Every finding on record at Accel at Willow Bend

Based on observations, interviews, and records review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 3 residents (Residents #1, #2, and #3) reviewed for pressure ulcers.1. The facility failed to provide wound care to Resident #1's left buttocks pressure wound on 05/04/2026, 05/05/2026, 05/14/26, 05/15/26 and 05/22/26 and failed to follow the physician orders for Resident #1 while providing wound care on 06/12/26.2. The facility failed to provide wound care to Resident#2's left buttock on 05/02/26, 05/04/26, 05/05/26, 05/14/26, 05/15/26, 05/17/26, 05/22/26, and 05/28/26 and failed to follow the physician orders for Resident #2 while providing wound care on 06/12/26.3. The facility failed to provide wound care to Resident #3's sacrum wound on 05/07/26, 05/08/26, 05/09/26, 05/10/26, 05/11/26, 05/22/26, 05/23/26 and 05/25/26 and failed to provide wound care to Resident #3's mid back wound on 06/02/26, 06/04/26, 06/05/26, 06/07/26, and 06/09/26.These failures placed residents at risk of developing new or worsening pressure ulcers, infection, and pain. Findings included:1.Record review of Resident #1's comprehensive MDS assessment, dated 03/13/2026, reflected she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included diabetes and hypertension. Resident #1's BIMS score was 11 which indicated moderate cognitive impairment. The MDS further revealed Resident #1 was at risk of developing pressure ulcers/injuries.Record review of Resident #1's care plan, dated 03/30/26, did not address wound care on left buttocks.Record review of Resident #1's wound care Order, dated 04/24/26, reflected the following: left buttock Cleanse with dermal wound cleanser, pat dry, apply manuka med cover with foam dressing(start [04/21/26 08:09] on day shift''.Record review of Resident #1's Order Summary Report, dated 06/10/26, reflected the following: - Coccyx (the tailbone)Wound Cleanse the wound with normal saline (NS). Pat the area dry. Apply Triad paste to the wound/peri wound area Dust miconazole powder over the affected area. Apply calcium alginate dressing. Cover with a dry dressing. ([START 06/11/26 14:07 ] On Day Shift [Time: Shift 1]) AND ([START 06/11/26 14:07] As needed anytime)''.Record review of Resident #1's Wound Care Administration Record for May 2026 reflected the Wound Care was not documented as being completed on 05/04/2026, 05/05/2026, 05/14/26, 05/15/26 and 05/22/26, for Resident#1's dermal wound due to shear friction of the left buttock.Record review of the progress notes for May 2026 reflected there was no documentation of wound treatment for the missed days .Observation and interview on 06/12/26 at 3:15 PM revealed Resident #1 was sitting in her chair in her room. Resident #1 said she had wounds on her bottom, and she got wound care, but she could not tell when. Observation on 06/12/26 at 03:56PM with LVN A, providing Resident #1 with wound care revealed, he disinfected the table and left it to dry . He removed gloves, washed hands, and put the supplies together. He washed hands and put on PPE. He wheeled the table to Resident #1's bedside. He then washed his hands and put on gloves. The dressing was observed off. The family member reported it had fallen when she was using the bathroom. He cleansed the wound with normal saline, removed his gloves, washed his hands, and put on new gloves. The wound was observed almost healed with no drainage or signs of infection observed. He applied calcium alginate, but he did not apply triad paste on peri wound area and he did not dust miconazole powder over the affected area as per the doctors' orders and covered with a dry dressing dated 06/12/26.2.Record review of Resident #2's Comprehensive MDS Assessment, dated 05/05/26, reflected Resident#2 was a [AGE] year-old male who initially admitted to facility on 11/03/21 and readmitted [DATE]. His diagnoses included traumatic brain injury (a disruption in normal brain function caused by a sudden bump, blow, jolt, or penetrating object to the head). The resident's BIMS score was not documented due to the resident being rarely/never understood. His MDS assessment indicated he was at risk of developing ulcer/ injuries.Record review of Resident #2's care plan, dated 11/06/25, reflected the following:wound care addressed but not on the left buttocks.Record review of Resident #2's order, dated 04/06/26 with a stop date to 05/17/26, reflected the following: - Left Buttock Cleanse Wound with normal saline, pat dry, apply calcium alginate, cover with dry dressing. ([START 04/06/26 09:21 ]{Sic} On Day Shift [Time: Shift ]) AND ([START 04/06/26 09:21][Sic} As needed anytime). Apply triad paste to peri wound''Record review of Resident #2's order, dated 05/17/26, reflected the following: - Left Buttock Cleanse Wound with normal saline, pat dry, triad paste to peri wound, Gentamicin ointment, manuka med, cover with dry dressing. ([START 05/17/26 15:17 ][ Sic]On Day Shift [Time: Shift 1]) AND ([START 05/17/26 15:17][Sic] As needed anytime)''. Record review of Resident #2's order summary report, dated 06/12/26, reflected the following: - Left Buttock Cleanse Wound with normal saline, pat dry, triad past e to peri wound, Gentamicin, Santyl, calcium alginate. cover with dry dressing. ([START 06/12/26 13:55 ][Sic] On Day Shift [Time: Shift 1]) AND ([START 06/12/26 13:55] [Sic] As needed anytime)''.Record review of Resident #2's wound care administration record for May 2026 reflected there were missed entries on 05/02/26, 05/04/26, 05/05/26, 05/14/26, 05/15/26, 05/17/26, 05/22/26, and 05/28/26. The spaces were documented as Missed.Review of the progress notes for May 2026 reflected there was no documentation of wound treatment on the missed days.Observation on 06/12/26 at 03:27PM with LVN A, providing Resident #2 with wound care revealed, he disinfected the table and left it dry . He removed gloves, washed hands, and put the supplies together. He washed hands and put on Personal Protective Equipment (PPE). He wheeled the table to Resident #2's bedside. He then washed his hands, put on gloves, and removed the old dressing on Resident #2's left buttock. The old dressing was observed to be dated 06/12/26. He did not change gloves and perform hand hygiene. He cleansed the wound with wound cleanser, removed his gloves, washed hands and put on new gloves. The wound was observed almost closing and no signs of infection were observed. He applied calcium alginate. He failed to apply triad paste on peri wound, gentamycin and Santyl as per doctors' orders and then covered wound with a dry dressing dated 06/12/26. 3. Record review of Resident #3's Comprehensive MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Pressure ulcer of sacral region (a painful wound over the tailbone caused by unrelieved pressure that cuts off blood flow to the skin). Section M indicated open lesion(s)other than ulcers. BIMS score was not documented as residents rarely/never understood. Record review of Resident #3's order, dated 05/05/26 with a stop date of 05/11/26, reflected the following: - sacrum wound cleanse with Dakin's 0.125%, pat dry. Apply Gentamycin ointment and Medi honey to wound bed, pack with Dakin's moist gauze. Cover with dry dressing. (Start 05/05/26 on day shift and start 05/05/26 as needed anytime) twice a dayRecord review of Resident #3's order summary report, dated 05/17/26, reflected the following: - sacrum wound cleanse with Dakin's 0.125%, pat dry. Gentamycin ointment, Medi honey, pack with Dakin's moist gauze. Cover with dry dressing. (Start 05/17/26 on day shift and start 05/17/26 as needed anytime)Record review of Resident #3's order, dated 05/17/26 with a stop date of 06/10/26, reflected the following: - Mid back wound cleanse with normal saline pat dry. Apply Calcium alginate, cover with dry dressing. (Start 05/17/26 on day shift).''Record review of Resident #3's Wound Care Administration Record for May 2026 reflected there were no entries, and the spaces were documented as Missed for: 05/07/2026, 05/08/26, 05/09/26, 05/10/26, 05/11/26 , 05/22/26, 05/23/26 and 05/25/25/26. Record review of Resident #3's Wound Care Administration Record for June 2026 reflected there were no entries, for wound care for the mid back on 6/2/26, 6/4/26, 6/5/26, 6/7/26, and 6/9/26 . Record review of Resident #3's care plan, dated 05/27/26, reflected the following:Problem: Skin breakdown. Goals: Measures will be taken to preventskin breakdown. Interventions: Administer skin/wound treatments as ordered.Interview on 06/12/26 at 4:17 PM with LVN A revealed he had not noticed wound care was being missed, because he was not the regular nurse for wound care. He said he knew he was supposed to review orders before wound care. He said he forgot to administer Gentamycin ointment ,triad paste and Santyl on Resident #2 wound on his left buttock/sacrum and miconazole dust on Resident #1 wound on her left buttock. LVN A said the risk of not following doctors wound care orders could lead to wounds getting infected or slow healing processes. An attempt was made to contact Hospice nurse, who was assigned to Resident #3, on 06/12/2026 at 04:52PM by phone; however, there was no answer.Interview on 06/12/26 at 06:07 PM with the Wound Care Nurse via phone revealed she was no longer the wound care nurse; she was fired after facility performed wound care sweep and they found more wounds that were not being addressed. She said she had not noticed wound care was being missed, because she had not paid attention to treatment administration records. She stated she worked Monday through Friday, and she was ensuring she documented wound care, but she was not aware the treatment record was showing as not performed, On the weekend wound care was provided by another nurse. She said Resident 3 had sacrum wounds that he had admitted with and he was on hospice and hospice, and facility staff were responsible for his wound care on his sacrum. She stated Resident #1 and Resident#2 both had wound on their left buttocks due to shear friction. She said she was responsible for ensuring wound care was being done by hospice and by her on Resident#3. She said when she noticed hospice was not performing wound care she reported it to the DON and Administrator. The Wound Care Nurse said the risk of not performing wound care could lead to wounds getting infected or slow healing processes.Interview on 06/12/26 at 06:41 PM with the DON revealed her expectation was all wounds were being treated as per physician orders. She said she expected the wound care nurse to document wound care on the treatment administration record. She stated the wound treatment nurse worked Monday through Friday, and she expected her to sign treatment administration record after wound care. She said when hospice residents get admitted , the facility received wound care orders from hospice, and it was facility's responsibility to put orders in the system and provide wound care. She said Resident #3 missed wound care because the nurse that received wound care orders from hospice put in the system as, as needed orders. The DON said all management teams go through medication administration records and treatment administration records during morning meetings, and they address missing orders and she thinks they missed wound care. The DON said if residents were not receiving wound care as ordered it could lead to increased risk of infection or wounds getting worse. She said if physician orders were not being followed it would slow the healing of the wounds, leading to deterioration and infection.Interview on 06/12/26 at 07:21 PM with the Administrator revealed his expectation was all wounds were being treated as per physician orders .He stated he expected those that provided wound care to have documented on the treatment administration record. He said he was notified of the confusion on wound care for Resident #3. He said wound care nurses were responsible for following wound care orders . He said failure to sign the treatment administration record revealed the wound care was not being performed. He stated his expectation was for nurses to follow the doctors' orders at all times. Record review of the facility's pressure ulcer/pressure injury (overview) policy, dated July 2018, reflected: Pressure ulcers/injuries will be identified, evaluated, and treated in accordance with generally accepted guidelines. A comprehensive wound and system evaluation is necessary for proper planning and treatment of the wounds. Initial, ongoing, and comprehensive wound evaluations may involve multidisciplinary team members over a period of time.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #2 observed for infection control.The facility failed to ensure LVN A performed hand hygiene and changed gloves during wound care for Resident #2.This failure could affect the residents by placing them at risk for worsening conditions and cross-contamination Findings included:Record review of Resident #2's Comprehensive MDS Assessment, dated 05/05/26, reflected Resident#3 was a [AGE] year-old male who initially admitted to facility on 11/03/21 and readmitted [DATE]. His diagnoses included traumatic brain injury (a disruption in normal brain function caused by a sudden bump, blow, jolt, or penetrating object to the head). The residents' BIMS score was not documented as resident is rarely/never understood. His MDS assessment indicated he was at risk of developing ulcer/ injuries.Record review of Resident #2's order summary report, dated 06/12/26, reflected the following: - Left Buttock Cleanse Wound with normal saline, pat dry, triad past e to peri wound, Gentamicin, Santyl, calcium alginate. cover with dry dressing. ([START 06/12/26 13:55] [Sic] On Day Shift [Time: Shift 1]) AND ([START 06/12/26 13:55] [Sic] As needed anytime)''.Observation on 06/12/26 at 03:27PM with LVN A, providing Resident #2 with wound care revealed, he disinfected the table and left it to dry. He removed gloves, washed hands, and put the supplies together. He washed hands and put on Personal Protective Equipment (PPE). He wheeled the table to Resident #2's bedside. He then washed his hands, put on gloves, and removed the old dressing on Resident #2's sacrum. He did not change gloves and perform hand hygiene. He cleansed the wound with wound cleanser, removed his gloves, washed his hands, put on new gloves, and applied calcium alginate and dry dressing dated 6/12/26.Interview with LVN A on 06/12/26 at 04:17 PM, revealed he was supposed to remove gloves after removing the old dressing and perform hand hygiene. He stated he forgot to change gloves and perform hand hygiene. He stated failure to perform hand hygiene and change of gloves would cause cross contamination and spread of infection. He stated he had done training on infection control and handwashing.Interview on 06/12/26 at 06:07 PM, the DON revealed her expectation was LVN A was supposed to change gloves from dirty to clean and wash hands. She stated failure to change gloves and perform hand hygiene could risk infection and wound getting worse. She stated she had done training with staff on infection control and hand washing during wound care.Record review of the facility Hand Hygiene for Staff and Residents policy, dated July 2024, reflected, .The purpose of this procedure is to reduce the spread of infection with proper hand hygiene '1.Hand hygiene is done:After: A. contact with soiled or contaminated articles, such as articles that are contaminated with body fluids.B. Resident contact.

Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 2 meals (breakfast on 06/12/26) reviewed for palatability and temperature. The facility failed to provide food that was palatable and appetizing temperature for the breakfast meal on 06/12/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. Findings included: Observation on 06/12/26 at 9:50 AM of the 300-hallway revealed residents' breakfast trays were on a mobile cart. Observation on 06/12/26 at 10:10 AM of the 300-hallway revealed the last residents' breakfast tray was passed to them in their room. Observation and interview on 06/12/26 at 10:11 AM with Resident #4, revealed he was in his room lying in his bed eating his breakfast. Resident #4 said his breakfast meal was cold today but he was so hungry he did not ask anyone to heat it up for him. Observation and interview on 06/12/26 at 10:15 AM with Resident #5, revealed he was in his room lying in his bed eating his breakfast. Resident #5 said his breakfast meal was cold today but he was hungry so he did not want anyone to heat it up for him because it would take too long. Interview on 06/12/26 at 1:54 PM with the DM, she said she had not received any cold food complaints recently. The DM said if a resident said the food was cold, the staff can heat the food up or go back to the kitchen to request a new plate that was warm. The DM said she expected the food to be warm when a resident received it. The DM said the purpose of the food being warm when a resident received it was because the taste of it changed. The DM said the kitchen was responsible for serving the food at a warm temperature. The DM said if food was not served to residents warm, they might get upset. Review of the facility's policy, revised 02/06/24, and titled Hot and Cold Food Temperatures reflected: All hot food items must be served to the resident at a palatable temperature.

Based on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #2) of 8 residents reviewed for accommodation of needs. The facility failed to ensure Resident #2 had their call light within reach. This failure could place residents at risk of not having their needs and preferences met.Findings included:Record review of Resident #2's face sheet, dated 05/28/26, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #2's Annual MDS, dated [DATE], reflected she was diagnosed with Non-Alzheimer's Dementia (any form of cognitive decline that was not caused by Alzheimer's Disease) and Diabetes Mellitus (chronic metabolic disease characterized by persistent high blood sugar levels). The MDS further reflected Resident #2 had a BIMS score of 3, indicating severe cognitive impairment and required moderate to maximal assistance with ADLs. Record review of Resident #2's care plan, dated 05/28/26, reflected she had a fall on 09/09/25 and 12/15/25 with an intervention to orient to call light and keep within reach. Observation and interview on 05/28/26 at 9:47 AM of Resident #2 revealed her sitting in the wheelchair next to her bed eating breakfast. The call light was observed on the opposite side of the bed, lying on the floor. Resident #2 stated she did use her call light when she could get to it. Resident #2 stated it was usually kept on her bed but was unable to find it during the interview. She stated she could push it when it was located on the bed but could not reach the floor. Observation on 05/28/26 at 10:54 AM revealed Resident #2 sitting in her wheelchair beside the bed. Call light observed on the floor on the opposite side of the bed. CNA D observed assisting Resident #2's roommate behind the closed curtain. Observation on 05/28/26 at 11:47 AM revealed Resident #2 being assisted to use the bathroom with CNA C and CNA D. Observation of Resident #2's call light observed on the floor beside the bed.Observation on 05/28/26 at 1:44 PM revealed Resident #2 in her wheelchair next to her bed. Observation of call light revealed it was on the opposite side of the bed, on the floor. Interview on 05/28/26 at 2:25 PM with LVN E revealed she had worked at the facility since February 2026. She stated she expected the call lights to always be within the residents' reach. LVN E stated the call light was used as a way for residents to ask for assistance from staff. She stated it was all staff's responsibility to ensure the residents could reach the call light. LVN E stated Resident #2 could not reach the call light if it was on the floor. LVN E stated the risk of not having the call light where Resident #2 could reach, was she may not be able to call staff, and something could happen to her. Interview on 05/28/26 at 2:45 PM with CNA C revealed she had worked at the facility for 2 years and was familiar with Resident #2. She stated Resident #2 would not be able to reach the call light if it was on the floor. CNA C stated she was not Resident #2's main aide and only entered her room to assist CNA D. She stated she did not see Resident #2's call light on the floor. CNA C stated all call lights were expected to be within the residents' reach. She stated the risk of not having the call light within reach was that a resident could not ask for help if they needed assistance with something and could potentially have a fall.Interview attempts in person on 05/28/26 with CNA D were unsuccessful. A phone interview attempt was also made at 3:53 PM on 05/28/26; however, there was no answer and no return phone call was received. Interview on 05/28/26 at 5:34 PM with the DON revealed she expected all staff to put the call lights within the residents' reach. She stated Resident #2 could not reach the call light with it on the floor. The DON stated she expected staff to check every round to ensure the call light could be used if they needed staff assistance. The DON stated the risk of not having the call light within reach was something could happen and Resident #2 could not use her call light for assistance. Interview on 05/28/26 at 6:13 PM with the Administrator revealed he expected all call lights to be within reach of the residents. He stated no call lights should be located on the floor. The Administrator stated it was all staff's responsibility to ensure the call lights were within reach. The Administrator stated the risk of call lights out of reach was the resident could not notify staff if there was a need. Record review of the facility's policy, Call Lights Answering revised 01/19/23, reflected the following: .7. When leaving the room, be sure the call light is place within the resident's reach .

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADL care.The facility failed to provide Resident #1 assistance with timely incontinence care for approximately 6 hours on 05/28/26, which resulted in Resident #1 being soaked with urine and soiled through her brief, draw sheet, and bed sheets. This failure could place the residents at risk for decreased feeling of self-worth, skin breakdown, and infection. Findings included:Record review of Resident #1's face sheet, dated 05/28/26, reflected Resident #1 admitted to the facility on [DATE] and readmitted on [DATE].Record review of Resident #1's Annual MDS, dated [DATE], reflected Resident #1 had the following diagnoses: Non-Alzheimer's Dementia (any form of cognitive decline that was not caused by Alzheimer's Disease), Seizure Disorder or Epilepsy (condition causing repeated seizures from abnormal brain activity), Anxiety (excessive fear or worry that could disrupt daily life), and Schizophrenia (mental health condition that affects how people think, feel, and behave). The MDS also reflected that she was always incontinent of bowel and bladder and Resident #1 was noted to be dependent on staff for toileting hygiene. Record review of Resident #1's care plan, dated 05/28/26, reflected she was incontinent of bowel and bladder with interventions to, assist with toileting needs; check and change, keep clean and dry; after each incontinent episode apply barrier cream. Observation and interview on 05/28/26 at 10:00 AM with Resident #1 revealed her lying in bed. Resident #1 appeared to be a poor historian at times throughout the interview. Resident #1 stated the staff come in occasionally to check on her. She stated the staff had already changed her and that they change her at least once a day. During the interview, Resident #1 appeared to get irritated and stopped answering questions. Observation and interview on 05/28/26 at 12:53 PM revealed CNA A performing incontinence care on Resident #1. CNA A pulled back the sheets on Resident #1. CNA A observed the sheets and stated she needed new sheets before starting incontinent care. Observation of the sheets revealed the urine in the brief had soaked through to the draw sheet and fitted sheet. Interview with CNA A revealed she had last changed Resident #1 at 7:00 AM. She stated her shift started at 6:00 AM and she did rounds and then started her showers. CNA A arrived back to the room with clean sheets and supplies and began performing incontinence care. When Resident #1's brief was undone, it was observed to be full of urine and feces and had a strong urine odor. When Resident #1 was turned onto her side during incontinence care, it was noted that the urine had soaked through her brief, draw sheet, and fitted sheet. Resident #1 observed to have redness to sacral area with no open areas. CNA A stated the redness was not new and they applied barrier cream to it. Resident #1 denied any concerns during the care and was unable to answer when she had last been changed.Interview on 05/28/26 at 2:02 PM with CNA A revealed she had worked at the facility since 2023. She stated she was expected to perform rounds every 2 hours. CNA A stated when she got caught up in another room, it could take her longer than the 2 hours. She stated not changing Resident #1 for that long was her fault since Resident #1 was assigned to her. She stated it was approximately 6 hours since she had last performed incontinence care on Resident #1. CNA A stated she had poked her head into the room to check on Resident #1 but never looked to see if she needed to be changed. CNA A stated Resident #1 was fully dependent on staff for incontinence care and had to be checked to confirm if she was wet. CNA A stated there was a horrible risk if rounds were not performed every 2 hours. She stated it put Resident #1 at risk of skin breakdown and bed sores. Interview on 05/28/26 at 5:05 PM with LVN B revealed she expected her CNAs to complete their rounds and check the residents at least every 2 hours. LVN B stated she was unaware that Resident #1 went 6 hours without incontinence care. LVN B stated she was assisting CNA A throughout the shift, and she had not asked for help with Resident #1. LVN B stated Resident #1 was dependent and always incontinent of bowel and bladder. LVN B stated she did check on Resident #1 but was unaware what time. LVN B stated not changing Resident #1's brief when she was wet, put her at risk of bed sores. She stated Resident #1 did have redness that had been there previously and the CNAs were applying barrier cream to it. Interview on 05/28/26 at 5:34 PM with the DON revealed she expected her staff to check and change residents at least every 2 hours. The DON stated it was unacceptable for Resident #1 to go 6 hours without incontinence care. The DON stated it was all staff's job to ensure that residents were being checked on every 2 hours. She stated Resident #1 not getting timely incontinence care placed her at risk of UTI, wounds, and more. Record review of the facility's Perineal care/Incontinent Care policy, dated April 2012, reflected: Staff will perform perineal/incontinent care with each bath and after each incontinent episode.

Based on observations and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 5 of 20 rooms (Rooms #501, #508, #510, #705, and #712) reviewed for accident hazards. The facility failed to ensure the sharps containers, which were used to store used needles, in Rooms #501, #508, #510, #705, and #712 were not overfilled.This failure could place residents at risk of exposure to bloodborne pathogens.Observation on 05/18/26 at 9:10 AM revealed the sharps container for room [ROOM NUMBER] was overfilled and two syringes were protruding out of the safety flap. Observation on 05/18/26 at 9:13 AM revealed the sharps container for room [ROOM NUMBER] was overfilled, and the safety flap could not be operated. Observation on 05/18/26 at 9:15 AM revealed the sharps container for room [ROOM NUMBER] was overfilled, and the safety flap could not be operated. Observation on 05/18/26 at 9:28 AM revealed the sharps container for room [ROOM NUMBER] was overfilled and had multiple syringes and needles protruding out of the safety flap.Observation on 05/18/26 at 9:30 AM revealed the sharps container for room [ROOM NUMBER] was overfilled and had multiple syringes and needles protruding out of the safety flap. During an interview on 05/18/26 at 9:45 AM, the Wound Care Nurse stated the nursing staff was responsible for changing out sharps containers when they reached the fill line on the container. She stated overfilling the container placed residents at risk of being stuck with a used needle and being exposed to possible bloodborne pathogens. During an interview on 05/18/26 at 9:49 AM, the ADON stated nursing staff and Central Supply staff were responsible for changing out sharps containers before they became overfilled. She stated the risk of an overfilled container, with needles protruding out of them, was a serious risk to the residents, potentially exposing them to blood or infectious materials on the needles. During an interview on 05/18/26 at 1:24 PM, the DON stated all staff were responsible for checking the sharps containers and alerting nursing staff if one needed to be changed out. Nursing staff were responsible for changing out the containers and for not overfilling them. Continuing to force needles into a sharps container that was filled past the fill line placed the residents at risk of being stuck with a protruding needle and exposure to bloodborne pathogens. Record review of the facility's Regulated Waste policy, dated 01/22/24, reflected: Sharps:.3. Wall mounted sharps containers access is at eye level, approximately five feet up.4. Sharps containers are discarded when 3/4 or less filled.

Based on interviews and record reviews the facility failed to ensure pharmacy services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident was done for 4 of 10 residents (Residents #1, #2, #3, and #4) reviewed for medication administration. The facility failed to consistently monitor the blood sugar levels and administer insulin accordingly for Residents #1, # 2, #3, and #4. This failure could place residents at risk of untreated high or low blood sugar levels, resulting in a worsening of their medical conditions. Resident #1Record review of Resident #1's admission MDS, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of diabetes. Resident #1's BIMS score was 15, indicating she was cognitively intact. Her Functional Abilities assessment indicated she used a wheelchair for mobility and relied on some staff assistance with her ADLs. Her Medications assessment indicated she used insulin daily.Record review of Resident #1's care plan, dated 05/05/26, reflected she had a nutritional risk related to her diabetes and was at risk of high or low glucose levels with interventions of administering medications as ordered and monitoring for adverse side effects and monitor blood sugar levels per MD order. Record review of Resident #1's physician order dated 05/07/26 indicated blood sugar levels were to be monitored before breakfast, lunch, and dinner (6:00 AM, 11:30 AM, and 5:00 PM), and insulin administered according to what the level was based on sliding scale a method used to manage blood glucose (sugar) levels by adjusting the insulin dose based on the resident's current blood glucose level). Her sliding scale was 0-199=0u, 200-250=4u, 251-300=6u, 351-400=10u and, 401-450 = 12u and notify MD.Record review of Resident #1's insulin administration record for May 2025 revealed glucose levels were not checked, and her insulin was not administered. on the following dates: 04/24/26 her 6:00 AM glucose level was 216 and treated, her 11:30 check was missed, and her 5:00 PM level was 114, no treatment needed. 05/02/26 her 6:00 AM check was missed, her 11:30 level was 147, no treatment needed. 05/06/26 her 6:00 AM glucose level was 174, her11:30 AM check was missed, her 5:00 PM level was 183, no treatment needed Record review of Resident #1's EHR from 05/01/26 to 05/18/26 revealed no nursing progress noted indicating why the doses were missed. During an interview on 05/18/26 at 9:10 AM, Resident #1 stated staff did not always give her insulin properly. She stated that some days it was checked after she had eaten her meal, and some days it was not checked but once or twice. She stated she would tell the nurses they were not administering her insulin properly, and they would either ignore her or tell her they were following the doctor's orders. Resident #1 stated she did not feel her glucose levels ever got out of control, being too high or too low. Resident #2Record review of Resident #2's quarterly MDS assessment, dated 03/18/26, reflected he was a 74-tear-old male admitted to the facility on [DATE] with a diagnosis of diabetes. His BIMS score was 15, indicating he was cognitively intact. His Functional Abilities assessment indicated he required minimal assistance with his ADLs. His Medication assessment indicated he used insulin once in the previous 7 days. Record review of Resident #2's care plan, dated 03/24/26, reflected he had diabetes and was at risk for high or low glucose levels with interventions of monitoring blood sugar levels as ordered and administer diabetic medicines as ordered. Record review of Resident #2's physician orders revealed *Insulin Lispro was ordered on 3/18/26 to be monitored before breakfast, lunch and dinner (6:00 AM, 11:30 AM, and 5:00 PM). Insulin was to be administered per his sliding scale. His sliding scale was - 60 = 0 UNITS * MD Call, 61- 149 = 0 UNITS 150 - 200 = 4 UNITS, 201 - 250 = 6 UNITS 251 - 300 = 8 UNITS, 301 - 350 = 10 UNITS, 351 - 400= 0 UNITS * MD Call 401 or greater * Lantus was ordered on 03/15/26, was to be administered before breakfast. Record review of Resident #2's insulin administration record revealed glucose level was not checked, and his fast-acting insulin was not administered on the following dates: 05/01/26 at 6:00 AM his glucose was 216 and was treated, his 11:30 check was missed, and his 5:00 PM level was 213 and was treated. 05/04/26 his 6:00 check was missed and his 11:30 glucose level was 242 and was treated. 05/05/26 his 6:00 AM glucose level was 239 and treated, his 11:30 check was missed, and his 5:00 PM level was 280 and treated. 05/06/26 his 6:00 AM was 218 and was treated, his11:30 check was missed, his 5:00 PM glucose level was 270. 5/11/25 his 6:00 AM glucose level was 215 and treated, his 11:30 AM check was missed, and his 5:30 level was 241 and treated. 05/15/26 his 6:00 AM glucose level was 204 and treated, his 11:30 check was missed, and his 5:30 level was 306. Record review of Resident #2's EHR from 05/01/26 to 05/18/26 revealed no nursing progress notes indicating why the doses were missed. During an interview on 05/18/26 at 2:10 PM, Resident #2 stated he felt like he was not always getting his insulin like he was supposed to, but the nurses said he was. Resident #2 said he would get confused sometimes, so he assumed the nurses were right. He denied having high or low glucose level issues. Resident #3Record review of Resident #3's quarterly MDS, dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of diabetes. His BIMS score was 15, indicating he was cognitively intact. His Functional Abilities assessment indicated he was completely reliant on staff to meet his ADLs. His Medication assessment indicated he used insulin daily in the past 7 days.Record review of Resident #3's care plan, dated 03/27/26 reflected he required maximum assistance with his ADLs, had diabetes with interventions of checking blood sugar levels as ordered and administering diabetic medications as ordered, and was at risk of high or low glucose levels with interventions of diet as ordered, and administer medications as ordered. Record review of Resident #3's physician orders revealed as follows:His fast-acting insulin was ordered on 02/04/26, his glucose levels were to be checked before breakfast, lunch, dinner, and before bedtime (8:00 AM, 4:30 PM, 8:00 PM, and 12:30 AM), and his insulin was to be administered according to his sliding scale which was 0-199=0u, 200-250=4u, 251-300=6u, 301-350=8u and notify MD, 401-450 = 12u and notify MD,. His long acting was to be administered at bedtime. Record review of Resident #3's insulin administration record revealed glucose level was not checked, and his fast-acting insulin was not administered. on the following dates: 05/04/26 his 12:30 AM glucose level was 176, no treatment needed, his 8:00 AM check was missed, and his 4:30 level was 198 and treated, his 8:00 PM check was missed. 05/08/26 his 12:30 AM glucose level was 137, no treatment needed, his 8:00 AM check was missed, his 4:30 PM level was 225 and was treated. 05/11/26 his 12:30 AM glucose level was 161, no treatment needed. His 8:00 AM check was missed, and his 4:30 level was 233 and was treated. 05/13/26 his 12:30 AM glucose level was 127, his 8:00 AM check was missed, and his 4:30 PM level was 240 and treated. 05/14/26 his 12:30 AM glucose level was 129, no treatment needed, his 8:00 AM check was missed, and his 4:30 level was 199 and was treated. 05/15/26 his 12:30 AM glucose level was 129, no treatment needed, his 8:00 AM check was missed and his 4:30 level was 145, no treatment neededRecord review or Resident #3's EHR from 05/01/26 to 05/18/26 revealed no nursing documentation of why the doses were missed. During an interview on 05/18/26 at 2:20 PM, Resident #3's interactions were limited due to his disease process. Resident did not express any concern about his medications. Resident #4Record review of Resident #4's quarterly MDS assessment, dated 03/01/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of diabetes. His BIMS score was 4, indicating severe cognitive impairment. His Functional Abilities assessment indicated he was totally dependent on staff to meet his ADLs. His Medication assessment indicated he used insulin daily in the previous 7 days. Record review of Resident #4's care plan, dated 03/13/26, reflected that he had cognitive losses, required assistance with his ADLs, and had diabetes with interventions of check blood sugar levels as ordered and administer diabetic medications as ordered. Record review of Resident #4's physician orders revealed an order, dated 09/22/25, for fast acting insulin to be administered before breakfast, lunch, and dinner (7:00 AM, 11:30 AM, and 5:00 PM) according to his sliding scale which was 0-60= 0 units (Call MD), 61-149= 2 units, 150-199= 4 units, 250-299= 6 units, 300- 349= 8 units, 350 or greater administer 10 units and notify MD. Record review of Resident #4's insulin administration record revealed glucose levels were not checked, and his insulin was not administered on the following dates: *05/02/26 he was not checked or treated the whole day (7:00 AM, 11:30 AM, and 5:00 PM). *05/03/26 his 7:00 AM glucose level was 178. *05/05/26 his 7:00 glucose level was 237 and treated, his 11:30 check was missed, and his 5:00 PM level was 292 and treated. *05/11/26 he was not checked or treated the whole day (7:00 AM, 11:30 AM, and 5:00 PM). Record review of Resident #4's EHR from 05/01/26 to 05/18/26 revealed no nursing documentation for the missed doses. An interview was attempted with Resident #4 on 05/18/26 at 2:25 PM, but it was unsuccessful. An attempt was made to interview Resident #4's Physician on 05/18/26 at 2:00 PM, but the attempt was unsuccessful. A message was left with no return call. During an interview on 05/18/26 at 2:35 PM, LVN B stated he did not know about residents missing doses of insulin. He stated he monitored the diabetic residents closely in case there was an issue. The missed dates for Resident #4 were reviewed with LVN B, and he stated he was not working on any of the dates. He stated there was a lot of agency staff that worked at the facility. He stated the risk of not checking glucose levels and administering insulin could be high glucose levels, leading to a diabetic coma. During an interview on 05/18/26 at 2:40 PM, the ADON stated missing insulin doses was not allowed. She stated the nurse could always ask for help if they were behind and needed help with their glucose checks and insulin administration. She stated the risk to the residents was either high or low glucose levels. During an interview on 05/18/26 at 2:55 PM, the DON stated missing doses of insulin was not acceptable. She stated the risk of the resident's glucose levels getting too high or going too low was too great. She stated she had no idea doses were being missed. She stated the nurses were responsible for administering all medications as ordered by the physician. Record review of the facility's Medication Administration policy, dated January 2025, reflected: 1. Medications are administered in accordance with written orders of the prescriber.

Based on observations, interviews, and record reviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible, or resident preferences indicate otherwise for 1 of 5 residents (Resident #1) reviewed for nutritional status. The facility failed to monitor Resident #1 weight as ordered, resulting in unexpected weight loss of 4.8%. This failure could place residents at risk of unrecognized weight loss and malnutrition.Record review of Resident #1's admission MDS, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included diabetes, post operative spinal surgery, and chronic pain. She was 64 inches tall and her current weight was 189.2 pounds. Resident #1's BIMS score was 15, indicating she was cognitively intact. Her Functional Abilities assessment indicated she used a wheelchair for mobility and relied on some staff assistance with her ADLs. Her Swallowing/Nutritional Status assessment did not indicate the resident required a therapeutic diet. Record review of Resident #1's care plan, dated 05/05/26, reflected she had a nutritional risk related to diabetes, with interventions of administering medications as ordered and monitoring for adverse side effects and monitor blood sugar levels per MD order; and had impaired mobility related to the spinal surgery, with interventions of assist with ADLs and maintain weight bearing status. Review of Resident #1's physician orders revealed an order, dated 04/22/26, Weekly weights x 4 weeks and a diet order for a regular diet.Record review of Resident #1's weight record revealed she was only weighed once since her admission to the facility, at admission on [DATE]. Her weight was 189.2 pounds at that time. During an observation on 05/18/26 at 3:30 PM, Resident #1 was weighed, and her weight was 180.0 pounds. During an interview on 05/18/26 at 9:10 AM Resident #1 stated there was confusion on her diet when she was admitted , and she was out of it for a few days. Once she was more alert, she was able to pick to understand that the facility did not have a diabetic diet, she was to pick options that best fit her restrictions.During an interview on 05/18/26 at 11:10 AM, the ADON stated the facility's policy was to weigh all residents once a week for the first four weeks to establish a baseline. The ADON stated not monitoring residents for weight loss could result in them becoming malnourished. She stated the CNAs were responsible for weighing residents and reporting it to the nurse. During an interview on 05/18/26 at 11:35 AM, CNA A stated they were alerted to a resident needing to be weighed when it populated on the Kardex which they were supposed to check every day. During an interview on 05/18/26 at 1:24 PM., the DON stated all residents were weighed once a week for the first four weeks at the facility. This establishes a baseline, and alerts staff that the resident might not be adjusting to their new environment if they are losing weight. The DON stated unexpected or unrecognized weight loss could lead to a resident becoming malnourished. An interview was attempted on 05/18/26 at 2:00 PM with the Physician via telephone; however, the attempt was unsuccessful. A message was left with no return phone call. Record review of the facility's Weight Monitoring policy, dated 05/19/23, reflected: Residents weights will be recorded and monitored at a minimum frequency monthly.b. Newly admitted and re-admitted residents are weighed upon admission and weekly x4 and then monthly thereafter, unless otherwise indicated by physician's order.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Residents #1, #2 and #3) reviewed for infection control practices.1. MA A failed to disinfect the blood pressure cuff before checking Resident #1's blood pressure after she removed the cuff from her (MA A's) wrist.2. CNA B and CNA C failed to perform hand hygiene before contact, between care, and change of gloves while providing incontinence care to Resident #2 and Resident #3.These failures could place residents at risk of exposure to infectious agents and could lead to the development of infection. Findings included: 1. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. Resident #1 was cognitively intact with a BIMS score of 14. He had diagnoses which included hypertension (abnormally high arterial blood pressure) and anemia (a condition in which the blood is deficient in red blood cells, in hemoglobin, or in total volume).Observation on 02/03/26 at 10:54 AM revealed MA A removed a blood pressure cuff from her own wrist. Without disinfecting the blood pressure cuff, she entered Resident #1's room and she checked Resident #1's blood pressure.Interview/observation with MA A on 02/03/26 at 11:39 AM revealed she was still wrapping the blood pressure cuff on her wrist. She stated she did not disinfect the blood pressure cuff before checking Resident #1's blood pressure. She stated she was supposed to use the disinfectant wipes to clean the blood pressure cuff after unwrapping it from her wrist and before applying the cuff on Resident #1 to prevent the spread of infection, but she forgot. She stated she had received training on the care and disinfection of reusable equipment, but she could not recall when.2. Record review of Resident #2's Quarterly MDS Assessment, dated 12/16/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE] and readmitted [DATE]. The resident had severe cognitive impairment with a BIMS score of 7, and her diagnoses included hypertension and diabetes (a condition that happens when your blood sugar is too high). Record review of Resident #2's care plan, dated 07/18/25, reflected: Focus: [Resident #2] At risk for problems with eliminations bowel and bladder. Goal: [Resident #2] will have incontinent products available on daily basis over the next 90 days. Interventions: Provide peri care [the hygiene practice of cleaning and maintaining the genital and anal areas to prevent infection, discomfort, or skin breakdown] after each incontinent episode.Observation on 02/03/26 at 11:30 AM revealed CNA B went to Resident #2's room to provide the resident incontinence care. She first knocked on the resident's door and then entered the room. Without washing her hands, she put on gloves and put her supplies together. Next, CNA B used wet wipes to cleanse Resident #2's abdominal folds and perineal area (the anatomical region located between the thighs). Her technique was one wipe, one swipe. She wiped down the peri area from inner area towards the outer area. Resident #2 then turned on her right side, and CNA B wiped the resident's buttocks and thighs from inner area towards the outer area. Resident #2 was wet. CNA B then removed the soiled brief and discarded it. Without performing hand hygiene or changing her gloves, CNA B took a clean brief and put the clean brief on Resident #2. She then positioned the resident in bed with the call light in reach. Lastly, she removed her gloves, washed her hands, and left the resident's room. Interview with CNA B on 02/03/26 at 12:00 PM revealed she knew she was supposed to perform hand hygiene before contact with Resident #2, between the care, and with each removal of gloves. She stated she forgot. She stated failure to perform hand hygiene before contact, between care, and after removal of gloves could lead to contamination and spread of infection. She stated she had done training on hand washing, but she could not remember when.3. Record review of Resident #3's Comprehensive MDS Assessment, dated 12/26/25, reflected the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS score of 0, and his diagnoses included hypertension.Record review of Resident #3's care plan, dated 01/06/26, reflected: Focus: [Resident #3] Bowel and Bladder. Goal: [Resident #3] Improve or maintain current bladder and bowel continence. Interventions: Check and change, keep clean and dry.Observation on 02/03/26 at 3:40 PM revealed CNA C prepared incontinence care supplies and then entered Resident #3's room. Without washing his hands, CNA C put on gloves. He then positioned the resident and cleansed the resident's abdominal walls, penis, and Foley catheter starting from tip downwards. Resident #3 was observed to have had a bowel movement. CNA C then turned the resident, and he cleansed the resident's buttocks from the inner area towards the outer area. CNA C was observed changing gloves between care, but he did not perform hand hygiene. When the resident was clean, CNA C removed his gloves and put on new gloves, but he did not perform hand hygiene. CNA C then took a clean brief and put it on Resident #3. Next, CNA C applied cream on the resident. He then removed his gloves and put on new gloves without performing hand hygiene. CNA C positioned the resident in bed in a low position with his call light within reach. Lastly, CNA C removed his gloves, washed his hands, and left the resident's room. Interview with CNA C on 02/03/26 at 4:01 PM revealed he was supposed to perform hand hygiene before contact and with each change of gloves, but he forgot. He stated that failure to perform hand hygiene during incontinence care on Resident #3 could lead to cross contamination and infection. He stated he had received hand washing in-services in the facility.Interview with the DON on 02/03/26 at 5:10 PM revealed her expectation was for staff to perform hand hygiene before contact with residents, between care, and when they changed gloves. The DON stated she also expected staff to disinfect the reusable equipment before using it on a resident and after use. She stated failure to perform hand hygiene before contact, between care, and change of gloves could lead to cross contamination and spread of infection. She stated the failure to disinfect reusable equipment before contact with residents and after use could also lead to cross contamination. She stated she had been in the facility for four weeks, and she had not done training on infection control. She stated she had training on infection control that morning with staff. She stated the facility had offered training on hand washing and cleaning of equipment, and she was not sure whether the staff were in attendance. Record review of the facility's training records for the topic of Hand Washing Before and After Patient Care, dated 08/02/25, reflected CNA B and CNA C had not attended the training. Record review of the facility's training records for Focus on Infection Control-Cleansing of Designated Resident Devices, dated 08/20/25, reflected that MA A had not attended the training.Record review of the facility's current Cleaning, Disinfecting and Sterilizing Care Equipment policy, dated March 2025, reflected the following: .3. Noncritical items are those that either do not ordinarily touch the resident or touch only intact skin. Such items include.blood pressure cuffs, and other medical accessories. These items rarely transmit diseases. However, it is imperative that these items are clean. Depending on the piece of equipment or item, washing with a detergent or disinfectant detergent, rinsing and thorough drying may be sufficient.Record review of the facility's current Hand Hygiene for Staff and Residents policy, dated February 2025, reflected the following: Hand hygiene is the most important component for preventing the spread of infection.1 Hand Hygiene is done:Before A Resident contactAfter:A. Contact with soiled or contaminated articles such as articles that are contaminated with body fluids.B. Resident contact Note: Wash hands at end of procedures where glove changes are not required. For procedures in which change golfese's. clean gloves to sterile gloves, it is indicated follow the specific standard of practice. If gloves, hands become contaminated as gloves are changed hands can be washed

Based on observations, record reviews and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents and staff for 1 (Door #1) of 7 entry doors reviewed for environment. The facility failed to safely monitor individuals who gained access to the facility using the posted security code next to Door #1. This failure could affect the safety of all the residents and staff at the facility and diminish residents' quality of life.The findings include: During an observation of the facility's Door #1 on 1/6/26 at 8:35am surveyor saw a 4-digit code posted next to the door by the keypad. Surveyor entered the four-digit code that was posted, the door unlocked, and Surveyor entered the facility. Upon entry there was no one at the front desk and no one in the two halls that led to the nurses' stations to assist Surveyor. There was no alarm that notified staff that Surveyor had entered the building. Surveyor waited for approximately 7-10 minutes, then went to the 2nd office door behind the front desk to notify a staff member that the surveyors had entered the building. During an telephone interview with the Anonymous Staff Member on 1/9/25 at 2:26pm revealed she was very concerned about the safety of the residents, particularly after 4pm when there were no staff by Door #1. The Anonymous Staff Member stated she had had multiple complaints from relatives of the residents and stated one lady had entered the facility late and was concerned about the safety of her loved one because the code was visible to the public and could open Door #1 after hours, particularly closer to midnight. She stated the concern was brought to the Administrator's attention, but he had not provided a response to her complaint. She stated the risk to the residents of Door #1 not being monitored while the code to enter was posted, was someone could have come into the facility with a gun to harm staff or residents and the staff would not know the person was in the building. During an interview with the Social Worker on 1/6/26 at 3:30pm revealed over the summer she had a resident that complained about the safety of the building, related to unknown people in the hall at night talking. The Social Worker stated they talked to staff about allowing personal visitors to the building. She stated there were no staff in the evenings and at night at the front desk and it was the nurses' responsibility to monitor Door 1. The facility had a receptionist by Door #1 during the day throughout the week and weekend. The social worker stated they could stand at the nurses' stations and look down the hall to see if someone was coming down the halls. During an interview with the Director of Maintenance on 1/6/26 at 3:35pm revealed doors at the facility could not have been opened unless the individuals had a code to open the doors. He stated all the doors at the facility, including Door #1, had an alarm and the alarm would sound if someone attempted to enter the doors without the access code. He stated Door #1 had the code posted on the inside and outside so that staff and other individuals could enter the building without issues. He stated he was unsure how the facility monitored individuals who entered the building through Door #1 when the staff was not close to it. He stated once a person entered the code, they gained access to the building and there was no alarm or bell to notify the staff in the building that someone had entered the building. He stated the code had been posted 24 hours a day for several months. He could not recall the exact number of months the code was posted. He stated he was instructed to post the code by Door #1 because family members would come to the building and would jerk the door open causing the alarm to sound and would break the door. He was unwilling to state the risks to the residents of having the code posted outside without monitoring the door and stated, you need to talk to the Administrator. During an interview with LVN B on 1/6/26 at 4:15pm revealed it was the responsibility of all floor staff to keep an eye on who entered the building through Door #1 in the evenings. He stated he only knew when someone entered through Door #1 if they came to the nurse's station because he was usually providing care to patients. LVN B stated it would have been a safety concern that anyone could enter the building through Door #1 using the posted code, but it was not his decision to make. He stated he would not have his house unlocked at night and if he was the owner of the facility, he would have Door #1 locked or have a staff member at the front desk. He stated he always locked all his doors because anything can happen, however it was out of his pay grade to decide if the code was posted outside after hours and at night. He stated he would prefer visitors after hours to call the phone number to be allowed to enter the building. During an interview with LVN C on 1/6/26 at 4:35pm revealed no one monitored Door #1 after hours, as she usually worked until 10pm and there was no staff at Door #1. LVN C stated she knew the code was posted to enter Door #1 and anyone could come in, which was a risk for her and the residents. She personally had not felt safe because she did not know when someone came into the building during her shift. She stated she locked her door at her home at night to not allow anyone to come in and would expect the same from the facility. During an interview with ADON A on 1/7/26 at 8:33am revealed there was staff by Door #1 from about 8am to 3:30pm daily including the weekends. ADON A stated when there were no staff in front, by Door #1, and therefore it was everyone's responsibility to monitor Door #1. She stated although staff were busy in the units she was hopeful staff were walking around to ensure there were no random people in the building. ADON A believed it was a safety concern, no one was monitoring Door #1 after hours because bad things could happen. ADON A stated the safety concern crossed her mind when there was an irate spouse who was threatening staff because their loved one passed away. ADON A stated she believed the code had been posted for at least 6 months. During an interview with the Administrator on 1/7/26/ at 10:40am it was revealed the code to enter Door #1 had been posted for several months. The code was posted due to family members and staff forgetting the code. The Administrator stated he had not had any incidents in which having the code posted put people's lives in danger. He stated, In the world we live in anything is a safety concerns and we cannot prevent everything and therefore did not believe it was a true safety concern to the residents. He stated he did not believe there was risk of having the code posted to enter the building without monitoring individuals entering the building. During record review of the facility's policy Resident Rights revised August 14, 2022, reflected Policy: The staff will abide by and protect resident rights in accordance with state and federal guidelines. Procedure: Staff will abide by resident rights as outlined within CMS state Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities. Requested physical environment policy from the Administrator and was provided the Resident Rights policy.

Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of two residents (Resident #1) reviewed for accident hazards/supervision/devices The Facility failed to ensure CNA D used a gait belt correctly when transferring Resident #1 from his wheelchair to the bed and then from her bed back to the wheelchair on 01/06/26. These failures could affect the residents by placing the residents at risk for discomfort, pain, falls, injuries, and skin tears.Findings included: Record Review of Resident #1's Quarterly MDS assessment, dated 09/17/25, reflected an [AGE] year-old female admitted to the facility on [DATE]. She was severely cognitively impaired with a BIMs score of 3. She required moderate assistance with transfers, toileting, and personal hygiene and required the assistance of 1 person. She was occasionally incontinent of urine and frequently incontinent of bowels. She had sustained one fall without injury since the prior assessment. Diagnoses included dementia, diabetes and hypertension. Review of Resident #1's care plan revised on 06/09/25 reflected, Impaired Physical mobility related to .generalized weakness.left sided weakness.right lower extremity weakness.Goal.Resident will maintain or improve physical function in.Transfer.Interventions.Provide appropriate level of assistance to promote safety of resident.Requires assistance of one staff.Requires extensive assistance. In an interview and observation with Resident #1 on 01/06/26 at 9:15 a.m. resident was observed sitting in her wheelchair in her room. She stated she had fallen recently, and the staff and her family have told her she was not to get up by herself. She chuckled and stated she did not think she needed help to go to the bathroom but stated she was trying to keep her family happy and ask for help. In an observation on 01/06/2026 at 9:55 a.m. Resident #1 was observed being assisted from her wheelchair to the bed by CNA D. Resident #1 was able to hold to the side rail of the bed but required extensive assistance to stand up with CNA D holding on to her arm and pulling her up with the back of the resident's pants. Resident #1 was very unsteady and shaky. No gait belt was used during the transfer. CNA D provided incontinence care and then assisted the resident onto the side of the bed. Resident #1 attempted to hold the arm of the wheelchair while CNA D held her under her arm and once again grabbed the back of her pants to try and assist her to a standing position. Resident #1 was not able to completely stand, and CNA D struggled to get her from the bed to the wheelchair. CNA D then had the resident sit back down on the side of the bed and she placed both of her arms around the resident and lifted her from the bed to the wheelchair. In an interview with CNA D on 01/06/26 at 10:10 a.m. she stated they were not supposed to lift residents under their arms because it could cause injury to their shoulders. CNA D stated she tried not to put her hand directly under her arm pit to prevent injury. She stated she did not know she was supposed to grab the back of the resident's paints. She stated they were supposed to use a gait belt but stated she did not see one in the resident's room. She stated she had been trained on gait belt transfers. In an interview with the DOR on 01/06/26 at 12:15 p.m. she stated the facility does annual gait belt training with the staff and nursing does the training at the employee's time of hire. She stated Resident #1 was currently on therapy services due to a recent fall and her decline in transfers and standing ability. She stated she required extensive assistance with transfers. She stated it was not acceptable to lift someone under their arm pits due to the potential for injury not only to the resident but also to the caregiver. She stated it increased the risk of falls, fractures and nerve damage. In an interview with the DON on 01/06/26 at 02:00 p.m. she stated she had started with the facility about 3 weeks ago and was still learning the facility's procedures but stated no one should be lifting a resident under their arms or by their clothing. She stated she would expect staff to use a gait belt when transferring a resident. She stated the risk of staff not following the correct procedure for transfers were injury to a resident's shoulders and arm and or the risk of the resident falling. She stated she would be doing one on one training with the CNA and also begin Inservice with all of the staff to ensure staff were providing correct transfer techniques. Record review of CNA D's staff education/ orientation checklist reflected she had been skills checked for gait belt transfers on 06/25/25 and had met the criteria for proper technique. Record review of the facility's policy, ADL Care-Transfer Techniques dated June 2023, reflected, Staff will provide safe and effective transfer techniques for resident in accordance to standard practice guidelines.Transfer from, bed to chair.Use stand-and-pivot technique with one caregiver if appropriate.Apply gait/transfer belt snugly and low so it circles the resident's waist.Grasp transfer/gait belt keeping palms along resident's side.Rock resident to standing position.Maintain stability of the resident's weakened leg with knee.Pivot on foot farthest from chair.Instruct resident to use armrest on chair for support and ease into chair.

Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 3 (Resident #3, Resident #13, Resident #30) of 5 residents reviewed for care planning.1.The facility failed to accurately complete the Physician Orders section on the baseline care plan, to indicate Resident #3 was being admitted to the facility with psychotropic medications.2.The facility failed to have a baseline care plan for Resident # 13 and Resident #30 This failure could place newly admitted residents at risk of not having their needs met, not receiving appropriate medications, not receiving necessary treatments, resulting in poor quality of life. 1) Record review of Resident #3's admission MDS Assessment, dated 7/31/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnosis of anxiety disorder. The resident BIMS score was 11 indicating moderately impaired cognition. Section E reflected none of the above for potential indicators of psychosis and no behavioral symptoms. Section N reflected Resident #3 was admitted with Antipsychotic Medication and indication noted. Review of Resident #3's Admit Baseline Care Plan dated 7/28/25 under Physician Orders/Medications/Treatments reflected Resident had no psychotropic therapy. Record review of Resident #3 Physician's Orders dated 7/28/25 reflected Quetiapine Fumarate 50mg tablet (QUEtiapine Fumarate) for G47.00 Insomnia, unspecified ([Start 7/28/25 18:34] 1 tablet by mouth at Bedtime). Record review of Resident #3's Medication Record for 8/1/25 - 8/31/25 reflected administration of Quetiapine Fumarate as ordered each day. 2) Record review of Resident #13's face sheet dated 08/21/2025 reflected she was a [AGE] year-old female with an original admission date of 07/18/2025.Record review of Resident #13's care plan revealed she did not have a baseline care plan.3) Record review of Resident #30s MDS dated [DATE] reflected he was an [AGE] year-old male with an admission date of 07/30/2025, BIMS score of 09 indicated moderate cognitive impairment. His diagnoses included Chronic Obstructive Pulmonary Disease (breathing difficulty).Record review of Resident #30's care plan revealed he did not have a baseline care plan. Interview with the MDS Coordinator on 8/21/25 at 2:35pm revealed she did not complete baseline care plans; she stated the nurse who admitted the resident was responsible for completing the baseline care plan. The risk of not having completed the baseline care plan accurately would be the staff would not know how to provide accurate care and interventions to the resident when they are admitted . Interview with LVN E on 8/21/25 at 3:25pm revealed nurses are responsible for completion of the baseline care plan. LVN E stated the nurses had 24-72 hours to complete a resident's admission which included the baseline care plan. LVN E stated she answered questions on the baseline care plan using notes and residents' assessments. If a resident arrived at the facility with psychotropic medication they would mark psychotropic therapy on the baseline care plan. Seroquel would be considered psychotropic medication and therefore psychotropic therapy would be check marked on the baseline care plan. The risk of not identifying psychotropic medications on the baseline care plan would be all staff wouldn't know what the resident's needs were and wouldn't know to monitor the side effects and behaviors. Interview with the DON on 8/21/25 at 4:09pm revealed nurses were responsible for the completion of baseline care plans. The DON stated they got a new electronic record's system on 7/22/25 and the nurses had been struggling to complete the baseline care plan efficiently. The DON reported he was working with nurses' side by side to help teach them the new system. The facility also had super users in the building that helped with major issues with the system. Regarding Resident #3's baseline care plan, Psychotropic therapy should have been checked off for the resident due to him being prescribed Seroquel. The risk of not noting the psychotropic therapy on the baseline care plan was it could have impeded the resident's treatment plan. The DON stated he was unsure of the reason psychotropic medication was not marked on Resident #3's baseline care plan. Review of the facility's policy Person Centered Care Plans revised 6/25/22 reflected .1. The facility must develop and implement a baseline person-centered care plan that meets professional standards of quality care. The baseline care plan will consist of the following: 2. Be developed within 48 hours of a resident's admission. 3. Include the minimum healthcare information necessary to properly care for a resident including but not limited to:.b. physician orders.

Based on record review and interviews, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 5 residents (Resident #3) reviewed for care plan development. The facility failed to complete Resident #3's comprehensive care plan in a timely manner after his comprehensive assessment was completed. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.Record review of Resident #3's admission MDS Assessment, dated 7/31/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] . Resident #3 had the following diagnoses: Anxiety Disorder, Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood circulation), Heart Failure, Diabetes and Asthma. Section M reflected resident was developing a pressure ulcer. Resident was admitted with the following medications: Antipsychotic, Anticoagulant (blood thinner), Antibiotic, Diuretic and Hypoglycemic (including insulin). Section O reflected resident needed continuous oxygen. Record review of Resident #3's Admit Baseline Care Plan reflected a completion date of 7/28/25.Record request for Resident #3's Comprehensive Care Plan on 8/21/25 at 2:04pm revealed he did not have one completed.Interview with the MDS Coordinator on 8/21/25 at 2:35pm revealed she was responsible for the completion of the Comprehensive Care Plan. The MDS Coordinator stated the expectation was she completed the MDS first and the Comprehensive Care plan would have been completed within 14 calendar days after the resident admitted to the facility. The MDS Coordinator stated she overlooked the care plan for Resident #3 and had not completed his comprehensive care plan yet. The MDS Coordinator stated she would used the CAA, notes from physician, nurses' notes and physician orders to complete the Comprehensive Care Plan. The MDS Coordinator stated psychotropic medications would be on the Comprehensive Care Plan, along with behavioral monitoring and monitoring of side effects. The risk to the resident of not having a comprehensive care plan in a timely manner was staff would not know how to provide accurate care and interventions. The MDS Coordinator completed the following trainings: RAI and Care Planning. The MDS Coordinator also referred to regional resources and trainings when she had questions on completion of the Care Plans. She stated the training for Care Planning was ongoing. Interview with LVN E on 8/21/25 at 3:25pm revealed the MDS Nurse or Unit Manager created and updated care plans. Nurses did not complete care plans. Interview with the DON on 8/21/25 at 4:09 pm revealed the comprehensive care plan was due 21 days from admission. The countdown started from the first day of admission and was calendar days. The nurses were responsible for acute comprehensive care plans, but the CAA triggers were completed by the MDS nurse. He stated Resident #3 should have had his comprehensive care plan completed already. The risk of not having had the care plan done would be it could impede the resident's treatment. He was unsure of the reason the care plan had not been completed. Interview with the Administrator on 8/21/25 at 4:49 pm revealed the expectation was the MDS nurse or nursing staff completed the care plans. The risk to the resident of not having a completed care plan was a lot of things could have gotten messed up and affected the resident negatively. Review of the facility's policy Person Centered Care Plans revised 6/25/22 reflected .Standard of Practice: Each resident will have a person-centered care plan developed and implemented to meet his or her other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.9. Comprehensive Care Plan - must be developed within seven (7) days after completion of the comprehensive assessment, quarterly, annually and with any change of condition.

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (300 Hall Nurses Cart and 200 Hall Nurses Cart) of 4 medication carts reviewed for pharmacy services in that:The facility failed to ensure: 1- 300 Hall Nurses Cart did not have:o 1 insulin pen for Resident #64 without an open date on 08/19/25. o 1 insulin pen for Resident #58 without an open date on 8/19/25. o 1 insulin pen for Resident #7 without an open date on 08/19/25. o 1 insulin pen for Resident #51 without an open date on 08/19/25. 2- 200 Hall Nurses Cart did not have: o 1 insulin pen for Resident #44 without an open date on 08/19/25. These failures could affect residents resulting in diminished effectiveness and not receiving the therapeutic benefits of the medications.1- Record review and observation on 08/20/25 at 8:56 AM of the 300 Hall Nurses Cart, with RN A revealed: - The pen of insulin Lispro 100 unit/ml for Resident #64 with no open date. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use. - The pen of insulin Novolog 100 unit/ml for Resident #58 with no open date. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use.- The pen of insulin Lispro 100 unit/ml for Resident #7 with no open date. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use.- The pen of insulin Lantus 100 unit/ml for Resident #51 with no open date. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use Interview on 08/19/25 at 9:21 AM, RN A stated nurses were responsible to check the medication carts and the insulin pens for the open dates before giving insulin. He stated the nurse was supposed to label the pen with the open date when first opened. RN A stated the purpose of putting an open date was for expiration purposes because the insulin was only good for 28 days. He stated after 28 days the insulin would be ineffective. 2- Record review and observation on 08/19/25 at 9:27 AM of the 200 Hall Nurses Cart, with LVN I revealed: The pen of insulin Lantus 100 unit/ml for Resident #67 with no open date. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use. Interview on 08/19/25 at 9:45 AM, LVN I stated nurses were responsible to check the medication carts and the insulin pens for the open dates before giving insulin. She stated the insulin was good for 28 days only after opened, after 28 days the insulin should be discarded because its effectiveness decreased. Interview on 08/20/25 at 3:42 PM, the DON stated the insulin flex pens and vials, once opened, needed to be dated because each insulin pen and vial had a specific day's shelf life and if not thrown out by that time the insulin could lose its effectiveness. The DON stated the pharmacy consultant checked the carts monthly and he stated he would do random checks of the medication carts for monitoring.Record review of the facility's policy titled Medication Storage, dated January 2024, reflected . Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used.

Based on observations, interviews, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in:1. The facility failed to ensure food items in the facility walk-in refrigerator, walk-in freezer and dry storage were dated or labeled.2. The facility failed to ensure food stored in the freezer were properly closed and sealed to prevent exposure to the air. 3. The facility failed to ensure during lunch service kitchen staff used proper hand hygiene while serving residents' trays on 8/19/25.4. The facility failed to take temperatures of all food being served during lunch service on 8/19/25.5. The facility failed to place serving spoons on a sanitized surface during lunch services on 8/19/25.These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination.Observation of the walk-in refrigerator and an interview with the Dietary Manager on 08/19/2025 at 8:47 am revealed: -a clear plastic sealed gallon-sized bag with 3, 8-ounce globs of thick white substance with no label of contents. The Dietary Manager stated it was cream cheese.-a clear plastic sealed gallon-sized bag with about a 1/4 full of small black 1-centimeter circular items without a label of contents. The Dietary Manager stated they were chocolate chips. She stated everything should have been labeled with what the contents were and should have had a date received and date opened. Observation of the walk-in freezer and an interview with the Dietary Manager on 8/19/25 at 8:57 am revealed: - a 20-lb opened box of beef patties, with about 65 patties left, in plastic bags opened to the air and not sealed. The Dietary Manager stated all food must be sealed and closed appropriately when in the freezer to prevent freezer burn. Observation of the dry goods storage area on 8/19/25 at 9:00 am revealed: -3, 5-lb bags of manufacture sealed plastic bags, filled with about 1 cm beige objects with no label of what the item was.-17 small plastic 2oz cups with lids and a brown liquid substance, not labeled with contents. An interview with the Dietician on 8/19/25 at 10:45 am revealed she had been helping the Dietary Manager because she was new to the position. She stated all items in refrigerator, freezer, and dry storage should be labeled with date received, date opened, and list the name of the item. She stated all food that was opened should be sealed. She stated the box of patties should be sealed and not opened to the air. She stated the 3 bags of beige items were rice crispy cereal and should be labeled when they removed them from their original box. She stated the risk to the residents of not properly labeling the items would be wrong items could be served to residents. The risk to residents of the frozen patties not being sealed appropriately would be freezer burned and poor-quality food. Observation of lunch service on 8/19/25 at 11:54am revealed the Dietary Manager was cooking gravy on the stove. She then poured the gravy in the warming tray. [NAME] M nor Dietary Manager temped the food before serving the gravy to the first resident. Observation of lunch service on 8/19/25 at 12:15 pm revealed two metal serving spoons on the metal counter in front of the warming food. [NAME] M's clothing was rubbing back and forth on the counter where the spoons were placed. [NAME] M grabbed one of the metal spoons on the counter and put it in the pureed meat and proceeded to serve a meal tray. Observation of lunch service on 8/19/25 at 12:40 pm revealed [NAME] M left the serving area with her gloves on and went to the freezer to grab frozen fries. She returned to the serving area with the same gloves and poured the fries from the bag into the fryer. She left the fries frying and took the frozen fries back to the freezer with the same gloves on. When she returned to the serving area, she had removed the gloves, but had not washed her hands. She then put a new set of gloves on and continued to serve food. She removed the fries from the fryer, poured them on to a plate, and handed the plate to the Dietary Manager who served them immediately and did not temp them. Observation of lunch service on 8/19/25 at 12:45 pm revealed the Dietary Manager asked [NAME] M for the oatmeal. [NAME] M got the cooked oatmeal that was already served and being held in a warmer and handed it to the Dietary Manager. The Dietary Manager removed the plastic covering over the oatmeal container, did not temp it, and served it on a tray. Interview with the Dietician on 8/19/25 12:50 pm revealed all food, to include gravy, fries, and oatmeal should have been temped. The Dietician stated the only item that should not need temping was bread. The risk to the resident of not temping all food was food borne illness and potentially undercooked food. The serving spoons were all sanitized and the counter should have been sanitized as well, however, since [NAME] M's clothing was touching the counter and the spoons were on it then there would be a risk for cross contamination. Regarding the observation of [NAME] M not washing hands between glove changes, she stated she corrected her once during the observation and would in-service her again. [NAME] M stated the risk to the residents of in-proper hand hygiene during food service was cross contamination. Interview on 8/20/25 at 10:37 am with the Dietary Manager revealed the expectation for hand washing for kitchen staff was for them to wash their hands after every change of gloves or change of tasks. The risk to the resident of kitchen staff not washing their hands appropriately was residents could have gotten sick due to cross contamination. The Dietary Manager stated kitchen staff was in-serviced monthly on hand hygiene and they in-serviced them yesterday as well. The Dietary Manager stated the expectation for labeling was everything should be labeled and the risk to the resident of not labeling items was they may be served something they could not or should not be eating. The expectation for food temperatures was all food must be temped and there was no exception to that rule. The Dietary Manager stated it was the cook's responsibility to temp all food, but she temped foods at times. The risk to the resident of not temping food was they could be serving raw food and make residents sick. Interview with [NAME] M on 8/21/25 at 10:20 am revealed when an item was opened it needed to be put in a secured bag with a label of what it was, date opened, and the used- by date. [NAME] M stated kitchen staff needed to wash hands all the time. She stated their hands must be washed after gloves were taken off and before gloves were put on. The risk to the resident of improper hand hygiene and improper labeling was possible sickness or cross contamination. [NAME] M stated serving spoons should be taken off the wall and placed directly in the food and not on dirty surfaces. All food needed to be temped, both hot and cold. The risk of not temping the food was staff may not know if the food was fully cooked. [NAME] M stated she had been in-serviced already on hand hygiene. Interview with the Administrator on 8/21/25 at 4:49 pm revealed the expectations on food temperatures was all foods needed to be temped before serving. The Administrator stated the expectation for hand hygiene in the kitchen was once staff stepped away from the serving line to do something else, staff must wash your hands. The Administrator stated dietary staff needed to wash their hands before they put on new gloves and after they removed used gloves. The risk to the residents of not using proper hand hygiene was a break in infection control. The risk to the resident of not taking all temperatures on food before it was served was food might not be held at the right temperature and could be served to the resident. The expectation on labeling was all foods should be labelled with contents, date opened, and date use by. Review of the facility's policy Hot and Cold Food Temperatures revised 2/6/24 reflected: .Procedure: 1. Cooking temperatures must be achieved and maintaining according to recipes and regulations. 2. Hot temperatures will be taken and recorded prior to service to ensure foods are at or above 135.Review of the facility's policy Employee Infection Control revised 4/8/25 reflected .7. Employees will wash their hands before handling food in preparation. 8. Employees will clean and sanitize equipment and work areas after use and when changings tasks.Review of the facility's policy Food Storage revised 4/8/25 reflected .Storeroom.airtight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened.Refrigerator.all foods are covered, labeled and dated.Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 6 residents (Residents #66, #38) reviewed for care plans.1. The facility failed to develop the following comprehensive person-centered care plans for Resident #66: playing music calmed her her representative preferred her nightstand lamp to stay on at night the need for bilateral (left and right) palm guards due to hand contractures.2. The facility failed to develop a comprehensive person-center care plan that reflected Resident #38 preferred to have her medication placed in her hand, one at a time, during medication administration due to being legally blind. These deficient practices could place residents at risk of not receiving the necessary care or services.Findings included:1. Record review of Resident #66 Quarterly MDS assessment, dated 07/20/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Alzheimer's Disease (loss of cognition), anxiety (feelings of intense worry), and depression (feelings of sadness/loss of interest). Review of Section N- Medications- N0415. High-Risk Drug Classes- reflected she was taking antipsychotic, antianxiety, and an antidepressant. N0450. Antipsychotic Medication Review reflected the resident received antipsychotic medications on a routine basis and a gradual dose reduction (GDR) had not been attempted, the physician had not documented the GDR as clinical contraindicated. Review of Section O- Special Treatments, Procedures, and Programs reflected there were no days of restorative programs performed for a splint or brace assistance.Record review of Resident #66's care plan, printed 08/19/25, reflected she was a fall risk related to contractures and paralysis with an onset date of 10/07/24, and reviewed and continued 05/06/25. Interventions included anticipate resident's needs, check frequently, low bed, and therapy referral. Review of the care plan revealed no documentation that playing music calmed Resident #66. Review revealed no documentation that Resident #66's representative preferred Resident #66's nightstand lamp to stay on at night. Review of the care plan revealed no documentation that Resident #66 required bilateral (left and right) palm guards due to hand contractures.Record review of Resident #66's Kardex, printed 08/19/25, reflected blank spaces for what the resident enjoyed to do, what made life meaningful to the resident, and contracture devices. Record review of Resident #66's physician orders, printed 08/21/25, reflected no orders for palm guards or contracture devices.In an observation on 08/19/25 at 10:19 AM of Resident #66, she was asleep in bed on the lowest position with music playing from a music player on her nightstand next to her bed wearing a palm guard to her left hand. There was a sign on the wall that reflected: Music calms her-helps if she is yelling turn CD player on and a sign on the lamp on her nightstand that reflected: please leave light on at night, thank you. In an interview on 08/19/25 at 1:23 PM with Resident #66's representative, she stated she had put up the signs to ensure staff were aware of what helped Resident #66 to be calmer and the staff were good about following the interventions. She stated she participated in care plan meetings. She stated she was not sure if it was something they discussed during the care plan meetings. She stated she frequently visited Resident #66 and saw that staff were aware of the Resident's needs.An observation on 08/20/25 at 12:05 PM revealed Resident #66 was lying in bed and mumbling incoherently and was wearing a palm guard to her left hand. An interview on 08/20/25 at 12:10 PM with MA J revealed Resident #66 was not able to communicate coherently and sometimes yelled out in agitation. MA J stated Resident #66 was calmed when they played music that was on her nightstand, and she was aware because of the signs posted in Resident #66 room by the representative. She stated she was not sure if Resident #66's music and lamp light staying on at night, or palm guard were care planned. She stated she knew of Resident #66's interventions because of the signs in her room. She stated staff were informed during change of shift of residents needs and she was able to see the Kardex and Medication Administration Record (MAR).An interview on 08/21/25 at 9:09 AM with CNA H revealed Resident #66 had on a palm guard to her left hand and none on her right hand. Observation of Resident #66's right and left hands with CNA H revealed her nails were trimmed with no jagged areas and the skin of her palms had no injuries. CNA H stated that the CNAs only had access to the Kardex and if there were resident preferences, CNAs were informed by nursing management or during change of shift and could find information in the Kardex. She stated she was aware that music helped Resident #66 calm down because other staff told her and she followed the signs the representative had placed in Resident #66's room. In an interview on 08/21/25 at 9:16 AM with CNA K, she stated she was the restorative aide for the facility. She stated Resident #66 was not currently on restorative services and had a hand brace due to a contracture.In an interview on 08/21/25 at 9:28 AM with the Director of Rehabilitation Services revealed Resident #66 had been assessed upon admission and quarterly. She stated Resident #66 was not currently on therapy services. She stated that she did not see any orders for a palm guard and the resident was on their contracture log which noted she had bilateral palm guards. She stated with the facility transferring to a new electronic health record, she was not sure if Resident #66 had an order for the bilateral palm guards. In an interview on 08/21/25 at 9:35 AM with LVN I, she stated Resident #66 was typically in bed, and Resident #66's Representative had brought the music player and told staff that it helped to relax Resident #66 and it really helped Resident #66. She stated she was not sure if the intervention of playing music for Resident #66 was care planned and thought it would be helpful because if a new staff member came to care for Resident #66, they would know what helped the resident. In an interview on 08/21/2025 at 2:57 PM, ADON L stated Resident #66 was nonverbal, mumbled incoherently, and occasionally yelled out. She stated the signs that indicated music calmed Resident #66 and to leave the nightstand light on at night should be care planned. She stated the care plan informed staff of residents' needs and preferences. She stated she wasn't aware until today about Resident #66's need for palm guards and stated it was important to care plan her need so that everyone was aware for her to have it on to prevent injuries of her palm from her nails. In an interview on 08/21/25 at 12:38 PM with the DON, he stated that Resident #66's need for palm guards, keeping the bedside lamp light on a night, and music that calmed her, should be care planned and he was not aware that it was not care planned. He stated that the MDS Coordinator was responsible for updating care plans and they were reviewed in morning meetings, quarterly, or upon change of condition. He stated the facility had switched to a new electronic medical record system and they were going to continue to audit care plans. He stated it was important for care plans to reflect a resident's needs and preferences, so they were honored by staff. In an interview on 08/21/25 at 2:35 PM with the MDS Coordinator, she stated she was responsible for updating care plans during morning meetings, upon a change of condition, or quarterly. She stated she was not aware of the signs in Resident #66's room that stated music was calming or about the lamp light staying on at night. She stated it would be something that should be care planned because it helped staff know what helped the resident. She stated the resident requiring palm guards should also be something that was care planned and she was not aware until now and if it was not care planned then staff might not know that the resident needed to wear a palm guard. She stated it was important that care plans reflected a resident's preferences to ensure their preferences were honored and was going to update Resident #66's care plan. 2. Record review of Resident # 38's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses of stroke, kidney failure, and hypertension (high blood pressure), severely impaired vision, and intact cognition. Record review of Resident #38's care plan, printed 08/21/25, reflected she had a visual impairment due to being legally blind and interventions included keep furniture in same place, keep most frequently used items in a consistent area within reach, dated 01/13/25. The interventions did not reference any preferences for medication administration. Further review reflected Resident #38 resisted care as manifested by: refusing medications after medication aide gives them to her and telling her which medication is which and it happens only during the morning med pass. with a goal to have less than 3 episodes per week, dated 08/14/25. Review revealed no documentation that Resident #38 preferred to have her medication placed in her hand, one at a time, during medication administration due to being legally blind. Interventions included administer medications as ordered, approach calmly, explain why procedures and care are needed before provided, and allow highest level of independence when making choices regarding care.In an interview on 08/19/25 at 11:00 AM with Resident #38, she stated that she was legally blind and during medication passes she preferred staff to tell her what the medication was and hand it to her in her hand so she could feel the pill because it reassured her. She stated she knew what her medications felt like and could make out some colors. She stated that she was not sure if it had been mentioned in care plan meetings and usually staff administered her medications to her by her preference except for a recent interaction with a new medication aide which the facility was responsive in addressing and informed her that the aide would no longer pass her medications, and the nurse was going to pass her medications. In an interview on 08/20/25 at 12:10 PM with MA J, she stated that she had passed medication to Resident #38 when she first started working at the facility and when she put them in a cup and handed them to Resident #38 she would not take them and requested to be informed of which pill she was being handed and it be placed in the palm of her hand so she could feel it. She stated she knew now that Resident #38 preferred medication administration a certain way because she was legally blind and knew the shape and color of the medications she took. She stated she was not aware if it was care planned and would typically look at the Kardex or was informed by nursing staff about resident preferences. In an interview on 08/21/25 at 9:35 AM with LVN I, she stated that Resident #38 was blind and during medication passes she wanted staff to tell her what the medication was and placed in the palm of her hand so she could feel the medication shape and sometimes could make out colors. LVN I stated she was not sure if that was care planned. She stated it would be important to care plan Resident #38's preference for medication pass to ensure her preferences were honored. In an interview on 08/21/25 at 9:18 AM with RN A, he stated Resident #38 was legally blind and during medication passes she wanted staff to tell her what each medication was, one at a time, then placed in her hand so she could feel the shape of the medication. He stated that if he was passing medications to her, he took her to wash her hands then proceeded to give her medications using her preferred method. He stated she requested medications be given in this way every time he passed medications to her. He stated he was not sure if it was care planned and stated it would be important to care plan to ensure all staff knew of the resident's preferences. In an interview on 08/21/25 at 12:38 PM with the DON he stated he was aware Resident #38 was legally blind and had heard the team speak about her preference for medication administration by placing the medications in the palm of her hand. He stated Resident #38's preference for medication administration should have been care planned to ensure her preferences were honored by staff and that staff were aware. In an interview on 08/21/25 at 2:35 PM with the MDS Coordinator, she stated she was aware that Resident #38 preferred the nurse to put the medications in the palm of her hand and she had updated the care plan after a medication aide had attempted to give Resident #38 her medication in a cup and Resident #38 refused her medications. She reviewed Resident #38's care plan and stated she could see how the updated care plan on 08/14/25 could've been made to seem more like a behavioral concern of refusing medications rather than a preference due to the resident being legally blind and wanting the medication in her palm so she could feel the medication. She stated person-centered care plans were important to ensure residents received their plan of care. In an interview on 08/21/2025 at 2:57 PM with ADON L, she stated Resident #38 was legally blind and during medication administration she liked to have the pills placed in the palm of her hand because it reassured Resident #38 because she knew what the pills felt like and could make out some colors. ADON L stated she was not sure if Resident #38's care plan was updated to reflect her preference and the MDS Coordinator was responsible for updating resident care plans. ADON L stated it was important to care plan Resident #38's medication administration preference so that other people were aware of her residents preferences and if a new staff member was going to work with the resident, they would be able to look at it and learn the resident too.In an interview on 08/21/25 at 4:43 PM with the Administrator, he stated that it was important to ensure a resident's care plan was as personalized as possible and would have expected Resident #66 and Resident #38's preferences to be care planned. He stated it was important for care plans to personalized so residents received the care they needed. The Administrator stated the MDS Coordinator was responsible for updating resident care plans and they were reviewed and updated upon change of condition, admission, and quarterly. Record review of the facility's care plan policy, titled Care Planning and dated revised 10/24/22 reflected: .To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs . Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #56) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #56 had his fingernails cleaned and trimmed on 8/19/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Record review of Resident #56's Quarterly MDS assessment dated [DATE] reflected Resident #56 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident (a condition that occurs when blood flow to the brain is blocked. The blockage can lead to brain tissue death.), and elevated blood pressure. Resident #56's BIMS score of 14, indicated Resident #56' cognition was intact. The MDS assessment indicated Resident #56 required maximal assistance with bathing. Record review of Resident #56's Care Plan revised 07/02/25, reflected the following: Care area: Self-care deficit . Goal: [Resident #56] will accept assistance with area of dressing, grooming hygiene and bathing over the next 90 days . Interventions: . provide assistance with self-care as needed. In an observation and interview on 08/19/25 at 10:24 AM revealed Resident #56 was lying in his bed. The nails on both his hands were approximately 0.3cm in length extending from the tip of his fingers. The nails were discolored tan and had brownish colored residue on the underside. Resident #56 stated he did not like his nails long and dirty and he did not tell staff because they were busy. In an interview on 08/19/25 at 2:08 PM, LVN I stated CNAs and nurses were responsible to clean and cut the residents' nails. LVN I stated she did not notice Resident #56's nails. She stated she would do it right then. She stated the risk would be infection control and injury. In an Interview on 08/20/25 at 3:42 PM, the DON stated nail care should be completed as needed and every time aides washed the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated he expected CNAs and nurses to offer to cut and clean nails if they were long and dirty. The DON stated the ADONs would do the routine rounds to monitor. The DON stated residents having long and dirty nails could be an infection control issue and skin break down if scratching. Record review of the facility's policy ADLs/Bathing revised February 2020, did not address the concern of fingernails care.

Based on interviews and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section for 1 of 5 residents (Resident #3) reviewed for unnecessary medications.1.The facility failed to have an adequate indication for the use of the medication Quetiapine Fumarate (Seroquel - an antipsychotic) for Resident #3. 2. The facility failed to monitor behaviors and side effects of Quetiapine Fumarate (an antipsychotic) for Resident #3. The failures could place residents at risk of increased behaviors, negative outcomes, adverse reactions and even a decline in health.Record review of Resident #3's admission MDS Assessment, dated 7/31/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had a diagnoses of anxiety disorder. The resident's BIMS score was 11, indicating moderately impaired cognition. Section E reflected none of the above for potential indicators of psychosis and no behavioral symptoms. Section N reflected Resident #3 was admitted with Antipsychotic Medication with indication noted. Review of Resident #3's Admit Baseline Care Plan dated 7/28/25, reflected the resident had no psychotropic therapy. Record review of Resident #3 Physician's Orders dated 7/28/25 reflected Quetiapine Fumarate 50mg tablet (QUEtiapine Fumarate) for G47.00 Insomnia, unspecified ([Start 7/28/25 18:34] 1 tablet by mouth at Bedtime). No order for behavior monitoring or side effect monitoring was found. Record review of Resident #3's Medication Record for 8/1/25 - 8/31/25 reflected administration of Quetiapine Fumarate as ordered each day. The record did not include documented evidence the facility was monitoring for side-effects related to the use of the Quetiapine Fumarate or monitoring the resident's behaviors for signs of psychosis. Record review of progress notes for Resident #3 dated 7/28/25 to 8/21/25 did not reveal any documented behavioral or psychotic issues. Interview with LVN B on 8/20/25 at 1:53pm revealed Resident #3 had no significant behavioral issues and no major incidents since admittance to the facility. She stated Resident #3 was receiving psychiatric services for anxiety and was receiving Quetiapine Fumarate for depression. She stated there was no order to monitor his behaviors, but she monitored his behaviors due to his medications. She stated the nurses were supposed to chart how many episodes a resident had each shift, and it should have been documented in the MAR. She stated she was not currently charting any behaviors because she was learning the facility's new electronic record system. She stated the risk of not monitoring behaviors could lead to other problems such as over treatment and increased psychiatric symptoms. She stated if Resident #3 was having behaviors she would report to the ADON, DON and Administrator. She stated she could also reach out to the doctors immediately if residents had acute needs. She stated the last time she was in-serviced on monitoring behaviors was about 2 weeks ago. Interview with ADON F on 8/20/25 at 2:50pm revealed Resident #3 was being prescribed Seroquel (Quetiapine Fumarate) for mood and bipolar disorder. When questioned about the physician's order stating it was for Insomnia, she stated Resident #3 came from the hospital with that medication. ADON F stated insomnia was not an appropriate diagnosis for the use of Seroquel and stated the corrected diagnosis needed to be entered on the orders. ADON F stated there should have also been an order monitoring the resident's behaviors and side effects related to the psychotropic medications. Behaviors and side effects should have been monitored every shift and documented on the MAR. The risk of not documenting an adverse reaction to the medication would be the doctor would not have gotten a clear picture of how the resident was doing and therefore couldn't take the appropriate actions. Behavior monitoring was important to make sure patients were safe. If behaviors were not documented, then it puts the resident at risk of being over or under medicated . Interview with the DON on 8/20/25 at 3:12pm revealed antipsychotic medications were verified with the doctor upon a resident's admission. If a resident was admitted with psychotropic medication, they would ask the social worker to make a referral for psychiatric services. If the hospital discharged a resident with a psychotropic medication and the order stated it was for insomnia, they should have spoken to the doctor about it because insomnia was not an appropriate diagnosis for psychotropic medication. The facility should have an order for monitoring behaviors and monitoring side effects when the residents were taking anti-psychotic medications, regardless of the medical diagnosis used to prescribe it. The monitoring of behaviors would help to monitor the resident's medication and the need for it. The risk of not having an order to monitor the behaviors and side effects would be dependent on the skills set of the nurse, and whether they knew what behaviors and side effects to look for with residents on anti-psychotic medications . Interview with ADON G on 8/20/25 at 3:54pm revealed all psychotropic medications prescribed should have an appropriate diagnosis for the use of the medication. Insomnia would not be an appropriate diagnosis for an anti-psychotic medication like Seroquel. The facility should also have an order for behavior monitoring and monitoring of adverse reactions and it should be documented in the TARs and MARs. The risk to the resident of not having had an appropriate diagnosis for antipsychotic medication was the resident may have no longer needed the medication. The risk to the resident of not having an order for side effects or behaviors was the doctor wouldn't know if the medication was effective. Review of the facility's policy Psychotropic Drugs - Use reflected Purpose: 1. The community will use psychotropic drug therapy when appropriate to enhance the qualify of life, while maximizing functional potential and well being of the patient/resident. 2. Qualified staff will monitor the patient/resident for potential undesirable side effects that are associated with the use of psychotropic drugs according to CMS, State specific rules and regulation and Practice Guidelines.Standard of Practice:.B. Antipsychotics: Only appropriate for the following acceptable diagnosis(es):*Schizophrenia *Huntington's disease *Tourette's syndrome. Antipsychotic drugs are not used if one or more of the following is/are the ONLY indication:.7. Insomnia.Note: Careful evaluation of the residents' records should be reviewed for appropriate diagnosis for medication use.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #41) of two residents reviewed for incontinence care. The facility failed to ensure CNA P provided appropriate perineal care for Resident #41 after an incontinent episode when she failed to clean the resident's labia on 08/19/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections. Record review of Resident #41's Quarterly MDS assessment dated [DATE] reflected Resident #41 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), and elevated blood pressure. Resident #41's BIMS score of 03, indicated Resident #41's cognition was severely impaired. The MDS assessment indicated Resident #41 was frequently incontinent of bowel and bladder. Record review of Resident #41's Care Plan reviewed 07/14/25, reflected the following: Problem: At risk for problems with elimination. Goal: Resident's elimination status will be maintained or improved over the next 90 days. Interventions: . provide incontinent care after each incontinent episode .In an observation on 08/19/25 at 2:56 PM revealed CNA P entered Resident #41's room to provide incontinence care. CNA C washed her hands and put on gloves and unfastened the brief to reveal the resident had been incontinent of urine. CNA P pushed the soiled brief down between the resident's legs, toward her buttocks and cleaned her peri area (the area of skin between the anus and the external genitalia) from the front to back but did not separate the labia and clean down the middle. CNA C rolled the resident onto her side revealing the resident had soaked through her brief. CNA C continued to provide incontinence care, wiping the resident's buttocks from back to front and reapplied a clean brief. She removed her gloves and washed her hands. An interview with CNA P on 08/19/25 at 3:02 PM revealed she failed to separate the resident's labia, and she wiped the resident's buttocks from back to front and by providing inappropriate incontinent care that could lead to an infection. She stated she had been in training and knew the importance of properly cleaning a resident. In an interview on 08/20/25 at 03:42 PM, the DON stated when providing incontinent care, staff were to clean the peri area including the labia for female residents, then moving toward the buttocks and always clean from the front to back. He stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. He stated he would monitor by doing skills check on all CNAs periodically. Record review of the facility's policy titled, Perineal Care/Incontinent Care, dated April 2012, reflected, .For female patient/resident: Separate the labia and wash downward (down the center of labia), then downward on each side of the labia using a different per wipe with each stroke.Clean outer hip of buttocks going upwards towards back .

Based on observations, interview and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 6 (Resident #66) reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #66's contracture to her left hand on 04/22/25. The facility failed to ensure physician orders were written for bilateral ( left and right) palm guards for Resident #66 on admission on [DATE].This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record review of Resident #66 Quarterly MDS assessment, dated 07/20/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Alzheimer's Disease (loss of cognition), anxiety (feelings of intense worry), and depression (feelings of sadness/loss of interest). Review of Section O- Special Treatments, Procedures, and Programs reflected there were no days of restorative programs performed for a splint or brace assistance.Record review of Resident #66's care plan, printed 08/19/25, reflected she was a fall risk related to contractures and paralysis dated onset of 10/07/24, and reviewed and continued 05/06/25. Interventions included anticipate resident's needs, check frequently, low bed, and therapy referral. Record review of Resident #66's Kardex, printed 08/19/25, reflected blank spaces for what the resident enjoyed doing, what made life meaningful to the resident, and contracture devices. Record review of Resident #66's current physician orders did not indicate an order for a palm hand guard. Record review of Resident #66's Kardex, printed 08/19/25, reflected a section for contracture devices was blank. Record review of Resident #66's admission record, dated 10/07/24, active order summary reflected an order for palm protector to left hand with an order start date of 10/21/21. Further review revealed page noting the Resident Representative's notes for Resident #66's care that included Fussy Behavior: If she shouts out, she is usually in pain or anxiety.Nighttime: Blue brace on left arm comes off and is replaced with smaller white brace. This is so she doesn't cut her hands with her fingernails. [NAME] brace can stay on right hand. (can come off for a few hours if it bothers her). Morning: Put blue brace back on. [NAME] brace can stay on right hand.Record review of Resident #66's treatment administration record for the month of August 2025 did not reflect a palm guard. Record review of the facility's contracture log reflected Resident #66 had a contracture to her left and right elbows flexion (bent) and her left and right hands and was on staff management. Resident #66 was last treated on 10/31/25 for physical and occupational therapy and was previously screened on 07/18/25. Resident #66 had bilateral (left and right) palm guards. Record review of Resident #66's therapy screening, dated 07/18/25, reflected she had contractures to both elbows in flexion (bent) and both hands. Further review reflected palm guards for [bilateral] hand contractures are managed by nursing staff, pt has had no functional changes and no skilled PT/OT/ST services are warranted at this time. with recommendations to continue current interventions. In an interview on 08/21/25 at 12:38 PM with the DON, he stated that Resident #66 had been assessed by the therapy department upon admission and most recently on 07/18/25 where the recommendation was to continue bilateral palm guards for her hand contractures. An interview and observation on 08/21/25 at 9:09 AM with CNA H revealed Resident #66 had on a palm guard to her left hand and none on her right hand. Observation of Resident #66's right and left hands with CNA H revealed her nails were trimmed with no jagged areas and the skin of her palms had no injuries. CNA H stated that the CNAs only had access to the Kardex and if there were resident preferences, CNAs were informed by nursing management or during change of shift and could find information in the Kardex. She stated she was aware that music helped Resident #66 calm down because other staff told her and she followed the signs the representative had placed in Resident #66's room. In an interview on 08/21/25 at 9:16 AM with CNA K, she stated she was the restorative aide for the facility. She stated Resident #66 was not currently on restorative services and had a hand brace due to a contracture.In an interview on 08/21/25 at 9:28 AM with the Director of Rehabilitation Services revealed Resident #66 had been assessed upon admission and quarterly. She stated Resident #66 was not currently on therapy services. She stated that she did not see any orders for a palm guard and the resident was on their contracture log which noted she had bilateral palm guards. She stated with the facility transferring to a new electronic health record, she was not sure if Resident #66 had an order for the bilateral palm guards. In an interview on 08/21/25 at 9:35 AM with LVN I, she stated Resident #66 was typically in bed and she had a contracture to one hand and wore a palm guard. She reviewed the contracture log and stated she was not aware that the resident had bilateral contractures and palm guards to both hands and was only aware of one hand having the palm guard. She stated she would have expected there to be an order for the palm guards so it would show up in the treatment administration record. She stated she was not sure if there was a physician order for the palm guards and stated that it was important to ensure the resident wore the palm guards and if there was no order then no one would know that the resident wore palm guards. In an interview on 08/21/25 at 1:24 PM with the Medical Director revealed he was Resident #66's physician for many years before she admitted to the facility in October of 2024. The Medical Director stated he was not aware that there was no order for bilateral palm guards for Resident #66 and he was not sure why they did not transfer over from her admission in October, 2024. He stated there should be a physician order, and he visited the facility multiple days per week and signed orders in batches. He stated it was important to ensure there was a physician order for palm guards so the treatment was provided to the resident. In an interview on 08/21/2025 at 2:57 PM ADON L, she stated she wasn't aware until today about Resident #66's need for palm guards and did not know there was not an order for the palm guards. ADON L stated it there should be a physician order or physical therapy order was important to have for Resident #66 to ensure that palm guards had been evaluated by the physician or physical therapy and ensure it was followed by staff to prevent injuries of her palm from her nails.Record review of the facility's policy on admitting residents titled Admitting a Resident, dated reviewed April 23, 2024, reflected: Nursing staff will admit the resident to the community in accordance with applicable law and regulation, as well as helping the resident with adjustment to his/her new surroundings and initiating the appropriate assessments and the Plan of Care.The licensed nurse reviews transfer papers that accompany the resident.Record review of the facility's policy on rehabilitation services titled Clinical Policies and Procedures: Subject: Resident Screening Form, dated revised 01/01/2025, reflected: The screening process will provide a means of providing rehabilitation information into the care plan process for newly admitted patients, referrals, and established patients on a quarterly basis, as well as to indicate the need for an evaluation and aid in determining the patient's ability to participate in a skilled rehabilitation program. Review the following examples of the type of medication conditions and changes which should be monitored for appropriate therapy referrals (this list is not all inclusive). progressive joint contractures.review the following documentation during the screening process: . admission sheet, physician notes or history and physical.physician order sheet.patient care plan.Record review of the facility's policy on physician orders titled Physician Orders-Electronic, dated reviewed November 27, 2023, reflected: Policy:1. The licensed nurse will receive and transcribe the physician's orders according to the Practice Guidelines. 2. The licensed nursing staff will provide resident with medications and treatments as ordered by his/her physician.Procedure.2.The licensed nurse clarifies and reconciles all orders that may lead to an administration error. 3. The electronically entered order will be automatically transcribed onto the Medication admission Record (MAR) or Treatment Record.

Based on interviews and record review, the facility failed to protect the resident's right to be free from abuse for one (Resident #1) of 10 residents reviewed for abuse. CNA A, who was assigned to Resident #1 for the night shift from 12/31/23 to 1/1/24 failed to provide care or check on Resident #1 during the entire shift from 10:00 PM 12/31/2023 - 6 AM 1/1/2024 and CNA B who failed to provide care on her shift from 6 AM 1/1/2024 to 10:22 AM 1/1/24. As a result, Resident #1 was not provided incontinent care or repositioned for over 13 hours on 12/31/23 9:05 PM to 01/01/24 at 10:22 AM. These failures could affect the residents by placing them at deprivation of goods abuse, risk for a delay in ADL care including incontinent care and life-saving treatments, which could result in psychosocial harm. Findings included: Review of Resident #1's Admission MDS assessment dated [DATE] revealed he was [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Critical illness myopathy (significant slowing of the muscle fiber) , hypertension, pneumonia, Diabetes mellitus, aphasia (loss of ability to understand or express speech, caused by brain damage) , Cerebrovascular Attack , Respiratory Failure, Dysphagia (difficult swallowing) , G-tube feeding dependent (G-tube is a tube inserted through the belly that brings nutrition directly to the stomach). Resident #1 required extensive assistance of at least two people with Activities of Daily Living. He was totally dependent with transfers and bathing. It revealed that Resident#1 was always incontinent of urine and bowel. MDS assessment revealed BIMS of 99 indicating resident had severe cognitive impairment. Review of Resident #1's physician order dated 12/20/23 revealed Resident #1 was on Furosemide 20 mg tablet 1 tablet by mouth per day which was prescribed for DX of primary hypertension (high blood pressure). ( Furosemide is a diuretic will make a resident urinate more often to remove the body of excess fluid/fluid retention). Review of Resident #1's physician order dated 12/23023 revealed Resident #1 was on Nystatin 100,000 unit/gram topical cream 2 times per day for rash on the peri area. Review of Resident # 1 ADL Documentation on EHR for 12/31/23- 1/1/24 revealed incontinent care documented at 9 PM on 12/31/23 and 10 am on 1/1/24. There was no documentation of incontinent care on the ADL in the electronic health record or paper documentation. Review of Resident #1 Admission Care Plan dated 12/9/2023 revealed Resident #1 was on Diuretic therapy , Furosemide 20 mg tablet 1 tablet 1 time per day; Resident will have decrease in edema during drug therapy. Review of Resident #1 Nurses note on the EHR revealed that there was no documentation for 12/31/23. Record Review of LVN D Nurse's progress noted dated 1/1/24 charted on 12:32 PM on 1/1/24 revealed Resident #1 Family Member A came to nurse station upset and yelling that Resident #1 was not changed overnight. This nurse informed Family Member A that his shift started at 0600 and was unsure who worked last night. Family Member A stated that nobody was on camera and wanted to talk to manager. Told resident to go to front and speak to secretary. Resident also stated she saw this nurse give meds and asked for Resident #1 to be pulled up. Resident is a TWO PERSON ASSIST with everything per family request. This LVN C could not find CNA at the time and continued with my med pass and blood glucose checks. Resident is clean and dry. Resting comfortably in bed with call light within reach. Observation on 1/3/24 at 2:18 PM of Resident #1 room revealed resident had Blink camera in the room that detects any motion close to the resident in the room. Observed Resident #1 was lying in the bed and covered with sheets. Resident #1 looked groomed, and no odors noted. Also observed tube feeding pump next to the bed and infusing tube feed formula. Observed call light within reach. Interview with Resident #1 attempted on 1/3/24 at 2:20 PM revealed resident is not verbal and cannot respond as stated by the resident's #1 Family Member A that was present in the room. Interview with Resident#1's Family Member A and Family Member B on 1/3/24 at 2:18 PM revealed that she was very concerned that Resident#1 was not changed during the night shift of 12/31/23. Resident# 1 admitted to the facility on [DATE]. She stated when she came to the facility around 11 am on 1/1/24, she noted that Resident#1's side support pillow and other pillow was placed on the chair in the room and was soaking wet and smelled of urine. She picked up the pillow from the chair and saw the chair was wet from the pillow. She then called Resident#1 Family Member B to check if she could review the camera to see when Resident#1 was last changed. Family Member A also stated that per camera placed in the room revealed Resident#1 was not changed or repositioned from 12/31/23 at 9:05 PM until 1/4/24 at 10:20 AM. She also stated that she had requested LVN D to reposition resident#1 around 7 am on 1/1/24 through the camera. She then stated that she went to LVN D who told her he started his shift at 6 AM on 1/1/24 and did not know which nursing staff was assigned for Resident #1 that worked on night shift of 10 am -6 AM on 12/31/23. Family Member A asked LVN D if he received shift report in the morning for Resident# 1's care and which nursing staff provided the report. Per Family Member A , LVN D refused to talk to the Family Member A and directed her to the front office. She stated that she was not able to find any Administrator nursing staff and was told ADON B had left for the day. Family Member A also revealed that she had complained to the DON regarding her concerns with Resident# 1 ADL care earlier on 12/18/23 and approached the DON that Resident#1 needed two people assist on all ADL's, including incontinent care. She also stated that on the night shift on 12/17-12/18/23 CNA A was changing and repositioning the resident by herself incorrectly when resident's Family Member B intervened from the camera and had to come to the facility at midnight to make sure that Resident #1 was okay. She stated that resident's Family Member B spoke with Charge Nurse LVN I on 12/18/23, who stated that she will have another CNA care for the resident for that night. She also stated that Resident#1's Family Member B spoke with the DON on 12/21/23 regarding needing two people assist on all ADL care including incontinent care and repositioning. Family Member B also stated that she had told the Nurse that Resident #1 had a diaper rash and they started ointment on it couple of days back. She stated the DON reported it was not the facility policy to turn the resident every 2 hours, but the DON and Family Member A agreed on checking on the resident every four hours. Family Member A reported that Resident #1's room was fitted with a Blink Mini indoor plug-In HD Smart security motor detection camera and will detect any motion that will take place around the resident. It will not show any activity on the camera if there is no motion around the resident. Review of Resident #1's electronic monitoring video along with Family Member A date and time stamped on 12/31/23/20 at 9:05 PM revealed 2 staff members providing incontinent care and repositioning Resident # 1. Review of Resident #1's electronic monitoring video along with Family Member A date and time stamped on 12/31/23/20 at 10:43-10:45 PM revealed LVN C changed the tube feeding bag and worked on the tube feed pump setting. Review of Resident #1's electronic monitoring video along with Family Member A revealed no motion detection from 12/31/23 at 10:45 PM to 1/1/24 6:47 AM. Review of Resident #1's electronic monitoring video along with Family Member A date and time stamped on 1/1/24 at 6:47 AM revealed LVN D walking into the Resident #1 room and briefly lifted Resident #1 sheets to check for possible incontinence. Review of Resident #1's electronic monitoring video along with Family Member A date and time stamped on 1/1/24 at 7:01 AM to 7:03 AM revealed that LVN D providing G-tube medications and checking blood sugar levels. LVN D did not reposition or provide incontinent care to Resident #1 between 7:01 am - 7:03 am. Review of Resident #1's electronic monitoring video along with Family Member A date and time stamped on 1/1/24 at 8:30 AM revealed LVN D resetting the tube feeding pump. LVN D did not reposition or provide incontinent care to Resident #1 at 8:30 am Review of Resident #1's electronic monitoring video along with Family Member A date and time stamped on 1/1/24 at 10:22 AM revealed that CNA B and Staffing Coordinator changed the resident. Resident# 1's Family Member A was unable to provide actual video recording as a continuous stream of events from 9:05 PM 12/31/23 -10:20 AM on 1/1/24 due to technical difficulties. Interview with LVN D on 1/4/24 at 2:36 PM revealed that he had started working in the facility around November 2023, he reported he was the LVN who was taking care of Resident #1 on 1/1/24 morning shift from 6 AM-2 PM. He reported that he checked on Resident #1 around 7am on 1/1/24 and administered his G-tube (medications and checked Resident#1's blood glucose). He also reported that he briefly lifted Resident#1 sheets and it appeared that Resident #1 brief was dry. He stated that he did not physically check on Resident#1 for incontinence. He also stated that Family Member A talked to him from the camera around 7 am on 1/1/24 when he was providing G-tube care to the resident and asked him to reposition Resident#1. He reported that since Resident#1 was 2-person assist, LVN D went to look for CNA and could not find the CNA, so he continued with his med pass and blood glucose checks to other residents in the hall. LVN D reported he did not reposition Resident #1. LVN D also stated that the Staffing Coordinator and CNA B provided incontinent care and repositioning around 10 am on 1/1/24. He also reported that Resident#1's Family Member A came to him at the nurse's station around 11am on 1/1/24 stating that Resident #1 was not changed on the night shift of 12/31/23 and asked for nursing staff that took care of the resident the previous night. LVN D redirected Family Member A to the front office. He reported that Family Member A came to him again after some time (around noon) asking to put Nystatin ointment on resident's peri-area by herself. LVN D informed Family Member A that since the ointment is a prescribed medication, it will need to be applied by a nursing staff. LVN D stated he did not feel comfortable entering the resident's room by himself and hence he, along with Staffing Coordinator entered the Resident's room and applied Nystatin ointment for Resident#1. LVN D reported that Nystatin was applied to resident's peri care area between 12:15 PM - 12:30 PM on 1/1/24. LVN D reported that Nystatin was started on Resident #1 on 12/30/23 for diaper rash and it was usually used for fungal infection or skin irritation that can be caused if area was wet for a long time. LVN D stated that he did not report the allegation from the Family Member A that the resident was not changed over several hours of night shift to anyone. LVN D reported when he started at the facility about a month ago, he was provided with several in services that included abuse and neglect as well. He defined neglect as resident not being provided the needed care and services by the facility. He stated he knew to report any allegation of abuse and neglect to the Abuse Coordinator immediately. He stated that if the allegation from the Family Member A was true that the resident indeed did not receive incontinent or ADL care during the night shift, it looked like neglect to him, and he should have reported it then. Interview with CNA E on 1/3/24 at 2:42 PM revealed that she worked in the facility for last 8-9 months. She stated that she did not work on the night shift from 10PM to 6 AM on 12/31/23 in the facility and She usually worked the 2PM -10 PM shift. She had taken care of Resident #1 in the past and was aware with Resident #1 care needs. She reported that Resident #1 needed two-person assist with all ADL care and she always took help from the Nurse or CNA from other halls for changing or repositioning the resident. She reported that she was not aware of rounding policy for the facility, but she rounded on her residents at least every two hours. She also reported that resident#1 has Nystatin cream for diaper rash that was always applied by Nursing staff when they change the resident. CNA E also reported that he was provided abuse and neglect in services in the past and defined neglect as resident not getting the needed goods or services. She also stated that if a resident had not been provided ADL care may result in neglect and should be reported to the administration team immediately. Interview with LVN C on 1/3/24 at 2:50 PM revealed that he worked at the facility for about 2 years. He reported that he worked the night shift 10PM - 6AM on 12/31/23. He reported that he hung a new tube feeding bag and reprogrammed the feeding pump around 10:30-11 PM on 12/31/23, but he did not check resident for incontinent care at that time nor did he repositioned Resident #1 at that time. LVN C also stated that he did not repositioned or provided incontinent care to Resident #1 at all during his shift because he thought the CNA would have provided that care. He also reported that he was the Charge Nurse for the unit on the night of 12/31/23. He reported as a Charge Nurse, he assigned residents to CNA's that they need to take care of during their shift. He reported that Resident #1 was assigned to CNA A along with all other residents on 500, 600, 700 Hall. He reported he became aware of the incident that family alleged that resident was not provided ADL care including incontinent care on the night shift of 12/31/23 when Resident #1's Family Member A approached him during his afternoon shift 2PM- 10 PM on 1/1/24. LVN C also stated that CNA A did not tell him that she will not be caring for Resident#1 anytime during the night shift of 12/31/23 when they worked the halls together. He stated that when he spoke with CNA A around 10 PM on 1/1/24 she told him she assumed he knew that she will not take care of Resident#1 because of some prior concerns that CNA A had with Resident#1's family. He further added that he asked CNA A if she communicated this with him beforehand OR ask for swapping residents so other CNA could take care of the resident OR made nursing administration aware of her dispute or displeasure to work with Resident #1, CNA A replied NO to all his questions. He also stated that since CNA's usually took care of all ADL's, he did not check whether Resident #1 was provided ADL care, including incontinent care. He also stated that Resident #1 was two persons assist and that most CNA's will ask for help from Nurses on the floor or CNAs from other halls. LVN C reported that he had received in-services on abuse and neglect and defined neglect as not providing good and services to the resident. He also said that CNA A not providing care was an example of neglect. He also stated that he was going to report the alleged Neglect to the Abuse Coordinator soon but waited to speak with CNA A about the incident. Interview with ADON B on 1/3/24 at 3:05 PM revealed that she was familiar with Resident#1's care. She stated she spoke with Resident#1's Family Member B during the admission care conference. She had not spoken with the Family Member regarding family's concern for two persons assist for ADL's; however, she was aware of family requesting two-person assist with ADL care from the DON. She stated that she was not aware if DON had filed any grievance report regarding family concern of resident care. She also reported that family approached her about 30 minutes before this interview regarding their allegation of Resident#1 not being provided ADL care included incontinent care during the night shift of 12/31/23. She also stated that no other staff member including Charge nurses, CNA or floor Nurses reported the allegation to her before the Family Member . She reported she will file a grievance report and investigate the incident soon. She also reported that she was the on-call Nurse Manager for night shifts of 12/30/23, 12/31/23 and 1/1/24. She also stated that she had not reported the allegation of potential neglect for not providing care to the resident at the time of this interview and was preparing to send the email to the Abuse Coordinator . ADON B stated that if Family Member A 's allegation of not providing resident with ADL care throughout the night shift was true, that would be an example of neglect since the resident was not provided with service he needed. She also reported that any resident can have rash in peri area if the area was wet for long time. She also stated that Resident#1 cannot reposition himself and her expectation was staff checked on resident every two hours for ADL care. She stated that if ADL care including incontinent care was not provided in a timely manner it can lead to rash, skin breakdown and Resident's dignity and comfort can be compromised. Attempted phone interview with CNA A on 1/3/24 3:16 PM, left voicemail to call back. In a phone interview with CNA A on 1/4/24 9:03 AM she revealed she was aware of Resident#1's care. She stated she worked the night shift 10pm-6am on 12/31/23 and was assigned to the resident#1's care per assignments provided to her by the Charge Nurse, LVN C. She also stated that she did not provide any ADL care including incontinent care or repositioning to Resident #1 on the night shift from 10pm-6am on 12/31/23. She does not know if any other CNA or LVN provided care to the resident that night. She reported that she had a situation with the Family Member s of Resident#1 roughly 2 weeks ago, she does not remember the exact date - but thought it was around 18/19th of December. CNA A stated that the family was rude to her and was not happy with the ADL care she provided to the resident the night of December 18th. She stated the incident was reported to LVN I who was charge Nurse that shift since the family came to the facility at midnight. She reported she failed to communicate with LVN C about her decision to not provide care to Resident#1 on the night shift and further stated that she assumed LVN C was aware of her previous incident with the family and her decision to not care for Resident #1. She also stated that it was her fault for assuming and not communicating with the Charge Nurse regarding her decision to not provide care. She reported that the risk to dependent resident for not providing ADL care, including incontinent care over a period of 8-hour shift, could lead to skin breakdown and diaper rash. She also revealed she has been provided Inservice education regarding abuse and neglect. She defined neglect as not providing service to the resident. She acknowledged that her decision of not providing ADL care to Resident #1 and not communicating her decision to the charge Nurse on the night of 12/31/23 was a form of neglect. She reported that when she worked on the night shift of 1/1/24 at the facility, she had a conversation with LVN C about care not being provided on 12/31/23. She also stated that she continued to work in the facility on 1/1/24 on a different hall and was not assigned to care for Resident #1. In an interview with CNA B on 1/4/24 9:28 AM revealed that she worked the morning shift 6 AM-2PM on 1/1/24 and was assigned to care for residents on three halls that included Resident#1. She reported that when she came to work in the morning, call lights for most residents were on and she was trying her best to take care of the resident needs one by one. It took her some time, after breakfast, around 10 am to go and check on Resident #1. She reported since Resident #1 was a two person assist for ADL's, including incontinent care, she called for help from Staffing Coordinator , who is also an LVN to change the resident. She reported that as soon as she moved the support pillow it was soaking wet in urine. Then they removed the covers, Resident #1 was covered with urine from head to toe, the brief was saturated with urine, and had a small bowel movement as well. They proceeded to clean, change and repositioned Resident #1. She reported that Resident #1 was not verbal but had distressed look on his face She also stated that the support pillow was left on the chair in the resident's room to dry and sheets were taken to laundry since they were saturated in urine. She also reported that when she came back to the resident's hall, she saw that the call light for Resident #1 was on, and the Family Member A was coming out of Resident #1 room to the nurse's station. The Family Member A looked very upset and stated to CNA B that resident# 1 was not changed through the entire night shift and showed CNA B the video recording of last time the resident was changed, which was around 9 pm on 12/31/23. She also asked for Nystatin cream to apply on Resident#1. CNA B reported that she would inform LVN D and left the room. She then communicated with LVN D regarding Family Member A 's request for Nystatin cream. CNA B left to pass out Lunch trays after that. CNA B reported that she has been trained on abuse and neglect and defined neglect as not providing care to the resident. She also stated that she was aware any allegation of abuse and neglect needed to be reported to Abuse Coordinator immediately. She also stated that Family Member A alleged Resident#1 had not been provided care during the night shift was an example of neglect. She stated that she told the Staffing Coordinator to bring it up in the morning meeting for the next day but did not report it to the Abuse Coordinator immediately per policy since she was very busy on her shift. In an interview with Staffing Coordinator on 1/4/24 9:45 AM, she revealed she worked on 1/1/24 from around 8:30 am to 7PM and was providing care on the floor. She reported that she was called by CNA A to assist with ADL care for Resident#1. Around 10 am, when CNA A and Staffing Coordinator went to Resident#1, they found that Resident #1's sheet and pillows, support pillows were soaked in urine and had some feces in his brief. They cleaned, changed, and repositioned Resident #1. She was then called around noon by LVN D to help apply nystatin cream to Resident#1. She reported Resident#1's Family Member A was present in the room, was visibly upset and complained that Resident#1 was not changed or repositioned for the entire night shift of 12/31/23. Staffing Coordinator reported she had been provided several in services about abuse and neglect and defined neglect as resident not being provided goods and services. She revealed that Family Member A 's allegation of not providing care to the resident was an example of neglect and she failed to report it to the Abuse Coordinator immediately per facility policy. She also reported that most residents should be checked or provided care every 2-3 hours but stated it also depended on staffing ratios. She was not sure if there was a facility policy on how often resident should be provided ADL care by the Nursing staff. She reported that if a resident is not provided ADL care including incontinent care, it can lead to skin breakdown and possible infections. The Staffing Coordinator also reported that she was responsible for scheduling and was not aware of CNA A's concern with providing care to Resident #1. She stated that if she was made aware she would have not had CNA A work in the unit; Resident #1 was present. Record Review of Nurse and CNA Assignments for 12/31/23 revealed that there was a total of 4 CNA's (CNA A, CNA F, CNA G, CNA H that were scheduled on the 10 pm - 6am shift on 12/31/23. In a phone interview with CNA F on 1/4/24 at 10:25 AM revealed that she worked the night shift on 12/31/23 on Unit 1 and did not take care of Resident #1 who was in Unit 2. She has worked Unit 2 on prior nights and was aware of care needs for Resident #1 and that he was on 2 persons assist for ADL's. She also revealed that she has been provided Inservice on abuse and neglect and knows she needed to report any allegations of abuse or neglect immediately. In a phone interview with CNA G on 1/4/24 at 11:05 AM; she revealed that she worked the night shift on 12/31/23 on Unit 1 and she does not remember going to Unit 2 on 12/31/23 where Resident #1 was. She also stated that about a week or two ago, she remembered changing assignments and taking care of Resident #1 as instructed by LVN I since CNA A had issues with the family; so CNA G and CNA H took care of the resident since Resident#1 was two-person assist. She also stated that on the night of 12/31/23, no one instructed them to change assignments, hence she did not take care of the Resident #1. She revealed she was provided abuse and neglect in service and defined neglect as not taking care of resident needs. She stated she knows she needed to report any allegation of abuse and neglect to the Abuse Coordinator immediately. In a phone interview with CNA H on 1/4/24 11:21 AM revealed that she called out on 12/31/23 and did not work that night at the facility. She also reported that some days back, she does not remember the date but recollected that she and CNA G took care of Resident #1 as instructed by LVN I since Resident #1's family had some concerns with CNA's care to Resident #1. She reported that she has been provided numerous in services on abuse and neglect; and defined neglect as not providing care to resident and to report any abuse or neglect to the Abuse Coordinator immediately. Attempted phone interview for LVN I on 1/4/24 at 1:48 PM, left voicemail to call back the writer. In an interview with DON interview on 1/4/24 2:30 PM revealed that her expectation for dependent resident with incontinence was that there was no facility policy on how often residents should be checked for continence or nursing rounds. She expected that dependent resident who needed incontinent care be changed when they are visibly spoiled or as needed and Nursing to round throughout the shift. DON also stated that as a Registered Nurse, she would check on resident at least three times per shift. DON stated that CNA and Nurses were responsible for providing ADL care including incontinent care. She also reported that if CNA did not provide care to resident, it was her expectation that she would notify Charge Nurse or Nursing Administration immediately. She also stated that Staffing Coordinator was responsible for scheduling and assigning CNAs to the residents for all the shifts. The DON also stated there she was not aware of any restrictions for any CNA's that cannot go to resident room and if there were any restrictions Staffing Coordinator should have been aware. If there were any changes to be made, Charge Nurses can reassign CNAs on duty as needed. DON reported that she was not aware if CNA A had any restrictions on caring for Resident#1 and hence there was no communication to Nurses on the floor. She also stated that CNAs cannot decide about not caring for Resident that they were assigned to. If a CNA had any reservation regarding resident's care, she should be communicating it with charge nurses or nursing administration. The DON stated that she was aware Resident#1's family had some concerns with care provided by CNA A since the family spoke to the DON about it on the 12/18/23 and 12/21/23. DON reported that Resident#1 family was speaking to CNA A over the camera that Resident #1 was a two person assist and that she was providing care by herself. She also reported that family came to the facility midnight and verbal threats that were made by family and CNA A. DON reported she was not sure if any grievances were filed regarding the incident, but she was still investigating the incident at the time of this interview. DON reported that management had not provided any direction to CNA to not enter Resident #1's room or provide care to Resident #1. DON also stated Resident #1 was on therapy and needed maximum assistance for transfers, however not for all ADL care. DON reported that maximum assistance was defined as resident needing 2 people to provide care. She stated that Resident#1's family requested two persons assist on all ADL cares. DON reported the risk to resident for not providing ADL care that included incontinent care for dependent resident may lead to skin breakdown and infections. DON defined Abuse and Neglect as follows : Abuse is willfully doing something wrong to the resident that may result in harm. Neglect defined as not providing service or goods to resident. DON also stated that if CNA does not provide care to the resident assigned to her is an example of neglect. She sated she expected staff to report any allegation of abuse and neglect immediately to the Abuse Coordinator , who is the Facility Administrator and DON was the backup for Abuse Coordinator . In an interview with Facility Administrator on 1/4/24 at 3:03 PM revealed that he was made aware of the incident regarding allegation that CNA A did not provide ADL care including incontinent care to Resident #1 on 1/3/24 at 3:45 PM. He reported that he was in the process of investigating the incident and was talking to Nursing Staff from Night shift of 12/32/23 and Morning shift of 1/1/24. He also reported that CNA A was suspended yesterday pending outcome of the investigation. The Administrator stated that he had provided numerous in-services to all staff for abuse and neglect, and it was his expectation to report any allegation of abuse and neglect to him immediately. He defined abuse willfully, regardless of intent, harming the resident and Neglect was when good or services are not provided to the resident. He added that he explained that his simple explanation to staff regarding abuse and neglect was To abuse to occur - I must be facing you. To neglect - I actively turn my back on you. He stated that as an Abuse Coordinator, his role was to investigate the allegation thoroughly and report to TX HHS within 2 hours of the incident . He also reported that he was not aware of any grievance filed by Resident # 1 family. He stated that about a week after Resident #1 admission, around 17th or 18th of December , family had concerns with care provided by CNA A and requested two persons assist for all ADL care. DON spoke with the family and provided Inservice that Resident #1 will need two persons assist for all ADL care. He also stated that Management had not told CNA A that she could not go to Resident #1 room or take care of the resident. He continued I think it's her (CNA A) impression that she could not go to the room. Administrator also reported that risk to a dependent resident for not providing ADL care, including incontinent care, was potential skin breakdown and infections. Record reviews of Employee files for CNA A revealed she was provided Abuse and neglect policy and reporting requirements upon hire on 11/4/23. Record Review of Employee file for CNA B revealed she was provided Abuse and neglect policy and reporting requirements upon hire on 11/4/23. Record Review of Employee file for LVN D revealed she was provided Abuse and neglect policy and reporting requirements upon hire on 11/4/23. Record Review of Employee file of Staffing Coordinator revealed she was provided Abuse and neglect policy and reporting requirements upon hire on 11/14/23. Record review of Facility's Resident abuse, neglect and Exploitation and misappropriation of resident property dated 06/23/2017 revealed that Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serv [TRUNCATED]

Based on interview and record review, the facility failed to implement written policies and procedures to prevent abuse to ensure residents were free from abuse for one (Resident #1) of 10 residents reviewed for abuse. 1) The facility deprived goods abuse for Resident #1. 2) CNA B, LVN C, LVN D, and Staffing Coordinator reported an allegation of abuse and neglect on 01/01/24 to the Administrator, who is the Abuse Coordinator immediately when they found Resident #1 soaked in urine and bowel movement. These failures could affect the residents by placing them at risk for a delay in intervention and Providing ADL care including incontinent care and life-saving treatments that could lead to psychosocial harm. Findings included: Review of facility's policy Abuse, Neglect and Exploitation and Misappropriation of Resident Property dated 06/23/17 reflected, The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (Unit) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property . 3.2 All facility staff members have a duty to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the Administrator of the facility, who serves as the Abuse Coordinator . In the Administrator's absence, the Director of Nursing (DON) or another designee will be appointed to function as the interim Abuse Coordinator . Upon learning of a suspected incident of resident abuse, neglect, exploitation, and/or misappropriation of resident property, the Charge Nurse or other Department Manager or Supervisor must immediately notify the Abuse Coordinator or the DON of the incident. The person receiving the report or designee must document all incidents of alleged abuse/neglect on incident reports, which are to forwarded directly to the Abuse Coordinator . Review of Resident #1's Admission MDS assessment dated [DATE] revealed he was [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Critical illness myopathy (significant slowing of the muscle fiber) , hypertension, pneumonia, Diabetes mellitus, aphasia (loss of ability to understand or express speech, caused by brain damage) , Cerebrovascular Attack , Respiratory Failure, Dysphagia (difficult swallowing) , tube feeding dependent (Tube feeding is a therapy where a feeding tube in inserted into the abdomen ans supplied nutrients to people who cannot get enough nutrition through eating). Resident #1 required extensive assistance of at least two people with Activities of Daily Living. He was totally dependent with transfers and bathing. It revealed that resident#1 was always incontinent of urine and bowel. MDS assessment revealed BIMS of 99 indicating resident had sever cognitive impairment. Review of Resident #1 Admission Care plan dated 12/9/2023 revealed Resident #1 at risk for problems with Elimination (updated 1/6/24) . Administer stool softeners, laxatives, suppositories or enemas as ordered; Monitor for signs and symptoms of urinary tract infection; Requires two-person assistance with bowel, bladder, and ADL; Uses brief. Review of Resident #1's physician order dated 12/20/23 revealed Resident #1 was on Furosemide 20 mg tablet 1 tablet by mouth per day which was prescribed for DX of primary hypertension (high blood pressure). ( Furosemide is a diuretic will make a resident urinate more often to remove the body of excess fluid/fluid retention). Review of Resident #1's physician order dated 12/23023 revealed Resident #1 was on Nystatin 100,000 unit/gram topical cream 2 times per day for rash on the perineal area. Review of Resident # 1 ADL Documentation on EHR for 12/31/23- 1/1/24 revealed incontinent care documented at 9 pm on 12/31/23 and 10 am on 1/1/24. There was no documentation of incontinent care on the ADL in the electronic health record or paper documentation. Observation on 1/3/24 at 2:18 PM of Resident #1 room revealed resident had Blink camera in the room that detects any motion close to the resident in the room. Observed Resident #1 was lying in the bed and covered with sheets. Resident #1 looked groomed, and no odors noted. Also observed tube feeding pump next to the bed and infusing tube feed formula. Observed call light within reach. Interview with Resident #1 attempted on 1/3/24 at 2:20 PM revealed resident is not verbal and cannot respond as stated by the resident's #1 Family Member A that was present in the room. Interview with Resident#1's Family Member A and Family Member B on 1/3/24 at 2:18 PM revealed that she was very concerned that Resident#1 was not changed during the night shift of 12/31/23. Resident# 1 admitted to the facility on [DATE]. She stated when she came to the facility around 11am on 1/1/24, she noted that resident#1's side support pillow and other pillow was placed on the chair in the room and was soaking wet and smelled of urine. She picked up the pillow from the chair and saw the chair was wet from the pillow. Shen then called Resident#1 Family Member B to check if she could review the camera to see when Resident#1 was last changed. Family Member A also stated that per camera placed in the room revealed Resident#1 was not changed or repositioned from 12/31/23 at 9:05 PM until 1/4/24 at 10:20 AM. She also stated that she had requested LVN D to reposition Resident#1 around 7 AM on 1/1/24 through the camera. She then stated that she went to LVN D who told her he started his shift at 6 AM on 1/1/24 and did not know which nursing staff was assigned for Resident #1 that worked on night shift of 10am - 6AM on 12/31/23. Family Member A asked LVN D if he received shift report in the morning for Resident# 1's care and which nursing staff provided the report. Per Family Member A , LVN D refused to talk to the Family Member A and directed her to the front office. She stated that she was not able to find any Admin nursing staff and was told ADON B had left for the day. Family Member A also revealed that she had complained to the DON regarding her concerns with Resident# 1 ADL care earlier on 12/18/23 and approached the DON that Resident#1 needed two people assist on all ADL's including incontinent care. She also stated that on the night shift on 12/17-12/18/23 CNA A was changing and repositioning the resident by herself incorrectly when Resident #1's Family Member B intervened from the camera and had to come to the facility at midnight to make sure that Resident #1 was okay. She stated that resident's Family Member B spoke with Charge Nurse LVN I on 12/18/23 who stated that she will have another CNA care for the resident for that night. She also stated that Resident#1's Family Member B spoke with the DON on 12/21/23 regarding needing two people assist on all ADL care including incontinent care and repositioning. She stated DON reported it was not the facility policy to turn the resident every 2 hours, but the DON and wife agreed on checking on the resident every four hours. Interview with LVN D on 1/4/24 at 2:36 PM revealed that he had started working in the facility around November 2023, he reported he was the LVN who was taking care of Resident #1 on 1/1/24 morning shift from 6am-2 pm. He reported that he checked on Resident #1 around 7am on 1/1/24 and administered his G-tube (meds and checked Resident#1's blood glucose. He also reported that he briefly lifted Resident#1 sheets and it appeared that Resident #1's brief was dry. He stated that he did not physically check on Resident#1 for incontinence. He also stated that Family Member A talked to him from the camera around 7 am on 1/1/24 when he was providing G-tube care to the resident and asked him to reposition Resident#1. He reported that since Resident#1 was a 2-person assist, LVN D went to look for CNA and could not find the CNA, so he continued with his med pass and blood glucose checks to other residents in the hall. LVN D reported he did not reposition Resident #1. LVN D also stated that the Staffing Coordinator and CNA B provided incontinent care and repositioning around 10 am on 1/1/24. He also reported that Resident #1 Family Member A came to him at the nurse's station around 11am on 1/1/24 stating that Resident #1 was not changed on the night shift of 12/31/23 and asked for nursing staff that took care of the resident the previous night. LVN D redirected the Family Member A to the front office. He reported that Family Member A came to him again after some time (around noon) asking to put nystatin ointment on resident's peri-area by herself. LVN D informed Family Member A that since the ointment is a prescribed medication, it will need to be applied by a nursing staff. LVN D stated he did not feel comfortable entering the resident's room by himself and hence he, along with Staffing Coordinator entered the Resident's room and applied Nystatin ointment for resident#1. LVN D reported that nystatin was applied to resident's peri care area between 12:15 PM - 12:30 PM on 1/1/24. LVN D reported that Nystatin was started on Resident #1 on 12/30/23 for diaper rash and it was usually used for fungal infection or skin irritation and can be caused if area was wet for a long time. LVN D stated that he did not report the allegation from the Family Member A that the resident was not changed over several hours of night shift to anyone. LVN D reported when he started at the facility about a month ago, he was provided with several in services that included abuse and neglect as well. He defined neglect as resident not being provided the needed care and services by the facility. He stated he knew to report any allegation of abuse and neglect to the Abuse Coordinator immediately. He stated that if the allegation from the Family Member A was true that the resident indeed did not receive incontinent or ADL care during the night shift, it looked like neglect to him, and he should have reported it then. Interview with CNA E on 1/3/24 at 2:42 PM revealed that she worked in the facility for last 8-9 months. She usually worked the 2PM -10 PM shift. She had taken care of Resident #1 in the past and was aware with Resident #1 care needs. She reported that Resident #1 needed two-person assist with all ADL care and she always takes help from the Nurse or CNA from other halls for changing or repositioning the resident. She reported that she was not aware of rounding policy for the facility, but she rounded on her residents at least every two hours. She also reported that Resident#1 has Nystatin cream for diaper rash that was always applied by Nursing staff when they change the resident. She also reported that he was provided abuse and neglect in services in the past and defined neglect as resident not getting the needed goods or services. She also stated that if a resident had not been provided ADL care may result in neglect and should be reported to the administration team immediately. Interview with LVN C on 1/3/24 at 2:50 PM revealed that he worked at the facility for about 2 years. He reported that he worked the night shift 10PM - 6AM on 12/31/23. He reported that he hung a new tube feeding bag and reprogrammed the feeding pump around 10:30-11 PM on 12/31/23, but he did not check resident for incontinent care at that time nor did he repositioned Resident #1 at that time. LVN C also stated that he did not repositioned or provided incontinent care to Resident #1 at all during his shift because he thought the CNA would have provided that care. He also reported that he was the Charge Nurse for the unit on the night of 12/31/23. He reported as a Charge Nurse, he assigned residents to CNA's that they need to take care of during their shift. He reported that Resident #1 was assigned to CNA A along with all other residents on 500, 600, 700 Hall. He reported he became aware of the incident that family alleged that resident was not provided ADL care including incontinent care on the night shift of 12/31/23 when Resident #1's Family Member A approached him during his afternoon shift 2PM- 10 PM on 1/1/24. LVN C also stated that CNA A did not tell him that she will not be caring for Resident#1 anytime during the night shift of 12/31/23 when they worked the halls together. He stated that when he spoke with CNA A around 10 PM on 1/1/24 she told him she assumed he knew that she will not take care of Resident#1 because of some prior concerns that CNA A had with resident#1's family. He further added that he asked CNA A if she communicated this with him beforehand OR ask for swapping residents so other CNA could take care of the resident OR made nursing administration aware of her dispute or displeasure to work with Resident #1, CNA A replied NO to all his questions. He also stated that since CNA's usually take care of all ADL's, he did not check whether Resident #1 was provided ADL care including incontinent care. He also stated that Resident #1 was two persons assist and that most CNA's will ask for help from Nurses on the floor or CNAs from other halls. LVN C reported that he had received in-services on abuse and neglect and defined neglect as not providing good and services to the resident. He also said that CNA A not providing care was an example of neglect. He also stated that he was going to report the alleged Neglect to the Abuse Coordinator soon but waited to speak with CNA A about the incident. Interview with ADON B on 1/3/24 at 3:05 PM revealed that she was familiar with Resident#1's care. She stated she spoke with Resident#1's Family Member B during the admission care conference. She had not spoken with the Family Member regarding family's concern for two persons assist for ADL's; however, she was aware of family requesting two-person assist with ADL care from the DON. She stated that she was not aware if DON had filed any grievance report regarding family concern of resident care. She also reported that family approached her about 30 minutes before this interview regarding their allegation of Resident#1 not being provided ADL care included incontinent care during the night shift of 12/31/23. She also stated that no other staff member including Charge nurses, CNA or floor Nurses reported the allegation to her before the Family Member . She reported she will file a grievance report and investigate the incident soon. She also reported that she was the on-call Nurse Manager for night shifts of 12/30/23, 12/31/23 and 1/1/24. She also stated that she had not reported the allegation of potential neglect for not providing care to the resident at the time of this interview and was preparing to send the email to the Abuse Coordinator . ADON B stated that if Family Member A 's allegation of not providing resident with ADL care throughout the night shift was true, that would be an example of neglect since the resident was not provided with service he needed. She also reported that any resident can have rash in peri area if the area was wet for long time. She also stated that resident#1 cannot reposition himself and her expectation was staff checked on resident every two hours for ADL care. She stated that if ADL care including incontinent care was not provided in a timely manner it can lead to rash, skin breakdown and Resident's dignity and comfort can be compromised. Attempted phone interview with CNA A on 1/3/24 3:16 PM, left Voicemail to call back. In a phone interview with CNA A on 1/4/24 9:03 AM she revealed she was aware of Resident#1's care. She stated she worked the night shift 10PM -6AM on 12/31/23 and was assigned to the Resident#1's care per assignments provided to her by the Charge Nurse, LVN C. She also stated that she did not provide any ADL care including incontinent care or repositioning to Resident #1 on the night shift from 10PM-6AM on 12/31/23. She did not know if any other CNA or LVN provided care to the resident that night. She reported that she had a situation with the Family Member s of Resident#1 roughly 2 weeks ago, she did not remember the exact date - but thought it was around 18/19th of December. CNA A stated that the family was rude to her and was not happy with the ADL care she provided to the resident the night of December 18th. She stated the incident was reported to LVN I who was charge Nurse that shift since the family came to the facility at midnight. She reported she failed to communicate with LVN C about her decision to not provide care to Resident#1 on the night shift and further stated that she assumed LVN C was aware of her previous incident with the family and her decision to not care for Resident #1. She also stated that it was her fault for assuming and not communicating with the Charge Nurse regarding her decision to not provide care. She reported that the risk to dependent resident for not providing ADL care including incontinent care over a period of 8-hour shift could lead to skin breakdown and diaper rash. She also revealed she has been provided Inservice regarding abuse and neglect. She defined neglect as not providing service to the resident. She acknowledged that her decision of not providing ADL care to Resident #1 and not communicating her decision to the Charge Nurse on the night of 12/31/23 was a form of neglect. She reported that when she worked on the night shift of 1/1/24 at the facility, she had a conversation with LVN C about care not being provided on 12/31/23. She also stated that she continued to work in the facility on 1/1/24 on a different hall and was not assigned to care for Resident #1. In an interview with CNA B on 1/4/24 9:28 AM revealed that she worked the morning shift 6 AM-2PM on 1/1/24 and was assigned to care for residents on three halls that included Resident#1. She reported that when she came to work in the morning, call lights for most residents were on and she was trying her best to take care of the resident needs one by one. It took her some time, after breakfast, around 10 AM to go and check on Resident #1. She reported since Resident #1 was a two person assist for ADL's including incontinent care, she called for help from Staffing Coordinator , who was also an LVN to change the resident. She reported that as soon as she moved the support pillow it was soaking wet in urine. Then they removed the covers, Resident #1 was covered with urine from head to toe, brief was saturated with urine, and had a small bowel movement as well. They proceeded to clean, change and repositioned Resident #1. She reported that Resident #1 was not verbal but had a distressed look on his face She also stated that the support pillow was left on the chair in the resident's room to dry and sheets were taken to laundry since they were saturated in urine. She also reported that when she came back to the resident's hall, she saw that the call light for Resident #1 was on, and the Family Member A was coming out of Resident #1 room to the nurse's station. The Family Member A looked very upset and stated to CNA B that Resident# 1 was not changed through the entire night shift and showed CNA B the video recording of last time the resident was changed, which was around 9 pm on 12/31/23. She also asked for Nystatin cream to apply on Resident#1. CNA B reported that she would inform LVN D and left the room. She then communicated with LVN D regarding Family Member A 's request for Nystatin cream. CNA B left to pass out Lunch trays after that. CNA B reported that she has been trained on abuse and neglect and defined neglect as not providing care to the resident. She also stated that she was aware any allegation of abuse and neglect needed to be reported to Abuse Coordinator immediately. She also stated that Family Member A alleged of resident#1 not been provided care during the night shift was an example of neglect. She stated that she told the Staffing Coordinator to bring it up in the morning meeting for the next day but did not report it to the Abuse Coordinator immediately per policy since she was very busy on her shift. In an interview with Staffing Coordinator on 1/4/24 9:45 AM, she revealed she worked on 1/1/24 from around 8:30 am to 7PM and was providing care on the floor. She reported that she was called by CNA A to assist with ADL care for Resident#1. Around 10 am, when CNA A and Staffing Coordinator went to Resident#1, they found that Resident #1's sheet and pillows, support pillows were soaked in urine and had some feces in his brief. They cleaned, changed, and repositioned Resident #1. She was then called around noon by LVN D to help apply Nystatin cream to Resident#1. She reported Resident#1's Family Member A was present in the room, was visibly upset and complained that resident#1 was not changed or repositioned for the entire night shift of 12/31/23. Staffing Coordinator reported she had been provided several in services about abuse and neglect and defined neglect as resident not being provided goods and services. She revealed that Family Member A 's allegation of not providing care to the resident was an example of neglect and failed to report it to the Abuse Coordinator immediately per facility policy. She also reported that most residents should be checked or provided care every 2-3 hours but stated it also depended on staffing ratios. She was not sure if there was a facility policy on how often resident should be provided ADL care by the Nursing staff. She reported that if a resident is not provided ADL care including incontinent care, it can lead to skin breakdown and possible infections. She also reported that she was responsible for scheduling and was not aware of CNA A's concern with providing care to Resident #1. She stated that if she was made aware she would have not had CNA A work in the unit; Resident #1 was present. In an interview with DON interview on 1/4/24 2:30 PM revealed that her expectation for dependent resident with incontinence was that there was no facility policy on how often residents should be checked for continence or nursing rounds. She expected that dependent resident who need incontinent care be changed when they were visibly spoiled or as needed and Nursing to round throughout the shift. DON also stated that as a Registered Nurse, she would check on resident at least three times per shift. DON stated that CNA and Nurses were responsible for providing ADL care, including incontinent care. She also reported that if CNA did not provide care to a resident, it was her expectation that she would notify Charge Nurse or Nursing administration immediately. She also stated that Staffing Coordinator was responsible for scheduling and assigning CNAs to the residents for all the shifts. The DON also stated there she was not aware of any restrictions for any CNA's that cannot go to resident room and if there were any restrictions Staffing Coordinator should have been aware. If there were any changes to be made, Charge Nurses can reassign CNAs on duty as needed. DON reported that she was not aware if CNA A had any restrictions on caring for Resident#1 and hence there was no communication to Nurses on the floor. She also stated that CNAs cannot make a decision about not caring for Resident that they were assigned to. If CNA had any reservation regarding resident's care, she should be communicating it with charge nurses or nursing administration. DON stated that she was aware Resident#1's family had some concerns with care provided by CNA A since the family spoke to the DON about it on the 12/18/23 and 12/21/23. DON reported that resident#1 family was speaking to CNA A over the camera that Resident #1 was a two person assist and that she was providing care by herself. She also reported that family came to the facility midnight and verbal threats that were made by family and CNA A. DON reported she was not sure if any grievances were filed regarding the incident, but she was still investigating the incident at the time of this interview. DON reported that management had not provided any direction to CNA to not enter Resident #1's room or provide care to Resident #1. DON also stated Resident #1 is on therapy and needed maximum assistance for transfers, however not for all ADL care. DON reported that maximum assistance was defined as resident needing 2 people to provide care. She stated that Resident#1's family requested two persons assist on all ADL cares. DON reported the risk to resident for not providing ADL care that included incontinent care for dependent resident may lead to skin breakdown and infections. DON defined Abuse and Neglect as follows : Abuse is willfully doing something wrong to the resident that may result in harm. Neglect defined as not providing service or goods to resident. DON also stated that if CNA does not provide care to the resident assigned to her is an example of neglect. She sated she expected staff to report any allegation of abuse and neglect immediately to the Abuse Coordinator , who is the Facility Administrator and DON was the backup for Abuse Coordinator . In an interview with Facility Administrator on 1/4/24 at 3:03 PM revealed that he was made aware of the incident regarding allegation that CNA A did not provide ADL care including incontinent care to Resident #1 on 1/3/24 at 3:45 PM. He reported that he was in the process of investigating the incident and was talking to Nursing Staff from Night shift of 12/32/23 and Morning shift of 1/1/24. He also reported that CNA A was suspended yesterday (1/03/24) pending outcome of the investigation. Administrator stated that he had provided numerous in-services to all staff for abuse and neglect, and it was his expectation to report any allegation of abuse and neglect to him immediately. He defined abuse willfully, regardless of intent, harming the resident and Neglect was when good or services are not provided to the resident. He added that he explained that his simple explanation to staff regarding abuse and neglect was To abuse to occur - I must be facing you. To neglect - I actively turn my back on you. He stated that as an Abuse Coordinator , his role was to investigate the allegation thoroughly and report to TX HHS within 2 hours of the incident . He also reported that he was not aware of any grievance filed by resident # 1 family. He stated that about a week after Resident #1 admission, around 17th or 18th of December , family had concerns with care provided by CNA A and requested two persons assist for all ADL care. DON spoke with the family and provided Inservice that Resident #1 will need two persons assist for all ADL care. He also stated that Management had not tell CNA A that she could not go to Resident #1 room or take care of the resident. He continued I think it's her (CNA A )impression that she could not go to the room. Administrator also reported that risk to a dependent resident for not providing ADL care including incontinent care is potential skin breakdown and infections. Review of CNA A's timesheet from 12/30/23-01/01/24 revealed CNA A worked on the 10pm-6 am shift. CNA was scheduled to work on 01/03/24 but was suspended after surveyor intervention on 1/3/24. 48560

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one (Resident #1) of 10 residents reviewed for ADLs. The facility failed to provide incontinent care to Resident #1 for 13 hours on 12/31/23 9:05 pm to 01/01/24 at 10:22 AM. CNA A was assigned to Resident #1 and failed to provide care to Resident #1 on night shift. Resident #1 was not provided incontinent care for over 13 hours (including 8 hours of night shift of 12/31/23 and part of 1/1/24 day shift) on 12/31/23 9:05 pm to 01/01/24 at 10:22 AM. On 01/01/24 when Staffing Coordinator and CNA B provided incontinent care and found Resident #1's clothing and bedding soaked urine. Resident #1's brief was soaked in urine and had bowel movement. These failures could place residents at risk of delay in ADL care including incontinent care and life-saving treatments, which could result in psychosocial harm. Findings included: Review of Resident #1's Admission MDS assessment dated [DATE] revealed he was [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Critical illness myopathy (significant slowing of the muscle fiber) , hypertension, pneumonia, Diabetes mellitus, aphasia (loss of ability to understand or express speech, caused by brain damage) , Cerebrovascular Attack , Respiratory Failure, Dysphagia (difficult swallowing) , G-tube feeding dependent (G-tube is a tube inserted through the belly that brings nutrition directly to the stomach). Resident #1 required extensive assistance of at least two people with Activities of Daily Living. He was totally dependent with transfers and bathing. It revealed that resident#1 was always incontinent of urine and bowel. MDS assessment revealed BIMS of 99 indicating resident had severe cognitive impairment. Review of Resident #1 Admission Care Plan dated 12/9/2023 revealed Resident #1 is on Diuretic therapy , Furosemide 20 mg tablet 1 tablet 1 time per day; Resident will have decrease in edema during drug therapy. ( Furosemide is a diuretic will make a resident urinate more often to remove the body of excess fluid/fluid retention). Review of Resident # 1 ADL Documentation on EHR for 12/31/23- 1/1/24 revealed incontinent care documented at 9 pm on 12/31/23 and 10 am on 1/1/24. There was no documentation of incontinent care on the ADL in the electronic health record or paper documentation. Interview with Resident#1's Family Member A and Family Member B on 1/3/24 at 2:18 PM revealed that she was very concerned that Resident#1 was not changed during the night shift of 12/31/23. Resident# 1 admitted to the facility on [DATE]. She stated when she came to the facility around 11am on 1/1/24, she noted that resident#1's side support pillow and other pillow was placed on the chair in the room and was soaking wet and smelled of urine. She picked up the pillow from the chair and saw the chair was wet from the pillow. Shen then called Resident#1 Family Member B to check if she could review the camera to see when Resident#1 was last changed. Family Member A also stated that per camera placed in the room revealed Resident#1 was not changed or repositioned from 12/31/23 at 9:05 PM until 1/4/24 at 10:20 AM. She also stated that she had requested LVN D to reposition Resident#1 around 7 am on 1/1/24 through the camera. She then stated that she went to LVN D who told her he started his shift at 6 AM on 1/1/24 and did not know which nursing staff was assigned for Resident #1 that worked on night shift of 10am -6AM on 12/31/23. Family Member A asked LVN D if he received shift report in the morning for resident# 1's care and which nursing staff provided the report. Per Family Member A , LVN D refused to talk to the Family Member A and directed her to the front office. She stated that she was not able to find any Administration nursing staff and was told ADON B had left for the day. Family Member A also revealed that she had complained to the DON regarding her concerns with Resident# 1 ADL care earlier on 12/18/23 and approach the DON that Resident#1 needed two people assist on all ADL's including incontinent care. She also stated that on the night shift on 12/17-12/18/23 CNA A was changing and repositioning the resident by herself incorrectly when resident's Family Member B intervened from the camera and had to come to the facility at midnight to make sure that Resident #1 was okay. She stated that resident's Family Member B spoke with Charge Nurse LVN I on 12/18/23 who stated that she will have another CNA care for the resident for that night. She also stated that Resident#1 Family Member B spoke with the DON on 12/21/23 regarding needing two people assist on all ADL care including incontinent care and repositioning. She stated DON reported it was not the facility policy to turn the resident every 2 hours, but the DON and wife agreed on checking on the resident every four hours. Interview with LVN D on 1/4/24 at 2:36 PM revealed that he had started working in the facility around November 2023, he reported he was the LVN who was taking care of Resident #1 on 1/1/24 morning shift from 6am-2 pm. He reported that he checked on Resident #1 around 7am on 1/1/24 and administered his G-tube (meds and check resident#1's blood glucose. He also reported that he briefly lifted Resident#1 sheets and it appeared that Resident #1 brief was dry. He stated that he did not physically check on Resident#1 for incontinence. He also stated that Family Member A talked to him from the camera around 7 am on 1/1/24 when he was providing G-tube care to the resident and asked him to reposition resident#1. He reported that since Resident#1 was 2-person assist, LVN D went to look for CNA and could not find the CNA, so he continued with his med pass and blood glucose checks to other residents in the hall. LVN D reported he did not reposition Resident #1. LVN D also stated that the Staffing Coordinator and CNA B provided incontinent care and repositioning around 10 AM on 1/1/24. He also reported that Resident#1's Family Member A came to him at the nurse's station around 11am on 1/1/24 stating that Resident #1 was not changed on the night shift of 12/31/23 and asked for nursing staff that took care of the resident the previous night. LVN D redirected the Family Member A to the front office. He reported that Family Member A came to him again after some time (around noon) asking to put nystatin ointment on resident's peri-area by herself. LVN D informed Family Member A that since the ointment is a prescribed medication, it will need to be applied by a nursing staff. LVN D stated he did not feel comfortable entering the resident's room by himself and hence he, along with Staffing Coordinator entered the Resident's room and applied Nystatin ointment for resident#1. LVN D reported that nystatin was applied to resident's peri care area between 12:15 PM - 12:30 PM on 1/1/24. LVN D reported that Nystatin was started on Resident #1 on 12/30/23 for diaper rash and it is usually used for fungal infection or skin irritation and can be caused if area is wet for a long time. LVN D stated that he did not report the allegation from the Family Member A that the resident was not changed over several hours of night shift to anyone. LVN D reported when he started at the facility about a month ago, he was provided with several in services that included abuse and neglect as well. He defined neglect as resident not being provided the needed care and services by the facility. He stated he knew to report any allegation of abuse and neglect to the Abuse Coordinator immediately. He stated that if the allegation from the Family Member A was true that the resident indeed did not receive incontinent or ADL care during the night shift, it looked like neglect to him, and he should have reported it then. Interview with CNA E on 1/3/24 at 2:42 PM revealed that she worked in the facility for last 8-9 months. She stated that she did not work on the night shift from 10PM to 6 AM on 12/31/23 in the facility and She usually worked the 2PM -10 PM shift. She had taken care of Resident #1 in the past and was aware with Resident #1 care needs. She reported that Resident #1 needed two-person assist with all ADL care and she always takes help from the Nurse or CNA from other halls for changing or repositioning the resident. She reported that she was not aware of rounding policy for the facility, but she rounded on her residents at least every two hours. She also reported that resident#1 has Nystatin cream for diaper rash that was always applied by Nursing staff when they change the resident. She also reported that he was provided abuse and neglect in services in the past and defined neglect as resident not getting the needed goods or services. She also stated that if a resident had not been provided ADL care may result in neglect and should be reported to the administration team immediately. Interview with LVN C on 1/3/24 at 2:50 PM revealed that he worked at the facility for about 2 years. He reported that he worked the night shift 10PM - 6AM on 12/31/23. He reported that he hung a new tube feeding bag and reprogrammed the feeding pump around 10:30-11 PM on 12/31/23, but he did not check resident for incontinent care at that time nor did he repositioned Resident #1 at that time. LVN C also stated that he did not repositioned or provided incontinent care to Resident #1 at all during his shift because he thought the CNA would have provided that care. He also reported that he was the Charge Nurse for the unit on the night of 12/31/23. He reported as a Charge Nurse, he assigned residents to CNAs that they need to take care of during their shift. He reported that Resident #1 was assigned to CNA A along with all other residents on 500, 600, 700 Hall. He reported he became aware of the incident that family alleged that resident was not provided ADL care including incontinent care on the night shift of 12/31/23 when Resident #1's Family Member A approached him during his afternoon shift 2PM- 10 PM on 1/1/24. LVN C also stated that CNA A did not tell him that she will not be caring for Resident#1 anytime during the night shift of 12/31/23 when they worked the halls together. He stated that when he spoke with CNA A around 10 PM on 1/1/24 she told him she assumed he knew that she will not take care of Resident#1 because of some prior concerns that CNA A had with resident#1's family. He further added that he asked CNA A if she communicated this with him beforehand OR ask for swapping residents so other CNA could take care of the resident OR made nursing administration aware of her dispute or displeasure to work with Resident #1, CNA A replied NO to all his questions. He also stated that since CNA's usually take care of all ADL's, he did not check whether Resident #1 was provided ADL care including incontinent care. He also stated that Resident #1 was two persons assist and that most CNA's will ask for help from Nurses on the floor or CNAs from other halls. LVN C reported that he had received in-services on abuse and neglect and defined neglect as not providing good and services to the resident. He also said that CNA A not providing care was an example of neglect. He also stated that he was going to report the alleged Neglect to the Abuse Coordinator soon but waited to speak with CNA A about the incident. In a phone interview with CNA A on 1/4/24 9:03 AM she revealed she was aware of Resident#1's care. She stated she worked the night shift 10pm-6am on 12/31/23 and was assigned to the Resident#1's care per assignments provided to her by the Charge Nurse, LVN C. She also stated that she did not provide any ADL care including incontinent care or repositioning to Resident #1 on the night shift from 10pm-6am on 12/31/23. She does not know if any other CNA or LVN provided care to the resident that night. She reported that she had a situation with the Family Member s of Resident#1 roughly 2 weeks ago, she does not remember the exact date - but thought it was around 18/19th of December. CNA A stated that the family was rude to her and was not happy with the ADL care she provided to the resident the night of December 18th. She stated the incident was reported to LVN I who was charge Nurse that shift since the family came to the facility at midnight. She reported she failed to communicate with LVN C about her decision to not provide care to Resident#1 on the night shift and further stated that she assumed LVN C was aware of her previous incident with the family and her decision to not care for Resident #1. She also stated that it was her fault for assuming and not communicating with the charge Nurse regarding her decision to not provide care. She reported that the risk to dependent resident for not providing ADL care including incontinent care over a period of 8-hour shift could lead to skin breakdown and diaper rash. She also revealed she has been provided Inservice regarding abuse and neglect. She defined neglect as not providing service to the resident. She acknowledged that her decision of not providing ADL care to Resident #1 and not communicating her decision to the charge Nurse on the night of 12/31/23 was a form of neglect. She reported that when she worked on the night shift of 1/1/24 at the facility, she had a conversation with LVN C about care not being provided on 12/31/23. She also stated that she continued to work in the facility on 1/1/24 on a different hall and was not assigned to care for Resident #1. In an interview with CNA B on 1/4/24 9:28 AM revealed that she worked the morning shift 6 AM-2PM on 1/1/24 and was assigned to care for residents on three halls that included Resident#1. She reported that when she came to work in the morning, call lights for most residents were on and she was trying her best to take care of the resident needs one by one. It took her some time, after breakfast, around 10 am to go and check on Resident #1. She reported since Resident #1 was a two person assist for ADL's including incontinent care, she called for help from Staffing Coordinator , who was also an LVN to change the resident. She reported that as soon as she moved the support pillow it was soaking wet in urine. Then they removed the covers, Resident #1 was covered with urine from head to toe, brief was saturated with urine, and had a small bowel movement as well. They proceeded to clean, change and repositioned Resident #1. She reported that Resident #1 was not verbal but had distressed look on his face She also stated that the support pillow was left on the chair in the resident's room to dry and sheets were taken to laundry since they were saturated in urine. She also reported that when she came back to the resident's hall, she saw that the call light for Resident #1 was on, and the Family Member A was coming out of Resident #1 room to the nurse's station. The Family Member A looked very upset and stated to CNA B that resident# 1 was not changed through the entire night shift and showed CNA A the video recording of last time the resident was changed, which was around 9 pm on 12/31/23. She also asked for Nystatin cream to apply on Resident#1. CNA B reported that she would inform LVN D and left the room. She then communicated with LVN D regarding Family Member A 's request for Nystatin cream. CNA B left to pass out Lunch trays after that. CNA B reported that she has been trained on abuse and neglect and defined neglect as not providing care to the resident. She also stated that she was aware any allegation of abuse and neglect needed to be reported to Abuse Coordinator immediately. She also stated that Family Member A alleged of resident#1 not been provided care during the night shift was an example of neglect. She stated that she told the Staffing Coordinator to bring it up in the morning meeting for the next day but did not report it to the Abuse Coordinator immediately per policy since she was very busy on her shift. In an interview with Staffing Coordinator on 1/4/24 9:45 AM, she revealed she worked on 1/1/24 from around 8:30 AM to 7PM and was providing care on the floor. She reported that she was called by CNA A to assist with ADL care for resident#1. Around 10 am, when CNA A and Staffing Coordinator went to Resident#1, they found that Resident #1's sheet and pillows, support pillows were soaked in urine and had some feces in his brief. They cleaned, changed, and repositioned Resident #1. She was then called around noon by LVN D to help apply Nystatin cream to Resident#1. She reported Resident#1's Family Member A was present in the room, was visibly upset and complained that resident#1 was not changed or repositioned for the entire night shift of 12/31/23. Staffing Coordinator reported she had been provided several in services about abuse and neglect and defined neglect as resident not being provided goods and services. She revealed that Family Member A 's allegation of not providing care to the resident was an example of neglect and failed to report it to the Abuse Coordinator immediately per facility policy. She also reported that most residents should be checked or provided care every 2-3 hours but stated it also depended on staffing ratios. She was not sure if there was a facility policy on how often resident should be provided ADL care by the Nursing staff. She reported that if a resident is not provided ADL care including incontinent care, it can lead to skin breakdown and possible infections. She also reported that she was responsible for scheduling and was not aware of CNA A's concern with providing care to Resident #1. She stated that if she was made aware she would have not had CNA A work in the unit; Resident #1 was present. In an interview with DON interview on 1/4/24 2:30 PM revealed that her expectation for dependent resident with incontinence was that there was no facility policy on how often residents should be checked for continence or nursing rounds. She expected that dependent resident who need incontinent care be changed when they were visibly spoiled or as needed and Nursing to round throughout the shift. DON also stated that as a Registered Nurse, she would check on resident at least three times per shift. DON stated that CNA and Nurses are responsible for providing ADL care including incontinent care. She also reported that if CNA does not provide care to resident, it was her expectation that she would notify Charge Nurse or Nursing administration immediately. She also stated that Staffing Coordinator was responsible for scheduling and assigning CNAs to the residents for all the shifts. She also stated there she was not aware of any restrictions for any CNA's that cannot go to resident room and if there were any restrictions Staffing Coordinator should have been aware. If there were any changes to be made, Charge nurses can reassign CNAs on duty as needed. DON reported that she was not aware if CNA A had any restrictions on caring for Resident#1 and hence there was no communication to Nurses on the floor. She also stated that CNAs cannot decide about not caring for Resident that they are assigned to. If CNA had any reservation regarding resident's care, she should be communicating it with charge nurses or nursing administration. DON stated that she was aware Resident#1's family had some concerns with care provided by CNA A since the family spoke to the DON about it on the 12/18/23 and 12/21/23. DON reported that Resident#1 family was speaking to CNA A over the camera that Resident #1 was a two person assist and that she was providing care by herself. She also reported that family came to the facility midnight and verbal threats that were made by family and CNA A. DON reported she was not sure if any grievances were filed regarding the incident, but she was still investigating the incident at the time of this interview. DON reported that management had not provided any direction to CNA to not enter Resident #1's room or provide care to Resident #1. DON also stated Resident #1 was on therapy and needed maximum assistance for transfers, however not for all ADL care. DON reported that maximum assistance was defined as resident needing 2 people to provide care. She stated that Resident#1's family requested two persons assist on all ADL cares. DON reported the risk to resident for not providing ADL care that included incontinent care for dependent resident may lead to skin breakdown and infections. DON defined Abuse and Neglect as follows : Abuse is willfully doing something wrong to the resident that may result in harm. Neglect defined as not providing service or goods to resident. DON also stated that if CNA does not provide care to the resident assigned to her is an example of neglect. She sated she expected staff to report any allegation of abuse and neglect immediately to the Abuse Coordinator , who is the Facility Administrator and DON was the backup for Abuse Coordinator . Review of facility's Restorative Policy titled Perineal care/Incontinence Care Dated April, 2012, revised 01/06/2024 stated Staff will perform perineal/incontinent care with each bath and after each incontinent episode. Care will be provided frequently as defined as every 2 to 3 hours and as needed to meet resident needs, prevent skin breakdown, and infection. Staff will document in EHR after care has been provided for incontinent episodes. In the event that POC devices are not operable, paper documentation will be utilized. 48560

48560 Based on observation, interview, and record review the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise when the facility failed to implement significant weight loss interventions for two (Residents #58 and #28) of seven residents reviewed for significant weight loss, in that: 1. Dietitian failed to communicate and follow-up on Resident #58's significant weight loss of 18 pounds from 01/31/23 to 05/10/23 to the facility and verify adequate nutrition was provided via enteral tube feeding or PEG tube (surgical placement of feeding tube in the stomach to provide nutrition, hydration and/or medicines) for Resident #58. Dietitian also failed to implement resident centered enteral tube feeding nutrition plan for Resident #58. 2. LVN G, LVN I and LVN F failed to administer enteral feedings to Resident #58 as ordered by the physician for last 72 hours (May 13, May 14, and May 15). 3. Facility failed to notify the physician regarding resident's significant weight loss and failed to initiate timely intervention to prevent weight loss when Resident #58 experienced continuous significant weight loss of -7.85% (11.5 pounds) in the last three months since 2/22/2023 AND -12% (18.5 pounds) since admit weight of 2/3/2023. 4. Dietitian failed to communicate reweights timely and follow-up on Resident #28's significant weight loss of 20.8% on 05/02/23 since admission on 04/21/23. Dietitian failed to put significant weight loss intervention in place for Resident #28 who a had a low body mass index until 05/12/23 when Resident #28 continued to have significant weight loss of 23% on 05/11/23. DON failed to follow up to ensure Resident #28 had significant weight loss interventions in place. An Immediate Jeopardy (IJ) situation was identified on 05/17/23 at 5:39 PM. While the IJ was removed on 05/20/23 at 5:30 PM, the facility remained out of compliance at a scope of pattern at the severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. These failures could place residents who are completely dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown and overall decline in quality of care. Findings included: 1. Review of MDS assessment dated [DATE] for Resident #58 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of Parkinson's disease (brain disorder that causes unintended or uncontrollable moments), Dysphagia of oropharyngeal phase (difficulty swallowing), Pneumonitis due to inhalation of food and vomit (lung infection caused by inhaling food, saliva or other), Cognitive Communication deficit ( inability to communicate properly) , Dysarthria (difficulty in speaking related to weak muscles), Dysphonia (difficulty speaking related to physical disorders of vocal cords), Muscle weakness and other chronic pain conditions. Review revealed the resident had a BIMS score of (09), which meant the resident was moderately impaired cognition. The resident required extensive assistance with ADLs and was incontinent of bowel and bladder. It reflected that patient had PEG tube in place for enteral feedings on admission and was NPO, dependent on PEG tube feedings for nutrition and hydration. The resident was at risk for weight loss. The resident's height was 5 feet 8 inches, and the hospital admission weight was 153 pounds. Residents' # 58 Ideal body weight: 154 pounds (+/- 10%) In an observation with Resident # 58, on 05/16/2023, at 10:44 a.m., it was noted that the resident was resting in his recliner. Observed tube feeding pump next to the recliner on the pole was off. Resident # 58 was not interviewable at time of visit. Resident # 58 could only answer in yes and no questions, however, did not have clear perception of time, date or place. During exit from resident's room, Noted X-ray tech had entered Resident # 58's room to take images. In a phone interview with Resident #58's responsible party at 11:44 am on 5/16/2023, it was revealed that resident had lost some weight and looked skinny and bony lately than from time of admit in January. They also stated that the resident had missed some of his nocturnal tube feeds via pump for couple days in the past but had not seen that lately. Responsible party could not substantiate time frame as to when exactly the resident did not get feedings or who reported this to her. Responsible party did not voice any other concerns for the resident at that time. Record Review of weight chart for the resident included the following: Date Weight (in Pounds) 02/03/2023 153.5 02/15/2023 153.5 02/22/2023 146.5 03/01/2023 143.9 03/08/2023 142.0 03/15/2023 143.7 03/22/2023 143.2 03/29/2023 140.5 04/06/2023 140.5 04/19/2023 139.5 05/03/2023 140.0 05/10/2023 135.0 On 5/10/2023, residents' weight was 135 pounds and triggered for significant weight loss of -7.85% (11.5 pounds) in the last three months since 2/22/2023 AND -12% (18.5 pounds) since admit weight of 2/4/2023. Record review for Nutrition assessment by Dietitian indicated the following: 1/31/2023: Diabetisource AC 50ml/hr x 22-hour continuous feeding via PEG tube via pump per hospital orders. Ideal body weight: 154 pounds +/- 10% 2/3/2023: Dietitian changed orders to Diabetisource AC 75ml/hr x 10 hours (from 8pm-6 am) + Diabetisource AC Bolus feeds (250 ml each) three times per day bolus feeds via PEG Tube. This provided 1800kcal/ 90g protein and 2008 ml total fluids. Per Dietitian notes, admission enteral order was changed since it did not meet resident's nutrition needs and Resident # 58 expressed not wanting to push the tube feeding pole down the hall during therapy. Hence, nocturnal 10 hour feeding regimen + bolus feeding regimen in the daytime was added. 2/27/2023: Dietitian documented significant weight loss of -2.6% x 7 days AND -6.4% x 1 month. Tube feeds orders changed to Diabetisource AC 80 ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day via PEG Tube which provided 1860 kcal/ 93 g protein and 2090 ml total fluids. 3/13/2023: Dietitian changed Tube feeds orders again to Diabetisource AC 85ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day via PEG Tube to provide 1920 kcal/ 96 g protein and 2091 ml fluids + med flush. 3/24/2023: Dietitian documented weight stable this month with increased tube feed rate to 85ml/hr since 3/13/2023. She documented she suspected weights of 153.5 pounds (weighed on 2/15) and 153.5 pounds (weighed on 2/3/2023) were inaccurate. 4/30/2023: no changes to enteral orders. Weekly weight monitoring continued. No excess residuals, distensions, or other signs of intolerance noted in Dietitian note. 5/14/2023: Dietitian documented significant weight loss of - 12.05% x 6 months and -8.79% x 3 months. Dietitian noted that current enteral feeding should have been adequate in meeting estimated nutritional needs however resident had exhibited significant weight loss. Dietitian deemed recent infection Pneumonia and Shortness of breath likely contributed to weight loss. Record Review of Resident's #58 progress notes revealed that he was NPO and dependent on enteral tube feeding for his nutrition and hydration. Resident #58 had a deficit of 900 kcal in past 72 hours and 45 grams deficit in past 72 hours as indicated by pump history record review. Record Review of Resident #58 MAR indicated that Tube feed formula Diabetisource AC 85ml/hr x 10 hours on at 8 pm and off at 6 am + 250 ml Diabetisource three times per day via bolus feeding daily. Clear pump and record intake. Record review of TAR between 5/1/2023 - 5/16/2023 on 6 am shift indicated that pump feeding records had values ranging from 85,520,680, 800, 1000 ml. Similarly, on the 8 pm shift from 5/1/2023-5/16/2023, TAR revealed that values were between 85, 100, 180, 200, 240, 250, 320, 500 ml. There was no consistency in documenting between the actual volume of feedings resident received. Record review of care plans revealed that significant weight loss Care plan was added on 5/14/2023, however there were no Goals or Interventions for the associated care plan. As of 5/16/2023, there was no documentation for change in condition in the care plan documentation based on significant weight loss triggered on 5/10/2023. Record review of care plan also had no documentation regarding any behavior resident #58 was displaying such as moving about in the night, thus accidentally disconnecting the feeding pump. In an observation with LVN G on 5/16/2023 12:16 pm, Resident # 58 was standing at the door of his room with his walker. LVN G performed hand hygiene, don gloves and proceeded to administer resident with one can (250 ml) of Diabetisource AC via PEG tube via bolus feed. Also noted that, Resident #58 got two crush medicine (Carbidopa and Entacapone) mixed with water along with bolus tube feeding. LVN G then administered appropriate amount of water flush post medicine and feed administration. Tube feed kangaroo pump history was reviewed with LVN G. Observation on 05/16/2023 at 12:25 pm the Kangaroo pump (used for tube feeding) revealed that for the last 72 hours Resident #58 received 60 ml/hr for PEG tube feeding and total volume fed was at 2008 ml. Water flush was set at 200ml every 4 hours, water flush administered via pump was at 1740 ml. Reviewed physician orders along with LVN for the tube feeding pump, the feed rate in the physician order was for 85ml/hr, dated March 13, 2023 per MAR. LVN G stated he was not aware of the 85ml/hr physician order. On asking, if the feed rate set on the kangaroo pump (used for tube feeding) was checked against the physician orders in chart, LVN G answered he usually would take the resident off the pump during his shift and did not note the pump rate or record actual feed volume on the pump or cleared the pump settings after the tube feeding administration was completed, which was also noted on the physician orders. In an interview with LVN G on 5/16/2023 at 2:02 p.m., LVN G was working with the facility for six weeks now as a full time LVN, he worked as an agency LVN before in the same facility. He usually worked 6am-2pm shift and had known the resident well. He worked the morning 6am-2pm and afternoon 2pm-10 pm shift on Monday 15th, 2023 and morning 6am-2pm shift on Tuesday 16th, 2023. Weights were also reviewed with LVN G. Resident had triggered for weight loss pattern since admit. Resident had 7.85% significant weight loss over a three-month period from 02/22/23 to 05/10/23. LVN G noted that he had not seen any weight loss, and no one had made him aware of resident losing weight. LVN G agreed he was seeing weight loss on the weight chart in electronic medical record and stated that if someone had made him aware of it, he would have paid closer attention to resident's tube feeding rate. He also stated that he is not sure if resident's physician had been informed about significant weight loss that was triggered on 5/10/2023. LVN G stated that if a resident who is dependent on tube feeds for all his nutrition and hydration does not get prescribed tube feeding, it would result in weight loss and possible skin breakdown. In an interview with LVN J, on 5/16/2023 at 3:05 p.m., LVN J revealed that he was not familiar with Resident # 58 tube feeding rate or pump since it was his first time working with the resident that day (2pm-10 pm shift on 5/16/2023). LVN J was not aware of any significant weight loss Resident # 58 was experiencing. LVN J revealed he had seen the Resident # 58 walking the hallways multiple times with his walker when he worked the other halls. In an interview with Agency LVN H on 5/15/2023 at 3:42 p.m., She worked the 10pm- 6 am shift on the following days - May 9, 10, 11th 2023Agency LVN H stated she had disconnected the Resident # 58 tube feeding pump at 6 am when the tube feeding was completed; however, she did not remember the actual rate but thought the pump had been on feed rate of 65ml/hr. She did not document the total fed rate (as shown on the kangaroo pump) on MAR or TAR, nor did she clear the pump after the shift ended. She did not double check the physician order in the EMR since she thought the pump has already been programmed to the correct rate. She also stated that she was not provided any training on PEG feedings / kangaroo pump administration by the facility since she is Agency RN, they are expected to know PEG feedings/ how Kangaroo pump functions. She has only worked 10pm-6 am shifts at the facility and has been responsible for disconnecting the resident's feeding tube at 6 am by the end of the shift. In an interview with LVN I, full time facility LVN on 5/16/2023 at 3:49 p.m., stated that he worked 5/13 and 5/14 on 10pm-6 am shift. He verbalized he disconnected resident's feeding tube as part of his night shift duties at 6 am in the morning when his shift ended. He mentioned he did not usually look at the pump rate when he disconnected the feeding from the resident and did not check the enteral pump feed rate against the physician orders. He also he did not typically record volume infused on the pump or clear the pump settings as outlined in the physician order. LVN I also stated that patient had some behavior issues such as resident would be irritable at night, get up by himself and move himself from recliner to bed in the night, and in the process resident's PEG tube would be disconnected sometimes in the night. He also stated that he knows some agency LVN's who forgot to administer resident's nightly tube feeds at 8 pm, and then would bolus a can of feeding at that time; this happened 1-2 occasions in the last 3 months. LVN I did not provide names of agency RN's. He also stated he did not document this in the Nursing progress notes. LVN I stated that he was not aware that Resident # 58 was losing weight or triggered for significant weight loss on 5/10/2023, but he thought that the resident looked [NAME] at times. Again, LVN I did not bought up Resident # 58 behavior issues in the night or not receiving tube feed formula via pump to any other Nursing staff in the facility. In an interview with Dietitian, on 5/16/2023 at 4:10 p.m., it was revealed that she wrote tube feeding orders for the facility. She also stated that she had known Resident # 58 and was not aware of any issues with resident tolerating tube feeds. She acknowledged Resident # 58 had lost weight since admit to the facility, however stated that resident's weight was stable in the last month. Dietitian also stated that the resident had antibiotic treatment started recently for pneumonia which could be the cause of recent weight loss in the last week. Dietitian stated that she provided a list of residents who triggered for weight loss either weekly or monthly via email to the DON. She was not sure of the process the facility had in place for reweighing residents once weight loss was identified. She did not make any additional changes to Resident # 58's enteral feeding since she found significant weight loss that was triggered on 5/10. She was due to see the resident on the day of this interview. She revealed that she had not seen a reweigh was done on the resident since 5/10 significant weight loss. Dietitian stated that she had not seen any high blood glucose levels on the resident's labs since admit, hence specialty Glucose controlled formula was not required; but was not clear on why higher calorie tube feed formula (v/s the current 1.2 Diabetisource formula) was not used despite continued weight loss pattern Resident # 58 displayed. She revealed that she usually goes to resident's room to check on feeding pump, but she did not check on residents # 58 pump settings in the room since the order was changed to Diabetisource 85ml/hr x 10 hours in March. She also verbalized that since she had seen the resident sleeping in his recliner most times and wanted to change Resident # 58 tube feedings to 22-hour continuous regimen. She noted that she had not consulted with DON, Charge nurse or resident's treating physician on this recommendation. Dietitian reported she was not aware of resident being mobile and walked the hallways with walker. Dietitian failed to communicate and follow-up on significant weight loss of 18 pounds from 01/31/23 to 05/10/23 to the facility; verify adequate nutrition was provided via PEG tube as ordered and implement resident centered enteral tube feeding nutrition plan. Record reviews of Resident # 58 laboratory report dated 5/12/2023 indicated that Blood glucose was within normal range. Attempted to reach LVN L who worked 5/13/2023 on Morning shift 6am-2pm and afternoon shift 2pm-10 pm, however she could not be reached despite leaving voicemail for her at 4:16 p.m. on 5/16/2023; also asked the facility to contact LVN L. No call back received. In a phone interview with Agency LVN F on 5/17/2023 at 8:55 a.m., she stated that she worked on 5/14/2023 from 2 pm-10 pm shift. She reported she double checked the tube feed rate with the orders. She does not remember the feed rate on the pump. Agency LVN F stated that she did not had to reprogram or clear the pump when she started the pump that evening to administer the feeding. Agency LVN F also did not documented fed volume from the pump to eMAR. Agency LVN F noted that she was not provided any training by the facility regarding PEG tube/ weights/ kangaroo pump functioning when she started working at the facility. In an interview with Restorative Aide on 5/17/2023 at 10:50 AM, it was revealed that she did the weekly weights in the facility for the past one year for most residents. Weekly weights were performed every Wednesday and Resident # 58 was on weekly weight list since February 2023. Restorative Aide confirmed she weighed the patient on February 22, April 5, April 19, May 3 and May 10. Restorative Aide noted that resident can walk up to the weighing scale independently with a walker and can stand up unassisted on the weighing scale. Restorative Aide also stated that she saw Resident # 58 walking hallways of the facility on many occasions with a walker. In an interview DON on 5/17/2023 at 11:40 a.m., revealed the DON had been at the facility for about four weeks only. Restorative Aide was responsible for doing the weekly weights and Staffing Coordinator was responsible to ensure weekly weights and re-weighs were completed. DON stated after Dietitian informed her on 05/10/23 of residents including Resident #58 who need to be re-weighed she included the Staffing Coordinator in a text to have these residents' re-weights. She had been informed of Resident #58 needing to be re-weighed on 05/10/23 but had not followed through to ensure re-weight was completed for Resident #58. She stated ADON's were responsible for monitoring weights, but they were both new to the facility as well. She reported that ADON's are responsible to see if the residents are receiving the enteral formula as ordered by the physician. She stated the risk for residents who are NPO and dependent on enteral feeding for all their nutrition and hydration orders are weight loss, hydration issues, potential skin breakdown and deranged lab values. Interview with the ADON A on 5/17/2023 at 12:10 p.m., revealed she had started at the facility about 2 weeks ago. She was not aware who was the designated person for weight monitoring. ADON A stated that she did not receive training for monitoring of weights and is still learning the system. She stated she had not had the opportunity to look at Resident #58's enteral feeding pump to ensure Resident #58 received the physician ordered enteral feeding. Interview with the DON on 05/17/23 at 12:42 p.m., revealed on Resident #58's kangaroo feeding pump if the settings were not cleared by nurse, you can go back and see the volume history of how much enteral feeding Resident #58 received. DON stated she was unaware of nurses lack of administering Resident #58's appropriate tube feeding for Resident #58 nocturnal feeding at 85 ml/hour for 10 hours. She stated she had not had an opportunity to look at Resident #58's enteral feeding pump to ensure Resident #58 received the appropriate enteral feeding. In an interview with Physician A on 5/17/2023 at 1:39 p.m., he stated that he was notified of significant weight loss earlier, but he did not remember when exactly, he recollected couple of months ago. He does not recollect recent notification for weight loss. Physician A was not aware of significant weight loss that was triggered on 5/10/2023; he was not informed. Physician A stated that he expected the physician order as put in by Dietitian to be followed for all enteral feeding patients. Physician A also stated that he was not aware that the Resident # 58 is not getting his prescribed feedings. 2. Review of Resident #28's Admission MDS assessment dated [DATE] reflected Resident #28 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of wedge compression fracture of vertebra, hypertension, Alzheimer's disease and dementia. Resident #28's height was 62 inches and weight of 113. She had a BIMS of 7 indicating she was severely cognitively impaired. Resident #28 required extensive assistance with ADLs except for toileting. Resident #28 eating ADL occurred once or twice with one person physical assistance. Review of Resident #28's Hospital discharge paperwork dated 04/21/23 did not reflect a height or weight for Resident #28. Review of Resident #28's Weight Record reflected the following: Date Weight (in Pounds) 04/21/2023 113 05/02/2023 89.5 05/11/2023 87 05/18/2023 89.5 Weight Loss calculations reflected on 05/02/23 - Resident #28 had a 20.8% weight loss with 23.5 lb loss since admission, 05/11/2023 had a 23% weight loss with 26 lbs lost since admission. Review of Resident #28 Nutrition Assessments reflected: - Record date of 04/24/23 and signed 05/03/23 by Registered Dietitian reflected Resident #28 was regular diet with thin liquids, oral intake was 75 to 100%, current weight of 89.5 lbs, 16.4 BMI (underweight) and adjusted body weight IBW (ideal body weight) 110+/-10%, hospital labs potassium low (3.3), BUN high (28), creatine low (0.5). Interventions included diet as prescribed, recommended 1) Nursing - please obtain reweight to confirm true weight loss 2) Nursing: Weekly weight x 4 weeks. Please follow to assure cessation of weight loss. 3) Nursing: Add order for diet texture. - Record date and signed date of 05/12/23 by Registered Dietitian reflected RD note to address sig wt loss for 5/2023- Resident is receiving a regular diet (no therapeutic diet restrictions). Tolerating without issue - consuming 75-100% of meals. She is independent/occasional staff assist with eating and usually eats in her room. Impaired cognition per notes. No constipation per staff - on Colace. No pressure wounds or skin breakdown noted on today's wound report. Labs/meds reviewed- MVI QD. UA still pending. Estimated needs: Kcals/day: 1260-1440 kcal/d (30-35 kcal/kg CBW)*underweight. Prot gm/day: 49-53 gm/d (1.2-1.3 gm/kg CBW)*underweight.Fluid ml/day: 1500 ml/d minimum or per MD. Anticipate alteration in nutrition and hydration status r/t impaired cognition, BMI status and sig wt loss.Weights: (5/11) 87, (5/2) 89.5, (4/21) 113.CBW (5/11) 87 - significant wt loss of -2.79% x 7 days and -23% since admission.BMI 15.91 underweight. She is at high risk for malnutrition. Question accuracy of 4/21 weight.Anticipate alteration in nutrition and hydration status r/t impaired cognition, BMI status and sig wt loss. Recommend: 1) Nursing: Weekly weights x 4 weeks. Please follow to assure cessation of weight loss. 2 Nursing: Add .order for diet texture. 3) Nursing: Encourage meals in dining room for monitoring and additional assistance as needed. 4)Boost 1 carton po QD at 230 pm (240 kcal, 10 gm prot) for weight maintenance. RD to follow as needed. Review of the DON's email with subject line RD visit and recommendations 5/2/23 from Registered Dietitian dated 05/04/23 at 5:26 PM reflected Registered Dietitian emailed the Administrator, ADONs and the DON about Resident #28 being a new admit and possible weight loss. Registered Dietitian reflected recommendations of (Nursing - Please obtain reweight to confirm true weight loss. 2) Nursing: Weekly weights x 4 weeks. [NAME] follow to assure cessation of weight loss. 3) Nursing: Add order for diet texture. Review of Resident #28's Meal Intake for May 2023 reflected Resident #28 had meal intake of 50 to 100% intake. Review of Resident #28's Physician Orders and eMAR for May 2023 reflected Resident #78 was started on boost daily. No other weight loss interventions were in place as of 05/17/23 and 05/19/23. Interview on 05/19/23 at 10:35 AM, with Registered Dietitian reflected she completed her first nutrition note for Resident #28 on 05/02/23 and she did see there was a concern with weight loss. She stated Resident #28 had good oral intake of 75 to 100% intake and did not add any weight loss interventions since resident was eating well. She stated she recommended weekly weights and put texture order in system. She stated Resident #28 was a new admit already on weekly weights. She did not ask for re-weights on 05/02/23 and sent the DON her recommendations via email as she normally did. She did not follow up with DON or nursing to ensure re-weight was completed. She stated nursing was responsible for notifying the physician of significant weight loss. She stated she either communicated in passing or in email her recommendations to the DON. She stated on 05/12/23 when Resident #28 continued to lose weight of 2.5 lbs more she recommended Resident #28 to be put on one boost shake daily. She stated she had not followed up to see how Resident #28 was tolerating and if compliant with boost shake. She stated she questioned the admission weight but did not communicate with DON about it. She stated Resident #28 did have a low body mass index but she had good oral intake. Review of DON's text dated 05/10/23 at 9:22 PM reflected resident reweights for Residents #28 and #58 who was included in the text message. Interview on 05/19/23 at 11:19 AM with DON revealed she did not request re-weights for Resident #28 until 05/10/23. She had only been at the facility about 4 weeks. She stated reweights should have been completed with 24 hours on 05/02/23 when significant weight loss triggered. She stated the Registered Dietitian could have communicated with me on 05/02/23 when she reviewed the weight for Resident #28 to have her re-weighed and about her significant weight loss. She stated she was ultimately responsible for ensuring weights were monitored. She stated the communication with the Registered Dietitian was by email about her recommendations, but she did not include in her documentation about what the percentage of the significant weight loss was. She stated Resident #28 was a new admit and should have been weighed weekly for at least 4 weeks. She stated Resident #28 would be notified today of significant weight loss and should have been notified on 05/02/23 when first triggered for significant weight loss. In an interview with Medical Director, who is Resident #28's Physician at 5/17/2023 on 1:48 p.m., was asked what the risk for a resident who is dependent on enteral feeds for nutrition and hydration, NPO status and not receiving Enteral feeds as ordered. The Medical Director responded, resident would be at risk for dehydration, malnutrition, weight loss and skin breakdown. He also stated he would like to be notified if one of his residents had significant weight loss and if physician orders were not followed. Review of facility's policy Weight Monitoring revised 01/12/20 reflected Resident weights will be recorded and monitored at a minimum frequency of monthly. Procedures: 1. Nursing weighs residents within 24 hours of admission and re-admission. Newly admitted residents are weighed upon admission and then weekly x4 and then monthly thereafter, unless otherwise indicated by physician's order. 2. Weights and re-weigh results are recommended to be recorded in the EHR .3. If the month-to-month show more than a five percent (5%) gain or loss, the resident is reweighed within 24 hours. If there is an actual five percent (5%) or more gain or loss in one moth, the resident/family, physician and the Registered Dietitian are notified by the Nursing Department. The date of such notification is documented in the nurses note in the EHR. 5. The Registered Dietitian reviews the resident's nutritional status and makes recommendations for intervention in the nutritional therapy assessment if significant weight change is noted. 6. Significant, unplanned changes in weights are reviewed at the Standards of Care Committee meeting. The Committee will also identify any gradual weight loss trends. Significant changes in weights are documented in the plan of care with goals and approaches/interventions listed .8. Unplanned and undesired weight variance will be evaluated for significance utilizing the Resident Assessment Instrument Guidelines. Suggested guidelines are as followed: 5% in 30 days 7.5% in 90 days and 10% in 180 days. Review of facility's policy Enteral Nutrition for Closed System Nasogastric, Nasointestinal, Gastric and Jejunal feeding tubes last revised 01/12/20 reflected Enteral nutrition therapy will be performed in a safe manner by qualified licensed nurses according to standard practice guidelines .Procedures: .3. Check physician's order for formula, route, rate and frequency .9. Turn on pump. Follow manufacturer's specifications. The Administrator was notified of the Immediate Jeopardy on 05/17/23 at 5:36 PM due to the above failures and provided the IJ template. A Plan of Removal was requested. The Facility's Plan of Removal was accepted on 05/19/23 at 2:36 PM and included the following: The facility's response to the IJ for the facility to implement a Plan of Removal to prohibit weight loss for Resident #58 on enteral feedings. On 5/17/2023 the facility failed to ensure that nursing staff implemented the interventions of enteral feeding at 85 ml/hr. for 10 hours. Resident #58 had a 7.85% significant weight loss over a three-month period from 02/22/23 to 05/10/23. Process Due Date Note: When ADON is referenced in this plan of removal, it is referencing to the ADON assigned to the room the resident resides in. ADON and rooms are detailed below: Rooms 200 thru 406, [NAME] Valentine LVN ADON A Rooms 407 thru 716, ADON B Within 24 hours of the resident's admission or readmission, the resident will be weighed by the admission nurse. The admission nurse will then enter the weight in the resident's weight log. The charge nurse is the back-up for this process when the admission nurse is not available. RN Nurse Consultant will train DON and Administrator on this process. DON will train the ADONs and other nursing staff on this process prior to the start of their shift. 5-19-23 The assigned ADON will monitor the previous days new admissions and readmissions daily to ensure the weight is obtained and entered in the resident's weight log. The Director of Nursing is the back-up for this process when the respective ADON is not available. RN Nurse Consultant will train DON and Administrator on this process. DON will train the ADONs and other nursing staff on this process prior to the start of their shift. 5-19-23 Newly admitted or readmitted residents will be weighed weekly by Restorative Aide for four weeks, starting the following week. Once this four-week period is complete, then the resident will be weighed monthly or

48560 Based on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for one (Resident #58) of the four residents reviewed for enteral tube feeding, in that: 1. Dietitian failed to communicate and follow-up on Resident #58's significant weight loss of 18 pounds from 01/31/23 to 05/10/23 to the facility and verify adequate nutrition was provided via enteral tube feeding or PEG tube (surgical placement of feeding tube in the stomach to provide nutrition, hydration and/or medicines) for Resident #58. Dietitian also failed to implement resident centered enteral tube feeding nutrition plan for Resident #58. 2. LVN G, LVN I and LVN F failed to administer enteral feedings to Resident #58 as ordered by the physician for last 72 hours (May 13, May 14, and May 15). Resident #58 experienced continuous significant weight loss of -7.85% (11.5 pounds) in the last three months since 2/22/2023 AND -12% (18.5 pounds) since admit weight of 2/3/2023. An Immediate Jeopardy (IJ) situation was identified on 05/17/23 at 5:39 PM. While the IJ was removed on 05/20/23 at 5:30 PM, the facility remained out of compliance at a scope of isolated at the severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. These failures could place residents who are completely dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown and overall decline in quality of care. Findings included: Review of MDS assessment dated [DATE] for Resident #58 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of Parkinson's disease (brain disorder that causes unintended or uncontrollable moments), Dysphagia of oropharyngeal phase (difficulty swallowing), Pneumonitis due to inhalation of food and vomit (lung infection caused by inhaling food, saliva or other), Cognitive Communication deficit ( inability to communicate properly) , Dysarthria (difficulty in speaking related to weak muscles), Dysphonia (difficulty speaking related to physical disorders of vocal cords), Muscle weakness and other chronic pain conditions. Review revealed the resident had a BIMS score of (09), which meant the resident was moderately impaired cognition. The resident required extensive assistance with ADLs and was incontinent of bowel and bladder. It reflected that patient had PEG tube in place for enteral feedings on admission and was NPO, dependent on PEG tube feedings for nutrition and hydration. The resident was at risk for weight loss. The resident's height was 5 feet 8 inches, and the hospital admission weight was 153 pounds. Residents' # 58 Ideal body weight: 154 pounds (+/- 10%) In an observation for Resident # 58 on 05/16/2023 at 10:44 pm, it was noted that the resident was resting in his recliner. Observed tube feeding pump next to the recliner on the pole was off. Resident was not interviewable at time of visit. Resident could only answer in yes and no questions, however, did not have clear perception of time, date or place. During exit from resident's room, Noted X-ray tech had entered resident's room to take images. In a phone interview with Resident #58's responsible party on 5/16/2023 at 11:44 am , it was revealed that Resident # 58 had lost some weight and looked skinny and bony lately than from time of admit in January. They also stated that the resident had missed some of his nocturnal tube feeds via pump for couple days in the past but had not seen that lately. Responsible party could not substantiate time frame as to when exactly the resident did not get feedings or who reported this to her. Responsible party did not voiced any other concerns for the resident at that time. Record review of weight chart for the resident included the following: Date Weight (in Pounds) 02/03/2023 153.5 02/15/2023 153.5 02/22/2023 146.5 03/01/2023 143.9 03/08/2023 142.0 03/15/2023 143.7 03/22/2023 143.2 03/29/2023 140.5 04/06/2023 140.5 04/19/2023 139.5 05/03/2023 140.0 05/10/2023 135.0 On 05/10/2023, Resident # 58's weight was 135 pounds and triggered for significant weight loss of -7.85% (11.5 pounds) in the last three months since 2/22/2023 AND -12% (18.5 pounds) since admit weight of 2/4/2023. Record review for Nutrition assessment by Dietitian indicated the following: 01/31/2023: Diabetisource AC 50ml/hr x 22-hour continuous feeding via PEG tube via pump per hospital orders. Ideal body weight: 154 pounds +/- 10% 02/03/2023: Dietitian changed orders to Diabetisource AC 75ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day bolus feeds via PEG Tube. This provided 1800kcal/ 90g protein and 2008 ml total fluids. Per Dietitian notes, admission enteral order was changed since it did not meet resident's nutrition needs and Resident # 58 expressed not wanting to push the tube feeding pole down the hall during therapy. Hence, nocturnal 10 hour feeding regimen + bolus feeding regimen in the daytime was added. 02/27/2023: Dietitian documented significant weight loss of -2.6% x 7 days AND -6.4% x 1 month. Tube feeds orders changed to Diabetisource AC 80 ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day via PEG Tube which provided 1860 kcal/ 93 g protein and 2090 ml total fluids. 03/13/2023: Dietitian changed Tube feeds orders again to Diabetisource AC 85ml/hr x 10 hours (from 8pm-6 am) +Diabetisource AC Bolus feeds (250 ml each) three times per day via PEG Tube to provide 1920 kcal/ 96 g protein and 2091 ml fluids + med flush. 3/24/2023: Dietitian documented weight stable this month with increased tube feed rate to 85ml/hr since 3/13/2023. She documented she suspected weights of 153.5 pounds (weighed on 2/15) and 153.5 pounds (weighed on 2/3/2023) were inaccurate. 04/30/2023: no changes to enteral orders. Weekly weight monitoring continued. No excess residuals, distensions, or other signs of intolerance noted in Dietitian note. 05/14/2023: Dietitian documented significant weight loss of - 12.05% x 6 months and -8.79% x 3 months. Dietitian noted that current enteral feeding should have been adequate in meeting estimated nutritional needs however resident had exhibited significant weight loss. Dietitian deemed recent infection Pneumonia and Shortness of breath likely contributed to weight loss. Record Review of resident's #58 progress notes revealed that he was NPO and dependent on enteral tube feeding for his nutrition and hydration. Resident #58 had a deficit of 900 kcal in past 72 hours and 45 grams deficit in past 72 hours as indicated by pump history record review. Record Review of Resident #58 MAR indicated that Tube feed Diabetisource AC 85ml/hr x 10 hours on at 8 pm and off at 6 am + 250 ml Diabetisource three times per day via bolus feeding daily. Clear pump and record intake. Record review of TAR between 5/1/23 - 5/16/23 on 6 am shift indicated that pump feeding records had values ranging from 85,520,680, 800, 1000 ml. Similarly, on the 8 pm shift from 5/1/23-5/16/23, TAR revealed that values were between 85, 100, 180, 200, 240, 250, 320, 500 ml. There was no consistency in documenting between the actual volume of feedings resident received. Record review of Resident # 58's care plans revealed that significant weight loss Care plan was added on 5/14/2023, however there were no Goals or Interventions for the associated care plan. As of 5/16/2023, there was no documentation for change in condition in the care plan documentation based on significant weight loss triggered on 5/10/2023. Record review of care plan dated 02/03/2023 had no documentation regarding any behavior Resident #58 was displaying such as moving about in the night, thus accidentally disconnecting the feeding pump. In an observation with LVN G 12:16 pm on 5/16/2023, Resident # 58 was standing at the door of his room with his walker. LVN G performed hand hygiene, don gloves and proceeded to administer resident with 1 can (250 ml) of Diabetisource AC via PEG tube via bolus feed. Also noted that, Resident # 58 got two crush medicine (Carbidopa and Entacapone) mixed with water along with bolus tube feeding. LVN G then administered appropriate amount of water flush post medicine and feed administration. Tube feed kangaroo pump history was reviewed with LVN G. Observation on Tube feed Kangaroo pump revealed that for the last 72 hours resident #58 received 60 ml/hr for PEG tube feeding and total volume fed was at 2008 ml. Water flush was set at 200ml every 4 hours, water flush administered was at 1740 ml. Reviewed physician orders along with LVN for the tube feeding pump, the feed rate in the physician order was for 85ml/hr, dated March 13, 2023 per MAR. LVN G stated he wasn't aware of the 85ml/hr physician order. On asking, if the feed rate set on the enteral feeding pump was checked against the physician orders in chart, LVN G answered he usually would take the resident off the pump during his shift and did not note the pump rate or record actual feed volume on the pump or clear the pump settings after the tube feeding administration was completed, which was also noted on the physician orders. In an interview with LVN G on 5/16/2023 atr 2:02 p.m., LVN G was working with the facility for six weeks now as a full time LVN, he worked as an agency LVN before in the same facility. He usually worked 6am-2pm shift and had known the resident well. He worked the morning 6am-2pm and afternoon 2pm-10 pm shift on Monday 15th, 2023 and morning 6am-2pm shift on Tuesday 16th, 2023. Weights were also reviewed with LVN G. Resident had triggered for weight loss pattern since admit. Resident had 7.85% significant weight loss over a three-month period from 02/22/23 to 05/10/23. LVN G noted that he had not seen any weight loss, and no one had made him aware of resident losing weight. LVN G agreed he was seeing weight loss on the weight chart in electronic medical record and stated that if someone had made him aware of it, he would have paid closer attention to resident's tube feeding rate. He also stated that he is not sure if resident's physician had been informed about significant weight loss that was triggered on 5/10/2023. LVN G stated that if a resident who is dependent on tube feeds for all his nutrition and hydration does not get prescribed tube feeding, it would result in weight loss and possible skin breakdown. In an interview with LVN J, on 5/16/2023 at 3:05 p.m., LVN J revealed that he was not familiar with Resident # 58 tube feeding rate or pump since it was his first time working with the resident that day (2pm-10 pm shift on 5/16/2023). LVN J was not aware of any significant weight loss Resident # 58 was experiencing. LVN J revealed he had seen the Resident # 58 walking the hallways multiple times with his walker when he worked the other halls. In an interview with Agency LVN H on 5/15/2023 at 3:42 p.m. , She worked the 10pm- 6 am shift on the following days - May 9, 10, 11th, 2023. Agency LVN H stated she had disconnected the Resident # 58 tube feeding pump at 6 am when the tube feeding was completed; however, she did not remember the actual rate but thought the pump had been on feed rate of 65ml/hr. She did not document the total fed rate (as seen on the pump) on MAR or TAR, nor did she clear the pump after the shift ended. She did not double check the physician order in the EMR since she thought the pump has already been programmed to the correct rate. She also stated that she wasn't provided any training on PEG feeding / kangaroo pump administration by the facility since she is Agency RN, they are expected to know PEG feedings/ how Kangaroo pump functions. She has only worked 10pm-6 am shifts at the facility and has been responsible for disconnecting the resident's feeding tube at 6 am by the end of the shift. In an interview with LVN I, full time facility LVN at 3:49 pm on 5/16/2023 at 3:49 p.m. , stated that he worked 5/13/23 and 5/14/23 on 10pm-6 am shift. He verbalized he disconnected resident's feeding tube as part of his night shift duties at 6 am in the morning when his shift ended. He mentioned he did not usually look at the pump rate when he disconnected the feeding from the resident and did not check the enteral pump feed rate against the physician orders. He also he did not typically record volume infused on the pump or clear the pump settings as outlined in the physician order. LVN I also stated that patient had some behavior issues such as resident would be irritable at night, get up by himself and move himself from recliner to bed in the night, and in the process resident's PEG tube would be disconnected sometimes in the night. He also stated that he knows some agency LVN's who forgot to administer resident's nightly tube feeds at 8 pm, and then would bolus a can of feeding ( 250 ml Diabetisource AC formula) at that time; this happened 1-2 occasions in the last 3 months. LVN I did not provide names of agency RN's. He also stated he failed to document that certain Agency Nurses did not administer tube feeding via pump in the Nursing progress notes. LVN I stated that he was not aware that Resident # 58 was losing weight or triggered for significant weight loss on 5/10/2023, but he thought that the resident looked [NAME] at times. LVN I did not bought up Resident # 58 behavior issues in the night to any other Nursing staff in the facility. In an interview with Dietitianon 5/16/2023 at 4:10 p.m., it was revealed that she wrote tube feeding orders for the facility. She also stated that she had known Resident # 58 and was not aware of any issues with resident tolerating tube feeds. She acknowledged resident had lost weight since admit to the facility, however stated that resident's weight was stable in the last month. She also stated that the resident had antibiotic treatment started recently for pneumonia which could be the cause of recent weight loss in the last week. Dietitian stated that she provided a list of residents who triggered for weight loss either weekly or monthly via email to the DON. She was not sure of the process the facility had in place for reweighing residents once weight loss was identified. She did not make any additional changes to Resident # 58 tube feeding since she found significant weight loss that was triggered on 5/10/23. She was due to see the resident on the day of this interview. She revealed that she had not seen a reweigh was done on the Resident # 58 since 5/10/2023 significant weekly weight loss. Dietitian stated that she had not seen any high blood glucose levels on the resident's labs since admit, hence specialty Glucose controlled formula was not required; but was not clear on why higher calorie tube feed formula (v/s the current 1.2 Diabetisource formula) was not used despite continued weight loss pattern Resident # 58 displayed. She revealed that she usually goes to resident's room to check on feeding pump, but she did not check on Residents # 58 pump settings in the room since change order of Diabetisource 85ml/hr x 10 hours in March, 2023. She also verbalized that since she had seen the resident sleeping in his recliner most times and wanted to change Resident # 58 tube feedings to 22-hour continuous regimen. She noted that she had not consulted with DON, Charge nurse or Resident # 58 treating physician on this recommendation. Dietitian reported she was not aware of resident being mobile and walked the hallways with walker. Dietitian said she failed to verify adequate nutrition was provided via PEG tube as ordered and implement resident centered enteral tube feeding nutrition plan. Record reviews of Resident # 58 laboratory report dated 5/12/2023 indicated that Blood glucose was within normal range. Attempted to reach LVN L who worked 5/13/2023 on Morning shift 6am-2pm and afternoon shift 2pm-10 pm, however she could not be reached despite leaving voicemail for her on 5/16/2023 at 4:16 pm ; also asked the facility to contact LVN L. No call back received. In a phone interview with Agency LVN F on 5/17/2023 at 8:55am she stated that she worked on 5/14/2023 from 2 pm-10 pm shift. She reported she double checked the tube feed rate with the orders. She does not remember the feed rate on the pump. Agency LVN F stated that she did not had to reprogram or clear the pump when she started the pump that evening to administer the feeding. Agency LVN F also did not documented fed volume from the pump to eMAR. Agency LVN F noted that she was not provided any training by the facility regarding PEG tube/ weights/ kangaroo pump functioning when she started working at the facility. In an interview with Restorative Aide on 5/17/2023 at 10:50 a.m., it was revealed that she did the weekly weights in the facility for the past one year for most residents. Weekly weights were performed every Wednesday and Resident # 58 was on weekly weight list since February 2023. Restorative Aide confirmed she weighed the patient on February 22, April 5, April 19, May 3 and May 10. Restorative Aide noted that resident can walk up to the weighing scale independently with a walker and can stand up unassisted on the weighing scale. Restorative Aide also stated that she saw Resident # 58 walking hallways of the facility on many occasions with a walker. In an interview DON on 5/17/2023 at 11:40 a.m., revealed that DON had been at the facility for about four weeks only. Restorative Aide was responsible for doing the weekly weights and Staffing Coordinator was responsible to ensure weekly weights and re-weighs were completed. DON stated after Dietitian informed her on 05/10/23 of residents including Resident #58 who need to be re-weighed she included the Staffing Coordinator in a text to have these residents' re-weighed. She had been informed of Resident #58 needing to be re-weighed on 05/10/23 but had not followed through to ensure re-weight was completed for Resident #58. She stated ADON's were responsible for monitoring weights, but they were both new to the facility as well. She reported that ADON's are responsible to see if the residents are receiving the enteral formula as ordered by the physician. She stated the risk for residents who are NPO and dependent on enteral feeding for all their nutrition and hydration orders are weight loss, hydration issues, potential skin breakdown and deranged lab values. Interview with the ADON A 5/17/2023 at 12:10 p.m., revealed she started at the facility about 2 weeks ago. She was not aware who was the designated person for weight monitoring. ADON A stated that she did not receive training for monitoring of weights and is still learning the system. She stated she had not had the opportunity to look at Resident #58's enteral feeding pump to ensure Resident #58 received the physician ordered enteral feeding. Interview with the DON on 05/17/2023 at 12:42 p.m., revealed on Resident #58's enteral feeding pump if the settings were not cleared by nurse you can go back and see the volume history of how much enteral feeding Resident #58 received. DON stated she was unaware of nurses lack of administering Resident #58's appropriate enteral feeding for Resident #58 nocturnal feeding at 85 ml/hour for 10 hours. She stated she had not had an opportunity to look at Resident #58's enteral feeding pump to ensure Resident #58 received the appropriate enteral feeding. In an interview with Physician A on 5/17/2023 at 1:39 p.m. at he stated that he was notified of significant weight loss earlier, but he does not remember when exactly, he recollected couple of months ago. He does not recollect recent notification for weight loss. Physician A was not aware of significant weight loss that was triggered on 5/10/2023; he was not informed. Physician A stated that he expected the physician order as put in by Dietitian to be followed for all enteral feeding patients. Physician A also stated that he was not aware that the resident is not getting his prescribed feedings. In an interview with Medical Director on 5/17/2023, at 1:48 p.m., was asked what the risk for a resident who is dependent on enteral feeds for nutrition and hydration, NPO status and not receiving Enteral feeds as ordered. The Medical Director responded, resident would be at risk for dehydration, malnutrition, weight loss and skin breakdown. He also stated that he would be like to be notified if resident has significant weight loss or if physician orders are not followed as ordered. Review of facility's policy Enteral Nutrition for Closed System Nasogastric, Nasointestinal, Gastric and Jejunal feeding tubes last revised 01/12/20 reflected Enteral nutrition therapy will be performed in a safe manner by qualified licensed nurses according to standard practice guidelines .Procedures: .3. Check physician's order for formula, route, rate and frequency .9. Turn on pump. Follow manufacturer's specifications. Review of facility's policy Enteral or Parenteral Nutrition Care: effective 08/01/18 reflected Enteral nutrition will be available for residents who are unable to meet their metabolic needs via oral intake. Procedure: 1. Residents identified with orders for enteral or parenteral nutrition will be assessed by the dietitian according to state and federal guidelines and professional standards of practice. 2. The assessment will include a calculation of the resident's nutritional requirements and a comparison will be made between the resident's requirements and the physician ordered enteral formula.3. The dietitian will routinely assess the nutrition status of the resident receiving enteral nutrition support and determine the appropriateness of continued enteral feeding for nutrition support .The dietitian will review how the formula is being administered, monitor weight, skin condition, labs, physical symptoms, tolerance to feeding,, and oral food/fluid intakes when applicable. The Administrator was notified of the Immediate Jeopardy on 05/17/23 at 5:36 PM due to the above failures and provided the IJ template. A Plan of Removal was requested. The Facility's Plan of Removal was accepted on 05/19/23 at 2:36 PM and included the following: The facility's response to the IJ for the facility to implement a Plan of Removal to prohibit weight loss for resident #58 on enteral feedings. On 5/17/2023 the facility failed to ensure that nursing staff implemented the interventions of enteral feeding at 85 ml/hr. for 10 hours. Resident #58 had a 7.85% significant weight loss over a three-month period from 02/22/23 to 05/10/23. Process Due Date Note: When ADON is referenced in this plan of removal, it is referencing to the ADON assigned to the room the resident resides in. ADON and rooms are detailed below: Rooms 200 thru 406, ADON A Rooms 407 thru 716, ADON B An order will be added for each resident utilizing a g-tube pump that has the charge nurse clear out the pump at the end of their shift and document completion on MAR. For each resident on nutritional support, the charge nurse will document the cc intake during their shift on the Medication Administration Record. ADON will monitor the intake for each resident receiving nutritional support in the morning clinical meeting and the clearing of the pumps. If intake does not match the physician order, the ADON will investigate the root cause of such variance. Corrective actions will be made including notification to physician and one on one in-service with nurse or nurses responsible. The DON is the back-up for this process when the respective ADON is not available. Nurse Consultant will train DON and Administrator on this process. DON will train the ADONs and other nursing staff on this process prior to the start of their shift. 5-19-23 5-19-23 The charge nurse (onging and offgoing) will round each shift when providing shift-to-shift report and visualize residents utilizing g-tube pumps and compare the ordered rate to the rate set on the pump. If a discrepancy is identified, the charge nurse will correct the pump setting, notify the ADON, and enter the information on the 24-hour report. The ADON /DON / or Designee will round each morning, on residents utilizing g-tube pumps and compare the ordered rate to the rate set on the pump. If a discrepancy is identified an investigation will be started to identify the root cause of the discrepancy. The ADON will provide one on one in-service for any deficiencies found. Corrective actions will be made including notification to physician and one on one in-service with nurse or nurses responsible The Director of Nursing will be the back-up for this process if the ADON is not available. Nurse Consultant will train DON and Administrator on this process. DON will train the ADONs and other nursing staff on this process prior to the start of their shift. 5-19-23 5-19-23 For any residents on continuous enteral feedings the RD, DON, ADON, Therapy Manager will meet to ensure a person-centered care plan is in place. This meeting will be held prior to the RD assessment. The care plan will be updated. Nurse Consultant will train the RD, DON, ADONs, Therapy Manager, and Administrator on this process. 5-19-23 Education and Training & Immediate Actions 1:1 Inservice on resident centered care to RD given by head of dietary services. 5-19-23 100% was performed on all resident with enteral feeding orders. The sweep found that all orders and careplan were accurate. 5-19-23 1:1 Nurses given to all charge nurses on hall 300. Inservice on: Following doctors' orders 5-19-23 An immediate sweep of all G-Tube residents. Matched the orders to the flow rate, with updated resident centered care plans have been updated. 5-19-23 Policies and procedures reviewed and updated by Chief of Clinical Operations RNC will train DON/ ADON A /ADON B / Staffing / Primary Aid / Back Up Aid on Policies and procedures and changes 5-1-23 RNC to Inservice all Clinical Management on G-Tube Feedings 5-19-23 RNC to Inservice all Clinical Management on Orders 5-19-23 Inservice on all nurse staff on G-Tube Feedings 5-19-23 Competency on all nurse staff on G-Tube Feedings 5-1-23 RNC will train DON/ ADON A /ADON B / Staffing on weight systems, G-Tube, and competencies. 5-19-23 DON and RD will do a 6 month look back of all weights and identify any residents with a weight loss. 5-19-23 DON and RD will do a 6 month look back of all weights and identify any residents that are at risk for weight loss. 5-19-23 Any Identified residents with weight loss and or high-risk RD completed a new assessment. Care plan to be updated. 5-19-23 Staffing will be responsible for ensuring that any agency nurse has been trained on G-Tubes and G-Tube Process prior to the start of any shift. ADON will be back up for this process 5-19-23 The DON is ultimately responsible for the oversight of the enteral feeding orders and this proces. 5-19-23 The facility's implementation of IJ Plan of Removal was verified through the following: Review of Resident #58's Clinical Record on 05/20/23 revealed interventions were put in place for Resident #58's significant weight loss and Resident #58's current enteral feeding physician order was Isosource 1.5 bolus 375 ml via peg tube for times daily. Resident #58's responsible party and physician was notified. Review of Resident #58's MAR reflected current tube feeding volumes recorded correctly at the ordered times per physician order. Observation on 05/20/23 at 12:27 PM of Resident #58's bolus feeding with LVN S revealed Resident was administered the correct dosage of enteral feeding as ordered by physician with no issues with enteral feeding. Observations on 05/20/23 at 1:20 PM and 1:34 PM of Residents #45 and #75 revealed no issues with enteral feedings. Observations and Interviews with Agency LVN K and RN O revealed able to demonstrate and show surveyors which information they record on the MAR for resident's enteral feedings and knew the process of g-tube administration to ensure physician orders were followed for residents. Reviewed Resident #45 and #75's clinical record on 05/20/23 for current physician orders for resident enteral feedings, correct documentation on Nurse MAR on g-tubes. Interviews on 05/20/23 from 12:27 PM to 4:20 PM with nine nurses from all shifts including facility, weekend and agency nurses (Agency LVN F, LVN G, LVN H, LVN I, Agency LVN K, RN O, LVN P, LVN S, Agency LVN T) revealed nurses had been in-serviced on weight monitoring, enteral feeding pump training, following physician orders and documenting intake for g-tube residents' feeding and change of condition. All nine nurses were aware physician and resident and/or resident responsible party must be notified of change of condition including significant weight loss. All nine nurses were aware of new admits and readmits must be weighed within 24 hours and cannot use the hospital weight to input as new admit weight for residents. All nine residents were able to describe the process to verify physician orders for enteral feedings, how to set up a resident on enteral feeding pump, how to find the volume of enteral feeding intake from the pump, where to document setting and intake of enteral feeding pump. All nine nurses were aware to document about g-tube feedings for residents on 24 hour report. Interviews on 05/20/23 at 4:32 PM to 4:45 PM with ADON A and ADON B revealed were knowledgeable of enteral feeding pumps and how to monitor to ensure residents receive the correct physician ordered enteral feedings. Both were knowledgeable of nurses expected to document on MARs with ongoing and offgoing nurse to review the enteral feeding pump settings at shift change for residents on enteral feeding pump. They both were responsible to ensure any agency nurses or facility nurses who came to work were in-serviced prior to starting their shift on g-tube administration, enteral feeding pumps including documentation and following physician orders. They stated moving forward they both will review g-tube administration records to ensure residents receive the appropriate physician order enteral feedings. Interview on 05/20/23 at 4:57 PM with DON revealed she was ultimately responsible to ensure residents on enteral feeding received the appropriate nutrition intake as ordered by the physician. She stated ADONs will check each morning to ensure residents have the correct enteral feeding and to look at the enteral feeding pumps to ensure residents receive the correct amount of intake. She stated the ADONs will be responsible to review and to calculate resident's enteral feedings from all shifts to ensure residents on enteral feedings receive the appropriate enteral feedings intake. She state they will have clinical stand up meeting to review residents on enteral feedings. On 05/20/23 at 5:30 PM, the Administrator was notified the IJ was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not IJ, due to facility continuation of in-servicing and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable for one (Resident #69) of 19 residents reviewed for limited ROM. The facility failed to implement timely interventions for Resident #69's left hand when her left hand began to contract. Resident #69 is left hand dominant. The facility was aware of the resident's contracture on 02/24/22 but failed to implement any interventions and did not refer her for a therapy evaluation until 03/22/22; the resident expressed pain during the evaluation. This failure could place residents at risk for decline in range of motion, decreased mobility, pain, decreased quality of life and ability to maintain independence. Findings include: Review of Resident #69's significant change MDS assessment, dated 02/18/22, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident had a BIMS of 00, which indicated she was severely cognitively impaired. She required extensive assistance with all ADLs with two persons for transfers and bed mobility. The MDS indicated she had functional limitation in Range of Motion to both lower extremities, but indicated she had no limitation to her upper extremities. She had no signification weight loss in the last 3 months. She had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication the resident had a stroke or [CONDITION(S)] (muscle weakness or [CONDITION(S)] on one side of the body). Review of Resident #69's care plan, with a review date of 11/03/21, reflected, .Impaired physical mobility .Goal .Resident will maintain or improve physical function in bed mobility, transfer, ambulation, locomotion, and ROM over the next 90 days .Interventions .OT/PT screen and/or evaluation as needed .RNA referral as needed . There was no indication of a contracture to the resident's left hand, or interventions to prevent the risk of worsening of the contracture. Record review of the facility's restorative list dated 03/22/22 did not reflect Resident #69 was on restorative services. Record review of Resident #69's Physician consolidated Orders for March 2022, reflected, .ST to Eval and treat as indicated . with a start date of 03/11/22. There were no orders for OT to evaluate and treat. Record review of Resident #69's Nurse progress note written by LVN F on 02/24/22, reflected, Resident having trouble to straighten last 3 fingers of left hand needs to be seen to help prevention of contractures. Rag put in place to help with prevention Review of Occupational Therapy discharge summary, dated 03/24/21, reflected .Pt is a [AGE] year old female with recent right hip fx (Fracture) with ORIF ( open reduction internal fixation) and COVID .equipment prior to Onset: Pt has 4 WW (wheeled walker) and WC (wheelchair) Patient has reached maximum potential with skilled services .Function skills .Self Feeding=Modified independence .Upper body dressing .stand by assist .Discharge recommendations .Patient d/c to this LTC with assist from staff for self-care and mobility's and recommendations for restorative nursing . There was no indication on the discharge summary the resident had a contracture to her left hand or limited ROM to her upper body extremities. An observation on 03/22/22 at 09:46 a.m. revealed Resident #69 lying in her bed. Resident's left hand was clinched into a fist. When asked if she could open her hand, resident was able to extend her thumb and index finger, but could not extend her 3rd, 4th, and 5th finger. Resident had no hand roll in use and when asked if she had ever had a splint for her hand, she shook her head no. An interview and observation on 03/22/21 at 11:40 a.m. with Resident's #69's family member who was at bedside visiting with resident indicated the resident did not have any difficulty with her left hand until about 6 weeks ago. She stated another family member, had come about 3 weeks ago, and had trimmed the resident's nails to keep them from digging into the palm of her hand and stated they needed to keep a washcloth in her hand. Observed the family member attempting to assist the resident into opening her fingers on her left hand, and Resident #69 stated don't, it hurts, and pulled her hand back. The family member stated she had brought a soft rubber ball to the facility and had asked the CNAs to try and put it in her hand but stated she had not ever seen it in her hand. She stated she did not think the resident was on any kind of physical therapy. She stated she was being seen by a Speech Therapist to determine if she could go back to regular food instead of chopped up food. She stated she knew the CNAs and nursing staff were aware of her concerns with the Resident's left hand. In an interview with the Speech Therapist on 03/22/22 at 12:10 p.m. stated she thought OT was seeing Resident #69 but was not certain. She stated she had been evaluating the resident to determine if she would be able to advance to a regular diet. She stated she started seeing the resident on 03/11/22. She stated she had not noticed the contracture on Resident #69's hand but stated the family member had brought it to her attention last week and she had reported it to the DOR one day last week. Observation of Resident #69 on 03/22/22 at 12:30 p.m. in the dining room. Resident was served a diet of mechanical soft. Resident was observed grasping her fork with her left hand and was able to hold the fork with her thumb and index finger and was able to feed herself. In an interview with CNA D on 03/23/22 at 9:20 a.m. she stated she started with the facility at the end of January 2022 and stated Resident #69's left hand had been contracted as long as she had been at the facility. She stated the family member had brought in a soft rubber ball and had asked them to place it in the resident's hand, but stated the resident was not able to open her fingers enough to be able to hold the ball. She stated she had never been told by anyone at the facility that they were to do anything special with the resident's left hand. She stated she was not aware if the resident was on restorative care or receiving therapy for her hand. In an interview with RN C on 03/23/22 at 9:15 a.m. revealed she was aware of the contracture to Resident #69's left hand about a month ago and stated she thought therapy was trying to get a carrot (soft hand roll for contracted hands). She stated she assumed therapy was seeing her. She stated anytime a resident had a change in condition with range of motion they were to report it to the ADON and the DOR to screen the resident and then get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview with LVN F on 03/24/22 at 12:53 p.m. revealed she worked at the facility on a as needed basis. She stated she did report Resident #69's contracture to ADON B on 02/24/22 and she asked her if she needed to refer her to therapy or call the physician. She stated ADON B stated she would take care of it. In an interview with the DOR on 03/23/22 at 8:45 a.m. revealed she had been told by the Speech Therapist late last week, either Thursday or Friday about the family members concern about Resident #69's left hand. She stated she had not had OT screen her until 03/22/22. She stated they had not received a referral from the nursing department until then and stated they could not start therapy without a referral. She stated she and the MDS nurse due quality of life rounds each week. She stated they will do the residents whose quarterly assessment are due and anyone that nursing had indicated had a change in condition. She stated the change in Resident #69's hand was not reported to her until last week. She sated she did look at the resident's hand on 03/18/22 and told nursing to put a washcloth in her hand but stated she did not report the change to the MDS nurse last week. She stated the resident did not have a contracture to her left hand when she discharged from therapy in March of 2021. She stated changes are also reported each day in stand-up meetings with the department heads. She stated the 24-hour report is reviewed at that time. In an interview with ADON B on 03/23/22 at 10:30 a.m. revealed she had been told by LVN F on 02/24/22 about Resident #69's left hand contracture. She stated she normally would text the DOR and let her know they have a resident with a change that needs to be evaluated. She stated she looked back in her phone and determined she had not notified the DOR. She stated she also failed to care plan it. She stated she was not sure why it was missed in the morning meetings. Interview with MDS Coordinator G on 03/23/22 at 9:05 a.m. revealed she had completed a significant change assessment on Resident #69 because her family had revoked hospice services. She stated the resident had only been on hospice for about a week. She stated the family decided they did not want hospice services. She stated she had not been made aware of Resident #69's contracture to her left hand until yesterday (03/22/22). She stated the nurse's or ADON were responsible for updating the care plan if there were any change that occurred after the residents' quarterly assessments. She stated she and the DOR made weekly rounds on residents' who were due for their quarterly assessments, and for any changes the nursing staff had brought up during daily stand-up meetings. In an interview with the DON on 03/23/22 at 11:15 a.m. revealed she had been notified yesterday (03/22/22) by ADON B of the concern with Resident #69's left hand contracture. She stated it appeared they had just dropped the ball and failed to follow through with the process for referring this resident to therapy and implementing any interventions which could lead to worsening of her contracture. She stated they had already put an immediate plan of correction into place as of yesterday, which included in servicing the CNAs on the use of the stop and watch report to note any changes in mobility to the nurse managers. She stated the nurse managers are to send an E-mail to MDS and therapy for therapy referral and evaluation to be completed. She stated they had done a sweep of all the long-term care residents for contracture risk management assessment and any need to update and revise their care plans. She stated going forward they would be monitoring the 24-hour report for any changes in mobility for the next 30 days. She stated she hoped this never occurred again and stated the only thing she can contribute to this situation was it occurred during the few days of icy weather and people were having trouble getting into work and it just got overlooked. In an interview with the Administrator on 03/23/22 at 12:10 p.m. he stated they had daily stand-up meetings and discussed any changes in the residents. He stated each department head participated in those meetings. He stated he wrote down how many therapy screenings were planned but does not write down which resident were scheduled to be screened. He stated looking back at his notes for last week, he only listed one OT screening was scheduled for last Friday but does not know which resident that was for. He stated therapy can screen anytime without determining a payor source. He stated once therapy determined the need for services then a referral would be requested from the physician. In an interview with the OT on 03/23/22 at 12:30 p.m. revealed she was not told about Resident #69's need for OT services until yesterday. She stated she did an assessment and confirmed she had a contracture to her left hand which involved her 3rd, 4th, and 5th finger. She stated after working with the resident today, she was able to get her to extend her 4th and 5th finger slightly, but her 3rd finger is very tight, and she was not able to get much movement out that finger. She stated she hoped to get her hand to a point where it will be able to be splinted to prevent any further decline. In an interview with Resident #69's Physician on 03/23/22 at 1:46 p.m. revealed he thought he was told of the contractures to the resident's hand one day last week but could not recall for certain. He stated he relied on therapy to address those types of concerns and would defer to them on what would be best for the resident. Review of the OT Evaluation and plan of treatment dated 03/22/22 reflected, .reason for therapy .skilled OT indicated to address contracture and joint mobility for improved skin integrity and prevention of further contracture Clinical Impressions: Patient present with joint contracture to Left hand digits 3,4 and 5. Patient express pain with PROM (passive range of motion) .Recommendations .Splint/Orthotic Recommendations: recommend palm guard/roll to left hand .Pain assessment .Pain with Movement=9/10: Frequency =Intermittent; Location: pain with movement to left hand digits 3,4 5 .Pain limits ability to grasp utensils for feeding .Patient had expressions of pain with PROM and stretching to Left hand . Review of the facility's policy titled, Change of Condition (Acute) dated February 12, 2020, reflected, The nurse assigned to the resident or supervising the care of the resident is responsible for notification of communication to the medical staff regarding significant changes or significant deterioration in the resident's condition and for assuring that there is physician response .Procedure .Changes in the condition of the patient are determined by current and past medical condition, medical orders, patient safety factors and/or by assessments .Categories are listed as .Immediate notification .Any symptoms, sign or apparent discomfort that is .Acute or Sudden in onset, and A marked change (i.e. more severe) in relation to usual symptoms and signs, or Unrelieved by measure already prescribed . Non-immediate notification .New or worsening symptoms that do not meet above criteria .As part of the interdisciplinary team, Certified Nursing Assistants (C.N.A's) .are expected to report findings that might represent an Acute change in condition. This should be communicated in the form of the Stop and Watch Tool Change of Condition is completed prior to notification to practitioner, if not emergent .The nurse notifies the responsible physician .as necessary, notify the nursing supervisor and/or administrator on-call for administrative and/or clinical consultation and/or assistance . Review of the facility's policy titled, Screening, Rehabilitation, dated April 2012, reflected, .Any patient/resident identified by the interdisciplinary team, as requiring a rehabilitation scree will have the screening initiate by a Physical, Occupation Therapist or Assistant, or Speech Language Pathologist withing 48 hours of notification of the request and quarterly A patient /resident is referred for a rehabilitation screen in response to any of the following .Contracture risks or splinting needs .Decline in ROM .A rehab screen is a hands-off' process by which the therapist reviews the medical record, observes the patient/resident, and interviews the patient/resident, caregivers, interdisciplinary team, and/or family to identify the patient's /resident's prior level of function, expectations for return of function and discharge plan .The screening process requires no more than 10 to 15 minutes of the therapist time .The outcome of the screen may be to proceed with a request for a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's policy titled, Quality of Life Rounds Procedures,' dated May 7, 2017, reflected, To identify all therapy/restorative appropriate changes in condition of residents and provide medically necessary services as indicate to ensure the highest practical level of care for each resident .The facility will first ensure that current systems are in place for addressing changes in condition .Any residents identified with decline in ADL, balance problems, falls, pain and /or weight loss will be referred to Therapy for screening .A team including a MDS, Charge Nurse, CNA, Restorative Aide and Therapy Representative assigned to cover each hall of the nursing facility will be established .The teams will make rounds .complete the quarterly joint mobility screens ( Nursing) and screen resident (Therapy). Changes noted on the mobility screen, declines identified by staff, or triggers noted on Quality Measures will be documented (by charge nurse) and resident will be referred for a therapy eval .Residents identified in the morning meeting to have changes in condition, falls or other related conditions will be referred to therapy via the Nursing to Therapy communication form .These forms will be returned withing 72 hours with the results of the therapy screen .

Based on interview and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of six residents reviewed for abuse. 1. LVN A failed to monitor, assess, and provide interventions when Resident #1 experienced a change of condition over a six-hour period, including agitation, calling out, and difficulty breathing. When Resident #1, who was a full code, became unresponsive and displayed agonal breathing LVN A failed to initiate CPR or immediately contact 911. Resident #1 was transported to the hospital with continued compressions and ventilation. Resident #1 expired at the hospital with a time of death at 5:18 AM. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received and signed the IJ template on [DATE] at 5:00 PM. These failures could affect the residents by placing them at risk for a delay in intervention and life-saving treatments, which could result in death. Findings included: Review of Resident #1's Admission MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 required extensive assistance of at least two people with Activities of Daily Living. He was totally dependent with transfers and bathing. Review of Resident #1's Comprehensive Care Plan last reviewed [DATE] reflected the following: - advanced directive evidenced by Code Status - Full Code may use AED. Interventions included Staff will notify physician and representative of any changes in the resident's condition. - breathing patterns evidenced by .oxygen 2 liter per minute inhalation every shift as need SOB (shortness of breath). Interventions included adjust head of bed and body positioning to assist ease of respirations; administer medications, respiratory treatments and oxygen as ordered; monitor lung sounds, pallor, cough and character of sputum; monitor respiratory rate, depth and effort; and notify MD (medical doctor) and family of any change of condition. - noncompliance related to keeping nasal cannula or mask on for oxygen. Interventions included to ask resident what changes in routines or procedures might enhance compliance . give positive feedback and reinforcement for resident's compliance . inform resident about risks on non-compliance. Review of Resident #1's physician order [REDACTED]. Review of Resident #1's physician order [REDACTED]. Review of Resident #1's electronic monitoring video date and time stamped on [DATE] at 22:06:26 (10:06 PM) revealed Resident #1 lying in bed with head of bed elevated and oxygen mask on Resident #1. Resident #1 was motioning with his right upper arm for aide (CNA B) to come to him. A voice was heard saying, What's wrong? but she was no longer in camera view and Resident #1 pointed to his chest area. Review of Resident #1's electronic monitoring video date and time stamped for [DATE] at 22:32:10 (10:32 PM) revealed Resident #1 lying in bed with the oxygen mask on. A female staff member (LVN A) went into Resident #1's room and said I will be back turning her head to the door and Resident #1 responded what the hell. She turned back and walked towards Resident #1 saying I'll tell you what. She adjusted his head of bed back. She walked out of the room without assessing Resident #1 or checking his vitals. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 23:07:53 (11:07 PM) revealed Resident #1 was lying in bed with his mouth open but no oxygen mask on his face. The resident was supine on the bed with the head of bed upright. Resident could be seen using accessory muscles (abdominal) with breathing. The female staff member picked up the oxygen mask off the bed next to his abdomen, placed the oxygen mask onto the resident's face and told the resident that he needed to wear his oxygen mask. The staff member asked the resident what's wrong? The resident lifted his hand to lift his gown. The staff member asked the resident if he was hot. The female staff member left the room. Review of Resident #1's electronic monitoring video date and time stamped for [DATE] at 00:28:06 (12:28 AM) revealed Resident #1 was lying in bed with his oxygen mask on the left side of his face. He was exhibiting breathing difficulty using his accessory, abdominal muscles. A female staff member (LVN A) came into the room. She got Resident #1's water pitcher, moved his head of bed up, and gave him water through straw. She then reached over him putting the pitcher back on bedside table. Resident #1 saying ah ah ah and brought his right hand to his face coughing. She started changing Resident #1's peg tube dressing. While this staff member changed the dressing, Resident #1 said oh several times and kept moving his head to the left. LVN A then turned her back doing something on the tower with the bag. Resident #1 moaned oh a couple times and put his left arm up with pulse oxy up. The staff member then put the head of bed down and and left the room. Resident #1 was louder saying oh several times. LVN A never placed the oxygen mask on Resident #1 when she was in the room. Resident #1 was yelling out let me out of here please, let me out of here. He then said oh my God, oh my God. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 1:34:26 AM revealed Resident #1 was lying in bed without his oxygen mask on. The resident was talking out loud. The resident did not have any clothes on. The resident was observed using his abdominal muscles with breathing. A female staff member was observed picking up an item off the floor near the foot of the bed. The staff member then walked to the head of the bed, picked up the oxygen mask off the floor and placed it on the resident's face. The staff member was observed removing the feeding tube from the resident's hand. The staff member asked the resident what was going on and told the resident not to pull on the feeding tube. The staff member told the resident to wear the mask so he could breathe. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 1:35:35 AM revealed a female staff member (CNA B) putting Resident #1's gown back on him. Resident #1 was using his accessory muscles with breathing. The female staff member took off Resident #1's oxygen mask to put a gown on and then replaced the mask back after the gown was on Resident #1. She asked Resident #1 Do you want to turn over? He responded by putting his left arm up pointing his finger to the ceiling. Then she placed a pillow under Resident #1's left foot and Resident #1 moaned oh while she was doing it. The female staff member then said Here you go. All right and picked up something from the bedside table. Resident #1's took his left hand and moved the oxygen mask off his mouth and placed it on top of his head. The staff member left the room. Another staff member (LVN A) came into the room and placed something on the extra bed. Resident #1 was using his accessory muscles to breath. This staff member reached for the bed remote and moved Resident #1's head of bed up. Resident #1 was yelling ah several times. She looked at Resident #1 and then walked out of room. Resident #1's oxygen mask was still sitting on the top of his head. The staff member came back into Resident #1's room and walked out after looking at Resident #1. Resident #1's oxygen mask was still off his face. The staff member came back in and Resident #1 said oh my God. Resident #1's oxygen mask was to the left on the bed next to his head. The staff member left the room again. Resident #1 yelled oh my God louder several times. Review of Resident #1's electronic monitoring video date and time stamped [DATE] 1:42:25 AM revealed Resident #1 lying in bed supine with his oxygen mask in bed next to head. He said oh faintly several times and reached his right arm to his head a couple of times. He had both arms out yelling oh several times. Resident #1 was using his accessory (abdominal ) muscles to breath. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 1:54:40 AM revealed Resident #1 was lying supine in bed. The resident was not wearing an oxygen mask. The resident was using his accessory muscles with breathing. Review of a second video at [DATE] at 1:54 AM revealed Resident #1 was lying in bed, using his accessory muscles with breathing. The resident was not wearing his oxygen mask and was yelling out help several times. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 4:23:02 AM revealed the resident was supine lying in bed without his oxygen mask on. The resident had agonal breathing. A staff member (CNA B) stated, hey put your oxygen mask on and was observed putting the face mask onto the resident. The staff member stated that the resident needed to put on the face mask. The staff member (CNA B) was observed leaving the resident room. Another female person (phlebotomist) carrying a tool kit-like box was observed in the room. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 4:24:16 AM revealed Resident #1's privacy curtain was pulled and a staff member with black pants not wearing a gown (CNA B) left the room and then the (CNA B) came back with something white in her left hand. The camera did not have a view behind the privacy curtain. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 4:34:57 AM revealed Resident #1's privacy curtain was pulled and Staffing Coordinator LVN walked by the privacy curtain. EMS attendant was seen in video coming in after Staffing Coordinator LVN left room. EMS attendant pulled the privacy curtain open. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 4:36:09 revealed LVN A moved back and two EMS attendants took over. Resident #1 was lying supine on his back not breathing. Interview with Staffing Coordinator LVN on [DATE] at 2:15 PM revealed he identified the following staff members in Resident #1's electronic monitoring video on the identified dates and times: [DATE] at 10:06 PM as CNA B. He stated she was wearing scrubs and her hair was up in a bun. [DATE] at 22:32:10 as LVN A. He stated she had on a gown and a mask. [DATE] 00:28:06 (12:28 AM) as LVN A [DATE] at 1:34 AM as CNA B. He stated she was wearing scrubs and her hair was up in a bun. Interview on [DATE] at 4:35 PM through 4:45 PM with the Administrator and DON revealed the Administrator and DON identified the following staff members in Resident #1's electronic monitoring video on the identified dates and times: [DATE] at 1:34 AM as CNA B [DATE] at 1:35 AM revealed the first staff member in the video was identified as CNA B and then the second staff member in the video was identified as LVN A. [DATE] at 4:23 AM as CNA B Review of The Journal of Emergency Medical Services article How to Assess and Treat Acute Respiratory Distress, written by Mike McEvoy, PhD, NRP, RN, CCRN and dated [DATE], revealed: Five key signs you want to look for that suggest severe respiratory distress include: 1. Retractions and the use of accessory muscles to breathe; 2. Inability to speak full sentences (or difficulty speaking be-tween breaths); 3. Inability to lie flat; 4. Extreme diaphoresis (sweating); and 5. Restlessness, agitation or declining level of consciousness. Accessed on [DATE] from https://www.jems.com/[DATE]/how-assess-and-treat-acute-respiratory-d/ Review of online Medical Dictionary accessed on [DATE] from medical-dictionary.thefreedictionary.com reflected the definition of agonal breathing as shallow breathing pattern that is often related to [MEDICAL CONDITION] and death. Review of Resident #1's nurse note dated [DATE] completed by LVN C reflected, Late Entry (for [DATE]): Resident received in bed alert, responsive but restless, yelling, calling out and constantly taking off O2 (oxygen) mask off. Staff checking on resident frequently and fixing O2 mask on face. 1600 (4:00 PM): Nurse able to redirect resident from calling out but would not keep O2 mask on face. VS (vital signs) and BS (blood sugar) check and WNL (within normal limits). IV (intravenous) Antibiotic midline infusing and no distress noted. Resident refused dinner, took meds and boost encouraged. GT flushed/patient feeding infusing. Medicated with prn [MEDICATION NAME] for increase agitation, restlessness, screaming would not keep O2 mask on face and unable to redirect. Prn Tylenol given for elevated temp at 2130 (9:30 PM) and report given to oncoming nurse. Review of Resident #1's PRN medication administration by LVN C on [DATE] reflected at 9:24 PM [MEDICATION NAME] 0.5 mg tablet for anxiety and Tylenol 325 mg tablet ([MEDICATION NAME]) 2 tablet by mouth for pain/temp were given. Review of the 24-hour report dated [DATE] written by LVN C reflected Resident #1 had an elevated temperature and prn apap was given at 9:30 PM and gave prn [MEDICATION NAME] for screaming. New order received for [MEDICATION NAME] 3 mg by mouth at bedtime. New order for Linezolid ABT for wound infection. Review of Resident #1's nurse's note dated [DATE] at 6:21 AM completed by LVN A reflected, Called to resident room by phlebotomist at 0425 (4:25 AM); secondary to resident being unresponsive. Resident assessed. No heartbeat or respiration found. Initiated CPR while calling 911. Code called. Continued CPR till Medics arrived at 0435 and took over CPR. Medics continued CPR. Left facility at 0500 while doing CPR. Resident taken to (local hospital). Attempted to call family multiple times. Son-in-law responded at 0507 and notified of transport. Review of Resident #1's EMS records dated [DATE] reflected dispatched at [DATE] 4:26 AM, arrived on scene at 4:30 AM, and arrived to patient at 4:35 AM. Resident #1 had a [MEDICAL CONDITION] prior to EMS arrival. Staff on scene stated they witnessed the patient had difficulty breathing prior to going unresponsive. While en route the dispatch noted the patient had gone pulseless and facility was initiating CPR. Patient contact to find (Resident #1) laying supine in bed, pulseless, and compressions being performed by facility staff. Pulse was quickly checked by FD (fire department), no pulse found and staff was instructed to continue manual compressions. Patient was placed on the monitor and monitor as pre-charged at 360 . V-fib (Ventricular fibrillation) was noted and charge was delivered .Suctioning of the patient mouth was made, food and some blood were noted in patient's mouth. Intubation was obtained for (Resident #1). Compressions and ventilation were continued during transport. Rhythm checks were made and no change to patient condition was noted . CPR was continued by ER. Review of Resident #1's Hospital emergency room records dated [DATE] reflected Resident #1 presented to the ED (emergency department) via ambulance due to a witnessed arrest. Per report, the staff at the facility went to go check on the patient and saw that he began breathing faintly and became unresponsive. CPR was started immediately and was resumed by paramedics upon arrival; down for approximately 30 minutes upon arrival with CPR for same period of time. He did have a brief VFib and was shocked once. Received 3 rounds of epi ([MEDICATION NAME] injection) and one of sodium [MEDICATION NAME] .Patient intubated in the field and placed on vent (ventilator) upon arrival to the ED 5:18 AM .Patient has not had any spontaneous respirations or cardiac activity. Unresponsive for >35 minutes. Will cease resuscitative efforts .Time of death at 5:18a. Interview on [DATE] at 11:15 AM with CNA B revealed on [DATE] on the night shift she was assigned to Resident #1. She stated Resident #1 was anxious and had difficulty sleeping during her shift. She stated he was yelling out, so she would go in his room and try to calm him down. She stated Resident #1 kept taking off his oxygen mask, so she would put it back on him . She stated the phlebotomist came and got her and reported Resident #1 was unresponsive and having difficulty breathing. CNA B stated she went to go check on Resident #1 and see if she could get him to respond. CNA B stated Resident #1 did not have his oxygen mask on. He was having difficulty breathing and gasping. CNA B put his oxygen mask back on and left the room to go get LVN A. She stated LVN A came in, tried to get Resident #1 to respond, and checked his pulse oxygen and pulse levels. CNA B stated she left the room herself to get another nurse. She stated she thought the other nurse had gotten the crash cart but was not sure . She stated she did not notice anything about Resident #1's breathing prior to the phlebotomist telling her. CNA B stated she was not CPR certified. She stated she did tell LVN A Resident #1 was taking off his oxygen mask . Interviews on [DATE] at 9:41 AM and [DATE] at 9:59 AM with LVN A revealed on [DATE] on the night shift she worked and was assigned to Resident #1. LVN A stated this was the first night working with Resident #1 and was only told Resident #1 yelled at night due to anxiety. She stated Resident #1 was yelling throughout the shift and she went into his room to calm him . She stated she was unable to give Resident #1 [MEDICATION NAME] because the previous nurse had given him a prn dosage around 9:00 PM. She stated she checked on him every 2 hours. She stated she changed Resident #1's peg tube dressing and did notice his oxygen mask was off. She could not recall when she put the oxygen mask back on Resident #1 but stated she must have done it before, during or after she changed his peg tube dressing. She stated she should have put the oxygen mask back on Resident #1 as soon as she noticed it was off and checked his oxygen saturation along with other vitals. She stated she did not know what the pulse oxygen saturation levels were, but they were in 90s. She stated around 2:00 or 2:30 AM on [DATE] Resident #1 was quiet not yelling anymore so she went to his room. She stated he was sleeping and saw his chest was going up and down, so she did not bother him or assess him. She stated she did not assess his vitals or check his oxygen saturation levels. She stated she did not contact Resident #1's physician in the middle of the night because they are unavailable at night, but she would contact the physician in the morning to see about getting a new order for antianxiety medication due to his yelling out behaviors. She stated she was called to Resident #1's room by CNA B around 4:00 or 4:30 AM who reported Resident #1 was not responsive and had difficulty breathing. She stated this was the first time she noticed any issues with the resident's breathing on her shift. She stated when she entered the room Resident #1 was unresponsive and would not respond to her or CNA B. She stated Resident #1 had shallow/faint breathing. She stated his pulse oxygen saturation was in the 50s but could not recall any other vital signs. She stated it was like Resident #1 was leaving. She stated she left the room and went to get the crash cart because CNA B would not know where it was at. She stated CNA B was not CPR certified and she knew Resident #1 a full code status. She stated she should have stayed with Resident #1 and had CNA B get help to call the code. She stated she called 911 and started CPR after she got the crash cart. She stated she contacted Resident #1's responsible party and the physician after EMS took over CPR. She stated she did not get ahold of the physician but left him a voicemail about Resident #1 being sent to the hospital and required CPR. She stated she was aware Resident #1 had an electronic monitoring device in his room . Interview on [DATE] at 10:46 AM with LVN D revealed she worked on the night shift on [DATE] with LVN A. She stated she remembered during the beginning of her shift hearing someone yelling which lasted about 2 hours at most and she asked LVN A who that was sometime on the shift. She stated LVN A told her it was Resident #1, and he was agitated. She told her she could not give Resident #1 any medication since the previous nurse gave him antianxiety medication at the end of her shift. LVN D stated she told LVN A she could contact the doctor to see if there was something she could give Resident #1 for increased agitation. LVN D stated sometime after 4:00 AM LVN A came to her when she was on her hall with the medication cart to ask for the work phone. LVN D stated LVN A told her she needed to use the work phone to send a resident to the hospital. LVN D stated LVN A did not mention she had an emergency or a code. She stated LVN A asked her to print off Resident #1's paperwork so she could send him out to hospital. She stated LVN A did not use the work phone once she got it from her but headed back down her hall. LVN D did not see LVN A use the phone. She stated she went to print off Resident #1's paperwork. She stated the phlebotomist told her when she was printing paperwork that she was unable to draw Resident #1's blood and said he was not feeling well, and she was not comfortable drawing his blood. LVN D stated if a resident is exhibiting signs of agonal breathing, unresponsive with no pulse she would stay with resident and initiate CPR as necessary. She would then call out for help and whoever arrives next she would have them get the crash cart and AED. She stated she would have assisted LVN A if she knew there was a code, but she did not know. She stated no code was called during the shift . Interviews on [DATE] at 10:30 AM and [DATE] at 2:10 PM with Staffing Coordinator LVN revealed he was working as a charge nurse on the 500 and 700 halls on [DATE] from 10 pm to 6 am on [DATE]. He stated in the early morning of [DATE] when he was on the 500 hall getting gloves the phlebotomist was motioning for him with her hand to come speak with her. He stated the phlebotomist told him he should go check on Resident #1 who was gasping when she went to draw his blood. The Staffing Coordinator LVN stated he went to Resident #1's room and found the crash cart in front of the resident's doorway. He stated when he entered the room the privacy curtain was already pulled. He stated LVN A and CNA B were near the head of Resident #1's bed just looking at Resident #1 but neither of them were performing CPR or checking vitals. He stated LVN A was on the phone initially, but he was not sure with whom. He stated Resident #1 was gasping, had shallow breathing and took a breath in but did not exhale back out. He stated Resident #1 had a full code status, was unresponsive and needed CPR. He stated he cussed at them and told them they needed to get the back board so they could do CPR. He stated they assisted him to put the back board under Resident #1 and the Staffing Coordinator LVN started CPR, not LVN A. He stated he had one of them go get the AED because it was not there. He stated LVN A told him she had called 911. He stated it was not too long before EMS arrived and facility staff maybe did about three rounds of CPR before they arrived. He stated when EMS arrived they took over CPR. He stated no code was called by LVN A and he had no idea anything was going on with Resident #1 until the phlebotomist came and got him. He stated they were unable to revive Resident #1. He stated Resident #1 did yell out at times but only when he was anxious wanting someone to stay with him. He stated when he worked with Resident #1 he would check on him often because of his anxiety and Resident #1 would take his oxygen mask off. He stated he provided orientation training for LVN A on conducting a code about 2 months ago and LVN A should have alerted for help and initiated CPR before he got there. Staffing Coordinator LVN stated if a resident is exhibiting signs of agonal breathing, unresponsive with no pulse he would stay with resident and initiate CPR as necessary. He would then call out for help and whoever arrives next he would have them get the crash cart and AED along with calling a code so all available staff could come to assist in this emergency situation. Interview on [DATE] at 2:25 PM with LVN Staff Coordinator after being shown the video [DATE] at 4:34 AM he stated he had done about three sets of compressions of CPR prior to EMS arriving with no change noted. Interview on [DATE] at 4:19 PM with LVN C revealed she worked the 2:00 PM to 10:00 PM shift on [DATE]. She stated Resident #1 did have an elevated temperature and she was told by CNA F Resident #1 was not wanting to eat much of his supper near the end of her shift on [DATE]. She gave Resident #1 Tylenol prn order. She stated Resident #1 not eating much was not out of his normal and he received a [DEVICE] feeding at night. She stated she and the aides checked on Resident #1 more frequently, at least every 30 minutes, due to Resident #1 taking his oxygen mask off. LVN C stated if he took the mask off, he would not put it back on himself. She stated he was alert, oriented and talking to her like normal on her shift. She stated when Resident #1 took his oxygen off, she placed it back on him after checking the mask, oxygen tubing and concentrator along with his pulse and pulse oxygenation saturation levels. She stated Resident #1 did not show any signs of respiratory distress or difficulty breathing on her shift. She stated if Resident #1's oxygen mask was not on him, his pulse oxygen saturation levels would go down below 90. She stated Resident #1 was sent to the hospital before when his oxygen levels went too low and unable to stabilize. She stated she gave Resident #1 prn [MEDICATION NAME] to help with the yelling and increased agitation on her shift. She stated she did give report to LVN A about Resident #1 having an elevated temperature, yelling and had a new IV antibiotic which needed to be started. She stated she was unable to do it on her shift. Interview on [DATE] at 2:45 PM with CNA F revealed Resident #1 did not want to eat his supper on [DATE] but he was able to get him to eat a couple bites. He stated Resident #1 was alert, oriented on his shift. He denied any breathing issues or respiratory distress. Interview on [DATE] at 3:05 PM with MA G revealed she did work with Resident #1 on [DATE] on the 2:00 PM to 10:00 PM shift. She stated Resident #1 did not want to take his medications. She stated Resident #1 seemed shaky and restless near the end of the shift but the restlessness was not unusual for him. She notified LVN C who then checked on Resident #1. She denied any issues with Resident #1's breathing or respiratory distress. She stated he was alert and oriented on her shift. Interviews on [DATE] at 1:20 PM and [DATE] at 1:11 PM with DON revealed Resident #1 did take his oxygen mask off but she expected the nurse to assess the resident by checking vitals and oxygen saturation levels and put the oxygen mask back on the resident after ensuring mask and tubing were connected to the oxygen concentrator. She stated if Resident #1 did not have the oxygen mask or nasal cannula on his oxygen saturation levels would go down. She stated LVN A should have assessed Resident #1 when he was showing signs of difficulty breathing. She stated LVN A should have assessed Resident #1 when not wearing his oxygen mask and put oxygen mask back on Resident #1. She stated after reviewing the video she stated LVN A did not assess Resident #1's oxygen saturation levels and vital signs. She stated LVN A did not check Resident #1's vitals and did not intervene when Resident #1 had a change of condition of labored breathing using his accessory (abdominal) muscles. She stated LVN A should have notified Resident #1's physician about the change of condition for further guidance. She stated Resident #1 was using his accessory muscles (abdominal) when breathing and LVN A should have checked Resident #1's vitals including respirations, listen for lung sounds, pulse, temperature, blood pressure and oxygen saturation. She stated LVN A should not have left Resident #1 when he exhibited agonal breathing, but she should have called for help and had CNA B get the crash cart and AED. She stated LVN A should have followed up with Resident #1 after CNA B put the oxygen mask back on Resident #1. Interview on [DATE] at 1:33 PM with the Medical Director revealed if a resident took off the oxygen mask and had orders for oxygen, he would expect the nurse to assess the resident, check oxygen saturation levels, check the oxygen mask and oxygen tubing to ensure working, put the oxygen mask back on the resident and increase the oxygen if necessary. He stated he would expect the nurse to ensure the oxygen saturation levels were stable. He stated he expected the nurse to notify him immediately if a resident was having a change of condition. He stated if resident was showing signs of agonal breathing or gasping he would expect the nurse to get help, do a quick assessment of airway, breathing and circulation; and check if the resident was alert and responsive. He would expect the nurse to stay with the resident and call for help and initiate CPR when necessary. Review of LVN A's employee file revealed a hire date of [DATE] as LVN. She was CPR and AED certified on [DATE] with a renewal date of ,[DATE]. Review of LVN A's timesheet from [DATE] to [DATE] reflected she worked on [DATE] from 9:57 pm to [DATE] at 7:23 AM. She worked on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] on the night shift. She clocked out on [DATE] at 7:01 AM. Interview with the Administrator on [DATE] at 4:30 PM revealed LVN A was suspended pending investigation yesterday evening, [DATE], after the IJ was called. He stated CNA B would no longer be working at the facility due to the failure to call and no showed for two shifts policy violations. Review of CNA B's timesheet from [DATE] to [DATE] reflected she worked on [DATE] from 9:58 PM to [DATE] at 6:07 AM. She worked on [DATE], [DATE], [DATE], [DATE] on the night shift. She clocked out on [DATE] at 6:26 AM and this was last time she worked at the facility. Review of facility's policy Cardiopulmonary Resuscitation (CPR): Basic Life Support (BLS)/Hands-Only CPR dated [DATE] reflected, CPR - is a group of emergency treatments that are executed when someone's breathing or heartbeat has stopped. The treatments consist of rescue breathing and chest compressions. CPR allows [MEDICATION NAME] blood to circulate to vital organs such as the brain and heart. Under General Guidelines: 1. The goal of CPR is to try to maintain life until the emergency medical response team arrive to deliver Advanced Life Support (ALS). Under Steps in the procedure reflected for Bystander/Unlicensed staff 1. Summon for help 2. Request AED 3. Check for Responsiveness (for example shaking, tap shoulder and shout 'are you okay' etc) 4. While awaiting AED, if unresponsive being performing chest compressions (unless known code status is DNR). Continue until licensed staff arrive. 5. If responsive stay with resident until help arrives. CPR Certified Staff 1. Determine unresponsiveness; if no response 2. Request AED and summon for help 3. Check for no breathing or no normal breathing 4. Check for pulse (no more than 10 seconds) 5. Initiate community emergency response 6. Start CPR as trained. Review of article Diaphragm: A mnemonic to describe the work of breathing in patients with r (TRUNCATED)

Based on interviews and record reviews, the facility failed to ensure personnel provided basic life support, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [REDACTED].#1) of six residents reviewed for CPR. 1. LVN A failed to monitor, assess, and provide interventions when Resident #1 experienced a change of condition over a six-hour period, including agitation, calling out, and difficulty breathing. When Resident #1, who was a full code, became unresponsive and displayed agonal breathing LVN A failed to initiate CPR or immediately contact 911. Resident #1 was transported to the hospital with continued compressions and ventilation. Resident #1 expired at the hospital with a time of death at 5:18 AM. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received and signed the IJ template on [DATE] at 5:00 PM. These failures could affect the residents by placing them at risk for a delay in intervention and life-saving treatments, which could result in death. Findings included: Review of Resident #1's Admission MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 required extensive assistance of at least two people with Activities of Daily Living. He was totally dependent with transfers and bathing. Review of Resident #1's Comprehensive Care Plan last reviewed [DATE] reflected the following: - advanced directive evidenced by Code Status - Full Code may use AED. Interventions included Staff will notify physician and representative of any changes in the resident's condition. - breathing patterns evidenced by .oxygen 2 liter per minute inhalation every shift as need SOB (shortness of breath). Interventions included adjust head of bed and body positioning to assist ease of respirations; administer medications, respiratory treatments and oxygen as ordered; monitor lung sounds, pallor, cough and character of sputum; monitor respiratory rate, depth and effort; and notify MD (medical doctor) and family of any change of condition. - noncompliance related to keeping nasal cannula or mask on for oxygen. Interventions included to ask resident what changes in routines or procedures might enhance compliance . give positive feedback and reinforcement for resident's compliance . inform resident about risks on non-compliance. Review of Resident #1's physician order [REDACTED]. Review of Resident #1's physician order [REDACTED]. Review of Resident #1's electronic monitoring video date and time stamped on [DATE] at 22:06:26 (10:06 PM) revealed Resident #1 lying in bed with head of bed elevated and oxygen mask on Resident #1. Resident #1 was motioning with his right upper arm for aide (CNA B) to come to him. A voice was heard saying, What's wrong? but she was no longer in camera view and Resident #1 pointed to his chest area. Review of Resident #1's electronic monitoring video date and time stamped for [DATE] at 22:32:10 (10:32 PM) revealed Resident #1 lying in bed with the oxygen mask on. A female staff member (LVN A) went into Resident #1's room and said I will be back turning her head to the door and Resident #1 responded what the hell. She turned back and walked towards Resident #1 saying I'll tell you what. She adjusted his head of bed back. She walked out of the room without assessing Resident #1 or checking his vitals. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 23:07:53 (11:07 PM) revealed Resident #1 was lying in bed with his mouth open but no oxygen mask on his face. The resident was supine on the bed with the head of bed upright. Resident could be seen using accessory muscles (abdominal) with breathing. The female staff member picked up the oxygen mask off the bed next to his abdomen, placed the oxygen mask onto the resident's face and told the resident that he needed to wear his oxygen mask. The staff member asked the resident what's wrong? The resident lifted his hand to lift his gown. The staff member asked the resident if he was hot. The female staff member left the room. Review of Resident #1's electronic monitoring video date and time stamped for [DATE] at 00:28:06 (12:28 AM) revealed Resident #1 was lying in bed with his oxygen mask on the left side of his face. He was exhibiting breathing difficulty using his accessory, abdominal muscles. A female staff member (LVN A) came into the room. She got Resident #1's water pitcher, moved his head of bed up, and gave him water through straw. She then reached over him putting the pitcher back on bedside table. Resident #1 saying ah ah ah and brought his right hand to his face coughing. She started changing Resident #1's peg tube dressing. While this staff member changed the dressing, Resident #1 said oh several times and kept moving his head to the left. LVN A then turned her back doing something on the tower with the bag. Resident #1 moaned oh a couple times and put his left arm up with pulse oxy up. The staff member then put the head of bed down and and left the room. Resident #1 was louder saying oh several times. LVN A never placed the oxygen mask on Resident #1 when she was in the room. Resident #1 was yelling out let me out of here please, let me out of here. He then said oh my God, oh my God. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 1:34:26 AM revealed Resident #1 was lying in bed without his oxygen mask on. The resident was talking out loud. The resident did not have any clothes on. The resident was observed using his abdominal muscles with breathing. A female staff member was observed picking up an item off the floor near the foot of the bed. The staff member then walked to the head of the bed, picked up the oxygen mask off the floor and placed it on the resident's face. The staff member was observed removing the feeding tube from the resident's hand. The staff member asked the resident what was going on and told the resident not to pull on the feeding tube. The staff member told the resident to wear the mask so he could breathe. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 1:35:35 AM revealed a female staff member (CNA B) putting Resident #1's gown back on him. Resident #1 was using his accessory muscles with breathing. The female staff member took off Resident #1's oxygen mask to put a gown on and then replaced the mask back after the gown was on Resident #1. She asked Resident #1 Do you want to turn over? He responded by putting his left arm up pointing his finger to the ceiling. Then she placed a pillow under Resident #1's left foot and Resident #1 moaned oh while she was doing it. The female staff member then said Here you go. All right and picked up something from the bedside table. Resident #1's took his left hand and moved the oxygen mask off his mouth and placed it on top of his head. The staff member left the room. Another staff member (LVN A) came into the room and placed something on the extra bed. Resident #1 was using his accessory muscles to breath. This staff member reached for the bed remote and moved Resident #1's head of bed up. Resident #1 was yelling ah several times. She looked at Resident #1 and then walked out of room. Resident #1's oxygen mask was still sitting on the top of his head. The staff member came back into Resident #1's room and walked out after looking at Resident #1. Resident #1's oxygen mask was still off his face. The staff member came back in and Resident #1 said oh my God. Resident #1's oxygen mask was to the left on the bed next to his head. The staff member left the room again. Resident #1 yelled oh my God louder several times. Review of Resident #1's electronic monitoring video date and time stamped [DATE] 1:42:25 AM revealed Resident #1 lying in bed supine with his oxygen mask in bed next to head. He said oh faintly several times and reached his right arm to his head a couple of times. He had both arms out yelling oh several times. Resident #1 was using his accessory (abdominal ) muscles to breath. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 1:54:40 AM revealed Resident #1 was lying supine in bed. The resident was not wearing an oxygen mask. The resident was using his accessory muscles with breathing. Review of a second video at [DATE] at 1:54 AM revealed Resident #1 was lying in bed, using his accessory muscles with breathing. The resident was not wearing his oxygen mask and was yelling out help several times. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 4:23:02 AM revealed the resident was supine lying in bed without his oxygen mask on. The resident had agonal breathing. A staff member (CNA B) stated, hey put your oxygen mask on and was observed putting the face mask onto the resident. The staff member stated that the resident needed to put on the face mask. The staff member (CNA B) was observed leaving the resident room. Another female person (phlebotomist) carrying a tool kit-like box was observed in the room. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 4:24:16 AM revealed Resident #1's privacy curtain was pulled and a staff member with black pants not wearing a gown (CNA B) left the room and then the (CNA B) came back with something white in her left hand. The camera did not have a view behind the privacy curtain. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 4:34:57 AM revealed Resident #1's privacy curtain was pulled and Staffing Coordinator LVN walked by the privacy curtain. EMS attendant was seen in video coming in after Staffing Coordinator LVN left room. EMS attendant pulled the privacy curtain open. Review of Resident #1's electronic monitoring video date and time stamped [DATE] at 4:36:09 revealed LVN A moved back and two EMS attendants took over. Resident #1 was lying supine on his back not breathing. Interview with Staffing Coordinator LVN on [DATE] at 2:15 PM revealed he identified the following staff members in Resident #1's electronic monitoring video on the identified dates and times: [DATE] at 10:06 PM as CNA B. He stated she was wearing scrubs and her hair was up in a bun. [DATE] at 22:32:10 as LVN A. He stated she had on a gown and a mask. [DATE] 00:28:06 (12:28 AM) as LVN A [DATE] at 1:34 AM as CNA B. He stated she was wearing scrubs and her hair was up in a bun. Interview on [DATE] at 4:35 PM through 4:45 PM with the Administrator and DON revealed the Administrator and DON identified the following staff members in Resident #1's electronic monitoring video on the identified dates and times: [DATE] at 1:34 AM as CNA B [DATE] at 1:35 AM revealed the first staff member in the video was identified as CNA B and then the second staff member in the video was identified as LVN A. [DATE] at 4:23 AM as CNA B Review of The Journal of Emergency Medical Services article How to Assess and Treat Acute Respiratory Distress, written by Mike McEvoy, PhD, NRP, RN, CCRN and dated [DATE], revealed: Five key signs you want to look for that suggest severe respiratory distress include: 1. Retractions and the use of accessory muscles to breathe; 2. Inability to speak full sentences (or difficulty speaking be-tween breaths); 3. Inability to lie flat; 4. Extreme diaphoresis (sweating); and 5. Restlessness, agitation or declining level of consciousness. Accessed on [DATE] from https://www.jems.com/[DATE]/how-assess-and-treat-acute-respiratory-d/ Review of online Medical Dictionary accessed on [DATE] from medical-dictionary.thefreedictionary.com reflected the definition of agonal breathing as shallow breathing pattern that is often related to [MEDICAL CONDITION] and death. Review of Resident #1's nurse note dated [DATE] completed by LVN C reflected, Late Entry (for [DATE]): Resident received in bed alert, responsive but restless, yelling, calling out and constantly taking off O2 (oxygen) mask off. Staff checking on resident frequently and fixing O2 mask on face. 1600 (4:00 PM): Nurse able to redirect resident from calling out but would not keep O2 mask on face. VS (vital signs) and BS (blood sugar) check and WNL (within normal limits). IV (intravenous) Antibiotic midline infusing and no distress noted. Resident refused dinner, took meds and boost encouraged. GT flushed/patient feeding infusing. Medicated with prn [MEDICATION NAME] for increase agitation, restlessness, screaming would not keep O2 mask on face and unable to redirect. Prn Tylenol given for elevated temp at 2130 (9:30 PM) and report given to oncoming nurse. Review of Resident #1's PRN medication administration by LVN C on [DATE] reflected at 9:24 PM [MEDICATION NAME] 0.5 mg tablet for anxiety and Tylenol 325 mg tablet ([MEDICATION NAME]) 2 tablet by mouth for pain/temp were given. Review of the 24-hour report dated [DATE] written by LVN C reflected Resident #1 had an elevated temperature and prn apap was given at 9:30 PM and gave prn [MEDICATION NAME] for screaming. New order received for [MEDICATION NAME] 3 mg by mouth at bedtime. New order for Linezolid ABT for wound infection. Review of Resident #1's nurse's note dated [DATE] at 6:21 AM completed by LVN A reflected, Called to resident room by phlebotomist at 0425 (4:25 AM); secondary to resident being unresponsive. Resident assessed. No heartbeat or respiration found. Initiated CPR while calling 911. Code called. Continued CPR till Medics arrived at 0435 and took over CPR. Medics continued CPR. Left facility at 0500 while doing CPR. Resident taken to (local hospital). Attempted to call family multiple times. Son-in-law responded at 0507 and notified of transport. Review of Resident #1's EMS records dated [DATE] reflected dispatched at [DATE] 4:26 AM, arrived on scene at 4:30 AM, and arrived to patient at 4:35 AM. Resident #1 had a [MEDICAL CONDITION] prior to EMS arrival. Staff on scene stated they witnessed the patient had difficulty breathing prior to going unresponsive. While en route the dispatch noted the patient had gone pulseless and facility was initiating CPR. Patient contact to find (Resident #1) laying supine in bed, pulseless, and compressions being performed by facility staff. Pulse was quickly checked by FD (fire department), no pulse found and staff was instructed to continue manual compressions. Patient was placed on the monitor and monitor as pre-charged at 360 . V-fib (Ventricular fibrillation) was noted and charge was delivered .Suctioning of the patient mouth was made, food and some blood were noted in patient's mouth. Intubation was obtained for (Resident #1). Compressions and ventilation were continued during transport. Rhythm checks were made and no change to patient condition was noted . CPR was continued by ER. Review of Resident #1's Hospital emergency room records dated [DATE] reflected Resident #1 presented to the ED (emergency department) via ambulance due to a witnessed arrest. Per report, the staff at the facility went to go check on the patient and saw that he began breathing faintly and became unresponsive. CPR was started immediately and was resumed by paramedics upon arrival; down for approximately 30 minutes upon arrival with CPR for same period of time. He did have a brief VFib and was shocked once. Received 3 rounds of epi ([MEDICATION NAME] injection) and one of sodium [MEDICATION NAME] .Patient intubated in the field and placed on vent (ventilator) upon arrival to the ED 5:18 AM .Patient has not had any spontaneous respirations or cardiac activity. Unresponsive for >35 minutes. Will cease resuscitative efforts .Time of death at 5:18a. Interview on [DATE] at 11:15 AM with CNA B revealed on [DATE] on the night shift she was assigned to Resident #1. She stated Resident #1 was anxious and had difficulty sleeping during her shift. She stated he was yelling out, so she would go in his room and try to calm him down. She stated Resident #1 kept taking off his oxygen mask, so she would put it back on him . She stated the phlebotomist came and got her and reported Resident #1 was unresponsive and having difficulty breathing. CNA B stated she went to go check on Resident #1 and see if she could get him to respond. CNA B stated Resident #1 did not have his oxygen mask on. He was having difficulty breathing and gasping. CNA B put his oxygen mask back on and left the room to go get LVN A. She stated LVN A came in, tried to get Resident #1 to respond, and checked his pulse oxygen and pulse levels. CNA B stated she left the room herself to get another nurse. She stated she thought the other nurse had gotten the crash cart but was not sure . She stated she did not notice anything about Resident #1's breathing prior to the phlebotomist telling her. CNA B stated she was not CPR certified. She stated she did tell LVN A Resident #1 was taking off his oxygen mask . Interviews on [DATE] at 9:41 AM and [DATE] at 9:59 AM with LVN A revealed on [DATE] on the night shift she worked and was assigned to Resident #1. LVN A stated this was the first night working with Resident #1 and was only told Resident #1 yelled at night due to anxiety. She stated Resident #1 was yelling throughout the shift and she went into his room to calm him . She stated she was unable to give Resident #1 [MEDICATION NAME] because the previous nurse had given him a prn dosage around 9:00 PM. She stated she checked on him every 2 hours. She stated she changed Resident #1's peg tube dressing and did notice his oxygen mask was off. She could not recall when she put the oxygen mask back on Resident #1 but stated she must have done it before, during or after she changed his peg tube dressing. She stated she should have put the oxygen mask back on Resident #1 as soon as she noticed it was off and checked his oxygen saturation along with other vitals. She stated she did not know what the pulse oxygen saturation levels were, but they were in 90s. She stated around 2:00 or 2:30 AM on [DATE] Resident #1 was quiet not yelling anymore so she went to his room. She stated he was sleeping and saw his chest was going up and down, so she did not bother him or assess him. She stated she did not assess his vitals or check his oxygen saturation levels. She stated she did not contact Resident #1's physician in the middle of the night because they are unavailable at night, but she would contact the physician in the morning to see about getting a new order for antianxiety medication due to his yelling out behaviors. She stated she was called to Resident #1's room by CNA B around 4:00 or 4:30 AM who reported Resident #1 was not responsive and had difficulty breathing. She stated this was the first time she noticed any issues with the resident's breathing on her shift. She stated when she entered the room Resident #1 was unresponsive and would not respond to her or CNA B. She stated Resident #1 had shallow/faint breathing. She stated his pulse oxygen saturation was in the 50s but could not recall any other vital signs. She stated it was like Resident #1 was leaving. She stated she left the room and went to get the crash cart because CNA B would not know where it was at. She stated CNA B was not CPR certified and she knew Resident #1 a full code status. She stated she should have stayed with Resident #1 and had CNA B get help to call the code. She stated she called 911 and started CPR after she got the crash cart. She stated she contacted Resident #1's responsible party and the physician after EMS took over CPR. She stated she did not get ahold of the physician but left him a voicemail about Resident #1 being sent to the hospital and required CPR. She stated she was aware Resident #1 had an electronic monitoring device in his room . Interview on [DATE] at 10:46 AM with LVN D revealed she worked on the night shift on [DATE] with LVN A. She stated she remembered during the beginning of her shift hearing someone yelling which lasted about 2 hours at most and she asked LVN A who that was sometime on the shift. She stated LVN A told her it was Resident #1, and he was agitated. She told her she could not give Resident #1 any medication since the previous nurse gave him antianxiety medication at the end of her shift. LVN D stated she told LVN A she could contact the doctor to see if there was something she could give Resident #1 for increased agitation. LVN D stated sometime after 4:00 AM LVN A came to her when she was on her hall with the medication cart to ask for the work phone. LVN D stated LVN A told her she needed to use the work phone to send a resident to the hospital. LVN D stated LVN A did not mention she had an emergency or a code. She stated LVN A asked her to print off Resident #1's paperwork so she could send him out to hospital. She stated LVN A did not use the work phone once she got it from her but headed back down her hall. LVN D did not see LVN A use the phone. She stated she went to print off Resident #1's paperwork. She stated the phlebotomist told her when she was printing paperwork that she was unable to draw Resident #1's blood and said he was not feeling well, and she was not comfortable drawing his blood. LVN D stated if a resident is exhibiting signs of agonal breathing, unresponsive with no pulse she would stay with resident and initiate CPR as necessary. She would then call out for help and whoever arrives next she would have them get the crash cart and AED. She stated she would have assisted LVN A if she knew there was a code, but she did not know. She stated no code was called during the shift . Interviews on [DATE] at 10:30 AM and [DATE] at 2:10 PM with Staffing Coordinator LVN revealed he was working as a charge nurse on the 500 and 700 halls on [DATE] from 10 pm to 6 am on [DATE]. He stated in the early morning of [DATE] when he was on the 500 hall getting gloves the phlebotomist was motioning for him with her hand to come speak with her. He stated the phlebotomist told him he should go check on Resident #1 who was gasping when she went to draw his blood. The Staffing Coordinator LVN stated he went to Resident #1's room and found the crash cart in front of the resident's doorway. He stated when he entered the room the privacy curtain was already pulled. He stated LVN A and CNA B were near the head of Resident #1's bed just looking at Resident #1 but neither of them were performing CPR or checking vitals. He stated LVN A was on the phone initially, but he was not sure with whom. He stated Resident #1 was gasping, had shallow breathing and took a breath in but did not exhale back out. He stated Resident #1 had a full code status, was unresponsive and needed CPR. He stated he cussed at them and told them they needed to get the back board so they could do CPR. He stated they assisted him to put the back board under Resident #1 and the Staffing Coordinator LVN started CPR, not LVN A. He stated he had one of them go get the AED because it was not there. He stated LVN A told him she had called 911. He stated it was not too long before EMS arrived and facility staff maybe did about three rounds of CPR before they arrived. He stated when EMS arrived they took over CPR. He stated no code was called by LVN A and he had no idea anything was going on with Resident #1 until the phlebotomist came and got him. He stated they were unable to revive Resident #1. He stated Resident #1 did yell out at times but only when he was anxious wanting someone to stay with him. He stated when he worked with Resident #1 he would check on him often because of his anxiety and Resident #1 would take his oxygen mask off. He stated he provided orientation training for LVN A on conducting a code about 2 months ago and LVN A should have alerted for help and initiated CPR before he got there. Staffing Coordinator LVN stated if a resident is exhibiting signs of agonal breathing, unresponsive with no pulse he would stay with resident and initiate CPR as necessary. He would then call out for help and whoever arrives next he would have them get the crash cart and AED along with calling a code so all available staff could come to assist in this emergency situation. Interview on [DATE] at 2:25 PM with LVN Staff Coordinator after being shown the video [DATE] at 4:34 AM he stated he had done about three sets of compressions of CPR prior to EMS arriving with no change noted. Interview on [DATE] at 4:19 PM with LVN C revealed she worked the 2:00 PM to 10:00 PM shift on [DATE]. She stated Resident #1 did have an elevated temperature and she was told by CNA F Resident #1 was not wanting to eat much of his supper near the end of her shift on [DATE]. She gave Resident #1 Tylenol prn order. She stated Resident #1 not eating much was not out of his normal and he received a [DEVICE] feeding at night. She stated she and the aides checked on Resident #1 more frequently, at least every 30 minutes, due to Resident #1 taking his oxygen mask off. LVN C stated if he took the mask off, he would not put it back on himself. She stated he was alert, oriented and talking to her like normal on her shift. She stated when Resident #1 took his oxygen off, she placed it back on him after checking the mask, oxygen tubing and concentrator along with his pulse and pulse oxygenation saturation levels. She stated Resident #1 did not show any signs of respiratory distress or difficulty breathing on her shift. She stated if Resident #1's oxygen mask was not on him, his pulse oxygen saturation levels would go down below 90. She stated Resident #1 was sent to the hospital before when his oxygen levels went too low and unable to stabilize. She stated she gave Resident #1 prn [MEDICATION NAME] to help with the yelling and increased agitation on her shift. She stated she did give report to LVN A about Resident #1 having an elevated temperature, yelling and had a new IV antibiotic which needed to be started. She stated she was unable to do it on her shift. Interview on [DATE] at 2:45 PM with CNA F revealed Resident #1 did not want to eat his supper on [DATE] but he was able to get him to eat a couple bites. He stated Resident #1 was alert, oriented on his shift. He denied any breathing issues or respiratory distress. Interview on [DATE] at 3:05 PM with MA G revealed she did work with Resident #1 on [DATE] on the 2:00 PM to 10:00 PM shift. She stated Resident #1 did not want to take his medications. She stated Resident #1 seemed shaky and restless near the end of the shift but the restlessness was not unusual for him. She notified LVN C who then checked on Resident #1. She denied any issues with Resident #1's breathing or respiratory distress. She stated he was alert and oriented on her shift. Interviews on [DATE] at 1:20 PM and [DATE] at 1:11 PM with DON revealed Resident #1 did take his oxygen mask off but she expected the nurse to assess the resident by checking vitals and oxygen saturation levels and put the oxygen mask back on the resident after ensuring mask and tubing were connected to the oxygen concentrator. She stated if Resident #1 did not have the oxygen mask or nasal cannula on his oxygen saturation levels would go down. She stated LVN A should have assessed Resident #1 when he was showing signs of difficulty breathing. She stated LVN A should have assessed Resident #1 when not wearing his oxygen mask and put oxygen mask back on Resident #1. She stated after reviewing the video she stated LVN A did not assess Resident #1's oxygen saturation levels and vital signs. She stated LVN A did not check Resident #1's vitals and did not intervene when Resident #1 had a change of condition of labored breathing using his accessory (abdominal) muscles. She stated LVN A should have notified Resident #1's physician about the change of condition for further guidance. She stated Resident #1 was using his accessory muscles (abdominal) when breathing and LVN A should have checked Resident #1's vitals including respirations, listen for lung sounds, pulse, temperature, blood pressure and oxygen saturation. She stated LVN A should not have left Resident #1 when he exhibited agonal breathing, but she should have called for help and had CNA B get the crash cart and AED. She stated LVN A should have followed up with Resident #1 after CNA B put the oxygen mask back on Resident #1. Interview on [DATE] at 1:33 PM with the Medical Director revealed if a resident took off the oxygen mask and had orders for oxygen, he would expect the nurse to assess the resident, check oxygen saturation levels, check the oxygen mask and oxygen tubing to ensure working, put the oxygen mask back on the resident and increase the oxygen if necessary. He stated he would expect the nurse to ensure the oxygen saturation levels were stable. He stated he expected the nurse to notify him immediately if a resident was having a change of condition. He stated if resident was showing signs of agonal breathing or gasping he would expect the nurse to get help, do a quick assessment of airway, breathing and circulation; and check if the resident was alert and responsive. He would expect the nurse to stay with the resident and call for help and initiate CPR when necessary. Review of LVN A's employee file revealed a hire date of [DATE] as LVN. She was CPR and AED certified on [DATE] with a renewal date of ,[DATE]. Review of LVN A's timesheet from [DATE] to [DATE] reflected she worked on [DATE] from 9:57 pm to [DATE] at 7:23 AM. She worked on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] on the night shift. She clocked out on [DATE] at 7:01 AM. Interview with the Administrator on [DATE] at 4:30 PM revealed LVN A was suspended pending investigation yesterday evening, [DATE], after the IJ was called. He stated CNA B would no longer be working at the facility due to the failure to call and no showed for two shifts policy violations. Review of CNA B's timesheet from [DATE] to [DATE] reflected she worked on [DATE] from 9:58 PM to [DATE] at 6:07 AM. She worked on [DATE], [DATE], [DATE], [DATE] on the night shift. She clocked out on [DATE] at 6:26 AM and this was last time she worked at the facility. Review of facility's policy Cardiopulmonary Resuscitation (CPR): Basic Life Support (BLS)/Hands-Only CPR dated [DATE] reflected, CPR - is a group of emergency treatments that are executed when someone's breathing or heartbeat has stopped. The treatments consist of rescue breathing and chest compressions. CPR allows [MEDICATION NAME] blood to circulate to vital organs such as the brain and heart. Under General Guidelines: 1. The goal of CPR is to try to maintain life until the emergency medical response team arrive to deliver Advanced Life Support (ALS). Under Steps in the procedure reflected for Bystander/Unlicensed staff 1. Summon for help 2. Request AED 3. Check for Responsiveness (for example shaking, tap shoulder and shout 'are you okay' etc) 4. While awaiting AED, if unresponsive being performing chest compressions (unless known code status is DNR). Continue until licensed staff arrive. 5. If responsive stay with resident until help arrives. CPR Certified Staff 1. Determine unresponsiveness; if no response 2. Request AED and summon for help 3. Check for no breathing or no normal breathing 4. Check for pulse (no more tha (TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #10) of four residents reviewed for accidents. CNA A failed to ensure she had assistance when providing incontinent care to Resident #10 who required the assistance of two people with activities of daily living on 01/05/20. Resident #10 slid to the floor from the bed and sustained a right femur fracture on 01/05/20 which required surgery. This failure could place residents at risk for accidents, harm or serious injury. Findings included: Review of Resident #10's admission MDS assessment dated [DATE] reflected she was a [AGE] year-old female with the following Diagnoses: [REDACTED]. She had a BI[CONDITION] of 12 which indicated she was cognitively intact. Resident #10 required two-person extensive assistance with ADLs including toileting. Resident #10 was incontinent. Review of Resident #10's Quarterly MDS assessment dated [DATE] on her readmittance from the hospital after surgery, reflected she was a [AGE] year-old female with the following Diagnoses: [REDACTED]. She had a BI[CONDITION] of 13 which indicated she was cognitively intact. Resident #10 required two-person extensive assistance with ADLs including toileting. Resident #10 was incontinent. Review of the Resident # 10 change in condition report dated 01/05/20 revealed Resident # 10 complained of right leg pain and was sent to the hospital for further evaluation. She was found on the floor and had to be sent to the hospital after her symptoms worsened with movement. Review of Resident # 10's nursing notes revealed the exact same verbiage as the change in condition report with no further documentation on the incident. Review of Resident #10's Care Plan dated 01/21/20, reflected, . Impaired physical mobility r/t (related to) BKA ([MEDICAL CONDITION]) and right femur fracture. Provide appropriate level of assistance to promote safety of resident. Review of Resident #10's x-ray report from the local hospital dated 01/05/20 revealed a spiral [MEDICAL CONDITION] femoral shaft (long, straight part of the thigh bone). Review of Resident #10's hospital post-operative X-ray dated 01/06/20 revealed there are plate and screws placed along the lateral portion of the right femoral diaphysis (the shaft or central part of a long bone.) The surgical hardware are in expected position. There is no angulation (an angular position) or displacement across the fracture line. According to the American Academy of Orthopedic Surgeons with a spiral fracture the fracture line encircles the shaft like the stripes on a candy cane. A twisting force to the thigh causes this type of fracture. Accessed from https://orthoinfo.aaos.org/en/diseases--conditions/femur-shaft-fractures-broken-thighbone/ on 03/05/20. In an interview with Resident #10 on 02/18/20 at 9:30 a.m. she stated regarding the incident on 01/05/20, the weekends seemed to have less staff and the incident occurred on the weekend. She stated CNA A was changing her and turned her to her left side and she yelled for CNA A to stop because she was falling. Resident #10 stated CNA A's response was, no you're not. Resident #10 stated she ended up on the floor with her right arm caught in the bedrail. She stated another CNA came in and they both assisted her back to bed. She stated initially only her elbow hurt, but then her right leg started hurting and an ambulance was called. An interview with Resident #10 on 02/20/20 at 12:49 p.m., regarding the events of 01/05/20, revealed she immediately had discomfort in her right arm following the incident. Resident # 10 stated she told CNA A multiple times during care that she felt like she was falling. She stated the pain in her right leg began about one hour after the fall. Resident #10 described it as a different kind of pain and stated she just wanted to go to the hospital because something was wrong with her leg. Resident #10 stated she went to the hospital per her request. An interview with CNA A on 02/18/20 at 11:30 a.m., regarding the events of 01/05/20 revealed she was agency staff and that she was not aware if Resident #10 required the assistance of one or two people with her incontinent care. CNA A stated she asked the resident and the resident indicated she was able to assist with turning. CNA A stated on 01/05/20 she was providing incontinent care to Resident #10 by herself when the resident's legs started to slide off the bed. CNA A stated the resident told her that she was sliding off the bed, so she lowered the bed to the floor. CNA A stated at that point Resident #10 was half off the bed with her right foot on the floor and her arm in the bed rail. She removed Resident #10's right arm from the rail and lowered the resident to the floor. CNA A stated the nurse then assessed the resident, and Resident #10 complained her right arm hurt. CNA A stated within three to four hours of the incident, the resident was sent to the hospital. An interview with LVN D on 0[DATE] at 9:06 a.m. revealed regarding events of 01/05/20, she was called by CNA A during dinner time to Resident #10's room. When she walked in, she saw Resident #10 lying on her back on the floor with her foot toward the head of the bed and her head toward the foot of the bed. LVN D stated she was more concerned with getting the resident off the floor because the resident was in pain. Resident #10 was put back to bed with the Hoyer lift. LVN D stated the resident complained of pain in the right arm and an x-ray was ordered. LVN D stated Resident #10 told her she slid off the bed, but she did not fall. LVN D stated after the right elbow was x-rayed, the resident complained of right groin pain and it was suggested she go to the hospital. She stated Resident #10's responsible party was notified on the resident's phone and 911 was called. An interview with the Weekend Supervisor on 0[DATE] at 10:00 a.m. revealed on 01/05/20, when she arrived to Resident #10's room, the resident was lying on the floor. She stated LVN D assessed the resident and wanted to send her to the hospital. Weekend Supervisor stated LVN D observed a lump which came up on Resident #10's right elbow. She stated Resident #10 complained of an achy pain but had no other areas of injury. She reported CNA A reported to her she was providing care to Resident #10 and the resident slid off the bed. An interview with LVN E on 0[DATE] at 10:30 a.m. revealed prior to 01/01/20's hospitalization , Resident #10 was a two-person assist with all ADLs. LVN E stated Resident #10 could not reposition herself. She stated the resident's care requirements were in the POC (Plan of Care) tablet which all CNAs could access. An interview with LVN F on 0[DATE] at 10:45 a.m. revealed prior to 01/05/20's hospitalization , Resident #10 was typically a two-person assist with ADLs. She stated every CNA had access to the resident's POC. An interview on 0[DATE] at 11:15 a.m. with CNA G revealed Resident #10 was a two-person toileting assist with the bedpan. An interview on 0[DATE] at 11:45 a.m. with CNA H revealed on the POC, Resident #10 was an extensive two-person assist with ADLs. An interview with the Nurse Consultant on 02/18/20 at 11:20 a.m. revealed staffing was much better. She stated agency staff received some education on the POC tablet. The Nurse Consultant stated the facility hired quality people as permanent workers and they were not using agency staff unless they absolutely had to. In an interview on 0[DATE] at 2:15 p.m. the Nurse Consultant stated her expectations of staff and agency staff was to use the POC tablet and, if in doubt, ask. The Nurse Consultant stated extensive assist would be two people providing assistance for sure. Review of the facility's Fall Prevention and Program dated February 2020 revealed: 1. The community will identify each resident who is at risk for falls and will implement interventions to manage falls by providing an environment that is free from potential hazards.

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #273) of four residents reviewed for medications. The facility failed to ensure Resident #273, who was admitted to the facility on [DATE] with transfer orders from the hospital for a [MEDICATION NAME], was administered as ordered. The facility did not obtain prescription for the order for the [MEDICATION NAME]es from the pharmacy upon her admission. Upon the order being received from the pharmacy (reportedly on the evening of 12/06/18 or on the morning of 12/07/18), the facility failed to apply a [MEDICATION NAME] as soon as it was available. Resident #273 was without her [MEDICATION NAME] for two days. Per Mayo Clinic (https://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-[MEDICATION NAME]-route/proper-use/drg- 152, reviewed on 12/21/18), .Remove the patch after 3 days (72 hours), or as directed by your doctor. Choose a different place on your skin to apply the next patch. If possible, use a place on the other side of your body. Wait at least 3 days before using the first area again . This failure could affect residents who received scheduled narcotics/pain medication to treat pain and placed the residents at risk for further decline in their mental or physical functioning, as well as unnecessary pain and suffering. Findings included: Review of Resident #273's Face Sheet, dated 12/07/18, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a hospital Medication Administration Record [REDACTED]. Review of Resident #273's Facility Transfer Orders from the hospital, dated 12/03/18, reflected an order for [REDACTED]. Review of Resident #273's physician's orders [REDACTED]. The orders specified to administer one patch every three days, as well as to remove the [MEDICATION NAME] prior to placing the next patch. Review of the Resident #273's MAR from the facility, printed on 12/07/18 at 10:42 a.m., reflected she was to receive [MEDICATION NAME] 25mcg/hr [MEDICATION NAME]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR further reflected the medication was not administered at any point between 12/05/18 and when the MAR indicated [REDACTED]. Resident #273 received this medication once on 12/03/18, three times on 12/04/18, once on 12/05/18, twice on 12/06/18, and once on 12/07/18. Review of Resident #273's MAR PRN from the facility, printed on 12/07/18 at 1:37 p.m., reflected the following the following pain scales for the administration of [MEDICATION NAME]-[MEDICATION NAME] 10mg-325mg tablets: 12/03/18 - Pain Scale 9 - Follow Up 0 12/04/18 - Pain Scale 5 - Follow Up 0 12/04/18 - Pain Scale 8 - Follow Up 0 12/04/18 - Pain Scale 7 - Follow Up 0 12/06/18 - Pain Scale 8 - Follow Up 0 12/06/18 - Pain Scale 7 - Follow Up 0 Review of Resident #273's Nurse's Notes, dated 12/03/18 to 12/07/18, reflected the following pain evaluations were completed after Resident #273 was administered her prescription of [MEDICATION NAME]-[MEDICATION NAME] 10mg-325mg tablet: 12/03/18 at 9:38 p.m. - Pain Evaluation: 0 12/04/18 at 6:46 a.m. - Pain Evaluation: 0 12/04/18 at 4:22 p.m. - Pain Evaluation: 0 12/04/18 at 9:39 p.m. - Pain Evaluation: 0 12/06/18 at 11:57 a.m. - Pain Evaluation: 0 12/06/18 at 10:24 p.m. - Pain Evaluation: 0 12/07/18 at 10:46 a.m. - Pain Evaluation: 0 Review of Resident #273's Baseline Care Plan, dated 12/04/18, reflected she experienced acute pain within the previous seven days. Observation of and interview with Resident #273 on 12/07/18 at 10:14 a.m. revealed she was displaying signs and symptoms of pain. She was observed to wince several times throughout the conversation. Resident #273 verbalized pain and discomfort. She stated she thought the pain and discomfort was caused by the mass in her stomach. Resident #273 denied anyone had placed a [MEDICATION NAME] on her body. She said she was prescribed [MEDICATION NAME] which was sometimes effective, but it did not always take all the pain away. Observation of LVN S completing a pain assessment for Resident #273 on 12/07/18 at 11:20 a.m. reflected Resident #273 reported she had not a whole lot of pain. She said her pain was bearable and was a level 3 on a scale of 1-10. During an interview with LVN S on 12/07/18 at 10:24 a.m., she stated Resident #273's prescription for [MEDICATION NAME]es was just received the night prior. She stated Resident #273 was not administered a [MEDICATION NAME] because it did not trigger on her MAR. She stated per Resident #273's MAR, a [MEDICATION NAME] was not triggered to be placed on her until either 12/08/18 or 12/09/18. LVN S stated a [MEDICATION NAME] previously triggered to be placed on Resident #273 (12/05/18), but the patch was not available to be administered. She stated this was because [MEDICATION NAME] required a triplicate order. LVN S stated she contacted the physician (12/05/18) who oversaw resident pain and spoke with the Nurse Practitioner, who said she wanted to meet with the resident. After the Nurse Practitioner met with Resident #273 (12/06/18) and determined an order for [REDACTED].#273's [MEDICATION NAME] was received last night, on 12/06/18. When asked if she was going to place the [MEDICATION NAME] on Resident #273 this morning (12/07/18), LVN S stated she was not going to administer the medication because it would not trigger on the MAR indicated [REDACTED] During an interview with the DON on 12/07/18 at 1:40 p.m., she stated a [MEDICATION NAME] was placed on Resident #273 at the hospital and within a day of her transfer to the facility. She stated Resident #273 had the [MEDICATION NAME] on her body when she was admitted to the facility on [DATE]. When the [MEDICATION NAME] was due to be changed (12/05/18), LVN S contacted the pharmacy and was advised a triplicate was needed in order to fill the prescription. LVN S contacted the Physician's Assistant for the physician (12/05/18) who oversaw residents' pain management, and the Physician's Assistant said to place the order on hold. The Physician's Assistant wanted to assess Resident #273 prior to a triplicate order being written. The DON stated the Physician's Assistant came to the facility and assessed Resident #273 on 12/06/18. The facility then received the appropriate triplicate order and submitted it to the pharmacy (12/06/18). The DON stated Resident #273's prescription of [MEDICATION NAME] was received either on the evening of 12/06/18 or on the morning of 12/07/18. She stated upon receipt of the medication, a new [MEDICATION NAME] should have been applied to Resident #273 and her orders should have been updated. She said facility staff should not wait for the MAR indicated [REDACTED]. The DON further stated an order for [REDACTED].#273's admission. During an interview with ADON R on 12/07/18 at 2:35 p.m., she stated per Resident #273's MAR from the hospital, a [MEDICATION NAME] was applied to her skin on 12/02/18, which was the morning prior to her admission to the facility. ADON R said upon Resident #273's admission to the facility, she input the orders from the hospital into the facility's system. She said based on the MAR from the hospital, the facility's MAR indicated [REDACTED]. ADON R said the facility typically attempted to get orders for medications that required triplicates upon admission. She said she did not know why this was not completed in Resident #273's case. ADON R stated the Physician's Assistant came to the facility to assess Resident #273 on 12/06/18. A triplicate was obtained and sent to the pharmacy. ADON R stated the order for Resident #273's [MEDICATION NAME] was received around midnight (approximately 14.5 hours prior). She said at the time when the medication was received, the facility's MAR indicated [REDACTED]. During an interview with the Physician's Assistant on 12/07/18 at 12:43 p.m., she stated upon Resident #273's admission to the facility, she was contacted and advised that Resident #273 was a new admit and was prescribed [MEDICATION NAME]. She said on 12/05/18, she was contacted by the facility and told that Resident #273 triggered on her MAR indicated [REDACTED]. The Physician's Assistant said because [MEDICATION NAME] is a high-risk medication, she advised the facility to place the order on hold until she could assess Resident #273. The Physician's Assistant stated she assessed Resident #273 for the first time on 12/06/18. She said that Resident #273 reported having breakthrough pain between 7-8 on a scale of 1-10. Resident #273 was initially hesitant about continuing the order of [MEDICATION NAME] from the hospital, but because her pain was managed better in the hospital with the [MEDICATION NAME], she decided she wanted to continue the medication. The Physician's Assistant stated the plan discussed was for Resident #273 to have an order for [REDACTED]. Observation of Resident #273 on 12/07/18 at 3:35 p.m. revealed she had a [MEDICATION NAME] on her left arm that was dated 12/2 8:30 a.m. Observation of ADON R and LVN S on 12/07/18 at 3:48 p.m. revealed they placed a new [MEDICATION NAME] on Resident #273's skin. LVN S was not previously aware that the [MEDICATION NAME] from the hospital was still on Resident #273's body.

Based on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #273) of four residents reviewed for pain. The facility failed to ensure Resident #273, who was admitted to the facility on [DATE] with transfer orders from the hospital for a [MEDICATION NAME], was administered as ordered. The facility did not obtain prescription for the order for the [MEDICATION NAME]es from the pharmacy upon her admission. Upon the order being received from the pharmacy (reportedly on the evening of 12/06/18 or on the morning of 12/07/18), the facility failed to apply a [MEDICATION NAME] as soon as it was available. Resident #273 was without her [MEDICATION NAME] for two days. Per Mayo Clinic (https://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-[MEDICATION NAME]-route/proper-use/drg- 152, reviewed on 12/21/18), .Remove the patch after 3 days (72 hours), or as directed by your doctor. Choose a different place on your skin to apply the next patch. If possible, use a place on the other side of your body. Wait at least 3 days before using the first area again . This failure could affect residents who received scheduled narcotics/pain medication to treat pain and placed the residents at risk for further decline in their mental or physical functioning, as well as unnecessary pain and suffering. Findings included: Review of Resident #273's Face Sheet, dated 12/07/18, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a hospital Medication Administration Record [REDACTED]. Review of Resident #273's Facility Transfer Orders from the hospital, dated 12/03/18, reflected an order for [REDACTED]. Review of Resident #273's physician's orders [REDACTED]. The orders specified to administer one patch every three days, as well as to remove the [MEDICATION NAME] prior to placing the next patch. Review of the Resident #273's MAR from the facility, printed on 12/07/18 at 10:42 a.m., reflected she was to receive [MEDICATION NAME] 25mcg/hr [MEDICATION NAME]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR further reflected the medication was not administered at any point between 12/05/18 and when the MAR indicated [REDACTED]. Resident #273 received this medication once on 12/03/18, three times on 12/04/18, once on 12/05/18, twice on 12/06/18, and once on 12/07/18. Review of Resident #273's MAR PRN from the facility, printed on 12/07/18 at 1:37 p.m., reflected the following the following pain scales for the administration of [MEDICATION NAME]-[MEDICATION NAME] 10mg-325mg tablets: 12/03/18 - Pain Scale 9 - Follow Up 0 12/04/18 - Pain Scale 5 - Follow Up 0 12/04/18 - Pain Scale 8 - Follow Up 0 12/04/18 - Pain Scale 7 - Follow Up 0 12/06/18 - Pain Scale 8 - Follow Up 0 12/06/18 - Pain Scale 7 - Follow Up 0 Review of Resident #273's Nurse's Notes, dated 12/03/18 to 12/07/18, reflected the following pain evaluations were completed after Resident #273 was administered her prescription of [MEDICATION NAME]-[MEDICATION NAME] 10mg-325mg tablet: 12/03/18 at 9:38 p.m. - Pain Evaluation: 0 12/04/18 at 6:46 a.m. - Pain Evaluation: 0 12/04/18 at 4:22 p.m. - Pain Evaluation: 0 12/04/18 at 9:39 p.m. - Pain Evaluation: 0 12/06/18 at 11:57 a.m. - Pain Evaluation: 0 12/06/18 at 10:24 p.m. - Pain Evaluation: 0 12/07/18 at 10:46 a.m. - Pain Evaluation: 0 Review of Resident #273's Baseline Care Plan, dated 12/04/18, reflected she experienced acute pain within the previous seven days. Observation of and interview with Resident #273 on 12/07/18 at 10:14 a.m. revealed she was displaying signs and symptoms of pain. She was observed to wince several times throughout the conversation. Resident #273 verbalized pain and discomfort. She stated she thought the pain and discomfort was caused by the mass in her stomach. Resident #273 denied anyone had placed a [MEDICATION NAME] on her body. She said she was prescribed [MEDICATION NAME] which was sometimes effective, but it did not always take all the pain away. Observation of LVN S completing a pain assessment for Resident #273 on 12/07/18 at 11:20 a.m. reflected Resident #273 reported she had not a whole lot of pain. She said her pain was bearable and was a level 3 on a scale of 1-10. During an interview with LVN S on 12/07/18 at 10:24 a.m., she stated Resident #273's prescription for [MEDICATION NAME]es was just received the night prior. She stated Resident #273 was not administered a [MEDICATION NAME] because it did not trigger on her MAR. She stated per Resident #273's MAR, a [MEDICATION NAME] was not triggered to be placed on her until either 12/08/18 or 12/09/18. LVN S stated a [MEDICATION NAME] previously triggered to be placed on Resident #273 (12/05/18), but the patch was not available to be administered. She stated this was because [MEDICATION NAME] required a triplicate order. LVN S stated she contacted the physician (12/05/18) who oversaw resident pain and spoke with the Nurse Practitioner, who said she wanted to meet with the resident. After the Nurse Practitioner met with Resident #273 (12/06/18) and determined an order for [REDACTED].#273's [MEDICATION NAME] was received last night, on 12/06/18. When asked if she was going to place the [MEDICATION NAME] on Resident #273 this morning (12/07/18), LVN S stated she was not going to administer the medication because it would not trigger on the MAR indicated [REDACTED] During an interview with the DON on 12/07/18 at 1:40 p.m., she stated a [MEDICATION NAME] was placed on Resident #273 at the hospital and within a day of her transfer to the facility. She stated Resident #273 had the [MEDICATION NAME] on her body when she was admitted to the facility on [DATE]. When the [MEDICATION NAME] was due to be changed (12/05/18), LVN S contacted the pharmacy and was advised a triplicate was needed in order to fill the prescription. LVN S contacted the Physician's Assistant for the physician (12/05/18) who oversaw residents' pain management, and the Physician's Assistant said to place the order on hold. The Physician's Assistant wanted to assess Resident #273 prior to a triplicate order being written. The DON stated the Physician's Assistant came to the facility and assessed Resident #273 on 12/06/18. The facility then received the appropriate triplicate order and submitted it to the pharmacy (12/06/18). The DON stated Resident #273's prescription of [MEDICATION NAME] was received either on the evening of 12/06/18 or on the morning of 12/07/18. She stated upon receipt of the medication, a new [MEDICATION NAME] should have been applied to Resident #273 and her orders should have been updated. She said facility staff should not wait for the MAR indicated [REDACTED]. The DON further stated an order for [REDACTED].#273's admission. During an interview with ADON R on 12/07/18 at 2:35 p.m., she stated per Resident #273's MAR from the hospital, a [MEDICATION NAME] was applied to her skin on 12/02/18, which was the morning prior to her admission to the facility. ADON R said upon Resident #273's admission to the facility, she input the orders from the hospital into the facility's system. She said based on the MAR from the hospital, the facility's MAR indicated [REDACTED]. ADON R said the facility typically attempted to get orders for medications that required triplicates upon admission. She said she did not know why this was not completed in Resident #273's case. ADON R stated the Physician's Assistant came to the facility to assess Resident #273 on 12/06/18. A triplicate was obtained and sent to the pharmacy. ADON R stated the order for Resident #273's [MEDICATION NAME] was received around midnight (approximately 14.5 hours prior). She said at the time when the medication was received, the facility's MAR indicated [REDACTED]. During an interview with the Physician's Assistant on 12/07/18 at 12:43 p.m., she stated upon Resident #273's admission to the facility, she was contacted and advised that Resident #273 was a new admit and was prescribed [MEDICATION NAME]. She said on 12/05/18, she was contacted by the facility and told that Resident #273 triggered on her MAR indicated [REDACTED]. The Physician's Assistant said because [MEDICATION NAME] is a high-risk medication, she advised the facility to place the order on hold until she could assess Resident #273. The Physician's Assistant stated she assessed Resident #273 for the first time on 12/06/18. She said that Resident #273 reported having breakthrough pain between 7-8 on a scale of 1-10. Resident #273 was initially hesitant about continuing the order of [MEDICATION NAME] from the hospital, but because her pain was managed better in the hospital with the [MEDICATION NAME], she decided she wanted to continue the medication. The Physician's Assistant stated the plan discussed was for Resident #273 to have an order for [REDACTED]. Observation of Resident #273 on 12/07/18 at 3:35 p.m. revealed she had a [MEDICATION NAME] on her left arm that was dated 12/2 8:30 a.m. Observation of ADON R and LVN S on 12/07/18 at 3:48 p.m. revealed they placed a new [MEDICATION NAME] on Resident #273's skin. LVN S was not previously aware that the [MEDICATION NAME] from the hospital was still on Resident #273's body.