Every finding on record at Yorktown Nursing and Rehabilitation Center

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 2 of 7 residents (Residents #6 and#10) reviewed for infection control. 1. The facility failed to ensure CNA B took off her soiled gloves, sanitized her hands, and put on clean gloves prior to placing a clean brief on Resident #6 during catheter care. 2.The facility failed to ensure the ADON took off and replaced her gown after leaving the room to get more gloves when she performed wound care for Resident #6 who was on EBP. 3. The facility to ensure Resident #10 was on EBP by not having PPE outside his door and a sign on his door when he had a diabetic ulcer which required a dressing. These deficient practices could place residents at risk of cross contamination and infections.The findings included: 1. Record review of Resident #6's electronic face sheet dated 02/17/2026 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: pressure ulcer of sacral region (lower part of the spine), unstageable (depth of the ulcer cannot be determined due to the presence of necrotic tissue or eschar requiring specialized care and management), neuromuscular dysfunction of bladder (condition where the normal communication between the bladder and the nervous system is disrupted, leading to bladder control issues such as incontinence), urinary tract infection (infection in any part of the urinary system which can cause pain and burning with urination), cerebral infarction (medical condition occurs when blood flow to a part of the brain is obstructed which leads to the death of brain cells due to lack of oxygen and essential nutrients), aphasia (language disorder that affects a person's ability to speak, understand, read, or write due to brain damage), anxiety (feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to rapid cell death and potentially permanent neurological impairment), dysphagia (difficulty swallowing) and major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems). Record review of Resident #6's quarterly MDS assessment dated [DATE] reflected that she was not a candidate for a BIMS which signified her cognitive status was severely impaired. She was dependent on staff for her ADLS. She had an indwelling urinary catheter and a colostomy. She was noted to have a Stage 4 pressure sore (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). Record review of Resident #6's comprehensive person-centered care plan dated 05/19/2025 reflected Focus, alteration in elimination of bowel and bladder, indwelling urinary catheter and colostomy, Interventions/Tasks, indwelling catheter care every shift and as needed. Further review, dated 10/29/2025, Focus, actual pressure ulcer, Interventions/Tasks, treatments as ordered, Focus, resident is on enhanced barrier precautions (dated 02/17/2026), Gloves and gown should be donned if any of the following activities occur, wound care. Record review of Resident #6's Active Orders as of: 02/17/2026 reflected Enhanced barrier precautions, r/t peg tube, urinary catheter and wound every shift, start date 02/17/2026. Wound care: stage 4 pressure injury to sacrum-cleanse with wound cleanser, apply promogran prisma (collagen matrix wound dressing) skin prep surrounding tissue or peri wound apply border dressing, start date 12/25/2025. Observation on 02/18/2026 at 2:48 pm of CNA B performing catheter care for Resident #6, revealed she cross contaminated the field when she took off the resident's dirty brief and applied a clean brief and did not change her gloves and sanitize her hands. During an interview on 02/18/2026 at 2:55 pm, CNA B stated she forgot and then realized she had not removed her soiled gloves, sanitized her hands, or then put on Resident #6's clean brief. She stated she had infection control training, and she knew her actions could cause transmission of bacteria and could cause infection. Observation on 02/20/2026 at 09:00 am of the ADON performing wound care for Resident #6 revealed Resident #6 had an EBP sign outside her room by the door and a 3 drawered bin filled with PPE. The ADON put on a gown, sanitized her hands, put on gloves and proceeded to the room where the wound care supplies were waiting on a cleaned bedside table. She proceeded to perform wound care as ordered. During the procedure, the ADON stated she needed more gloves which were on the treatment cart outside the room in the hallway. She stopped what she was doing, removed her gloves and went to the door, left the room and retrieved more gloves from the treatment cart without changing her gown prior to returning to the room. She completed the wound care. During an interview on 02/20/2026 at 09:30 am, the ADON stated she should have changed her gown when she left the room because Resident #6 was on EBP. She stated in not changing her gown, cross contamination could occur from outside the room and be brought in the room. 3.Record review of Resident #10's electronic face sheet dated 02/20/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: unspecified dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), chronic obstructive pulmonary disease (certain types of irreversible lung and airway damage that block the airways and make it hard to breathe), major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems.), and type 2 diabetes mellitus (chronic condition characterized by insulin resistance and high blood sugar levels, often manageable through lifestyle changes and medication). Record review of Resident #10's quarterly MDS assessment dated [DATE] reflected he was understood by others and could usually understand others. He scored 04 of 15 on his BIMS which signified his cognitive status was severely impaired. He required moderate to extensive assistance with his ADLs. He was noted to have a diabetic foot ulcer. He had a pressure reducing device for bed and application of dressings to feet with or without topical medication. Record review of Resident #10's comprehensive person-centered care plan dated 12/17/2026 reflected Focus, has a diabetic ulcer r/t diabetes on right heel, Interventions/Tasks, treat wound as facility protocol. Record review of Resident #10's Weekly-Ulcer Assessment dated 02/12/2026 reflected location of area, right heel, type of ulcer, diabetic, area resolved, no, 1.40 cm x 1.40 cm x 1.96 cm. Record review of Resident #10's Active Orders as of: 02/20/2026 reflected Clean Rt heel with wound cleanser apply Promogran Prisma (collagen wound dressing), then apply Betadine (povidone iodine solution) moistened gauze and wrap with kerlix. Every other day and prn, start date 02/17/2026. Observation on 02/20/2026 at 10:00 am revealed Resident #10 did not have a sign outside his door or a bin with PPE. Observation of the ADON performing woundcare treatment for Resident #10 revealed she only sanitized hands, put on clean gloves and did not wear a gown. During an interview on 02/20/2026 at 10:30 am, the ADON stated she did not know why Resident #10 had not been placed on EBP since he had an open wound which required a dressing. During an interview on 02/20/2026 at 10:43 am, the DON stated she was not aware Resident #10 was not on EBP, and his wound was contained. She stated CNA B should have changed her gloves and sanitized her hands when she removed the soiled brief and applied the clean brief to Resident #6. She stated CNA B was trained in infection control. She stated when the ADON left Resident #6's room to get more gloves, she needed to change out her PPE and come in with clean PPE, not wear the same PPE she had on in the resident's room to prevent spreading infection. During an interview on 02/20/2026 at 10:45 am, the ADM stated Resident #10 had a chronic wound and after she reviewed the facility policy and procedure stated she thought Resident #10 needed to be on EBP to prevent any spread of infection. She stated staff needed to follow the facility's policies and procedures for infection control. Record review of CNA B's Proficiency Audit dated 07/01/2025 reflected she satisfactorily completed Infection Control Awareness competency. Record review of CNA B's training report dated 07/19/2025 reflected she satisfactorily completed Infection Control training. Record review of the facility's policy and procedure titled Enhanced Barrier Precautions, dated 04/01/2024 reflected has a chronic wound or indwelling medical device, without secretions, use EBP, yes. Record review of the facility's policy and procedure titled Fundamentals of Infection Control Precautions dated 2018 reflected A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions, hand hygiene, after handling soiled or used linens, gowns are removed before the personnel leave the resident's environment.

Based on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status for 3 of 16 residents (Residents #6, #28 and #34) reviewed for resident assessments. 1.The Facility failed to ensure Resident #6's active diagnosis of depression and her number of falls between assessments was accurately reflected on her quarterly MDS assessment, dated 01/12/2026. 2. The facility failed to ensure Resident #28's oxygen use was accurately reflected on her Significant Change MDS assessment, dated 01/16/2026. 3. The facility failed to ensure Resident #34's active diagnosis of dysphagia was accurately reflected on his quarterly MDS assessment, dated 12/29/2025 These deficient practices could place residents at risk of missed or inaccurate care. The findings include: Record review of Resident #6's electronic face sheet dated 02/17/2026 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: pressure ulcer of sacral region (lower part of the spine), unstageable (depth of the ulcer cannot be determined due to the presence of necrotic tissue or eschar requiring specialized care and management), neuromuscular dysfunction of bladder (condition where the normal communication between the bladder and the nervous system is disrupted, leading to bladder control issues such as incontinence), urinary tract infection (infection in any part of the urinary system which can cause pain and burning with urination), cerebral infarction (medical condition occurs when blood flow to a part of the brain is obstructed which leads to the death of brain cells due to lack of oxygen and essential nutrients), aphasia (language disorder that affects a person's ability to speak, understand, read, or write due to brain damage), anxiety (feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to rapid cell death and potentially permanent neurological impairment), dysphagia (difficulty swallowing) and major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems). Record review of Resident #6's quarterly MDS assessment dated [DATE] reflected that she was not a candidate for a BIMS which signified her cognitive status was severely impaired. She was dependent on staff for her ADLS. She did not have a diagnosis of depression coded and she was noted to have 1 fall from her last MDS assessment to the present. She had an indwelling urinary catheter and a colostomy. Record review of Resident #6's comprehensive person-centered care plan dated 02/17/2026 reflected Focus, requires antidepressant medication r/t DX of depression, Interventions/Tasks, give antidepressant medications ordered by the physician. Monitor/document side effects and effectiveness, Focus, is at risk for falls r/t unaware of safety needs dated )1/14/2026. Record review of Resident #6's Active Orders as of: 02/17/2026 reflected Fluoxetine (antidepressant) HCL oral solution, give 10 ml via G-Tube one time a day for depressive disorder, start date 09/24/2025. Record review of Resident #6's Psychological Services Progress Note dated 12/20/2025 reflected she was being seen for Major depressive disorder, Mood: Depressed, Anxious. Record review of Resident #6's FRA dated 02/15/2026 reflected she was assessed to be high risk for falls. Record review of the facility's accident and incidents list reflected Resident #6 had falls on 11/26/2025 and 12/09/2025 after her quarterly assessment dated [DATE] and before her quarterly assessment dated [DATE]. Observation on 02/17/2026 at 10:00 am revealed Resident #6 laying in a low bed in her room. She was positioned on an air mattress, had wedges for support behind her back, her feet were elevated, and she had a fall mat on the floor on each side of her bed. Her urinary catheter drainage bag was covered which rested in a basin by her bed. She was not interview able. 2. 3.Record review of Resident #34's electronic face sheet dated 02/18/2026 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), malaise (general feeling of discomfort, illness, or uneasiness), dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs) and major depressive disorder (persistently low mood, or decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy and poor concentration). Record review of Resident #34's quarterly MDS assessment dated [DATE] reflected he could understand others and be understood by others He scored 14 of 15 on his BIMS which signified his cognitive status was intact. He required moderate assistance with his ADLs. Dysphagia was not noted as an active diagnosis. He was noted to be on a mechanically altered diet while a resident. Record review of Resident #34's comprehensive person-centered care plan dated 05/19/2025 reflected Focus, Nutrition, at nutritional risk related to gastro esophageal reflux disease (happens when stomach acid flows up int the esophagus, and causes heartburn, intervention diet as ordered regular, mechanical soft texture with thin liquid consistency. Record review of Resident #34's Occupational Therapy Evaluation and Plan of Treatment dated 05/12/2026-07/06/2025 reflected Hx/complexities-PMHx: Esophageal structure s/p dilatation (an esophageal stricture is a narrowing of your esophagus. It can make swallowing become increasingly difficult. Record review of Resident #34's Active Orders as of: 02/18/2026 reflected regular diet, mechanical soft texture, regular consistency, start dated 07/17/2025. Observation on 02/17/2026 at 12:30 pm of Resident #34 revealed he was eating in the lunchroom, and his tray had a regular diet and his baked chicken thigh was of mechanically soft texture. Record review on 02/17/2026 at 12:35 pm, Resident #34's lunch ticket reflected Regular, mechanical soft, thin liquids. During an interview on 02/17/2026 at 12:37 pm, Resident #34 stated his food was ground because it was easier for him to eat and swallow. During an interview on 02/20/2026 at 08:31 am, the DON stated MDS accuracy was important because the information was related to the resident's care and what they required. She stated inaccurate MDS assessments could result in missed or inaccurate care. During an interview on 02/20/2026 at 09:42, the MDS Coordinator stated she was not aware of the missed fall for Resident #6 or her depression diagnosis having been missed. She did not say why it was missing. She stated she did not have evidence of Resident #34's dysphagia as being an active diagnosis even though he had the diagnosis and was on a mechanically altered diet. During an interview on 02/20/2026 at 10:45 am with the ADM, she stated she was responsible for the MDS's and stated the accuracy was important related to the care needed by the resident. The ADM said residents' care could be missed or not communicated if the MDS was inaccurate. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulation required the assessment accurately reflects the resident's status. Record review of Resident #28's face sheet dated 02/18/2026, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease, unspecified (a progressive, incurable, yet treatable lung disease that obstructs airflow and makes breathing difficult). Record review of Resident #28's Significant Change MDS assessment, dated 01/16/2026 Section O Special Treatments, Procedures, and Programs revealed C1 Oxygen Therapy was not coded for Resident #28's oxygen use while a resident. Record review of Resident #28's care plan, revision date of 02/17/2026, revealed Resident #28 had a focus of The resident has Asthma and interventions/task of Give nebulizer treatments and oxygen therapy as ordered. Record review of Resident #28's physician order summary dated, 02/18/2026, read, O2 via nasal cannula at 2L/min for shortness of breath/O2>89 with an order date of 01/09/2026. Record review of Resident #28's O2 Sats Summary dated, 02/19/2026, read, 01/13/2026 06:52 96% Oxygen via Nasal Cannula, 01/14/2026 08:26 99% Oxygen via Nasal Cannula, 01/15/2026 08:41 98% Oxygen via Nasal Cannula, 01/16/2026 08:03 97% Oxygen via Nasal Cannula. Observation and interview on 02/17/2026 at 11:12 a.m. revealed Resident #28 sitting in recliner wearing a nasal cannula with the oxygen concentrator set at 3.5. LPM Resident #28 stated she did not know what the oxygen concentrator was supposed to be set at and she would like to go home. However, she said she was passing out at home. Observation on 02/18/2026 at 9:12 a.m. revealed Resident #28 lying in her bed talking on the phone and wearing oxygen cannula. During an interview on 02/18/2026 at 9:25 a.m. LVN D stated Resident #28 was supposed to have her oxygen concentrator set at 2 liters continuously. Observation and interview on 02/19/2026 at 4:43 p.m., the MDS Coordinator stated she did not believe she coded Resident #28 for oxygen because there was no order for the oxygen use at the time of the MDS review and she further stated she had reviewed it and resident was receiving oxygen PRN, but did not believe during the look back period that the resident was using oxygen. The MDS Coordinator stated she reviewed Resident #28's MAR/TAR to see what the nurse had administered but it was not documented. The MDS Coordinator stated the nurses had not been checking off on the MAR for oxygen. The MDS Coordinator stated usually the MAR would tell the nurses to check the O2 sats and the nurses would document if they had to administer oxygen or not. The MDS Coordinator was observed reviewing Resident #28's O2 SATS summary in the Vitals section of Resident #28's EMR and stated the nurses had documented Resident #28 had been receiving oxygen by nasal cannula however she did not typically review the resident vitals when completing the MDS assessments. The MDS Coordinator stated the MDS Assessment coding was to show an accurate picture of the resident and care being provided. The MDS Coordinator stated that when the MDS Assessment was not coded properly it could affect the reimbursement for the care of the residents but did not have a direct effect to the care of the residents. During an interview on 02/19/2026 at 5:18 p.m., the RCN stated she had spoken to the MDS Coordinator and the MDS Coordinator said it was an oversight when she miscoded the oxygen use for Resident #28. The RCN stated the MDS Coordinator was new to the job. The RCN stated oxygen use while a resident should have been coded on the MDS for Resident #28. The RCN stated the MDS Coordinator could have seen in physician orders had Resident #28 had oxygen orders. The RCN stated when completing the MDS assessment they wouldn't necessarily look at the vitals because for the MDS the orders were where they would look. The RCN stated the MDS Coordinator was responsible for the coding accuracy of the MDS assessments. During an interview on 02/20/2026 at 9:16 a.m., the DON stated the MDS assessment was supposed to reflect the resident. The DON further stated money could be taken back if it was not coded properly. The DON stated the MDS Coordinator she believed was responsible for ensuring the MDS Assessments were properly coded, however that was only her 5th day working at the facility. During an interview on 02/20/2026 at 11:30 a.m., the Administrator stated the MDS coordinator was responsible for the coding of the MDS assessment and further stated it could affect the claiming rate or reimbursement for the resident's care.

Based on observations, interviews and record reviews, the facility failed to ensure in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurate, readily accessible and systematically organized for 2 (Residents #28 and #36) of 19 residents reviewed for clinical records. The facility failed to ensure Resident #28's MAR/TAR reflected her order for receiving oxygen at 2 LPM via nasal cannula for nurses to monitor for proper setting. 2. The facility failed to ensure LVN A accurately documented in Resident #36's TAR that his oxygen concentrator filter was not cleaned when she initialed that it was. These deficient practices could result in inaccurate clinical records and decreased continuity of care.The findings included: 2. Record review of Resident #36's electronic face sheet dated 02/18/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), acute bronchitis (inflammation of the bronchial tubes, often caused by viral infections leading to symptoms liked coughing, mucus production and chest discomfort), dysphagia (difficulty swallowing) and psychotic disorder (group of severe mental illnesses characterized by psychosis, which involves a loss of touch with reality). Record review of Resident #36's annual MDS assessment dated [DATE] reflected he could understand others and be understood by others. He scored 13 of 15 on his BIMS which indicated his cognitive status was intact. He required substantial assistance with his ADLs. He received oxygen therapy while he was a resident. Record review of Resident #36's comprehensive person-centered care plan dated 07/23/2025 reflected Focus, has chronic obstructive pulmonary disease, Interventions/Tasks, may use oxygen at 2L/min via nasal cannula every night shift. Record review of Resident #36's Active Orders as of: 02/18/2026 reflected May use oxygen at 2L/min via nasal canula every night shift related to chronic obstructive pulmonary disease, start dated 07/23/2026, clean oxygen concentrator filter weekly every Sunday, start dated 10/24/2024. Record review of Resident #36's TAR dated 02/01/2026-02/28/2026 reflected LVN A initialed on the TAR that the concentrator filter was cleaned on 02/15/2026. Observation on 02/17/2026 at 11:41 am, Resident #36's oxygen concentrator's black foam was covered with a thick gray coat of dust and dirt. Observation on 02/18/2026 at 09:00 am, Resident #36's oxygen concentrator's black foam filter was covered with a thick gray coat of dust and dirt. Observation on 02/19/2026 at 10:28 am, Resident #36's oxygen concentrator's black foam filter was covered with a thick gray coat of dust and dirt. Observation on 02/20/2026 at 09:15 am with the DON revealed Resident #36's oxygen concentrator filter was coated with gray dust and dirt. During an interview on 02/20/2026 at 10:34 am with LVN A, she stated she worked the night shift and initialed off on the oxygen tubing changes and the humidifier, but she did not remember the oxygen filter. She stated it was all included, but she did not clean the oxygen filter on the concentrator. She stated she initialed it off, but it was not done. She stated her documentation was not accurate about the filter being cleaned which misrepresented care was provided. During an interview on 02/20/2026 at 10:40 am, the DON stated LVN A should not have initialed off that Resident f#36's oxygen filter was cleaned when it was not. She stated the medical record was a legal document and the accounts needed to be accurate. During an interview on 02/20/2026 at 10:45 am with the ADM, she stated the nurses needed to follow physician orders or care could be compromised. She stated it was important for proper documentation to occur in the medical record to accurately reflect the care provided. Record review of LVN A's Nurse Proficiency Audit dated 07/01/2025 reflected she satisfactorily completed Documentation. Record review of the facility policy and procedure titled Oxygen Administration (undated) reflected The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring, responses, and safety precautions associated with it are performed by the nurse. Record review of the facility policy and procedure titled Documentation (undated) reflected The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. Record review of Resident #28's face sheet dated 02/18/2026, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease, unspecified (a progressive, incurable, yet treatable lung disease that obstructs airflow and makes breathing difficult). Record review of Resident #28's Significant Change MDS assessment, dated 01/16/2026, revealed the residents' BIMS score 14 for intact cognition with oxygen use not coded as being used as a resident in Section O. Record review of Resident #28's care plan, revision date of 02/17/2026, revealed Resident #28 had a focus of The resident has Asthma and interventions/task of Give nebulizer treatments and oxygen therapy as ordered. Record review of Resident #28's physician order summary dated, 02/18/2026, read, O2 via nasal cannula at 2L/min for shortness of breath/O2>89 with an order date of 01/09/2026. Record review of Resident #28's January MAR/TAR, dated 02/20/2026, revealed Resident #28's order was not present for nurses to monitor setting of the oxygen concentrator and the nasal cannula placement. Record review of Resident #28' February MAR/TAR, dated 02/20/2026, revealed Resident #28's physician order for oxygen use was added to the MAR/TAR on 02/19/2026, read, Oxygen LPM: 2L Via: Nasal cannula every shift relate to Chronic Obstructive Pulmonary disease, Unspecified Assess O2 Sat. Observation and interview on 02/17/2026 at 11:12 a.m. revealed Resident #28 was sitting in recliner wearing a nasal cannula with oxygen concentrator set between 3 and 4 LPM. Resident #28 stated she did not know what the oxygen concentrator was supposed to be set at. Observation on 02/18/2026 at 9:12 a.m. revealed Resident #28 was lying in her bed talking on the phone and wearing oxygen cannula attached to oxygen concentrator set between 3 and 4 LPM. During an interview and observation on 02/18/2026 at 9:25 a.m., LVN D stated as she entered Resident #28's room that Resident #28 was supposed to have her oxygen concentrator set at 2 liters per minute continuously. LVN D stated she had not touched the oxygen concentrator and as she approached the concentrator LVN D stated Why is it set almost at 4 liters per minute? LVN D was then observed adjusting Resident #28's oxygen concentrator to 2 liters per minute. LVN D stated that the oxygen concentrator could not be set higher than 2 liters per minute without an order. LVN D stated they should follow the physician orders for oxygen settings due to it could put residents at risk of over oxygenation. LVN D further stated it could cause the residents to become disoriented. During an interview on 02/20/2026 at 1:24 p.m., the MDS Coordinator stated Resident #28's oxygen order was not on the MAR/TAR when she had completed the Significant Change MDS assessment dated [DATE]. The MDS Coordinator stated she used the MAR/TAR when coding the MDS assessments and she did not see oxygen on the MAR/TAR for Resident #28's Significant Change MDS assessment. The MDS Coordinator stated she had reviewed the MAR/TAR to see what the nurse had administered but it was not documented. The MDS Coordinator further stated that the nurses had not been checking off on the MAR. The MDS Coordinator stated usually the MAR would say check the O2 sats and the nurses would document if they had to administer oxygen or not. During an interview on 02/20/2026 at 1:29 p.m. the DON stated oxygen use should be on the TAR. The DON further stated it would trigger the nurse to make sure the oxygen concentrator setting was correct, ensure everything was in place, tubing was good and this should have been done every shift. The DON stated oxygen use should have been on the TAR when the physician order was written. The DON stated by not putting the oxygen use on the TAR it could be set at a higher level and the level would be unknown causing a potential when unchecked of making Resident #28 sicker because she had COPD. The DON stated the nurse who put in the order initially should have put on the TAR. Record review of the facility's policy titled Medication Orders, dated v3-2025, read, Policy: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders are received only by licensed nurses or pharmacists and confirmed in writing by the prescriber within five (5) business days or per the specific States regulations if differs or is more stringent. Procedure: Elements of the medication order. 1. Documentation of the medication order. A. Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the current physician order sheet, the telephone order sheet, if it is a verbal order, and the Medication Administration Record (MAR). B. Transcribe or enter electronically newly prescribed medications on the MAR or treatment record.

Based on observations, interviews and record reviews, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. for 1 resident (Resident #10) of 2 residents observed for wound care. The facility failed to ensure the ADON followed physician orders when she performed Resident #10's diabetic ulcer (slow-healing open sore or wound, most commonly on the feet, that occurs as a complication of diabetes due to nerve damage and poor blood circulation) treatment. This deficient practice could result in a lack or delay in wound healing.The findings included: Record review of Resident #10's electronic face sheet dated 02/20/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: unspecified dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), chronic obstructive pulmonary disease (certain types of irreversible lung and airway damage that block the airways and make it hard to breathe), major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems.), and type 2 diabetes mellitus (chronic condition characterized by insulin resistance and high blood sugar levels, often manageable through lifestyle changes and medication). Record review of Resident #10's quarterly MDS assessment dated [DATE] reflected he was understood by others and could usually understand others. He scored 4 of 15 on his BIMS which signified his cognitive status was severely impaired. He required moderate to extensive assistance with his ADLs. He was noted to have a diabetic foot ulcer. He had a pressure reducing device for the bed and received the application of dressings to his feet with or without topical medication. Record review of Resident #10's comprehensive person-centered care plan dated 12/17/2026 reflected Focus, has a diabetic ulcer r/t diabetes on right heel, Interventions/Tasks, treat wound as facility protocol. Record review of Resident #10's Weekly-Ulcer Assessment dated 02/12/2026 reflected location of area, right heel, type of ulcer, diabetic, area resolved, no, 1.40 cm x 1.40 cm x 1.96 cm. Record review of Resident #10's Active Orders as of: 02/20/2026 reflected Clean Rt heel with wound cleanser apply Promogran Prisma (collagen wound dressing), then apply Betadine (povidone iodine solution) moistened gauze and wrap with kerlix. Every other day and prn, start date 02/17/2026. Observation on 02/20/2026 at 11:00 am of the ADON performing treatment for Resident #10 revealed the ADON sanitized her hands and wore gloves when she entered the room. She removed the old kerlix and dressing, cleaned the right heel wound with wound cleanser, applied the collagen wound dressing and rewrapped the foot with kerlix without using the moistened betadine gauze which was in a cup on the clean bedside table with the other treatment supplies. During an interview on 02/20/2026 at 11:30 am, the ADON stated she did not apply the betadine moistened gauze as was ordered. She stated she did not know why she did not use the betadine moistened gauze as ordered. She stated she was trained to follow physician orders and if an order was not followed delayed healing or complications could occur to the wound. During an interview on 02/20/2026 at 08:31 am, the DON stated the ADON missed applying the betadine to Resident #10's decubitus ulcer on his right heel. She stated she was accountable for the nursing care at the facility. She stated the ADON needed to follow physician orders or the wound could have delayed healing. During an interview on 02/20/2026 at 10:45 am with the ADM, she stated the nurses needed to follow physician orders or care could be compromised. Upon request on 02/20/2026 at 11:40 am, the DON and the ADM did not provide a facility policy and procedure on quality of care of following physician orders or pressure sores before exit.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; for 1 (room [ROOM NUMBER]) of 1 room on hallway with 6 residents residing on hallway reviewed for environment, in that:The facility failed to secure room [ROOM NUMBER] that was being used as storage with 2 unlocked housekeeping carts were not locked that contained potentially unsafe cleaning chemicals.This deficient practice could result in residents coming in contact with potentially unsafe cleaning chemicals.The findings included: Observation on 02/17/2026 at 11:20 a.m. revealed room [ROOM NUMBER] with no lock to the door and it was being used as storage for housekeeping floor cleaning machines along with 2 housekeeping carts in the room. The housekeeping carts had refills for the antibacterial hand foam sitting on the bottom of the carts and were not locked. Housekeeping cart #1 and cart #2 each had a 2-liter antibacterial hand foam bottle with approximately 3/4 of the bottle remaining sitting on the bottom shelf of the cart. Housekeeping cart #1 had the key in the door of the cart and was unlocked with the following chemicals in the cart: 1. Bold Power hard surface & glass cleaner 24-ounce bottle with approximately 11 ounces left warning to keep out of reach of children and may cause sensitivity or irritation to eyes, ears and lungs. 2. Biowaste Degrader 18-ounce bottle with approximately 12 ounces in the bottle warning on side of bottle may cause sensitivity or irritation to the eyes, ears and lungs. toilet bowl cleanser. Housekeeping cart #2 had no key with the door unlocked with the following chemicals in the cart: 1. Biowaste Degrader, 18-ounce bottle of cleaner disinfectant approximately 17 ounces in the spray bottle, Danger Precautionary STATEMENTS Hazards to Humans and Domestic Animals Danger keep out of reach of children. 2. Oder Neutralizer spray 18 ounces bottle warning on side of bottle may cause sensitivity or irritation to the eyes, ears and lungs. 3. Cream Cleanser 40 0unce bottle with approximately about 1/4 of bottle left. Warning notice on bottle Danger harmful if swallowed. Cause skin irritation. Causes serious eye damage. During interview and observation on 02/17/2026 at 11:46 a.m., the Housekeeping Supervisor stated housekeeping was given the room to put their stuff in, but the carts were supposed to be locked. The Housekeeping Supervisor was observed locking the carts and taking the key. The Housekeeping Supervisor stated they were refilling the soap and the antibacterial hand foam should have been locked up and removed from the carts. The Housekeeping Supervisor stated a resident could be at risk of coming into the room, and they might open it up and drink it or spray their eyes. The Housekeeping Supervisor stated a resident could get sick if they did that. The Housekeeping Supervisor stated the housekeeper and herself were responsible for making sure the carts were locked. The Housekeeping Supervisor further stated the room should have been locked. The Housekeeping Supervisor was observed taking the antibacterial hand foam and locking it in the housekeeping closet on another hall. During an interview on 02/20/2026 at 9:27 a.m., the DON stated by leaving housekeeping carts unattended and unlocked it could put residents at risk of being able to get the chemicals. The DON stated cleaning chemicals should be locked up and that the housekeepers were responsible for ensuring the carts were secure. During an interview on 02/20/2026 at 11:26 a.m., the Administrator stated housekeeping carts should have been stored locked, and all chemicals should not be left out opened on the cart and not locked up when not in view of a staff member. The Administrator stated that was so that residents could not access chemicals. The Administrator stated the potential effect to the residents could be the residents could ingest the chemicals or spill them. Review of the facility's policy, Daily Common Area Cleaning, dated 2021, read, It is the policy of this facility to maintain cleanliness in an orderly manner. The goal is to keep facilities clean and odor free, while providing the residents, their families, and staff with the safest environment possible and projecting a positive image. Housekeeping carts/chemicals must me locked when not within eyesight of a staff member.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for 2 (Residents #28 and #36) of 4 residents reviewed for oxygen therapy. The facility failed to ensure oxygen therapy was delivered at the prescribed rate for Resident #28. 2. The facility failed to ensure the oxygen concentrator that delivered oxygen to Resident #36 had a clean filter. These deficient practices could place residents at risk of respiratory distress.The findings included: 2. Record review of Resident #36's electronic face sheet dated 02/18/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), acute bronchitis (inflammation of the bronchial tubes, often caused by viral infections leading to symptoms liked coughing, mucus production and chest discomfort), dysphagia (difficulty swallowing) and psychotic disorder (group of severe mental illnesses characterized by psychosis, which involves a loss of touch with reality). Record review of Resident #36's annual MDS assessment dated [DATE] reflected he could understand others and be understood by others. He scored 13 of 15 on his BIMS which indicated his cognitive status was intact. He required substantial assistance with his ADLs. He received oxygen therapy while he was a resident. Record review of Resident #36's comprehensive person-centered care plan dated 07/23/2025 reflected Focus, has chronic obstructive pulmonary disease .Interventions/Tasks, may use oxygen at 2L/min via nasal cannula every night shift. Record review of Resident #36's Active Orders as of: 02/18/2026 reflected May use oxygen at 2L/min via nasal canula every night shift related to chronic obstructive pulmonary disease, start dated 07/23/2026, clean oxygen concentrator filter weekly every Sunday, start dated 10/24/2024. Record review of Resident #36's TAR dated 02/01/2026-02/28/2026 reflected LVN A initialed on the TAR that the concentrator filter was cleaned on 02/15/2026. Observation on 02/17/2026 at 11:41 am, revealed Resident #36's oxygen concentrator's black foam was covered with a thick gray coat of dust and dirt. Observation on 02/18/2026 at 09:00 am, revealed Resident #36's oxygen concentrator's black foam filter was covered with a thick gray coat of dust and dirt. Observation on 02/19/2026 at 10:28 am, revealed Resident #36's oxygen concentrator's black foam filter was covered with a thick gray coat of dust and dirt. Observation on 02/20/2026 at 09:15 am with the DON revealed Resident #36's oxygen concentrator filter was coated with gray dust and dirt. During an interview on 02/20/2026 at 09:20 am, the DON stated oxygen concentrator filters needed to be cleaned and changed as needed because it could result in respiratory difficulty for the resident by not cleaning the oxygen he received. During an interview on 02/20/2026 at 10:34 am with LVN A, she stated she worked the night shift and initialed off on the oxygen tubing changes and the humidifier, but she did not remember to clean the oxygen filter. She stated it was all included, but she did not clean the oxygen filter on the concentrator. She stated she initialed off on it, but it was not done. She stated it was important for the oxygen filter to be clean otherwise respiratory compromise could happen. During an interview on 02/20/2026 at 10:45 am with the ADM, she stated the nurses needed to follow physician orders or care could be compromised. She stated it was important to follow guidelines and to clean the oxygen filters on the concentrators to prevent complications and respiratory distress. Record review of LVN A's Nurse Proficiency Audit dated 07/01/2025 reflected she satisfactorily completed Oxygen/Respiratory, administration and maintenance. Record review of the facility 5-Liter oxygen concentrator A5LC-1 Owner's Manual (undated) reflected Physical features, has an intake filter and a cabinet filter to prevent dust and particulate from entering the concentrator., cleaning the cabinet filter, remove the filter from the access door, wash the cabinet filter with water, and allow to completely dry, WARNING: DO NOT operate the concentrator without the filters installed, or if they are wet. Record review of the facility policy and procedure titled Oxygen Administration (undated) reflected The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring, responses, and safety precautions associated with it are performed by the nurse. 1. Record review of Resident #28's face sheet dated 02/18/2026, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease, unspecified (a progressive, incurable, yet treatable lung disease that obstructs airflow and makes breathing difficult). Record review of Resident #28's Significant Change MDS assessment, dated 01/16/2026, revealed the residents' BIMS score was 14 indicating intact cognition. Record review of Resident #28's physician order summary dated, 02/18/2026, read, O2 via nasal cannula at 2L/min for shortness of breath/O2>89 with an order date of 01/09/2026. Record review of Resident #28's care plan, revised 02/17/2026, revealed Resident #28 had a focus of The resident has Asthma and interventions/task of Give nebulizer treatments and oxygen therapy as ordered. Observation and interview on 02/17/2026 at 11:12 a.m. revealed Resident #28 was sitting in a recliner wearing a nasal cannula attached to an oxygen concentrator set between 3 and 4 LPM. Resident #28 stated she did not know what the oxygen concentrator was supposed to be set at. Observation on 02/18/2026 at 9:12 a.m. revealed Resident #28 was lying in her bed talking on the phone and wearing an oxygen cannula with the oxygen concentrator set between 3 and 4 LPM. During an interview and observation on 02/18/2026 at 9:25 a.m., LVN D stated as she entered Resident #28's room Resident #28 was supposed to have her oxygen concentrator set at 2 liters per minute continuously. LVN D stated she had not touched the oxygen concentrator and as she approached the concentrator LVN D stated Why is it set almost at 4 liters per minute? LVN D was then observed adjusting Resident #28's oxygen concentrator to 2 LPM. LVN D stated that the oxygen concentrator could not be set higher than 2 liters per minute without an order. LVN D stated they should follow the physician orders for oxygen settings due to it could put residents at risk of over oxygenation. LVN D further stated it could cause the residents to become disoriented. During an interview on 02/20/2026 at 9:16 a.m., the DON stated the nurse over Resident #28 was responsible for ensuring the oxygen concentrator was at the proper setting. The DON further stated Resident #28 had COPD and by the concentrator not being at the proper setting it could cause further respiratory problems. During an interview on 02/20/2026 at 11:30 a.m., the Administrator stated that the nurse was responsible for ensuring the proper setting of the concentrator. The Administrator stated the oxygen not being set at the proper setting could affect the residents in getting the oxygen needed.

Based on observation, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication cart (Station II Medication Cart) reviewed.The facility failed to remove an expired tube of Medi-honey (wound gel, offers protection against invading bacteria, is effective against a wide variety of bacteria, cleans the wound, rapidly lifting dead tissue, reduces wound odor and provides a moist environment for healing) with an expiration date, of 07/01/2025 from Station II's II's medication cart.This deficient practice could result in decreased effectiveness of medications.The findings were: Observation on 02/18/2026 at 12:37 PM of Station II medication cart with LVN C revealed a small tube of Medi-honey with an expiration date of 07/01/2025. During an interview on 02/19/2026 at 12:40 pm, LVN C stated the Medi-honey was house stock and used for residents. During an interview on 02/19/2026 at 1:00 pm, LVN C stated expired substances should not be left on the medication cart and should be removed because they could be less potent after they expire. She stated nurses were responsible for checking the cart and removing expired medications. During an interview on 02/20/2026 at 10:42 am, the DON stated she checked Station I's medication cart, but did not get to Station II's. She stated the pharmacist checked the medication carts quarterly, and the nurses check the carts as needed and when they used the medication. She stated the expired Medi-honey was missed and needed to be discarded and replaced. She stated a medication could be less effective if used after the expiration date. During an interview on 02/20/2026 at 10:45 am with the ADM, she stated the nurses needed to check the carts and medication rooms for expired medications continually, because medications could be less effective after they expire. Record review of the facility's policy and procedure titled Expired Medications and Medications with Shortened Expiration Dates dated 2025 reflected Ensure all medications in the facility are rotated and/or reviewed on a consistent basis to prevent having expired medications in the facility.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility ice machine that provided ice for resident beverages at meals had visible rust on the outside and inside of the machine and contained large sections of yellow and brown ice. This failure could place residents who drink beverages with ice from the kitchen at risk for becoming sick from contaminated ice. The findings were: During an observation, 04/22/2025 at 11:02 a.m., the ice machine utilized by the kitchen for resident beverages was observed to have large sections of yellow and brown colored ice inside of the machine and rust stains on the inside and outside walled surfaces of the ice machine. During an interview with the Dietary Cook, 04/22/2025 at 11:42 a.m., the Dietary [NAME] stated the facility only had one ice maker and the facility residents were served ice from the ice maker for all beverages at meals. The Dietary [NAME] stated maintenance was responsible for cleaning the ice machine and said she did not know how often the ice machine should be cleaned. The Dietary [NAME] stated she had observed yellow and brown ice and rust on the machine and stated she had reported the issue to the Dietary Supervisor. The Dietary [NAME] stated she had not notified the Maintenance Director about the dirty ice and ice machine because that is [Dietary Supervisor name]'s job to do, not mine to do. The Dietary [NAME] said it was important to keep the ice machine clean because it could grow mold and all kinds of stuff in there and stated a resident could get real sick from receiving ice from a contaminated ice machine. The Dietary [NAME] stated she had not received training on cleaning the ice machine. During an interview and observation with the Dietary Cook, 04/22/2025 at 11:52 a.m., the Dietary [NAME] observed the ice machine and stated, Yes, I see the yellow ice and rust and rust build up inside and stated it appeared the ice machine had not been cleaned and stated it was the Maintenance Director's job to clean the ice machine. During an interview with LVN A, 04/23/2025 at 10:00 a.m., LVN A revealed she had observed yellow or brown ice in the ice machine and said, When I get ice, I get it from a section of the ice machine where it is not yellow or brown. I just get ice around it. LVN A stated she had not reported the discolored ice because everybody has seen it and it's been like that for a long time. During an interview with LVN C, 04/23/2025 at 12:00 p.m., LVN C stated she had observed facility residents being served yellow or brown ice and had observed yellow and brown ice in the ice machine. LVN C stated she had not reported the discolored ice because I know it is something they are aware of. LVN C stated, I noticed it when I started working here and I thought it was kind of gross. LVN C stated she had been working at the facility for 1 1/2 months. During an interview with the Dietary Supervisor, 04/24/2025 at 9:37 a.m., the Dietary Supervisor stated the Maintenance Director and Dietary Supervisor were responsible for ensuring the ice machine was cleaned and stated it should have been cleaned on a weekly basis. The Dietary Supervisor said, the cleaning schedule was in the Maintenance Director's computer program as a weekly task and said, But are all responsible for pulling out that yellowish looking ice and not serving it to our residents. The Dietary Manager stated the ice machine was cleaned on 4/22/2025 and stated it was important for the ice machine to be clean, because it is about sanitation and infection control and keeping our residents safe and happy. The Dietary Supervisor stated a resident who received ice from a dirty or contaminated ice machine could get sick if their immune system is down. The Dietary Supervisor stated the ice discoloration was due to the city water and occurred when the city flushed the fire hydrants. The Dietary Supervisor stated the city would notify the facility when they were flushing the hydrants, and this notification would give the facility the ability to make a plan to clean the ice machine according to the city notification. During an interview with the Maintenance Director, 04/24/2025 at 12:34 p.m., the Maintenance Director stated he was responsible for cleaning the ice machine and stated, I pulled out the filters and clean them and then I check for the yellow ice due to the city water and I scoop it out and throw it in the sink in the kitchen and wipe the inside down but sometimes I forget, that is probably why there was rust on it. The Maintenance Director stated there was no specific clean schedule but stated he cleaned the filters on the ice machine once a month and said, The yellow ice, if I think about it when I walk by, I will scoop it out. It is usually worse when the city flushes the hydrants on every other Thursday. The Maintenance Director stated there was not an assigned task in the maintenance program and stated he had not received any training on how to clean the ice machine. The Maintenance Director stated it was important to clean the ice machine so the residents would have clean ice. During an interview with the facility Administrator, 04/24/2025 at 1:24 p.m., the Administrator stated the facility Maintenance Director was responsible for cleaning the ice machine and said he thought the ice machine should be cleaned monthly. The Administrator stated it was important for the ice machine to be cleaned for sanitation and we don't want to grow any bacteria and for health and safety. The Administrator stated he was not sure what harm could occur to a resident who received ice from a contaminated or dirty ice machine but stated, I know it would not be healthy. The Administrator stated the Dietary Supervisor and Maintenance Director probably had training on cleaning the ice machine. During an observation of the ice machine, 04/24/2025 at 3:15 p.m., the outside and inside of the ice machine walled surfaces had been cleaned and there was no rust observed. Yellow ice was observed in the middle of the ice in the ice machine. Record review of a facility document titled, Environment (Dining Services Policy and Procedure Manual, Copyright Original 5/2014, Revised 9/2017), revealed a policy statement, All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The procedures for the policy included, 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner 2. The Dining Services Director will ensures that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food services equipment and surfaces .4. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the kitchen. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 11/20/2024 at 11:20 a.m. revealed the DM assisting with the meal tray preparation. The DM had washed her hands and put on gloves for cutting the bread, after cutting the bread she assisted with taking plates from the cook and placed them on trays. The cook asked for diet tickets on the other side of the DM in which the DM reached and grabbed tickets handed them to the cook, and continued to assist with putting plates on trays and placing bread on plates using tongs. The DM then proceeded to reach in a bread bag, grabbed a large stack of bread, placed her gloved hand on the bread, cut the bread in half and continued to place bread on trays. The DM did all this without changing gloves and washing hands. During an interview on 11/20/2024 at 11:28 a.m. the DM stated she should have cut all the bread first before helping with the plates. The DM further stated by not changing her gloves and washing her hands it could cause cross contamination. During an interview on 11/21/2024 at 1:05 p.m. the ADM stated the DM should have changed her gloves once she finished what she was doing with the use of the gloves. The ADM further stated she should have removed the gloves and before touching the bread again she should have washed her hands and put new gloves on. The ADM stated once the DM had touched the meal tickets, she should have taken her gloves off. The ADM stated the importance of removing the gloves and washing her hands was to prevent cross contamination. The ADM further stated by touching the tickets the DM risked the contamination of the food and it could be passed on to the residents. Review of the facility's policy Meal Distribution, revised 2/2023, read Policy Statements: Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner., Procedures: 6. Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of service-dining. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-301.14, When to Wash, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTNESILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks;.

Based on interviews and record review the facility failed to ensure all Pre-Admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 4 residents (Resident #5), reviewed for resident assessment. Resident #5's PASRR level 1 screening form did not indicate mental illness and the resident did not have a PASRR level II evaluation. This could place residents at risk of not receiving necessary specialized services to meet their individual needs. The findings were: Record review of Resident #5's face sheet dated 11/20/24 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included major depressive disorder recurrent severe with psychotic symptoms (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life with hallucinations, delusions, disorganized thoughts, speech, and actions), psychotic disorder with delusions due to known physiological condition (severe mental disorders that cause abnormal thinking and perceptions), and unspecified dementia severe with other behavioral disturbance (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Record review of Resident #5's EHR on 11/20/24 diagnoses list revealed the primary diagnosis for the resident was listed as unspecified dementia severe with other behavioral disturbance, but this was not entered until 6/25/24. Further review revealed psychotic disorder with delusions was entered on the day of admission to the facility on [DATE] indicating the resident had a mental illness not dementia upon admission to the facility. Record review of Resident #5's admission MDS assessment dated [DATE] section A1500 indicated the resident was not considered by the state level II PASRR process to have serious mental illness and section A1510 serious mental illness was not checked. The resident usually understands and was usually understood. The resident had a BIMS score of 3 out of 15 indicating the resident was severely cognitively impaired. The resident had delusions with physical and verbal aggression towards others 4-6 days but less than daily. The resident was frequently incontinent of urine and always incontinent of bowel and the resident had a psychotic disorder and unspecified dementia and received antipsychotic medications on a routine basis. Record review of Resident #5's undated care plan revealed a focus initiated on 3/19/24 for the resident receiving psychotropic medications and a focus initiated on 3/19/24 for behaviors which include cursing, hitting during care, yelling during care, refusing care, and exit seeking. Record review of Resident #5's EHR revealed a PASRR level 1 screening dated 3/19/24 which indicated the resident had a primary diagnosis of dementia and mental illness was marked 0 indicating no mental illness. Record review of Resident #5's EHR revealed no PASRR level 2 evaluation was completed, and no documents signed by the physician that dementia was the primary diagnosis. In an interview on 11/21/24 at 1:16 p.m. the DOCC stated resident #5 did not have a level II PASRR evaluation or form 1012 signed by the physician indicating dementia as the primary diagnosis. The DOCC stated they were going to contact the physician regarding the PASRR screening form and the resident's diagnoses. The DOCC stated it was important for residents with mental illness to have a level II PASRR evaluation, so the residents receive needed or specialized services to meet their needs . Review of the facility PASRR policy with an effective date of [DATE] revealed (Company name) follows the Long-Term-Care user guide for Preadmission Screening and Resident Review published by the Texas Medicaid and Healthcare Partnership (TMHP ).

Based on observations, interviews, and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #23) reviewed for quality of care. Resident #23's tube feeding was not labeled with the required information. This failure could place residents at risk of decreased continuity of care, errors in tube feeding, and nutritional deficits. The findings were: Record review of Resident #23's face sheet dated 11/21/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included anoxic brain damage (damaged caused by a complete lack of oxygen to the brain), dysphagia following cerebral infarction (difficulty swallowing following a stroke that disrupted blood flow to the brain due to problems with the blood vessels that supply it), and aphasia (aphasia is a language disorder that affects your ability to speak and understand what others say). Record review of Resident #23's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 99 which indicated the resident was unable to complete the BIMS assessment and she was moderately cognitively impaired. The resident had a feeding tube, no significant weight loss or gain, and received all her nutrition and hydration through her feeding tube. Record review of Resident #23's undated care plan revealed a focus revised on 10/22/24 for tube feedings with interventions that included Resident #23 is NPO (Nothing by Mouth). Enteral formula and feedings as ordered. Osmolite 1.5 (Formula) at 55 ml/hr (milliliters per hour) to provide 1800 KCALS (kilocalories) 76 grams protein, 800ml of water per 22 hours. Flush feeding tube with 200ml H2O Q 4 hours (water every 4 hours). Record review of Resident #23's physician orders revealed an order with a start date of 11/19/24 for osmolite 1.5 at 55ml/hr to provide 1800 KCALS, 76gms of protein, 800ml of water per 24 Hours. Via G-tube. In an observation on 11/18/24 at 12:10pm Resident #23 was in bed, head of bed was elevated, the resident was non-verbal but made eye contact and would nod her head slightly when asked a question and was smiling. The tube feeding bag was clear and had approximately 500ml of an unidentified formula in it. A label affixed to the tube feeding bag had Resident#23's last name, no room#, dated 11/16/24 at 8:00 p.m. and the number 55 all written in black marker. No formula name was listed. The label also had areas to record any additions to the bag with amount, time, and initials slots that were all blank. The tube feeding was running via enteral feeding pump at 55ml/hr with a flush of 200ml water every 4 hours. The pump indicated the resident had already received 4307mls of the formula feeding and 5053mls of water flush. In an observation and interview on 11/18/24 at 12:14 p.m. LVN A was examining the tube feeding bag and stated that the night nurse told her in report that she had hung it last night despite being dated 11/16/24 and the date was just written in error and should have been 11/17/24. LVN A further stated she trusted the night nurse and the formula was osmolite as ordered but admitted she had no proof but trusted the night nurse. When asked why it was important the label be filled out correctly, LVN A stated because when state walks in and then stated so that other nursing staff were aware of the feeding and when it was hung. In an interview on 11/21/24 at 11:15 a.m. the DON stated the tube feeding label should have the name of the formula used, rate, date, and time hung. The DON further stated the resident's orders state to hang new tubing every 2 days or 48 hours . The facility policy and procedure for hanging and labeling a tube feeding was requested in an email sent to the Administrator on 11/21/24 at 10:32 a.m. Review of the facility provided enteral nutrition policy revised August 1, 2012, was from the food service manual regarding assessment, orders, and documentation. This policy did not cover nursing procedures for hanging a tube feeding and or labeling the tube feeding bag. Review of Texas Health and Human Services Evidence-Based Best Practice for Nutritional Support revised 8/2023 revealed . These processes include ensuring timely turnover of enteral formula inventory well within the product expiration dates and appropriate labeling . Formula labels should include the following: person's name and room number, formula name and strength, date and time formula prepared and hung .

Based on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents (Resident #18) reviewed for pharmacy services. Resident #18's Tramadol (narcotic) medication was left unsupervised in the top drawer of the medication cart in a paper pill cup after it was popped out of the medication card. This could put residents at risk of pain, medication errors, and drug diversion. The findings were: Record review of Resident #18's face sheet dated 11/21/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included unspecified dementia unspecified severity with agitation (general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life and include agitation), muscle wasting and atrophy not elsewhere classified multiple sites (wasting or loss of muscle tissue), and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness or paralysis of right side of the body following a stroke due to damage to tissues in the brain due to a loss of oxygen to the area). Record review of Resident #18's annual MDS assessment dated [DATE] revealed the resident had a BIMS score of 3 out of 15 indicating the resident was severely cognitively impaired. The resident had unclear speech and was sometimes understood and usually understands. The resident was continent of urine and usually continent of bowel. The resident had frequent pain up to a 5 on a scale of 1-10 with 10 being worst pain and received routine and PRN pain medication. Record review of Resident #18's undated care plan revealed a focus for pain revised on 2/19/24 and interventions included to administer pain medication as ordered. Record review of Resident #18's physician orders revealed an order dated 11/14/24 for tramadol 100 mg (milligram) 1 tablet by mouth every 6 hours for pain. (Give at 12 a.m., 6:00 a.m., 12 noon, and 6:00 p.m.) Record review of Resident #18's EMAR for November 2024 revealed the resident had pain levels from 0 up to 2 with most days being none. In an observation and interview during station 2 medication cart check on 11/19/24 at 5:05 p.m. witnessed by LVN A in the top drawer of the medication cart, a paper medication cup with an oblong white pill in it, and the bottom of the paper cup written in pen was Resident #18's last name. LVN A stated it was a tramadol 100mg tab for Resident #18's 5pm dose and she had pre-popped it and signed out for it. LVN A further stated she never does that, and she was unsure why she did it this time. LVN A stated she was not supposed to pre-pop the medication and leave it in the cart and apologized. When asked why it was important not to pre-pop the medications from the cards, LVN A stated because you can accidently give it to the wrong resident or wrong time. The narcotic count sheet for tramadol indicated LVN A signed out the tramadol at 5pm, the narcotic count was correct. LVN A wasted the tramadol with another nurse and documented it as wasted and signed by both nurses on the narcotic count sheet. In an interview on 11/21/24 at 11:05 a.m. the DON stated medications should be popped out of the card at the time they were given and not to be stored for later. The DON stated it was important not to pre-pop medications and store for later because it could get lost, the medication might be taken by someone else, or the nurse could forget to give it. The facility policy on medication administration was requested in an email sent to the Administrator on 11/21/24 at 10:32 a.m. A medication competency check off was provided . Review of the facility provided medication administration competency audit for oral meds undated revealed steps in administration of medications included . 3. punching med into cup using proper infection control technique . 10. Observe resident swallow medications 11. Documents after administration of meds .

Based on interviews, observation, and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents. The facility failed to ensure Resident #1 received 2-person assistance when CNA A transferred the resident from the wheelchair to the bed independently with a mechanical lift with the wrong sized sling. This failure could place residents at risk of injuries, falls, and a decline in quality of life. The noncompliance was identified as PNC. The noncompliance began on 08/25/2024 and ended on 08/27/2024. The facility had corrected the noncompliance before the survey began. The findings included: Record review of Resident #1's Transfer/Discharge Report (face sheet) dated 09/06/2024 revealed she was admitted to the facility on [DATE] and Family Member F was the Responsible Party. Record review of Resident #1's Physician History & Physical, dated 05/27/2024 revealed diagnoses of osteoporosis (deterioration of the bone which causes an increased risk for fractures), high blood pressure, dementia (decline of cognitive abilities that affects an individual's ability to perform everyday tasks), and congestive heart failure (failure of the heart to adequately pump blood resulting in fluid building up around the heart). Record review of Resident #1's Quarterly MDS assessment dated [DATE], revealed her cognitive skills for daily decision making were severely impaired, and she was dependent on staff for chair/bed-to-chair transfers. Record review of Resident #1's Care Plan for the focus area of ADL's, revealed under interventions was Transfers = total lift with medium pad [sling] with help of 2 aides, initiated on 04/19/2023. Record review of Resident #1's Care Plan for the focus area of Transfers, revealed under interventions was Total lift Medium (Yellow) Sling, initiated on 05/26/2023. Record review of Resident #1's Care Plan for the focus area of Falls, revealed under interventions was use Mechanical lift with medium pad [sling] with 2 aides, initiated 05/30/2023. Record review of Resident #1's Physician Order summary Report, dated 08/27/2024, revealed Resident #1 was admitted to Hospice B on 05/12/2023. Record review of Resident #1's Lift Transfer Evaluation, dated 05/26/2024, revealed a total mechanical lift was required with use of a medium (yellow) sling and required 2 team members. Record review of Resident #1's Lift Transfer Evaluation, dated 08/26/2024, revealed a total mechanical lift was require with use of a medium (yellow) sling and required 2 team members. Record review of Resident #1's Nurse's Notes, dated 08/25/2024 at 19:10 (7:10 PM) by LVN D revealed I was called to resident's room by other nurse where I observed resident lying on the floor on her right side (sic) CNA was holding her head up off of the foot of the mechanical lift. Side of her head, right temporal area was bleeding. Resident was unable to say what had happened. CNA reported that resident was up in the mechanical lift .and resident fell hitting her head. RN E was notified at 7:21 PM. I called Hospice Nurse .at 7:33. Hospice Nurse would come to assess resident and call MD with her findings. [Hospice Nurse] Asked me to please call the family and after her assessment she would also call and report to family. At 7:43 PM and 7:55 PM I called and left message for Family Member F to please return my call. Family Member F called [back] approx. [approximately] 8:30 [PM] and I reported what had happened. Instructed that hospice nurse would be calling with her findings. Record review of Resident #1's Nurse's Notes, dated 08/25/2024 at 22:00 (10:00 PM) by LVN D revealed Resident #1 was transferred to Hospital G's ER. Record review of Resident #1's Nurse's Notes, dated 08/26/2024 at 04:45 (4:45 AM) by LVN D revealed Resident #1 returned from Hospital G, RN E was notified. Record review of Resident #1's Hospital G's ER report, dated 08/25/2024, revealed the resident was diagnosed with a zygomatic fracture (break in the cheek bone). Record review of Resident #1's Nurse's Notes, dated 08/26/2024 at 04:46 (4:46 AM) by LVN D revealed Resident #1 returned from Hospital G . in stable condition. Imaging shows fracture to right cheek area, .Resident received sutures to laceration to right temporal region .Called and reported to RN E on call. Record review of Resident #1's Nurse's Notes, dated 08/26/2024 by LVN C revealed Resident on f/u [follow-up] for fall. Nuero [sic] checks are continued. Resident has sutures to below right eye. No drainage noted from sutures. No nonverbal signs/symptoms of pain observed. Asked resident if she were in pain and she shook her head no. Record review of Resident #1's Fall Incident Report, dated 08/25/2024, revealed LVN D was called into the resident's room by another nurse, observed Resident lying on the floor on her right side. The CNA was holding her head up off the foot of the mechanical lift, the right side of Resident #1's head was bleeding. CNA reported the resident was up in the mechanical lift over her bed, and the resident fell to the floor hitting her head. Resident was assessed on the floor, vital signs were within normal limits, and neuro checks were within normal limits. The mechanical lift was used to safely place the resident back in bed. The open area to the right temple was cleaned with normal saline and gauze. An ice pack was placed to the side of her face to help with any swelling that may occur. RN E was called at 7:21 PM and informed of the resident's status. Then the hospice nurse was called at 7:33 PM. Resident #1's Family Member F was called at 7:43 PM. Record review of Resident #1's Rehabilitation Fall Screen, dated 08/26/2024, revealed resident had a fall on 08/25/2024, [the] resident fell out of mechanical lift with CNA. Record review of the facility's Provider Investigation Report, for intake #527624, dated 08/29/2024, revealed on 08/25/2024 at 7:09 PM, when CNA A was transferred the resident with the mechanical lift, the resident's bottom bumped the bed, caused the lift to jolt during the transfer, and caused the resident to transfer to the floor. The CNA was suspended during the investigation. All CNAs and nurses were retrained regarding safe transfers and competencies were completed. Lift/transfer evaluations were completed on all residents. A QAPI meeting was held with staff and the medical director. Observation on 09/06/2024 at 11:51 a.m. revealed Resident #1 was sitting in a specialized wheelchair with both of her legs elevated with pillows under her feet in the dining room. Resident #1 had a wound on her right cheek with no signs of bruising to the cheek and there were no sutures in the wound. In an interview on 09/06/2024 from 3:06 PM to 3:25 PM, CNA A stated on 08/25/2024 she was transferring Resident #1 from her wheelchair to the bed by herself with the mechanical lift, used the sling that was under the resident [a large sling instead of a medium size sling], and connected the sling correctly to the lift. CNA A said when she moved Resident #1 from her wheelchair over to the bed, the bed was too high. This caused Resident #1 to bump into it, caused the lift bar to tilt, and Resident #1 slid out of the sling and hit her head when she went down. The CNA said the resident's feet were still in the sling and all the sling loops were connected to the lift bar. The CNA stated she unfastened half of the sling loops after the resident was on the floor and was doing this transfer by myself. CNA A said she called the nurses to come help her and they assisted the CNA with putting the resident back into her bed with the mechanical lift. CNA A said she was the only aide on the floor so she transferred Resident #1 by herself, and she should have asked the nurse to help her. CNA A stated it was recommended to transfer Resident #1 with the mechanical lift using the yellow sling and 2 staff members. CNA A said she could look in the Kardex system or ask the nurse to determine how a resident was transferred and what size of sling was to be used. CNA A said the harm that could result by transferring a resident with a mechanical lift by 1 person was it could cause the resident to slip or fall and hit their head. CNA A stated she had training prior to the incident on how to use the lift. After the incident, she and all the other CNAs were trained on the use of the mechanical lifts with a return practice demonstration. In an interview on 09/06/2024 from 5:46 PM to 6:06 PM, LVN L stated she was in a resident's room when she heard CNA A yell for LVN D. LVN L stated she entered Resident #1's room, found the resident still connected to the lift with 1 side of the sling connected, the resident was all the way down on the floor and her head must have hit the floor or the base of the lift because there was blood on the floor and base of the lift. LVN L said she put a washcloth to the laceration to stop the bleeding and had CNA A hold the washcloth while she got LVN D to assist. LVN L said she did a head-to-toe assessment the best that she could when the resident was on the floor, LVN D, LVN L and CNA A lifted Resident #1 back into her bed with the mechanical lift to further assess the resident. LVN L stated she monitored Resident #1 while LVN D called hospice, the on-call RN and the family. Then LVN D came back into the room and informed LVN L she could leave the room and go back to her duties. LVN L stated CNA A was usually good at waiting for another staff member or nurse to assist her with the transfer and LVN L did not know why CNA A did not seek assistance that day. LVN L stated the harm that could result if a resident was transferred with a mechanical lift by 1 person instead of 2 as required could result in a lot of things, fall, fractures, skin tears, it would depend on the resident. In an interview on 09/06/2024 from 6:07 PM to 6:15 PM, LVN D stated she was in a resident's room and as she came out of the resident's room, LVN L told her they had a fall. When LVN D entered Resident #1's room, CNA A was holding the resident's head off the base of the mechanical lift and had a laceration to her head. LVN D said she tried to assess the resident who was on her right side before they lifted the resident with the mechanical lift and placed her in the bed for a further in-depth assessment. LVN D said she called the on-call nurse RN E who informed her to contact hospice. LVN D called Hospice Nurse N who told her she would come to the facility to assess the resident, she would call the hospice MD after she had assessed the resident, and asked LVN D to contact Resident #1's family. Hospice Nurse N would later contact the family after Resident #1 was assessed by Hospice Nurse N. LVN D stated she called Resident #1's Family Member F twice leaving a message both times. LVN D said she checked Resident #1's vital signs every 15 minutes which were within normal limits. LVN D stated the harm of 1 staff member transferring a resident with a mechanical lift instead of 2 could result in the resident falling, or their legs could hit the lift bar. In an interview on 09/07/2024 from 10:28 AM to 10:43 AM, RN E stated she was the on-call nurse on 08/25/2024 and received a call from LVN D who informed her CNA A had transferred Resident #1 and the resident had fallen during the transfer. RN E advised LVN D to assess Resident #1 and to contact hospice. RN E said she wanted to see the resident herself so when she arrived at the facility, Hospice Nurse N was in the facility evaluating the resident who had a laceration to her right cheek. RN E stated Hospice Nurse N contacted the hospice physician and the decision was made to send the resident to the hospital for evaluation. RN E stated the harm of 1 staff member transferring a resident with a mechanical lift instead of 2 could result in numerous things that could happen to the resident. In an interview on 09/07/2024 at 10:57 AM, Hospice Nurse LVN N stated she was not available at this time, but she would call the state surveyor back at the phone number provided. No return call was provided by Hospice Nurse LVN N before the state surveyor exited the facility. In an interview on 09/06/2024 at 4:27 PM the Interim DON stated the facility's investigation of the incident with Resident #1 revealed the lift sling under Resident #1 was a large size (blue) sling instead of the medium size (yellow) sling that was needed to transfer Resident #1. It caused the resident to slide out of the sling when the resident's bottom hit the bed as CNA A transferred the resident from the wheelchair to the bed by herself. The Interim DON stated after the incident, the Maintenance Director looked at the lift to make sure it was operating correctly, all the slings were checked to make sure they were not torn, and nursing staff were in-serviced on the size of slings to use. The Interim DON stated if a resident required 2 staff to transfer and there was only 1 CNA in the building, the CNA should ask the nurse to assist them with the transfer. In an interview on 09/06/2024 at 4:16 PM, the Interim DON stated a POC was initiated for the lift incident with Resident #1 and handed the state surveyor a blue binder with the facility's POC. The Interim DON stated the nursing staff were instructed on using the right colored lift sling, received a competency checkoff on how to use the mechanical lift, all residents who required transfer assistance had Lift Transfer Evaluations, residents who were transferred with mechanical lift had their care plans updated, and a sheet was created for the nursing staff with how the resident was to be transferred, what sling size to use, and was placed at the nurse's station. In a further interview on 09/07/2024 from 1:58 PM to 2:21 PM, the Interim DON stated inside the blue POC binder, the first sheet was a QAPI form provided by corporate which she and RN E completed to develop a plan and to start assessing other residents as soon as possible. The Interim DON said an ad hoc QAPI meeting was held with the medical director via phone and their signatures were on the back side of the QAPI form. The Interim DON stated the second tab in the blue POC binder had Resident #1's hospital record and facility record which included the neuro check sheet, Kardex printout, and her care plan for transfers. The Interim DON stated the third tab in the blue POC binder had the Lifter Sheet that was created and kept at the nurse's station for staff to access, all the Lift/Transfer Evaluations that were done on all the residents in the facility, and a list of residents who were going to be evaluated by OT. The Interim DON said the fourth tab in the blue POC binder had the Lift/Transfer Evaluations for the 2 residents who were admitted after 08/26/2024. The Interim DON stated the fifth tab had the in-service sign-in sheets for the Abuse and Neglect in-service. The Interim DON said all the skills checkoffs for the nurses and the CNAs use of the mechanical lift were in a yellow binder. Record review of the documents in the blue POC binder revealed there was a QAPI Identification Tool, a tab labeled Resident Actions, a tab labeled Identification of Others, a tab labeled New Admit Lift Audits and an unlabeled tab that had an email from the Interim DON to corporate and a sling audit tool. Record review of the undated QAPI Identification Tool in the facility's POC blue binder, revealed immediate actions taken for the resident identified revealed Resident #1 was taken to the ER for an evaluation and returned to the facility with sutures to a laceration on her head and a zygomatic fracture to her cheekbone. The lift and sling were taken out of service, the resident's care plan/Kardex was reviewed for appropriate lift and sling. The CNA A was in-serviced on 08/26/2024 on the use of the sling with return demonstration. Immediate actions that were taken to identify all residents potentially affected included conducting lift/transfer assessments on all current residents; residents care plans were updated as needed, all slings were assessed for any disrepair, and lift competencies were done with all nursing staff. System changes that were made or modified included in-service to 100% of the nursing staff on the lift/transfer program with return demonstration. Lift evaluations would be completed on all new admissions. The DON was to review the completed daily clinical meeting lift assessments, and the DON would do audits of lift assessments twice a week for 8 weeks then biweekly for 2 months. An Ad Hoc QAPI meeting was held with the Medical Director regarding the POC on 8/27/24 and results of the monitoring audits would be presented at QAPI for the next three months. The QAPI Identification Tool sheet was signed by the Administrator, Interim DON, and Medical Director. Record review of the documents under the first tab titled Resident Actions in the facility's POC blue binder, revealed Resident #1's ER hospital record for 8/25/24, the Neurological Evaluation Flow Sheet that was started 8/25/24 at 7:20 PM, and her Kardex which indicated the resident required to be transferred by 2 aides with a mechanical lift and a yellow sling. Resident #1's care plan for Transfers was included and she required a mechanical lift with a yellow sling for transfers. Record review of the documents under the second tab titled Identification of Others in the facility's POC blue binder, revealed the first sheet showed 11 residents listed who were transferred with a mechanical lift, and listed the color of sling used for the transfer. The second sheet was a Care Plan Item/Task Listing report for the 11 residents who required a mechanical lift transfer. Copies of the Lift Transfer Evaluations, dated 8/26/24 for all the residents who were in the facility on that day and 9/3/24 for the residents admitted after 8/26/24 were included along with a list of residents who were identified to be evaluated and treated by OT. Record review of the documents under the third tab titled Competencies in the facility's POC blue binder, revealed all 32 employees had been in-serviced on Abuse and Neglect. Record review of the documents under the fourth tab titled New Admit Lift Audits in the facility's POC blue binder, revealed Lift Transfer Evaluations were done on 2 newly admitted residents. Record review of the documents under the fifth untitled tab in the facility's POC blue binder, revealed a weekly sling inventory audit tool. Record review of the facility's Yellow Binder revealed the following: 1. Record review of Team Member Acknowledgment of the Facility's Lift Program Policy and Procedures sign-off sheet revealed This program has been implemented in an effort to provide a safe environment for the patients/residents in our care, and our team members. Our patients/residents will be evaluated upon admission to determine what type of assistive transfer equipment, if any, is needed based on the assessment criteria .failure to follow the lift program .may result in termination. 2. Record review of the Team Member Acknowledgement of the Facility's Lift Program Policy and Procedures sign-off sheets revealed 25 nursing staff (11 CNAs and 14 nurses) had signed the acknowledgement form on 08/26/2024 and on 08/27/2024. 3. Record review of the Mechanical Lift Skills Checklist revealed 25 nursing staff (11 CNAs and 14 nurses) had completed the skills checklist on 08/26/2024. 4. Record review of the Mechanical Lift Skills Checklist revealed CNA A had completed the skills checklist on 05/29/2024 and on 06/20/2024 in addition to training on 08/26/2024. 5. Record review of an Inservice Training Report Sign-In sheet, dated 08/25/2024, revealed 25 nursing staff (11 CNAs and 14 nurses) were trained on how to use the mechanical lift, falls prevention, and provided guidance/education with assisting residents to safely reposition or transfer the resident. CNA A had signed the in-service training sheet. Record review of an untitled, undated sheet with employee names and titles revealed the facility had 11 CNAs and 14 nurses (25 total nursing staff) and total of 32 employees. In an interview on 09/06/2024 at 1:06 PM, CNA H and CNA I stated a paper was kept at the nurse's station with information on what type of lift was required to transfer a resident and the size of the sling. Record review of the undated Lifter List kept in a binder at the nurse's station revealed the resident's name, type of lift required (if mechanical lift), and the lift sling size required. The sheet indicated Resident #1 required a mechanical lift with a medium (yellow) sized sling. In an interview on 09/06/2024 at 3:43 PM, LVN J stated she worked from 6 AM to 6 PM and recently received several trainings on how to use the mechanical lift which included skills check off and to use the correct color/size of lift sling. In a further interview on 09/06/2024 at 3:50 PM, CNA I stated she worked from 6 AM to 6 PM she had recently been trained on how to use the mechanical lift which included skills check off and to make sure the correct size of lift sling was used for the resident being transferred. In an interview on 09/06/2024 at 4:36 PM, LVN K stated she worked from 6 AM to 6 PM and she recently received several trainings on how to use the mechanical lift which included skills check off and to use the correct color/size of lift sling. In an interview on 09/06/2024 at 4:42 PM, the Maintenance Director stated after the incident he checked the lift to make sure it was functioning correctly and found no problems with the lift and the lift slings were checked to make sure they were not torn. In an interview on 09/06/2024 from 5:46 PM to 6:06 PM, LVN L stated she worked from 6 PM to 6 AM and recently received several trainings on how to use the mechanical lift which included skills check off and to use the correct color/size of lift sling. In an interview on 09/06/2024 from 6:07 PM to 6:15 PM, LVN D stated she worked from 6 PM to 6 AM and recently received several trainings on how to use the mechanical lift which included skills check off and to use the correct color/size of lift sling. In an interview on 09/06/2024 from 6:36 PM to 6:43 PM, CNA M stated she worked from 6 PM to 6 AM and recently received several trainings on how to use the mechanical lift which included skills check off and to use the correct color/size of lift sling. In a further interview on 09/07/2024 from 1:58 PM to 2:21 PM, the Interim DON stated the harm of 1 staff member transferring a resident with a mechanical lift instead of 2 could result in bruises, skin tears, fractures, or other injuries to the resident. The Interim DON said CNA A told her the other CNA who was scheduled to work was running late and CNA A did not ask for help from the nurses when she transferred Resident #1. In an interview on 09/07/2024 from 2:37 PM to 2:48 PM, the Administrator stated the harm that could happen to a resident if they had 1 person transferred the resident with a mechanical lift instead of the required 2 persons, could result in the resident sliding out of the sling. The Administrator said he thought CNA A thought she was capable of transferring Resident #1 by herself. The Administrator stated after the incident with Resident #1, the lift was taken out of service until it was evaluated and determined it was safe. The residents' care plans were reviewed, all CNAs and nurses were trained on how to do a mechanical lift, therapy evaluated residents, all slings were inspected, and none were found to be defective, and all residents had a Lift/Transfer Assessment completed. The Administrator said the medical records employee made sure the Lift/Transfer Assessment would popup to be completed in the electronic clinical record for new residents as part of their admission assessment. The Administrator stated monitoring would be done at the daily meetings by reviewing the Lift Assessments and completed audits would be presented at the QAPI meetings for the next three months. Record review of the Lift 4 care - Safe 4 All lifting policy, dated February 2023, revealed the purpose was To provide team members guidance with assisting residents to safely reposition or transfer .7. In order to maintain resident's' safety, residents should be lifted or transferred by the lift and sling which is deemed appropriate after the lift evaluation is completed, there should be no interchanging of lifts and slings.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 dining rooms reviewed, in that: A supply cabinet located in the facility dining room was unlocked and contained potentially dangerous materials. This deficient practice could place residents, staff, and the public at risk of exposure to potentially dangerous materials. The findings were: Observation on 09/26/2023 at 12:58 p.m. revealed a supply cabinet located in the facility dining room was closed but unlocked, and contained three containers of cleaning wipes labeled, Warning, Keep Out of Reach of Children, and six cans of shaving cream labeled, Warning, Keep Out of Reach of Children. During an interview with Housekeeper A on 09/26/2023 at 1:01 p.m., Housekeeper A confirmed a supply cabinet located in the facility dining room was closed but unlocked, and contained three containers of cleaning wipes labeled, Warning, Keep Out of Reach of Children and six cans of shaving cream labeled, Warning, Keep Out of Reach of Children. Housekeeper A further confirmed the storage cabinet was usually locked. During an interview with the Administrator on 09/28/2023 at 5:15 p.m., the Administrator confirmed the supply cabinet should have been locked and stated it was responsibility of all staff to ensure potentially dangerous materials were secured so that no residents could come into contact with such material. Record review of the facility policy, Hazard Areas, dated 09/01/2014, revealed, It is the policy of this center that residents be safeguarded from the life safety and other innate dangers associated with hazard areas.any hazard area should be locked to protect residents from hazards .

Based on observation, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The a/c vent above the prep area had gray fuzzy matter. 2. Salisbury steaks stored in a deep freezer were not properly sealed. 3. Cook E did not change her gloves after touching unclean items and going back to serving residents' lunch meals. These deficient practices could affect residents who received meals from the kitchen and place them at risk for food borne illness. The findings were: 1. An observation on 6/15/20 at 11:00 a.m. in the kitchen, revealed an ac return air vent grill had dark gray fuzzy matter. During an interview on 6/15/20 at 11:00 a.m., the Dietary Manager confirmed the return air vent's grill had dark gray fuzzy matter. The Dietary Manager reported the Maintenance Director cleaned the vents. Review of the TFER 2015, page 107, section §228.113(3) revealed non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; and page 109, section §228.114(c) revealed non-food contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 2. An observation on 6/15/20 at 11:04 a.m. in the kitchen, revealed inside a deep freezer there was a large clear bag with a brown meat which was not tied closed, exposing the meat. During an interview on 6/15/21 at 11:04 a.m., the Dietary Manager confirmed a large clear bag with a brown meat which was not tied closed. Review of the TFER 2015, page 52, section §228.66(a)(1) and 228.66(a)(1)(d) revealed packaged and unpackaged food shall be protected from cross contamination by storing the food in packages, covered containers, or wrappings; and page 59, section §228.69(a)(1)(A)-(C) revealed food should be stored in a clean dry location where it is not exposed to splash, dust, or other contamination; and at least 6 inches above the floor. 3. An observation in the kitchen on 6/17/21 at 10:39 a.m., revealed Cook E with her gloved right hand moved her glasses from the top of her head down to her eyes to read the menu for the serving utensil portion sizes. Cook E then moved her glasses back on top of her head and used her right hand to open the door and grab the clean serving utensil and placed them on the steam table. Cook E then adjusted her mask with her right hand. During an interview on 6/17/21 at 10:39 a.m., Cook E confirmed that she needed to wash her hands after touching her glasses and mask before finishing her tasks. An observation in the kitchen on 6/17/21 at 10:58 a.m., revealed the lunch meal service had started. Cook E was placing the prepared resident plates on the tray and also placed the drinks and supplements on the resident's tray. While preparing a resident's tray Cook E with her gloved hand open the freezer door to grab a frozen treat and it fell to the floor. Cook E then grabbed another one out of the freezer and placed it on the tray. Cook E then picked up the frozen treat off the floor with her gloved hand and put it in the trash can and afterwards came back to the serving line with the same gloves on. Cook E then was handed a finished resident's plate to place on the tray. The surveyor then asked Cook E if she should wash hands after picking the frozen treat off the floor and coming back to the line. Cook E confirmed that she should have washed her hands. Review of the TFER 2015, page 56, section §228.68 (e)(1) revealed if used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Record review of the facility's policy on Sanitation, dated 9/01/12, revealed it is the policy of this facility to maintain equipment, work surfaces, walls and floors in sanitary condition through daily, ongoing procedures.

Based on observation, interviews and record reviews, the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail or assess the resident for risk of entrapment from bed rails prior to installation or review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for two (Resident #5 and Resident #18) of 6 residents reviewed for bed rails in that: 1. Resident #5 was not completely assessed for use of bedrails, and did not have a signed consent, risks or benefits discussed or alternatives tried prior to installation or use. 2. Resident #18 was not completely assessed for use of bedrails, and did not have a signed consent, risks or benefits discussed or alternatives tried prior to installation or use. These deficient practices could affect residents with bed rails and could result in entrapment or injury. The findings were: 1. Review of Resident #5's electronic face sheet dated 6/18/21 revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's comprehensive care plan dated 3/26/21 revealed Resident has impaired bed mobility r/t cognitive impairment, insufficient muscle strength. Bed rail/bed buddy in place to help assist resident with bed mobility. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's quarterly MDS assessment with an ARD of 4/1/21 revealed Resident #5 scored a 1/15 on her BIMS which indicated she was severely cognitively impaired. She required limited assistance with care, one-person physical assist. Review of the facility Clinical Health Status Evaluation of Resident #5 dated 9/18/20 revealed she was ambulatory with poor safety awareness due to decreased cognitive functioning. Parts of the assessment form were incomplete: Is the resident currently taking any medication (s) which would required increased safety precautions? .Side rail safety verification .Evaluation .and risks and benefits and consent. Observation on 6/15/21 at 10:45 a.m. revealed Resident #5 sitting on her bed with 2 ¼ side rails up. Observation on 6/16/21 at 09:30 a.m. revealed Resident #5 in bed with 2 ¼ side rails up. Observation on 6/17/21 at 10:30 a.m. revealed Resident #5 sitting in bed with 2 ¼ side rails up. Interview on 6/17/21 at 11:00 a.m. with ADON B revealed that no assessments, consents, risks or benefits or alternatives tried were done with residents because they had bed canes and not bed rails. Interview on 6/18/21 at 10:23 a.m. with the DON revealed that she was not aware that assessments, consents, risks or benefits or alternatives tried were done with residents because they did not consider a bed cane a bed rail. 2. Review of Resident #18's electronic face sheet dated 6/18/21 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's comprehensive care plan dated 5/11/21 revealed MOBILITY .has impaired bed mobility r/t cognitive impairment, insufficient muscle strength. Bedrail/Bed Buddy in place to assist resident with bed mobility .interventions .assess residents' ability to properly use bed rail .assess residents bed rail/bed buddy for sturdiness/safety concerns. Review of Resident #18's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's quarterly MDS assessment with an ARD of 4/30/21 revealed a BIMS of 11/15 which indicated he was moderately cognitively impaired. He required extensive assistance with care and one-person physical assist. Review of Resident #18's Clinical Health Status Evaluation dated 12/23/19 revealed it was incomplete. Objective assessment .side rail restrictions .medications that would increase safety precautions .verification of side rail safety .risks and benefits and consent not completed. Evaluation .The resident will not utilize side rails at this time. Observation on 6/15/21 at 10:43 a.m. revealed Resident #18) lying on his bed with ¼ side rails up x2. Interview on 6/18/21 at 10:23 a.m. with the DON revealed the facility did not have a policy and procedure titled bed rails. She stated that she was not aware of any current assessments for siderails, consents, alternatives tried or risks and benefits for Residents #5 or #18.

Based on observation, interviews and record reviews, the facility failed to prevent a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one (Resident #13) of one resident observed for feeding tube medication administration in that: LVN A did not check for placement of Resident #13's G-tube prior to administering medications. This deficient practice could affect residents with enteral tubes and could result in aspiration pneumonia or vomiting. The findings were: Review of Resident #13's electronic face sheet dated 6/18/21 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's physician order dated 2/13/20 revealed Check enteral feeding tube placement before initiation of feeding/flushing. Review of Resident #13's comprehensive care plan dated 3/3/20 revealed PEG-Tube: The resident requires PEG-tube feeding r/t Post CVA, Dysphagia, Swallowing problem .Interventions .check for tube placement and gastric contents/residual volume per facility protocol. Review of Resident #13's quarterly MDS with an ARD of 4/22/21 revealed she was not a candidate for a BIMS which indicated she was severely cognitively impaired. Observation on 6/17/21 at 10:27 a.m. of LVN A administering medications to Resident #13 revealed she placed her stethoscope onto Resident #13's stomach, listened and flushed the tubing with 60 ml of water. Interview on 6/17/21 at 10:30 a.m. after several attempts by LVN A to unclog Resident #13's G-tube, she stated it has been awhile since I worked with a G-tube. When asked by the surveyor if she checked for placement per her facility policy and procedure she stated No, I didn't. Interview on 6/17/21 at 1:00 p.m. with the DON revealed that LVN A should have checked for enteral tube placement prior to flushing or medication administration per the facility policy and procedure which was to aspirate for residual volume. Review of the facility policy and procedure revised 12/11/19 titled Medication Administration through an Enteral Tube revealed Facility should check the placement of the gastrostomy tube .verify the tube is functioning before administering medications .checking gastric residual volume.

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for 1 of 13 residents (Resident #29) reviewed for care plans timing and revision, in that: Resident #29's care plan was not reviewed and revised after her Quarterly MDS assessment for changes in her [CONDITION(S)] medication usage. This deficient practice could affect residents by place them at risk for inadequate care and increase anxiety. The findings were: Record review of Resident #29's face sheet, dated 6/18/21, revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #29's Annual MDS, dated [DATE], revealed the resident had a BIMS of 15 which indicated the resident was cognitively intact. The record did not reveal the resident received any antianxiety medications. Record review of Resident #29's Clinical Physician Orders, dated 6/17/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #29's June 2021 Administration Record (which includes the MAR and TAR), dated 6/16/21, did not reveal the resident received any antianxiety medications from 6/01/21-6/16/21. Record review of Resident #29's care plan, undated, revealed a focus of ANXIETY [Resident #29] uses anti-anxiety medication r/t Anxiety disorder with an intervention to Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. During an interview on 6/18/21 at 10:45 a.m., the MDS Coordinator confirmed she was responsible for completing and updating residents' MDSs and care plans. The MDS Coordinator reported she just started working at the facility in March of 2021 and has been trying to complete an audit of residents' Care plans to make sure all their focus area was in order. The MDS Coordinator stated she believed Resident #29 was on anti-anxiety medication but had recently been taken off of it and had not had a chance to update it yet. During an interview on 6/18/21 at 11:41 a.m., the MDS Coordinator confirmed Resident #29 was taken off lorazepam on 5/05/21. The MDS Coordinator confirmed she should have change Resident #29's care plan to resolve off the resident's use of antianxiety medications after the MDS assessment documented that she was not receiving any antianxiety medications. Record review of the facility policy titled Care Plans, dated June 2017, revealed care plans will be developed for all patients and residents based upon the RAI manual and guidelines.

Based on interview and record review the facility failed to provide services that are furnished to maintain the resident's highest practicable physical, mental and psychosocial well-being for 1 of 13 residents (Resident #26) reviewed for care plans in that: Resident #26's care plan did not address activities. This failure could affect resident and place them at risk for not receiving appropriate treatment and services or activities. The findings include: Record review of Resident #26's face sheet, dated 6/18/21, revealed the resident was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #26's Annual MDS, dated [DATE], revealed a BIMS score of 15 which indicated the resident was cognitively intact. The record revealed the resident required total dependence for bed mobility, transfer and locomotion. The record also revealed the resident thought it was very important to listen to music she liked, keep up with the news, do things with groups of people, do [her] favorite activities, go outside and participate in religious activities. Review of Resident #26's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated the resident was cognitively intact. The record revealed the resident required extensive to total dependence for bed mobility, transfer and locomotion. Record review of Resident #26's care plan, undated, revealed there was no care plan focus for activities. During an interview on 6/16/21 at 9:33 a.m., Resident #26 was lying in her bed in her room. Resident #26 reported that she didn't participate in the facility activities and she normally stayed in her room watching TV. During an interview on 6/18/21 at 10:45 a.m., the MDS Coordinator confirmed she was responsible for completing and updating residents' MDSs and care plans. The MDS Coordinator reported she just started working at the facility in March of 2021 and has been trying to complete an audit of residents' Care plans to make sure all their focus area was in order. The MDS Coordinator stated she tried audit for residents' activity care plan because she noted some were missing this care plan, but she hadn't finished the audit. The MDS Coordinator reported she must have either missed or had not gotten to Resident #26's care plan to see that she did not have a care plan for activities. The MDS Coordinator confirmed Resident #26 should have an activity care plan to address her activity needs. Record review of the facility policy titled Care Plans, dated June 2017, revealed care plans will be developed for all patients and residents based upon the RAI manual and guidelines.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment was provided for 2 of 6 shared resident bathrooms (Shared resident bathrooms #30 and #32, #33 and #35) reviewed for environmental conditions. 1. The shared bathroom for resident rooms 33 and 35 had dark yellow and brown staining inside the toilet bowl. 2. The shared bathroom for resident rooms 30 and 32 had dark brown and black stains on the splash guard leading from the raised toilet to the toilet bowl. These failures could affect residents and place them at risk of feeling uncomfortable as a result of living in an unclean environment. The findings were: 1. An observation on 6/15/21 at 12:53 pm in the bathroom shared by resident rooms 33 and 35, revealed in the toilet on the upper left side of the bowl dark yellow and brownish streak stains. An observation and interview on 6/17/21 at 9:46 am in the bathroom shared by resident rooms 33 and 35, revealed in the toilet on the upper left side of the bowl dark yellow and brownish streak stains. Resident #34 reported that she was not sure when the last time they cleaned the toilet. During an interview on 6/17/21 at 9:48 am with Housekeeper G reported she was currently cleaning the railings and door knobs. Housekeeper G confirmed the staining to the bathroom shared by resident rooms 33 and 35. Housekeeper G reported they hadn't gotten to this hall for cleaning the bathrooms yet. Housekeeper G reported they try to clean the rooms daily. 2. An observation on 6/15/21 at 12:57 pm in the bathroom shared by resident rooms 30 and 32, revealed a raised toilet seat with handles and a splash guard that extended into the toilet bowl. On the splash guard there were dried dark brown black drip stains leading to the toilet bowl. An observation on 6/16/21 at 10:28 a.m. in the bathroom shared by resident rooms 30 and 32, revealed a raised toilet seat with handles and a splash guard that extended into the toilet bowl. On the splash guard they were dried dark brown black drip stains leading to the toilet bowl. During an interview on 6/16/21 at 10:38 a.m. in the bathroom shared by resident rooms 30 and 32, Housekeeper H confirmed that the bathroom did have dried staining in the on the splash guard. Housekeeper H stated they were down a housekeeper. Housekeeper H stated they usually try to clean each room daily. Housekeeper H confirmed that she was familiar with this room being a problem room for the resident having bowel episodes and that they have to soak it and then scrub it to get the substance off the bowl, but they hadn't gotten to clean it yet but she would get right on it. During an interview on 6/18/21 at 11:30 a.m., the Housekeeping and Laundry Supervisor confirmed they have been down some staff and that she just called a person in to help perform their normal housekeeping tasks. The Housekeeping and Laundry Supervisor stated that if staffed appropriately they would have 3 staff with one in the middle one in the back and one to do the odds and ends. The Housekeeping and Laundry Supervisor stated the bathroom shared by rooms 30 and 32 was usually one of their focus room but maybe it got missed with having few staff. Stated that usually before leaving and when getting on shift she does rounds of the residents' rooms to make sure they are clean. Record review of the facility's 7 Step Cleaning Method- Job: Step 5 Clean and Sanitize Commode, undated, revealed Step 1 clean and sanitize inside of bowl.

Based on interview and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the care plan for 1 of 7 residents (Resident #2) whose care was reviewed. LVN A and LVN C assessed Resident #2, who was a full code, as having no pulse, heartbeat, or respirations and did not call EMS/911 or initiate cardiopulmonary resuscitation and did not check Resident #2's code status for approximately 13 minutes after being found unresponsive. Resident #2 was pronounced dead by the Justice of the Peace on [DATE] at 11:05 pm (documented as 10:55 p.m.). This was determined to be past non-compliance at an Immediate Jeopardy level due to the facilitys implimentation of actions that corrected the non-compliance prior to the investigation on [DATE]. The facility was out of compliance from [DATE] through [DATE]. The facility's corrected action was completed on [DATE]. Theses failures could affect 15 residents in the facility that were a Full Code Status and could result in death. Findings: Record review of face sheet for Resident #2 revealed she was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Admission Advance Directives Acknowledgement, dated [DATE], revealed Resident #2 had prepared an advanced directive and Resident #2 was a Full Code status (if resident experiences [MEDICAL CONDITION], CPR is required). Review of Resident #2's Care Plan, dated [DATE] (with handwritten updates by nursing staff last dated [DATE]), revealed Resident #2 was a Full Code status and under Goal and Target Date: Staff will honor FULL CODE orders as per wishes of her and her family and administer CPR if she has an arrest (cessation of heart function). The document provides for: Identifying Full Code status per facility protocol, maintaining current physician orders [REDACTED]. Interview on [DATE] at 4:45 p.m., with CNA B revealed on [DATE] at approximately 10:40 p.m. CBA B checked Resident #2 ' s room and found that Resident #2 was not in her bed. CNA B said she, with the aid of CNA E, went to a room in another part of the building where Resident #2 was often visited privately by Resident #2' s family. CNA B said she had previously brought Resident #2 to the room after toileting Resident #2 at approximately 9:30 p.m. and her family member was present. CNA B said at 10:45 p.m. she and CNA E found Resident #2 unresponsive and deceased while seated in her wheelchair next to the B-bed where Resident #2 ' s family member was lying next to her, and holding her hand. CNA B said Resident #2 ' s family member was sleeping and was awakened when they came to check Resident #2. CNA B said Resident #2' s family member may not have been fully aware of Resident #2 ' s apparent death. CNA B said Resident #2' s face was white and was completely unresponsive, was cold to the touch, and appeared lifeless. CNA B said they moved Resident #2 to her room approximately 10 rooms away, continued to check her on the way, then placed Resident #2 in her bed before notifying the nurses, but did so as quickly as possible. CNA B said she advised LVN A and LVN C who immediately came to Resident #2' s room to assess Resident #2. CNA B said Resident #2 appeared dead and that she witnessed the LVNs assessing Resident #2 finding no signs of life. CNA B said she did not see LVN A or LVN C start or perform CPR and was not aware of a call to 911/EMS by anyone in the facility. Interview on [DATE] at 2:15 p.m., with CNA E revealed CNA E and CNA B, at approximately 10:40 p.m. on [DATE], were making rounds together and went to check on Resident #2 and were going to bring her to her room, as it was getting late as Resident #2 was a two person transfer. CNA E said Resident #2 was often visited by her family member and they were allowed visitation in another room down the hall from the assisted dining room on the back hall. CNA E said she and CNA B found Resident #2 unresponsive and apparently dead while seated in her wheelchair, next to the B-bed, where her family member was lying semi-prone next to her and holding her hand. CNA E said the family member appeared awake but not fully aware of Resident #2 ' s death. CNA E said Resident #2 's face was white in color, body was completely limp and did not move or respond in any way. CNA E said they decided to move Resident #2 to her assigned room, continued to check her on the way, then placed Resident #2 in her bed before notifying the nurses, but did so as quickly as possible. CNA E said she advised LVN A and LVN C Resident #2 was deceased and LVN A and LVN C immediately went to Resident #2' s room to assess Resident #2. CNA E said Resident #2 appeared dead and she witnessed the LVNs assessing Resident #2 finding no signs of life. CNA E said she did not see LVN A or LVN C start or perform CPR and was not aware of a call to 911/EMS by anyone in the facility. In an interview on [DATE] at 3:00 p.m., with LVN C, she said she and LVN A, at approximately 10:50 p.m. on [DATE], were notified by CNA B and CNA E that Resident #2 was in her room and was unresponsive. LVN C said she gathered a stethoscope, a blood pressure cuff and an oxygen monitor and responded immediately to Resident #2 ' s room. LVN C said she did not know how long Resident #2 had been unresponsive, with no pulse or respirations. LVN C said she assessed Resident #2 with assistance from LVN A and found no signs of life. LVN C said Resident #2's face and skin were blue in color, was cold to the touch, that Resident #2 ' s mouth and eyes were closed, had no pulse, no blood pressure, no respirations, no heartbeat was detected. LVN C said Resident #2 was in the appearance of clinical death and appeared to have been deceased for an hour or more. LVN C said both she and LVN A began to make notifications and called the Medical Director, the supervisor (LVN D) and the Justice of the Peace. LVN C said she was able to contact the JP to pronounce Resident #2 and had made one call to the Medical Director which was unanswered. LVN C said LVN A called the duty supervisor (LVN D) and this was the first time Resident #2's code status was questioned. LVN C said she checked the code status of Resident #2 by checking Resident #2's chart at the nurse's station on the direction of LVN A and LVN D and found a green-colored Full Code status sheet inside the front cover of the chart indicating CPR should have been started and 911/EMS should have been called. LVN C said she did not know the code status of Resident #2 prior to checking the chart and that Resident #2's medical condition with Stage [MEDICAL CONDITION] made her assume Resident #2 had a Do Not Resuscitate order. LVN C acknowledged she did not start or perform CPR and did not call 911/EMS to assist Resident #2. LVN C said she was aware of when CPR was indicated, was certified to perform CPR and that her certification was not expired. LVN C said she was provided training by the facility on responding to emergencies like CPR, and was aware that it was procedure to perform it when residents with a Full Code status were found unresponsive and while EMS is called to respond to the facility. In an interview on [DATE] at 4:05 p.m., with LVN D she said she was the on-call supervisor and said she was contacted on [DATE] at 10:58 p.m. by LVN A to advise of the death of Resident #2 and at that time asked the code status of Resident #2 which was not known by LVN A. LVN D said she was then told Resident #2's chart was physically checked and that check revealed a Full Code status. LVN D said LVN A said CPR had not been started and 911/EMS had not been called for Resident #2 at the time she was found unresponsive or in the interim, and the JP was on route to the facility and was expected in minutes. LVN D said she then called the DON and advised Resident #2 ' s Full Code status had not been known, and not been checked by LVN A and LVN C and Full Code procedures had not been followed. Interview on [DATE] at 12:05 p.m., with the DON revealed she was aware that Resident #2 was found unresponsive on [DATE] at approximately10:45 p.m. and she had been advised by her staff of Resident #2 ' s death. The DON said Resident #2 was a Full Code status but was deceased for an unknown period of time and the Medical Director was aware and had directed the J.P. to come to the facility and pronounce the resident. In an interview on [DATE] at 1:15 p.m., with the Medical Director revealed he was called by LVN A at 11:01 p.m. on [DATE] and was told the local J.P. had already been called due to the death of Resident #2. The Medical Director said he was not told the code status of Resident #2, there were no indications CPR was started, 911 was called and he would have responded directly to the facility if he had been advised Resident #2 was a Full Code status. The Medical Director said he was made aware of Resident #2 ' s Full Code Status and CPR was not performed or EMS/911 was not called by staff when he signed the discharge documents on [DATE]. The Medical Director said the LVNs should have checked the code status of Resident #2 and immediately started CPR and called EMS/911 when Resident #2 was found unresponsive and without vital signs on [DATE]. The Medical Director said the staff had treated Resident #2 as if she was a DNR and was not aware of anyone in the building that could have legally pronounced Resident #2 dead when she was found unresponsive at approximately 10:45 p.m. on [DATE]. The Medical Director acknowledged that EMS/911 should have been called for Resident #2 before attempting to call the administrative staff. Review of Resident #2 ' s nurses notes, dated [DATE], revealed the Medical Director was notified and he asked us to call Judge . Record review of the facility Transfer/Discharge Summary , including a current Plan of Care in an electronic version, dated [DATE] (with a time stamp of 3:17 a.m.) and signed by the Medical Director on [DATE] with notation of Prognosis: deceased , revealed that Resident #2 expired on [DATE] at 10:55 p.m. and was pronounced by the local Justice of the Peace. This document listed a Full Code status under Non-medication Orders, and listed Full Code status under Advanced Directives, more specifically: Identify FULL CODE status per facility protocol, maintain current physician orders [REDACTED]. Review of LVN C's documentation in Resident #2's Nurse's Notes dated [DATE] (at 12:21 a.m.), revealed: -at 10:40 p.m. (on [DATE]) CNAs go to another room to bring Resident #2 to her room; Resident #2 was found unresponsive and brought to room; CNA B notified LVN A and LVN C; LVN A and C assess Resident #2 and find no pulse, heartbeat, breaths and checked oxygen; Medical Director and JP advised; LVN D advised (no time listed) who in turn notified DON. -at 10:55 p.m. (on [DATE]) the Justice of the Peace (JP) pronounced as the time of death. -at 2:25 a.m. crematory personnel arrived to transport Resident #2's body -at 3:12 a.m. Resident #2's body released to crematory In an interview on [DATE] at 12:45 p.m., the DON said Resident #2 was a Full Code status when found unresponsive on [DATE] at approximately 10:40 p.m., was deceased longer than CPR was appropriate to be provided, the Medical Director was aware of the code status of Resident #2 and he authorized the J.P. to pronounce Resident #2 ' s death in the facility. In the interview on [DATE] at 6:45 p.m., the Administrator and DON acknowledged either LVN A or LVN C should have called 911 immediately after finding Resident #2 had no pulse or respirations. Review of facility policy and procedure Cardio [MEDICAL CONDITION] Resuscitation (CPR) dated [DATE] revealed: -CPR will be initiated when [MEDICAL CONDITION] occurs for residents who have: Requested CPR in their advance directives; Who have not formulated advance directives; Who do not have a valid DNR order. CPR certified staff will be available to provide CPR when needed. The facility Administrator was notified on [DATE] at 6:00 p.m., an IJ situation had been identified due to the above failures and it was later determined to be past non-compliance due to the facility's corrective action taken prior to the investigation. The facility's corrective action plan included: Step 1: Immediate review of deceased resident ' s record to include: · Code status-Full Code · Documentation of signs of death · Notification of Family and Physician · Pre/Post Mortem Care · Pronouncement of Death (Completed on: [DATE]; DNS = Director of Nursing Services). 100% of direct care licensed nurses re-educated before allowed to provide care: · Code status-Full Code or DNR · Green sheet identifying Full Code status · Red sheet identifying DNR status · Documentation needs to include signs of death · Pre/Post Mortem Care (Initiated on: [DATE]; Completed on: [DATE]; RN Director of Clinical Education) Step 2: 100% immediate review resident ' s records to identify: · Code status-Full Code or DNR · Care Plan verified for proper code status · Out of Hospital DNR form complete with all appropriate signatures · Physician ' s telephone order and Consolidated orders reflect Code Status · Code status in Electronic records for reference (Initiated on: [DATE]; Completed on: [DATE]; DNS) Second audit of 100% of Full Code Records on residents were checked to ensure the record included: · A written physician's order [REDACTED].· A Full Code green sheet identifying Full Code status (kept in chart until resident ' s discharge or resident ' s code status is changed) · Full Code status on consolidated orders and care plan · Full Code status in electronic records · 100% records of all Full Code status were correct and easily identified (Initiated on: [DATE]; Completed on: [DATE]; DNS) Step 3: New admission records will be reviewed upon admission to ensure proper code status documentation is in chart and easily identifiable. Once a week X 4 weeks the charts will be double checked during clinical start up meeting to ensure code status documentation is in chart and easily identifiable. After 4 weeks, this will occur monthly X3 months then quarterly throughout 2016. (Established on [DATE] and ongoing: DNS or designee). New licensed staff will be educated on location of and proper identification of code status during the orientation process before they provide direct care to patients. New licensed staff education will be reviewed once a week X 4 weeks, then monthly X 3 months then quarterly throughout 2016. (Established on [DATE] and ongoing: DNS or designee). Licensed staff has emergency number books available at both nurse ' s stations for physicians and co-workers. Books have been validated for accuracy. 911 will be called for emergencies. This will be reviewed during new hire orientation process with licensed staff. (Completion: [DATE]; DNS or designee). Step 4: Conduct mock code drills weekly X 4 weeks, then monthly X 3 months, then quarterly throughout 2016. (Established on [DATE] and ongoing). CPR/AED on-site certified instructor to provide training and /or any CPR/AED updates quarterly throughout 2016. (Established on [DATE] and ongoing). DNS or designee will review new admission charts during clinical start up and new licensed team members educated upon hire. Any discrepancies and trends will be reviewed in QAPI monthly with appropriate actions taken. (Established on [DATE]; DNS or designee). Corrective Action Plan Verification: The care plans, physician's orders [REDACTED]. In addition interviews were conducted with two of these residents to confirm their wishes of having a Full Code status. Observation verified that both nurse's stations had an emergency binder containing the accurate residents' code status. Interviews with facility nurses (4 LVNs, 1 RN and DON) and three CNAs on [DATE] from 3:00 p.m. to 6:45 p.m. revealed nurses and CNAs had received training in responding to CPR emergencies; were fully certified to provide CPR (licensed nurses only) and were knowledgeable in locations of residents' code status information. Nurses also listed steps to be taken immediately when residents are found to have no pulse and/or respirations. CNAs said they would immediately notify nursing staff for unresponsive residents. Interview and record review verified that two mock Full Code emergencies had taken place between [DATE] and [DATE] and that nursing staff had acted appropriately. Nursing staff interviewed were aware of changes in condition to residents and to whom to report such changes. According to a list provided by the facility on [DATE], there were 15 residents in the facility who were a Full Code status.

Based on interview and record review, the facility failed to provide services that met professional standards of quality for 1 of 7 residents (Resident #2) whose care was reviewed. LVN A and LVN C assessed Resident #2, who was a full code, as having no pulse, heartbeat, or respirations and did not call EMS/911 or initiate cardiopulmonary resuscitation and did not check Resident #2's code status for approximately 13 minutes after being found unresponsive. Resident #2 was pronounced dead by the Justice of the Peace on [DATE] at 11:05 pm (documented as 10:55 p.m.). This was determined to be past non-compliance at an Immediate Jeopardy level due to the facilitys implimentation of actions that corrected the non-compliance prior to the investigation on [DATE]. The facility was out of compliance from [DATE] through [DATE]. The facility's corrected action was completed on [DATE]. Theses failures could affect 15 residents in the facility that were a Full Code Status and could result in death. Findings: Review of the Texas Administrative Code, Title 22, Part 11, Chaper 217, Rule 217.11 Standards of Nursing Practice, (1) and (M) revealed: (1) Standards applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; Review of the Texas Administrative Code, Title 22, Part 11, Chaper 217, Rule 217.11 Unprofessional Conduct: The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees (1) Unsafe Practice--actions or conduct including, but not limited to: (A) Carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered, or advanced practice nursing in conformity with the standards of minimum acceptable level of nursing practice set out in Rule 217.11. (B) Carelessly or repeatedly failing to conform to generally accepted nursing standards in applicable practice settings Review of the Texas Board of Nursing website revealed: The decision to initiate CPR for all nurses should be a spontaneous clinical decision and nursing intervention for a client in cardiac or respiratory arrest. Delay in initiating CPR can be critical to the outcome of CPR. CPR should not be delayed to review the client ' s medical record or chart to determine the client ' s wishes or search physician orders [REDACTED]. Employers and nurses should take a proactive approach to ensure that healthcare setting policies are in place to ascertain a physician's order [REDACTED]. [REDACTED]. Review of facility policy and procedure Cardio [MEDICAL CONDITION] Resuscitation (CPR) dated [DATE] revealed: -CPR will be initiated when [MEDICAL CONDITION] occurs for residents who have: Requested CPR in their advance directives; Who have not formulated advance directives; Who do not have a valid DNR order. CPR certified staff will be available to provide CPR when needed. Record review of face sheet for Resident #2 revealed she was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Admission Advance Directives Acknowledgement, dated [DATE], revealed Resident #2 had prepared an advanced directive and Resident #2 was a Full Code status (if resident experiences [MEDICAL CONDITION], CPR is required). Review of Resident #2's Care Plan, dated [DATE] (with handwritten updates by nursing staff last dated [DATE]), revealed Resident #2 was a Full Code status and under Goal and Target Date: Staff will honor FULL CODE orders as per wishes of her and her family and administer CPR if she has an arrest (cessation of heart function). The document provides for: Identifying Full Code status per facility protocol, maintaining current physician orders [REDACTED]. Interview on [DATE] at 4:45 p.m., with CNA B revealed on [DATE] at approximately 10:40 p.m. CBA B checked Resident #2 ' s room and found that Resident #2 was not in her bed. CNA B said she, with the aid of CNA E, went to a room in another part of the building where Resident #2 was often visited privately by Resident #2' s family. CNA B said she had previously brought Resident #2 to the room after toileting Resident #2 at approximately 9:30 p.m. and her family member was present. CNA B said at 10:45 p.m. she and CNA E found Resident #2 unresponsive and deceased while seated in her wheelchair next to the B-bed where Resident #2 ' s family member was lying next to her, and holding her hand. CNA B said Resident #2 ' s family member was sleeping and was awakened when they came to check Resident #2. CNA B said Resident #2' s family member may not have been fully aware of Resident #2 ' s apparent death. CNA B said Resident #2' s face was white and was completely unresponsive, was cold to the touch, and appeared lifeless. CNA B said they moved Resident #2 to her room approximately 10 rooms away, continued to check her on the way, then placed Resident #2 in her bed before notifying the nurses, but did so as quickly as possible. CNA B said she advised LVN A and LVN C who immediately came to Resident #2' s room to assess Resident #2. CNA B said Resident #2 appeared dead and that she witnessed the LVNs assessing Resident #2 finding no signs of life. CNA B said she did not see LVN A or LVN C start or perform CPR and was not aware of a call to 911/EMS by anyone in the facility. Interview on [DATE] at 2:15 p.m., with CNA E revealed CNA E and CNA B, at approximately 10:40 p.m. on [DATE], were making rounds together and went to check on Resident #2 and were going to bring her to her room, as it was getting late as Resident #2 was a two person transfer. CNA E said Resident #2 was often visited by her family member and they were allowed visitation in another room down the hall from the assisted dining room on the back hall. CNA E said she and CNA B found Resident #2 unresponsive and apparently dead while seated in her wheelchair, next to the B-bed, where her family member was lying semi-prone next to her and holding her hand. CNA E said the family member appeared awake but not fully aware of Resident #2 ' s death. CNA E said Resident #2 's face was white in color, body was completely limp and did not move or respond in any way. CNA E said they decided to move Resident #2 to her assigned room, continued to check her on the way, then placed Resident #2 in her bed before notifying the nurses, but did so as quickly as possible. CNA E said she advised LVN A and LVN C Resident #2 was deceased and LVN A and LVN C immediately went to Resident #2' s room to assess Resident #2. CNA E said Resident #2 appeared dead and she witnessed the LVNs assessing Resident #2 finding no signs of life. CNA E said she did not see LVN A or LVN C start or perform CPR and was not aware of a call to 911/EMS by anyone in the facility. In an interview on [DATE] at 3:00 p.m., with LVN C, she said she and LVN A, at approximately 10:50 p.m. on [DATE], were notified by CNA B and CNA E that Resident #2 was in her room and was unresponsive. LVN C said she gathered a stethoscope, a blood pressure cuff and an oxygen monitor and responded immediately to Resident #2 ' s room. LVN C said she did not know how long Resident #2 had been unresponsive, with no pulse or respirations. LVN C said she assessed Resident #2 with assistance from LVN A and found no signs of life. LVN C said Resident #2's face and skin were blue in color, was cold to the touch, that Resident #2 ' s mouth and eyes were closed, had no pulse, no blood pressure, no respirations, no heartbeat was detected. LVN C said Resident #2 was in the appearance of clinical death and appeared to have been deceased for an hour or more. LVN C said both she and LVN A began to make notifications and called the Medical Director, the supervisor (LVN D) and the Justice of the Peace. LVN C said she was able to contact the JP to pronounce Resident #2 and had made one call to the Medical Director which was unanswered. LVN C said LVN A called the duty supervisor (LVN D) and this was the first time Resident #2's code status was questioned. LVN C said she checked the code status of Resident #2 by checking Resident #2's chart at the nurse's station on the direction of LVN A and LVN D and found a green-colored Full Code status sheet inside the front cover of the chart indicating CPR should have been started and 911/EMS should have been called. LVN C said she did not know the code status of Resident #2 prior to checking the chart and that Resident #2's medical condition with Stage [MEDICAL CONDITION] made her assume Resident #2 had a Do Not Resuscitate order. LVN C acknowledged she did not start or perform CPR and did not call 911/EMS to assist Resident #2. LVN C said she was aware of when CPR was indicated, was certified to perform CPR and that her certification was not expired. LVN C said she was provided training by the facility on responding to emergencies like CPR, and was aware that it was procedure to perform it when residents with a Full Code status were found unresponsive and while EMS is called to respond to the facility. In an interview on [DATE] at 4:05 p.m., with LVN D she said she was the on-call supervisor and said she was contacted on [DATE] at 10:58 p.m. by LVN A to advise of the death of Resident #2 and at that time asked the code status of Resident #2 which was not known by LVN A. LVN D said she was then told Resident #2's chart was physically checked and that check revealed a Full Code status. LVN D said LVN A said CPR had not been started and 911/EMS had not been called for Resident #2 at the time she was found unresponsive or in the interim, and the JP was on route to the facility and was expected in minutes. LVN D said she then called the DON and advised Resident #2 ' s Full Code status had not been known, and not been checked by LVN A and LVN C and Full Code procedures had not been followed. Interview on [DATE] at 12:05 p.m., with the DON revealed she was aware that Resident #2 was found unresponsive on [DATE] at approximately10:45 p.m. and she had been advised by her staff of Resident #2 ' s death. The DON said Resident #2 was a Full Code status but was deceased for an unknown period of time and the Medical Director was aware and had directed the J.P. to come to the facility and pronounce the resident. In an interview on [DATE] at 1:15 p.m., with the Medical Director revealed he was called by LVN A at 11:01 p.m. on [DATE] and was told the local J.P. had already been called due to the death of Resident #2. The Medical Director said he was not told the code status of Resident #2, there were no indications CPR was started, 911 was called and he would have responded directly to the facility if he had been advised Resident #2 was a Full Code status. The Medical Director said he was made aware of Resident #2 ' s Full Code Status and CPR was not performed or EMS/911 was not called by staff when he signed the discharge documents on [DATE]. The Medical Director said the LVNs should have checked the code status of Resident #2 and immediately started CPR and called EMS/911 when Resident #2 was found unresponsive and without vital signs on [DATE]. The Medical Director said the staff had treated Resident #2 as if she was a DNR and was not aware of anyone in the building that could have legally pronounced Resident #2 dead when she was found unresponsive at approximately 10:45 p.m. on [DATE]. The Medical Director acknowledged that EMS/911 should have been called for Resident #2 before attempting to call the administrative staff. Review of Resident #2 ' s nurses notes, dated [DATE], revealed the Medical Director was notified and he asked us to call Judge . Record review of the facility Transfer/Discharge Summary , including a current Plan of Care in an electronic version, dated [DATE] (with a time stamp of 3:17 a.m.) and signed by the Medical Director on [DATE] with notation of Prognosis: deceased , revealed that Resident #2 expired on [DATE] at 10:55 p.m. and was pronounced by the local Justice of the Peace. This document listed a Full Code status under Non-medication Orders, and listed Full Code status under Advanced Directives, more specifically: Identify FULL CODE status per facility protocol, maintain current physician orders [REDACTED]. Review of LVN C's documentation in Resident #2's Nurse's Notes dated [DATE] (at 12:21 a.m.), revealed: -at 10:40 p.m. (on [DATE]) CNAs go to another room to bring Resident #2 to her room; Resident #2 was found unresponsive and brought to room; CNA B notified LVN A and LVN C; LVN A and C assess Resident #2 and find no pulse, heartbeat, breaths and checked oxygen; Medical Director and JP advised; LVN D advised (no time listed) who in turn notified DON. -at 10:55 p.m. (on [DATE]) the Justice of the Peace (JP) pronounced as the time of death. -at 2:25 a.m. crematory personnel arrived to transport Resident #2's body -at 3:12 a.m. Resident #2's body released to crematory In an interview on [DATE] at 12:45 p.m., the DON said Resident #2 was a Full Code status when found unresponsive on [DATE] at approximately 10:40 p.m., was deceased longer than CPR was appropriate to be provided, the Medical Director was aware of the code status of Resident #2 and he authorized the J.P. to pronounce Resident #2 ' s death in the facility. In the interview on [DATE] at 6:45 p.m., the Administrator and DON acknowledged either LVN A or LVN C should have called 911 immediately after finding Resident #2 had no pulse or respirations. The facility Administrator was notified on [DATE] at 6:00 p.m., an IJ situation had been identified due to the above failures and it was later determined to be past non-compliance due to the facility's corrective action taken prior to the investigation. The facility's corrective action plan included: Step 1: Immediate review of deceased resident ' s record to include: · Code status-Full Code · Documentation of signs of death · Notification of Family and Physician · Pre/Post Mortem Care · Pronouncement of Death (Completed on: [DATE]; DNS = Director of Nursing Services). 100% of direct care licensed nurses re-educated before allowed to provide care: · Code status-Full Code or DNR · Green sheet identifying Full Code status · Red sheet identifying DNR status · Documentation needs to include signs of death · Pre/Post Mortem Care (Initiated on: [DATE]; Completed on: [DATE]; RN Director of Clinical Education) Step 2: 100% immediate review resident ' s records to identify: · Code status-Full Code or DNR · Care Plan verified for proper code status · Out of Hospital DNR form complete with all appropriate signatures · Physician ' s telephone order and Consolidated orders reflect Code Status · Code status in Electronic records for reference (Initiated on: [DATE]; Completed on: [DATE]; DNS) Second audit of 100% of Full Code Records on residents were checked to ensure the record included: · A written physician's order [REDACTED].· A Full Code green sheet identifying Full Code status (kept in chart until resident ' s discharge or resident ' s code status is changed) · Full Code status on consolidated orders and care plan · Full Code status in electronic records · 100% records of all Full Code status were correct and easily identified (Initiated on: [DATE]; Completed on: [DATE]; DNS) Step 3: New admission records will be reviewed upon admission to ensure proper code status documentation is in chart and easily identifiable. Once a week X 4 weeks the charts will be double checked during clinical start up meeting to ensure code status documentation is in chart and easily identifiable. After 4 weeks, this will occur monthly X3 months then quarterly throughout 2016. (Established on [DATE] and ongoing: DNS or designee). New licensed staff will be educated on location of and proper identification of code status during the orientation process before they provide direct care to patients. New licensed staff education will be reviewed once a week X 4 weeks, then monthly X 3 months then quarterly throughout 2016. (Established on [DATE] and ongoing: DNS or designee). Licensed staff has emergency number books available at both nurse ' s stations for physicians and co-workers. Books have been validated for accuracy. 911 will be called for emergencies. This will be reviewed during new hire orientation process with licensed staff. (Completion: [DATE]; DNS or designee). Step 4: Conduct mock code drills weekly X 4 weeks, then monthly X 3 months, then quarterly throughout 2016. (Established on [DATE] and ongoing). CPR/AED on-site certified instructor to provide training and /or any CPR/AED updates quarterly throughout 2016. (Established on [DATE] and ongoing). DNS or designee will review new admission charts during clinical start up and new licensed team members educated upon hire. Any discrepancies and trends will be reviewed in QAPI monthly with appropriate actions taken. (Established on [DATE]; DNS or designee). Corrective Action Plan Verification: The care plans, physician's orders [REDACTED]. In addition interviews were conducted with two of these residents to confirm their wishes of having a Full Code status. Observation verified that both nurse's stations had an emergency binder containing the accurate residents' code status. Interviews with facility nurses (4 LVNs, 1 RN and DON) and three CNAs on [DATE] from 3:00 p.m. to 6:45 p.m. revealed nurses and CNAs had received training in responding to CPR emergencies; were fully certified to provide CPR (licensed nurses only) and were knowledgeable in locations of residents' code status information. Nurses also listed steps to be taken immediately when residents are found to have no pulse and/or respirations. CNAs said they would immediately notify nursing staff for unresponsive residents. Interview and record review verified that two mock Full Code emergencies had taken place between [DATE] and [DATE] and that nursing staff had acted appropriately. Nursing staff interviewed were aware of changes in condition to residents and to whom to report such changes. According to a list provided by the facility on [DATE], there were 15 residents in the facility who were a Full Code status.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for 1 of 7 residents (Resident #2) whose care was reviewed for neglect in that: LVN A and LVN C assessed Resident #2, who was a full code, as having no pulse, heartbeat, or respirations and did not call EMS/911 or initiate cardiopulmonary resuscitation and did not check Resident #2's code status for approximately 13 minutes after being found unresponsive. Resident #2 was pronounced dead by the Justice of the Peace on [DATE] at 11:05 pm (documented as 10:55 p.m.). This was determined to be past non-compliance at an Immediate Jeopardy level due to the facilitys implimentation of actions that corrected the non-compliance prior to the investigation on [DATE]. The facility was out of compliance from [DATE] through [DATE]. The facility's corrected action was completed on [DATE]. Theses failures could affect 15 residents in the facility that were a Full Code Status and could result in death. Findings: Review of facility policy and procedure Cardio [MEDICAL CONDITION] Resuscitation (CPR) dated [DATE] revealed: -CPR will be initiated when [MEDICAL CONDITION] occurs for residents who have: Requested CPR in their advance directives; Who have not formulated advance directives; Who do not have a valid DNR order. CPR certified staff will be available to provide CPR when needed. Review of the facility policy and procedure Abuse (including Neglect), dated [DATE] revealed: -It is the policy of the center to take appropriate steps to prevent the occurrence of neglect . and to ensure that all alleged violations of Federal or State laws which involve . neglect . are reported immediately to the Administrator of the center. Such violations will also be reported to state agencies and law enforcement in accordance with existing state law. The Administrator will direct a thorough investigation of each such alleged violation. The Administrator is responsible to report the results of all investigations to the state agencies as required by state and federal law. -Reporting: All alleged violations involving . neglect . are reported immediately to the administrator and to other officials in accordance with State law through established procedures (including the State survey and certification agency). Immediately means as soon as possible, but ought not exceed 24 hours after the discovery of the incident The results of all investigations must be reported by the Administrator to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation. -Investigation: Federal law requires the center to have evidence of investigations of alleged violations. The investigation form or state required form shall be completed after the investigation is complete and provided to survey agencies when requested or required by state or federal law. Record review of face sheet for Resident #2 revealed she was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Admission Advance Directives Acknowledgement, dated [DATE], revealed Resident #2 had prepared an advanced directive and Resident #2 was a Full Code status (if resident experiences [MEDICAL CONDITION], CPR is required). Review of Resident #2's Care Plan, dated [DATE] (with handwritten updates by nursing staff last dated [DATE]), revealed Resident #2 was a Full Code status and under Goal and Target Date: Staff will honor FULL CODE orders as per wishes of her and her family and administer CPR if she has an arrest (cessation of heart function). The document provides for: Identifying Full Code status per facility protocol, maintaining current physician orders for Full Code, and staff awareness of Full Code status as per MD order. Interview on [DATE] at 4:45 p.m., with CNA B revealed on [DATE] at approximately 10:40 p.m. CBA B checked Resident #2 ' s room and found that Resident #2 was not in her bed. CNA B said she, with the aid of CNA E, went to a room in another part of the building where Resident #2 was often visited privately by Resident #2' s family. CNA B said she had previously brought Resident #2 to the room after toileting Resident #2 at approximately 9:30 p.m. and her family member was present. CNA B said at 10:45 p.m. she and CNA E found Resident #2 unresponsive and deceased while seated in her wheelchair next to the B-bed where Resident #2 ' s family member was lying next to her, and holding her hand. CNA B said Resident #2 ' s family member was sleeping and was awakened when they came to check Resident #2. CNA B said Resident #2' s family member may not have been fully aware of Resident #2 ' s apparent death. CNA B said Resident #2' s face was white and was completely unresponsive, was cold to the touch, and appeared lifeless. CNA B said they moved Resident #2 to her room approximately 10 rooms away, continued to check her on the way, then placed Resident #2 in her bed before notifying the nurses, but did so as quickly as possible. CNA B said she advised LVN A and LVN C who immediately came to Resident #2' s room to assess Resident #2. CNA B said Resident #2 appeared dead and that she witnessed the LVNs assessing Resident #2 finding no signs of life. CNA B said she did not see LVN A or LVN C start or perform CPR and was not aware of a call to 911/EMS by anyone in the facility. Interview on [DATE] at 2:15 p.m., with CNA E revealed CNA E and CNA B, at approximately 10:40 p.m. on [DATE], were making rounds together and went to check on Resident #2 and were going to bring her to her room, as it was getting late as Resident #2 was a two person transfer. CNA E said Resident #2 was often visited by her family member and they were allowed visitation in another room down the hall from the assisted dining room on the back hall. CNA E said she and CNA B found Resident #2 unresponsive and apparently dead while seated in her wheelchair, next to the B-bed, where her family member was lying semi-prone next to her and holding her hand. CNA E said the family member appeared awake but not fully aware of Resident #2 ' s death. CNA E said Resident #2 's face was white in color, body was completely limp and did not move or respond in any way. CNA E said they decided to move Resident #2 to her assigned room, continued to check her on the way, then placed Resident #2 in her bed before notifying the nurses, but did so as quickly as possible. CNA E said she advised LVN A and LVN C Resident #2 was deceased and LVN A and LVN C immediately went to Resident #2' s room to assess Resident #2. CNA E said Resident #2 appeared dead and she witnessed the LVNs assessing Resident #2 finding no signs of life. CNA E said she did not see LVN A or LVN C start or perform CPR and was not aware of a call to 911/EMS by anyone in the facility. In an interview on [DATE] at 3:00 p.m., with LVN C, she said she and LVN A, at approximately 10:50 p.m. on [DATE], were notified by CNA B and CNA E that Resident #2 was in her room and was unresponsive. LVN C said she gathered a stethoscope, a blood pressure cuff and an oxygen monitor and responded immediately to Resident #2 ' s room. LVN C said she did not know how long Resident #2 had been unresponsive, with no pulse or respirations. LVN C said she assessed Resident #2 with assistance from LVN A and found no signs of life. LVN C said Resident #2's face and skin were blue in color, was cold to the touch, that Resident #2 ' s mouth and eyes were closed, had no pulse, no blood pressure, no respirations, no heartbeat was detected. LVN C said Resident #2 was in the appearance of clinical death and appeared to have been deceased for an hour or more. LVN C said both she and LVN A began to make notifications and called the Medical Director, the supervisor (LVN D) and the Justice of the Peace. LVN C said she was able to contact the JP to pronounce Resident #2 and had made one call to the Medical Director which was unanswered. LVN C said LVN A called the duty supervisor (LVN D) and this was the first time Resident #2's code status was questioned. LVN C said she checked the code status of Resident #2 by checking Resident #2's chart at the nurse's station on the direction of LVN A and LVN D and found a green-colored Full Code status sheet inside the front cover of the chart indicating CPR should have been started and 911/EMS should have been called. LVN C said she did not know the code status of Resident #2 prior to checking the chart and that Resident #2's medical condition with Stage [MEDICAL CONDITION] made her assume Resident #2 had a Do Not Resuscitate order. LVN C acknowledged she did not start or perform CPR and did not call 911/EMS to assist Resident #2. LVN C said she was aware of when CPR was indicated, was certified to perform CPR and that her certification was not expired. LVN C said she was provided training by the facility on responding to emergencies like CPR, and was aware that it was procedure to perform it when residents with a Full Code status were found unresponsive and while EMS is called to respond to the facility. In an interview on [DATE] at 4:05 p.m., with LVN D she said she was the on-call supervisor and said she was contacted on [DATE] at 10:58 p.m. by LVN A to advise of the death of Resident #2 and at that time asked the code status of Resident #2 which was not known by LVN A. LVN D said she was then told Resident #2's chart was physically checked and that check revealed a Full Code status. LVN D said LVN A said CPR had not been started and 911/EMS had not been called for Resident #2 at the time she was found unresponsive or in the interim, and the JP was on route to the facility and was expected in minutes. LVN D said she then called the DON and advised Resident #2 ' s Full Code status had not been known, and not been checked by LVN A and LVN C and Full Code procedures had not been followed. Interview on [DATE] at 12:05 p.m., with the DON revealed she was aware that Resident #2 was found unresponsive on [DATE] at approximately10:45 p.m. and she had been advised by her staff of Resident #2 ' s death. The DON said Resident #2 was a Full Code status but was deceased for an unknown period of time and the Medical Director was aware and had directed the J.P. to come to the facility and pronounce the resident. In an interview on [DATE] at 1:15 p.m., with the Medical Director revealed he was called by LVN A at 11:01 p.m. on [DATE] and was told the local J.P. had already been called due to the death of Resident #2. The Medical Director said he was not told the code status of Resident #2, there were no indications CPR was started, 911 was called and he would have responded directly to the facility if he had been advised Resident #2 was a Full Code status. The Medical Director said he was made aware of Resident #2 ' s Full Code Status and CPR was not performed or EMS/911 was not called by staff when he signed the discharge documents on [DATE]. The Medical Director said the LVNs should have checked the code status of Resident #2 and immediately started CPR and called EMS/911 when Resident #2 was found unresponsive and without vital signs on [DATE]. The Medical Director said the staff had treated Resident #2 as if she was a DNR and was not aware of anyone in the building that could have legally pronounced Resident #2 dead when she was found unresponsive at approximately 10:45 p.m. on [DATE]. The Medical Director acknowledged that EMS/911 should have been called for Resident #2 before attempting to call the administrative staff. Review of Resident #2 ' s nurses notes, dated [DATE], revealed the Medical Director was notified and he asked us to call Judge . Record review of the facility Transfer/Discharge Summary , including a current Plan of Care in an electronic version, dated [DATE] (with a time stamp of 3:17 a.m.) and signed by the Medical Director on [DATE] with notation of Prognosis: deceased , revealed that Resident #2 expired on [DATE] at 10:55 p.m. and was pronounced by the local Justice of the Peace. This document listed a Full Code status under Non-medication Orders, and listed Full Code status under Advanced Directives, more specifically: Identify FULL CODE status per facility protocol, maintain current physician orders for FULL CODE on the chart, and Staff awareness of FULL CODE status as per MD order . Review of LVN C's documentation in Resident #2's Nurse's Notes dated [DATE] (at 12:21 a.m.), revealed: -at 10:40 p.m. (on [DATE]) CNAs go to another room to bring Resident #2 to her room; Resident #2 was found unresponsive and brought to room; CNA B notified LVN A and LVN C; LVN A and C assess Resident #2 and find no pulse, heartbeat, breaths and checked oxygen; Medical Director and JP advised; LVN D advised (no time listed) who in turn notified DON. -at 10:55 p.m. (on [DATE]) the Justice of the Peace (JP) pronounced as the time of death. -at 2:25 a.m. crematory personnel arrived to transport Resident #2's body -at 3:12 a.m. Resident #2's body released to crematory In an interview on [DATE] at 12:45 p.m., the DON said Resident #2 was a Full Code status when found unresponsive on [DATE] at approximately 10:40 p.m., was deceased longer than CPR was appropriate to be provided, the Medical Director was aware of the code status of Resident #2 and he authorized the J.P. to pronounce Resident #2 ' s death in the facility. In the interview on [DATE] at 6:45 p.m., the Administrator and DON acknowledged either LVN A or LVN C should have called 911 immediately after finding Resident #2 had no pulse or respirations. The facility Administrator was notified on [DATE] at 6:00 p.m., an IJ situation had been identified due to the above failures and it was later determined to be past non-compliance due to the facility's corrective action taken prior to the investigation. The facility's corrective action plan included: Step 1: Immediate review of deceased resident ' s record to include: · Code status-Full Code · Documentation of signs of death · Notification of Family and Physician · Pre/Post Mortem Care · Pronouncement of Death (Completed on: [DATE]; DNS = Director of Nursing Services). 100% of direct care licensed nurses re-educated before allowed to provide care: · Code status-Full Code or DNR · Green sheet identifying Full Code status · Red sheet identifying DNR status · Documentation needs to include signs of death · Pre/Post Mortem Care (Initiated on: [DATE]; Completed on: [DATE]; RN Director of Clinical Education) Step 2: 100% immediate review resident ' s records to identify: · Code status-Full Code or DNR · Care Plan verified for proper code status · Out of Hospital DNR form complete with all appropriate signatures · Physician ' s telephone order and Consolidated orders reflect Code Status · Code status in Electronic records for reference (Initiated on: [DATE]; Completed on: [DATE]; DNS) Second audit of 100% of Full Code Records on residents were checked to ensure the record included: · A written physician ' s order · A Full Code green sheet identifying Full Code status (kept in chart until resident ' s discharge or resident ' s code status is changed) · Full Code status on consolidated orders and care plan · Full Code status in electronic records · 100% records of all Full Code status were correct and easily identified (Initiated on: [DATE]; Completed on: [DATE]; DNS) Step 3: New admission records will be reviewed upon admission to ensure proper code status documentation is in chart and easily identifiable. Once a week X 4 weeks the charts will be double checked during clinical start up meeting to ensure code status documentation is in chart and easily identifiable. After 4 weeks, this will occur monthly X3 months then quarterly throughout 2016. (Established on [DATE] and ongoing: DNS or designee). New licensed staff will be educated on location of and proper identification of code status during the orientation process before they provide direct care to patients. New licensed staff education will be reviewed once a week X 4 weeks, then monthly X 3 months then quarterly throughout 2016. (Established on [DATE] and ongoing: DNS or designee). Licensed staff has emergency number books available at both nurse ' s stations for physicians and co-workers. Books have been validated for accuracy. 911 will be called for emergencies. This will be reviewed during new hire orientation process with licensed staff. (Completion: [DATE]; DNS or designee). Step 4: Conduct mock code drills weekly X 4 weeks, then monthly X 3 months, then quarterly throughout 2016. (Established on [DATE] and ongoing). CPR/AED on-site certified instructor to provide training and /or any CPR/AED updates quarterly throughout 2016. (Established on [DATE] and ongoing). DNS or designee will review new admission charts during clinical start up and new licensed team members educated upon hire. Any discrepancies and trends will be reviewed in QAPI monthly with appropriate actions taken. (Established on [DATE]; DNS or designee). Corrective Action Plan Verification: The care plans, physician's orders, and code status were verified for a sample of residents who had a Full Code status. In addition interviews were conducted with two of these residents to confirm their wishes of having a Full Code status. Observation verified that both nurse's stations had an emergency binder containing the accurate residents' code status. Interviews with facility nurses (4 LVNs, 1 RN and DON) and three CNAs on [DATE] from 3:00 p.m. to 6:45 p.m. revealed nurses and CNAs had received training in responding to CPR emergencies; were fully certified to provide CPR (licensed nurses only) and were knowledgeable in locations of residents' code status information. Nurses also listed steps to be taken immediately when residents are found to have no pulse and/or respirations. CNAs said they would immediately notify nursing staff for unresponsive residents. Interview and record review verified that two mock Full Code emergencies had taken place between [DATE] and [DATE] and that nursing staff had acted appropriately. Nursing staff interviewed were aware of changes in condition to residents and to whom to report such changes. According to a list provided by the facility on [DATE], there were 15 residents in the facility who were a Full Code status.

Based on interview and record review the facility failed to implement policies and procedures that prohibit neglect of residents for 1 of 7 residents (#2) whose care was reviewed for neglect in that: LVN A and LVN C assessed Resident #2, who was a full code, as having no pulse, heartbeat, or respirations and did not call EMS/911 or initiate cardiopulmonary resuscitation and did not check Resident #2's code status for approximately 13 minutes after being found unresponsive. Resident #2 was pronounced dead by the Justice of the Peace on [DATE] at 11:05 pm (documented as 10:55 p.m.). This was determined to be past non-compliance at an Immediate Jeopardy level due to the facilitys implimentation of actions that corrected the non-compliance prior to the investigation on [DATE]. The facility was out of compliance from [DATE] through [DATE]. The facility's corrected action was completed on [DATE]. Theses failures could affect 15 residents in the facility that were a Full Code Status and could result in death. Findings: Record review of face sheet for Resident #2 revealed she was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Admission Advance Directives Acknowledgement, dated [DATE], revealed Resident #2 had prepared an advanced directive and Resident #2 was a Full Code status (if resident experiences [MEDICAL CONDITION], CPR is required). Review of Resident #2's Care Plan, dated [DATE] (with handwritten updates by nursing staff last dated [DATE]), revealed Resident #2 was a Full Code status and under Goal and Target Date: Staff will honor FULL CODE orders as per wishes of her and her family and administer CPR if she has an arrest (cessation of heart function). The document provides for: Identifying Full Code status per facility protocol, maintaining current physician orders for Full Code, and staff awareness of Full Code status as per MD order. Interview on [DATE] at 4:45 p.m., with CNA B revealed on [DATE] at approximately 10:40 p.m. CBA B checked Resident #2 ' s room and found that Resident #2 was not in her bed. CNA B said she, with the aid of CNA E, went to a room in another part of the building where Resident #2 was often visited privately by Resident #2' s family. CNA B said she had previously brought Resident #2 to the room after toileting Resident #2 at approximately 9:30 p.m. and her family member was present. CNA B said at 10:45 p.m. she and CNA E found Resident #2 unresponsive and deceased while seated in her wheelchair next to the B-bed where Resident #2 ' s family member was lying next to her, and holding her hand. CNA B said Resident #2 ' s family member was sleeping and was awakened when they came to check Resident #2. CNA B said Resident #2' s family member may not have been fully aware of Resident #2 ' s apparent death. CNA B said Resident #2' s face was white and was completely unresponsive, was cold to the touch, and appeared lifeless. CNA B said they moved Resident #2 to her room approximately 10 rooms away, continued to check her on the way, then placed Resident #2 in her bed before notifying the nurses, but did so as quickly as possible. CNA B said she advised LVN A and LVN C who immediately came to Resident #2' s room to assess Resident #2. CNA B said Resident #2 appeared dead and that she witnessed the LVNs assessing Resident #2 finding no signs of life. CNA B said she did not see LVN A or LVN C start or perform CPR and was not aware of a call to 911/EMS by anyone in the facility. Interview on [DATE] at 2:15 p.m., with CNA E revealed CNA E and CNA B, at approximately 10:40 p.m. on [DATE], were making rounds together and went to check on Resident #2 and were going to bring her to her room, as it was getting late as Resident #2 was a two person transfer. CNA E said Resident #2 was often visited by her family member and they were allowed visitation in another room down the hall from the assisted dining room on the back hall. CNA E said she and CNA B found Resident #2 unresponsive and apparently dead while seated in her wheelchair, next to the B-bed, where her family member was lying semi-prone next to her and holding her hand. CNA E said the family member appeared awake but not fully aware of Resident #2 ' s death. CNA E said Resident #2 's face was white in color, body was completely limp and did not move or respond in any way. CNA E said they decided to move Resident #2 to her assigned room, continued to check her on the way, then placed Resident #2 in her bed before notifying the nurses, but did so as quickly as possible. CNA E said she advised LVN A and LVN C Resident #2 was deceased and LVN A and LVN C immediately went to Resident #2' s room to assess Resident #2. CNA E said Resident #2 appeared dead and she witnessed the LVNs assessing Resident #2 finding no signs of life. CNA E said she did not see LVN A or LVN C start or perform CPR and was not aware of a call to 911/EMS by anyone in the facility. In an interview on [DATE] at 3:00 p.m., with LVN C, she said she and LVN A, at approximately 10:50 p.m. on [DATE], were notified by CNA B and CNA E that Resident #2 was in her room and was unresponsive. LVN C said she gathered a stethoscope, a blood pressure cuff and an oxygen monitor and responded immediately to Resident #2 ' s room. LVN C said she did not know how long Resident #2 had been unresponsive, with no pulse or respirations. LVN C said she assessed Resident #2 with assistance from LVN A and found no signs of life. LVN C said Resident #2's face and skin were blue in color, was cold to the touch, that Resident #2 ' s mouth and eyes were closed, had no pulse, no blood pressure, no respirations, no heartbeat was detected. LVN C said Resident #2 was in the appearance of clinical death and appeared to have been deceased for an hour or more. LVN C said both she and LVN A began to make notifications and called the Medical Director, the supervisor (LVN D) and the Justice of the Peace. LVN C said she was able to contact the JP to pronounce Resident #2 and had made one call to the Medical Director which was unanswered. LVN C said LVN A called the duty supervisor (LVN D) and this was the first time Resident #2's code status was questioned. LVN C said she checked the code status of Resident #2 by checking Resident #2's chart at the nurse's station on the direction of LVN A and LVN D and found a green-colored Full Code status sheet inside the front cover of the chart indicating CPR should have been started and 911/EMS should have been called. LVN C said she did not know the code status of Resident #2 prior to checking the chart and that Resident #2's medical condition with Stage [MEDICAL CONDITION] made her assume Resident #2 had a Do Not Resuscitate order. LVN C acknowledged she did not start or perform CPR and did not call 911/EMS to assist Resident #2. LVN C said she was aware of when CPR was indicated, was certified to perform CPR and that her certification was not expired. LVN C said she was provided training by the facility on responding to emergencies like CPR, and was aware that it was procedure to perform it when residents with a Full Code status were found unresponsive and while EMS is called to respond to the facility. In an interview on [DATE] at 4:05 p.m., with LVN D she said she was the on-call supervisor and said she was contacted on [DATE] at 10:58 p.m. by LVN A to advise of the death of Resident #2 and at that time asked the code status of Resident #2 which was not known by LVN A. LVN D said she was then told Resident #2's chart was physically checked and that check revealed a Full Code status. LVN D said LVN A said CPR had not been started and 911/EMS had not been called for Resident #2 at the time she was found unresponsive or in the interim, and the JP was on route to the facility and was expected in minutes. LVN D said she then called the DON and advised Resident #2 ' s Full Code status had not been known, and not been checked by LVN A and LVN C and Full Code procedures had not been followed. Interview on [DATE] at 12:05 p.m., with the DON revealed she was aware that Resident #2 was found unresponsive on [DATE] at approximately10:45 p.m. and she had been advised by her staff of Resident #2 ' s death. The DON said Resident #2 was a Full Code status but was deceased for an unknown period of time and the Medical Director was aware and had directed the J.P. to come to the facility and pronounce the resident. In an interview on [DATE] at 1:15 p.m., with the Medical Director revealed he was called by LVN A at 11:01 p.m. on [DATE] and was told the local J.P. had already been called due to the death of Resident #2. The Medical Director said he was not told the code status of Resident #2, there were no indications CPR was started, 911 was called and he would have responded directly to the facility if he had been advised Resident #2 was a Full Code status. The Medical Director said he was made aware of Resident #2 ' s Full Code Status and CPR was not performed or EMS/911 was not called by staff when he signed the discharge documents on [DATE]. The Medical Director said the LVNs should have checked the code status of Resident #2 and immediately started CPR and called EMS/911 when Resident #2 was found unresponsive and without vital signs on [DATE]. The Medical Director said the staff had treated Resident #2 as if she was a DNR and was not aware of anyone in the building that could have legally pronounced Resident #2 dead when she was found unresponsive at approximately 10:45 p.m. on [DATE]. The Medical Director acknowledged that EMS/911 should have been called for Resident #2 before attempting to call the administrative staff. Review of Resident #2 ' s nurses notes, dated [DATE], revealed the Medical Director was notified and he asked us to call Judge . Record review of the facility Transfer/Discharge Summary , including a current Plan of Care in an electronic version, dated [DATE] (with a time stamp of 3:17 a.m.) and signed by the Medical Director on [DATE] with notation of Prognosis: deceased , revealed that Resident #2 expired on [DATE] at 10:55 p.m. and was pronounced by the local Justice of the Peace. This document listed a Full Code status under Non-medication Orders, and listed Full Code status under Advanced Directives, more specifically: Identify FULL CODE status per facility protocol, maintain current physician orders for FULL CODE on the chart, and Staff awareness of FULL CODE status as per MD order . Review of LVN C's documentation in Resident #2's Nurse's Notes dated [DATE] (at 12:21 a.m.), revealed: -at 10:40 p.m. (on [DATE]) CNAs go to another room to bring Resident #2 to her room; Resident #2 was found unresponsive and brought to room; CNA B notified LVN A and LVN C; LVN A and C assess Resident #2 and find no pulse, heartbeat, breaths and checked oxygen; Medical Director and JP advised; LVN D advised (no time listed) who in turn notified DON. -at 10:55 p.m. (on [DATE]) the Justice of the Peace (JP) pronounced as the time of death. -at 2:25 a.m. crematory personnel arrived to transport Resident #2's body -at 3:12 a.m. Resident #2's body released to crematory In an interview on [DATE] at 12:45 p.m., the DON said Resident #2 was a Full Code status when found unresponsive on [DATE] at approximately 10:40 p.m., was deceased longer than CPR was appropriate to be provided, the Medical Director was aware of the code status of Resident #2 and he authorized the J.P. to pronounce Resident #2 ' s death in the facility. In the interview on [DATE] at 6:45 p.m., the Administrator and DON acknowledged either LVN A or LVN C should have called 911 immediately after finding Resident #2 had no pulse or respirations. Review of facility policy and procedure Cardio [MEDICAL CONDITION] Resuscitation (CPR) dated [DATE] revealed: -CPR will be initiated when [MEDICAL CONDITION] occurs for residents who have: Requested CPR in their advance directives; Who have not formulated advance directives; Who do not have a valid DNR order. CPR certified staff will be available to provide CPR when needed. Review of the facility policy and procedure Abuse (including Neglect), dated [DATE] revealed: -It is the policy of the center to take appropriate steps to prevent the occurrence of neglect . The facility Administrator was notified on [DATE] at 6:00 p.m., an IJ situation had been identified due to the above failures and it was later determined to be past non-compliance due to the facility's corrective action taken prior to the investigation. The facility's corrective action plan included: Step 1: Immediate review of deceased resident ' s record to include: · Code status-Full Code · Documentation of signs of death · Notification of Family and Physician · Pre/Post Mortem Care · Pronouncement of Death (Completed on: [DATE]; DNS = Director of Nursing Services). 100% of direct care licensed nurses re-educated before allowed to provide care: · Code status-Full Code or DNR · Green sheet identifying Full Code status · Red sheet identifying DNR status · Documentation needs to include signs of death · Pre/Post Mortem Care (Initiated on: [DATE]; Completed on: [DATE]; RN Director of Clinical Education) Step 2: 100% immediate review resident ' s records to identify: · Code status-Full Code or DNR · Care Plan verified for proper code status · Out of Hospital DNR form complete with all appropriate signatures · Physician ' s telephone order and Consolidated orders reflect Code Status · Code status in Electronic records for reference (Initiated on: [DATE]; Completed on: [DATE]; DNS) Second audit of 100% of Full Code Records on residents were checked to ensure the record included: · A written physician ' s order · A Full Code green sheet identifying Full Code status (kept in chart until resident ' s discharge or resident ' s code status is changed) · Full Code status on consolidated orders and care plan · Full Code status in electronic records · 100% records of all Full Code status were correct and easily identified (Initiated on: [DATE]; Completed on: [DATE]; DNS) Step 3: New admission records will be reviewed upon admission to ensure proper code status documentation is in chart and easily identifiable. Once a week X 4 weeks the charts will be double checked during clinical start up meeting to ensure code status documentation is in chart and easily identifiable. After 4 weeks, this will occur monthly X3 months then quarterly throughout 2016. (Established on [DATE] and ongoing: DNS or designee). New licensed staff will be educated on location of and proper identification of code status during the orientation process before they provide direct care to patients. New licensed staff education will be reviewed once a week X 4 weeks, then monthly X 3 months then quarterly throughout 2016. (Established on [DATE] and ongoing: DNS or designee). Licensed staff has emergency number books available at both nurse ' s stations for physicians and co-workers. Books have been validated for accuracy. 911 will be called for emergencies. This will be reviewed during new hire orientation process with licensed staff. (Completion: [DATE]; DNS or designee). Step 4: Conduct mock code drills weekly X 4 weeks, then monthly X 3 months, then quarterly throughout 2016. (Established on [DATE] and ongoing). CPR/AED on-site certified instructor to provide training and /or any CPR/AED updates quarterly throughout 2016. (Established on [DATE] and ongoing). DNS or designee will review new admission charts during clinical start up and new licensed team members educated upon hire. Any discrepancies and trends will be reviewed in QAPI monthly with appropriate actions taken. (Established on [DATE]; DNS or designee). Corrective Action Plan Verification: The care plans, physician's orders, and code status were verified for a sample of residents who had a Full Code status. In addition interviews were conducted with two of these residents to confirm their wishes of having a Full Code status. Observation verified that both nurse's stations had an emergency binder containing the accurate residents' code status. Interviews with facility nurses (4 LVNs, 1 RN and DON) and three CNAs on [DATE] from 3:00 p.m. to 6:45 p.m. revealed nurses and CNAs had received training in responding to CPR emergencies; were fully certified to provide CPR (licensed nurses only) and were knowledgeable in locations of residents' code status information. Nurses also listed steps to be taken immediately when residents are found to have no pulse and/or respirations. CNAs said they would immediately notify nursing staff for unresponsive residents. Interview and record review verified that two mock Full Code emergencies had taken place between [DATE] and [DATE] and that nursing staff had acted appropriately. Nursing staff interviewed were aware of changes in condition to residents and to whom to report such changes. According to a list provided by the facility on [DATE], there were 15 residents in the facility who were a Full Code status.