a tray card on that tray when it went out of the kitchen, because she looks as she is fixing a tray and would hold up the line if the ticket was not there. Cook #1 stated that she briefly talked with the Administrator that day, about Resident #1 getting the wrong tray, but had not been interviewed about the incident until today. She also stated she talked with the Dietary Manager, who was on vacation. Cook #1 stated that months ago Therapy had worked with Resident #1 to have honey thickened liquids, but the resident couldn't handle it, so a slip was sent for NPO. Further interview with Cook #1 on 7/12/18 at 10:00 AM, revealed that she had only talked with the dietary staff of the choking event the day that it occurred, that nursing said there was a mixup in the trays. She stated that she told staff to check the tray and tickets. Cook #1 stated she did not attend a Quality Assurance (QA) meeting on 6/22/18. Interview with the Administrator on 7/10/18 at 11:55 AM, revealed on 6/22/18, Cook #1 came and met her in the hall and said nursing was trying to say there was not a tray card on the tray that was served to Resident #1. The Administrator stated that she did not talk to Cook #1 anymore after her initial report that morning. The Administrator stated that RN #1 said there was not a tray card and Cook #1 said there was. She stated she didn't look into the situation much further than that and stated, Whether there was a tray card or not, the CNA should have made sure that tray belonged to the correct resident. Interview with the Administrator on 7/11/18 at 10:00 AM, revealed the Dietary Contract Company was supposed to in-service dietary employees the weekend after the incident, specifically 6/23/18. She stated she had asked their Regional Director today and wanted the Dietary Department Competency Check-offs from 6/23/18. The Administrator stated they must have misunderstood on 6/22/18, because competency check-offs were not done. The Administrator stated that the company had completed an audit of their meal tracking system to physician orders [REDACTED]. The Administrator stated that she didn't ask for an in-service, just to do the competency check-offs. The Administrator stated, No, we did not in-service dietary. Further interview with the Administrator on 7/11/18 at 10:45 AM, revealed there was no official in-service or audits with Dietary after the choking incident with Resident #1. Interview with the Dietary Manager (DM) on 7/10/18 at 8:40 AM, revealed she was on vacation and Cook #1 notified her on 6/22/18, that Resident #1 received a meal tray and wasn't supposed to get one; it had a different resident's name on the menu card. The DM stated at that time Resident #4 was the only resident to get honey-thickened liquids. She stated Resident #4 lived in the room next to Resident #1. The DM stated Cook #1 went to the hall and identified the tray she was shown, that was fed to Resident #1, as Resident #4's meal tray; so they ordered him another tray. The DM described the tray as having large portions of eggs, grits, sausage and toast, all pureed. The DM stated the method used to identify a resident to their tray is the menu card; it has their name, therapeutic diet and texture. Interview with Director of Nursing (DON) #1, on 7/10/18 at 12:20 PM, revealed they started the orange dot system the day of the incident; in-services were done at the time clock. The DON stated they were going to put a note on the door of NPO residents to see the nurses before entering the room. She stated there will be an orange dot on the Care Card (CNA Care Guide) and NPO will be written in the orange dot. The DON stated that the Care Card already had NPO, but the orange dot will help staff associate the orange dot with NPO. She stated they were going to begin in-services today; she'd already printed the signs. She stated they were putting the orange dot on the door sign as well, so any visitors or layperson would know that a resident is NPO as well as educate staff. Interview with the Speech Therapist (ST) on 7/10/18 at 1:45 PM, confirmed that Resident #1 should have been NPO (6/22/18), due to her decline with ingestion of food upon return from the hospital on [DATE]; there had been a tremendous decline. The ST stated that Resident #1 had been on a trial of pureed food with nectar thickened liquids, fed only by herself, prior to going to the hospital. The ST stated she had always wanted a sign over the bed indicating residents were NPO; concerned that Residents like Resident #1 would be given something by mouth by family and/or visitors. Interview with the DON on 7/11/18 at 9:40 AM, revealed that prior to this incident on 6/22/18, the CNA Care Card was how the CNA's would know if any Resident was NPO. She stated, Part of initial CNA training is to pull the Care Card of a resident if not certain of a resident's diet. There is nothing specifically documented that shows CNA's are trained to not deliver a meal tray that does not have a meal/menu card on it, but it is included in their training on the 2nd day. DON #1 stated, The Care Card is the CNA care plan. Further interview with DON #1, on 7/11/18 at 10:08 AM, revealed, Nurses update the CNA Care Cards. They are updated when changes are ordered. CNA Care Card are started on admission for each resident. Further interview with the DON on 7/22/18 at 4:00 PM, revealed she expected the CNA to review the Care Card prior to beginning the shift, just in case of any changes in care, and CNA #1 had admitted she didn't review the Care Card for Resident #1 on 6/22/18. Interview with DON #1, on 7/11/18 at 3:10 PM, revealed that prior to the choking incident, the only therapeutic diets on CNA Care Cards were for resident who were NPO, Peg Tube Fed, and/or had Thickened Liquids. She stated Residents with a therapeutic diet other than NPO, Peg Tube fed, and thickened liquids did not have anything regarding meals; the CNA's relied on menu/tray cards or nurses to know any other type of therapeutic diet for residents. Interview with DON #1 on 7/11/18 at 10:08 AM, revealed When we did the cart audits, we did communicate with Dietary the adverse findings for a discharged resident still getting a tray. DON #1 said that they discovered discharged residents had still been getting a tray and now a new process had been put in place with the Diet Reconciliation Form. The DON stated that staff had not been using the Diet Reconciliation Form to let the Dietary Department know when a resident was discharged ; dietary might find out at the stand-up meeting the next day, after discharge. Interview with Dietary Manager #1, on 7/11/18 at 10:30 AM, and again at 10:50 AM, revealed that Cook #1 did an in-service on 6/22/18, with only dietary staff present that day, about the choking incident, but no one signed an in-service sheet until today. She stated the in-services covered the tray line process and to make sure meal tickets were on the trays. There were only five (5) signatures on the in-service sheet. Further interview with Dietary Manager #1, on 7/12/18 at 10:00 AM, revealed she did not attend the Quality Assurance meeting on 6/22/18, she was on vacation. Review of the sign in sheet of the Emergency Quality Assurance meeting, dated 6/22/18, about Resident #1's choking incident after being served a breakfast meal from a tray that came out of the Dietary Department, revealed that there was no one in the meeting representing the Dietary Department. The facility provided an Allegation of Compliance (AoC) on 7/13/18: At Approximately 11:20 AM on (MONTH) 12, (YEAR), the Administrator was notified by the surveyor that an immediate jeopardy was being called. The facility respectfully submits this allegation of compliance (A[NAME]). 1. On (MONTH) 22, (YEAR), at approximately 7:45 AM, CNA #1 delivered a tray to Resident #1 with an order to be NPO. CNA #1 proceeded to assist Resident #1 in eating. Resident #1 began to choke. CNA #1 notified RN #1 and RN #1 entered Resident #1's room and initiated the [MEDICATION NAME] maneuver for approximately twenty seconds until Resident #1 expelled the food particles. RN #1 and CNA #1 stated that there was not a tray card on the tray identifying whose tray it belonged to; rather there was a tray card that stated, Begin new cart. 2. On (MONTH) 22, (YEAR), at approximately 8:00 AM, RN #1 notified Nurse Practitioner #1, who was on site, of the incident and an order for [REDACTED].#1 was notified on (MONTH) 22, (YEAR) at approximately 8:30 AM, and Vital Stem treatment for [REDACTED]. The conclusion of the Chest X-Ray read, Modest infiltrate in the right upper lobe, possibly infectious process. Upon result of the chest X-Ray on (MONTH) 22, (YEAR), at approximately 1:32 PM, Physician #1, who is also Medical Director #1, was notified of the incident. At that time, he ordered [MEDICATION NAME] 500 mg for 7 days via peg tube beginning on (MONTH) 22, (YEAR), and ordered a repeat Chest X-Ray to be completed on (MONTH) 26, (YEAR). On (MONTH) 23, (YEAR) at approximately 10:00 AM, NP #2 assessed Resident. NP #2 discontinued the order for [MEDICATION NAME] and gave the following new orders: [MEDICATION NAME] 1 cap BID X 10 days, [MEDICATION NAME], O2 at 2L via nasal cannula, PRN monitoring of O2 Saturation with parameters to notify MD if O2 saturations drop below 90% and to hold therapy until (MONTH) 25, (YEAR). 3. Five (5) unsuccessful attempts were made by DON #1 to notify the Responsible Party. The second contact, who is the grandson and is actively involved, was notified on (MONTH) 22, (YEAR), at approximately 4:30 PM, by DON #1. 4. A Repeat Chest X-Ray was completed on (MONTH) 26, (YEAR) and at approximately 12:18 PM, results concluded that there was no acute findings in the chest and finding improved from (MONTH) 22, (YEAR). Due to a history of Resident #1 requesting food and water while being on an NPO diet, as well as her psychiatric diagnosis, the Psychiatric NP #1 assessed resident on (MONTH) 29, (YEAR). 5. On (MONTH) 22, (YEAR), at approximately 4:54 PM, an audit of C.N.A. care cards versus diet orders was initiated for 100% of census. (Care cards are the care plan for Certified Nursing Assistants). Risk Manager #1 completed the audit. Residents who were NPO (Nothing by Mouth) had NPO diet listed on their care cards already, however all other diet orders were not listed. All diet orders were added to C.N.A. care cards by Risk Manager #1 on (MONTH) 22, (YEAR) by handwriting them on the paper C.N.A. care cards. 6. On (MONTH) 22, (YEAR), at approximately 4:46 PM, an audit of care plans for residents with NPO diet orders confirmed that NPO diets were care planned. Audit was completed by MDS #1. 7. On (MONTH) 22, (YEAR), at approximately 4:54 PM, an initial tray card versus diet order versus actual food served audit was initiated by Risk Manager #1 and Staff Development Coordinator #1 during the evening delivery of meal trays to ensure that residents received the appropriate diet. Findings of the audit included six (6) diet order discrepancies that were corrected at the time of finding and placed on care cards. 8. On (MONTH) 22, (YEAR), at approximately 8:15 PM, all new admission diet orders from (MONTH) 20, (YEAR) to (MONTH) 22, (YEAR) were checked for accuracy with no adverse findings. Audit was completed by ADON #1. 9. On (MONTH) 22, (YEAR), at approximately 7:13 PM, a new process of using orange circular stickers used to visually identify residents with a diet order of NPO was initiated. These orange circular stickers were placed on the outside of the residents rooms by the name tag for six (6) of six (6) residents who had an order for [REDACTED].#1 applied the stickers. 10. On (MONTH) 22, (YEAR), at approximately 5:19 PM, Staff Development Coordinator #1 initiated an in-service titled, Education on Diet for Residents with Nursing, Activity, Social Services, and Administrative departments. Education material included excerpts from Chapter 17, Assisting with Nutrition, of the How to Be a Nurse Assistant, Integrating Excellence in Training with Quality of Care manual, as well as protocol related to the orange circular sticker visually identifying residents with an NPO order. Upon initiation of in-service, staff was notified that each had to receive the information prior to returning to work their next scheduled shift. 139 of 176 employees have been in-serviced. 36 of those employees had not worked after the incident and were terminated. One (1) employee has not been in-serviced and will not be allowed to return to work until the in-service is completed. 11. On (MONTH) 22, (YEAR) at approximately 9:30 AM, Cook #1 completed an in-service on the process of comparing tray tickets to the diets being loaded on the cart on (MONTH) 22, (YEAR) with five (5) of 14 dietary employees. 12. An audit was completed by Dietary Manager #1 and Dietary Employee #1 on (MONTH) 23, (YEAR) at 4:18 PM, of the Meal Tracker diet order system to facility's Diet Orders in Point Click Care electronic health care record system. Summary of audit findings: Seven (7) residents' diet orders were clarified between nursing and dietary systems. The findings were added to the care card. 13. A Quality Assurance (QA) meeting was held with Medical Director #1, Director of Nursing #1, Administrator #1, risk Manager #1, and Staff Development Coordinator #1 on (MONTH) 22, (YEAR) at 5:53 PM. During this QA meeting, the incident and initial investigation findings were discussed. There were no new policy changes, however a new protocol was adopted on (MONTH) 22, (YEAR), regarding implementing a system to identify Residents that are NPO. An action plan was developed including: 100% audit of Resident's Diet order to Care Cards to be completed (MONTH) 22, (YEAR) by Risk Manager #1 and again (MONTH) 24, (YEAR) by Risk Manager #1 and RN #2; Care Plans for Residents with an NPO order to be reviewed and revised on (MONTH) 22, (YEAR) by MDS #1, 100% audit of tray cards to diet order on the evening meal of (MONTH) 22, (YEAR) by Risk Manager #1 and RN #2; and an audit of resident diet orders to tray tickets on (MONTH) 23, (YEAR) to be completed by Dietary Manager #1. Meal tray audits of tray tickets to diet orders were scheduled once a day for seven (7) days beginning on (MONTH) 22, (YEAR); Review of the initiation of education with Nursing, Activity, Social Services, and Administrative Departments regarding the new system to identify residents that are NPO, importance of verifying tray cards, verifying care cards, risks of aspiration pneumonia and how to respond in and emergent situation. Dietary employees were to begin an initial in-service on the process of comparing tray tickets to diets being loaded into cart. Five (5) Dietary Employees of 14 total Dietary Employees were in-serviced on (MONTH) 22, (YEAR) by Cook #1. In-service was continued by Dietary Manager #1 on (MONTH) 10, (YEAR) with 12 Dietary employees of 14 total Dietary employees. On (MONTH) 12, (YEAR), 11 of 14 dietary employees were re-trained on this information by Registered Dietician #1 with subsequent test that all 11 employees passed. The three (3) remaining employees will not return until training is received and they pass the test. 14. A Quality Assurance meeting was held with Medical Director #1, Administrator #1, Director of Nursing #1, Social Services Director #1, Social Services Assistant #1, Dietary Manager #1, Activity Director #1, director of Rehabilitation #1, Staff Development Coordinator #1, Maintenance Director #1, Business Office Manager #1, Business Office Assistant #1, Housekeeping Director #1, MDS #1, Medical Records Director #1, ADON #1, Risk Manager #1, ADON #2, Case Manager #1, Assistant Administrator #1, Human Resources #1 on (MONTH) 12, (YEAR) at 12:03 PM. During this QA meeting the incident (for Resident #1) was reviewed. The team was notified that an Immediate Jeopardy had been issued. Additional education was planned for Dietary department. An audit schedule of tray tickets to diet orders in the dietary department was completed on (MONTH) 12, (YEAR) by Registered Dietician #1. On (MONTH) 9, (YEAR), Administrator #1 completed an audit of the orange stickers to identify three (3) of three (3) residents' with order for NPO. 15. On (MONTH) 22, (YEAR), at approximately 11:30 AM, CNA #1 received a verbal warning by DON #1 and Case Manager #1 regarding failure to verify a tray card prior to feeding a resident resulting in a choking episode. CNA #1 was contacted by Administrator #1, DON #1 and Risk Manager #1 on (MONTH) 22, (YEAR) at approximately 5:15 PM, for further interview. At the end of the interview, CNA #1 was suspended pending investigation by the Administrator #1. Upon completion of the facility investigation, it was determined that it was an isolated incident, in which CNA #1 of her own accord, failed to verify the tray card prior to delivering and assisting a meal tray to a resident. CNA #1's employment was terminated by Administrator #1 and DON #1 on (MONTH) 25, (YEAR), at approximately 4:45 PM. 16. Incident was called in by Director of Nursing #1 to the Mississippi State Department of Health Licensure and certification on (MONTH) 22, (YEAR) at 9:00 PM. The incident was reported to the Office of the Attorney General on (MONTH) 22, (YEAR), at 10:20 PM. On (MONTH) 25, (YEAR), the written report was submitted by the Administrator to the Mississippi State Department of Health at approximately 5:55 PM and to the Office of the Attorney General at approximately 5:57 PM. 17. Registered Dietician #1 was in-serviced by Risk Manager #1 on in-service material discussed during (MONTH) 12, (YEAR) QA. Registered Dietician #1 in turn in-serviced 11 of 14 Dietary employees on, Tray line assembly, orange dot for NPO residents, diet requisitions for residents, diet changes/discharges. The remaining three (3) employees who have not been in-serviced on the material will not be allowed to return to work until they do. 18. An audit of Tray Card to Diet Orders to actual food served was completed on the following date, per action plan schedule, by Administrator #1, Director of Nursing #1, Risk Manager #1, and Staff Development Coordinator #1: (MONTH) 22, (YEAR); (MONTH) 23, (YEAR); (MONTH) 24, (YEAR); (MONTH) 25, (YEAR); (MONTH) 26, (YEAR); (MONTH) 27, (YEAR), (MONTH) 28, (YEAR); (MONTH) 3, (YEAR); (MONTH) 5, (YEAR); (MONTH) 6, (YEAR); (MONTH) 10, (YEAR). The areas that were identified throughout the audits include discharged residents trays being sent out, diet type order clarifications needed, and tray card room numbers. Issues identified were corrected and findings reported to the QA Committee on (MONTH) 12, (YEAR). 19. Facility is alleging that all activities to remove the immediate jeopardy were completed as of (MONTH) 12, (YEAR), and the Immediate Jeopardy was removed as of (MONTH) 13, (YEAR). VALIDATION of the Allegation of Compliance: 1. The State Agency (SA) validated through record review and staff interviews that on (MONTH) 22, (YEAR), at approximately 7:45 AM, CNA #1 delivered a meal tray to Resident #1, who had orders to be NPO. CNA #1 assisted Resident #1 in eating. Resident #1 began to choke, CNA #1 notified RN #1 and RN #1 initiated the [MEDICATION NAME] maneuver until Resident #1 expelled the food particles. RN #1 and CNA #1 initially reported that there was not a tray card on the tray identifying whose tray it belonged to; rather there was a tray card that stated, Begin new cart. 2. Through interview and record review, the SA validated that on (MONTH) 22, (YEAR), RN #1 notified Nurse Practitioner #1, of the incident and an order for [REDACTED].#1 was notified on (MONTH) 22, (YEAR) and Vital Stem treatment for [REDACTED]. Record review revealed the Chest X-Ray read, Modest infiltrate in the right upper lobe, possibly infectious process. Upon result of the chest X-Ray on (MONTH) 22, (YEAR), Physician #1, who is also Medical Director #1, was notified of the incident and he ordered [MEDICATION NAME] 500 milligram (mg) for seven (7) days via feeding tube beginning on (MONTH) 22, (YEAR), and ordered a repeat Chest X-Ray to be completed on (MONTH) 26, (YEAR). On (MONTH) 23, (YEAR) NP #2 assessed Resident and discontinued the order for [MEDICATION NAME] and gave the following new orders: [MEDICATION NAME] 1 cap BID X 10 days, [MEDICATION NAME], O2 at 2L via nasal cannula, PRN monitoring of O2 Saturation with parameters to notify MD if O2 saturations drop below 90% and to hold therapy until (MONTH) 25, (YEAR). 3. The SA validated through record review and interview that there five (5) unsuccessful attempts were made by DON #1 to notify the Responsible Party. The second contact was notified on (MONTH) 22, (YEAR), by DON #1. 4. Through record review and interviews, the SA validated that a repeat Chest X-Ray was completed on (MONTH) 26, (YEAR), and results concluded that there was no acute findings in th

Based on record review, observation, interview, and policy review, the facility failed to manage pain for Resident #3 during a pressure ulcer treatment and failed to provide a pain patch as ordered for Resident #17, which resulted in increased pain. This was for two (2) of 17 residents reviewed. Findings include: Review of the facility's policy entitled "Pain Management Protocol", revised 09/08, revealed, "It is the policy of this facility to screen residents for pain and further assess if indicated for cause and severity of pain as well as what relieves the pain. The facility will address pain and implement a plan of care to manage or relieve pain. All residents should receive treatment for [REDACTED]." Resident #3 Observation of Resident #3, on 03/12/14 at 9:10 AM, revealed a treatment of [REDACTED].#3 assisted by Licensed Practical Nurse(LPN) #5. As the ulcer was cleaned by RN #3, the resident cringed and pulled away. LPN #5 told the Resident to hold her hand. RN #3 stated that the resident had received Tylenol prior to the treatment, that maybe the resident needed something stronger. The treatment was continued to completion. Interview, on 03/12/14 at 9:35 AM, upon completion of the treatment, Resident #3 was asked if the treatment had hurt. She responded "Yes." Interview, on 03/12/14 at 10:05 AM, with Licensed Practical Nurse (LPN) #9 revealed Resident #3 had received the routine 9:00 AM dose of Tylenol at approximately 8:50 AM. Interview, on 03/12/14 at 9:55 AM, with RN #1 revealed that Resident #3 had become more alert and responsive in the last month. RN #1 was asked for the documentation of the effectiveness of the pain relief for Resident #3. RN #1 stated this would be ongoing on the Medication Administration Record [REDACTED]. Review of the March 2014 MAR indicated [REDACTED]. Record review revealed that the facility readmitted Resident #3 on 11/04/13, with [DIAGNOSES REDACTED]. Review of the MinimumData Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated that Resident #3 's cognitive status was severely impaired. The MDS indicated that the resident was totally dependent in Activities of Daily Living. Review of Section J - Health Conditions revealed that the resident had been on a scheduled pain medication regimen. Should pain assessment interview be conducted was answered "Yes." Review of the physician's orders [REDACTED]. The resident could also receive Tylenol 325 milligrams every four (4) hours as necessary for pain not to exceed more than three (3) grams of [MEDICATION NAME] (Tylenol) per day from any source. Review of the 03/07/14 weekly Wound Assessment Report for Resident #3 revealed a Stage IV Pressure Ulcer to the sacrum measuring 5 centimeters (cm) in length, 4.5 cm in width, and 0.8 cm in depth. The assessment indicated that there was no pain with the wound/treatment. Review of the Pain Assessments for Resident #3 indicated the following: 08/23/13 Unable to assess pain intensity in the past 5 days. Physical assessment by nurse was documented as N/A (Not Applicable). The area of the stage IV pressure ulcer was not identified. How does the pain affect was documented as N/A. 11/04/13 The physical assessment by nurse was left blank although the sacral pressure area was indicated. How does the pain affect was left blank. 11/11/13 The physical assessment by the nurse was blank. 02/20/14 The physical assessment by the nurse was blank. How does the pain affect was blank. Review of a Risk Assessment Totals for Resident #3, dated 02/20/14 indicated the Pain Risk Score was Medium. Resident #17 Record review revealed the facility admitted Resident #17 on 02/10/14, with [DIAGNOSES REDACTED]. Review of Resident #17's cognitive status on the initial Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/28/14 revealed that Resident #17's Brief Interview for Mental Status (BIMS) score was 15 that indicated Resident #17 was cognitively intact. An observation on 03/11/14 at 9:25 AM revealed Resident #17 seated on bed with complaints of pain and refused medication ([MEDICATION NAME]) that Registered Nurse (RN) #4 had offered for anxiety. Resident #17 had 1 (one) [MEDICATION NAME] (substitution for [MEDICATION NAME]) on mid chest and said that he/she needed 2 (two) [MEDICATION NAME]es. Review of current Medication Administration Record [REDACTED]. A medication pass observation on 03/11/14 at 9:25 AM revealed no [MEDICATION NAME]es were available for Resident #17. Interview with Licensed Practical Nurse (LPN) #8 confirmed that Resident #17 did not have any [MEDICATION NAME]es and stated, "I will notify the doctor that he is out and call the pharmacy. That's what we do if a new prescription is needed or if we need something right away that is not in stock. He went to the hospital and they changed the order to one patch; he used to get two." Observation on 03/11/14 at 12:30 PM revealed Resident #17 was pacing in his room. Resident #17 pointed to drainage tube in abdomen and to [MEDICAL CONDITION] and complained of pain. Interview on 03/11/14 at 2:20 PM with LPN #8 revealed, "We called for stat med supply but the doctor said he had to order them and that he will order them when he gets back to the clinic so he can fax it to the pharmacy. He (Resident #17) went to the hospital and when he came back, he had to have all new hard scripts. We've called him (doctor) three times." Interview on 03/11/14 at 2:40 PM with RN #4 revealed, "We've offered PO (oral) pain meds (medications) but he (Resident #17) has refused PO pain meds since admission; says it messes with his bowels so I offered and took him a [MEDICATION NAME] this morning since he was upset about the patches but he refused that also." Interview on 03/11/14 at 4:45 PM with RN #4 revealed, "No, we still don't have his [MEDICATION NAME]es; I'm going to call the pharmacy and see what's going on. Maybe that can send someone with the medicine." RN #4 stated that routinely the medication is delivered on 3 to 11 shift or 11 to 7 shift. Review of the "Control Drug Record" on 03/12/14 at 6:50 AM for Resident #17's [MEDICATION NAME] 100 mcg/hr patches read "Date 03/11/14, Time 9:00, Patch #5 Applied, Signature LPN #6". Interview on 03/12/14 at 6:50 AM with Registered Nurse (RN) #5 confirmed that the MAR indicated [REDACTED]. I guess it did not come in yesterday on days; that's probably why it wasn't signed on the MAR." RN #5 confirmed LPN #6 had worked 3 to 11 shift on 03/11/14. Interview on 03/12/14 at 7:00 AM with Resident #17's physician confirmed that he had been notified on 03/11/14 that Resident #17 did not have any [MEDICATION NAME]es available and that he had to get to a fax machine to send a new prescription. The physician stated, "He (Resident #17) is on an unusual dose, it is actually 200 mcg per hour and some people are a little scared of that. When he goes out to the hospital, the orders often get changed and there is confusion. I was getting his chart next to review and see what is going on." Physician said that he faxed the prescription to the pharmacy around 1:30 PM. Interview on 03/12/14 at 7:35 AM with Director of Nursing (DON), "I was aware that (Resident #17) did not have the [MEDICATION NAME]es yesterday. (Resident #17 is a special case because he refuses any oral med for break through pain. I was informed that they had called (Pharmacy #1); normally (Pharmacy #1) calls (Pharmacy #2) if they know we need something stat. Yes, we have to let (Pharmacy #1) know if we need it right away. The routine meds are delivered on 3 to 11 shift or 11 to 7 shifts. I don't know if the [MEDICATION NAME]es were delivered with routine meds or not. " Interview on 03/12/14 at 10:35 AM with DON confirmed that the [MEDICATION NAME]es were sent by special delivery at 5:15 PM on 03/11/14 and that the [MEDICATION NAME] was not administered as soon as it was delivered. Interview on 03/13/14 at 9:10 AM with RN #4, "When he (Resident #17) was re-admitted on [DATE], Friday, the doctor at (name of a local hospital) had changed the order to one [MEDICATION NAME]. I really don't know how or why he ran out of the patches; but, we had one and put it on him when he returned; placed on 03/08/14." Interview on 03/13/14 at 10:00 AM with RN #4 confirmed that she failed to transcribe the "Telephone Order" 3. [MEDICATION NAME] ([MEDICATION NAME]) 100 mcg apply 2 patches to skin Q (every) 72 hours" that was received on 03/11/14 and she stated, "I guess that's why he only got one patch." Review of the "Telephone Orders", dated 03/11/14, read "3. [MEDICATION NAME] ([MEDICATION NAME]) 100 mcg apply 2 patches to skin Q 72 hours" and RN #4 had signed to indicate this order was transcribed. Interview on 03/13/14 at 11:40 AM with the Pharmacist revealed, "We received a faxed prescription for 100 micrograms per hour, two patches every 72 hours (for Resident #17) from (name of physician). It was entered and processed at 2:30 PM and sent out to Trinity at 16:58. We are available 24/7 and if we are notified, we can get meds as needed. (Name of physician) is one of the doctors that allow us to contact him anytime.