Every finding on record at Advanced Health & Rehab Center of Garland

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four of ten residents (Residents #6, #73, #82, and #105) reviewed for respiratory care. 1.The facility failed to ensure Resident #6's nasal cannula was properly stored when not in use on 06/03/2026. 2.The facility failed to ensure Resident #73's BiPAP mask and breathing mask (a medical device used to deliver medication in the form of mist directly to the lungs) were properly stored when not in use on 06/02/2026. 3.The facility failed to ensure Resident #82's Yankauer suction tip was properly stored when not in use on 06/03/2026. 4.The facility failed to ensure Resident #105's BiPAP mask was properly stored when not in use on 06/02/2026. These failures could place residents at risk of respiratory infection and not having their respiratory needs met.Findings included: 1. Record review of Resident #6's Face Sheet, dated 06/04/2026, reflected a [AGE] year-old female admitted [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #6's Comprehensive MDS Assessment, dated 04/03/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident was on oxygen therapy. Record review of Resident #6's Comprehensive Care Plan, dated 04/09/2026, reflected that the resident used oxygen therapy and one of the interventions was to administer oxygen per physician's order. Record review of Resident #6's Physician Order, dated 03/17/2026, reflected, Supplemental oxygen as needed for OSA, hypoxia (insufficient amount of oxygen in the body) related to RESPIRATORY FAILURE (condition where there is not enough oxygen in the body or too much carbon dioxide in the body), UNSPECIFIED WITH HYPERCAPNIA (too much carbon dioxide in the blood) . DEPENDENCE ON SUPPLEMENTAL OXYGEN . O2 to keep saturations > 92%. During an observation and interview on 06/03/2026 at 7:44 a.m., Resident #6 was in her bed, awake. It was observed that a nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) connected to an oxygen concentrator was on the floor. The resident said she would use the oxygen at night every time they put on her BiPAP. She said somebody helped her take it off every morning. During an observation and interview on 06/03/2026 at 8:04 a.m., CNA H said she did not notice that the nasal cannula was on the floor when she transferred Resident #6. She said whoever took it off should put it a bag to prevent respiratory infection. She said there was not even a bag on the oxygen concentrator or inside the resident's drawer. She pulled the nasal cannula from the oxygen concentrator and threw it in a waste can. She said she would tell the nurse that Resident #6 needed a new nasal cannula. 2. Record review of Resident #73's Face Sheet, dated 06/04/2026, reflected a [AGE] year-old female admitted [DATE]. The resident was diagnosed with sleep apnea (interruption in breathing during sleeping) and respiratory failure with hypercapnia (high concentration of carbon dioxide in the blood). Record review of Resident #73's Comprehensive MDS Assessment, dated 05/04/2026, reflected that the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident was using a BiPAP and had respiratory failure with hypercapnia. Record review of Resident #73's Comprehensive Care Plan, dated 04/30/2026, reflected the resident did not have a care plan for her BiPAP. The care plan indicated the resident had impaired respiratory status and one of the interventions was to monitor for shortness of breath and implement appropriate ordered interventions. Record review of Resident #73's Physician Order, dated 04/22/2026, reflected, BiPAP @ _16__ cm H20 Inspiration (higher pressure delivered during inspiration); _8___cm H20 Expiration (lower pressure delivered during exhalation) with 02 at _2_ liters with humidification. BIPAP scheduled start at HS. Discontinue upon waking. Evaluate Respirations, BP, pulse, and oxygen saturation before application at bedtime for sleep apnea. Record review of Resident #73's Physician Order, dated 05/22/2026, reflected, Formoterol Fumarate Inhalation Nebulization Solution 20 MCG/2ML (Formoterol Fumarate) 1 vial inhale orally via nebulizer two times a day for SOB. During an observation and interview on 06/02/2026 at 9:14 a.m., Resident #73 was in bed, awake. It was observed that a BiPAP machine was on top of the resident's side table with a BiPAP mask connected to it. The BiPAP mask was not bagged and was on the floor. The resident said she used the BiPAP every night, and the staff would put it on at night and would take it off in the morning. It was also observed that there was a breathing mask (a medical device used to deliver medication in the form of mist directly to the lungs) on the resident's semi-open drawer. The breathing mask was not bagged. Resident #73 said she was not given her breathing treatment yet. She said she did not see any plastic bags for the BiPAP mask and breathing mask. During an observation and interview on 06/02/2026 at 9:27 a.m., RN C said Resident #73's masks should be bagged in order to avoid any respiratory issues like respiratory infections. She went inside the room of the resident and saw that the BiPAP mask was on the floor and the breathing mask inside the drawer was not bagged. She said she would clean the BiPAP mask and put it in a bag. She said she would get a new breathing mask before she would give the resident's breathing treatment. She said with regards to the BiPAP mask, it was the night nurse that would put it on at night and take it off in the morning, but she should have been mindful to check that the masks were bagged on her shift. During an interview on 06/03/2026 at 6:22 a.m., LVN F said Resident #73's BiPAP mask was still on when she left on the morning of 06/02/2026. She said, Maybe she took it off and asked an aide to put it on the table. 3. Record review of Resident #82's Face Sheet, dated 06/04/2026, reflected a [AGE] year-old male admitted [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #82's Comprehensive MDS Assessment, dated 05/18/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident used a suction. Record review of Resident #82's Comprehensive Care Plan, dated 04/30/2026, reflected the resident did not have a care plan for suction use. Record review on 06/02/2026 of Resident #82's Physician Orders, reflected no order for suctioning. During an observation and interview on 06/03/2026 at 9:30 a.m., Resident #82 was in bed, awake. A suction machine was observed on top of the resident's side table with a Yankauer suction tip attached to it. The suction tip was not bagged and was touching the side of the table. The resident did not reply when asked when was the last time he was suctioned. During an observation and interview on 06/03/2026 at 9:44 a.m., RN D said she did not notice that Resident #82's Yankauer suction tip was not bagged when she checked on him earlier. She said it should be bagged when not in use to keep it clean. She disconnected the suction tip and said she would get a new one and would place it inside a plastic bag. 4. Record review of Resident #105's Face Sheet, dated 06/04/2026, reflected a [AGE] year-old female admitted [DATE]. The resident was diagnosed with sleep apnea. Record review of Resident #105's Comprehensive MDS Assessment, dated 03/02/2026, reflected t the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident was using a non-invasive mechanical ventilator (provides respiratory support without the need for invasive procedures). Record review of Resident #105's Comprehensive Care Plan, dated 05/30/2026, reflected that the resident wore a BiPAP at night and one of the interventions was to educate the resident on the importance of wearing a BiPAP at night. Record review of Resident #105's Physician Order, dated 01/15/2026, reflected, BIPAP/NIV with the following settings: Inspiratory positive airway pressure (IPAP: higher pressure delivered during inhalation) 16 Expiratory positive airway pressure (EPAP: lower pressure applied during exhalation) 10 Respiratory rates: 16at bedtime for OSA. During an observation and interview on 06/02/2026 at 11:13 a.m., Resident #105 was in bed awake. It was observed that the resident had a BiPAP machine with a mask connected to it. The mask was not bagged. When asked who took the mask off, the resident shrugged her shoulders. During an observation and interview on 06/02/2026 at 11:18 a.m., LVN E said she did not notice the BiPAP mask was not bagged. She said the mask should be bagged when not in use to prevent any respiratory issues. During an interview on 06/04/2026 at 8:43 a.m., ADON B said the BiPAP masks, the breathing mask, the nasal cannula, and the Yankauer suction tip should be inside a plastic bag when not in use to maintain its cleanliness as well as its patency (unobstructed). She said bagging the masks, nasal cannula, and the suction tip was important to prevent cross contamination and development of respiratory infections. She said the staff taking off the BiPAP masks and the nasal cannula were responsible for bagging them or at least providing a bag and educating the residents of the reason why the mask should be bagged. She said she would coordinate with the DON about the issue. During an interview on 06/04/2026 at 9:21 a.m., the DON said the staff were responsible for making sure the BiPAP mask, breathing mask, nasal cannula, and the suction tip were bagged when not in use to prevent any respiratory infection. She said she would start an in-service about respiratory care. During an interview on 06/04/2026 at 9:58 a.m., the Administrator said the expectation was for all the masks, nasal cannula, and the suction tip to be bagged when the residents were not using them to keep them clean. She said the residents already had respiratory issues and using dirty masks, nasal cannula, and suction tip could add to their medical issues. She said she would coordinate with the DON about the issue. Record review of the facility's policy titled, CPAP/BiPAP Support 2001 MED-PASS. Inc., revised April 4, 2025, reflected, Purpose . 3. To promote resident comfort and safety . General Guidelines for Cleaning . 5. Masks, nasal pillows, and tubing: . Place and store mask in covered device . between uses.Record review of the facility's policy titled, Respiratory Policy & Procedures, revised April 2026 reflected, PURPOSE: To provide guidelines for exceptional infection control within all respiratory related practices and care of equipment . PROCEDURE . 4. When not in use, all tubing should be stored in plastic bags or other approved storage bag method.

Based on observation, interview, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for three of eighteen residents (Residents #3, #6, and #59) reviewed for medication storage. 1.The facility failed to ensure that Resident #3 did not have an antibiotic (medication for infections) ointment inside her room on 06/03/2026. 2.The facility failed to ensure that Resident #6 did not have wound cleansers inside her room on 06/03/2026. 3.The facility failed to ensure that Resident #59 did not have a tube of zinc oxide (medicated cream used to prevent skin irritation) inside his room on 06/02/2026.4.The facility failed to ensure that Resident #123 did not have containers of lantiseptic creams at bedside on 06/02/2026. These failures could place residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.Findings included: 1. Record review of Resident #3's Face Sheet, dated 06/04/2026, reflected a [AGE] year-old female admitted [DATE]. The resident was diagnosed with a local infection of the skin. Record review of Resident #3's Comprehensive MDS Assessment, dated 05/06/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had local infection of the skin. Record review of Resident #3's Comprehensive Care Plan, dated 05/01/2026, reflected that the resident had fragile skin and one of the interventions was to keep skin clean and dry. Record review on 06/03/2026 of Resident #3's Physician Orders, reflected no order for antibiotic ointment. Record review of Resident #3's Clinical Assessment Notes, dated 06/03/2026, reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 06/03/2026 at 7:14 a.m., Resident #3 was in her wheelchair, awake. It was observed that an antibiotic ointment was on top of her overbed table. The resident said she would use it sometimes if she had a wound. She said the staff helped her apply it. During an interview on 06/03/2026 at 7:16 a.m., RN C said she did not notice that Resident #3 had an antibiotic ointment on her table. She said she would talk to the resident about the medication. She said if residents did not have an assessment that they could safely administer the medication, then they could not have medications inside their rooms. RN C said if residents were assessed that they could apply their medication, then it should not be within reach of other residents who may be confused and would enter rooms of other residents. She said a confused resident might use the ointment inappropriately. She said she would also check if the resident had an order for the antibiotics. 2. Record review of Resident #6's Face Sheet, dated 06/04/2026, reflected a [AGE] year-old female admitted [DATE]. The resident was diagnosed with aftercare following surgical amputation (surgical removal of a body part). Record review of Resident #6's Comprehensive MDS Assessment, dated 04/03/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had a surgical wound. Record review of Resident #6's Comprehensive Care Plan, dated 04/09/2026, reflected that the resident had a stump (remaining portion of the limb after an amputation) after a surgical procedure and one of the interventions was to do wound care as ordered. Record review of Resident #6's Physician Order, dated 03/06/2026, reflected, Change dressing to left leg stump three times weekly Cleanse with normal saline and pat dry apply xeroform across entire incision cover with abd pain Wrap kerlex around in a figure 8 pattern Secure with ace wrap every day shift every Mon, Wed, Fri for wound care. Record review of Resident #6's Clinical Assessment List, dated 06/03/2026, reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage her wound care. During an observation and interview on 06/03/2026 at 7:44 a.m., Resident #6 was in her bed, awake. It was observed that containers of wound cleansers were on top of her side table and her drawers. The resident said the staff would use it to clean the incision on her amputated leg. She said she did not know who left the wound cleansers inside her room. During an interview on 06/03/2026 at 10:53 a.m., the Treatment Nurse said he was not the one doing Resident #6's wound care. He said the nurses were responsible for cleaning Resident #6's surgical wound. He said the wound cleansers were not supposed to be left inside the room but should be stored inside the treatment cart because confused residents might drink it. During an interview on 06/04/2026 at 10:00 a.m., LVN N said he was one of the staff that was cleaning Resident #6's surgical wound, but he was not the one who left the wound cleansers inside the resident's room. He said it should not be inside the room because confused residents could spray it on their faces and eyes. 3. Record review of Resident #59's Face Sheet, dated 06/04/2026, reflected an [AGE] year-old male admitted [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #59's Comprehensive MDS Assessment, dated 05/13/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident was incontinent for bowels. Record review of Resident #59's Comprehensive Care Plan, dated 03/12/2026, reflected that the resident had an ADL self-care performance deficit, and the interventions were to assist with toilet use. Record review of Resident #59's Clinical Assessment Notes, dated 06/02/2026, reflected no assessment for self-administration of medications or an assessment that the resident was competent to apply his skin barrier. During an observation and interview on 06/02/2026 at 9:18 a.m., Resident #59 was in his bed, awake. It was observed that a tube of zinc oxide was on top of the resident's side table. The tube had a note on it that read for skin irritation. Resident #59 said the staff would use it every time they cleaned him up and changed him. He said the zinc oxide had always been on his side table. During an interview on 06/02/2026 at 9:32 a.m., CNA H said zinc oxides should not be left inside the rooms of the residents or somewhere they could reach them because they could be confused and consume them. She said she would make a round to check if there were any zinc oxide inside the rooms of the residents. During an interview on 06/04/2026 at 8:43 a.m., ADON B said barrier creams with zinc oxide should not be within reach of the residents. She said confused residents might mistakenly consume them or use them inappropriately. She said the barrier creams should be somewhere not accessible to the residents. She said the antibiotic ointment and the wound cleansers medications should not be inside the residents' rooms for the same reason. She said the antibiotic ointment should be inside the nurse's carts and the wound cleanser should be inside the treatment carts because the nurses and the Treatment Nurse should be the ones applying them. She said she would coordinate with the DON about the issues. During an interview on 06/04/2026 at 9:21 a.m., the DON said medications, whether oral or topical, should not be inside the residents' rooms because the residents might use them inappropriately and that could result in adverse reactions, such as overdosing. She said skin barriers were applied topically and could be harmful when ingested. She said the skin barriers should be inside the carts, and the aides could ask the nurse for some and put them in cups. She said the expectation was for the staff to be vigilant when they entered the residents' room to check for any medications and for staff using the skin barriers to not leave the tubes within reach of the residents. She said she would start an in-service about medications and zinc oxides inside the rooms of the residents. During an interview on 06/04/2026 at 9:58 a.m., the Administrator said the expectation was for the staff to make sure there were no medications and zinc oxides inside the rooms of the residents because the residents might consume them or use them on their eyes causing irritation. She said she would coordinate with the DON about the issue.4.Record review of Resident # 123's face sheet dated 06/04/2026 reflected a [AGE] year-old female who was admitted on [DATE]. Her diagnosis included unspecified dementia (clear symptoms of cognitive decline), major depressive disorder (a serious mood disorder characterized by persistent sadness), hypertension (high blood pressure) and breast cancer.Record review of Resident # 123's quarterly MDS assessment dated [DATE] reflected a BIMS score of 1 which indicated severe cognitive impairment. Resident #123 required moderate assistance with toileting, showers, upper and lower body dressing and personal hygiene. She was independent with transfers and walking.Record review of Resident #123's comprehensive care plans dated 06/01/2026 reflected impaired cognition and at risk for further decline related to dementia and poor safety awareness. She also resides in a secure unit related to cognitive impairment. Record review of Resident #123's Clinical assessment notes dated 06/04/2026 reflected no assessment for self-administration of medications or an assessment that the resident was competent to apply the lantiseptic.In an observation and interview on 06/02/2026 at 9:22 a.m. Revealed 2 containers of Lantiseptic cream were on the nightstand next to her bed. Resident # 123 was in the large dining/TV room. When asked about the containers and where she got them and why she had them, she made eye contact but did not respond to the questions. The warning stated to keep out of reach of children and to contact a physician or poison control if ingested.In an interview on 06/02/2026 at 10:01 a.m. with LVN L revealed that Resident #123 spends most of the day in the dining room area with another resident. She stated that residents should not have any kind of cream at bedside especially since it is a memory care. She stated the risk to the residents is that they may not know what it is and could put it in their eyes or ingest it.In an interview on 06/04/2026 at 1:35 p.m. with the DON revealed that residents should not have any kind of medication or ointments at bedside. She stated the risk to the resident was they could put it on themselves and ingest it.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services.The facility failed to ensure all food items in the facility's kitchen were dated and discarded prior to their use-by date and were properly sealed. These failures could place residents at risk of food contamination and food-borne illness. Finding included: During an observation on 06/02/26 between 9:10 A.M. and 9:45 A.M. in the facility's kitchen revealed:One plastic bin containing Penne pasta noodles dated 02/19/26 with an expiration date of 04/19/26. One plastic bin containing bow-tie pasta noodles dated 05/16/26 with no visible expiration date. One plastic bin containing pasta egg noodles with no visible dates. One gallon bag containing seasoned stuffing mix with no visible dates, not properly sealed and exposed to air contaminants. One plastic bin containing multiple coffee creamers dated 04/29/26 with an expiration date of 05/29/26. One plastic bin containing multiple cream cheese packets dated 04/29/26 with an expiration date of 05/29/26. One stainless steel container with pineapple dated 05/28/26 with an expiration date of 05/31/26. One 10 lb. box containing pork sausage with no visible expiration date, not properly sealed and exposed to air contaminants. During an interview on 06/04/26 at 10:14 A.M., DM stated she was the person overall responsible for ensuring the kitchen met guidelines for food storage and kitchen sanitization. DM confirmed surveyor observations and stated the listed items would be corrected. DM stated once items were opened, they should be properly sealed and dated. DM stated he was responsible for ensuring policy was followed. DM stated he and the kitchen aides were responsible for labeling and making sure that the items were labeled properly. DM stated the risk to residents if policy was not followed was a health risk to the residents. DM stated the items should be labeled, and the risk of the concerns not being addressed could result in food-borne illnesses. DM stated if food items were not dated when opened, then they would not know how long the item would last. DM stated a full in-service completed in reference to food rotation and storage pertaining to what the proper procedures were dealing with food rotation and storage. DM stated the risk of serving foods that were past the use-by date, or serving food that was not labeled or dated, could cause food borne illness. During an interview on 06/04/2026 at 1:55 PM, the ADMIN stated she oversaw all departments, and ensured residents were taken care of. ADMIN stated DM made her aware of the concerns observed in the kitchen. ADMIN stated the issues could cause food contamination. She stated if items were expired, they should not serve them to residents. ADMIN stated the risk of all those concerns observed in the kitchen could result in residents getting sick. ADMIN stated she would expect the DM to ensure that the kitchen followed all guidelines, including ensuring the food items were labeled properly in the kitchen. She said the risk to residents if policy was not followed, was they could get sick from food borne illnesses. ADMIN stated he expected staff to ensure they were following policies and procedures of the facility kitchen policy, to protect residents and to deliver good care. Record review of the facility's, Food Receiving and Storage Policy, dated November 2022, indicated, Policy Statement - Foods shall be received and stored in a manner that complies with safe food handling practices.Dry Food Storage 3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging untilthey are ready to use.4. Dry foods that are stored in bins are removed from original packaging, labeled, and dated ( use by date).Such foods are rotated using a first in - first out system.Refrigerated/Frozen Storage7. Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, ordiscarded.8. Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods muststay intact until thawing.9. Uncooked and raw animal products and fish are stored separately in drip-proof containers and below fruits,vegetables and other ready-to-eat foods to prevent meat juices from dripping onto these foods.

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 six of twenty residents (Resident #3, Resident #5, Resident #6, Resident #20, Resident #52, and Resident #87) reviewed for infection control.1.The facility failed to ensure CNA G performed hand hygiene, changed her gloves, and wore a gown when she did Resident #6's incontinent care, when she transferred her, and changed her bed linens on 06/03/2026. 2. The facility failed to ensure MA I sanitized the shared use blood pressure device before, between, and/or after use with Resident #3 and Resident #52 on 06/02/2026. Additionally, MA J failed to sanitize the shared use blood pressure device before, between, and/or after use with Resident #5 and Resident #87 on 06/03/2026. 3. The facility failed to ensure Resident #20's nephrostomy bags located to the left and the right side of her bed were elevated off the resident's floor upon observation on 06/02/2026. These failures could place residents at risk of cross-contamination and development of infections. Findings included:Findings included: 1. Record review of Resident #6's Face Sheet, dated 06/04/2026, reflected a [AGE] year-old female admitted [DATE]. The resident was diagnosed with kidney failure and aftercare of surgical amputation. Record review of Resident #6's Comprehensive MDS Assessment, dated 04/03/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident was incontinent (uncontrolled) for bladder and bowel and had a surgical wound. Record review of Resident #6's Comprehensive Care Plan, dated 04/09/2026, reflected the resident had bowel and bladder incontinence and one of the interventions was to check as required for incontinence. The plan indicated that the resident had a stump after a surgical procedure and one of the interventions was to do wound care as ordered. Record review of Resident #6's Physician Order, dated 03/06/2026, reflected, Change dressing to left leg stump three times weekly. Cleanse with normal saline and pat dry, apply xeroform across entire incision, cover with abd pain Wrap kerlex around in a figure 8 pattern. Secure with ace wrap. Record review of Resident #6's Physician Order, dated 03/05/2026, reflected, Enhanced Barrier Precautions: Staff to wear gown and gloves during high-contact care due to wound/device or MDRO (Multi-Drug-Resistant Organisms: refers to microorganisms that are resistant to one or more antibiotics) risk. Maintain standard precautions. Resident may attend activities. Continue until discontinued. During an observation on 06/03/2026 at 7:41 a.m., CNA G was about to do Resident #6's incontinent care, who had a surgical wound to the left leg. She went inside the room and put on a pair of gloves. She did not do hand hygiene before putting on the pair of gloves. She also did not wear a gown before doing incontinent care. It was observed that there were no gloves or sanitizer on the resident's table. She took a brief from the resident's overbed table and placed it on the resident's side. She cleaned the resident's perineal area (genital and/or groin area) using the front-to-back technique. She then rolled the resident and cleaned the bottom of the resident. It was observed that CNA G's clothes touched the resident's bed when the resident was turned. After cleaning the resident's bottom, she pulled the soiled brief and threw it to the trash can. She took the brief from the side of the resident, opened it, placed it under the resident, and fixed it. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. She took off her gloves when she was done with incontinent care. She did not wash her hands after she was done with incontinent care. There was a sign outside the resident's room that stated the resident was on EBP, and a gown was required when changing the brief. The sign also indicated to clean the hands before entering and when leaving the room. It was also observed that there was a PPE cart outside the resident's room. During an observation on 06/03/2026 at 7:55 a.m., CNA G transferred Resident #6 to her wheelchair via stand and pivot. She put on a pair of gloves but did not wash her hands and wear a gown while transferring the resident. There was a sign outside the resident's room that stated the resident was on EBP, and a gown was required during transfer. During an observation on 06/03/2026 at 8:06 a.m., CNA G changed Resident #6's bed linens. She put on a pair of gloves but did not wash her hands and wear a gown while changing the resident's bed linens and she was leaning on the resident's bed during the process. There was a sign outside the resident's room that stated the resident was on EBP, and a gown was required during changing of linens. During an interview on 06/03/2026 at 8:09 a.m., CNA G said she should have washed her hands or sanitized her hands before doing incontinent care to make sure her hands were clean before touching the resident. She said after cleaning the resident's bottom, the gloves should have been changed because using soiled gloves to open the brief basically contaminated the new brief. She said she forgot to wear a gown, and she knew a gown was needed when doing incontinent care, transferring, and changing linens when a resident was on EBP. She said her actions could result in the development of infection and spread of infection because of the risk of transferring microorganisms from one resident to another. During an interview on 06/04/2026 at 8:43 a.m., ADON B said the staff should have sanitized their hands before and after any care, changed their gloves after touching anything soiled, and wear a gown when required to prevent cross contamination and potential infection. She said the procedure should always be from clean to dirty and not the other way around. She said there was an EBP sign and a PPE cart outside the rooms of the residents, who required EBP, to remind the staff to wear a gown and to wash their hands. She said she would coordinate with the DON about the infection control issue. During an interview on 06/04/2026 at 9:21 a.m., the DON said if a resident was on EBP, then the staff doing care should wear a gown every time they had contact with the resident to prevent cross contamination and spread of infection. She said gloves should have been changed after cleaning the resident's bottom to make sure they were using clean gloves when touching the new brief. She said, also, hands should be washed or sanitized before and after doing any care for the same reasons. She said the concerns discussed were all infection control issues. She said the expectation was for the staff to wear a gown when needed and to change their gloves after touching anything dirty. She said the expectation was for the staff to follow the policies and really understand what the in-service was for. She said she already did a one-on-one in-service with CNA G and would start an in-service about infection control for all the staff that were doing direct care to the residents. During an interview on 06/04/2026 at 9:58 a.m., the Administrator said the expectation was for the staff to be mindful not to spread any infection and that the staff would adhere to the policy of infection control. She said the staff should wear gowns in addition to the gloves if the residents were on EBP, should perform hand hygiene before and after any care and treatment, and to change their gloves if required. She said the concerns discussed would all contribute to the development and spread of infection. She said she would coordinate with the DON about the issues. 2. The facility failed to ensure MA I sanitized the shared use blood pressure device and cuff before, between, and/or after use with Resident #3 and Resident #52 on 06/02/2026. Additionally, MA J failed to sanitize the shared use blood pressure device and cuff before, between, and/or after use with Resident #5 and Resident #87 on 06/03/2026. Record review of Resident #3's Face Sheet dated 06/03/26 at 9:57 a.m., revealed a [AGE] year-old female admitted on [DATE] from acute care. Relevant diagnoses included acute and chronic respiratory failure (long term condition where the respiratory system cannot properly oxygenate the blood and/or remove carbon dioxide,) COPD with acute exacerbation (worsening of respiratory symptoms upon exertion,) and type 2 diabetes (insulin resistance leading to high blood sugar levels and impaired cellular function.) Record review of Resident #52 Face Sheet dated 06/04/26 at 1:09 pm revealed an [AGE] year-old male admitted on [DATE] from acute care. Relevant diagnoses included dementia (decline of cognitive abilities,) and type 2 diabetes (insulin resistance leading to high blood sugar levels and impaired cellular function.) Record review of Resident #5's Face Sheet dated 06/04/26 at 1:12 pm revealed she was a [AGE] year-old female admitted on [DATE] from acute care. Relevant diagnoses included chronic respiratory failure (long term condition where the respiratory system cannot properly oxygenate the blood and/or remove carbon dioxide,) COPD (worsening of respiratory symptoms upon exertion,) and type 2 diabetes (insulin resistance leading to high blood sugar levels and impaired cellular function.) Record review of Resident #87's Face Sheet dated 06/04/26 at 1:15 p.m., revealed a [AGE] year-old female admitted [DATE] from another nursing home. Relevant diagnoses included multiple sclerosis (chronic autoimmune disease that disrupts nerve signals to the brain causing vision loss, muscle weakness, numbness, and poor balance) and paraplegia (lower body paralysis.) During an observation of MA I on 06/02/26 at 9:26 a.m., she entered Resident #3's room to obtain her morning vital signs. MA I placed the blood pressure device cuff on her right wrist. She provided Resident #3 with her medications and proceeded to Resident #52's room. She entered Resident #52's room, performed hand hygiene, and placed the blood pressure device cuff on his right wrist. MA I failed to sanitize the blood pressure device and cuff before, between, and/or after Resident #3 and Resident #52's care. During an observation of MA J on 06/03/26 at 8:31 am, she entered Resident #5's room to obtain morning vital signs. MA J placed the blood pressure device cuff on her right wrist. She provided Resident #5 with her medications and proceeded to Resident #87's side of the room. She performed hand hygiene, placed the blood pressure device cuff on her right wrist. MA J failed to sanitize the blood pressure device cuff before, between, and/or after Resident #5 and Resident #87's care. During an interview with MA I on 06/02/26 at 10:11 a.m. she stated she forgot to sanitize the blood pressure device and cuff before and after resident contact. She stated it was important for infection control reasons, and it was her responsibility to ensure it was completed. During an interview on 06/03/26 at 8:53 a.m., MA J stated she was not sure why she did not sanitize the blood pressure device and cuff before and after resident contact. She stated it was important for infection control reasons, and it was her responsibility to ensure it was completed. During an interview on 06/04/26 at 10:23 am, the DON stated it was her expectations that staff sanitize shared use equipment between resident use and contact for infection control purposes. She stated it was important to prevent cross contamination. She stated if shared use equipment could not be sanitized between resident use and/or contact, it should not be used. She stated it was ultimately her responsibility to ensure clinical staff adhere to infection control policy, procedures, and principles. In interview with Administrator on 06/04/26 at 12:53 pm, she stated it was her expectations that staff sanitize shared use equipment between resident use and contact for infection control purposes. She stated it was the DONs responsibility to ensure competencies. 3. The facility failed to ensure Resident #20's nephrostomy bags (bag of urine originated from a flexible tube inserted into the lower back directly into the kidneys) located to the left and the right side of her bed were elevated off the resident's floor upon observation on 06/02/2026. Record review of Resident #20's Face Sheet, dated 06/03/26 at 9:07 a.m., revealed a [AGE] year-old female admitted on hospice 04/30/26 from an acute care facility. Relevant diagnoses included hemiplegia after cerebral infarction (paralysis after blood flow to the brain is blocked or reduced,) chronic kidney disease (long term kidney disease leading to decrease function,) and infection of nephrostomy catheter (infection of the flexible tube inserted into lower back directly into the kidneys with the purpose of draining urine.) Record review of Resident #20's admission MDS assessment, dated 05/25/26, revealed she was cognitively intact with a BIMS score of 15. Resident #20 was dependent upon staff for shower/bathing, toileting, and personal hygiene. She had an indwelling catheter appliance. Record review of Resident #20's Comprehensive Care Plan dated 06/03/26 at 9:30 a.m. revealed: Urinary Catheter: with Nephrostomy . monitor and document output, administer medications per physician's order and monitor for unusual/adverse reactions and effectiveness, use . securement device to keep the urinary catheter securely in place . and [Resident #20] has left sided hemiplegia/hemiparesis related to stroke . PT, OT, ST evaluate and treat as ordered . During an observation and interview with Resident #20 on 06/02/2026 at 11:25 am, she was resting in her bed in her room. Situated to both sides of her were her nephrostomy bags hooked to her bed. Both the right and left bag were observed touching the floor below Resident #20's bed. Upon interview with Resident #20 she stated she could not see the bags and was not aware they were touching the floor. She denied pain and stated she knew it was important for infection to keep her nephrostomy bags elevated off the floor. During an interview on 06/02/26 at 11:40 a.m., RN O stated Resident #20's nephrostomy bags should not be touching the floor for infection control purposes. She stated she was not sure why the bags were touching the floor and stated it was to prevent cross contamination to maintain Resident #20's nephrostomy bags elevated off the floor. She stated it was all of the staff's responsibility to ensure resident devices were maintained off the floor. During an interview on 06/04/26 at 10:23 a.m., the DON stated her expectations were for all resident catheter bags were maintained elevated off the floor. She stated that Resident #20's nephrostomy bags should have been maintained off the floor for infection control purposes. She stated it was everyone's responsibility to ensure resident devices are maintained off the floor. Record review of the facility's policy titled, Hand Hygiene, revised February 11, 2022, reflected, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . Policy Explanation and Compliance Guidelines . 1. Staff will perform hand hygiene when indicated . 6. Additional considerations . a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Hand Hygiene Table . Between resident contacts . After handling contaminated objects . Before applying and after removing personal protective equipment (PPE), including gloves . Before and after handling clean or soiled dressings, linens . Before performing resident care procedures . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . When, during resident care, moving from a contaminated body site to a clean body site . After assistance with personal body functions. Record review of the facility's policy titled, Incontinence Care Nursing Procedure Manual, dated February 14, 2020, reflected, Purpose: To outline a procedure for cleansing the perineum and buttocks after an incontinence episode . Procedure . 4. Wash hands . 5. Put on non-sterile, latex-free gloves . 15. Remove and discard gloves . 16. Wash hands. Record review of the facility's policy titled, Infection Prevention and Control Program, dated November 06, 2024, reflected, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 6. Enhanced Barrier Precautions . EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following . b. Wounds . During high-contact resident care activities . Transferring . Providing hygiene . Changing linens . Changing briefs. 10. Equipment Protocol. a. All reusable items and equipment requiring special cleaning. shall be cleaned in accordance with our current procedures governing the cleaning and sterilization. Record review of the facility's policy titled, Indwelling Foley Catheter Guidelines, dated 02/10/20, revealed Maintain unobstructed urine flow. Do not rest the bag on the floor.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for 1 (Resident # 22) of 2 residents observed for dignity.The facility failed to ensure Resident #22's did not have to wait to be served his lunch tray for approximately 10 minutes after his tablemate was served. This failure could place the residents at risk of experiencing humiliation, degradation and a decreased quality of life.Finding included: Review of Resident # 22's face sheet dated 06/04/2026 reflected a [AGE] year-old male who was admitted on [DATE]. His diagnosis included chronic kidney disease, dysphagia (difficulty swallowing food), dementia (a group of cognitive symptoms such as memory loss and language impairment) and hypertension (high blood pressure).Review of Resident #22's Quarterly MDS dated [DATE] reflected the resident had a BIMS score of 3, which indicated severe cognitive impairment. Resident #22 required supervision with eating, toileting hygiene and showers, he was independent with dressing, transferring and walking.Review of Resident #22's comprehensive care plans dated 05/20/2026, reflected he had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to dementia. He had restrictions on his diet diet, pureed texture, mildly thick-nectar, consistency and was at risk for nutritional & hydration deficit related to chronic kidney disease and mild protein-caloric malnutrition.In an observation on 05/09/2026 at 12:14 p.m., Resident # 22's tablemate was served her lunch. She did not take the lid off her tray and she waited approximately 10 minutes for Resident #22 to receive his meal. At 12:24 p.m. he was provided with his lunch tray. In an interview on 05/09/2026 at 12:16 p.m., Resident #22 stated he felt bad that his table mate had to wait on him to get his food, but that he appreciated her waiting.In an interview of 05/09/2026 at 12:43 p.m., CNA M stated that she always tried to serve residents at the same table at the same time. She stated that she did not see when Resident #22's table mate had been served, and she was not aware until she saw his tray was the last one on the cart. She stated the risk to the residents was they could get upset that they had to wait on their tray.In an interview on 05/04/2026 at 1:20 p.m. LVN L stated that she expected the residents at the same table to be served at the same time. She stated that earlier in the week, they had extra staff assisting with passing out trays and that Resident #22 was overlooked. She stated the risk to the resident was they could feel left out by not getting their tray at the same time as the other table mates.Record review of the policy titled Resident Rights dated 02/20/2021 revealed the following, The resident has the right to a dignified existence.and the right to make choices about aspects of his or her life that are significant to the resident.and the right to a homelike environment.

Based on observation, interview and record review the facility failed to ensure there was an accurate Level 1 pre-screening of new residents for MD/ID or a related condition, prior to admission to the facility for one (Residents #7) of eight residents reviewed for Preadmissions Screening and Annual Resident Review (PASRR). The facility failed to notify the SMHA to ensure Resident #7 received a new PASRR level 1 screening following identification of his diagnosis of bipolar disorder on 01/10/2022. This failure could place the residents at risk of not receiving the care and services they need in the most appropriate setting when a significant change in their status occurs.Findings included: Record review of Resident #7's Face Sheet, dated 06/04/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The admitting diagnoses included bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows). Record review of Resident #7's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs) dated 01/21/2022, reflected the resident had bipolar disorder. Record review of Resident #7's Comprehensive MDS Assessment, dated 04/08/2026, reflected that the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score (screening tool used to assess cognitive status) of 15 and had bipolar disorder. Record review of Resident #7's Comprehensive Care Plan, dated 04/01/2026, reflected that the resident had cognitive impairment related to bipolar disorder and interventions included to engage in simple, structured activities that avoid overly demanding tasks. The plan was initiated on 01/26/2022. Record review of Resident #7's PASSR Level 1 Screening (an assessment required to all individuals seeking admission to a nursing facility), dated 01/11/2022, reflected the resident was negative for mental illness, intellectual disability, and developmental disability when he was admitted to the facility. Record review on 06/03/2026 of Resident #7's Documents reflected the resident did not have a PASSR II (in-depth assessment if the individual seeking admission to a nursing facility had mental illness, intellectual disability, and developmental disability) or a new PASSR I. During an observation and interview on 06/03/2026 at 9:38 a.m., Resident #7 was in his wheelchair, awake. He said he just had his breakfast and was feeling ok. He said he had a good sleep, and he said he was ready for the day. The resident then started rolling himself out of the room. The resident did not have any behaviors noted. During an observation and interview on 06/03/2026 at 9:03 a.m., the MDS Coordinator said he started working for the facility a month ago, and he was responsible in doing the PASSR of the residents if needed. He said a PASSR level I was required for all individuals seeking placement in a nursing facility. He said that PASSR level I was done to identify individuals with mental illness, intellectual disability, and developmental disability, and to ensure right placement and access to specialized services. He said if a resident was PASSR positive, meaning the resident was diagnosed with any mental illness or had indicators for intellectual and developmental disability, then a PASSR level II should be done to determine if the resident needed any specialized services. He said if a resident was PASSR I negative and during resident's stay in the facility was diagnosed with a new mental illness such as depression, anxiety, dementia, bipolar disorder, and delusional disorder, then a new PASSR I should be done for the same reason. He said if a resident was PASSR I negative and was admitted to the facility with a mental illness, then the facility should have caught it and did a new PASSR I. He logged on to his computer and looked at Resident #7's profile. He said the resident was PASSR I negative and then checked the resident's medical diagnosis and saw the resident had bipolar disorder when admitted [DATE]. He said the facility should have done a new PASSR I. He then checked if there was a new PASSR I that was done and he said there was none. He said the resident's issue with PASSR was before he was hired but said it was not an excuse. He said he would do an audit since the issue was brought to his attention. During an interview on 06/04/2026 at 8:43 a.m., ADON B said Resident #7 was taking psychotropic medications. She said she was not familiar with how the PASSR worked. During an interview on 06/04/2026 at 9:21 a.m., the DON said she was not familiar with PASSR but would coordinate with the MDS Coordinator about the issue. During an interview on 06/04/2026 at 9:58 a.m., the Administrator said there should be a process in place to determine if a new PASSR I was needed or PASSR II should be done. She said she would coordinate with the MDS Coordinator to prevent the issue from happening again. Review of the facility's policy Preadmission and Screening Resident Review (PASRR) Rules revised July 2023 reflected Guideline: It is the intent of . to meet and abide by all State and Federal regulations that pertain to resident Preadmission and Screening Resident Review (PASRR) Rules . Purpose . The purpose of this guideline is to direct the user through the PASRR procedures . Procedure . Referring Entity completes a PL1 . If negative . If the resident has a qualifying MI diagnosis and the NF feels the resident should be positive, they should talk to the referring Entity and ask them to correct the PL1.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for two of ten residents (Resident #73 and Resident #82) reviewed for care plans. 1.The facility failed to ensure that Resident #73 had a care plan for her BiPAP (bilevel positive airway pressure - normalizes breathing by delivering pressurized air into the upper airway leading into the lungs) on 06/02/2026.2.The facility failed to ensure that Resident #82 had a care plan for suctioning and his osteomyelitis (infection of the bone) on 06/02/2026. This failure could place the residents at risk of not receiving the necessary care and services.Findings included: 1.Record review of Resident #73's Face Sheet, dated 06/04/2026, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Record review of Resident #73's Comprehensive MDS Assessment, dated 05/04/2026, reflected that the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident was using a BiPAP. Record review of Resident #73's Comprehensive Care Plan, dated 04/30/2026, reflected that the resident did not have a care plan for her BiPAP. Record review of Resident #73's Physician Order, dated 04/22/2026, reflected BiPAP @ _16_cm H20 Inspiration (higher pressure delivered during inspiration); _8_cm H20 Expiration (lower pressure delivered during expiration) with O2 at _2_ liters with humidification. BIPAP scheduled start at HS. Discontinue upon waking. Evaluate Respirations, BP, pulse, and oxygen saturation before application at bedtime for sleep apnea. During an observation and interview on 06/02/2026 at 9:14 a.m., Resident #73 was in her bed, awake. A BiPAP machine was observed sitting on top of the resident's side table with a BiPAP mask connected to it. The resident said she used the BiPAP every night. During an interview on 06/02/2026 at 9:27 a.m., RN C said the resident would use the BiPAP at night. 2.Record review of Resident #82's Face Sheet, dated 06/04/2026, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included dysphagia (difficulty in swallowing) and osteomyelitis. Record review of Resident #82's Comprehensive MDS Assessment, dated 05/18/2026, reflected the resident had severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was used a suction machine (mechanical aspiration of pulmonary secretions to clear the airway) and had osteomyelitis. Record review of Resident #82's Comprehensive Care Plan, dated 04/30/2026, reflected that the resident did not have a care plan for suction use or his osteomyelitis. Record review on 06/02/2026 of Resident #82's Physician Order reflected no order for suctioning. Record review of Resident #82's Physician Order, dated 05/16/2026, reflected Cefepime HCl Injection Solution Reconstituted 1 GM (Cefepime HCl) Use 1 gram intravenously every 8 hours for BONE INFECTION related to OSTEOMYELITIS OF VERTEBRA, SACRAL AND SACROCOCCYGEAL REGION . LOCAL INFECTION OF THE SKIN AND SUBCUTANEOUS TISSUE, UNSPECIFIED . PRESSURE ULCER OF SACRAL REGION, STAGE 4 . until 06/19/2026 23:59. During an observation and interview on 06/03/2026 at 9:30 a.m., Resident #82 was in his bed, awake. A suction machine was observed on top of the resident's side table with a Yankauer suction tip (a firm plastic suction tip used to suction secretions in the mouth) attached to it. The resident was observed to have a PICC line to his right upper arm. The resident did not reply when asked when was the last time he was suctioned and what was the IV for. During an interview on 06/03/2026 at 9:44 a.m., RN D said she did not know how often the suction machine was used. She said she had not used it on her shift and that the suction machine had always been inside Resident #82's room. She said the resident had osteomyelitis; that was why he was receiving an antibiotic. During an interview on 06/03/2026 at 9:03 a.m., the MDS Coordinator said he only started working for the facility a month ago, and he was responsible for making the care plans of the residents. He said Resident #73's BiPAP should have been cared planned when she started using it last April. He said he did not know how it was missed. He opened the resident's profile and saw that the resident had an order for her BiPAP, was coded for non-invasive ventilator, but did not have a care plan for the BiPAP. He said he would do one for the resident's BiPAP, so the staff would know how to manage it, like bagging when not in use, if it was effective, and if the resident was refusing it. He said he would also audit the other residents with BiPAP and CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) if care plans were in place. During an interview on 06/04/2026 at 8:43 a.m., ADON B said the care plan should be in place to protect the residents and the facility. She said the care plan reflected the needs of the residents that needed to be addressed. She said the care plan served as the facility's agreement with the resident in terms of the care and services that the facility would be providing. She said if the resident had a BiPAP, then there should be care plan for it. She said another purpose of the care plan was that the individuals taking care of the residents would be on the same page. She said she would coordinate with the DON and the MDS Coordinator to fix the resident's care plan and audit the care plans of the other residents. During an interview on 06/04/2026 at 9:21 a.m., the DON said Resident #73's BiPAP should have been care planned. She said care plans were extensions of the care given to the residents. She said the care plans were to reassure that the residents were being taken care of. She said care plans should be in place and should reflect realistic goals and interventions and assess as well if the expectations were being met. She said the care plan should also be done if the resident had a fall, came back with an order for antibiotics, or was declining. She said the expectation was for the residents to be care planned accordingly. She said she would coordinate with the MDS Coordinator regarding the issue. During an interview on 06/04/2026 at 9:58 a.m., the Administrator said that all the residents should have a care plan in line with their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. She said the expectation was for all the residents to be care planned. She said she would coordinate with the DON and the MDS Coordinator to make sure all the residents were care planned. During an interview on 06/04/2026 at 10:28 a.m., the MDS Coordinator said Resident #82 should have a care plan for his suction. He said he would make a care plan for the resident's suction and his diagnosis of osteomyelitis, especially if it was actively being treated. He said, maybe, the suction was not captured because it did not have an order. He said he would do one for osteomyelitis. During an interview on 06/04/2026 at 12:10 p.m., the DON said if a resident had a suction, then there should be a care plan for it as well as for osteomyelitis. Record review of the facility's policy Comprehensive Care Plans Policy revised September 04, 2024, reflected Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . Policy Explanation and Compliance Guidelines . 1. The care planning process will include an assessment of the resident's strengths and needs . in developing goals of care . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment . 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

Based on observations, interviews, and record reviews, the facility failed to ensure that the residents' environment remained free of hazards as was possible for two direct care staff (RN C and Treatment Nurse) of five direct care staff reviewed for accident hazard. 1.The facility failed to ensure a container of germicidal wipes (substance that destroys germs and microorganism) was not left on the ledge of the nurse station unattended on 06/03/2026. 2.The facility failed to ensure RN C did not leave a container of germicidal wipes on top of her cart unattended on 06/03/2026. 3.The facility failed to ensure the Treatment Nurse did not leave a container of germicidal wipes on top of his cart unattended on 06/03/2026. These failures could place residents at risk of injuries and exposure to toxic chemicals.Findings included: 1.During an observation on 06/03/2026 at 7:06 a.m. revealed a container of germicidal wipes was left on top of the ledge of the nurses' station unattended. It was observed that there were no staff inside the station and several residents were passing by the station. At the back of the container was a note that said, Keep out of reach of children. 2.During an observation on 06/03/2026 at 8:15 a.m., RN C was about to do treatment for one of the residents. Before going inside the room of the resident, she took a container of germicidal wipes from the last drawer of her cart, pulled one wipe, and cleaned the resident's overbed table. She then went inside the resident's room, closed the door, and did the treatment. The container of germicidal wipes, with open lid, was left unattended on top of the cart all throughout the duration of the treatment. At the back of the container was a note that said, Keep out of reach of children. Several residents were passing by the cart. During an interview and observation on 06/03/2026 at 8:37 a.m., RN C said she used the germicidal wipes to sanitize the table that she used. She said she forgot to put the container of germicidal wipes back to the drawer before going inside the resident's room. She said she should have placed the germicidal wipes inside the cart before she closed the door because residents might be able to get hold of the wipes and use them to clean their faces and eyes that could result in irritations. She said some residents were confused and might go inside the rooms of other residents. She took the container of germicidal wipes and put it inside the last drawer of the cart she was using. She said there they had a population that would wander around the facility. 3.During an observation on 06/03/2026 at 10:12 a.m., revealed the Treatment Nurse was about to do wound care for one of the residents. Before going inside the room of the resident, he took a container of germicidal wipes from the last drawer of his cart, pulled one wipe, and cleaned the resident's overbed table. He then went inside the resident's room to do the treatment. He closed the door while doing the treatment but left the container of germicidal wipes, with an open lid, unattended. It was observed that at the back of the container was a note that said, Keep out of reach of children. Several residents were observed passing by the cart. During an interview on 06/03/2026 at 10:51 a.m., the Treatment Nurse said he should have returned the container of germicidal wipes inside his cart before closing the door because residents might think it was just regular wipes and use it on their face. He said confused residents might eat the wipes and would not be aware of the harm it could cause. He said he would go back to his cart and make sure that there were no germicidal wipes on top of his cart. During an interview on 06/04/2026 at 8:43 a.m., ADON B said the container of disinfectant, close or opened, should have been placed inside the cart when staff were leaving their cart and inside the nurses' station. She said residents could get them and use them on their face and body. She said the wipes could cause irritation, that was why the staff used gloves when using them. She said the expectation was for the staff not to leave the germicidal wipes within reach of the residents. She said would coordinate with the DON regarding the issue. During an interview on 06/04/2026 at 9:21 a.m., the DON said the germicidal wipes should not be left unattended because the residents might get hold of the wipes and use them to clean their eyes or their private parts. She said the expectation was for all the staff to not leave the germicidal wipes unattended. She said she would start an in-service to re-educate the staff about the harm germicidal wipes could cause. During an interview on 06/04/2026 at 9:58 a.m., the Administrator said germicidal wipes could be hazardous and might cause irritations. She said the expectation for the staff to store the germicidal wipes accordingly before walking away from their carts and before leaving the nurses' station to ensure that residents would not be able to get any wipes that they might use inappropriately. She said she would coordinate with the DON about the germicidal wipes. Record review of facility policy, Medication Storage Policy implemented January 20, 2021, reflected Policy Explanation and Compliance Guidelines . 3. External Products: Disinfectants and drugs for external use are stored separately from internal and injectable medications.

Based observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one of four residents (Resident #6) reviewed for incontinent care. The facility failed to ensure that CNA G did not use the wipes that were already used to clean Resident #6's perineal (area between the thighs) area on 06/03/2026. This failure could place the residents at risk of urinary tract infection.Findings included: Record review of Resident #6's Face Sheet, dated 06/04/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with kidney failure (kidneys stopped working). Record review of Resident #6's Comprehensive MDS Assessment, dated 04/03/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident was incontinent (uncontrolled) for bladder and bowel. Record review of Resident #6's Comprehensive Care Plan, dated 04/09/2026, reflected that the resident had bowel and bladder incontinence and one of the interventions was to check as required for incontinence. During an observation on 06/03/2026 at 7:41 a.m., CNA G was about to do Resident #6's incontinent care. She went inside the room, put on a pair of gloves, and proceeded with incontinent care. She pulled some wipes and cleaned the perineal area (area between the legs) using the front to back technique. She then folded the wipes and used it again to wipe the perineal area. She then took some wipes and cleaned the sides of the perineal area. After cleaning the sides, she folded the wipes and cleaned the perineal area again. During an interview on 06/03/2026 at 8:09 a.m., CNA G said that was how she was trained to fold the wipes and use it again. During an interview on 06/04/2026 at 8:43 a.m., ADON B said the staff should discard the wipes after every wipe. She said CNA G told her what happened and also told her the same reason that she was trained that way from another state. She said she corrected CNA G that staff could not re-use the wipes once used because it could cause UTI. She said she also told her that she could not use the wipes that were used to clean the sides of the perineal area to clean the perineal area. She said she would coordinate with the DON about the issue. During an interview on 06/04/2026 at 9:21 a.m., the DON said the right procedure in cleaning a female resident was not to fold the wipe and use it again. She said wipes could not be re-used because it could cause urinary tract infection because the staff was introducing any microorganism that was acquired during the first wipe. She said the expectation was for the staff to do the right procedure in performing incontinent care. She said she already did a one-on-one in-service with CNA G and would start an in-service for all the staff performing incontinent care. She said they would also do check offs and random checking. During an interview on 06/04/2026 at 9:58 a.m., the Administrator said soiled wipes could not be used to clean the middle part of the female's perineal area. She said the issue could result to urinary tract infection. She said the expectation was for the staff to follow the right procedures for incontinent care. She said she would coordinate with the DON about the issue. Record review of the facility's policy Incontinence Care Nursing Procedure Manual reviewed February 14, 2020, reflected Purpose: To outline a procedure for cleansing the perineum and buttocks after an incontinence episode . Procedure . 11. Cleanse peri-area and buttocks with cleansing agent wiping from front of perineum toward rectum. Record review of the facility's policy Hand Hygiene Policy revised February 11, 2022, reflected Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection . Policy Explanation and Compliance Guidelines . When, during resident care, moving from a contaminated body site to a clean body site.

Based on observation, interview, and record review the facility failed to ensure a resident who required a colostomy, urostomy, or ileostomy services received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (Resident #20) of five residents reviewed for colostomy, urostomy, and/or ileostomy care. The facility failed to prevent Resident #20's indwelling bilateral urinary urostomy catheter device from contact with the floor upon observation on 06/02/26 at 11:25 am. These failures could place the resident with colostomy, urostomy, and/or ileostomy devices at risk for the development of new or worsening urinary tract infections.Findings included: In record review of Resident #20's Face Sheet, dated 06/03/26 at 9:07 am revealed she was a [AGE] year-old female admitted on hospice 04/30/26 from an acute care facility. Relevant diagnoses included hemiplegia after stroke (paralysis after blood flow to the brain is blocked or reduced,) chronic kidney disease (long term kidney disease leading to decrease function,) and infection of nephrostomy catheter (infection of the flexible tube inserted into lower back directly into the kidneys with the purpose to drain urine.) In record review of Resident #20's MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. Resident #20 was dependent upon staff for shower/bathing, toileting, and personal hygiene. She had an indwelling catheter appliance. In record review of Resident #20's Comprehensive Care Plan on 06/03/26 at 9:30 am revealed: Urinary Catheter: with Nephrostomy . monitor and document output, administer medications per physician's order and monitor for unusual/adverse reactions and effectiveness, use . securement device to keep the urinary catheter securely in place . and [Resident #20] has left sided hemiplegia. related to stroke . PT, OT, ST evaluate and treat as ordered . In observation and interview with Resident #20 on 06/02/2026 at 11:25 am, she was resting in her bed in her room. Situated to both sides of her were her nephrostomy bags hooked to her bed. Both the right and left bag were observed touching the floor below Resident #20's bed. Upon interview with Resident #20 she stated she was not able to see the bags and was not aware they were touching the floor. She denied pain and stated she knew it was important for infection to keep her nephrostomy bags elevated off the floor. In interview on 06/02/26 at 11:40 am, RN O stated Resident #20's nephrostomy bags should not be touching the floor for infection control purposes. She stated she was not sure why the bags were touching the floor and stated it was to prevent cross contamination to maintain Resident #20's nephrostomy bags elevated off the floor. She stated it was all of the staff's responsibility to ensure resident devices are maintained off the floor. In interview on 06/04/26 at 10:23 am, the DON stated her expectations were for all resident catheter bags to be elevated off the floor. She stated that Resident #20's nephrostomy bags should have been maintained off the floor for infection control purposes. She stated it was everyone's responsibility to ensure resident devices are maintained off the floor. In record review of facility policy Indwelling Foley Catheter Guidelines, rev. 02/10/20, revealed Maintain unobstructed urine flow. Do not rest the bag on the floor. In record review of the facility's policy Infection Prevention and Control Program rev. 11/06/24 revealed Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one of four residents (Residents #133) reviewed for feeding tube management. The facility failed to ensure Resident #133 had orders to check for g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) placement, check the gastric residual, to flush before and after medications, and to flush in-between medications on 06/03/2026. This failure could place residents at risk for proper procedure not being done that could result in aspiration and clogging of the g-tube. Findings included: Record review of Resident #133's Face Sheet, dated 06/04/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #133's Comprehensive MDS Assessment, dated 05/27/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Record review of Resident #133's Comprehensive Care Plan, dated 05/19/2026, reflected the resident required the use of feeding tube and the interventions were to administer tube feeding and water flushes as ordered, elevate head of bed 45 degrees or as ordered by physician while feeding tube is being used for feeding and at least 30 minutes after bolus or tube feedings, to check for tube placement, and to monitor gastric contents residual (fluid, food, medications that were still inside the stomach) volume per facilityprotocol. Record review of Resident #133's Physician Order, dated 011/06/2025, reflected every shift Jevity 1.5, 70 ml/hr with TVBI 1540 to run concurrently with 30 ml H2O flush every 1 hour. Record review o06/03/2026 of Resident #133's Physician Order reflected that the resident did not have an order to check the placement of the g-tube. Record review on 06/03/2026 of Resident #133's Physician Order reflected that the resident did not have an order to check the gastric residual. Record review on 006/03/2026 of Resident #133's Physician Order reflected that the resident did not have an order to flush the g-tube before and after medication administration. Record review on 06/03/2026 of Resident #133's Physician Order reflected that the resident did not have an order to flush between medication administration. During an observation on 06/03/2026 at 8:15 a.m., RN C was about to administer Resident #133's medication via g-tube. She put on a pair of gloves and sanitized the resident's overbed table. After sanitizing the overbed table, she washed her hands and put on a pair of gloves. She put the medications in a small plastic cup one by one, crushed them, returned the crushed medications to the small plastic cup, and dissolved them. She also prepared two plastic glasses and put some water in it. She then went inside the resident's room and placed the small cups of medications and water on the resident's overbed table. She put on a gown and proceeded to administer the medication. She took a 60 ml piston syringe from a plastic bag hanging on an IV pole, turned off the machine, and disconnected the g-tube from the formula. After disconnecting the g-tube, she attached the barrel of the syringe, with the plunger halfway, on the g-tube, placed a stethoscope on the resident's abdomen, and checked the placement of the gtube. She then pulled the plunger of the syringe and checked the gastric residual. After checking the placement and the residual, she pulled the plunger and flushed the g-tube with 30 cc of water. After flushing the g-tube, she poured the medications one by one and flushed in between with 10 cc. After she was done administering the medications, she flushed the g-tube, detached the syringe, connected the g-tube to the formula, and cleaned the table and the syringe. During an observation and interview on 06/03/2026 at 8:47 a.m., RN C said she did check for the placement, gastric residual, flushed before and after medication administration, and flushed between each medication. When asked if the resident had orders for the procedures mentioned, she opened the resident's profile and saw that there were no orders to check for the placement and residuals, and to flush before, in between, and after medication administration. She said, as a nurse, she knew she was supposed to check the placement and the residuals and to flush before, in between, and after medication administration. She said this should have been caught earlier by whoever was administering the resident's medications, so orders were put in place. She said she was partly at fault because she did not check the orders before medication administration. She said she got used to doing the procedure that she did not check the orders prior to medication administration. She said that new nurses might not be familiar with how to administer medications via g-tube and ended up not checking for the placement and residuals and not flushing the g-tube that could result in clogging and aspiration. She said there should be an order for everything done for the resident to ensure continuity of care. During an interview on 06/04/2026 at 8:43 a.m., ADON B said there should be orders for everything done for the residents. She said even though the nurses knew what to do, there should be an order in the resident's profile to check for the placement, the residual, and to flush before, during, and after medication administration. She said it was an oversight for those administering the resident's medication. She said it was also an oversight on her part because she was supposed to check the orders as well. She said she already did an audit of the resident with g-tube to check if orders pertaining to g-tube were in place. During an interview on 06/04/2026 at 9:21 a.m., the DON said even though the staff did the right procedure and knew to check the placement, to check the gastric residual, and to flush g-tube, there should still be orders for them. She said the orders would ensure that the treatments were safe for the residents and medically necessary. She said there were orders for everything done for the residents like therapy, diet, wound care, treatments, and medications. She said was for the nurses to check if appropriate orders for g-tube medication administration were in place. She said new nurses might not check the placement, residual, and would not flush the g-tube because there were no orders resulting in aspiration and clogging. She said she would start an in-service regarding the need for physician orders. During an interview on 06/04/2026 at 9:58 a.m., the Administrator said there should be appropriate orders in place for the procedures done for g-tube. She said she was not a clinician and would let the DON take a lead on the issue of g-tube to ensure the residents with g-tube would receive the proper care needed. Record review of the facility's policy Medication Administration via Enteral Tube P & P Committee revised November 01, 2025, reflected Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . Policy Explanation and Compliance Guidelines . 7. A physician's order is required . 11. Procedure: a. Verify physician orders. Record review of the facility's policy Following Physician Orders Policy implemented September 28, 2021, reflected Policy: The policy provide guidance on receiving and following physician orders . Policy Explanation and Compliance Guidelines . 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will be required . a. Document the order by entering the order and the time, date, and signature on the physician order sheet . b. Follow facility procedures . transcribing to medication or treatment administration record . c. Carry out and implement physician orders.

Based on observation, interview, and record review, the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance to physician orders for one of three residents (Resident #82) reviewed for parenteral (delivery of medications through injection)/IV (intravenous: administering fluids or medications directly into a vein) fluids. The facility failed to ensure RN D made sure that Resident #82's IV port was covered with a disinfecting cap on 06/03/2026. This failure could place the residents receiving IV medications at risk of infections, IV infiltration, clogging, pain, which may result in required replacement of IV.Findings included: Record review of Resident #82's Face Sheet, dated 06/04/2026, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with osteomyelitis. Record review of Resident #82's Comprehensive MDS Assessment, dated 05/18/2026, reflected that the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had osteomyelitis. Record review of Resident #82's Comprehensive Care Plan, dated 05/30/2026, reflected that the resident did not have a care plan for his osteomyelitis. Record review of Resident #82's Physician Order, dated 05/16/2026, reflected Cefepime HCl Injection Solution Reconstituted 1 GM (Cefepime HCl) Use 1 gram intravenously (administering fluids or medications directly into a vein) every 8 hours for BONE INFECTION related to OSTEOMYELITIS OF VERTEBRA (small bones forming the back bone), SACRAL (pertaining to bones at the bottom of the spine) . LOCAL INFECTION OF THE SKIN AND SUBCUTANEOUS (under the skin) TISSUE, UNSPECIFIED . PRESSURE ULCER (wound on the skin caused by prolonged pressure to specific area of the body) OF SACRAL REGION, STAGE 4 (wound that would extend up to the bone) . until 06/19/2026 23:59. Record review of Resident #82's Physician Order, dated 05/15/2026, reflected Change transparent dressing to the Midline site one time only for PICC (long, flexible tube inserted into the vein used for administering intravenous medications) IV (intravenous: administering fluids or medications directly into a vein) ACCESS for 1 Day upon admission or 24 hours post insertion. Measure upper arm circumference and exterior catheter length. AND every day shift every 7 day(s) for PICC IV ACCESS Measure upper arm circumference and exterior catheter length with each dressing change. AND as needed for compromised dressing. During an observation and interview on 06/03/2026 at 9:30 a.m. revealed Resident #82 was in bed, awake. It was observed that the resident had a PICC line to his right upper arm, and the PICC access port was not covered. The resident did not reply when asked what his IV was for. During an observation and interview on 06/03/2026 at 9:44 a.m., RN D said she saw that Resident #82's IV port did not have a cap. She said she looked for one but did not see one. She said the IV port should be capped to prevent any microorganism crawl inside, but the facility did not have any green cap used to cover the access port. She said the resident was receiving an antibiotic for his osteomyelitis. She said she already told ADON about the green cap, and she said they would buy some. She said, for the meantime, she would cover it with a clean gauze and would clean the IV port thoroughly before using it. During an interview on 06/04/2026 at 8:43 a.m., ADON B said the port of the IV should be covered and they were already in the process of buying some. She said she did not know they did not have any green caps for the IV port. She said the green caps protect the IV needleless connectors and helped reduce the risk of contaminants entering the IV port. During an interview on 06/04/2026 at 9:21 a.m., the DON said she did not know that the facility did not have the disinfecting caps for the IV ports. She said the cap was used to prevent any cross contamination that could compromise the resident's antibiotic therapy. She said she would start an in-service about capping the IV port and to let the supply staff if the caps were running low. She said the facility might not have a policy regarding capping the IV port, but that was the best practice. During an interview on 06/04/2026 at 9:58 a.m., the Administrator said the expectation was for the staff to cover the IV ports to ensure that the antibiotics that the residents were receiving would be effective and not compromised. She said she would coordinate with the DON about the issue. Record review of the facility's policy Intravenous Therapy Policy revised April 02/2024 reflected Policy: The facility will adhere to accepted standards of practice regarding infusion practices . 14. IV sites are checked every shift and PRN . 11. Attach male end of tubing to catheter hub directly or into the disinfected needleless connector.

Based on observation, interview, and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #117) reviewed for dialysis. The facility failed to have a communication process for Resident #117's medications that were to be administered by the dialysis facility on 06/02/2026. This failure could place residents at risk of not being able to take their medication as scheduled. Findings included: Record review of Resident #117's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old male admitted [DATE]. The resident was diagnosed with end stage renal disease (a condition where the kidneys can no longer function adequately). Record review of Resident #117's Comprehensive MDS Assessment, dated 03/03/2026, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident was undergoing dialysis (medical treatment that filters waste and excess fluids from the blood when the kidney can no longer function). Record review of Resident #117's Comprehensive Care Plan, dated 03/02/2026, reflected the resident received dialysis every Monday, Wednesday, and Friday due to renal failure (kidneys were not functioning) and one of the interventions was to monitor the access site. Record review of Resident #117's Physician Order, dated 03/05/2025, reflected Dicyclomine HCl Oral Tablet 20 MG (Dicyclomine HCl) Give 1 tablet by mouth three times a day for treatment of functional/irritable bowel syndrome OK to take 2pm dose with him to Dialysis. Record review of Resident #117's Physician Order, dated 03/18/2025, reflected, Auryxia Oral Tablet 1 GM 210 MG (Fe) (Ferric Citrate). Give 2 tablet by mouth three times a day for Chronic kidney disease TAKE WITH MEALS - OK to take 2 pm dose with him to Dialysis. During an observation and interview on 06/02/2026 at 9:07 a.m., Resident #117 was in his wheelchair, awake. It was observed that two pills, inside a pill crusher pouch, were on top of his overbed table. The resident said those pills were handed over to him to take during dialysis. He said nobody would ask him if he took his medications when he returned to the facility. During an interview on 06/03/2026 at 9:51 a.m., MA I said she was the one who gave Resident #117 his medications that he was supposed to take when he was at the dialysis center, as per ordered. She said one of the medications was for his kidney failure. During an interview on 06/04/2026 at 8:43 a.m., ADON B said Resident #117's medications that were supposed to be taken during his dialysis were not communicated to the dialysis center to ensure timely medication administration. She said considering that one of the medications was for his kidney, it could indirectly impact the effectiveness of his dialysis. She said one of the responsibilities of the facility was to make sure that his medications were provided and taken during dialysis treatment days. She said there were orders that he could carry the medications to dialysis, but nobody was checking if the resident was able to take them. She said she already included in his dialysis binder for the dialysis facility to check if the resident was able to take his medications and already placed an order in his eMAR for the staff to check if the medications were still with the resident when he returned to the facility. During an interview on 06/04/2026 at 9:21 a.m., the DON said they already had a meeting about Resident #117's medication that he carried with him during his dialysis treatment. She said they already communicated with the dialysis center to check if the resident took his 2:00 p.m. medications because the resident's treatment finished at around 4:00 p.m. She said, in terms of the facility's responsibility, whichever was the charge nurse who received Resident #117 back from the dialysis center should check if the resident took his medications or not. She said if the medications were seen on a Tuesday morning, then most probably, the medications were for the day before. She said she would personally go follow-up with the staff to make sure that his renal management was not compromised. During an interview on 06/04/2026 at 9:58 a.m., the Administrator said the staff needed to check if the resident took his medications that the resident carried with him to the dialysis facility. She said they already communicated with the dialysis facility to check as well because one of the responsibilities of the facility was to provide his medications on dialysis treatment days but it would not stop there because the facility must ensure that the resident was able to take them. During an interview on 06/03/2026 at 12:34 p.m. via email, the facility's policy for dialysis was requested from the Administrator but was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for two of eighteen residents (Resident #117 and Resident #133) reviewed for pharmaceutical services. 1.The facility failed to ensure Resident #117 took his medications after his return from the dialysis facility on 06/02/2026. 2.The facility failed to ensure that Resident #133 took his medications on 06/02/2026. These failures could place residents at risk of not receiving medications as ordered, taking medications without a self-administration assessment, potential overdose, and adverse effects.Findings included: 1. Record review of Resident #117's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old male admitted [DATE]. The resident was diagnosed with end stage renal disease (a condition where the kidneys can no longer function adequately). Record review of Resident #117's Comprehensive MDS Assessment, dated 03/03/2026, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident was undergoing dialysis (medical treatment that filters waste and excess fluids from the blood when the kidney can no longer function). Record review of Resident #117's Comprehensive Care Plan, dated 03/02/2026, reflected the resident received dialysis every Monday, Wednesday, and Friday due to renal failure (kidneys were not functioning) and one of the interventions was to monitor the access site. Record review of Resident #117's Physician Order, dated 03/18/2025, reflected Auryxia Oral Tablet 1 GM 210 MG(Fe) (Ferric Citrate). Give 2 tablet by mouth three times a day for Chronic kidney disease TAKE WITH MEALS-OK to take 2 pm dose with him to Dialysis. Record review of Resident #117's Physician Order, dated 03/05/2025, reflected, Dicyclomine HCl Oral Tablet 20 MG (Dicyclomine HCl) Give 1 tablet by mouth three times a day for treatment of functional/irritable bowel syndrome OK to take 2pm dose with him to Dialysis. During an observation and interview on 06/02/2026 at 9:07 a.m., Resident #117 was in his wheelchair, awake. It was observed that two pills, inside a pill crusher pouch, were on top of his overbed table. The resident said those pills were handed over to him to take during dialysis. He said he did not know if and when he forgot to swallow them. During an interview on 06/03/2026 at 9:51 a.m., MA I said she was the one who gave Resident #117 his medications that he was supposed to take when he was at the dialysis facility, as per ordered. She said she did not know why it was still with the residents. She said one of the medications was for his kidney failure. She said the nurse told her the resident could carry the medications with him, but she had no idea how the facility would check if the resident was able to swallow his medications. She said the last time Resident #117 went for a dialysis was on Monday, 06/01/2026. She said, if the resident still had the medications on 06/022026, at 9:51 a.m., then maybe the resident was not able to take his medications intended for 06/01 2026, afternoon. 2. Record review of Resident #133's Face Sheet, dated 06/04/2026, reflected an [AGE] year-old male admitted [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar), bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows), atherosclerotic (the buildup of fats, cholesterol, and other substances in and on the artery walls) heart disease, and GERD (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #133's Comprehensive MDS Assessment, dated 04/22/2026, reflected the resident had moderate impairment in cognition with a BIMS 12. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus (high blood sugar), bipolar disorder, atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls), and GERD (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #133's Comprehensive Care Plan, dated 03/05/2026, reflected the resident had behavioral problems like spitting medications when the nurse leaves the area and one of the interventions was to monitor for effectiveness. Record review of Resident #133's Physician's Order, dated 03/01/2025, reflected, Aspirin Tablet Chewable 81 MG Give 1 tablet by mouth one time a day for CAD related to ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS (chest pain) . PERIPHERAL VASCULAR DISEASE (a slow and progressive circulation disorder), UNSPECIFIED. Record review of Resident #133's Physician's Order, dated 03/01/2025, reflected, Depakote ER Oral Tablet Extended Release 24 Hour 250 MG (Divalproex Sodium)Give 2 tablet by mouth one time a day for borderline personality disorder (mental condition characterized by emotional instability and impulsive behaviors) related to BIPOLAR DISORDER, UNSPECIFIED . Record review of Resident #133's Physician's Order, dated 04/29/2025, reflected. Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day for diabetes related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS . Record review of Resident #133's Physician's Order, dated 03/01/2025, reflected, Omeprazole Oral Capsule Delayed Release 10 MG (Omeprazole) Give 1 capsule by mouth in the morning for GERD. During an observation and interview on 06/02/2026 at 11:36 a.m., Resident #133 was sitting in a chair beside his bed. It was observed that there were four pills on top of the resident's side table. The medications were on a plain view. When asked about the medications, the resident started to talk about a different topic. During an observation and interview on 06/02/2026 at 11:39 a.m., ADON A said the resident had a history of hoarding medications but said it was not an excuse because they still need to make sure that Resident #133 took his medications and document if he refused. She said whoever giving the medications should check again if the resident swallowed his medications and would not leave the resident until the pills were taken. She said it was almost noon and nobody noticed the pills on his overbed table. She went inside Resident #133's room and removed the medications. She said nobody knew how long the medications were on top of the overbed table. During an interview on 06/02/2026 at 11:41 a.m., LVN E said she did not notice that Resident #133 did not take his medications. She said, considering that the resident was sometimes hoarding and spitting the medications, the more the staff needed to check on him because if he was not taking his medications, then his medical issues would not be addressed. She said the resident might take the medications along with the next batch that could result in overdosing. During an interview on 06/03/2026 at 9:20 a.m., MA J said she did not know about the four pills that were found inside Resident #133's room. She said the resident took all the medications that she gave that morning. She said the resident should be monitored for if he was swallowing his medication because of the probability that the resident would take them outside the ordered time or take them with the next batch, and nobody would know. She said the incident could result in underdosing or overdosing. During an interview on 06/04/2026 at 8:43 a.m., ADON B said somebody should be checking if Resident #117 was able to take his medications or not. She said she would also check with the staff giving the medications and receiving the resident after dialysis because they could not just click his eMAR without checking if Resident #117 took his medications. During an interview on 06/04/2026 at 9:21 a.m., the DON said the staff should be checking if the residents took their medications. She said Resident #133 had a history of hoarding and spitting his medications so the more that the staff should monitor. She said the Resident #133's pills were seen almost noon and nobody noticed that the pills were spit out. She said somebody should also check if Resident #117 took the medications that he brought with him during his dialysis. She said the residents might accidentally take the medications that were missed along with the next doses that could result in overdosing. She said she would start an in-service about medication administration. She said she would also do a self-medication assessment to see if it was still safe for Resident #117 to take his medication with him to dialysis. During an interview on 06/04/2026 at 9:58 a.m., the Administrator said the expectation was for the staff to check if the residents took their medications. She said she would coordinate with the DON about the issue. Record review of the facility's policy titled, Medication -Treatment Administration and Documentation Guidelines, dated ??, reflected, . Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments . Fundamental Information: Medication are administered according to manufacturer's guidelines unless otherwise indicated by physician order . Process . 1. Verify labels accurately reflect the physician's orders on the Electronic Medication Administration Record (EMAR) and Electronic Treatment Administration Record (ETAR) prior to administering patient medications and treatments . 3. Verify and provide medication or treatment . 4. Administer the medication according to the physician's order. Document e- signature for medications and treatments administered on the EMAR or ETAR immediately following administration. Record review of the facility's policy titled, Medication Storage, implemented January 20, 2021, reflected Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored . to ensure . security . Policy Explanation and Compliance Guidelines . 1. General Guidelines . c. During a medication pass, medications must be under the direct observation of the person administering medications

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment, in two (Resident #3 and Resident #16) of twelve residents reviewed for environment. Upon observation on 06/02/26, room mates' Resident #3 and Resident #16's bathroom entry area and door jam was damaged with exposed screws propped up near the bathroom entry. This failure could place Resident #3 and Resident #16 at risk for injury and decreased dignity due to her living environment.Findings included: In record review of Resident #3's Face Sheet dated 06/03/26 at 9:57 a.m. revealed she was a [AGE] year-old female admitted on [DATE] from acute care. Relevant diagnoses included acute and chronic respiratory failure (long term condition where the respiratory system cannot properly oxygenate the blood and/or remove carbon dioxide,) COPD with acute exacerbation (worsening of respiratory symptoms upon exertion,) and type 2 diabetes (insulin resistance leading to high blood sugar levels and impaired cellular function.) In record review of Resident #3's Quarterly MDS assessment, dated 05/31/26, revealed she was cognitively intact with a BIMS score of 15. She utilized a walker and wheelchair for mobility. Resident #3 required staff supervision for toileting, dressing, and personal hygiene. She was occasionally incontinent of bladder and frequently incontinent of bowel. In record review of Resident #16's Face Sheet dated 06/04/26 at 1:05 pm revealed she was a [AGE] year-old female admitted [DATE] from an acute care hospital. Relevant diagnoses included schizophrenia (complex brain disorder that alters how a person interprets reality,) dementia (decline of cognitive abilities,) and major depressive disorder (persistent low mood and/or loss in interest in activities.) In record review of Resident #16's Quarterly MDS assessment, dated 03/03/26, revealed she was severely cognitively impaired, unable to complete BIMS assessment, and had short and long term memory problems. She utilized a wheelchair for mobility. Resident #16 was dependent upon staff for toileting, shower/baths, and personal hygiene. She was always incontinent of bladder and bowel. During an observation and interview with Resident #3 on 06/02/26 9:25 a.m., the resident was observed in bed . Resident #3's bathroom doorway was observed with a sliding barn style door opening with a plastic door jam propped up in the corner beside the door opening with multiple screws exposed. Resident #3 stated it was like that for months and stated her wheelchair got caught on the door frame. She stated maintenance had not repaired it and denied any related injuries. During an observation with Resident #16 on 06/02/26 at 9:30 a.m. the resident was in her wheelchair on her side of the room. Interview was not successful due to the resident's cognitive limitations; but no injuries were present on residents' arms or legs. In interview with Maintenance on 06/02/26 9:45 am stated this was a recurring issue with Resident #3's room. Maintenance stated he worked on it multiple times, patched it, but she destroys it. When asked what a long-term solution he stated he, .just reports and fixes it. He stated it had been happening for a couple of weeks and denied any injuries related to the damage. In interview with facility Administrator on 06/04/26 at 12:53 pm she stated her expectations were for every resident room to be safe and any damage be repaired. She stated she was not sure why the damage in the room was not repaired upon observation; when asked about a long-term solution she stated she would check into it. She further stated it was the staff's responsibility to report any needed repairs in resident rooms and it was maintenance's responsibility to repair the damage promptly for resident safety. Record review of the facility's resident roster, dated 06/02/26, revealed Resident #3 and Resident #16 resided in the same room. Record review of facility's grievance log on 06/04/26 titled Grievance Log with a look-back period of 1 month revealed no documented concerns related to Resident #3 and Resident #16's room. Record review of facility maintenance log on 06/04/26 titled Maintenance Repairs Request with a look-back period of 6 months revealed on 04/06/26 at 9:00 am it was reported Bathroom wall on entry damaged in Resident #3 and Resident #16's room with no resolution documented. Record review of the facility's policy titled, Resident Rights, rev. 02/20/21 revealed, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from types of abuse: mental abuse/verbal abuse/physical abuse/sexual abuse/deprivation of goods and services by facility staff for 1 resident (Resident #5) out of 10 residents reviewed for abuse and neglect. The facility failed to ensure Resident #5 was free from abuse when CNA-C spanked him twice on his bottom while he was lying on the floor on 3/13/2025. This failure could place residents at risk of being physically or emotionally abused.Record Review of Resident #5's face sheet revealed he was an [AGE] year-old male and was admitted on [DATE] and readmitted [DATE]. His diagnoses included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Difficulty in Walking, Major Depressive Disorder (characterized by a persistent, intense, and low mood, along with a loss of interest in activities), Repeated falls, Abnormalities of Gait and Mobility, Adjustment Disorder (stress-related mental health condition which causes emotional or behavioral symptoms that are disproportionate to the stressor) and Cognitive Communication Deficit (impairment in communication caused by underlying disruptions in cognitive processes).Record Review of Resident #5's Quarterly MDS dated [DATE] revealed he was unable to complete a cognitive assessment which gave him no score for BIMS, which meant he was severely cognitively impaired. Resident #5's MDS revealed he rarely/never made himself understood or understood others. The MDS revealed Resident #5 had short- and long-term memory problems. Resident #5's MDS revealed he was dependent for toileting, shower hygiene and needed substantial assistance with dressing.Record Review of Resident #5's Care Plan dated 7/7/25 revealed the following care areas:*Impaired cognition and was at risk for further decline in cognition and functional abilities.*Behavior problems as evidenced by him urinating in dresser drawers, closets, trash cans, sinks, corners, and common areas.*Behaviors of pushing on exit or egress doors and was difficult to redirect*Behavior of continuing to remove personal clothing when dressed by staff.*Behavior of sitting on the floor as a refusal mechanism.*Resistant to care as he would refuse to shower.Further review revealed the facility's intervention for these behaviors was to Approach resident in a calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing care, allow time for a response and do no rush. Interview on 2/3/26 at 10:11 a.m. Resident #5 stated he thought the facility was pretty good. He stated he was comfortable with the temperature in his room, had no falls, got his brief changed as often as he needed and had no concerns with the facility or staff.Interview on 2/3/26 at 11:15 a.m. LVN-A stated they did abuse/neglect trainings often with the last time being about two weeks ago. He stated Resident #5 had been there for three or four years. His family had five cameras in his room. LVN-A stated the family complained all the time. He stated if he saw any abuse, he would report it to the Admin and complete an incident report. A telephone interview on 2/3/26 at 4:33 p.m. the NP stated Resident #5 was her patient and she did not have any concerns for him. She had talked to Resident #5's FM in the past but not recently. The FM would catch her in the hallway but never expressed any concerns to her about the facility.Interview on 2/3/26 at 4:40 p.m. with the DON, stated Resident #5's FM always had concerns with a particular nurse that worked on the weekend. The DON stated the FM was concerned about how long he was in the bathroom or how long a break he took. The DON stated the FM had complained about another resident being half dressed all day. She tried to explain that behaviors for dementia residents looked different for each person.Interview on 2/3/26 at 5:00 p.m. with the Admin, stated Resident #5's FM did complain to her about several things. The Admin stated the FM did not care for a weekend nurse at all. The FM had stated the weekend nurse took too long on bathroom and on meal breaks. The Admin stated the FM complained about a resident walking around half clothed. The Admin stated Resident #5's FM had concerns he was missing clothes, he was cold and had a wet bed.Notified on 2/4/26 at 10:12 a.m. of an Addendum Video intake had received from FM on 2/3/26 at 5:25 p.m. with Resident #5 and CNA-B.Observation on 2/4/26 at 10:12 a.m. of a video with no date or time stamp revealed:CNA-B came into the room where Resident #5 laid on the floor next to his bed on his left side. CNA-B asked, Why you do this again, huh? She tells him to Get up and slapped him on his right buttock once with her hand. CNA-B asked, why you did this and slapped him on the right buttock with her hand again. Resident #5 said Oh shit, lady. CNA-B said why you did this two more time and said Come on. No, you are not supposed to do this, come on, sit up. Come on. Resident #5 said I can't. CNA-B said Yes, you can. Why you come on the floor in the first place? Resident #5 said Oh shit. CNA-B said Oh shit, why you say oh shit? Give me your hand. So, this place is better than a bed? Resident #5 said Yes ma'am. CNA-B said It's not. Get up. Come on. CNA-B took his hand. Resident #5 said something unintelligible, and CNA-B walked out of view and the video ended.Interview on 2/4/26 at 10:23 a.m. Resident #5's FM stated the video was from 3/13/25. She stated she had lots of text and videos she sent to the Admin and former ADON but normally, they did not reply.Interview on 2/4/26 at 2:45 p.m. Resident #5's FM stated she had not seen CNA-B anymore and she was not sure how long it had been since she had seen her. She was not sure if she texted the video to both ADON and the ADMIN. She did not talk to either one of them personally about the video. She stated she figured they had got it and were not going to do anything about it.Interview on 2/4/26 at 2:55 p.m. the DON stated abuse could be physical, psychological, verbal, or monetary. She stated neglect would be not doing care as needed. The DON stated abuse was active and purposeful while neglect was something one should be aware of regarding care. She stated hitting a resident on the bottom would not be alright.Interview and observation on 2/4/26 at 3:03 p.m. the Admin stated abuse was verbal towards a resident or anyone taking something from a resident. She stated it would never be alright to hit a resident. She stated CNA-B stopped working at the facility not long after she started in November 2024. She stated if she remembered correctly, they had CNA-B scheduled and she did not show up. The Admin stated she never saw a video of anything from the FM. She stated she was not sure if she had given her personal cell phone number or the Admin number back in March 2025. She stated their corporate office had turned off the Admin phone and required her to use her personal phone around August 2025. The Admin stated she was not even sure she had business cards back in March 2025. Observed Admin's business card to have a sticky note number covering another phone number. The Admin stated the number on the business card was the Admin phone number and the sticky note number was her personal number. The Admin viewed the video of Resident #5 and CNA-B and stated that it should not have happened. She stated if she had seen the video, she would have suspended CNA-B and investigated the incident. The Admin stated Resident #5's FM never talked to her about the video or abuse.Interview and observation on 2/4/26 at 3:34 p.m. Resident #5's FM stated she texted 5 videos to the Admin on 3/14/25. She texted a screenshot to surveyor showing it was sent 3/14/25 at 8:54 a.m. with 5 videos attached and no text message. The FM stated she sent the videos to the number for the Admin's personal number.An attempted telephone interview on 2/4/26 at 3:56 p.m. with CNA-B, the phone went straight to voicemail. A message was left requesting a return phone call. No return call was received.Interview and observation on 2/4/26 at 4:15 p.m. the Admin showed she only had one text from Resident #5's FM on 1/26/26. She stated as far as she knew, she did not get any text messages from the FM in March 2025. She stated she did regularly delete messages as it was her personal phone, and she had paid for extra money for memory due to the amount of text messages she received.Interview on 2/5/26 at 9:56 a.m. with the Admin stated she called in an incident report last night for the 3/13/25 video of Resident #5 and CNA-B. She talked with Resident #5's FM last night. The Admin stated she was going to meet with the FM once a week as it appeared she was telling different staff complaints, and it was not being relayed to her. She had started doing abuse and neglect training with staff also.Interview on 2/5/26 at 10:19 a.m. with Resident #5's FM stated she talked with the Admin last night. She stated if she saw staff members of the facility, she would talk to them. She stated she could not remember what was on the 5 videos now. Resident #5's FM stated she talked to staff if she saw them in Resident #5's area.Interview on 2/5/26 at 10:45 a.m. CNA-C stated they did abuse/neglect training every month and yesterday was the last time she did the training. Abuse would be leaving a resident in a chair. Neglect would be if staff did not answer a call light within 2 minutes or if staff did not do something for a resident that needed to be done for them. She stated it was never acceptable to hit a resident. CNA-C stated a resident being hit by staff could indirectly affect the resident mentally.Record Review of the facility's Policy and Procedures for Abuse, Neglect and Exploitation dated 10/24/22, revealed under Abuse means the willful infliction of injury.intimidation or punishment with resulting physical harm, pain, or mental anguish.It includes verbal abuse.physical abuse, and mental abuse. Under Willful means the individual must have acted deliberately, not that individual must have intended to inflict injury or harm.Physical Abuse includes but is not limited to, hitting, slapping. Under Policy Explanation and Compliance Guidelines: 1. The facility provides resident protection that include: a) Prevention/prohibit resident abuse. Under III. Prevention of Abuse, Neglect and Exploitation, The facility will make every effort to prevent and prohibit all types of abuse.

Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one of five residents (Resident #1) reviewed for assistive devices and supervision. The facility failed to ensure Resident #1 was provided increased supervision, due to psychiatric issues, Mild intellectual disability, and Diabetes. In addition, she resided on the memory care unit prior to going to the appointment 01/05/2026. Resident #1 was not returned to the memory care unit upon returning from the elopement incident. An Immediate Jeopardy (IJ) situation was identified on 01/08/2026. While the IJ was removed on 01/09/2026, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems.This failure could place all residents who requiring supervision in the community due to physical and/or cognitive deficits at risk for emotional decline, physical injury, and diminished quality of life due to a lack of safe accommodations. Resident #1 resided on the memory care unit prior to elopement on 01/05/2026, and on 01/07/2026 she was placed on the main hall after her elopement.Record review of Resident #1's face sheet, dated 01/07/2026, reflected a 57 years-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Schizoaffective Disorder (a serious mental illness (psychosis like hallucinations/delusions) with a mood disorder (major depression or bipolar disorder), featuring periods were psychotic symptoms) Diabetes Mellitus (changes in blood glucose levels) and Mild intellectual disabilities (deficits in intellectual functioning (like reasoning and problem-solving).Record review of Resident #1's admission Elopement assessment at admission, dated 11/12/2025 at 3:38 PM, by LVN-A, reflected she had a minimal risk for elopement.Record review of Resident #1's admissions MDS, dated [DATE], reflected a BIMS score of 07, which indicated the resident was severely impaired cognitively. Section D for mood 0, D0700 sometimes socially isolated. Section GG Functional Status: Prior Functioning: Everyday Activities indicated Resident #1 required supervision and touching for toileting and bathing, eating, oral hygiene, and personal hygiene. Section I. indicated the resident received treatment of Diabetes, for a non-pressure ulcer (damaged skin) wound infection, Diabetes Mellitus (unstable Blood sugars), Schizophrenia (chronic brain disorder), (Asthma (chronic lung disease), Section Q: no referral to LCA (local contact agency) referral not wanted. Section V. CAA and Care Planning on 11/14/2025: Cognitive Loss/Dementia; 05. ADL Functioning/Rehab potential; Urinary incontinence; Fall protocols; Nutrition/diet; Dehydration; PU; and Psychotropic drug use. MDS was signed on 11/14/2026 by RN-M. Record review of Resident #1 care plan, dated 11/20/2025, reflected Resident has adjustment issues to admission. Learn to recognize/Help the residents identify their stressors. Intervene and remove stressors where possible. Provide the resident with as many situations as possible which give them the control over their environment & care delivery.Resident has a behavior problem as evidenced by schizoaffective disorder, bipolar type.Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, person involved, and situations. Document behaviors and interventions in behavior log. Approach resident in a calm manner.Talk while providing cares, allow time for a response, and do not rush. Resident has a diagnosis of Diabetes.DX of diabetes and at risk of unstable blood sugars and abnormal labs. Resident has a venous Stasis Ulcer (slow healing wound on the lower ankle) at risk of decreased circulation, infections, and pain.Resident takes Psychotropic medications and requires monitoring for changes in medications ordered.Discharge Plans, Resident is in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidenced by an inability to provide selfcare and discharge planning is not needed. Either the family or the resident has requested that questions regarding return to the community only be asked on comprehensive assessments. Record review of Resident #1 change in condition-MDS, dated [DATE], reflected a BIMS score of 07, which indicated the resident was severely impaired cognitively. Section I: reflected Resident #1 received treatment for Diabetes Mellitus. The resident received treatment for Multidrug-Resistant Organism (MDRO referring to bacteria or other microbes resistant to multiple antibiotics, making infections difficult to treat) wound was infected and she required IV. Record review of Resident #1's BIMS assessment, on 01/07/2026 at 9:59 AM, reflected a BIMS score of 13, which indicated the resident was cognitively intact. Record review of Resident #1's elopement assessment, dated 01/07/26 at 11:21 AM, by RNC reflected a minimal risk for elopement. Record review of Resident #1's elopement assessment, dated 01/07/26 at 11:21 AM by the DON, reflected she reflected she had a minimal risk for elopement. Record review of Resident #1's consolidated physician's orders, dated 11/11/2025 reflected the following:Psychiatric Care and/or Psychological Care evaluation for treatment. resident is unable to understand rights.referral for MD-L d/t abnormal vascular findings. assess for pain q shift.Venous wound to left lower leg.Record review of Resident #1's consolidated physician's orders, dated 11/12/2025 reflected an order for Insulin Lispro (1 Unit Dial) Subcutaneous SolutionPen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 150 = 0; 151 - 199 = 2; 200 - 249 = 4; 250 - 299 = 6; 300 - 349 = 8, subcutaneously before meals and at bedtime for diabetes for sugar greater than 350 give as ordered and notify MD/NP. Record review of Resident #1's PN nurse assessment notes, by RN-Y, dated 01/05/2026 at 10:43 AM, reflected the following information prior to departing the facility for her appointment. Vitals T-97.8, R-18, BP106/55, SpO2-97, no pain, no symptoms.Resident was alert to person, place, clear speech.Summary: Resident with prior diagnosis of cellulitis (bacterial skin infection) of the left lower limb, now resolved following completion of prescribed antibiotic therapy. Residents report no pain or discomfort. VSS. Will continue routine skin assessments, reinforce safety with mobility, and monitor any recurrence of symptoms. Record review of Resident #1's Progress Notes (MD/PN), dated 01/07/2026 at 2:05 PM, by the NP, History of present illness: Patient is being seen today to follow up on her status. Patients had an appointment earlier this week with a vascular surgeon. She is scheduled for a procedure (possible stent placement) on the 15th. At the time of this visit, the patient was tired. She recently bathed and is resting comfortably in bed. No signs of distress are noted. Patients continue with leg wounds that are slow to heal due to her vascular issues. She denies pain at this time. No shortness of breath or coughing is noted. Per staff with no further issues, continue to monitor. Respiratory: Clear to auscultation throughout without evidence of wheezing, Chronic or labored respirations. CV (cardiovascular): S1/S2 (abnormal heart sound), regular rate, regular rhythm without [NAME], rubs, or heaves. [NAME]. +4 Edema noted: Soft, non-tender, non-distance. Bowel sounds present and normal Musculo: No swelling, tenderness. Skin: chronic Wound noted to left lower leg Neuro: A&Ox2. Psychiatric: Patient is calm at this time.Record review of Resident #1's PN, dated 01/07/2026 at 7:12 AM, by LVN L reflected Note Text: At about 0712 this morning, this (LVN L) received patient from (Hospital) accompanied by the Administrator. She was awake and alert, respirations even and unlabored, no cough/congestion noted. Head to Toe skin assessment was initiated and completed. Upon assessment, no new skin changes were noted, but the venous wound of the left lower leg remains, wound care provided by the wound care nurse. V/S at this time were 116/73,98,20,97.8,18,97%, NP was aware. Shower was given and she tolerated it well, tolerated all meals and all due medication, needs attended to safety-maintained call light placed within reach, staff will continue to provide care.type 2 diabetes mellitus with unspecified complications Chronic/stable (unexpected duration) Most recent blood sugar was 119 mg/dL Continue insulin lispro via sliding scale Admit labs drawn on (11/18/2025) show an HA1c (blood test that shows the test measuring average blood sugar glucose)levels. of 5.5% Continue to monitor. chronic venous hypertension (idiopathic) (high pressure in leg veins) with ulcer of left lower extremity Chronic/ongoing Non healing wound present. Will have a vascular (blood vessel disease) procedure on 1/15 Continue to monitor. Record review of Resident #1's (PD) report completed by [NAME]-W at 01/05/2026 at 7:11 PM, reflected Missing persons from hospital. (Resident #1), reported by ADM and (DON) Incident Supplement ( # number ), incident record (#) On Monday (01/05/2026), at approximately 6:54 P.M. [NAME] were dispatched on a missing person at (Address).[NAME] F arrived on scene and spoke to (ADM name).(ADM) stated that a patient (B/F ) from the (facility name) was transported by the facility to (hospital location) for a regular vascular appointment. The driver dropped (Resident #1) off at the door then left, when the driver returned, he could not locate (Resident #1) .(ADM) stated that they attempted to locate (Resident #1) but were unsuccessful. (ADM) stated that she called (PD) who told her to contact (PD).(DON) is a nurse at the facility and gave the following medical information.(Resident #1) suffers from type 2 diabetes (irregular sugar levels) and would need to eat or receive insulin (hormone that regulates blood sugar) every 6 to 8 hours to maintain healthy levels. (DON) stated that if (Resident #1) insulin dropped low she would enter a coma (deep unconsciousness) state.(Resident #1) also suffers from schizoaffective disorder, bipolar disorder, major depressive disorder and mild intellectual disability.(Resident #1) is approximately (height/weight) It is unknown what (Resident #1) was last wearing. (Resident #1) has no access to money, credit cards, or a cellphone.[NAME]-F NCIC check with (County) and (Resident #1) is not incarcerated. ([NAME]-F called (hospital) and (Resident #1) is not a patient there.Body camera footage is available.[NAME]-F narrative reflected the following.'01/05/2026 8:15 PM on Monday (01/052026), at approximately 6:54 P.M. (Police) were dispatched on a missing person at (facility address, city, and county) .01/05/2026 9:30 pm.' On 01/05/2026, Lt. spoke with (ADM) by phone. (ADM) informed Lt. that missing person (Resident #1) was taken to (MD-L) vascular office located at (address, city, sate) this morning for a checkup and was taken into a medical room and while waiting to be seen by the doctor, (Resident #1) decided to leave the location against the medical staff's advice. (ADM) stated she was informed of this by the medical staff at (MD-L) office and that this occurred between 12 noon and 1 p.m. The phone number to MD-L phone numbers, at the time of this supplement, (MD-L) office was closed. (ADM) also stated that she has been in contact with (Resident #1) RP: however, she has not heard from (Resident #1) and stated that (Resident #1) usually ends up in jail or the hospital because of her psychological history. At 9:47 AM, (MD-L) office provided the demographics, NE, office administrator. Appointments as at 10:00 AM as a new patient. Arrived at 9:56 AM (during vitals). No one came with the resident. Resident was scheduled for 12/15/2026. New patient. Procedure: office visit, ultra-sound of her leg.After the ultrasound, resident said she did not want to wait for results. In the exam room, she asked for a soda. (Resident #1) stated that she did not want to wait. Then she walked out the door. This was at 11:00 AM. The staff walked out to search. Contact campus security for hospitals. Report filed with TS-L reported to (PD). She had transportation to the office, and they were contacted. He called the facility to report that the resident was missing. After 3 hours of searching the officers were unable to find the resident. (PD) came and searched for 3 more hours and did not find her. Called the facility 3 times to see if the resident was back. Between 11:00 AM and 5:09 PM call. (DON) called the next day and stated the resident was missing and they needed the information from her visits.They (MD-L) were notified on 01/08/2026 was notified that the resident had been located on a bus. VS-N stated that while in the clinic she left to go to the rest room several times. Driver (named). Aides for the facility arrived to search for the resident. Time is unknown. After an hour, the staff came.(Driver) told, the facility he saw the resident getting on the bus. Record review of the facility's provider investigation, dated 01/07/2026, reflected On 1/5/2026, (Resident #1) had a scheduled physician appointment at MD-L. At approximately 3:00 pm, office staff from MD-L contacted the facility and reported that (Resident #1) left the appointment Against Medical Advice (AMA) and could not be located. Staff from MD-L office later stated that (Resident #1) had been placed in a waiting room while awaiting test results, and when staff returned, she was no longer present. Facility staff immediately began attempts to locate (Resident #1). The (PD) was notified at approximately 6:00 p.m. on 01/5/2026, followed by notification to (Public Transportation) Police at 6:45 p.m. The Responsible Party (RP) was notified immediately and remained in constant communication with the Administrator throughout the incident. Facility staff conducted an active search of (address of appointments, utilizing both vehicle and foot patrols, for approximately six hours. On 01/07/2026 at approximately 3:30 a.m., (Resident #1) was located on a train by (Public Transportation) Police. The Administrator was notified and subsequently transported (Resident #1) from (Hospital) back to the facility. (Resident #1) signed hospital discharge paperwork prior to returning. Upon return, the Administrator interviewed (Resident #1) regarding her whereabouts. (Resident #1) stated, I just went to (city) and got me a piece of chicken and a soda. When asked how she traveled, she stated, By the train, I know how to get around there. (Resident #1) returned safely to the facility and remains in the facility at this time with no injuries or trending concerns observed. A head-to-toe assessment was completed by RN-O; Head-to-toe assessment completed with no injuries or adverse findings. Resident #1 requires no level of supervision, independently ambulatory, interview able, and compacity to make informed decisions. The resident was alert and oriented with X 3, schizoaffective disorder, bipolar. Facility investigation confirmed findings of missing person. Staff in-service initiated on 01/05/2026 at 1:00 PM. Post investigation actions from the provider included Safe Surveys completed with no trending concerns. Abuse and Neglect in-service completed.Missing person in-service completed. Interviews Completed. Record review of the facility's investigation safe surveys reflected Does staff treat you with dignity and respect? If not, tell me some examples of where the staff did not treat you with dignity and respect. 2. Have you ever been treated roughly by staff? 3. Do you ever feel afraid because of the way you or some other resident is treated? 4. as staff ever yelled or rude to you? If the answer is yes, ask who, when, what was said or what happened? 5. Do you feel safe and free of harm? 6. Are you aware of any threats of safety towards you or any other residents? and 7. Have you felt unsafe? The review determined that the reviewed residents had no concerns. Record review of ADM interview with Resident #1 on 01/07/2026 time unknown reflected Administrator asked (Resident #1) where she went on 1/5/2026, she stated I just went downtown and got me some food and a soda. Administrator asked how she got around, (Resident #1) stated I rode the train wherever I needed to go. (Resident #1)it's fine, I know that area pretty well. This resident then proceeded to state it's okay you didn't do anything wrong; you're doing the right thing. Record review of Resident #1's assessment on 01/07/2026 at 7:00 AM by LVN O. Head to toe assessment completed. No adverse findings. Record review of PD's follow up report, dated 01/06/2026 at 1:43 P.M., by MPD-I reflected on 01/6/2026, (MPD-I) confirmed that (Resident #1) is entered on NCIC/TCIC as a missing person. (MPD-I) contacted reporting party (ADM) who stated she has not seen or heard from (Resident #1) since approximately 1:00 P.M. on 01/05/2026.(ADM) provided the contact information for (Resident #1) (RP), (phone number). (MPD-I) reported that (Resident #1) will either end up being incarcerated or hospitalized . (MPD-I) contacted (hospital name) and confirmed that Resident #1 is not currently a patient and has not been admitted . (MPD-I) also checked (AIS) and there was no record of (Resident #1). RP notifiedMD notifiedPD report 2026E001710,Public Transportation police notifiedSafe surveys initiated Record review of the missing person Locator worksheet reflected in part.Whenever a staff member discovers a patient missing or hears an alarm that may indicate a patient has left the center, the staff member immediately notifies the Charge Nurse who initiates an initial internal or simultaneous external search of the immediate area to locate the patient. (Page overhead code for missing patient -Silver).2. The administrator or the charge nurse acts as search coordinator and coordinates and documents all search efforts. If an alarm has sounded or patient cannot be located an immediate face-to-face head count of all patients in the center is conducted The search coordinator organizes a thorough building search includes all rooms (locked and unlocked), bathrooms, closets, stairwells, elevators, storage spaces, walk-ins in the dietary department, maintenance, laundry, therapy, and roof areas. Potential hiding areas, e.g behind curtains, furniture, under beds, and behind doors or equipment are searched .4. The search coordinator, after confirming that a patient is missing, via the head count, immediately notifies the administrator and director of nursing, as well as all other department heads.The search coordinator interviews staff to determine where and when patient was last seen, customary routine, recent mood or behavioral disturbances, attire and physical condition. Identify environmental circumstances fire drill, change of shift, visitors departing, activity group departing, etc. Check working condition of alarm system.The search coordinator interviews staff to determine where and when patient was last seen, customary routine, recent mood or behavioral disturbances, attire and physical condition. Identify environmental circumstances fire drill, change of shift, visitors departing, activity group departing, etc. Check working condition of alarm system. Record review of the facilities policy titled Missing Resident Policy, dated 10/24/2022 Revised: 8/15/23reflected in part.This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.Definitions:Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless.Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements .2. Staff are to be vigilant in responding to alarms in a timely manner .3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary .Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering .1. Residents will be assessed for risk of elopement and unsafe wandering upon admission, quarterly and as needed throughout their stay by the interdisciplinary care plan team 2. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan .3. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff .4. Supervision will be provided to help prevent accidents or elopements .5. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, document and report to Administrator/Director of Nurses accordingly .6. The effectiveness of interventions will be evaluated, and changes will be made as needed .Any changes or new interventions will be communicated to relevant staff.5. Procedure for Locating Missing Resident 1. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g., internal alert code) .2. The designated facility staff will look for the resident .If the resident is not located in the building or on the grounds, the Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office .DON or designee shall notify the physician and family member or legal representative .Police will be given a description and information about the resident; include any photos .All parties will be notified of the outcome once the resident is located .Appropriate reporting requirements to the State Survey agency shall be conducted .Procedure post-elopement a. A nurse will perform a physical assessment, implement intervention to reduce elopement risk, document, and report findings to physicians. b. Any new physician orders will be implemented and communicated to the family/authorized representative. c. Nurses will complete follow up documentation on resident response post elopement. d. A social service designee will reassess the resident and make any referrals for counseling or psychological/psychiatric consults. e. The residents and family/authorized representatives will be included in the plan of care. f. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. g. When repeated elopement attempts occur, after the facility has exhausted possible care approaches, the resident may be referred for alternate placement in an appropriate facility. h. Documentation in the medical record will include findings from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes as applicable. Record review of the facility's in-service, dated 01/05/2026, 01/06/2026, titled Abuse and Neglect reflected the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion, and corporal punishment. Training Employees: Prevention, Intervention, Detection, Reporting and Employee Rights Train employees, through orientation and on-going sessions on issues related to abuse prohibition practices such as: I. How and who to report their knowledge of a suspicion of a crime. abuse, or witnessed abuse, neglect, or misappropriation of resident property. 2. How to report. a reasonable suspicion of a crime without fear of retaliation. 3. Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. 4. How to recognize signs of burnout, frustration and stress that may lead to abuse; and 5. What constitutes abuse, neglect, and misappropriation of resident property? 6. Discuss behavioral interventions that can be used for inappropriate resident behaviors. Signatures of attendance for over Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The in-service documentation and sign in sheet were reviewed by the surveyor and reflected that all active staff had attended the training. Record review of facility's in-service, dated 01/05/2026, 01/06/2026, titled Staff to go with all high-risk residents to appointments and residents on station #1 are always high risk. The check list reflected the following Section I. Residents of risk factors. Section 2 Supervision needs non-emergency transport to appointments. Section 3 Transport agreements, instructions provided to the transport staff, Section 4. Documents and notifications. Section 5 Signatures of the Charge nurse and DON. The form titled Therapeutic Leave Form reflected 1. By signing up for the facility, I understand I am responsible for my safety and well-being. If I leave the property alone, I understand the risk associated with traveling in the community in a wheelchair or on foot. Even though it is not recommended, I choose to exercise my right to leave .2. I am aware of the written Bed Hold Policy that was signed upon admission and have the right to request a bed hold if applicable .3. It is my responsibility (resident/RP or individual signing this form) to notify the facility if for whatever reason the resident chooses not to return at the time/date previously stated. The in-service sign in reflected 21 staff attendance signatures. Record review of PD communication supplement in the report, dated 01/07/2026 at 3:26 AM, reflected (PD), confirmed on missing subject (Resident #1) .located at (TL at 01/07/20926 at 3:05 AM.). Record review of PD CID clearance stated by MPD-I on 01/07/2026 at 8:20 A.M. reflected on 01/07/2026, (PD) located and confirmed on missing person, Staff from (facility name) responded to the scene and transported (Resident #1) back to (facility address).The incident will be cleared as no criminal offense and remain on file to document the reported incident.closed.Record review of Resident #1's care plan conference notes dated 01/09/2026 at 10:00 AM and completed by DON, RN. Resident #1's RP was in attendance, and other electronically signed disciplines signatures included: SW, DOR, DM, DON, AD, and the Administrator. The plan reflected met with [Resident #1's] [RP] regarding resident's care going forward. [RP] stated that she was not qualified to say what should be done and wants the facility to do what we feel is best. [RP] stated that she did not want [Resident #1's] to be locked up like a prisoner. [RP] says if being on an unlocked unit doesn't work, then we can move [Resident #1's] to memory care. [RP] says that [Resident #1's] .has issues with regulating her medications and taking them on a consistent basis. [RP] says that there was no wander guard on [Resident #1's] at last facility. [RP] says that she is willing to accompany [Resident #1's] [RP] to all future appointments.Social services Interdisciplinary Care Plan meeting conducted with SW, DON, Administrator, Activity Director, Dietary Mgr, and resident's family ([RP] via telephone conference) in attendance. Updates provided on the residents' medications.Resident is here for long-term care.[RP] presented concerns regarding resident's placement in the facility and resident safety.states that resident is not believed to be exit seeking and does not have a history of elopement. All concerns raised by the family were addressed by both the DON, SW, and administrator. [Resident #1's] will currently remain in long term care outside of memory care per family request. [RP] states they are currently pleased with care at the facility.no change in code status. The care plan did not address the residents interventions for recent incident or supervision on appointments moving forward. During an observation and interview on 01/07/2026 at 1:00 PM, revealed Resident #1 was well-groomed, somewhat confused ( observed with loss for words, unable to recall or respond to questions or the details of the events while she was gone. she did not know her locations or any contact information) and free of injuries. She stated she tried to call her previous placement for assistance (SNF). Resident #1 stated public (transportation) staff found her today (01/07/2025). Resident #1 said a TS (name unknown) approached her with her picture and told her she was reported missing. Resident #1 said that SC was called EMT's. Resident #1 said they checked her for injuries, then transported to the hospital for evaluation. Resident #1 was moved to a private room, and a staff member was observed with her to monitor and supervise safety. Resident #1 stated she was transported to the hospital for an appointment for her leg. Resident #1 stated she left the hospital after the procedure and boarded the city transportation bus. Resident #1 said he had $5.00 in her possession. Resident #1 said she took the bus downtown and talked with others at the bus stop. She stated she went to a (Fast food chain) and got French fries and a drink. Resident #1 said she called the previous placement (SNF), and there was no answer (she could not remember the name of the SNF). Resident #1 said she dd not have the phone number for her RP or the facility to pick her up. Resident #1 stated she was safe, not afraid, and not harmed while missing. During an interview on 01/07/2026 at 10:00 AM with the ADM said the resident was transported by IMTS transportation on 01/05/2026 for a vascular appointment at the hospital. Both stated she resided on the memory unit, and the facility staff were considering moving her to the main population. The ADM said the resident was returned to the facility this morning. The ADM stated the IMTS-S notified the facility the resident had left the hospital and boarded a bus. The ADM immediately alerted the staff to a missing person, and a search was initiated. The ADM called and made a missing person's report to the PD, then PD, and RT and sent a face sheet. The ADM said 2 staff were sent to the hospital to assist with searching for Resident #1. The ADM said the staff searched for 3 hours and did not locate the resident. The ADM and RP arrived at the hospital to continue the search and communicate with staff. The ADM said Resident #1's room was located on the memory unit due to a history of behaviors associated with mental illness DX. The ADM said Resident #1 had no previous reports or incidents of wandering off. The ADM said the DON approved by the DON to be transported without supervision at the appointment. The resident was found by RT in [NAME], Texas. The ADM said the resident did not have any injuries. Resident left the clinic sometime after lunch on 01/05/2026, time unknown. During an interview on 01/07/2026 at 10:30 AM, the DON revealed she approved Resident #1 to be transported without supervision to the appointment on 01/05/2026. The DON said Resident #1 was alert and oriented to make decisions. The DON stated Resident #1 had no previous incidents of this nature since being admitted . The DON said she did not call the RP prior to the appointment to communicate the plan to transport Resident #1. The DON stated Resident #1 was placed on the memory unit at admissions due to reports of

Based on interviews and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being, for one (Resident #1) of 3 residents reviewed for care plans, in that: Resident #1's care plan did not address her behaviors of wandering, intellectual disability, or her most recent elopement incident. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. Record review of Resident face sheet dated 01/07/2026, reflected she was a 57 years-old, female that was admitted on [DATE]. Resident DX: Schizoaffective Disorder (a serious mental illness (psychosis like hallucinations/delusions) with a mood disorder (major depression or bipolar disorder), featuring periods of psychotic symptoms.) Diabetes Mellitus (changes in blood glucose levels), and Mild intellectual disabilities (deficits in intellectual functioning (like reasoning and problem-solving). Record review of Resident #1 admissions-MDS dated [DATE] by RN-M reflected in Section C-Cognition she had a BIMS score of 07 indicating the resident severely impaired cognitively.Section D for mood 0, D0700 sometimes socially isolates. Section GG Functional Status: Prior Functioning: Everyday Activities indicated Resident #1 required supervision and touching for toileting and bathing, eating, oral hygiene, and personal hygiene. Section I. indicated that the resident received treatment for Diabetes, for a non-pressure ulcer wound infection, DM, Schizophrenia, Asthma, Section Q: no referral to LCA (local contact agency) referral not wanted. Section V. CAA and Care Planning on 11/14/2025: Cognitive Loss/Dementia; 05. ADL Functioning/Rehab potential; Urinary incontinence; Fall protocols; Nutrition/diet; Dehydration; PU; and Psychotropic drug use.Record review of Resident #1 change in condition -MDS dated [DATE] reflected in Section C-Cognition she had a BIMS score of 07 indicating the resident severely impaired cognitively. Section I: reflected Resident #1 received treatment Diabetes Mellitus, Resident received treatment for Multidrug-Resistant Organism (MDRO referring to bacteria or other microbes resistant to multiple antibiotics, making infections difficult to treat.) wound was infected and she required IV. Record review of Resident #1 care plan dated 11/20/2025 reflected Resident has adjustment issues to admission. Learn to recognize/Help the residents identify their stressors. Intervene and remove stressors where possible. Provide the resident with as many situations as possible which give them the control over their environment & care delivery.Resident has a behavior problem as evidenced by schizoaffective disorder, bipolar type.Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, person involved, and situations. Document behaviors and interventions in behavior log. Approach resident in a calm manner.Talk while providing cares, allow time for a response, and do not rush. Resident has a diagnosis of Diabetes.Resident takes Psychotropic medications and requires monitoring for changes in medications ordered.Discharge Plans, Resident is in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidenced by an inability to provide selfcare and discharge planning is not needed. Either the family or the resident has requested that questions regarding return to the community only be asked on comprehensive assessments.resident has an ADL Self Care Performance Deficit and is at risk for not activities of daily living (ADLs) having their needs met in a timely manner. Performance Deficit and is at risk for non-skilled activities of daily living (ADLs) having their needs met in a timely manner . Resident #1's care plan did not address her behaviors of wandering, intellectual disability, or her most recent elopement incident 01/05/2026. Record review of Resident #1's care plan conference notes dated 01/09/2026 at 10:00 AM and completed by DON, RN. Resident #1's RP was in attendance, and other electronically signed disciplines' signatures included: SW, DOR, DM, DON, AD, and the Administrator. The plan reflected met with (Resident #1) (RP) regarding resident care going forward. (RP) stated that she was not qualified to say what should be done and wants the facility to do what we feel is best. (RP) stated that she did not want (Resident #1's) to be locked up like a prisoner. (RP) says if being on an unlocked unit does not work, then we can move (Resident #1's) to memory care. (RP) says that (Resident #1'ss) has issues with regulating her medications and taking them on a consistent basis. (RP) says that there was no wander guard on (Resident #1's) at the last facility. (RP) says that she is willing to accompany (Resident #1's) (RP) to all future appointments.Social services Interdisciplinary Care Plan meeting conducted with SW, DON, Administrator, Activity Director, Dietary Mgr., and resident's family ((RP) via telephone conference) in attendance. Updates provided on the residents' medications.Resident is here for long-term care. (RP) presented concerns regarding resident's placement in the facility and resident safety. states that resident is not believed to be exit seeking and does not have a history of elopement. All concerns raised by the family were addressed by both the DON, SW, and administrator. (Resident #1 will currently remain in long term care outside of memory care per family request. (RP) states they are currently pleased with care at the facility.no change in code status. Resident #1's care plan did not address her behaviors of wandering, intellectual disability, or her most recent elopement incident on 01/05/2026. Record review of consolidated physician's orders, dated 11/11/2025 reflected the following: Senior Psychiatric Care and/or Senior Psychological Care evaluation for treatment. Residents are unable to understand their rights. Record review of Resident #1's dated 11/11/2025 completed by MDSC-W reflected in Section C: C0092. Primary DX of Dementia. Is there evidence that dementia is the primary diagnosis for this individual? No.C0100 Mental illness. Is there evidence or an indicator this is an individual that has a Mental Illness? Yes, C0200. Intellectual Disability.Is their evidence or an indicator this is an individual that has an Intellectual Disability? Yes.C0300. Developmental Disability Is their evidence or indicators that this is an individual that has a Developmental Disability (Related Condition) other than an Intellectual Disability? No. During an interview on 01/09/2026 at 3:30 PM with MDSC, she stated that care plan updates and changes were conducted by the MDS nurses. MDSC said the resident care plan will not reflect the current treatments and care needs if not updated with changes. During an interview on 01/09/2026 at 4:05 PM, the DON stated that it was her expectation for resident care plans to accurately reflect their individual care needs. DON said it was the MDSC along with nursing staff's responsibility to monitor and communicate resident changes to be updated in the care plan. The DON did not address risks to the residents when they were not updated to reflect recent incidents. During an interview on 01/13/2025 at 4:50 PM with a CI, a staff member that wishes to remain anonymous stated that residents' safety and care are paramount for accurate treatment. CI said that the CI stated that Resident #1 had not eloped from the facility. During an interview with the ADM on 11/23/2025 at 1:20 PM who stated it was her expectation that clinical staff follow the procedures for care plan monitoring under the supervision and guidance of the DON. During a second interview on 01/14/2026 6:22 PM with RP to clarify latest information added in the care conference notes on 01/09/2026 at 10:00 AM. Initially the RP did not recall the care plan conference. Then she reported that she received a call from the ADM and SW regarding Resident #1's care needs. The RP said the ADM assured her that Resident #1was being supervised by the staff and doing well in the general population. RP said she was told the staff will continue to monitor Resident #1. The RP said it was her understanding that the facility door alarms would sound off alerting staff that a resident was existing the building. RP said Resident #1 will wander off and should never have been allowed to go to her hospital appointment alone on 01/05/2026. The RP stated that the resident's previous placement was a locked memory unit, and the door alarms would sound, and this was not a wander-guard. The surveyor reviewed the previous interview stating that Resident #1 wore a wander guard at her previous placement. The RP stated that Resident #1 was not on a wander guard. Record review of the policy and procedure entitled Comprehensive Person-Centered Care Planning dated 3-2022; 12.2023 read in part .It is the policy of this facility that the interdisciplinary team (IDT) along with the resident, legal representative, and clinical staff develop a comprehensive person-centered care plan includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment . to provide effective and person-centered care that meet professional

Based on interview, record review, and observations, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 7 residents (Resident #1) reviewed for pain management. The facility failed to provide Resident #1, who was on hospice services for end-stage cancer to the breast, liver, bone, and bile ducts, with effective pain management from 12/26/25 through 01/04/26. The facility did not reevaluate, advocate, or provide the full amount of pain medication available as allowed by physician's orders for appropriate pain management. This failure resulted in Resident #1 exhibiting non-verbal signs of excruciating pain to include screaming during care, crying, thrashing/writing in bed, and moaning. An IJ was identified on 01/04/26. The IJ Template was provided to the facility on [DATE] at 5:15 PM. While the IJ was removed on 01/05/26, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of prolonged and unnecessary pain and suffering, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 01/04/26 reflected the resident was a [AGE] year-old female with diagnoses that included malignant neoplasm of central portion of right female breast (right breast cancer), malignant neoplasm of liver (cancer in the liver) and intrahepatic bile duct (cancer in the bile ducts inside the liver), malignant neoplasm of bone (cancer in the bone), unspecified pain, depression, and other chronic pain. Record review of Resident #1's Care Plan dated 01/04/26 reflected: Focus: Communication (Impaired): Resident has a communication problem related to Goal: Resident will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained. Interventions: Provide information to resident/family about community resources: (Associations for the blind) for further adaptive devices: (talking clocks and calendars, interpreter services). Record review of the facility's EHR further revealed that Resident #1 did not have a finished Baseline or Care Plan completed.Record review of Resident #1's Initial Pain assessment dated [DATE] reflected the resident had: .3b1. Breathing - independent of vocalization: 1) Occasional labored breathing. Short periods of hyperventilation. 3b2. Negative vocalization: Repeated troubled calling out. Loud moaning or groaning. Crying. 3b3. Facial expression: 2) Facial Grimacing. 3b4. Body language: 1) Tense. Distressed pacing. Fidgeting. 3b5. Consolability: 0) No need to console. Pain assessment further revealed a pain score of 6 with generalized body pain and resident's acceptable level of pain as 0. Record review of Resident #1's progress note on 12/26/25 at 7:03 PM reflected: Patient 48 Y/O female patient admitted from home for respite stay via stretcher by two transporters under the care of [Facility MD] with diagnosis of Malignant neoplasm of right breast. Head to toe assessment completed, patient confused and disoriented unable to answer any question but crying. Patient is restless and unable to control he body. Patient is already under [Hospice company] who came and admitted patient. [Facility MD] notified, and he said OKAY to continue with hospice orders. Record review of Resident #1's progress notes on 12/26/25 at 7:04 PM reflected the resident received a PRN dose of morphine sulfate oral solution (liquid morphine). At 7:28 PM, the follow-up pain scale was 4. Record review of Resident #1's physician's orders on 12/26/25 reflected the following: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate) *Controlled Drug* Give 0.25 ml by mouth every 2 hours as needed for SOB/PAIN. Record review of Resident #1's progress notes on 12/31/25 reflected that new orders were received from the hospice company and the morphine (narcotic pain medication) and lorazepam (anxiety medication) orders were updated to be given routinely. Record review of Resident #1's Physician's orders reflected the following: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML. Give 0.25 ml by mouth every 4 hours for pain every four hours.Record review of Resident #1's progress notes on 01/03/26 at 1:42 AM reflected the following: Hospice nurse at bedside to assess resident. Hospice nurse spoke with resident's [Friend] regarding resident's condition and POC. New hospice orders:1.DC routine morphine and Ativan.2.Start morphine 20mg/ml 0.25-1.0ml q 1 h PRN; anxiety/agitation. Record review of Resident #1's MAR reflected Resident #1 had no ordered breakthrough or long-acting pain medications. Record review of Resident #1's EHR reflected there were no pain assessments completed.Record review of Resident #1's progress notes revealed there was no documentation indicating the physician or hospice was notified when Resident #1 displayed signs of pain. Record review of Resident #1's Narcotic logs revealed she received the following morphine doses: 12/26/25: 0.25 ml at 7:28 PM 12/27/25: 0.25 ml at 10:00 AM, 0.25 ml at 1:00 PM, 0.25 ml at 5:00 PM, 0.25 ml at 9:30 PM12/28/25: 0.25 ml at 8:00 AM, 0.25 ml at 1:00 PM, 0.25 ml at 6:00 PM, 0.25 ml at 10:15 PM12/29/25: 0.25 ml at 4:00 AM, 0.25 at 12:00 PM, 0.25 ml at 8:38 PM12/30/25: 0.25 ml at 1:00 AM, 0.25 ml at 4:00 AM, 0.25 ml at 6:30 AM, 0.25 ml at 8:15 PM, 0.25 ml at 10:15 PM12/31/25: 0.25 ml at 12:00 AM, 0.25 ml at 4:00 AM, 0.25 ml at 6:00 AM, 0.25 ml at 9:00 AM, 0.25 ml at 4:00 PM, 0.25 ml at 6:00 PM, 0.25 ml at 8:00 PM01/01/26: 0.25 ml at 12:00 AM, 0.25 ml at 4:00 AM, 0.25 ml at 8:00 AM, 0.25 at 12:00 PM, 0.25 ml at 2:00 PM, 0.25 ml at 4:00 PM, 0.25 ml at 8:00 PM01/02/26: 0.25 ml at 12:00 AM, 0.25 ml at 4:00 AM, 0.25 ml at 6:00 AM, 0.25 ml at 12:00 PM, 0.25 ml at 4:00 PM, 0.25 ml at 11:55 PM 01/03/26: 0.25 ml at 8:00 AM, 0.25 ml at 10:05 AM, 0.25 ml at 1:00 PM, 0.25 ml at 5:00 PM, 0.25 ml at 11:00 PM01/04/26: 0.25 ml at 7:00 AM, 0.25 ml at 10:35 AM, 0.5 ml at 12:25 PMObservation on 01/04/26 at 9:30 AM reflected Resident #1 was lying in bed. Resident #1 was observed to be thrashing around the bed, crying and moaning. Resident #1 was clenching her teeth with facial grimacing noted. Resident #1 was not able to be consoled, respond to name, or answer any questions. Observation on 01/04/26 at 10:10 AM reflected Resident #1 was crying and writhing in bed. Resident #1 was not answering any questions. Interview and observation on 01/04/26 at 10:38 AM reflected LVN A standing in front of Resident #1's room. LVN A stated he was going to give her medication because she was crying. LVN A stated Resident #1 usually cried because she had breast cancer that had spread and was in pain. LVN A also stated that even after he gave Resident #1 the medication, she would still cry because it was not effective. LVN A stated the morphine was as needed every 1-2 hours. LVN A was observed repositioning Resident #1. Resident #1 noted to be writhing, crying, and moaning. Resident #1 had facial grimacing with a tense jaw. Symptoms were noted to worsen with movement. LVN A was observed giving Resident #1 0.25 mL of morphine. Interview on 01/04/26 at 11:34 AM with Resident #1's Hospice Nurse revealed she was familiar with Resident #1. The Hospice Nurse stated she had been caring for Resident #1 frequently and she had been in pain. The Hospice Nurse stated her morphine was started routine to help manage Resident #1's pain. However, the Hospice Nurse reported that Resident #1's Concerned Party was struggling with the death process and got upset with the facility medicating Resident #1. The Hospice Nurse stated that Resident #1 did not have a POA, but they had been trying to navigate respecting the Concerned Party's wishes and keeping Resident #1 comfortable. The Hospice Nurse stated the morphine order was changed to PRN to make the Friend less upset with facility staff. The Hospice Nurse stated that Resident #1 had been crying and moving around the bed since she arrived at the facility. Observation on 01/04/26 at 12:06 PM revealed Resident #1 resting. At 12:07 PM Resident #1 was back awake. Upon awaking, she was thrashing and writhing around the bed, while moaning and crying. Resident #1 appeared to be very tense and grimacing. Observation on 01/04/26 at 12:20 PM of incontinent care for Resident #1 with CNA B and CNA C. Resident #1 was crying, writhing around bed with facial grimacing prior to incontinent care. During the incontinent care, Resident #1 was screaming with any touch and when being wiped. Interview on 01/04/26 at 1:18 PM with LVN A revealed that non-verbal signs of pain were groaning, moving around a lot, and turning. LVN A stated Resident #1 had exhibited all those signs. LVN A stated Resident #1 was on hospice services and was unable to communicate. LVN A stated he read Resident #1's body language which revealed she was uncomfortable. He stated he was not present when the morphine order was changed, but he was aware it was routine and changed to PRN. LVN A stated the current morphine order was 0.25 - 1 mL every one-hour PRN. LVN A stated at one point he felt that 0.25 mL was effective which was why he gave that dose. He stated when he gave the 0.25 mL, she relaxed but it never lasted long. LVN A stated last week she would be screaming and crying, then sleep and then wake back up shortly after. LVN A was unable to specify the exact time. LVN A stated on 01/04/26, the 0.25 mL had not been working, so he stated he just gave a 0.5 mL dose, but it was still ineffective. LVN A stated he was charting the morphine in the narcotic book, not on the MAR. He stated he had spoken with his supervisor and contacted the hospice nurse and she was coming to visit. He stated he had not spoken to the MD because she was on hospice and they managed her orders. LVN A stated the CNAs were reporting to him that Resident #1 was in pain. He stated she did not receive any other pain medications; only the morphine. He stated he had been assessing Resident #1's pain every 30-60 minutes, but did not chart it. He stated that morning her pain level was 7. Interview on 01/04/26 at 1:35 PM with CNA B revealed it was her first day caring for Resident #1. CNA B stated it seemed like Resident #1 was in a lot of pain. She stated with incontinent care, Resident #1 was moving all over the bed and screaming. CNA B also stated that Resident #1 had been grimacing, restless, and crying. CNA B stated she was not sure where the pain was coming from because Resident #1 was unable to communicate. CNA B stated she did report to LVN A that Resident #1 was in pain. CNA B stated she was not sure what LVN A did, but he put something in Resident #1's mouth. CNA B stated even after the medication, Resident #1 was still moaning, and she was unable to tell if the medication was effective. CNA B revealed Resident #1 would only sleep for short periods, and then start moving around and moaning again. Interview on 01/04/26 at 1:48 PM with CNA C revealed she had been working with Resident #1 since she was admitted to the facility. CNA C stated Resident #1 was always crying. CNA C stated she asked a nurse yesterday why Resident #1 was crying because she would scream and cry every time she was changed. CNA C stated the nurse told her it was due to Resident #1's cancer. CNA C stated she was notifying the nurse when she saw Resident #1 cry. She stated the non-verbal signs of pain were crying, screaming, and moving around. CNA C stated the nurse gave her medications, but she still cried after receiving them. CNA C stated she was not sure if the medications were effective because she was unsure exactly when they were given. She stated Resident #1 just cried a lot. CNA C stated Resident #1 had been crying ever since arriving at the facility. CNA C stated she just assumed it was a mental issue that caused her to cry so much. Observation and interview on 01/04/26 at 2:15 PM revealed Resident #1 tossing and turning in bed. Resident #1 was also moaning and grimacing. Resident #1's Family member #3 was at her bedside. Family member #3 stated she had visited a few times since the resident came to the facility. Family member #3 stated she was in pain which was why Resident #1 was crying. She stated when Resident #1 was home, she only started to cry when the pain got worse. Family member #3 stated at that point, she was still alert and could tell you when she was in pain. Family member #3 stated she felt the facility was not managing her pain because Resident #1 had been like this every time she had visited. Family member #3 stated she would like the facility to care more so Resident #1 was not writhing and constantly in pain. She stated Resident #1 had stage 4 cancer and it was continuing to get worse. Family member #3 stated the facility staff were coming in to check on her, but they just glanced into the room and did not perform a full assessment. She stated she would like the staff to have had more compassion for Resident #1 because it was not her fault she had cancer. Family member #3 stated the Concerned Party had no POA and should not make any decisions. Family member #3 stated she heard the Concerned Party was telling staff to not give her medications. Family member #3 stated she would like Resident #1 to be pain free and comfortable. Observation and interview on 01/04/26 at 3:48 PM revealed Resident #1 moaning, groaning, crying, and had facial grimacing. Family Member #3 stated she was just given morphine, but it did not seem to be working. Family Member #4 stated Resident #1 had been crying every time he visited. Interview on 01/04/26 at 3:48 PM revealed LVN A gave Resident #1 0.5 mL of morphine around 3:25 PM. Interview on 01/04/26 at 4:21 PM with the DON revealed Resident #1 started at the facility for respite care, but then shortly switched to staying at the facility fulltime. The DON stated she did not have a POA, but Family Member #3 was working on that. The DON stated Resident #1 had metastatic breast cancer and currently had 2 cancer spots coming out of her skin. The DON stated Resident #1 had been in a lot of pain, so she had been in contact with hospice to change orders to make her more comfortable. The DON stated there had been a dynamic between her Concerned Party and Family Members regarding her care. The DON stated Family Member #3 wanted Resident #1 to be comfortable and she was the one who could make decisions. The DON stated the Concerned Party did not want her to be sleepy and was concerned with Resident #1 not eating. The DON stated there was a lot of anger between the Concerned Party and the staff. The DON stated everyone processed grief differently, and Resident #1 was transitioning and imminent (actively dying). The DON stated when she visited Resident #1, she had just received pain medications and was still crying out for more. The DON stated she contacted hospice, and they were coming out to assess and change orders. The DON stated Resident #1 no longer had mild pain due to the cancer being far along. The DON stated Resident #1's pain was always severe. The DON stated the morphine order was confusing with the range, and she had asked hospice to change it to just one order. The DON stated she expected her staff to call hospice to come in and evaluate the resident for further pain medications if they were ineffective. The DON also stated she expected her staff to advocate for all the residents. The DON stated Resident #1's pain was not controlled because hospice and her staff were listening to what the Concerned Party wanted. The DON stated the risk of not managing pain was the residents could pass uncomfortable and be in pain. Interview on 01/04/26 at 4:41 PM with the Administrator revealed when Resident #1 admitted , she was aware she had cancer. The Administrator stated she was not involved in any of the direct care, but did receive a voicemail about Resident #1 on 01/03/25. The Administrator stated the voicemail was confusing, but she notified the DON and set up a care plan meeting with hospice. The Administrator said they planned to call hospice on 01/05/26 to set up the meeting. The Administrator stated her expectation was that pain was addressed by either contacting hospice or the physician. The Administrator stated the risk of not managing residents' pain was a decreased quality of life. Interview and observation on 01/04/26 at 5:33 PM with LVN A revealed that he was administering morphine (0.5 mL) and lorazepam to Resident #1. Resident #1 was observed to be awake and restless. LVN A stated he tried to call hospice again to get an ETA, but could only got ahold of the main line, and left a message for the nurse. Interview on 01/04/26 at 5:19 PM with the Hospice MD revealed that his experience was through the hospice nurses. He stated Resident #1 was admitted to facility due to increased pain and agitation at home. The Hospice MD stated the morphine was originally scheduled PRN to figure out her symptoms and what was needed to control her pain. He stated Resident #1 had a decline and stopped eating and communicating shortly after arriving at the facility. He stated Resident #1 was crying, restless, and screaming out, so the medications were changed to routine. The Hospice MD stated as far as he was aware, the routine was maintaining her comfort. The Hospice MD stated Resident #1's Friend became concerned with her decline, and assumed it was due to the medication. The Hospice MD stated it was the natural death process, but the Concerned Party could not understand that. The Hospice MD stated the orders were changed to PRN to benefit the Concerned Party; not Resident #1. The Hospice MD stated the order was changed to PRN and the frequency was increased. He stated he wanted Resident #1 to continue receiving the medication, the staff were just to do an assessment prior to administration. The Hospice MD stated he expected Resident #1 to be comfortable and pain free. He stated she was transitioning and at the end of life. The Hospice MD stated he was not aware of any changes in Resident #1 since the medication order was changed on 01/03/26. Interview on 01/04/25 at 6:32 PM with the Hospice nurse at the facility, she stated hospice was starting the process for a Crisis Care nurse (provides immediate, intensive, short-term nursing care 24 hours/day) to come and be at Resident #1's bedside. She stated they were working on getting a nurse staffed. The Hospice Nurse stated she updated the morphine orders to one order instead of the range. Interview on 01/05/26 at 9:42 AM with Resident #1's Friend revealed he had been with Resident #1 since she was living at home. He stated the first day he saw her after she arrived at the facility, she was pulling her shirt off and moving around a lot. He stated she had been crying a lot because she had crusties in her eyes that took a while to clean out. Resident #1's Friend stated he wanted the staff to feed her more, but he felt they were only giving her morphine. He stated the staff did not seem to understand that she needed them to do everything for her. He stated that the morning of 01/03/25, the hospice nurse came and stayed with him until 3:00 AM. Resident #1's Friend stated he felt like she got too much morphine and that was why she was no longer with it. He stated that hospice changed the morphine order, so the facility staff had to assess Resident #1 first and not give it if she was sleeping. He stated Resident #1 was in pain because the facility staff did not even know what was wrong with her. Resident #1's Friend stated Resident #1 would be screaming in pain, and the door would be closed. He stated the morphine would make her sleep, but it never lasted long, and she would wake back up groaning and crying. He stated Resident #1 would cry a lot. He stated he wanted Resident #1 to be able to talk and say goodbyes to visitors, but she was either awake, moaning, and groaning, or sleeping. Resident #1's Friend stated one day he came to the facility, and Resident #1 was crying and it was heard all the way down the hall. He said she was screaming and crying in pain most of the time while she was at the facility.Record review of the facility's Pain Management policy, revised July 2015, reflected the following: Residents shall be assessed for factors that predispose to pain upon admission to the facility and subsequently thereafter according to the findings of the assessment. Residents shall receive treatment for pain relief as necessary and monitored for effectiveness. Fundamental Information Evaluate the resident for pain upon admission, during periodic scheduled assessments, and with change in condition or status (e.g., after a fall, with change in behavior or mental status). Identification and evaluation of a patient's response to the plan of care is necessary until it is determined that the patient's pain is resolved or meets the patient's goal for relief. Procedure Utilize the following process steps as a systematic approach for clinical pain management Evaluation: Initial screen (Nursing admission Evaluation), Pain Data Collection Tool, Minimum Data Set (MDS) Plan: Initial Plan of care, Establish pain management goals, Individualized patient interventions Implement: Patient and family education, Anticipated measuresMonitorPatient response to interventions: Pharmacologic, Adjuvant, Non-pharmacologic, Psychosocial Record review and revise Plan Treatment:A. Assessment and evaluation by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, etc.) may include a. Asking the patient to rate the intensity of his/her pain using a numerical scale or a verbal or visual descriptor that is appropriate and preferred by the resident. b. Record review of the resident's diagnoses or conditions and any additional factors that may be causing or contributing to pain. c. Identifying key characteristics of the pain d. The resident's goals for pain management and his/her satisfaction with the current level of pain control e. The effectiveness of specific pharmacological, non-pharmacological and treatments used in the past to treat pain. Approach to Pain Management: 1. Evaluate - identify, anticipate events or circumstances that will trigger or cause pain. 2. Treat by pre medicating the patient prior to the pain trigger or cause 3. Prevent - implement pharmacological and non-pharmacological interventions to avoid pain experiences 4. Monitor- patient's response to pharmacological and non-pharmacological measures. 5. Report - to physician patient response to interventions. 6. Management - the goal of the pain treatment plan is to improve the patient's quality of life and activity of daily living by managing pain around the clock with pharmacological and non-pharmacological interventions.Record review of the facility's Coordination of Hospice Services, dated 04/21/21, reflected: Policy: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff to promote the resident's highest practicable physical, mental, and psychosocial well-being.Policy Explanation and Compliance Guidelines: .2. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible.4. The facility will monitor and evaluate the resident's response to the hospice care plans.5. The hospice will maintain communication with the facility as it related to the resident's plan of care and services to ensure each entity is aware of their responsibilities.6. The plan of care will include directives for managing pain and other uncomfortable symptoms and will be revised and updated as necessary.7. The facility will monitor for medications and medical supplies to ensure they are provided by hospice as indicated in the plan of care for palliation and management of the terminal illness.9. The facility will immediately contact and communicate with the hospice staff, attending physician/practitioner and the family resident representative regarding any significant changes in the resident's status, clinical complications or emergent situations. The Administrator and DON were notified on 01/04/26 at 5:15 PM that an IJ had been identified and an IJ template was provided. The Administrator and DON were asked to provide a Plan of Removal.The following Plan of Removal was accepted on 01/05/26 at 10:05 AM: Plan of Removal - F697 - Pain Management1. Immediate actions (initiate 01/04/26): Charge Nurse/DON/designee immediately assessed pain using appropriate tool (0-10 scale if able; PAINAD/non-verbal tool if unable) and documented signs/symptoms and current comfort level. Facility immediately contacted hospice nurse and attending/medical provider to report uncontrolled pain episodes and frequency of distress behaviors documented on 01/04/26. Facility obtained clarified, complete medication orders from prescriber/hospice that include clear administration parameters (e.g., which dose to give under which conditions) and documented these orders per policy. Facility updated the care plan to reflect end-of-life comfort needs, pain assessment frequency, medication administration/reassessment expectations, and hospice coordination. Facility implemented enhanced monitoring until pain controlled: pain checks and comfort rounds at least hourly, with reassessment after each intervention and documentation of effectiveness. Completion date: 01/04/26-01/05/26 (same day/within 24 hours)2. How the facility will identify other residents having the potential to be affected and take corrective actionFacility-wide review (initiate 01/04/26; complete 01/05/26): DON/Designee will run a list of:o All residents on hospice, [NAME] All residents with active opioid PRN range orders and/or recent pain complaints. For each identified resident, licensed nurse/designee will audit for:o Presence of complete parameters on PRN/range orders (no range without direction),o Pain assessment and reassessment documentation after PRN administration,o Evidence of provider/hospice notification for uncontrolled pain,o Care plan alignment with pain management needs. Any orders lacking parameters will be held for clarification (facility will contact provider/hospice promptly) and residents will be assessed and managed per hospice/provider direction.3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recurA. Process Changes (effective 01/05/26)1. PRN Range/Opioid Order Parameter Requiremento Facility will not accept or implement range/variable dose orders (e.g., 0.25/0.5/0.75/1.0 ml) without written parameters from prescriber/hospice (how to choose dose, frequency limits, reassessment expectations, and any hold criteria).o Orders missing parameters trigger an automatic provider/hospice clarification call and documented follow-up.2. Uncontrolled Pain Escalation Pathwayo If pain is not relieved after interventions or distress behaviors persist, staff must notify hospice/provider according to defined escalation triggers (facility-defined triggers included in policy such as repeated PRN use, persistent severe pain behaviors, or frequent crying/screaming).o Hospice residents: facility will use a Hospice Symptom Escalation Call Log to document time of call, who was contacted, response received, and new orders.B. Documentation Standards (effective 01/05/26) Pain must be documented:o Every shift and with any complaint/behavior suggestive of pain,o Before PRN administration (baseline),o Reassessed after medication/intervention within facility policy timeframe,o Effectiveness documented and, if ineffective, escalation documented.Completion date for systemic rollout: 01/05/263. Staff Education / Competency Training topics (complete by 01/5/26): Pain assessment (including non-verbal pain tools) End-of-life comfort care expectations in SNF + hospice coordination PRN opioid documentation and reassessment standards Clarifying incomplete orders / range dose parametersWho: All licensed nurses before shift via quick in-service, Staff unavailable to attend in service on 1/5/26 will receive personalized education and posttest prior to assuming their duties. Verification: Sign-in sheet + 5-question post-test 4. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recurAudits/MonitoringAudit Tool: Pain Management & Hospice Coordination Audit (licensed nurse audit)What will be monitored: PRN opioid/range orders include parameters Pain assessment completed and documented Reassessment documented after each PRN Evidence of hospice/provider notification when pain uncontrolled Care plan reflects pain needs and hospice involvementFrequency: Weekly x 4 weeks, then Monthly x 2 months, then Quarterly Responsible party: DON/ADON/Designee; unit managers for follow-upReporting: Results reviewed in QAPI and trends/actions documented.5. What QA (Quality Assurance) committee will do to oversee compliance QAPI will review audit results, identify patterns (e.g., missing parameters, missed reassessments, delays calling hospice/provider), and implement additional actions (targeted re-education, disciplinary action if warranted, EMR prompts, staffing workflow changes). The surveyor monitored the facility's implementation of the accepted Plan of Removal on 01/05/26, which revealed the following: During interviews on 01/05/26 from 11:26 AM-3:58 PM, CNA D, CNA E, CNA F, MA I, CNA G, CNA H, MA J, from different shifts, stated they were all in-serviced on pain management before working their shifts. The CNAs verbalized the signs and symptoms of non-verbal pain and their plan of action if any residents notified them or appeared in any pain. Their plan of action included notifying the nurse immediately and ensuring the residents were treated for pain prior to any care. During interviews on 01/05/26 from 11:03 AM-4:04 PM, LVN K, LVN L, LVN U, RN O, RN P, RN Q, LVN R, RN S, from different shifts stated they had been in-serviced on pain management and hospice care prior to their shifts. These LVNs and RNs verbalized how to assess pain in residents, which included non-verbal pain indicators. All verbalized what to do if a resident had pain, how to assess, medicate, reassess, and notify hospice/physician if medications were ineffective. Nurses also verbalized appropriate medication orders, clarifying with the physician as needed, and ensuring the baseline/care plans were updated and corrected as needed. Record review of facility's in-service records , dated 01/04/26 and 01/05/26, and titled Pain Management And Baseline Care Plan reflected the DON provided an in-service training on the following topics: PRN medications given appropriately with clear parameters, effectiveness reassessed and documented, hospice/provider notified when uncontrolled, new orders implemented properly, baseline care plans included pain management instructions, and communication documented (resident/RP/family/hospice) The in-service included a post-test to demonstrate understanding of topics and 19 nurses were present during the in-service and passed the post test before their shift was worked.Record reviews and observations of 7 residents , Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8 who received pain medications, revealed no signs or complaints of pain. The EHR revealed pain assessments and care plans were completed, and orders updated accordingly. Record review further revealed morphine orders were updated to ensure no medication ranges without parameters. Record review of the facility's audit tool on pain management and hospice coordination revealed the audit was completed on 12 residents to ensure a pain assessment was completed/identified, medication and parameters were updated, medications administration and reassessment, hospice provider coordination/escalation, decision-maker verifi[

Based on observation, interview, and record review, 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 meets professional standards of quality care for 1 of 10 residents (Resident #1) reviewed for baseline care plans. The facility failed to develop a baseline care plan within 48 hours of Resident #1's admission to the facility on [DATE] that addressed the resident's pain management needs while on hospice services for an end-stage diagnoses of malignant cancer of the breast, liver, bone, and bile ducts. As a result, she experienced on-going, excruciating pain from 12/26/25-01/04/26. This failure could place residents at risk of not having their individual care needs met in a timely manner, diminished quality of life, and unnecessary pain and suffering.Findings included: Record review of Resident #1's face sheet dated 01/04/26 reflected a [AGE] year-old female with diagnoses that included Malignant Neoplasm of Central Portion of Right Female Breast (Right Breast Cancer), Malignant Neoplasm of Liver (Cancer in the liver) and Intrahepatic Bile Duct (Cancer in the bile ducts inside the liver), Malignant Neoplasm of Bone (Cancer in the bone), Unspecified Pain, Depression, and Other Chronic Pain. Record review of Resident #1's Entry MDS dated [DATE], indicated she admitted to the facility on [DATE]. Record review of the MDS indicated the BIMS was not completed. Record review of Resident #1's Comprehensive Care Plan dated 01/04/26 reflected, Focus: Communication (Impaired): Resident has a communication problem related to Goal: Resident will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained. Interventions: Provide information to resident/family about community resources: (Associations for the blind) for further adaptive devices: (talking clocks and calendars, interpreter services). Record review of the facility's EHR further revealed that Resident #1 did not have a finished Baseline or Care Plan completed. The baseline care plan had been started but contained no information about Resident #1's pain or receiving hospice services. Record review of Resident #1's Initial Pain assessment dated [DATE] reflected the resident had, .3b1. Breathing - independent of vocalization: 1) Occasional labored breathing. Short periods of hyperventilation. 3b2. Negative vocalization: Repeated troubled calling out. Loud moaning or groaning. Crying. 3b3. Facial expression: 2) Facial Grimacing. 3b4. Body language: 1) Tense. Distressed pacing. Fidgeting. 3b5. Consolability: 0) No need to console. Pain assessment further revealed a pain score of 6 with generalized body pain and resident's acceptable level of pain as 0. Record review of Resident #1's progress note on 12/26/25 at 7:03 PM: Patient 48 Y/O female patient admitted from home for respite stay via stretcher by two transporters under the care of [Facility MD] with diagnosis of Malignant neoplasm of right breast. Head to toe assessment completed, patient confused and disoriented unable to answer any question but crying. Patient is restless and unable to control he body. Patient is already under [Hospice company] who came and admitted patient. [Facility MD] notified, and he said OKAY to continue with hospice orders. Observation on 01/04/26 at 9:30 AM reflected Resident #1 was lying in bed. Resident #1 was observed to be thrashing around the bed, crying and moaning. Resident #1 was clenching teeth with facial grimacing noted. Resident #1 did not console, respond to name or answer any questions. Interview and observation on 01/04/26 at 10:38 AM reflected LVN A standing in front of Resident #1's room. LVN A stated he was going to give her medication because she was crying. LVN A stated she usually cries because she had breast cancer that had spread and was in pain, but even after he gives Resident #1 the medications, she would still cry because it was not effective. LVN A stated the morphine was as needed every 1-2 hours. Observation revealed LVN A repositioning Resident #1. Resident #1 noted to be writhing, crying, and moaning. Resident #1 had facial grimacing and tense jaw. Symptoms were noted to worsen with movement. Observation revealed LVN A giving Resident #1 0.25 mL of morphine. Observation on 01/04/26 at 12:06 PM revealed Resident #1 resting. At 12:07 PM Resident #1 was back awake. Upon awaking, she was thrashing and writhing around the bed, while moaning and crying. Resident #1 was very tense and grimacing. Observation on 01/04/26 at 12:20 PM of incontinent care for Resident #1 with CNA B and CNA C. Resident #1 was crying, writhing around bed with facial grimacing prior to incontinent care. During the incontinent care, Resident #1 was screaming with any touch and when being wiped. Interview on 01/04/26 at 1:35 PM with CNA B revealed it was her first day caring for Resident #1. CNA B stated it seemed like Resident #1 was in a lot of pain. She stated with incontinent care, she was moving all over the bed and screaming. CNA B also stated that Resident #1 had been grimacing, restless and crying. CNA B stated she was not sure where the pain was coming from because Resident #1 was unable to communicate. CNA B stated she did report to LVN A earlier that Resident #1 was in pain. CNA B stated she was not sure what LVN A did, but he did put something in Resident #1's mouth. CNA B stated even after the medication, Resident #1 was still moaning, and she was unable to tell if the medication was effective. CNA B revealed Resident #1 would only sleep for short periods and then start moving around and moaning again. Interview on 01/04/26 at 1:48 PM with CNA C revealed she had been working with Resident #1 since she was admitted to the facility. CNA C stated Resident #1 was always crying. CNA C stated she asked a nurse yesterday why Resident #1 was crying because she would scream and cry every time she was changed. CNA C stated the nurse told her it was due to Resident #1's cancer. CNA C stated she was notifying the nurse when she saw Resident #1 cry. She stated the non-verbal signs of pain were crying, screaming, and moving around. CNA C stated the nurse gave her medications, but she still cried after receiving them. CNA C stated she was not sure if the medications were effective because she was unsure exactly when they were given. She stated Resident #1 just cried a lot. CNA C stated Resident #1 had been crying ever since arriving at the facility. CNA C stated she just assumed it was a mental issue that caused her to cry so much. Observation and interview on 01/04/26 at 2:15 PM revealed Resident #1 tossing and turning in bed. Resident #1 was also moaning and grimacing. Resident #1's Family member #3 noted to be at bedside. Family member #3 stated she had visited a few times since the resident came to the facility. Family member #3 stated she was in pain which was why Resident #1 was crying. She stated when Resident #1 was home, she only started to cry when the pain got worse. Family member #3 stated at that point she was still alert and could tell you when she was in pain. Family member #3 stated she feels the facility was not managing her pain because Resident #1 had been like this every time she had visited. Family member #3 stated she would like the facility to care more so Resident #1 was not writhing and constantly in pain. She stated Resident #1 had stage 4 cancer and it was continuing to get worse. Family member #3 stated facility staff were coming in to check on her, but they just glanced into the room and did not perform a full assessment. She stated she would like the staff to have had more compassion for Resident #1 because it was not her fault she had cancer. Family member #3 stated the Friend had no POA and should not make any decisions. Family member #3 stated she heard the Friend was telling staff to not give medications. Family member #3 stated she would like Resident #1 to be pain free and comfortable. Observation and interview on 01/04/26 at 3:48 PM revealed Resident #1 moaning, groaning, crying, and had facial grimacing. Family Member #3 stated she was just given morphine, but it did not seem to be working. Family Member #4 stated Resident #1 had been crying every time he visited. Interview on 01/04/26 3:48 PM revealed LVN A gave Resident #1 0.5 mL of morphine around 3:25 PM. Interview on 01/04/26 at 4:21 PM with the DON revealed Resident #1 started at the facility for respite care, but then shortly switched to staying at the facility full-time. The DON stated Resident #1 had metastatic breast cancer and currently had 2 cancer spots coming out of her skin. The DON stated Resident #1 had been in a lot of pain, so she had been in contact with hospice to change orders to make her more comfortable. The DON stated Resident #1 was transitioning and imminent. The DON stated when she visited Resident #1 she had just received pain medications and was still crying out for more. The DON stated she contacted hospice, and they were coming out to assess and change orders. The DON stated Resident #1 no longer had mild pain due to the cancer being far along. The DON stated Resident #1's pain was always severe. The DON stated there was no pain management in the baseline care plan for Resident #1. She stated it was all nurses' responsibility to ensure the baseline care plan completed. She stated her expectation was that residents received a thorough assessment on admission which would include pain and hospice services included on the baseline care plan. Interview o n 01/04/26 at 4:41 PM with The Administrator revealed when Resident #1 admitted , she was aware she had cancer. The Administrator stated she would expect pain to be on Resident #1's baseline care plan and she did not see it care planned. The Administrator stated the risk of not managing residents' pain was a decreased quality of life. Observation on 01/04/26 at 5:33 PM with LVN A revealed that he was administering morphine (0.5 mL) and lorazepam to Resident #1. Resident #1 observed to be awake and restless. Interview on 01/04/25 at 6:32 PM with the Hospice nurse at the facility, she stated hospice was notified and starting the process for a Crisis Care nurse (provides immediate, intensive, short-term nursing care 24 hours/day) to come and be at Resident #1's bedside. She stated they were working on getting a nurse staffed. The Hospice Nurse stated she updated the morphine orders to one order instead of the range. Interview on 01/05/26 at 9:42 AM with The Friend revealed he had been with Resident #1 since she was living at home. He stated the first day he saw her after she arrived at the facility, she was pulling her shirt off and moving around a lot. He stated she had been crying a lot because she had crusties in her eyes that took a while to clean out. The Friend stated he wanted the staff to feed her more, but he felt they were only giving her morphine. He stated the staff did not seem to understand that she needed them to do everything for her. He stated that the morning of 01/03/25, the hospice nurse came and stayed with him until 3 am. The Friend stated she would be screaming in pain, and the door would just be shut. He stated the morphine would make her sleep, but it never lasted long, and she would wake back up groaning and crying. He stated Resident #1 would cry frequently. The Friend stated one day he came to the facility and Resident #1 was crying and it was heard all the way down the hall. He said she was screaming and crying in pain most of the time while she was at the facility. The Friend stated the facility called him on 01/04/26 and he received an update from the Administrator, but he was unable to come to the facility until 01/05/26. Interview on 01/05/26 at 11:03 AM with LVN K revealed all new admissions to the facility received an initial assessment and that determined if the resident had any pain. He stated if they did not show signs, staff must assess the residents for any non-verbal signs. LVN K stated he would review the baseline care plan if he did not do the initial assessment on a new resident. He stated the baseline care plan was where they got the orders from, so it was especially important that if a resident had pain that it was put on the baseline care plan because it gives staff a regimen to follow. He stated it was especially important for hospice residents to coordinate care. LVN K stated the risk of not having pain included on the baseline care plan was not effectively managing a resident's pain. Interview on 01/05/26 at 11:26 AM with CNA D revealed she reviewed care plans on every new resident with the nurse. She stated she would expect pain to be on the care plan because it was how she was notified if a resident required pain medications prior to care. Interview on 01/05/26 at 11:30 AM with ADON M revealed that she expected baseline care plans to be completed on all residents . ADON M stated that pain would absolutely need to be included in the baseline care plan. ADON M stated it is all nurses' responsibility to ensure the baseline care plan is completed. She stated it was important to have pain included so that all staff knew how to care for the residents and what interventions to complete. ADON M stated if pain were not included, it could result in the residents' pain not being managed. Interview on 01/05/26 at 11:45 AM with LVN L revealed that pain should be in the baseline care plans. LVN L stated it was important to include pain because that was how he knew to control the pain. LVN L stated that without pain care planned, the residents could have uncontrolled pain. Interview on 01/05/26 at 12:13 PM with LVN U revealed that baseline care plans were completed by the nurse on admission . LVN U stated she expected pain in the care plan if it was an issue for the residents. She stated it was important so staff could control the residents' pain. LVN U stated the baseline care plan provided levels and interventions to complete to ensure the pain was being managed. LVN U stated that without pain being on the baseline care plan, it put the resident at risk for unmanaged pain. She stated the pain could also affect the aides and their ADL care. LVN U stated Resident #1 should have had pain included on the baseline care plan. Interview on 01/05/26 at 12:38 PM with ADON N revealed that pain should be included in the baseline care plan if it was an issue. ADON N stated it was important for it to be included so the staff know how to care for the residents and be aware of the residents' baseline. ADON N stated the nurse who admitted the resident and performed the initial assessment, typically completed the baseline care plan. He stated if pain was not on the care plan, it was hard for the nurses to know exactly what was going on with the resident and how to help. ADON N stated the pain could not be managed as well. ADON N stated he was not sure why Resident #1 did not have a baseline care plan. He stated it was missing when she admitted . Interview on 01/05/26 at 12:50 PM with the DON revealed Resident #1's baseline care plan was not triggered when she started at the facility for respite care. The DON stated staff started one, but it was never completed. She stated the baseline care plans gave the plan of care and what to do if there was pain. The DON stated it gave interventions to start with and help manage the symptoms. She stated that the care plan should be updated with changes. The DON stated the baseline care plans helped ensure that symptoms were more managed, and guided the staff. The DON stated the risk of not including pain on the baseline care plan was unmanaged pain and symptoms. Interview on 01/05/26 at 2:07 PM with RN O revealed she had completed baseline care plans. She stated if the resident had any pain, it should be included in the baseline care plan. RN O stated including pain ensured the resident received interventions and the whole staff was aware of the resident's situation. RN O stated if it were not on the care plan, it could affect the plan of care, and directly affect the residents and family. She stated it put the residents at risk of not receiving proper or adequate care. Interview on 01/05/26 at 3:47 PM with The Administrator revealed Resident #1's baseline care plan was not completed. The Administrator stated the baseline care plan should be completed on all admissions by the nurse. She stated the baseline care plan was important because it gave staff an idea of how to care for the residents. The Administrator stated not having pain on the baseline care plan put the residents at risk of not receiving effective interventions. Record review of the facility's Baseline Care Plans, revised 04/02/25 reflected: Policy: Resident person-centered baseline care plans are developed and implemented for new admission residents. Fundamental Information: Resident person-centered baseline care plans communicate fundamental care approaches and goals for resident related clinical diagnosis, identified concerns and as a result of the admission evaluation/assessment of each healthcare discipline. The baseline care plans are inclusive to support effective individualized resident care that meet professional standards of quality care and services Baseline care plans are developed and implemented within 48 hours of a resident new admission. The baseline care plans include measurable objectives to address the resident's immediate medical, clinical, functional, mental, and psychosocial person-centered needs. Baseline care plans are developed by Registered Nurses and other healthcare team members. The LVNs and other healthcare team members execute baseline care plans. Overall care coordination of the resident is evaluated by the DON/designee. Process: 1. The baseline care plans will be developed and implemented from minimum healthcare information necessary to properly care for a resident including but not limited to initial goals based on admission orders, admission evaluation/assessments, physician orders, dietary orders, therapy services, social services, and resident choices. 2. Obtain information and input from the resident, resident's family, surrogate or representative, to develop baseline care plans that includes measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs .5. Baseline care plans may be implemented as an Acute Care Plan.

Based on interview and record review, the facility failed to ensure when there is a transfer or discharge of resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge appropriate information is communicated to the receiving health care institution; and the facility failed to provide and document sufficient preparation and orientation in a form and manner the resident could understand for one (Resident #1) of five residents reviewed for hospital transfers. 1. The facility sent Resident #1, who they indicated was having a behavioral emergency (pulling on his g-tube, ostomy and catheter) and was in danger of dislodging them, in a private non-medical transport vehicle and left him without facility staff or a family member to supervise him while in the ER waiting area.2. The facility failed to notify and coordinate with Resident #1's RP prior to sending him out to the ER, which did not allow the RP to select the preferred hospital of her choice or be there in time to supervise him and interpret for hospital staff. 3. The facility failed to provide the hospital ER with any clinical information prior to Resident #1's arrival on [DATE], including what his medical emergency was. 4. The facility did not notify and update the MD/NP that EMS refused to transport Resident #1 to the ER because they felt he was not having a medical emergency after the NP gave a verbal order to send him out. 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 no actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included:Record review of Resident #1's face sheet, dated [DATE], reflected he was a 71 year old male admitted on [DATE]. Active diagnoses included nontraumatic intracerebral hemorrhage (bleeding within the brainstem), anxiety disorder (mental health condition causing agitation), colostomy status (surgical opening in the colon for stool elimination), urinary retention with catheter use (inability to empty bladder requiring a tube), and gastrostomy status (feeding tube placed into the stomach). Resident #1 had a family member [RP] listed as his representative.Record review of Resident #1's admission care plan, dated [DATE], reflected focus areas included risk for line dislodgement, infection, aspiration, weight loss, and dehydration. The care plan did not address any behavioral concerns. Record review of Resident #1's facility admission orders reflected he was not discharged from the hospital with any routine or PRN psychotropic medications, including anxiety medication. Additionally there were no transfer orders to send Resident #1 to the ER on [DATE]. Record review of Resident #1's admission nursing note written by RN F on [DATE] at 11:11PM reflected the resident was confused and anxious, attempted to pull at his tubes, and required one to one supervision to prevent device removal.Record review of a follow up skilled nursing note on [DATE] at 3:57 AM reflected Resident #1's vitals were all within normal limits and he was in no pain. The skilled nursing note stated, .The resident is disoriented.The resident is unable to speak.Other Observations: Resident new admit day 1/3 alert and confused very agitated, anxious pulling tubes abdominal binder in place to secure g-tube, foley and colostomy. Awake all night resident on one and one. Total care with adl.Record review of Resident #1's nursing progress note, dated [DATE] at 12:31 PM by the DON, reflected, This writer received call from primary nurse that resident was attempting to remove urinary catheter peg tube and ostomy device. We were unable to successfully redirect the resident and he required ongoing higher-level care. Primary nurse was instructed by MD to send resident to ER for evaluation due to unable to keep resident safe in current building due to pulling lines and aggressive behavior. The DON further wrote, Action: 911 was called by primary nurse, upon their arrival this writer spoke with [name redacted] from [Fire Station] who advised this writer that paramedics would not be taking this resident to the hospital as per them he appeared to be medically stable and that the safety aspect of his care would need to be addressed with the [city Police Department or private transportation. This writer then requested nursing staff to arrange private transport via [private transport company] car. Related to RP notification, the DON wrote, Response: [RP] was notified of transfer and requested that resident be sent 'anywhere but [previous hospital]' Resident was transported via [private transport company] to [different nearby hospital]. Information was relayed by this nurse to triage nurse at [nearby hospital], as well as to [ER MD] for continuity of care.An interview with Resident #1's RP on [DATE] at 11:45 AM revealed the entire discharge from the hospital, admission to the facility and discharge the next morning to the ER was a really bad experience. She stated Resident #1 was transferred to the ER without clinical documentation and without a staff escort. The RP reported that upon arrival, the resident's ostomy was leaking and he was agitated. The RP further stated the ER staff were upset because the resident was by himself, the ER did not receive information about the resident's diagnoses or reason for transfer and were unable to communicate with the resident who did not speak English. The ER staff asked the RP who transported Resident #1 to the ER and the RP assumed he was sent out 911. The ER nurses indicated to the RP that Resident #1 appeared to be brought in a wheelchair in a normal vehicle, no paperwork, no reports, no nothing. They told her Resident #1 was then transferred to a hospital wheelchair by the person who drove him there, taken to the front desk, and told the resident was there. The RP stated she found out Resident #1 was transported through a private company which was upsetting to her. The RP stated, They know this is not right, what they did with [Resident #1]! What if they had taken him and put him in the street? Who was this person transporting him? A medical person? No one stayed with [Resident #1] when they took him to the ER! The ER nurses told the RP that he was brought in through what looked like a ride share company. The RP stated, That is not a proper way to bring someone.I was like who are these people? They just dumped him? How would we know where he was? The facility was not responding, the (ER) staff heard me trying to talk to the facility about sending any reports. An interview with the DON on [DATE] at 10:45 AM revealed the facility initially attempted to send Resident #1 via EMS, but EMS declined transport, determining the situation was not a medical emergency. The DON stated staff then arranged private non medical transport. The DON confirmed only a medication list was sent with Resident #1 and verbal report was given to a different hospital prior to rerouting the transport. The DON acknowledged that no staff accompanied the resident and that the ER nurse contacted her and was upset and expressed concern that Resident #1 arrived unsupervised, non English speaking, and without medical documentation. The DON stated she also spoke with the ER physician who was also asking questions about why the resident was sent to the ER and why there was no information on him. The DON stated that when Resident #1 was brought into the ER, he was left in the ER by med transport as that is protocol. The DON stated that if Resident #1 had been brought in via 911, then he would have been taken back immediately to an ER bed and evaluated.An interview with LVN A on [DATE] at 1:04 PM revealed she was the 6a-2p nurse and arrived to work the morning of [DATE] around 5:45 AM and was told by the overnight nurse during report the staff was having problems with Resident #1, he did not sleep at all and was pulling at everything coming out of him, his foley, colostomy and g-tube. LVN A stated the overnight nurse was not the normal nurse who worked, it was a PRN nurse. When LVN A went to see Resident #1 during her first rounds, he had disconnected his g-tube tubing. LVN A stated Resident #1 did not speak English and the facility did not have a interpreting services. LVN A stated and he was not letting her reconnect his g-tube and he did not know what was going on cognitively. LVN A stated the facility did have a supply of abdominal binders available to use for residents in that situation and she could have placed one on him quickly to prevent him from accessing the gtube but did not. LVN A also stated Resident #1 had no routine or PRN meds to administer to help him relax. LVN A stated the facility did have PRN anxiety medications available for behavioral emergencies in an e-Kit [facility's emergency medication supply], but she did not contact the MD or NP to ask about those as a possible intervention. LVN A stated, I called the staffing person and said there was someone watching him over night but I can't stay with him, I didn't know he was an issue til I got here, so DON called me and said he was danger to himself, so send him out.and to send him back where he came from. LVN A stated when the EMTs arrived, they took Resident #1's vitals and even though he was still pulling at everything, they said it was not a medical emergency and would not take him. When LVN A spoke with the DON again, she told LVN A to have their transport services take Resident #1 back to the hospital. LVN A stated there was a driver the facility used who did medical appointments and hospital transfers, but she was out in the field busy, so non-medical transport was set up instead. LVN A stated she did notify Resident #1's RP after he was picked up by the private transport company of his transfer to the ER. She said the RP told her Resident #1 could not go back to the hospital he had just come from the day before, But he was already in route. LVN A then contacted the DON who called the private transport person enroute to tell him to take the resident to the closer ER by the facility. LVN A stated she contacted the RP back to let them know, but the RP was not happy with the local ER because it was too far for her to get too. LVN A stated, [The RP] never told me where [they] wanted him to go. I was already frustrated and two hours behind schedule and called [the RP] twice and then I sent [the RP] to the DON and I don't know anything after that. LVN A stated that the facility could send residents anywhere the family wanted and did respect family requests. LVN A stated she did not call the facility's MD or NP G but did let NP G know after the transfer to the ER was done. She said NP G was housed onsite at the facility every weekday but was not at the facility when the decision was made to send Resident #1 to the ER. Regarding clinicals and transfer documentation, LVN A stated Resident #1 did not have anything to send and only sent his face sheet and list of medications. LVN A stated, I was going to send the whole packet from the hospital but I thought no, we may need it when he comes back. It would not have helped the receiving hospital. It was just a list of meds and stuff. LVN A stated she called and gave report to the previous hospital Resident #1 was originally going to be taken back to, before it was changed to the local ER. LVN A stated, And then I don't know what happened after that because I passed it to the DON. LVN A stated the importance of giving the receiving hospital ER a report was to let them know why the resident was being sent out, his diagnoses, what was going on with him at the moment. LVN A stated she never followed up and contacted the local ER to give them a report on why he was sent there because she thought the DON did. LVN A stated she did not think anyone stayed with Resident #1 once he arrived at the ER. She said with non-medical transport, the driver would usually drop the resident off at the ER and let them the ER front desk know the resident was there. LVN A said she did not think Resident #1 was safe to be at the ER by himself because she thought him pulling at his three lines would still be an issue. She said normally for a resident that was not alert and oriented, the resident would have family go with them to the ER or a staff would be with the resident until family could meet them there. LVN A said the risk of Resident #1 being alone in the ER waiting room area was that he could have pulled one of his lines out and caused damage.An interview with Staff C on [DATE] at 1:47 PM revealed she was a CNA and the facility van driver and was working the day Resident #1 was sent out to the ER. She said the resident was trying to pull out his gtube and she was trying to stop him and when the paramedics came in, he calmed down. They took his vitals and said it was a non-emergency unless he pulled out his g-tube, then they could take him. Staff C stated LVN A asked for her to help with transportation, so Staff C contacted the non-emergency private transport company. She stated the typical medical transport company was too busy that day to transport Resident #1 to the ER. Staff C stated, I needed someone and he needed to go to the hospital, he was irritable, trying to pull the g-tube and he was going back to the hospital he came from. Staff C stated she and LVN A let the DON know transport was secured, got Resident #1's face sheet, got him dressed, caressed his arm and told him no one was going to harm him and she was there to assist while using her phone translator to translate into his native language, and he told her thank you back in his language. She stated she got a sheet and tucked it around his torso and he seemed to relax. Staff C stated, They saw him being fidgety but it was not an emergency for him. She stated for non-emergency transportation to the ER, a family member had to be present if the resident had a cognitive impairment and for skilled residents, the family would meet the staff at the hospital. Staff C stated with someone like Resident #1, with him being feisty, a family member would need to be present for him because of the translation barrier. She said if she took a resident to the hospital and it was a resident she knew could not be left alone and family was not present, by all means, I stay at the appointment. Staff C stated because Resident #1 did not speak English, was pulling at his g-tube and agitated, he would need someone to be with him for supervision. Staff C stated normally the charge nurse of the resident would let her know if she needed to stay with a resident at the hospital or not, but with Resident #1, she was not the driver that day, she only assisted with finding transportation. An interview with CNA D on [DATE] at 2:09 PM revealed she was present when Resident #1 was sent to the ER. She stated he was restless, fighting to push his pants off, and trying to pull out his g-tube, . She said he was saying something in another language she could not understand. She said she did incontinent care and placed a brief on him. CNA D stated there were other residents in the facility that sometimes pulled at their tubes and when they did, there was a rubber belt the facility had that could be fixed on the resident and zipped to hold the tubing in place covered and it was very hard to get into and pull off. She stated Resident #1 did not have an abdominal binder on when she saw him on [DATE]. An interview with Receptionist E on [DATE] at 3:01 PM revealed sometime during the early morning of [DATE], an unidentified nurse , told her they were sending out Resident #1. She did not ask any questions but was there to tell the EMT where to go. She said he ended up not going out 911 and did not know why, but she saw him taken out by a non-medical transport. Receptionist E stated once Resident #1 left the facility, his RP called asking why the RP was not notified or why the hospital had not contacted her yet. Receptionist E stated the RP was mad and called back again right before the shift was over saying she needed someone from higher up at the facility to email her the resident's clinicals for the ER to have for review. Receptionist E stated the RP told her the facility was going to be reported to State by the RP as well as the hospital who was filing a complaint against the facility. An interview with RN F on [DATE] at 3:27 PM reflected she was the admitting nurse at the facility on [DATE] and was told Resident #1 was admitting on her shift. He arrived on a stretcher with his RP present. RN F stated she did her nursing assessment and remembered Resident #1 was trying to pull at his tubes and not being still. She asked his RP to stay at the facility because she felt the resident needed to be watched. RN F stated the facility did not know Resident #1 had that behavior as it was not in the report from the discharging hospital. She said she knew Resident #1 was coming with an open surgical incision with a g-tube and catheter. RN F stated Resident #1 had an ace wrap on his abdomen from the hospital, not an abdominal binder, and it was not being effective. RN F said when a CNA came to sit with Resident #1 1:1, his RP left for the night. She stated the purpose of the 1:1 was to prevent the resident from rolling out of bed and to make sure he did not pull his tubes. RN F stated there was one time during her 2-10pm shift where the 1:1 CNA reported he disconnected his g-tube, which was just a connection issue. RN F said besides that one time, the 1:1 CNA did not report any other concerns to her during her shift. An interview with NP G on [DATE] at 10:14 AM revealed Resident #1 admitted after she left on [DATE] and was gone the next morning before she arrived the facility, so she never saw him. She stated she heard he was very volatile, aggressive, and punched someone the day before at the hospital. NP G stated the morning of [DATE], [LVN A ] updated me because she came into this scene and let me know it was too much, so we sent him back out. NP G said she gave a verbal order to LVN A for the ER transfer. NP G stated she got the impression from staff that Resident #1 was out of control due to agitation and confusion but she did not have a baseline to go from. NP G stated she assumed Resident #1 was sent to the ER via ambulance. She stated she did not know the EMTs assessed him and determined he did not have a medical emergency. She stated, I was not aware of that. I would not think it is safe to transport him via non-emergency because if he is actively agitated, the EMTs can handle it. That's what I thought he was doing, going out via ambulance. NP G stated if she knew the EMTs deemed him not in a medical emergency state, she would have ordered PRN medications at the facility to help address the behaviors. She stated she did not see his clinicals so she did not know if he had a qualifying diagnosis to justify their use. NP G stated giving a report to the ER when sending them a resident was important so they could know what to expect, try to prepare, and have anticipated interventions in place if they were having issues related to cardiac distress, behavioral emergency, and so forth. A follow up interview with the DON on [DATE] at 10:48 AM revealed she was notified by the facility staffing coordinator on [DATE] that LVN A felt Resident #1 was being antsy and aggressive. The DON stated she did not know until after the fact that Resident #1 had been given Haldol by the discharging hospital during his stay due to him punching a hospital staff. She said that was not sent with his hospital clinicals prior to admission. The DON stated, They didn't relay any of that information to us. They didn't tell anybody; they just were like here he's yours now. The DON said she had not observed him herself, so her decision was based on what she was told secondhand. The DON said she contacted NP G who told her to send him out to the hospital. The DON stated 911 was called but when they came out, the EMT did not feel like Resident #1 was having a medical emergency so they would not transport him to the hospital. The DON stated she did not contact NP G after EMT refused the transport to update her that the order to send out via 911 could not be done. The DON stated the information was relayed to NP G after the resident was sent out via a private transport company. The DON stated she did not consider discussing PRN medication options with the staff or NP because it could not be given to keep him subdued from pulling at his lines and it walks that fine line of are you chemically restraining a patient? The DON said with other residents in the facility with lines and pulled on them, the staff had rapport so they could more easily calm them down. The morning Resident #1 had the behaviors, [DATE], the DON stated she did not talk with his RP until after he was sent out in the private transport vehicle. The DON said she was under the impression that the RP had already been notified but did not know who did the notification. The DON said regarding sending Resident #1 to the ER via a private transport company, We felt like it was our only option.I couldn't put him in my car and take him so that was really our only recourse to get him where he needed to be. The DON said they knew the driver stayed with Resident #1 in the ER until he was checked in and gave the hospital all the information they needed before he left, Which was basically his med list. The DON said the facility did not have to supervise Resident #1 when he was taken to the ER and checked in. She stated, Technically once they leave the building they have been discharged or transferred.We ensure that they get to a place where they are safe, which we did, through a third party transport company and so at that point the hospital assumed responsibility for him once he was checked in [at the front desk]. The DON further stated she could not bill for Resident #1 so she could not send a facility staff member to sit with him since the facility would not get paid for it. An interview with the ADM on [DATE] at 11:35 AM revealed she wondered how the overnight CNA was able to manage Resident #1's behaviors during his first night of admission to the facility, And then all of a sudden it becomes this huge emergency the next morning? She stated going forward, for late night admissions, the staff needed to be more informed on what the resident's care needs were , ensure the hospital clinicals were reviewed prior to admission, and make sure interventions were in place. An interview with the private transport company, Driver H, on [DATE] at 11:47 AM revealed he remembered transporting Resident #1 by himself to the ER on [DATE]. He stated he initially started driving Resident #1 to one hospital further away but was re-routed by the facility to a closer hospital. He said when he arrived at the ER, the staff at the ER desk said to leave him there so he transferred him to a hospital wheelchair. Driver H said while in the ER waiting area, Resident #1 was trying to escape and could walk. He stated the ER staff were trying to talk to Resident #1 but he did not speak any English and they were trying to figure out what language he spoke so they could use their translator. Driver H stated he gave the ER staff the resident's face sheet, which was the only document he was given by the facility. He stated he left the hospital at that point so he did not know what else happened. A follow up interview with the ADM on [DATE] at 4:00 PM revealed the facility did not send a facility staff to supervise Resident #1 because the transport company had a driver that stayed with him. The ADM stated the only reason Resident #1 had been a 1:1 the night before was to make sure he didn't pull anything out. She stated, He [Resident #1] didn't need a 1:1 because driver of the van was with him. While he was here in the room, there was no one in the room so that is why we put an aide in. IF he had pulled out lines, the drivers are CPR trained and he was told if he needed to call 911, he could, by our nursing staff. The ADM stated the transport company said they could handle it and the company will know based on their own assessment from what we tell them, but they also observe the resident when they arrive to make sure they are appropriate [for transport]. The ADM stated, So they felt confident they could do it, we felt confident they could do it. She said the facility's responsibility for resident's supervision ended when once they were checked in at the hospital. We make sure they are there and give report and one there, they are the hospital's concern. The ADM said she felt once the DON realized that the EMTs were not going to transport Resident #1 due to him not having an emergency, maybe she felt it was not that serious of an issue and could send him out non-emergent. The ADM said she felt like the level of emergency changed when the EMTs saw Resident #1. She stated, It was not like he was in respiratory distress or about to die, so the rest of us were thinking okay, if not emergency, then next best thing. The ADM continued to state that the facility trusted the transport company to make sure the residents got from point A to point B. The ADM said she herself, talked to Driver H and he told her he stayed with Resident #1 at the ER for about 15-20 minutes until the ER staff took him to a room and she said the transport staff would never leave a patient there. The ADM stated Driver H did not tell her Resident #2 had tried to get up, rather that he sat there with him the whole time. A follow up interview with the DON on [DATE] at 4:20 PM revealed the reason Resident #1 was sent to the ER without staff supervision was because his family/RP was meeting him at the hospital. The DON did not feel that sending a staff member would have been helpful to intervene if Resident #1 had pulled at his lines during transport because that staff would be buckled in in front or behind, and not able to intervene if there was an emergency and the van was moving. The DON stated again that a resident was no longer the facility's responsibility once they left the facility when they were sent out to a higher level of care. The DON said she did not know if [Company Name] did medical transports, but there were not normally used for emergency transportations. The DON stated a staff member would accompany a resident to the ER on ly if that resident did not have a family member meeting them at the hospital. She said Resident #1 did have his family member/RP in route to meet him at the ER. Review of the facility's contract with the transport company dated, reflected in part, .l. Services Provided. (Company Name) provide patients of the Facility with nonemergency transportation services to or from locations designated by the Facility (the Services). The vehicles used by (Company Name) in the delivery of the Services shall be staffed by at least two (2) persons who are licensed or certified by law to render emergency medical care for Stretcher and Basic Life Support vehicles and at least (I) person/driver for Wheelchair Ramp and Sedan vehicles. (Company Name) shall make the Services available twenty-four (24) hours per day, seven (7) days per week, The Services do not include, and this Agreement does not affect, the delivery by (Company Name) of emergency medical transportation services. The determination of whether a transport is an emergency or nonemergency shall be made by (Company Name) in accordance with the standards and protocols established and approved by the Emergency Physicians Advisory Board.The facility's policy titled, Transfer and Discharge last revised [DATE], reflected, .7. Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident: a. Obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis; b. Notify resident and/or resident representative; c. Contact an ambulance service and provider hospital, or facility of resident's choice, when possible, for transportation and admission arrangements; d. Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents: i. Resident status, including baseline and current mental, behavioral, and functional status and recent vital signs; ii. Current diagnosis, allergies, and reasons for transfer/discharge; iii. Contact information of the practitioner responsible for the care of the resident; iv. Resident representative information including contact information; v. Current medications (including when last received), treatments, most recent relevant lab and/or radiological findings and recent immunizations; vi. Special instructions or precautions for ongoing care to include precautions such as isolation or contact; vii. Special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; viii. Comprehensive care plan goals, and ix. Any other documentation, as applicable, to ensure a safe and effective transition of care.g. Provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form and manner that the resident can understand; h. Document assessment findings and other relevant information regarding the transfer in the medical record.This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The ADM was notified. The ADM was provided with the IJ template on [DATE] at 12:02 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 3:45 PM and reflected: Immediate Actions Taken (Date: [DATE]):1. None- the resident did not return after discharge.Systemic Changes Implemented:Transport Protocol:1. EMT refusal of transport will trigger an automatic notification to the physician and DON before arranging alternative transport.2. A return to acute check list for non-emergency transport was created to document resident behaviors and medical devices prior to any transfer. 3. The checklist assists staff in decision making to determine if supervision is needed during non-emergency transport for residents who are not alert and oriented and have behaviors. The determination of supervision is not just for appointments, but for any destinations, including the ER.4. A trained CNA, or Licensed nurse will be assigned to supervise transportation if supervision is deemed necessary from the checklist. The DON or Designee will arrange supervision if needed.5. The supervising staff member will stay with the resident at the ER and check them in with ER personnel.6. If there is a behavioral emergency during transport staff are instructed to pull over to a safe place, stay with the resident and call 911.Education & Training1. Regional Nurse DON/designee will educate DON on emergency transport vs non-emergency transport with posttest. Completion by [DATE]. DON/designee will educate all licensed nurses on emergency transport vs non-emergency transport with posttest. Completion by [DATE]. DON/designee will educate license nurses on the Return to Acute Checklist before calling non-emergency transport. Completion by [DATE]. DON/designee will educate CNAs on recognizing and reporting line-pulling, fidgeting, and self-harm risks immediately to the charge nurse. Completion by [DATE]. Staff unavailable to attend in service on [DATE] will receive personalized education and posttest prior to assuming their duties. Monitoring:1. DON/Designee will audit 100% of all hospital/ER transfers for 30 days to verify:a. Completion of Return to Acute Checklist for non-emergency transport.2. Findings will be reviewed in QA/QI Committee meetings monthly for 3 months, then quarterly thereafterDate Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE].Monitoring interviews for the Immediate Jeopardy were started on [DATE] at 2:45 PM with nine nursing staff and management across multiple shifts to include: DON, ADM, RN B, ADON I, ADON J, RN K, LVN L, LVN M and LVN N. All staff were able to provide competency of education on the new Resident Transfer Checklis

Based on observation, interview, and record review, the facility failed to ensure that each resident received necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan and the residents' choice for 3 (Resident #1, Resident #2, and Resident #3) of 8 residents reviewed for respiratory care. 1. On [DATE] RN H failed to obtain a physician's order to administer oxygen to Resident #1 when readmitted to the facility after an acute care hospital stay with the primary diagnoses of Acute on Chronic Respiratory Failure with Hypoxia (a worsening of chronic respiratory failure that can lead to hypoxia [low blood oxygen]); COPD; and CHF. 2. The facility failed to provide appropriate dispensing of oxygen by providing Resident #1 oxygen via nasal cannula (usually delivers oxygen up to ,d+[DATE] liters per minute) at levels that ranged from 7 LPM - 10 LPM on [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE], LVN A failed to accurately assess for a respiratory change of condition when Resident #1 requested to go back to the hospital. 3. LVN A failed to perform adequate supervision or monitoring of Resident #1 for nearly 6 hours during his eight-hour scheduled shift on [DATE] 10:00 PM -6:00 AM ([DATE]) to oversee Resident #1 who required or received respiratory care services (i.e., oxygen therapy, ventilator/noninvasive ventilation, or nebulizer/metered-dose inhalers) to assure that Resident #1 received proper treatment and care. CNA U found Resident #1 unresponsive on [DATE] at approximately 5:05 AM. Resident #1 passed away in the facility. EMS officially declared Resident #1 dead on [DATE] at 5:23 AM. 4. The facility failed to safely handle and perform infection control practices for Resident #2's tracheostomy tubing that was dated [DATE] and was observed resting on the floor on [DATE]. 5. On [DATE], the facility failed to provide consistent oxygen therapy for Resident #3. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:45 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to all staff had not been in-serviced and the facility continuing to monitor the implementation and effectiveness of the corrective systems. These failures placed residents at the risk of not receiving enough or high levels of oxygen, which can cause difficulty breathing, result in a decline in health or possible worsening of symptoms, including death. Findings included: Record review of the nursing schedule dated [DATE] revealed LVN A [Station 3] was scheduled and worked on [DATE] 10:00 PM - 6:00 AM ([DATE]) shift. RESIDENT #1 Record review of Resident #1's 5-day MDS assessment, dated [DATE], reflected the resident was an [AGE] year-old female initially admitted to the facility on [DATE] with primary diagnoses of COPD; Pulmonary Fibrosis (a chronic lung disease that causes scarring of the lungs, making it difficult to breathe); T2DM (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar levels to be abnormally high); and Acute and Chronic Respiratory Failure with Hypercapnia (also known as CO? retention, a condition where there is too much carbon dioxide in the blood). Resident #1's most recent readmission to the facility was on [DATE] after an acute care hospital stay [[DATE] - [DATE]] - primary diagnosis at discharge included Acute on Chronic Respiratory Failure with Hypoxia (a worsening of chronic respiratory failure that can lead to hypoxia [low blood oxygen]); COPD; and CHF. Resident #1 had a BIMS Summary Score of 15, which indicated Resident #1 was cognitively intact. The 5-day MDS assessment reflected Resident #1 had shortness of breath or trouble breathing when lying flat and required respiratory treatments - continuous oxygen therapy. The 5-day MDS assessment revealed respiratory therapy was administered for 7 days in the last 7 days. Record review revealed Resident #1 did not receive end of life care, hospice, or palliative care. Resident #1 passed away in the facility on [DATE]. Record review of Resident #1's care plan, closed [DATE], reflected: [Resident #1] refused to wear BiPAP (initiated [DATE]; revised [DATE]). Goal: will be clean, well groomed, and episodes of resistance will decrease to less than weekly through the next review (initiated: [DATE]; revised [DATE]; target [DATE]). Interventions included: Monitor behavior episodes and attempt to determine underlying cause; provide positive reinforcement for tasks accomplished and when accepted needed assistance (initiated [DATE]). [Resident #1] is on Antibiotic Therapy r/t infection. (Initiated [DATE]; cancelled [DATE]). Goal: will be free of any discomfort or adverse side effects of antibiotic therapy through the review date (initiated [DATE]; Target date [DATE]; cancelled [DATE]). Interventions included: Administer medication as ordered (Initiated [DATE]); encourage coughing and deep breathing exercises (Initiated [DATE]); Observe for possible side effects every shift. (Initiated [DATE]). [Resident #1] used oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. (Date initiated: [DATE]). Goal: [Resident #1] will have no s/sx of hypoxia (poor oxygen) through the next review date (Date initiated: [DATE]; Target Date: [DATE]). Interventions included: Administer oxygen therapy per physician's orders; Monitor for s/sx of respiratory distress and report to MD PRN; Encourage resident to change position at least every two hours to promote lung expansion and to facilitate secretion movement and drainage; Position with head of bed elevated whenever possible to allow for optimal lung expansion and gas exchange. (Initiated: [DATE]) Respiratory Status: Impaired. [Resident #1] had impaired respiratory status and is at risk for shortness of breath, respiratory distress, increased anxiety, and hypoxia. This is related to a diagnosis of COPD. (Date initiated: [DATE]). Goal: [Resident #1] will have no reports of unrelieved shortness of breath through the next review date (Date initiated: [DATE]; Target Date: [DATE]). Interventions included: may use BiPAP with home settings (Initiated: [DATE]); Administer medications as ordered; Monitor for shortness of breath, respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions. Notify physician if interventions are not effective; Encourage and remind resident to use call light to call for assistance. Instruct resident to report any shortness of breath immediately (initiated [DATE]). Record review of Resident #1's Order Summary Report, printed [DATE], reflected: - Verbal Order date - [DATE]: May see [telehealth] Physician PRN. - Verbal Order date - [DATE]: Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 mL) inhale orally every four hours as needed for Shortness of Breath, Wheezing. [DISCONTINUED on [DATE]] - Prescriber Entered Order date - [DATE]: Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 mL) inhale orally via nebulizer one time only for wheezes throughout; rhonchi bilateral lobes posterior r/t Acute and Chronic Respiratory Failure with Hypoxia and COPD until [DATE]. - Prescriber Entered Order date - [DATE]: Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 mL) 0.083% (Albuterol Sulfate) 2.5 mg inhale orally via nebulizer four times a day for fluid in lungs r/t COPD until [DATE]. - Phone Order date - [DATE]: Chest x-ray (CXR) for cough related to COPD exacerbation. [COMPLETED] - Prescriber Entered Order date - [DATE]: Azithromycin ([antibiotic] used to treat certain bacterial infections) Oral Tablet 500 mg by mouth one time a day for fluid in lungs until [DATE]. - Prescriber Entered Order date - [DATE]: Azithromycin Oral Tablet 250 mg by mouth one time a day for fluid in lungs until [DATE]. - Prescriber Entered Order date - [DATE]: CBC, CMP STAT r/t COPD with exacerbation. [COMPLETED] - Prescriber Entered Order date [DATE]: Furosemide (a strong diuretic [water pill]) Oral Tablet 20 mg. Give 20 mg by mouth three times a day r/t COPD until [DATE]. - Verbal Order date - [DATE]: Full Code - Verbal Order date - [DATE]: Inspect external O2 filter weekly. Clean/change if needed every night shift every Wednesday for oxygen use. - Verbal Order date - [DATE]: Inspect external O2 filter weekly. Clean/change if needed every night shift for delivering clean oxygen. - Verbal Order date - [DATE]: BiPAP (a noninvasive form of mechanical ventilation delivered through nasal or full-face masks with inspiration (inspiratory positive airway pressure - [IPAP]) and exhalation pressures (expiratory positive airway pressure - [EPAP]) at 12 cm H2O Inspiration and 5 cm H2O Expiration with Oxygen at 5 LPM without humidification. BiPAP scheduled start at bedtime for sleep apnea related to Pulmonary Fibrosis, uns; COPD, uns. Discontinue upon waking. - Verbal Order date - [DATE]: Wipe down the mask, tubing, and machine after each use. Clean the machine, humidifier, mask, and tubing per the manufacturer's recommendations or weekly in the morning for sleep apnea. - Verbal Order date - [DATE]: Change Nebulizer tubing and administration device weekly. Clean/change the nebulizer filter every night shift every Monday for delivering oxygen in clean tubing. Ensure that tubing is dated when changed. - Verbal Order date [DATE]: Change O2 tubing, and humidifier bottle every night shift every Monday. Ensure that tubing is dated when changed. - Verbal Order date [DATE]: Change O2 tubing, and humidifier bottle every night shift for oxygen delivery system hygiene. - Verbal Order date - [DATE]: Incentive Spirometry. Assist/instruct resident to place the mouthpiece in the mouth, sealing lips around it, and breathe in as slowly and deeply as possible, trying to raise the piston towards the top of the column. Instruct them to hold their breath as long as possible before exhaling for 10 repetitions and 4 sets. Encourage the resident to cough between breaths. - Verbal Order date - [DATE]: Monitor respirations and oxygen saturation while using CPAP/BiPAP every 4 hours for sleep apnea. - Verbal Order date - [DATE]: O2 at 9 LPM via NC. Monitor O2 Saturation. Notify physician if SpO2 ([oxygen saturation], a measurement of the percentage of oxygen in the blood relative to its maximum capacity) falls below 90% every shift. [DISCONTINUED [DATE]] - Verbal Order date - [DATE]: Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 mL) 0.083% (Albuterol Sulfate). 1 vial inhale orally every four hours as needed for Shortness of Breath r/t Acute and Chronic Respiratory Failure with Hypoxia. - Prescriber Entered Order date - [DATE]: Nursing: [Resident] to do I/S after each nebulizer treatment. Goal is to pull 2000 mL. Device at bedside. Four times a day for mobilization of secretions related to COPD. - Phone Order date - [DATE]: STAT Chest x-ray r/t cough. [DISCONTINUED] - Verbal Order date - [DATE]: STAT Chest x-ray r/t fluid overload. [DISCONTINUED] - Prescriber Entered Order date - [DATE]: CBC, CMP STAT r/t Acute and Chronic Respiratory Failure with Hypoxia; COPD with exacerbation. [COMPLETED] - Phone Order date - [DATE]: STAT BNP (blood test about how heart is working by measuring the levels of the BNP protein in the bloodstream) r/t fluid overload. [DISCONTINUED] - Verbal Order date - [DATE]: O2 at 5 LPM via NC. Monitor O2 Saturation. Notify physician if SpO2 falls below 90%. - Prescriber Entered Order date - [DATE]: Levofloxacin ([antibiotic] used to treat bacterial infections) Oral Tablet 500 mg. Give 500 mg by mouth one time a day for PNA (pneumonia) until [DATE] for 5 days. - Prescriber Entered Order date - [DATE]: Methylprednisolone ([a steroid] used to treat inflammatory conditions and respiratory disorders) oral tablet 4 mg. Give 4 mg by mouth two times a day for fluid in lungs r/t Acute and Chronic Respiratory Failure, COPD until [DATE]. Record review of Resident #1's [DATE] eMAR/eTAR, printed [DATE], reflected Methylprednisolone 4 mg tablet ordered to start [DATE] at 4:00 PM was not administered; Levofloxacin 500 mg tablet ordered on [DATE] was not started; oxygen ordered on [DATE] at 9 LPM via NC and [DATE] at 5 LPM via NC were not initialed by a nurse that indicated oxygen was administered. Albuterol Nebulizer treatments were scheduled at 8AM, 12 PM, 4 PM, and 8 PM. The [DATE] eMAR/eTAR did not reflect PRN Albuterol nebulizer treatments (ordered [DATE]; discontinued [DATE]) initialed by a nurse or LVN A that indicated a PRN nebulizer treatment was administered on [DATE] or [DATE]. Record review of Resident #1's Readmit Evaluation, dated [DATE], RN H documented Admitting Diagnosis Acute on chronic Respiratory Failure with Hypoxia, Chronic Pulmonary Edema. Vitals ([DATE] at 8:30 PM): BP ,d+[DATE]; HR 69; Respirations 18. No cough. Breath sounds were clear bilaterally, no shortness of breath noted while lying, sitting, or on exertion. Uses Oxygen at 4 LPM via NC. No sleep aids. Record review did not reflect physician orders for oxygen administration. Record review of Resident #1's progress notes reflected: Alert Note entered by RN H on [DATE] at 9:07 PM, Readmit from [Hospital] via stretcher by 2 paramedics for continued care under [PCP] with the diagnosis of Acute on chronic respiratory failure with hypoxia and Chronic Pulmonary Edema. Head to toe assessment completed. (Vital signs measured - BP, P, R, T), O2 sat 95% on O2 at 4 LPM via nasal cannula, no respiratory distress noted. [PCP] notified of [Resident #1] arrival, [PCP] said to continue hospital transfer orders and to use standard sliding scale for regular insulin. Alert Note entered by LVN A on [DATE] at 11:30 PM, Report received from outgoing nurse (RN H) that [Resident #1] refused the BiPAP and would like it applied later. [Resident #1] refused again. WCTM. Alert Note entered by LVN A on [DATE] at 1:00 AM, [Resident #1] refused the BiPAP again. WCTM. Alert Note entered by LVN A on [DATE] at 4:22 AM reflected, [Resident #1] told this nurse [LVN A] to call [Resident #1's daughter] and inform that [Resident #1] was going back to the hospital. [LVN A] asked [Resident #1] why was she going to the hospital and [Resident #1] responded I don't know. [LVN A] indicated that Resident #1's oxygen level was difficult to read due to fingers and toes were too cold. Eventually, a 63% [O2 sat] resulted. LVN A indicated that he turned off the fan and covered [Resident #1] entire body up with blankets and obtained a (90% O2 sat) in less than 2 minutes. [Resident #1] stated, 'I was very cold. This feel better'. With resident calm, [LVN A] left the room and returned in about 5 minutes, gave resident her due medication (omeprazole 20mg) and oxygen level re-checked at 99. [Resident #1] denied having a breathing problem and responded yes when asked if she could see her oxygen level in the pulse ox. WCTM. Physician Progress Note entered by NP N (effective date: [DATE] 1:09 PM), New patient [Resident #1] here for COPD exacerbation and needing BiPAP; refusing. [Resident #1] says she feels shortness of breath just sitting up in bed with O2 at 3 LPM per NC. [Resident #1] clarified she does not 'refuse' the BiPAP, but that it makes her nose run and it gets in her mouth, making her feel like she's choking. Auscultated (heard by listening with a stethoscope) wheezes throughout and rhonchi in posterior lobes. c/o anxiety and shortness of breath. Assessment: Wheezes heard throughout; rales heard in both lower lobes posteriorly; [Resident #1] is short of breath just sitting and becomes 'more short' of breath and labored respiration when moves in bed. Alert Note entered by LVN A on [DATE] at 11:45 PM, [Resident #1] refused BiPAP. No SOB noted. WCTM. No Daily Skilled Note entered on [DATE]. Alert Note entered by LVN A on [DATE] at 5:46 AM, [Resident #1] is calm and with eyes closed. On continuous oxygen at 10 LPM via nasal canula and tolerating well. Nursing Note entered by LVN J on [DATE] at 11:12 AM, [NP N] in the building this shift doing rounds. New order per NP N for CXR due to COPD exacerbation. Order faxed to [mobile diagnostic]. Alert Note entered by RN H on [DATE] at 4:58 PM, Following chest x-ray result, [Resident #1] was placed on Zithromycin 500 mg by mouth, 1 dose today followed by 250 mg daily by mouth for four days for fluid in the lungs and nebulizer treatment every four hours. Order initiated. Family visiting, aware of new order. Alert Note entered by LVN I on [DATE] at 11:17 PM, [Resident #1] c/o SOB and had all her clothes off saying she is very hot and want to go back to the hospital. Vitals were T 97, P 82, R 18, BP ,d+[DATE], O2 sat was 78% via NC at the maximum (An oxygen concentrator can generate up to 15 liters of oxygen per minute. A nasal cannula usually delivers oxygen up to ,d+[DATE] liters per minute. A simple face mask is necessary to deliver oxygen at a flow rate of ,d+[DATE] liters per minute). [LVN I] remained at [Resident #1] bed side to reduce [Resident #1] anxiety. [Resident #1] was reassured dressed warm and nebulizer treatment was administered. After treatment, O2 sat was 97%. [Resident #1] showed sign of relief and went to sleep. WCTM. Physician's Note entered by NP N dated [DATE] (effective date: [DATE] 5:45 AM), CXR late yesterday revealed fluid in most lobes. Per nurse, [Resident #1] is on 10 LPM O2 via NC with O2 sats at 97%. Nurse says [Resident #1] is moving around a lot, had taken off her clothes earlier in the night and O2 sats were found to be 79%. After clothes were placed back on by nurse, O2 sats increased to 95% on 10 LPM O2 per NC. No Daily Skilled Note entered on [DATE]. Daily Skilled Note LATE ENTRY entered by RN B dated [DATE] at 11:28 AM, [Resident #1] requires daily skilled observation for respiratory issues. Respiratory rate is regular. Has shortness of breath noted with exertion. Shortness of breath present when lying flat. Oxygen therapy utilized. Nebulizer treatment was administered. [Resident #1] was repositioned to alleviate SOB. Wheezes are noted upon auscultation of breath sounds. No cough noted this shift. [Resident #1] on O2 at 7 LPM via BiPAP. Daily Skilled Note entered by RN B on [DATE] at 10:45 AM, [Resident #1] requires daily skilled observation for respiratory issues. SpO2 at 96% with oxygen in place. Respiratory rate is regular. No shortness of breath noted this shift. Lungs are clear. No cough noted this shift. Resident on O2 at 7 LPM via BiPAP. OTHER OBSERVATIONS: Dyspnea on exertion. Daily Skilled Note entered by LVN J on [DATE] at 11:15 AM, [Resident #1] requires daily skilled observation for cardiac issues, circulatory issues, teaching/education. SpO2 at 95% on room air with oxygen in place. Respiratory rate is regular. No shortness of breath noted this shift. Lungs are clear. No cough noted this shift. [Resident #1] on O2 at 3 LPM via NC. No changes were noted to the resident's respiratory status. Record review of lab results dated [DATE] at 11:03 AM revealed CO2 (bicarbonate) levels 40.0 HIGH (normal range: 22.0 - 29.0). Record review of Resident #1's progress notes reflected: Lab Note entered by LVN J on [DATE] at 1:53 PM, Lab results in for CBC and CMP. Reviewed by NP N. No new orders. Physician Progress Note entered by NP N (effective date: [DATE] 2:22 PM), Follow up visit for COPD exacerbation. [Resident #1] on 9 LPM 02 via NC with 02 sats at 96%. Nurse says [Resident #1] is yelling out a lot saying she 'can't catch my breath'. Per night shift nurse 97% on 10L O2. [Resident #1] appears anxious. Physician Progress Note entered by NP N (effective date: [DATE] 4:16 AM), [PCP L] informed of [Resident #1's] condition. [PCP L] saw [Resident #1] suggested to give medication by mouth and to cancel midline. Physician Progress Note entered by NP N ([Addendum] effective date: [DATE] 6:09 AM), Lab results show [potassium] 4.0 and WBC 9.1. Will continue round of antibiotics and continue with Lasix and potassium replacement. Physician Progress Note entered by NP N dated [DATE] at 12:13 PM, Follow up visit for COPD exacerbation. Pt is on 9 LPM O2 via NC with O2 sats at 96%. [Resident #1] says she is feeling the same as yesterday. Shown how to do IS (incentive spirometer) properly. Wheezes heard throughout; is SOB with exertion and becomes more SOB when [Resident #1] panics. Rales heard in middle lobes posteriorly, crackles heard in base of posterior left lobe. Physician Progress Note entered by NP N dated [DATE] at 2:47 PM, [Resident #1] has wheezes, rales throughout. Crackles in both bases, more in left lower base. [Resident #1] has been on 9 LPM per NC with O2 sat of 96%, although, [Resident #1] has been unable to rest, is agitated, becomes 'more short' of breath with minor position change. 2 IV attempts made to left arm, unsuccessful. Right arm has Do Not Use bracelet on. Midline has been ordered STAT. CXR, BNP, CBC, CMP ordered STAT. Physician Progress Note entered by NP N dated [DATE] 4:12 PM, [PCP L] made aware of [Resident #1's] condition. [PCP L] saw [PCP L] suggested midline IV be cancelled. [PCP L] stated medication by mouth would be just as effective as IV. Midline cancelled. IV methylprednisolone cancelled and ordered by mouth. Alert Note entered by RN H on [DATE] at 7:09 PM, [Resident #1] seen by [NP N] during rounds and started on a lot of orders for the diagnosis of Pneumonia, fluid overload, acute and chronic respiratory failure with hypoxia not limited to Dexamethasone 4 mg, 1 tab by mouth twice daily until [DATE], STAT BNP, CBC, and CMP. Levaquin 500 mg 1 tab PO daily until [DATE], check vital signs after each nebulizer treatment and to do incentive spirometry after each treatment goal to pull 2000 mL. [Resident #1's] son at bedside, aware of new orders. Alert Note entered by RN H on [DATE] at 7:39 PM, Lab here STAT CBC, CMP and BNP drawn per order. Record review of lab results dated [DATE], collected at 7:24 PM, revealed a critical result was called to the facility and accepted by RN H at 9:26 PM. The results were faxed to the facility at 10:45 PM. The results revealed CO2 (bicarbonate) levels > (greater than) 45.0 HIGH PANIC (normal range: 20.0 - 31.0). Record review of Resident #1's progress notes reflected: Alert Note entered by RN H effective date [DATE] at 8:08 PM, Lab called with critical CO2 same called to on call, said to continue treatment, that has Pneumonia, and she is already on antibiotics. Assisted with using I/S and nebulizer treatment per order, tolerating well. Dexamethasone not available, awaiting pharmacy delivery. Report given to night nurse to follow up with STAT labs and STAT chest x-ray. [On call telehealth] Health Note entered by APN K dated [DATE] 1:13 AM (Effective Date: [DATE] at 10:01 PM), Details: Nurse Name (RN H). Primary Chief complaint: Lab Review. Abnormal results requiring provider assessment. Received critical CO2 lab result. Result reveals CO2 level of >45. [Resident #1] has pneumonia and is on antibiotic. Reviewed past medical history and medications. Per nurse Vitals T 97; HR 76; BP ,d+[DATE]; Respirations 20; SpO2 94%. Physical exam findings per nurse and video observation. Orders: continue to monitor pt. Disposition: Stay at facility. Technology used: Audio and video with patient and nurse present. Alert Note entered by LVN A on [DATE] at 11:04 PM, Radiology report received, Moderate bilateral scattered pneumonias. Report forwarded to [APN K, on call TeleDoc provider]. No new orders. [Resident #1] already on treatment for pneumonia, per APN K. No Daily Skilled Note entered on [DATE]. [On call telehealth] Health Note entered by APN K dated [DATE] 2:11 AM (Effective Date: [DATE] at 11:02 PM), Details: Nurse Name (LVN A). Primary Chief complaint: Radiology review. Abnormal results requiring provider assessment. Received chest x-ray result. Result reveals moderate bilateral scattered pneumonias. Pt already started on Levaquin 500 mg one time daily today. [Resident #1] VSS. Reviewed past medical history and medications. Per nurse Vitals T 97.4; HR 67; BP ,d+[DATE]; Respirations 16; SpO2 95%. Physical exam findings per nurse and video observation. No new order. Will continue to monitor pt. Disposition: Stay at facility. Technology used: Audio and video with patient and nurse present. Alert Note entered by LVN A on [DATE] at 7:06 AM (Effective date: [DATE] at 1:00 AM), Resident in bed resting. No form of distress noted. Oxygen at 10 LPM in continuous use with nasal cannula in place. Respiration even and non-labored. WCTM. Alert Note entered by LVN A on [DATE] at 07:27 AM (Effective date: [DATE] at 2:45 AM), Rounds made and resident is awake and requested for a breathing treatment which this nurse administered and waited for the treatment to be completed. O2 sat after the treatment was 95%. This nurse exit the room around 3:04 AM. Alert Note entered by LVN A on [DATE] at 8:17 AM (Effective date: [DATE] at 4:50 AM) indicated that [LVN A] was called to the room that resident is unresponsive. This nurse left the med pass and went with the staff. Code blue is called and CPR started. A nurse called 911 and 2 policemen came followed by the emergency crew which pronounced resident dead around 0515. The nurse that called 911, also informed this nurse that the family had been notified and were on their way to the facility. The policemen obtained information, needed and gave a report number. The policemen gave the medical examiners numbers to this nurse to call, that the examiner is waiting on the call. This nurse called the medical examiner and was issued a report number. Alert Note entered by LVN A effective date [DATE] at 8:29 AM, DON and ADON aware. Physician Progress Note entered by PCP effective date [DATE] at 12:15 PM, Service date: [DATE], Pt seen today as routine visit. All recent notes and documents were reviewed; all recent vital signs and labs were reviewed; all medications were reviewed; no issues or concerns per nursing except for pt refusing CPAP at night. Pt was just hospitalized ; does not feel like her breathing is improving; pt appears in no distress but condition is guarded. Document e-signed by PCP on [DATE] at 10:15 AM. Record review of the F.D. Care Report dated [DATE] reflected a call date and time, [DATE] at 5:13 AM for a Cardiac Arrest - Possible DOA. The response mode was Emergent (Immediate Response) to the facility. The arrival time at scene was 5:20 AM and at Resident #1, 5:22 AM. The Care Report narrative reflected, [EMS] arrives on scene [at facility] and finds [Resident #1] lying in bed with facility staff performing CPR. EMS takes over and assesses. [Resident #1] has no pulse and has signs incompatible with life (Rigor and dependent lividity) [considered early postmortem changes that occur 3 to 72 hours after death]. Resuscitation efforts discontinued and [Resident #1] declared dead on scene. EMS clears from scene. The disposition reflected Patient Dead at Scene - No Resuscitation Attempted. EMS departed at 5:34 AM. Record review of the P.D. Incident Report dated [DATE] at 6:38 AM, the officer's [Officer V] narrative reflected officers were dispatched to the facility on [DATE] at 5:14 AM. Upon arrival, officers observed [LVN A] performing CPR on [Resident #1] who was lying fully dressed, on her back, in her bed. [LVN A] advised Officer V that approximately 3:00 AM ([DATE]), LVN A had gone to Resident #1's room to give oxygen. LVN A stated that Resident #1 was in good health, with no apparent complications. At approximately 5:00 AM ([DATE]), CNA U made her last checkup rounds before end of shift at 6:00 AM. CNA U found [Resident #1] to be unconscious and not breathing. CNA U immediately called for LVN A, at which point [LVN A] began to perform CPR on Resident #1 and shortly thereafter officers arrived on scene. Officer V spoke with CNA U who advised the same exact story. The F.D. arrived on scene and declared the time of death at 5:23 AM ([DATE]). Record review of the Detective's Clearance Statement dated [DATE] at 1:08 PM reflected, On [DATE] [Detective] reviewed the unattended death of [Resident #1]. [Detective] spoke with [family member] who described Resident #1 cold to touch upon arrival to facility after notification that Resident #1 passed away. [Family member] stated that there was video that revealed LVN A did not check on Resident #1 at 3:00 AM. Video was received from [family member] and reviewed. The video did not reveal that any staff appeared to check in on [Resident #1] (at approximately before or after 3:00 AM) until found deceased ([DATE] after 5:00 AM). During an interview on [DATE] at 11:50 AM, the MOD stated he was the RN weekend supervisor, 6A - 10P. The MOD said that he recalled Resident #1 and described her as able to verbalize wants and needs, received oxygen continuously, but was unaware of any respiratory distress during the weekend of [DATE] and [DATE]. The MOD said that [Resident #1] often complained about shortness of breath and if her O2 sat levels were below 88% with oxygen, [Resident #1] would be sent to the hospital. The MOD said other respiratory changes of condition included, difficulty speaking or gasping due to breathing difficulty; tightness in chest; or unresolved wheezes with breathing treatment. An attempt to interview PCP L by telephone on [DATE] at 11:58 AM was answered and routed to an automated system with hospital options. Unable to leave message. During an interview on [DATE] at 12:25 PM, the complainant stated that the police responded to a 911 call on [DATE] for a resident who was unresponsive. The complainant stated based on interviews and video evidence of the incident, the night nurse did not check on Resident #1 every two hours or provided treatments as [LVN A] stated to the police. The complainant stated the video evidence showed [Resident #1] was found around 5:00 AM unresponsive. The complainant stated that [Resident #1] was found deceased . The complainant stated that he would forward the video evidence to the investigator for review. Observation of video surveillance recorded [DATE] 9:45 PM - [DATE] 9:00 AM was conducted. The following time stamps from the video surveillance revealed (privacy curtain was drawn): LVN A did not perform change of shift rounds at start of shift ([DATE] at 10:00 PM). [DATE] at 11:33 PM: CNA U responded to and turned off Resident #1's call light. [DATE] at 11:37 PM: LVN A entered room and approached Resident #1. LVN A exited the room at 11:39 PM. There were no rounds activity to Resident #1's room again until [DATE] at 5:05 AM. [DATE] at 5:05 AM: CNA U entered room with incontinent care supplies and approached Resident #1. CNA U exited room a few seconds later. [DATE] at 5:06 AM: CNA U returned to Resident #1's room with LVN A. Both staff approached Resident #1 at bedside. CNA U exited the room at 5:07 AM. [DATE] at 5:08 AM: An unidentified male nurse entered [Resident #1's] room and approached Resident #1's bedside. Unidentified male nurse exited room at 5:09 AM. [DATE] at 5:11 AM: An unidentified staff member entered the room. At 5:12 AM a second unidentified staff member entered the room. [DATE] at 5:12 AM: The unidentified male nurse returned to Resident #1's room pushing the crash cart. [DATE] at 5:13 AM: An unidentified female staff entered the room with the AED. [DATE] at 5:21 AM: Two officers entered the room. [DATE] at 5:22 AM: Five EMS entered the room and approach [TRUNCATED]

Based on interviews, observations, and record reviews the facility failed to ensure residents in the locked memory care unit were free from physical abuse and physical restraints not required to treat the resident's medical symptoms for 2 (Residents #1 and #2) of 40 residents reviewed for abuse. The facility failed to: 1. protect Resident #1 from being abused by CNA A and Resident #2 from being abused by CNA C. 2. protect Resident #3 and Resident #5 from abuse. These failures could affect all 38 residents in the memory care unit by placing them at risk for abuse and physical restraints and could lead to serious injury, serious harm, serious impairment, pain, mental anguish, or death. An IJ was identified on 07/19/22 at 5:08 PM. The DON was notified, and a POR was requested. While the IJ was removed on 07/20/22 at 7:25PM, the facility remained out of compliance at a scope of pattern, at the severity level of no actual harm with potential for more than minimal harm due to the facility's need to complete in service training and evaluate the effectiveness of the corrective systems. Findings Included: Review of Resident #1's EHR on 07/19/22 reflected he was a [AGE] year old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's progress notes reflected the following was documented by LVN D on 07/08/22 at 5:13 PM, Under the directive of the Administrator this nurse performed a thorough head to toe assessment to rule out any form of injuries or pain in relation to an alleged incident of abuse of this resident during care. Patient remains comfortable and relaxed, up and about in the unit as usual. Upon assessment patient denies and showed no sign of pain or distress. no bruises or skin issues, no bleeding noted. vitals within normal limits . Resident is at baseline and stable, Notified MD . Called responsible person . and notified her of the incident. she verbalized understanding and further commended staff for taking good care of this resident even with his behaviors and issues with resisting care. She also thanked this nurse for updates on this patient. Will continue to monitor and provide care. Review of Resident #1's care plans with a start date of 05/25/22 reflected: 1. [Resident #1] has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to: Dementia . Date Initiated: 05/16/2019 . Revision on: 08/19/2020 . will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained through the next review date Administer medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Report abnormal findings to the physician . Monitor/document/report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes . Engage in simple, structured activities that avoid overly demanding tasks . Provide instructions to [Resident#1] using clear voice and simple sentences. Repeat as needed. Allow [Resident #1] time to respond . Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion . needs supervision/assistance with all decision making . Provide opportunities for [Resident #1] to make simple choices with ADL cares. Encourage participation . Use task segmentation to support short term memory deficits . 2. [Resident #1] is incontinent of bowel/bladder related to Dementia . Date Initiated: 05/16/2019 . Revision on: 12/07/2021 . 3. [Resident #1] has a behavior problem as evidenced by: Urinating on the floor of other resident's room and smearing feces . Date Initiated: 09/21/2020 . Revision on: 09/21/2020 . [Resident #1] will be clean, well groomed, and episodes of physical behaviors will decrease to less than weekly through the next review date physical behaviors will not interfere with the delivery of ADL cares by staff through the next review date . See other behavior care plan . Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log Assess and anticipate Resident #1 needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc . Intervene as necessary to protect the rights and safety of others. Remove [Resident #1] to an alternate location when needed to protect the rights and safety of others Minimize potential for disruptive behaviors by offering tasks or activities which divert attention . 4. [Resident #1] has a behavior problem as evidenced by: [Resident #1] has poor judgment and impulse control r/t Dementia and wanders in and out of others room and urinates and smears feces all on the walls and privacy curtains and other residents rooms [Resident #1] physical behaviors will not interfere with the delivery of ADL cares by staff through the next review date Plan to assist with shower at least once a week . Refer to psychiatrist and psychologist for behavior management . Administer medications as ordered. Monitor and document for effectiveness and potential adverse side effects . Approach [Resident #1] in a calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing cares, allow time for a response, and do not rush When [Resident #1] becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmly in conversation, or attempting to other interventions. If response is aggressive then approach at a later time after ensuring the safety of [Resident #1] and nearby residents . 5. [Resident #1] exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner . Date Initiated: 08/31/2021 . Revision on: 12/07/2021 . [Resident #1's] verbally abusive behavior will not result in harm or injury to self or others through the next review date . Administer medications as ordered by the physician and monitor for effectiveness and potential adverse side effects . Psychiatric consult as indicated or ordered by the physician . 6. [Resident #1] resides in a secured unit related to cognitive impairment secondary to dementia Date Initiated: 05/16/2019 . Revision on: 08/19/2020 . [Resident #1] will receive specialized dementia care appropriate for their stage of dementia on going and through the next review Review of the undated provider investigation report completed by the ADM reflected CNA B reported the ADM on 07/08/22 an incident which occurred on 07/06/22. The investigation included a witness statement completed by CNA B which was dated 07/08/22 at 8:45 AM and reflected, On [Wednesday] July 6, 2022 I was working on the floor with [CNA A] on the 400s hall at 4:04 PM we noticed [Resident #1] had soiled his pants. [CNA A] told him to come get changed . he said no leave him alone . she told him to come on he refused again so we started walking down the 400 hall to his room and [Resident #1] refused to go in there and [Resident #1] started walking to the front and that's when [CNA A] closed the doors and put her hands and foot on the doors . it was me, [Resident #1] and another resident on the 400 hall and [Resident #1] was trying to get out but [CNA A] refused to move. I told [CNA A] to be more respectful while talking to [Resident #1]. After 2 [minutes] she moved as she saw me and [Resident #1] walking towards his room then [CNA A] came down the 400 hall [Resident #1] went in his room and he was hitting [CNA A]. [CNA A] hit him back and I said that's not how you treat him. She said nobody likes to deal with him because of this [or] change him. As I was removing [Resident #1's] pants and cleaning him he hit [CNA A] again . She hit him again and told [Resident #1] he's not going to keep hitting her. I was trying to redirect [CNA A] while I was cleaning [Resident #1] . I got him clean put the pull up and pants on [Resident #1] and he walked back to the dining area . In a telephone interview on 07/18/22 10:49 AM, CNA B stated on 07/06/22 she was working on the memory care unit being trained. She stated between 3PM and 4PM she was training with CNA A. She said Resident #1 had soiled his pants and was refusing to go to his room. She said she, CNA A, and Resident #1 were walking down the hallway towards his room and Resident #1 turned around to go back to the day room. She said CNA A told Resident #1 he needed to go to his room, and after Resident #1 entered his room, CNA A closed the door with her foot and hand and Resident #1 began beating on the door and cursing let me out. CNA B said she told CNA A she did not have to do that, and she talked to Resident #1 and calmed him down. CNA A told Resident #1 he was a mess and he smelled, but Resident #1 did not want CNA A to change him and hit CNA A. CNA B said CNA A hit Resident #1's hand with an open hand and told CNA B she did not know Resident #1. CNA B said once Resident #1 was lying on the bed, CNA A held him down by restraining his arms and CNA B completed incontinent care for Resident #1Resident #1 again hit CNA A during incontinent care and CNA A retaliated by hitting Resident #1 on his forearm with a closed fist. CNA B said she told CNA A she should not hit a resident and CNA A told her she was new and that was why nobody wanted to work with Resident #1. CNA B said she did not say anything else to CNA A because she felt it was inappropriate to argue in front of a resident and CNA A then pointed her finger at Resident #1 and said, you don't hit me. CNA B said she got off work at 5PM on 07/06/22 and when she went to report the incident of abuse to the ADM or DON, there was nobody in the office. She stated she reported the incident of abuse to the ADM on the morning of 07/08/22. CNA B said she I received training on abuse and neglect, and she was going report the incident of abuse on 07/06/22 but there was no one in the office when [she] was leaving for the day, and she didn't know who to report it to. CNA B said once she reported the incident to the ADM, he thanked her for bringing it to his attention and had her write a witness statement. She stated the ADM also asked her if she had witnessed any other incidents of abuse and she provided the ADM with 2 witness statements regarding 2 incidents of abuse which occurred on 07/06/22. She stated the second incident of abuse occurred with an aide who worked the 2PM to 10PM shift on 07/06/22 but she did not know the aide's or the resident's name. She said on 07/06/22 at around 4:45 PM, they were getting ready for dinner, and she was passing out the dinner trays. She stated and aide was trying to get Resident #2 to sit down in another area and Resident #2 did not want to. She said Resident #2 hit the aide in the face and the aide slapped Resident #2 in the face. CNA B said there was another facility staff sitting at the nurses' desk and she approached the aide and said something to her in a different language. CNA B said the aide then said she did not hit Resident #2 and CNA B told her she saw he slap Resident #2 twice. CNA B said she did not know the name of Resident #2 but described her as an older white female with short gray hair and medium build. CNA B said she also did not know the name of the aide who slapped Resident #2 but knew she drove and older brown car. She described the aide as a black female in her mid twenties with a height around 5'6 and she wore a honey blonde or brown wig at times. CNA B said she was upset because she saw her still working at the facility after she reported the abuse to the ADM on 07/08/22. CNA B stated she took pictures of the witness statements she provided to the ADM on 07/08/22 and would send the pictures to HHSC surveyor. Review of pictures provided by CNA B on 07/18/22 reflected there was a second witness statement not included in the provider investigation report. The witness statement was signed by CNA C, was dated 07/08/22 at 8:57AM and reflected: On [Wednesday] July 6, 2022 I was working on the 300 400 hall . it was 4:49 PM . me and two more ladies [were] getting the residents seated for as one of the residents was not ready to sit in her seat as I was passing the trays I noticed that the resident was still standing there it was 4:51 PM the worker was talking to the resident and said sit in your [seat] Resident #2 . I don't know the resident's name. At that point the resident hit the worker on the face mask the worker then hit Resident #2 back the worker was yelling she not going to hit me. Worker #2 got up walked over to worker #1 and said something to worker #1 in [their] language that's when worker #1 said I didn't hit her [Resident #2] and I said I saw you then I walked out [because] I was upset about the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review reflected the background of the picture included the witness statements were laid on a surface with a gray wood grain. In a telephone interview on 07/18/22 at 3:31 PM, CNA B said she took the pictures of the witness statements on 07/08/22 while in the social workers office. CNA B said she normally took pictures of her documents for her protection because she always thought to have a copy. An observation on 07/08/22 at 3:45 PM reflected the social workers office had a desk which was a gray wood grain color. Record review of the facility's CNA assignments form for July 2022, reflected CNA C was the aide who worked on the memory care unit on 07/06/22 on the 2PM to 10PM shift. Further review reflected CNA A worked on the memory care unit from 6AM to 10PM on 07/06/22, from 6AM to 2PM on 07/07/22, and was scheduled to work from 6AM to 2PM on 07/08/22. CNA C worked the 2PM to 10PM shift on 07/06/22 07/12/22 and 07/15/22 07/17/22. She was the only CNA scheduled to work the memory care unit on 07/18/22 on the 2PM to 10PM shift. In a telephone interview on 07/18/22 at 1:42 PM, CNA A said on 07/06/22 she and another staff member went in to change Resident #1 because he was a dementia patient, and he was the refusing type. She said there were two staff in the room as usual and one person was holding him down and one was changing him. She said CNA B was in the room with her and Resident #1 and she was orienting CNA B. She said CNA B was cleaning Resident #1 and she was holding him down so he could get clean. CNA A said Resident #1 hit her on the shoulder but she didn't hit him back. CNA A said when staff dealt with Resident #1, he would beat them but they never beat him back. CNA A said she also worked the evening shift on 07/06/22 with CNA C. CNA A said she did not work the memory care unit regularly but had worked with CNA C previously. When asked if she had ever observed CNA C hit a resident, CNA A said she could not say for sure [CNA C] had never hit a resident. When asked a second time if she had ever observed CNA C hit a resident, CNA A said, I don't know. CNA A said Resident #1 was a psycho patient and he did not require 1 person assistance for care. She stated he required 2 3 staff to give care. In an interview on 07/18/22 at 2:30PM, the DON stated on 07/08/22 he spoke with the ADM immediately after the ADM had spoken with CNA B and the ADM told him he had initiated the self repot. The DON stated on 07/08/22 CNA B had come to the facility looking for the ADM and when she reported the incident of abuse the ADM told him he had educated CNA B on immediately notifying the ADM of abuse. The DON stated education on abuse reporting was given and signed by all employees upon hiring by the HR department. The DON stated the ADM was not at the facility on 07/18/22 and was scheduled to return on 07/20/22. The DON stated in the absence of the ADM, the DON, in coordination with the regional director of operations, was the abuse coordinator. The DON stated when an allegation of abuse was made, the ADM would immediately be notified, and an abuse investigation would be started by the ADM. The DON stated the investigation would include interviews of staff and residents, specifically any residents the alleged perpetrator worked with. The DON stated the nurse would complete a physical assessment of the resident and stated it should be done pretty soon after the allegation of abuse was made but was unsure if the facility's abuse policy stated a specific timeframe when the physical assessment had to be completed. The DON stated if abuse was not reported and investigated immediately, there was the potential a resident could be left under the alleged abuser's care. The DON stated the investigation needed to be completed as soon as possible so the facility could intervene as quickly as possible. The DON stated he was not aware of a second incident of abuse reported by CNA B to the ADM which occurred on 07/06/22 and the alleged perpetrator was a 2PM to 10PM staff who slapped a resident on the memory care unit. The DON stated he would reach out to the ADM to find out if he was aware of the second alleged abuse which occurred on 07/06/22. In a telephone interview on 07/18/22 at 3:11 PM, the ADM stated CNA B had been hired as a van driver and was on the memory care unit on 07/06/22 to complete some skills checkoffs. The ADM stated on 07/08/22, after his morning rounds, CNA B asked if she could talk to him. He stated CNA B told him she witnessed CNA A hit Resident #1 and that she had tried to report it to the DON on 07/06/22 but he wasn't there. The ADM said he completed an in service with CNA B about immediately reporting abuse to the charge nurse. The ADM stated he placed CNA B in another office and asked her to write a witness statement about exactly what happened on 07/06/22. The ADM said he then contacted the DON to bring in CNA A and asked her some questions. The ADM stated CNA A told him she was having some problems with Resident #1 on 07/06/22 and she was holding him down during care. The ADM stated he told CNA A that was abuse because she could not physically restrain a resident and should have notified the charge nurse instead of continuing care. The ADM stated he also told CNA A there was an allegation regarding [Resident #1] hit her and she hit him. The ADM stated he told CNA A he would need to suspend her pending the investigation. The ADM stated the witness statement provided by CNA B was regarding Resident #1. While trying to provide care, Resident #1 was really agitated, and CNA A closed the door and she hit Resident #1 while they were in the room. The ADM stated CNA C and CNA A were generally the two who provide care for Resident #1. The ADM stated that was the only incident of abuse CNA B reported to him and he denied any knowledge of the slapping incident involving CNA C and Resident #2. The ADM stated if the incident took place in the dining area, there would be camera footage, but he did not believe he would be able to retrieve footage from that date. The ADM gave the name of CNA C as who he believed would have been the alleged perpetrator of the second incident of physical abuse on 07/06/22 and stated he was going to have the DON suspend her and have him call the incident in to the state agency. The ADM stated he would need to reach out to IT to see if they can assist me with that footage from 07/06/22. In an interview on 07/20/22 at 4:10PM, the DON stated he did not understand why we assume the ex employee's [CNA B] statement was accurate if nobody else witnessed anything. The DON stated when an allegation of abuse was reported that information went to the ADM who was the abuse coordinator. He stated in the absence of the ADM, the information went to him, the DON. The DON then said if the abuse incident truly occurred, it could occur again. The DON stated staff were expected to report abuse immediately. The DON said after an abuse allegation was made, he expected a nurse to complete and assessment of the resident the same shift which it was reported. In a telephone interview on 07/20/22 at 5:16 PM, the ADM stated there were cameras in the memory care unit at the nursing station and recorded each hallway and potentially the dining areas. The ADM stated the information technology department would be able to retrieve the video footage from 07/06/22 but they wanted him to be onsite for him to review the monitors. In an interview on 07/18/22 at 1PM, CNA D stated she had worked the memory care unit at the facility for 5 years. She stated she had worked with CNA A and said CNA A always came to work and she floated different halls. CNA D said on 07/06/22 for the 6AM to 2PM shift, there were 2 new trainees, CNA B and CNA E. She said CNA A was assigned to train CNA B on 07/06/22. CNA D said CNA A would work all the time, and she would be cranky sometimes. CNA D said CNA A would be upset or bothered when asked questions at times and she told CNA A if she was tired, she should stop working so many doubles or working her off days. In an interview on 07/20/22 at 12:15 PM, ADON H said in the evening of 07/08/22, the ADM called him and asked him to complete a physical assessment on Resident #1 because of reported abuse. ADON H said he immediately went to the memory care unit to assess Resident #1 and did not see any bruises or injuries. ADON H said a physical assessment should be done by a nurse as soon as abuse is witnessed or reported. ADON H said it was important to immediately report abuse so the facility could stop worse things from happening such as more residents being abused, worse harm, or even death. ADON H said if the ADM was not here, abuse should be reported to DON or the charge nurse supervisor. ADON H said once abuse was reported, the abuser needed to be removed from the facility immediately, before even starting the investigation. In an interview on 07/20/21 at 2:51PM, HA J said she worked the memory care unit on the 2PM to 10PM shift. HA J said Resident #1 would be apprehensive and aggressive when he's confused and doesn't know what's going on. HA J said at least 2 aides were required to provide ADL care for Resident #1. She said one aide would try to keep him from swinging and one would clean and put a pull up or a diaper on him. She said one aide would hold his hands that way if he would swing, we would yell duck, and try to keep him as calm as possible HA J said she had worked with CNA C and said she was a little direct and moves a little too fast with some of the residents. HA J said she did not see CNA C hurt any of the residents, but she was too quick, would not explain the procedure to the residents, and the residents would be stunned. 2.Review of Resident #3's EHR on 07/18/22 reflected she was a [AGE] year old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's progress notes reflected on 7/16/22 at 7:50 AM LVN N documented, While getting resident up for breakfast, resident noted with small discoloration to upper left lip. Upon questioning resident stated that she bit her lip. No complaints of pain or discomfort at this time . Review of Resident #3's care plans reflected: a. [Resident #3] has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to Dementia . b. Behavioral Problem . has a behavior problem as evidenced by: packing her clothes and wanting to go home daily. Prefers to keep boxes on the floor and bags . physical behaviors will not interfere with the delivery of ADL cares by staff through the next review date . Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log . Intervene as necessary to protect the rights and safety of others. Remove Resident #3 to an alternate location when needed to protect the rights and safety of others. c. Verbal Behavior . verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner . Cursing and yelling [at] Staff verbal behaviors . episodes of verbal behaviors will decrease to less than weekly through the next review date . Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log . Provide positive feedback for good behavior. Emphasize the positive aspects of compliance . An observation and interview on 07/18/22 at 12:16 PM reveled of Resident #3 was finished eating her lunch and was sitting at a dining table. Resident #3 had two bruises to her face, one to the area above her left lip and below her left nostril which was dark purple at the center and yellow at the edges. It was irregularly shaped. She also had a yellow green circular bruise to her left chin. There was not any bruising on the resident's lips. Resident #3 stated the bruise occurred 2 to 3 days ago but could no recall how it occurred. Resident #3 stated she did not remember falling and said, nobody hit me, at least I don't think anyone hit me. In an interview on 07/18/22 at 1PM, CNA D said she first noticed the bruise above Resident #3's lip on the morning of 07/17/22. CNA D said she had asked Resident #3 was happened and the resident said didn't know. CNA D said she worked with Resident #4 on 07/15/22 on the 2PM to 10PM shift and did not notice a bruise at that time. In an interview with the DON on 07/18/22 at 2:30 PM, HHSC Surveyor notified the DON of the bruises to Resident #3's face and stated the documented reason for the bruise that the resident had bit herself. When asked if Resident #3's injuries should have been reported and investigated as an injury of unknown origin given the location of the bruises and the resident's cognition, the DON did not answer. In an interview and observation on 07/19/22 at 9:45 AM, LVN N measured Resident #3's bruises with a paper measuring tool. The bruise above her left lip was 3 cm by 2 cm, the bruise to her chin was 2 cm in diameter. LVN N said she was told in report that Resident #3 had bitten herself which led to the bruising on her left lip. She stated she did not know how Resident #3 obtained the bruise to her chin. In an interview on 07/20/21 at 2:51PM, HA J said she worked on the memory care unit on the 2PM to 10PM shift on 07/15/22. HA J said Resident #3 could have obtained the bruises to her face on 07/15/22. HA J said Resident #3 was irate, clawing and scratching when she was trying to exit the memory care unit. HA J said Resident #3 and Resident #5 had an altercation, and Resident #3 was hitting Resident #5 because he was making annoying noises. HA J said she tried to separate Resident #3 and Resident #5 but Resident #5 could have hit Resident #4. HA J said she did not report the physical altercation between Resident #3 and Resident #5, but she should have reported it to the nurse. In an interview on 07/20/22 at 3:39 PM, LVN K said she was the nurse on the memory care unit in 07/15/22 for the 2PM to 10PM shift. She stated no one reported to her a physical altercation between Resident #3 and Resident #5 on that shift. LVN K said she was off 07/16/22 and 07/17/22 and the first time she saw Resident #3's facial bruises was on 07/18/22. LVN K said it stated on the 24 hour nurses report Resident #3 had bitten herself as the reason for her bruises. LVN K stated she did not know if the given reason for the bruises matched the bruises. LVN K said the bruise above Resident #3's lip was a very small bruise maybe 0.1cm. LVN K said she did not see the bruise to Resident #3's chin. LVN K said Resident #3 was really aggressive in her sundowning period, she hits staff, and she pisses off staff, she throws stuff, she cusses. In an interview on 04/20/22 at 4:10 PM, the DON stated staff were expected to report abuse immediately. The DON said after an abuse allegation was made, he expected a nurse to complete and assessment of the resident the same shift which it was reported. In an interview on 07/20/22 at 6:10 PM, the DON stated HA J was suspended for the failure to report the incident which occurred on 07/15/22 between Resident #3 and Resident #5. Review of the facility's abuse policy dated 02/01/21 reflected the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, and physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion, and corporal punishment. Residents must not be subjected to abuse by anyone. Each covered individual shall report to the state agency suspicion of a crime against resident. Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion result in at cause the serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in bodily injury. All alleged violation involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately, but no later than 2 hours after the allegation is made. The report is made to the ADM of the facility and other officials. Ways to protect a resident from harm during an investigation of abuse include temporary one to one observation, reassignment of nursing staff duties, time off for nursing staff, increased supervision for staff or residents, protection of staff and/or residents from retaliation. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source will be reported immediately to the ADM or DON. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the charge nurse. The charge nurse supervisor must immediately contact the ADM or the DON of the incident. The ADM or designee will immediately begin an investigation including methods to support the individual and detect and prevent further victimization. The DON was notified of the IJ on 07/19/22 at 5:08 PM, a POR was requested and was provided the IJ template. The POR was accepted on 07/19/22 at 3:43 PM. Review of the POR included: . Immediate action(s) taken for the resident(s) found to have been affected include: Facility Administrator reported allegation of abuse to that happened on 07/6/2022 in the dining room to state agency. The surveyor brought the allegation of abuse to the attention of the DON and Administrator 7/18/2022. DON contacted the CNA (B) witnessed the slap that happened the dining room by CNA (C), to identify the resident. CNA (B) does not remember the residents name or can identify the resident. The LVN/charge nurse will complete a head to toe evaluation on all residents that reside in the memory care unit and document findings on the skin observation work sheet on 7/19/2022 The findings were no signs or symptoms of injury that wasn't previously identified Facility DON suspended CNA (C) who allegedly slapped the resident pending investigation on 7/18/2022 On 7/18/2022 Facility DON began immediately conducting an Abuse allegation investigation for the allegation made on 7/6/2022 investigation is on going . Actions to Prevent Occurrence/Recurrence: DON was in serviced on abuse policy by RNC on 7/18/2022 On 7/18/22 employees were in serviced by the DON and ADONs and Post Test was given on demonstrate understanding Abuse Policy which includes: All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately to the Administrator or the DON. Note: If the a [TRUNCATED]

Based on interview, observation, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect of residents for three (Resident #2, Resident #3, and Resident #5) of 38 residents reviewed for abuse and neglect. The facility failed to implement a policy and process for immediately investigating and reporting allegations of abuse and neglect to HHSC for: 1. allegations of abuse for Resident #2 reported to facility on 07/08/22 and 07/18/22; 2. injury of unknown origin for Resident #3 observed by the facility on 07/16/22; 3. and witnessed abuse on 07/15/22 of Resident #3 and Resident #5. These failures could affect all 38 residents in the memory care unit by placing them at risk for abuse and physical restraints and could lead to serious injury, serious harm, serious impairment, pain, mental anguish, or death. An IJ was identified on 07/19/22 at 5:08 PM. The DON was notified, and a POR was requested. While the IJ was removed on 07/20/22 at 7:25PM, the facility remained out of compliance at a scope of pattern, at the severity level of no actual harm with potential for more than minimal harm due to the facility's need to complete in service training and evaluate the effectiveness of the corrective systems. Findings included: Review of the facility's abuse policy dated 02/01/21 reflected the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, and physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion, and corporal punishment. Residents must not be subjected to abuse by anyone. Each covered individual shall report to the state agency suspicion of a crime against resident. Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion result in at cause the serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in bodily injury. All alleged violation involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately, but no later than 2 hours after the allegation is made. The report is made to the ADM of the facility and other officials. Ways to protect a resident from harm during an investigation of abuse include temporary one to one observation, reassignment of nursing staff duties, time off for nursing staff, increased supervision for staff or residents, protection of staff and/or residents from retaliation. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source will be reported immediately to the ADM or DON. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the charge nurse. The charge nurse supervisor must immediately contact the ADM or the DON of the incident. The ADM or designee will immediately begin an investigation including methods to support the individual and detect and prevent further victimization. In a telephone interview on 07/18/22 10:49 AM, CNA B stated on 07/06/22 she was working on the memory care unit being trained. She stated between 3PM and 4PM she was training with CNA A. She said Resident #1 had soiled his pants and was refusing to go to his room. She said she, CNA A, and Resident #1 were walking down the hallway towards his room and Resident #1 turned around to go back to the day room. She said CNA A told Resident #1 he needed to go to his room, and after Resident #1 entered his room, CNA A closed the door with her foot and hand and Resident #1 began beating on the door and cursing let me out. CNA B said she told CNA A she did not have to do that, and she talked to Resident #1 and calmed him down. CNA A told Resident #1 he was a mess and he smelled, but Resident #1 did not want CNA A to change him and hit CNA A. CNA B said CNA A hit Resident #1's hand with an open hand and told CNA B she did not know Resident #1. CNA B said once Resident #1 was lying on the bed, CNA A held him down by restraining his arms and CNA B completed incontinent care for Resident #1. Resident #1 again hit CNA A during incontinent care and CNA A retaliated by hitting Resident #1 on his forearm with a closed fist. CNA B said she told CNA A she should not hit a resident and CNA A told her she was new and that was why nobody wanted to work with Resident #1. CNA B said she did not say anything else to CNA A because she felt it was inappropriate to argue in front of a resident and CNA A then pointed her finger at Resident #1 and said, you don't hit me. CNA B said she got off work at 5PM on 07/06/22 and when she went to report the incident of abuse to the ADM or DON, there was nobody in the office. She stated she reported the incident of abuse to the ADM on the morning of 07/08/22. CNA B said she I received training on abuse and neglect, and she was going report the incident of abuse on 07/06/22 but there was no one in the office when [she] was leaving for the day, and she didn't know who to report it to. CNA B said once she reported the incident to the ADM, he thanked her for bringing it to his attention and had her write a witness statement. She stated the ADM also asked her if she had witnessed any other incidents of abuse and she provided the ADM with 2 witness statements regarding 2 incidents of abuse which occurred on 07/06/22. She stated the second incident of abuse occurred with an aide who worked the 2PM to 10PM shift on 07/06/22 but she did not know the aide's or the resident's name. She said on 07/06/22 at around 4:45 PM, they were getting ready for dinner and she was passing out the dinner trays. She stated and aide was trying to get Resident #2 to sit down in another area and Resident #2 did not want to. She said Resident #2 hit the aide in the face and the aide slapped Resident #2 in the face. CNA B said there was another facility staff sitting at the nurses' desk and she approached the aide and said something to her in a different language. CNA B said the aide then said she did not hit Resident #2 and CNA B told her she saw he slap Resident #2 twice. CNA B said she did not know the name of Resident #2 but described her as an older white female with short gray hair and medium build. CNA B said she also did not know the name of the aide who slapped Resident #2 but knew she drove and older brown car. She described the aide as a black female in her mid twenties with a height around 5'6 and she wore a honey blonde or brown wig at times. CNA B said she was upset because she saw her still working at the facility after she reported the abuse to the ADM on 07/08/22. CNA B stated she took pictures of the witness statements she provided to the ADM on 07/08/22 and would send the pictures to HHSC surveyor. CNA B stated she had not been at the facility since 07/15/22 and was not sure if or when she would return to the facility to help identify Resident #2. Review of pictures provided by CNA B on 07/18/22 reflected there was a second witness statement not included in the provider investigation report. The witness statement was signed by CNA C, was dated 07/08/22 at 8:57AM and reflected: On [Wednesday] July 6, 2022 I was working on the 300 400 hall . it was 4:49 PM . me and two more ladies [were] getting the residents seated for as one of the residents was not ready to sit in her seat as I was passing the trays I noticed that the resident was still standing there it was 4:51 PM the worker was talking to the resident and said sit in your [seat] Resident #2 . I don't know the resident's name. At that point the resident hit the worker on the face mask the worker then hit Resident #2. back the worker was yelling she not going to hit me. Worker #2 got up walked over to worker #1 and said something to worker #1 in [their] language that's when worker #1 said I didn't hit her [Resident #2] and I said I saw you then I walked out [because] I was upset about the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review reflected the background of the picture included the witness statements were laid on a surface with a gray wood grain. In a telephone interview on 07/18/22 at 3:31 PM, CNA B said she took the pictures of the witness statements on 07/08/22 while in the social workers office. CNA B said she normally took pictures of her documents for her protection because she always thought to have a copy. An observation on 07/08/22 at 3:45 PM reflected the social workers office had a desk which was a gray wood grain color. Record review of the facility's CNA assignments form for July 2022, reflected CNA C was the aide who worked on the memory care unit on 07/06/22 on the 2PM to 10PM shift. Further review reflected CNA A worked on the memory care unit from 6AM to 10PM on 07/06/22, from 6AM to 2PM on 07/07/22, and was scheduled to work from 6AM to 2PM on 07/08/22. CNA C worked on the memory care unit on the 2PM to 10PM shift on 07/06/22 07/12/22 and 07/15/22 07/17/22. She was the only CNA scheduled to work the memory care unit on 07/18/22 on the 2PM to 10PM shift. In a telephone interview on 07/18/22 at 1:42 PM, CNA A said on 07/06/22 she and another staff member went in to change Resident #1 because he was a dementia patient, and he was the refusing type. She said there were two staff in the room as usual and one person was holding him down and one was changing him. She said CNA B was in the room with her and Resident #1 and she was orienting CNA B. She said CNA B was cleaning Resident #1 and she was holding him down so he could get clean. CNA A said Resident #1 hit her on the shoulder but she didn't hit him back. CNA A said when staff dealt with Resident #1, he would beat them but they never beat him back. CNA A said she also worked the evening shift on 07/06/22 with CNA C. CNA A said she did not work the memory care unit regularly but had worked with CNA C previously. When asked if she had ever observed CNA C hit a resident, CNA A said she could not say for sure [CNA C] had never hit a resident. When asked a second time if she had ever observed CNA C hit a resident, CNA A said, I don't know. CNA A said Resident #1 was a psycho patient and he did not require 1 person assistance for care. She stated he required 2 3 staff to give care. In an interview on 07/18/22 at 2:30PM, the DON stated on 07/08/22 he spoke with the ADM immediately after the ADM had spoken with CNA B and the ADM told him he had initiated the self repot. The DON stated on 07/08/22 CNA B had come to the facility looking for the ADM and when she reported the incident of abuse the ADM told him he had educated CNA B on immediately notifying the ADM of abuse. The DON stated education on abuse reporting was given and signed by all employees upon hiring. The DON stated the ADM was not at the facility on 07/18/22 and was scheduled to return on 07/20/22. The DON stated in the absence of the ADM, the DON, in coordination with the regional director of operations, was the abuse coordinator. The DON stated when an allegation of abuse was made, the ADM would immediately be notified, and an abuse investigation would be started. The DON stated the investigation would include interviews of staff and residents, specifically any residents the alleged perpetrator worked with. The DON stated the nurse would complete a physical assessment of the resident and stated it should be done pretty soon after the allegation of abuse was made but was unsure if the facility's abuse policy stated a specific timeframe when the physical assessment had to be completed. The DON stated if abuse was not reported and investigated immediately, there was the potential a resident could be left under the alleged abuser's care. The DON stated the investigation needed to be completed as soon as possible so the facility could intervene as quickly as possible. The DON stated he was not aware of a second incident of abuse reported by CNA B to the ADM which occurred on 07/06/22 and the alleged perpetrator was a 2PM to 10PM staff who slapped a resident on the memory care unit. The DON stated he would reach out to the ADM to find out if he was aware of the second alleged abuse which occurred on 07/06/22. In a telephone interview on 07/18/22 at 3:11 PM, the ADM stated CNA B had been hired as a van driver and was on the memory care unit on 07/06/22 to complete some skills checkoffs. The ADM stated on 07/08/22, after his morning rounds, CNA B asked if she could talk to him. He stated CNA B told him she witnessed CNA A hit Resident #1 and that she had tried to report it to the DON on 07/06/22 but he wasn't there. The ADM said he completed an in service with CNA B about immediately reporting abuse to the charge nurse. The ADM stated he placed CNA B in another office and asked her to write a witness statement about exactly what happened on 07/06/22. The ADM said he then contacted the DON to bring in CNA A and asked her some questions. The ADM stated CNA A told him she was having some problems with Resident #1 on 07/06/22 and she was holding him down during care. The ADM stated he told CNA A that was abuse because she could physically restrain a resident and should have notified the charge nurse instead of continuing care. The ADM stated he also told CNA A there was an allegation regarding [Resident #1] hit her and she hit him. The ADM stated he told CNA A he would need to suspend her pending the investigation. The ADM stated the witness statement provided by CNA B was regarding Resident #1. While trying to provide care, Resident #1 was really agitated, and CNA A closed the door and she hit Resident #1 while they were in the room. The ADM stated CNA C and CNA A were generally the two who provide care for Resident #1. The ADM stated that was the only incident of abuse CNA B reported to him and he denied any knowledge of the slapping incident involving CNA C and Resident #2. The ADM stated if the incident took place in the dining area, there would be camera footage, but he did not believe he would be able to retrieve footage from that date. The ADM gave the name of CNA C as who he believed would have been the alleged perpetrator of the second incident of physical abuse on 07/06/22 and stated he was going to have the DON suspend her and have him call the incident in to the state agency. The ADM stated he would need to reach out to IT to see if they can assist me with that footage from 07/06/22. In an interview and observation on 07/18/22 at 4:13 PM, CNA C was on the memory care unit with a resident in a room with the door closed. When she exited the resident's room, she stated she was the only aide working the memory care unit and believed the other aide was running late. There were 2 nurses working the memory care unit. In an interview and observation on 07/18/22 at 5:05PM, CNA C was on the memory care unit passing out meal trays. She stated she was still the only aide working the memory care unit and believed the other aide had called in. In an observation on 07/18/22 at 5:33 PM, CNA C walked from the direction of the memory care unit to the front of the building towards the DON's office. In an interview on 07/20/22 at 4:10PM, the DON stated on 07/18/22 after he spoke with HHSC surveyor at 2:30 PM he called the ADM, and he confirmed the ADM did not have knowledge of a second abuse allegations regarding CNA D. The DON stated the ADM had told him he would follow up with the HHSC Surveyor and he did not speak with him until after the IJ was called. The DON stated he did not begin the abuse investigation regarding an unidentified aide who worked on 07/06/22 on the 2PM to 10PM shift because he was unaware it was considered to be a reportable. The DON stated he did not follow up with the ADM on 07/18/22 regarding the second abuse allegation because he did not feel like interrupting [the ADM's] funeral was the appropriate thing to do. The DON stated he did not understand why we assume the ex employee's [CNA B] statement was accurate if nobody else witnessed anything. The DON asked why the facility would report once incident of abuse and not the other. The DON stated when he spoke with HHSC Surveyor on 07/18/22 at 2:20 PM, the second allegation of abuse involving CNA C sounded like and angry ex employee [CNA B] making allegations. The DON said he did not care who makes the allegation, we will investigate and report. The DON stated when an allegation of abuse was reported that information went to the ADM who was the abuse coordinator. He stated in the absence of the ADM, the information went to him, the DON. He stated it was his responsibility to immediately make sure the residents were safe. The DON said he made sure the residents on the memory care unit were safe on 07/18/22 when he pulled [CNA C] off the unit. The DON said when abuse was reported, the alleged perpetrator should be removed from the facility ideally immediately. He said on 07/18/22 there was no name given of the second alleged perpetrator. The DON said if the alleged perpetrator was not named, he would try to figure if there's a description and if the only description was date and shift, he would have to potentially remove anybody that was on that shift. The DON said stated there was a delay in investigating the second alleged abuse incident and in removing CNA C from the facility because CNA B's witness statement was not shared with him and the DON denied HHSC surveyor informed him the incident occurred on 07/06/22 on the 2PM to 10PM shift. The DON stated if he was not given all the information to investigate an abuse allegation it was his responsibility to ask additional questions such as did you witness this? What time? What location? Do you know who was involved? Have you seen this happen before? He said on 07/18/22 he should have asked those type of questions to start the abuse investigation. The DON said if an alleged perpetrator of abuse was not removed from the facility, he did not know what could happen because that was speculative. The DON then said if the abuse incident truly occurred, it could occur again. The DON stated staff were expected to report abuse immediately. The DON said after an abuse allegation was made, he expected a nurse to complete and assessment of the resident the same shift which it was reported .In a telephone interview on 07/20/22 at 5:16 PM, the ADM stated there were cameras in the memory care unit at the nursing station and recorded each hallway and potentially the dining areas. The ADM stated IT stated they would be able to retrieve the video footage from 07/06/22 but they wanted him to be onsite for him to review the monitors. The ADM stated once abuse was reported, the facility should immediately ensure the resident safety and immediately suspend the staff member while you launch an investigation. The ADM stated on 07/18/22 the DON should have immediately reported the abuse allegation to the state agency and determined which staff were present on the memory care unit on 07/06/22 on the 2PM to 10PM shift by looking at the active staff from that day and punch time detail report, had the resident assessed, notified the RP, and determined an emotional distress of the resident. The ADM stated in his absence the DON was second in line as the abuse coordinator and he expected all staff to report all allegations of abuse to him, the ADM even if he was out, he identified. The ADM stated he identified CNA C as the alleged perpetrator based on the description and because CNA C was the staff who routinely worked on the memory care unit on the 2PM to 10PM shift. The ADM stated, right after he spoke with HHSC Surveyor on 07/18/22 at 3:11PM, he contacted the DON via telephone, told him to remove CNA C from the facility and told [the DON] about the investigation steps. In an interview on 07/18/22 at 1PM, CNA D stated she had worked the memory care unit at the facility for 5 years. She stated she had worked with CNA A and said CNA A always came to work and she floated different halls. CNA D said on 07/06/22 for the 6AM to 2PM shift, there were 2 new trainees, CNA B and CNA E. She said CNA A was assigned to train CNA B on 07/06/22. CNA D said CNA A would work all the time, and she would be cranky sometimes. CNA D said CNA A would be upset or bothered when asked questions at times and she told CNA A if she was tired, she should stop working so many doubles or working her off days. In an interview on 07/20/22 at 12:15 PM, ADON H said in the evening of 07/08/22, the ADM called him and asked him to complete a physical assessment on Resident #1 because of reported abuse. ADON H said he immediately went to the memory care unit to assess Resident #1 and did not see any bruises or injuries. ADON H said a physical assessment should be done by a nurse as soon as abuse is witnessed or reported. ADON H said it was important to immediately report abuse so the facility could stop worse things from happening such as more residents being abused, worse harm, or even death. ADON H said if the ADM was not here, abuse should be reported to DON or the charge nurse supervisor. ADON H said once abuse is reported, the abuser needed to be removed from the facility immediately, before even starting the investigation. In an interview on 07/20/21 at 2:51PM, HA J said she worked the memory care unit on the 2PM to 10PM shift. HA J said Resident #1 would be apprehensive and aggressive when he's confused and doesn't know what's going on. HA J said at least 2 aides were required to provide ADL care for Resident #1. She said one aide would try to keep him from swinging and one would clean and put a pull up or a diaper on him. She said one aide would hold his hands that way if he would swing, we would yell duck, and try to keep him as calm as possible HA J said she had worked with CNA C and said she was a little direct and moves a little too fast with some of the residents. HA J said she did not see CNA C hurt any of the residents, but she was too quick, would not explain the procedure to the residents, and the residents would be stunned. 2.Review of Resident #3's EHR on 07/18/22 reflected she was a [AGE] year old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's progress notes reflected on 7/16/22 at 7:50 AM LVN N documented, While getting resident up for breakfast, resident noted with small discoloration to upper left lip. Upon questioning resident stated that she bit her lip. No complaints of pain or discomfort at this time . Review of Resident #3's care plans reflected: a. [Resident #3] has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to Dementia . b. Behavioral Problem . has a behavior problem as evidenced by: packing her clothes and wanting to go home daily. Prefers to keep boxes on the floor and bags . physical behaviors will not interfere with the delivery of ADL cares by staff through the next review date . Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log . Intervene as necessary to protect the rights and safety of others. Remove Resident #3 to an alternate location when needed to protect the rights and safety of others. c. Verbal Behavior . verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner . Cursing and yelling [at] Staff verbal behaviors . episodes of verbal behaviors will decrease to less than weekly through the next review date . Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log . Provide positive feedback for good behavior. Emphasize the positive aspects of compliance . An observation and interview on 07/18/22 at 12:16 PM reveled of Resident #3 was finished eating her lunch and was sitting at a dining table. Resident #3 had two bruises to her face, one to the area above her left lip and below her left nostril which was dark purple at the center and yellow at the edges. It was irregularly shaped. She also had a yellow green circular bruise to her left chin. There was not any bruising on the resident's lips. Resident #3 stated the bruise occurred 2 to 3 days ago but could no recall how it occurred. Resident #3 stated she did not remember falling and said, nobody hit me, at least I don't think anyone hit me. In an interview on 07/18/22 at 1PM, CNA D said she first noticed the bruise above Resident #3's lip on the morning of 07/17/22. CNA D said she had asked Resident #3 was happened and the resident said didn't know. CNA D said she worked with Resident #4 on 07/15/22 on the 2PM to 10PM shift and did not notice a bruise at that time. In an interview with the DON on 07/18/22 at 2:30 PM, HHSC Surveyor notified the DON of the bruises to Resident #3's face and stated the documented reason for the bruise that the resident had bit herself. When asked if Resident #3's injuries should have been reported and investigated as an injury of unknown origin given the location of the bruises and the resident's cognition, the DON did not answer. In an interview and observation on 07/19/22 at 9:45 AM, LVN N measured Resident #3's bruises with a paper measuring tool. The bruise above her left lip was 3 cm by 2 cm, the bruise to her chin was 2 cm in diameter. LVN N said she was told in report that Resident #3 had bitten herself which led to the bruising on her left lip. She stated she did not know how Resident #3 obtained the bruise to her chin. In an interview on 07/20/21 at 2:51PM, HA J said she worked on the memory care unit on the 2PM to 10PM shift on 07/15/22. HA J said Resident #3 could have obtained the bruises to her face on 07/15/22. HA J said Resident #3 was irate, clawing and scratching when she was trying to exit the memory care unit. HA J said Resident #3 and Resident #5 had an altercation, and Resident #3 was hitting Resident #5 because he was making annoying noises. HA J said she tried to separate Resident #3 and Resident #5 but Resident #5 could have hit Resident #4. HA J said she did not report the physical altercation between Resident #3 and Resident #5, but she should have reported it to the nurse. In an interview on 07/20/22 at 3:39 PM, LVN K said she was the nurse on the memory care unit in 07/15/22 for the 2PM to 10PM shift. She stated no one reported to her a physical altercation between Resident #3 and Resident #5 on that shift. LVN K said she was off 07/16/22 and 07/17/22 and the first time she saw Resident #3's facial bruises was on 07/18/22. LVN K said it stated on the 24 hour nurses report Resident #3 had bitten herself as the reason for her bruises. LVN K stated she did not know if the given reason for the bruises matched the bruises. LVN K said the bruise above Resident #3's lip was a very small bruise maybe 0.1cm. LVN K said she did not see the bruise to Resident #3's chin. LVN K said Resident #3 was really aggressive in her sundowning period, she hits staff, and she pisses off staff, she throws stuff, she cusses. In an interview on 04/20/22 at 4:10 PM, the DON stated staff were expected to report abuse immediately. The DON said after an abuse allegation was made, he expected a nurse to complete and assessment of the resident the same shift which it was reported. In an interview on 07/20/22 at 6:10 PM, the DON stated HA J was suspended for the failure to report the incident which occurred on 07/15/22 between Resident #3 and Resident #5. The DON was notified of the IJ on 07/19/22 at 5:08 PM, a POR was requested and was provided the IJ template. The POR was accepted on 07/19/22 at 3:43 PM. Review of the POR included: . Immediate action(s) taken for the resident(s) found to have been affected include: Facility Administrator reported allegation of abuse to that happened on 0/6/2022 in the dining room to state agency. The surveyor brought the allegation of abuse to the attention of the DON and Administrator 7/18/2022. DON contacted the CNA (B) witnessed the slap that happened the dining room by CNA (C), to identify the resident. CNA (B) does not remember the residents name or can identify the resident. The LVN/charge nurse will complete a head to toe evaluation on all residents that reside in the memory care unit and document findings on the skin observation work sheet on 7/19/2022 The findings were no signs or symptoms of injury that wasn't previously identified Facility DON suspended CNA (C) who allegedly slapped the resident pending investigation on 7/18/2022 On 7/18/2022 Facility DON began immediately conducting an Abuse allegation investigation for the allegation made on 7/6/2022 investigation is on going . Actions to Prevent Occurrence/Recurrence: DON was in serviced on abuse policy by RNC on 7/18/2022 On 7/18/22 employees were in serviced by the DON and ADONs and Post Test was given on demonstrate understanding Abuse Policy which includes: All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately to the Administrator or the DON. Note: If the alleged abuse/neglect involves the Administrator, report incident immediately to the DON. If the DON is not available, report the incident immediately to the Regional Vice President or Regional Nurse Consultant. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the Charge Nurse or Supervisor in charge The Administrator will immediately report any allegation of mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property to the state survey office. The Charge Nurse or Supervisor must immediately contact the Administrator or the DON of the incident. No staff members will be allowed to work until they have received the Inservice and completed the post test. In servicing and post test for Abuse will be completed by 7/19/2022 Administrator will create an abuse file to include witness statements on abuse case then report abuse to state agency How the corrective action(s) will be monitored to ensure the practice will not recur: Effective 7/18/22 the ADONs and Charge nurse will supervise staff during rounds daily on the unit to identify inappropriate behaviors, such a using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate their beds through 8/18/22. Any findings will be documented in progress notes and reviewed by DON. The department heads during quality of life rounds will talk to residents about staffing practices during care such as inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, not answering call light, directing residents who need toileting assistance to urinate or defecate in their beds, and reporting skin alterations like bruises and skin tears. Daily the Charge nurses and the aides will document on the skin observation worksheet any skin alterations such as bruising, skin tears, and immediately report to the administrator and DON. The facility will not employ or otherwise engage individuals who Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Have disciplinary action in effect into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Have disciplinary action in effect against his or her professional license by the state licens [TRUNCATED]

Based on interview, observation, and record review, the facility failed to, in response to allegations of abuse, have evidence that all alleged violations are thoroughly investigated, prevent further potential abuse while the investigation was in progress, and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for three (Resident #2, Resident #3, and Resident #5) of 38 residents reviewed for abuse and neglect. The facility failed to investigate, prevent, and report allegations of abuse when: 1. allegations of abuse for Resident #2 were reported to facility on 07/08/22 and 07/18/22 and the facility did not investigate or implement measures to protect the residents from further abuse; 2. injury of unknown origin for Resident #3 was observed by the facility on 07/16/22 and was not investigated nor reported; 3. and witnessed abuse on 07/15/22 of Resident #3 and Resident #5 was not investigated nor reported. These failures could affect all 38 residents in the memory care unit by placing them at risk for abuse and physical restraints and could lead to serious injury, serious harm, serious impairment, pain, mental anguish, or death. An IJ was identified on 07/19/22 at 5:08 PM. The DON was notified, and a POR was requested. While the IJ was removed on 07/20/22 at 7:25PM, the facility remained out of compliance at a scope of pattern, at the severity level of no actual harm with potential for more than minimal harm due to the facility's need to complete in service training and evaluate the effectiveness of the corrective systems. Findings included: Review of the facility's abuse policy dated 02/01/21 reflected the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, and physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion, and corporal punishment. Residents must not be subjected to abuse by anyone. Each covered individual shall report to the state agency suspicion of a crime against resident. Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion result in at cause the serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in bodily injury. All alleged violation involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately, but no later than 2 hours after the allegation is made. The report is made to the ADM of the facility and other officials. Ways to protect a resident from harm during an investigation of abuse include temporary one to one observation, reassignment of nursing staff duties, time off for nursing staff, increased supervision for staff or residents, protection of staff and/or residents from retaliation. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source will be reported immediately to the ADM or DON. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the charge nurse. The charge nurse supervisor must immediately contact the ADM or the DON of the incident. The ADM or designee will immediately begin an investigation including methods to support the individual and detect and prevent further victimization. In a telephone interview on 07/18/22 10:49 AM, CNA B stated on 07/06/22 she was working on the memory care unit being trained. She stated between 3PM and 4PM she was training with CNA A. She said Resident #1 had soiled his pants and was refusing to go to his room. She said she, CNA A, and Resident #1 were walking down the hallway towards his room and Resident #1 turned around to go back to the day room. She said CNA A told Resident #1 he needed to go to his room, and after Resident #1 entered his room, CNA A closed the door with her foot and hand and Resident #1 began beating on the door and cursing let me out. CNA B said she told CNA A she did not have to do that, and she talked to Resident #1 and calmed him down. CNA A told Resident #1 he was a mess and he smelled, but Resident #1 did not want CNA A to change him and hit CNA A. CNA B said CNA A hit Resident #1's hand with an open hand and told CNA B she did not know Resident #1. CNA B said once Resident #1 was lying on the bed, CNA A held him down by restraining his arms and CNA B completed incontinent care for Resident #1. Resident #1 again hit CNA A during incontinent care and CNA A retaliated by hitting Resident #1 on his forearm with a closed fist. CNA B said she told CNA A she should not hit a resident and CNA A told her she was new and that was why nobody wanted to work with Resident #1. CNA B said she did not say anything else to CNA A because she felt it was inappropriate to argue in front of a resident and CNA A then pointed her finger at Resident #1 and said, you don't hit me. CNA B said she got off work at 5PM on 07/06/22 and when she went to report the incident of abuse to the ADM or DON, there was nobody in the office. She stated she reported the incident of abuse to the ADM on the morning of 07/08/22. CNA B said she I received training on abuse and neglect, and she was going report the incident of abuse on 07/06/22 but there was no one in the office when [she] was leaving for the day, and she didn't know who to report it to. CNA B said once she reported the incident to the ADM, he thanked her for bringing it to his attention and had her write a witness statement. She stated the ADM also asked her if she had witnessed any other incidents of abuse and she provided the ADM with 2 witness statements regarding 2 incidents of abuse which occurred on 07/06/22. She stated the second incident of abuse occurred with an aide who worked the 2PM to 10PM shift on 07/06/22 but she did not know the aide's or the resident's name. She said on 07/06/22 at around 4:45 PM, they were getting ready for dinner, and she was passing out the dinner trays. She stated and aide was trying to get Resident #2 to sit down in another area and Resident #2 did not want to. She said Resident #2 hit the aide in the face and the aide slapped Resident #2 in the face. CNA B said there was another facility staff sitting at the nurses' desk and she approached the aide and said something to her in a different language. CNA B said the aide then said she did not hit Resident #2 and CNA B told her she saw he slap Resident #2 twice. CNA B said she did not know the name of Resident #2 but described her as an older white female with short gray hair and medium build. CNA B said she also did not know the name of the aide who slapped Resident #2 but knew she drove and older brown car. She described the aide as a black female in her mid twenties with a height around 5'6 and she wore a honey blonde or brown wig at times. CNA B said she was upset because she saw her still working at the facility after she reported the abuse to the ADM on 07/08/22. CNA B stated she took pictures of the witness statements she provided to the ADM on 07/08/22 and would send the pictures to HHSC surveyor. CNA B stated she had not been at the facility since 07/15/22 and was not sure if or when she would return to the facility to help identify Resident #2. Review of pictures provided by CNA B on 07/18/22 reflected there was a second witness statement not included in the provider investigation report. The witness statement was signed by CNA C, was dated 07/08/22 at 8:57AM and reflected: On [Wednesday] July 6, 2022 I was working on the 300 400 hall . it was 4:49 PM . me and two more ladies [were] getting the residents seated for as one of the residents was not ready to sit in her seat as I was passing the trays I noticed that the resident was still standing there it was 4:51 PM the worker was talking to the resident and said sit in your [seat] Resident #2 . I don't know the resident's name. At that point the resident hit the worker on the face mask the worker then hit Resident #2 back the worker was yelling she not going to hit me. Worker #2 got up walked over to worker #1 and said something to worker #1 in [their] language that's when worker #1 said I didn't hit her [Resident #2] and I said I saw you then I walked out [because] I was upset about the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review reflected the background of the picture included the witness statements were laid on a surface with a gray wood grain. In a telephone interview on 07/18/22 at 3:31 PM, CNA B said she took the pictures of the witness statements on 07/08/22 while in the social workers office. CNA B said she normally took pictures of her documents for her protection because she always thought to have a copy. An observation on 07/08/22 at 3:45 PM reflected the social workers office had a desk which was a gray wood grain color. Record review of the facility's CNA assignments form for July 2022, reflected CNA C was the aide who worked on the memory care unit on 07/06/22 on the 2PM to 10PM shift. Further review reflected CNA A worked on the memory care unit from 6AM to 10PM on 07/06/22, from 6AM to 2PM on 07/07/22, and was scheduled to work from 6AM to 2PM on 07/08/22. CNA C worked on the memory care unit on the 2PM to 10PM shift on 07/06/22 07/12/22 and 07/15/22 07/17/22. She was the only CNA scheduled to work the memory care unit on 07/18/22 on the 2PM to 10PM shift. In a telephone interview on 07/18/22 at 1:42 PM, CNA A said on 07/06/22 she and another staff member went in to change Resident #1 because he was a dementia patient, and he was the refusing type. She said there were two staff in the room as usual and one person was holding him down and one was changing him. She said CNA B was in the room with her and Resident #1 and she was orienting CNA B. She said CNA B was cleaning Resident #1 and she was holding him down so he could get clean. CNA A said Resident #1 hit her on the shoulder but she didn't hit him back. CNA A said when staff dealt with Resident #1, he would beat them but they never beat him back. CNA A said she also worked the evening shift on 07/06/22 with CNA C. CNA A said she did not work the memory care unit regularly but had worked with CNA C previously. When asked if she had ever observed CNA C hit a resident, CNA A said she could not say for sure [CNA C] had never hit a resident. When asked a second time if she had ever observed CNA C hit a resident, CNA A said, I don't know. CNA A said Resident #1 was a psycho patient and he did not require 1 person assistance for care. She stated he required 2 3 staff to give care. In an interview on 07/18/22 at 2:30PM, the DON stated on 07/08/22 he spoke with the ADM immediately after the ADM had spoken with CNA B and the ADM told him he had initiated the self repot. The DON stated on 07/08/22 CNA B had come to the facility looking for the ADM and when she reported the incident of abuse the ADM told him he had educated CNA B on immediately notifying the ADM of abuse. The DON stated education on abuse reporting was given and signed by all employees upon hiring. The DON stated the ADM was not at the facility on 07/18/22 and was scheduled to return on 07/20/22. The DON stated in the absence of the ADM, the DON, in coordination with the regional director of operations, was the abuse coordinator. The DON stated when an allegation of abuse was made, the ADM would immediately be notified, and an abuse investigation would be started. The DON stated the investigation would include interviews of staff and residents, specifically any residents the alleged perpetrator worked with. The DON stated the nurse would complete a physical assessment of the resident and stated it should be done pretty soon after the allegation of abuse was made but was unsure if the facility's abuse policy stated a specific timeframe when the physical assessment had to be completed. The DON stated if abuse was not reported and investigated immediately, there was the potential a resident could be left under the alleged abuser's care. The DON stated the investigation needed to be completed as soon as possible so the facility could intervene as quickly as possible. The DON stated he was not aware of a second incident of abuse reported by CNA B to the ADM which occurred on 07/06/22 and the alleged perpetrator was a 2PM to 10PM staff who slapped a resident on the memory care unit. The DON stated he would reach out to the ADM to find out if he was aware of the second alleged abuse which occurred on 07/06/22. In a telephone interview on 07/18/22 at 3:11 PM, the ADM stated CNA B had been hired as a van driver and was on the memory care unit on 07/06/22 to complete some skills checkoffs. The ADM stated on 07/08/22, after his morning rounds, CNA B asked if she could talk to him. He stated CNA B told him she witnessed CNA A hit Resident #1 and that she had tried to report it to the DON on 07/06/22 but he wasn't there. The ADM said he completed an in service with CNA B about immediately reporting abuse to the charge nurse. The ADM stated he placed CNA B in another office and asked her to write a witness statement about exactly what happened on 07/06/22. The ADM said he then contacted the DON to bring in CNA A and asked her some questions. The ADM stated CNA A told him she was having some problems with Resident #1 on 07/06/22 and she was holding him down during care. The ADM stated he told CNA A that was abuse because she could physically restrain a resident and should have notified the charge nurse instead of continuing care. The ADM stated he also told CNA A there was an allegation regarding [Resident #1] hit her and she hit him. The ADM stated he told CNA A he would need to suspend her pending the investigation. The ADM stated the witness statement provided by CNA B was regarding Resident #1. While trying to provide care, Resident #1 was really agitated, and CNA A closed the door and she hit Resident #1 while they were in the room. The ADM stated CNA C and CNA A were generally the two who provide care for Resident #1. The ADM stated that was the only incident of abuse CNA B reported to him and he denied any knowledge of the slapping incident involving CNA C and Resident #2. The ADM stated if the incident took place in the dining area, there would be camera footage, but he did not believe he would be able to retrieve footage from that date. The ADM gave the name of CNA C as who he believed would have been the alleged perpetrator of the second incident of physical abuse on 07/06/22 and stated he was going to have the DON suspend her and have him call the incident in to the state agency. The ADM stated he would need to reach out to IT to see if they can assist me with that footage from 07/06/22. In an interview and observation on 07/18/22 at 4:13 PM, CNA C was on the memory care unit with a resident in a room with the door closed. When she exited the resident's room, she stated she was the only aide working the memory care unit and believed the other aide was running late. There were 2 nurses working the memory care unit. In an interview and observation on 07/18/22 at 5:05PM, CNA C was on the memory care unit passing out meal trays. She stated she was still the only aide working the memory care unit and believed the other aide had called in. In an observation on 07/18/22 at 5:33 PM, CNA C walked from the direction of the memory care unit to the front of the building towards the DON's office. In an interview on 07/20/22 at 4:10PM, the DON stated on 07/18/22 after he spoke with HHSC surveyor at 2:30 PM he called the ADM, and he confirmed the ADM did not have knowledge of a second abuse allegations regarding CNA D. The DON stated the ADM had told him he would follow up with the HHSC Surveyor, and he did not speak with him until after the IJ was called. The DON stated he did not begin the abuse investigation regarding an unidentified aide who worked on 07/06/22 on the 2PM to 10PM shift because he was unaware it was considered to be a reportable. The DON stated he did not follow up with the ADM on 07/18/22 regarding the second abuse allegation because he did not feel like interrupting [the ADM's] funeral was the appropriate thing to do. The DON stated he did not understand why we assume the ex employee's [CNA B] statement was accurate if nobody else witnessed anything. The DON asked why the facility would report once incident of abuse and not the other. The DON stated when he spoke with HHSC Surveyor on 07/18/22 at 2:20 PM, the second allegation of abuse involving CNA C sounded like and angry ex employee [CNA B] making allegations. The DON said he did not care who makes the allegation, we will investigate and report. The DON stated when an allegation of abuse was reported that information went to the ADM who was the abuse coordinator. He stated in the absence of the ADM, the information went to him, the DON. He stated it was his responsibility to immediately make sure the residents were safe. The DON said he made sure the residents on the memory care unit were safe on 07/18/22 when he pulled [CNA C] off the unit. The DON said when abuse was reported, the alleged perpetrator should be removed from the facility ideally immediately. He said on 07/18/22 there was no name given of the second alleged perpetrator. The DON said if the alleged perpetrator was not named, he would try to figure if there's a description and if the only description was date and shift, he would have to potentially remove anybody that was on that shift. The DON said stated there was a delay in investigating the second alleged abuse incident and in removing CNA C from the facility because CNA B's witness statement was not shared with him, and the DON denied HHSC surveyor informed him the incident occurred on 07/06/22 on the 2PM to 10PM shift. The DON stated if he was not given all the information to investigate an abuse allegation it was his responsibility to ask additional questions such as did you witness this? What time? What location? Do you know who was involved? Have you seen this happen before? He said on 07/18/22 he should have asked those type of questions to start the abuse investigation. The DON said if an alleged perpetrator of abuse was not removed from the facility, he did not know what could happen because that was speculative. The DON then said if the abuse incident truly occurred, it could occur again. The DON stated staff were expected to report abuse immediately. The DON said after an abuse allegation was made, he expected a nurse to complete and assessment of the resident the same shift which it was reported. In a telephone interview on 07/20/22 at 5:16 PM, the ADM stated there were cameras in the memory care unit at the nursing station and recorded each hallway and potentially the dining areas. The ADM stated IT stated they would be able to retrieve the video footage from 07/06/22 but they wanted him to be onsite for him to review the monitors. The ADM stated once abuse was reported, the facility should immediately ensure the resident safety and immediately suspend the staff member while you launch an investigation. The ADM stated on 07/18/22 the DON should have immediately reported the abuse allegation to the state agency and determined which staff were present on the memory care unit on 07/06/22 on the 2PM to 10PM shift by looking at the active staff from that day and punch time detail report, had the resident assessed, notified the RP, and determined an emotional distress of the resident. The ADM stated in his absence the DON was second in line as the abuse coordinator and he expected all staff to report all allegations of abuse to him, the ADM even if he was out, he identified. The ADM stated he identified CNA C as the alleged perpetrator based on the description and because CNA C was the staff who routinely worked on the memory care unit on the 2PM to 10PM shift. The ADM stated, right after he spoke with HHSC Surveyor on 07/18/22 at 3:11PM, he contacted the DON via telephone, told him to remove CNA C from the facility and told [the DON] about the investigation steps. In an interview on 07/18/22 at 1PM, CNA D stated she had worked the memory care unit at the facility for 5 years. She stated she had worked with CNA A and said CNA A always came to work and she floated different halls. CNA D said on 07/06/22 for the 6AM to 2PM shift, there were 2 new trainees, CNA B and CNA E. She said CNA A was assigned to train CNA B on 07/06/22. CNA D said CNA A would work all the time, and she would be cranky sometimes. CNA D said CNA A would be upset or bothered when asked questions at times and she told CNA A if she was tired, she should stop working so many doubles or working her off days. In an interview on 07/20/22 at 12:15 PM, ADON H said in the evening of 07/08/22, the ADM called him and asked him to complete a physical assessment n Resident #1 because of reported abuse. ADON H said he immediately went to the memory care unit to assess Resident #1 and did not see any bruises or injuries. ADON H said a physical assessment should be done by a nurse as soon as abuse is witnessed or reported. ADON H said it was important to immediately report abuse so the facility could stop worse things from happening such as more residents being abused, worse harm, or even death. ADON H said if the ADM was not here, abuse should be reported to DON or the charge nurse supervisor. ADON H said once abuse is reported, the abuser needed to be removed from the facility immediately, before even starting the investigation. In an interview on 07/20/21 at 2:51PM, HA J said she worked the memory care unit on the 2PM to 10PM shift. HA J said Resident #1 would be apprehensive and aggressive when he's confused and doesn't know what's going on. HA J said at least 2 aides were required to provide ADL care for Resident #1. She said one aide would try to keep him from swinging and one would clean and put a pull up or a diaper on him. She said one aide would hold his hands that way if he would swing, we would yell duck, and try to keep him as calm as possible HA J said she had worked with CNA C and said she was a little direct and moves a little too fast with some of the residents. HA J said she did not see CNA C hurt any of the residents, but she was too quick, would not explain the procedure to the residents, and the residents would be stunned. 2.Review of Resident #3's EHR on 07/18/22 reflected she was a [AGE] year old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's progress notes reflected on 7/16/22 at 7:50 AM LVN N documented, While getting resident up for breakfast, resident noted with small discoloration to upper left lip. Upon questioning resident stated that she bit her lip. No complaints of pain or discomfort at this time . Review of Resident #3's care plans reflected: a. [Resident #3] has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to Dementia . b. Behavioral Problem . has a behavior problem as evidenced by: packing her clothes and wanting to go home daily. Prefers to keep boxes on the floor and bags . physical behaviors will not interfere with the delivery of ADL cares by staff through the next review date . Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log . Intervene as necessary to protect the rights and safety of others. Remove Resident #3 to an alternate location when needed to protect the rights and safety of others. c. Verbal Behavior . verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner . Cursing and yelling [at] Staff verbal behaviors . episodes of verbal behaviors will decrease to less than weekly through the next review date . Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log . Provide positive feedback for good behavior. Emphasize the positive aspects of compliance . An observation and interview on 07/18/22 at 12:16 PM reveled of Resident #3 was finished eating her lunch and was sitting at a dining table. Resident #4 had two bruises to her face, one to the area above her left lip and below her left nostril which was dark purple at the center and yellow at the edges. It was irregularly shaped. She also had a yellow green circular bruise to her left chin. There was not any bruising on the resident's lips. Resident #3 stated the bruise occurred 2 to 3 days ago but could not recall how it occurred. Resident #3 stated she did not remember falling and said, nobody hit me, at least I don't think anyone hit me. In an interview on 07/18/22 at 1PM, CNA D said she first noticed the bruise above Resident #3's lip on the morning of 07/17/22. CNA D said she had asked Resident #3 was happened and the resident said didn't know. CNA D said she worked with Resident #3 on 07/15/22 on the 2PM to 10PM shift and did not notice a bruise at that time. In an interview with the DON on 07/18/22 at 2:30 PM, HHSC Surveyor notified the DON of the bruises to Resident #3's face and stated the documented reason for the bruise that the resident had bit herself. When asked if Resident #3's injuries should have been reported and investigated as an injury of unknown origin given the location of the bruises and the resident's cognition, the DON did not answer. In an interview and observation on 07/19/22 at 9:45 AM, LVN N measured Resident #3's bruises with a paper measuring tool. The bruise above her left lip was 3 cm by 2 cm, the bruise to her chin was 2 cm in diameter. LVN N said she was told in report that Resident #3 had bitten herself which led to the bruising on her left lip. She stated she did not know how Resident #3 obtained the bruise to her chin. In an interview on 07/20/21 at 2:51PM, HA J said she worked on the memory care unit on the 2PM to 10PM shift on 07/15/22. HA J said Resident #3 could have obtained the bruises to her face on 07/15/22. HA J said Resident #3 was irate, clawing and scratching when she was trying to exit the memory care unit. HA J said Resident #3 and Resident #5 had an altercation, and Resident #3 was hitting Resident #5 because he was making annoying noises. HA J said she tried to separate Resident #3 and Resident #5 but Resident #5 could have hit Resident #4. HA J said she did not report the physical altercation between Resident #3 and Resident #5 but said she should have reported the incident to the nurse. In an interview on 07/20/22 at 3:39 PM, LVN K said she was the nurse on the memory care unit in 07/15/22 for the 2PM to 10PM shift. She stated no one reported to her a physical altercation between Resident #3 and Resident #5 on that shift. LVN K said she was off 07/16/22 and 07/17/22 and the first time she saw Resident #3's facial bruises was on 07/18/22. LVN K said it stated on the 24 hour nurses report Resident #3 had bitten herself as the reason for her bruises. LVN K stated she did not know if the given reason for the bruises matched the bruises. LVN K said the bruise above Resident #3's lip was a very small bruise maybe 0.1cm. LVN K said she did not see the bruise to Resident #3's chin. LVN K said Resident #3 was really aggressive in her sundowning period, she hits staff, and she pisses off staff, she throws stuff, she cusses. In an interview on 04/20/22 at 4:10 PM, the DON stated staff were expected to report abuse immediately. The DON said after an abuse allegation was made, he expected a nurse to complete and assessment of the resident the same shift which it was reported. In an interview on 07/20/22 at 6:10 PM, the DON stated HA J was suspended for the failure to report the incident which occurred on 07/15/22 between Resident #3 and Resident #5. The DON was notified of the IJ on 07/19/22 at 5:08 PM, a POR was requested and was provided the IJ template. The POR was accepted on 07/19/22 at 3:43 PM. Review of the POR included: . Immediate action(s) taken for the resident(s) found to have been affected include: Facility Administrator reported allegation of abuse to that happened on 07/6/2022 in the dining room to state agency. The surveyor brought the allegation of abuse to the attention of the DON and Administrator 7/18/2022. DON contacted the CNA (B) witnessed the slap that happened the dining room by CNA (C), to identify the resident. CNA (B) does not remember the residents name or can identify the resident. The LVN/charge nurse will complete a head to toe evaluation on all residents that reside in the memory care unit and document findings on the skin observation work sheet on 7/19/2022 The findings were no signs or symptoms of injury that wasn't previously identified Facility DON suspended CNA (C) who allegedly slapped the resident pending investigation on 7/18/2022 On 7/18/2022 Facility DON began immediately conducting an Abuse allegation investigation for the allegation made on 7/6/2022 investigation is on going . Actions to Prevent Occurrence/Recurrence: DON was in serviced on abuse policy by RNC on 7/18/2022 On 7/18/22 employees were in serviced by the DON and ADONs and Post Test was given on demonstrate understanding Abuse Policy which includes: All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately to the Administrator or the DON. Note: If the alleged abuse/neglect involves the Administrator, report incident immediately to the DON. If the DON is not available, report the incident immediately to the Regional Vice President or Regional Nurse Consultant. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the Charge Nurse or Supervisor in charge The Administrator will immediately report any allegation of mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property to the state survey office. The Charge Nurse or Supervisor must immediately contact the Administrator or the DON of the incident. No staff members will be allowed to work until they have received the Inservice and completed the post test. In servicing and post test for Abuse will be completed by 7/19/2022 Administrator will create an abuse file to include witness statements on abuse case then report abuse to state agency How the corrective action(s) will be monitored to ensure the practice will not recur: Effective 7/18/22 the ADONs and Charge nurse will supervise staff during rounds daily on the unit to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate their beds through 8/18/22. Any findings will be documented in progress notes and reviewed by DON. The department heads during quality of life rounds will talk to residents about staffing practices during care such as inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, not answering call light, directing residents who need toileting assistance to urinate or defecate in their beds, and reporting skin alterations like bruises and skin tears. Daily the Charge nurses and the aides will document on the skin observation worksheet any skin alterations such as bruising, skin tears, and immediately report to the administrator and DON. The facility will not employ or otherwise engage individuals who Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; Have had

Based on observation, interview, and record review, it was determined the facility failed to ensure one (Resident #1) of five sampled residents was provided the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care when the resident fell and sustained a serious injury. Resident #1 fell on [DATE] at 12:15 AM. Following the fall, the resident complained of pain to her left leg when it was moved or touched. The resident was treated with a low dose of Tylenol to address the pain. It was determined facility staff were using an incorrect phone number to contact the resident's physician. The first attempt to contact the physician using the incorrect phone number did not occur until 3:00 AM. Resident #1's physician was not called until 10:30 AM (ten hours) after the resident initially fell . Upon contacting the physician at 10:30 AM, the physician ordered x-rays as well as [MEDICATION NAME] to treat the resident's pain symptoms. X-rays were done at 12:45 PM, and the results were reported to the facility and the physician at 1:45 PM. The results reflected Resident #1 had a Subcapital Fracture with Minimal Displacement of the Left Hip. The resident was transported to the hospital for treatment via ambulance service at 3:45 PM (fifteen hours) after she fell and began to exhibit signs of pain/discomfort to her left lower extremity. The failure to provide prompt intervention resulted in Resident #1 having delayed treatment to address symptoms of pain and discomfort related to a [MEDICAL CONDITION]. This failure had the potential to affect all 121 residents in the facility if they were to experience a change in condition. Findings included: 1) On 10/31/12 at 8:35 AM, Resident #1 was observed lying in her bed with an abduction pillow between her legs. 2) Resident #1's quarterly MDS assessment, signed by the DON/RN Assessment Coordinator as complete on 10/10/12, reflected Resident #1's most recent re-entry date to the facility was 01/29/12 from an acute hospital. The MDS assessment reflected Resident #1 was a [AGE] year-old female with the following active Diagnoses: [REDACTED]. The MDS assessment reflected Resident #1 required the limited assistance of one person with walking. The resident was assessed to have unsteady balance during transitions. In addition, the resident's walking was not steady as she was only able to stabilize with staff assistance while moving from a seated to a standing position, turning around and facing the opposite direction, moving off and on the toilet, and from surface-to-surface transfers. In addition, the assessment reflected Resident #1 had both short- and long-term memory problems, and she scored a 3 out of 15 on the BIMS, which indicated the resident had cognitive impairment. Resident #1's Face Sheet, dated 08/07/12, reflected she was admitted to the facility on [DATE] and re-admiitted on 01/29/12. 3) Resident #1's Care Plans, dated 08/26/12, 09/09/12, and 10/01/12, reflected the facility had developed a care plan to address the resident's fall risk. The care plan reflected: "Resident has a history of falls and is at risk for increased falls and fractures, as evidenced by: cognitive impairment and unsteady gait. Approach: bed alarm." 4) The Facility's Investigation Report, dated and signed by the DON on 10/26/12, reflected Resident #1 had a fall at the facility on 10/19/12 at 12:15 AM. The Investigation Summary reflected: "Resident resides on the Dementia Care Unit and has [DIAGNOSES REDACTED]. Resident has a prior history of falls, has an order for [REDACTED]. Resident will at times attempt to ambulate without assistance. Upon return from the hospital, resident has floor mat, bed alarm, bed in lowest position. Further investigation reveals: resident's roommate came to nurse's station stating resident was on the floor, the nurse (RN) came to (the) room and found resident on the floor on her left side close to her bed. Resident was assessed from head to toe including vital signs and assisted back to her bed with assistance from the nurse (RN) and CNA. Upon assessment there was no bruising, redness, or swelling noted. Resident denies hitting her head, but complained of discomfort to her left hip, stating she twisted it. PRN Tylenol 325mg was given for discomfort. According to nurse's documentation (RN) an initial phone call was made to the on call MD with no return call. A message was left for resident's family member regarding resident's condition. Another call was placed to the MD and a message was left to call the facility ASAP, because the resident may need an x-ray to rule out fracture. The on-coming nurse (LVN) was given report on resident's condition. Resident was re-assessed by nurse (LVN) and resident complaint of discomfort when she tried to move left extremity and Tylenol 325mg was given again for discomfort. Another call was made to the MD with a message left by nurse (LVN). When the split shift nurse (LVN) arrived she verified the phone number that the nurse was calling and the number was incorrect. The nurse was using an old phone list. The updated phone list was almost exactly like the old one with the exception of one name on the updated list. The split shift nurse (LVN) then gave the nurse the correct number that she should have been calling and the MD was called and a return phone call was received right after from the MD with instructions for the resident. MD then gave orders to x-ray left hip and to increase Tylenol 325mg from 1 tab to 2 tabs Q 4-6hrs PRN and to give [MEDICATION NAME] 5/325mg now. A call was placed to _____ ________ (radiology service) to obtain x-rays to the (resident's) left hip at that time. ______ ________ (Radiology service) came out to complete x-rays shortly after. Neuro checks done and were WNL. Received notification from x-ray company that resident had a fracture to (her) left hip. MD was immediately notified and gave order to give resident [MEDICATION NAME] 5/325mg now and to transfer (her) to (the) ER for treatment. family member was notified of results and that resident would be sent out for further evaluation. Call placed to __________ ____ (ambulance service) at that time for hospital transport. _________ ___ (Ambulance service) arrived and resident was transported to (the) ER." 5) Resident #1's Nurses Notes, dated 10/19/12 at 12:15 AM, reflected Resident#1's roommate went to the nurse's station to report that Resident #1 was on the floor. RN F went to the room and found Resident #1 on the floor lying on her left side near her bed. Resident #1 was assessed and her vital signs were taken along with neurological checks. Resident #1 denied hitting her head. She was assisted back to bed with the assistance of RN F and CNA D. Upon assessment there was no bruising, redness or swelling noted. Resident #1 complained of discomfort to her left hip and stated she had twisted it. The resident was given one tablet of Tylenol 325 mg for discomfort at 12:15 AM. 6) Resident #1's MAR, dated 10/19/12, reflected the resident had an order to receive one tablet of Tylenol 325 mg by mouth once every four hours as needed for pain. Tylenol was administered at 12:15 AM and 8:00 AM. The MAR indicated [REDACTED]. 7) Resident #1's Nurses Notes reflected the following entries: 10/19/12 at 3:00 AM RN F documented making an initial phone call to MD A. A message was left at that time. The initial call to notify the physician of Resident #1's fall occurred 2 hours and 45 minutes after the fall. 10/19/12 at 6:00 AM RN F documented that she left a message for Resident #1's family member notifying him of the resident's fall. This first attempt to notify the resident's family member occurred 5 hours and 45 minutes after the fall. 10/19/12 at 7:30 AM Documentation reflected a second attempt was made to contact MD A. A message was left for the physician to call the facility as soon as possible because Resident #1 needed an x-ray to rule out fracture. 10/19/12 at 7:40 AM Documentation reflected the on-coming nurse, LVN B, was given report regarding Resident #1's condition. There was no documentation in Resident #1's Nurse's Notes reflecting LVN B assessed the resident. 10/19/12 at 8:00 AM Documentation reflected Resident #1 complained of pain to her left lower extremity when she tried to move it. LVN B administered one tablet of Tylenol 325 mg to Resident #1 by mouth for pain. 10/19/12 at 8:15 AM LVN B made a third phone call to MD A, and she left a voicemail message. She documented that she was awaiting a return phone call from the physician. 10/19/12 at 9:15 AM Resident #1 complained of pain to her left lower leg when she tried to move. No pain medication was administered. 10/19/12 at 10:30 AM LVN B made the fourth phone call to Resident #1's physician, MD A, and she left a voicemail. This was the first call to the physician using the correct phone number. She documented that she was awaiting a return phone call from the physician. 10/19/12 at 10:30 AM LVN B made a phone call to MD A and PA E. She left a message and requested an x-ray be ordered for Resident #1's left lower extremity and requested an increase in the pain medication dosage. 10/19/12 at 11:00 AM LVN B received a phone call from MD A and new orders were given for "X-Ray to bilateral hips, left knee and left ankle. Increase Tylenol 2 tabs every four to six hours and to give [MEDICATION NAME] 5/325mg. Give 1 tablet by mouth now." 10/19/12 at 11:00 AM LVN B called the radiology company and ordered x-rays for Resident #1. 10/19/12 at 11:30 AM Resident #1 complained of pain to her left lower extremity when it was moved. 10/19/12 at 12:45 PM The x-ray service entered the facility to x-ray Resident #1. 10/19/12 at 12:45 AM Resident #1 refused to eat, and she was given fluids. 10/19/12 at 1:45 PM LVN B received results from the x-ray company, and she was informed that the x-ray revealed Resident #1 had a Subcapital Fracture with Minimal Displacement of the Left Hip. The x-ray of the resident's left ankle revealed soft-tissue swelling around the ankle, but there was no fracture or dislocation. The x-ray of the resident's left knee revealed no fracture or dislocation. 10/19/12 at 1:45 PM MD A was notified of the x-ray results, and new orders were given to give Resident #1 [MEDICATION NAME] 5/325 mg by mouth at that time. MD A also ordered the resident to be transferred to the hospital ER for treatment. 10/19/12 at 3:45 PM The ambulance service arrived at the facility to transport Resident #1 to the hospital. 8) Resident #1's undated Fall Management Plan of Care, reflected a movement sensor alarm and a one person transfer were identified as interventions to reduce the resident's incidence of falls and severity of related injuries. Resident #1's Fall Risk Assessment, dated 08/23/12, reflected Resident #1 scored a 24. A total score of 10 or greater on the assessment indicated the resident was a high-risk for potential falls. 9) A SBAR assessment completed for Resident #1, dated 10/19/12, reflected Residents#1's pain level was a four related to left hip pain. A Triage Nursing Assessment, dated 10/19/12, reflected on the night and day shift Resident #1 had swelling/[MEDICAL CONDITION] and complained of pain to her left lower extremity upon movement. 10) A telephone interview was conducted with Resident #1's family member on 10/31/12 at 12:10 PM regarding Resident #1's fall. The family member stated he/she was called about 6:00 AM on 10/19/12, he/she was told that Resident #1 had fallen during the night. He/She was told that Resident #1 was "ok." The family member stated he/she received a second call from the facility between 3:00 PM and 4:00 PM on 10/19/12. When he/she was called, he/she was told that Resident #1 was being transported to the hospital because she had broken her hip when she had fallen during the night. 11) RN F was interviewed via telephone on 11/06/12 at 12:15 PM. The surveyor attempted to contact RN F during the investigation, however, RN F was not reached until after the exit. RN F stated Resident #1's roommate came to the nurse's station about 12:15 AM stating that Resident#1 was on the floor. RN F stated she went to the room and found Resident#1 on the floor on her left side close to her bed. She stated she did not hear Resident #1's bed alarm sound when Resident #1 had gotten out of bed. RN F stated Resident #1 was assessed and her vital signs were taken along with neurological checks. Per RN F, the resident denied hitting her head. RN F stated she and CNA D assisted Resident #1 back to her bed. When she assessed Resident #1, there was no bruising, redness or swelling noted to the resident's lower extremities. RN F stated Resident #1 complained of discomfort to her left hip, and the resident stated she had twisted it. RN F stated she administered one tablet of Tylenol 325 mg to Resident #1 to treat the discomfort. RN F stated she called MD A at 3:00 AM, but she did not get an answer. She stated she left a message for the physician to return the call. RN F stated at about 7:30 AM she gave report to the on-coming nurse, LVN B, to follow up with the physician for x-rays. RN F stated she called the resident's family member at about 6:00 AM, and she left message for the family member to call the facility because his mother had fallen during the night. She stated she did not notify the DON or the Administrator. RN F stated the Administrator was out on vacation. 12) Review of a Witness Statement completed by LVN B on 10/24/12 revealed she received report from RN F around 7:30 AM on 10/19/12. At that time, RN F informed her that Resident #1 had fallen during the night and was given Tylenol. At about 8:00 AM, LVN B documented that she assessed Resident #1 to include taking her vital signs and neurological checks, which were identified as being within normal limits. LVN B documented that Resident #1 could not move her left leg due to complaints of pain. LVN B documented that she gave Resident #1 Tylenol 325 mg 1 tablet for pain. She then called MD A, and she left the physician a message. About an hour later, she again called MD A after she performed a second assessment on Resident#1. The assessment revealed the resident's vital signs and neurological checks were within normal limits except she noticed the resident moaned and groaned when her left leg was moved. LVN B documented that at about 8:30 AM on 10/19/12, she was informed by LVN C that she had been calling the physician using a wrong phone number. At that time, LVN C provided LVN B with the phone number to a direct line for the physician. LVN B called MD A, and she left a message. MD A returned the phone call, and she gave orders for x-rays to be done for Resident #1. Upon learning that Resident #1 had a [MEDICAL CONDITION], MD A later ordered that Resident #1 be sent to the hospital. 13) LVN C was interviewed on 11/02/12 at 1:20 PM. LVN C stated she came into the facility about 8:00 AM on 10/19/12 to cover for the ADON. LVN C stated she made copies of the 24-hour reports for Station 1. At about 8:30 AM, she went to a stand-up meeting. Following the stand-up meeting, she read the "hot" charts. Between 9:30 AM and 10:00 AM, LVN C stated she returned from the stand-up meeting. LVN C stated she then called MD A to report Resident #1's condition. She assessed Resident#1, who was resting in bed. She stated the resident was refusing care and fought with staff after falling that night. At about 11:00 AM, LVN C stated she went back and reassessed Resident #1. The resident continued to be aggressive and resisted care. LVN C stated Resident #1 would not let her touch her. 14) LVN C's written statement, dated 10/24/12, reflected: "I came back from stand up meeting and the nurse told me that she could not get the doctor _____________ (MD A) on the phone. I called the Dr. she picked up and I reported that the patient fell @ night and will be needing xrays. She ordered the xray. Then I went to assess the patient and realised (sic) that the patient was quite serious. I called the Dr. back and asked her to make the xrays STAT and also to give her a stronger pain medication which she did. While looking through the documentation about what happened I realised (sic) that the 10-6 (10:00 PM - 6:00 AM) nurse did not complete the paperwork...." 15) A telephone interview was conducted with MD A on 11/02/12 at 9:50 AM regarding Resident #1. MD A stated she did not receive any phone calls from the facility on 10/19/12 until 10:30 AM when LVN C contacted her to inform her of Resident #1's fall. She stated she gave orders for x-rays and for [MEDICATION NAME] to be given to address the resident's pain. MD A stated she retrieved her cell phone history, and there were no calls to her cell phone on 10/19/12 prior to 10:30 AM. MD A stated she contacted the facility Administrator on several occasions to have the incorrect phone numbers corrected. She explained the phone number the facility had listed belonged to a PA who no longer worked for her. She stated she requested for all phone numbers to be updated in the residents' charts to reflect the correct phone numbers and the correct physician. On 11/02/12 at 4:00 PM, MD A contacted the surveyor and stated she had spoken with PA E, and he had received a message on his cell phone at 3:58 AM. 16) CNA H was interviewed on 11/02/12 at 10:15 AM. CNA H stated she had worked on 10/19/12 on the night shift. CNA H stated she began her employment with the facility on 10/12/12. She stated she did not take care of Resident #1 because she was assigned to another hall. Per the facility's schedule, CNA H was assigned to the hall where Resident #1 resided. 17) CNA G was interviewed on 11/02/12 at 10:00 AM. CNA G stated he assisted the nursing staff when the resident was getting x-rays, and he stated Resident #1 hit at the staff because she wanted to be left alone. 18) The Administrator was interviewed on 11/02/12 at 11:33 AM. The Administrator stated she was on vacation when Resident #1 fell . She stated she was not aware of the incident until she returned from her vacation. The Administrator was asked if she was available to the facility by phone during the vacation, and she stated she was not available via telephone. In regard to the circumstances surrounding Resident #1's fall and subsequent delay in treatment, the Administrator stated RN F was going to be terminated as a result. However, RN F voluntarily resigned prior to her termination. 19) The facility provided an undated facility census to the survey team on 10/31/12 which reflected the facility census was 121.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (Resident #1) of five sampled residents received adequate supervision and assistive devices to prevent accidents as evidenced by the resident having a fall which resulted in serious injury. Resident #1 fell on [DATE] at 12:15 AM. The resident, due to a history of falls, was supposed to have a bed alarm in place while she was in bed. This alarm did not function when she fell on [DATE]. The resident sustained [REDACTED]. The failure to ensure care planned interventions to address falls were implemented for Resident #1 resulted in the resident sustaining a fall with serious injury. This failure had the potential to affect the ten residents on the 100 Unit who were supposed to have bed and/or chair alarms. Findings included: 1) On 10/31/12 at 8:35 AM, Resident #1 was observed lying in her bed with an abduction pillow between her legs. 2) Resident #1's quarterly MDS assessment, signed by the DON/RN Assessment Coordinator as complete on 10/10/12, reflected Resident #1's most recent re-entry date to the facility was 01/29/12 from an acute hospital. The MDS assessment reflected Resident #1 was a [AGE] year-old female with the following active Diagnoses: [REDACTED]. The MDS assessment reflected Resident #1 required the limited assistance of one person with walking. The resident was assessed to have unsteady balance during transitions. In addition, the resident's walking was not steady as she was only able to stabilize with staff assistance while moving from a seated to a standing position, turning around and facing the opposite direction, moving off and on the toilet, and from surface-to-surface transfers. In addition, the assessment reflected Resident #1 had both short- and long-term memory problems, and she scored a 3 out of 15 on the BIMS, which indicated the resident had cognitive impairment. Resident #1's Face Sheet, dated 08/07/12, reflected she was admitted to the facility on [DATE] and re-admitted on [DATE]. 3) Resident #1's Care Plans, dated 08/26/12, 09/09/12, and 10/01/12, reflected the facility had developed a care plan to address the resident's fall risk. The care plan reflected: "Resident has a history of falls and is at risk for increased falls and fractures, as evidenced by: cognitive impairment and unsteady gait. Approach: bed alarm." 4) The Facility's Investigation Report, dated and signed by the DON on 10/26/12, reflected Resident #1 had a fall at the facility on 10/19/12 at 12:15 AM. The Investigation Summary reflected: "Resident resides on the Dementia Care Unit and has [DIAGNOSES REDACTED]. Resident has a prior history of falls, has an order for [REDACTED]. Bed alarm has been replaced. Resident will at times attempt to ambulate without assistance. Upon return from the hospital, resident has floor mat, bed alarm, bed in lowest position. Further investigation reveals: resident's roommate came to nurse's station stating resident was on the floor, the nurse (RN) came to (the) room and found resident on the floor on her left side close to her bed. Resident was assessed from head to toe including vital signs and assisted back to her bed with assistance from the nurse (RN) and CNA. Upon assessment there was no bruising, redness, or swelling noted. Resident denies hitting her head, but complained of discomfort to her left hip, stating she twisted it. PRN Tylenol 325mg was given for discomfort. According to nurse's documentation (RN) an initial phone call was made to the on call MD with no return call. A message was left for resident's family member regarding resident's condition. Another call was placed to the MD and a message was left to call the facility ASAP, because the resident may need an x-ray to rule out fracture. The on-coming nurse (LVN) was given report on resident's condition. Resident was re-assessed by nurse (LVN) and resident complaint of discomfort when she tried to move left extremity and Tylenol 325mg was given again for discomfort. Another call was made to the MD with a message left by nurse (LVN). When the split shift nurse (LVN) arrived she verified the phone number that the nurse was calling and the number was incorrect. The nurse was using an old phone list. The updated phone list was almost exactly like the old one with the exception of one name on the updated list. The split shift nurse (LVN) then gave the nurse the correct number that she should have been calling and the MD was called and a return phone call was received right after from the MD with instructions for the resident. MD then gave orders to x-ray left hip and to increase Tylenol 325mg from 1 tab to 2 tabs Q 4-6hrs PRN and to give Norco 5/325mg now. A call was placed to _____ ________ (radiology service) to obtain x-rays to the (resident's) left hip at that time. ______ ________ (Radiology service) came out to complete x-rays shortly after. Neuro checks done and were WNL. Received notification from x-ray company that resident had a fracture to (her) left hip. MD was immediately notified and gave order to give resident Norco 5/325mg now and to transfer (her) to (the) ER for treatment. family member was notified of results and that resident would be sent out for further evaluation. Call placed to __________ ____ (ambulance service) at that time for hospital transport. _________ ___ (Ambulance service) arrived and resident was transported to (the) ER." 5) Resident #1's Nurses Notes, dated 10/19/12 at 12:15 AM, reflected Resident#1's roommate went to the nurse's station to report that Resident #1 was on the floor. RN F went to the room and found Resident #1 on the floor lying on her left side near her bed. Resident #1 was assessed and her vital signs were taken along with neurological checks. Resident #1 denied hitting her head. She was assisted back to bed with the assistance of RN F and CNA D. Upon assessment there was no bruising, redness or swelling noted. Resident #1 complained of discomfort to her left hip and stated she had twisted it. The resident was given one tablet of Tylenol 325 mg for discomfort at 12:15 AM. 6) Resident #1's MAR, dated 10/19/12, reflected the resident had an order to receive one tablet of Tylenol 325 mg by mouth once every four hours as needed for pain. Tylenol was administered at 12:15 AM and 8:00 AM. The MAR also reflected Resident #1 received one table of Norco 5/325 mg at 11:00 AM and 2:40 PM. 7) Resident #1's Nurses Notes reflected the following entries: 10/19/12 at 3:00 AM RN F documented making an initial phone call to MD A. A message was left at that time. This initial call to notify the physician of Resident #1's fall occurred 2 hours and 45 minutes after the fall. 10/19/12 at 6:00 AM RN F documented that she left a message for Resident #1's family member notifying him of the resident's fall. This first attempt to notify the resident's family member occurred 5 hours and 45 minutes after the fall. 10/19/12 at 7:30 AM Documentation reflected a second attempt was made to contact MD A. A message was left for the physician to call the facility as soon as possible because Resident #1 needed an x-ray to rule out fracture. 10/19/12 at 7:40 AM Documentation reflected the on-coming nurse, LVN B, was given report regarding Resident #1's condition. There was no documentation in Resident #1's notes reflecting LVN B assessed the resident. 10/19/12 at 8:00 AM Documentation reflected Resident #1 complained of pain to her left lower extremity when she tried to move it. LVN B administered one tablet of Tylenol 325 mg to Resident #1 by mouth for pain. 10/19/12 at 8:15 AM LVN B made a third phone call to MD A, and she left a voicemail message. She documented that she was awaiting a return phone call from the physician. 10/19/12 at 9:15 AM Resident #1 complained of pain to her left lower leg when she tried to move. No pain medication was administered. 10/19/12 at 10:30 AM LVN B made the fourth phone call to Resident #1's physician, MD A, and she left a voicemail. This was the first phone call made to the physician using the correct telephone number. She documented that she was awaiting a return phone call from the physician. 10/19/12 at 10:30 AM LVN B made a phone call to MD A and PA E. She left a message and requested an x-ray be ordered for Resident #1's left lower extremity and requested an increase in the pain medication dosage. 10/19/12 at 11:00 AM LVN B received a phone call from MD A and new orders were given for "X-Ray to bilateral hips, left knee and left ankle. Increase Tylenol 2 tabs every four to six hours and to give Norco 5/325mg. Give 1 tablet by mouth now." 10/19/12 at 11:00 AM LVN B called the radiology company and ordered x-rays for Resident #1. 10/19/12 at 11:30 AM Resident #1 complained of pain to her left lower extremity when it was moved. 10/19/12 at 12:45 PM The x-ray service entered the facility to x-ray Resident #1. 10/19/12 at 12:45 AM Resident #1 refused to eat, and she was given fluids. 10/19/12 at 1:45 PM LVN B received results from the x-ray company, and she was informed that the x-ray revealed Resident #1 had a Subcapital Fracture with Minimal Displacement of the Left Hip. The x-ray of the resident's left ankle revealed soft-tissue swelling around the ankle, but there was no fracture or dislocation. The x-ray of the resident's left knee revealed no fracture or dislocation. 10/19/12 at 1:45 PM MD A was notified of the x-ray results, and new orders were given to give Resident #1 Norco 5/325 mg by mouth at that time. MD A also ordered the resident to be transferred to the hospital ER for treatment. 10/19/12 at 3:45 PM The ambulance service arrived at the facility to transport Resident #1 to the hospital. 8) Resident #1's undated Fall Management Plan of Care, reflected a movement sensor alarm and a one person transfer were identified as interventions to reduce the resident's incidence of falls and severity of related injuries. Resident #1's Fall Risk Assessment, dated 08/23/12, reflected Resident #1 scored a 24. A total score of 10 or greater on the assessment indicated the resident was a high-risk for potential falls. 9) A SBAR assessment completed for Resident #1, dated 10/19/12, reflected Resident #1's pain level was a four related to left hip pain. A Triage Nursing Assessment, dated 10/19/12, reflected on the night and day shift Resident #1 had swelling/edema and complained of pain to her left lower extremity upon movement. 10) A telephone interview was conducted with Resident #1's family member on 10/31/12 at 12:10 PM regarding Resident #1's fall. The family member stated he/she was called about 6:00 AM on 10/19/12, he/she was told that Resident #1 had fallen during the night. He/She was told that Resident #1 was "ok." The family member stated he/she received a second call from the facility between 3:00 PM and 4:00 PM on 10/19/12. When he/she was called, he/she was told that Resident #1 was being transported to the hospital because she had broken her hip when she had fallen during the night. 11) Interview on 11/02/12 at 2:45 PM with the DON revealed there currently was no system in place to check the bed alarms for proper functioning or battery life. During the interview, the DON proposed developing a facility bed and chair alarm checklist. The DON stated the nurse was to check the residents for the placement and operation of alarms every shift. 12) RN F was interviewed via telephone on 11/06/12 at 12:15 PM. Attempts were made to contact RN F during the investigation, however, RN F could not be reached until after the exit. RN F stated Resident #1's roommate came to the nurse's station about 12:15 AM stating that Resident #1 was on the floor. RN F stated she went to the room and found Resident #1 on the floor on her left side close to her bed. She stated she did not hear Resident #1's bed alarm sound when Resident #1 had gotten out of bed. RN F stated Resident #1 was assessed and her vital signs were taken along with neurological checks. Per RN F, the resident denied hitting her head. RN F stated she and CNA D assisted Resident #1 back to her bed. When she assessed Resident #1, there was no bruising, redness or swelling noted to the resident's lower extremities. RN F stated Resident #1 complained of discomfort to her left hip, and the resident stated she had twisted it. RN F stated she administered one tablet of Tylenol 325 mg to Resident #1 to treat the discomfort. RN F stated she called MD A at 3:00 AM, but she did not get an answer. She stated she left a message for the physician to return the call. RN F stated at about 7:30 AM she gave report to the on-coming nurse, LVN B, to follow up with the physician for x-rays. RN F stated she called the resident's family member at about 6:00 AM, and she left a message for the family member to call the facility because Resident #1 had fallen during the night. She stated she did not notify the DON or the Administrator. RN F stated the Administrator was out on vacation. 13) Review of a Witness Statement completed by LVN B on 10/24/12 revealed she received report from RN F around 7:30 AM on 10/19/12. At that time, RN F informed her that Resident #1 had fallen during the night and was given Tylenol. At about 8:00 AM, LVN B documented that she assessed Resident #1 to include taking her vital signs and neurological checks which were identified as being within normal limits. LVN B documented that Resident #1 could not move her left leg due to complaints of pain. LVN B documented that she gave Resident #1 Tylenol 325 mg 1 tablet for pain. She then called MD A, and she left the physician a message. About an hour later, she again called MD A after she performed a second assessment on Resident #1. The assessment revealed the resident's vital signs and neurological checks were within normal limits except she noticed the resident moaned and groaned when her left leg was moved. LVN B documented that at about 8:30 AM on 10/19/12, she was informed by LVN C that she had been calling the physician using a wrong phone number. At that time, LVN C provided LVN B with the phone number to a direct line for the physician. LVN B called MD A, and she left a message. MD A returned the phone call, and she gave orders for x-rays to be done for Resident #1. Upon learning that Resident #1 had a fractured hip, MD A later ordered that Resident #1 be sent to the hospital. 14) LVN C was interviewed on 11/02/12 at 1:20 PM. LVN C stated she came into the facility about 8:00 AM on 10/19/12 to cover for the ADON. LVN C stated she made copies of the 24-hour reports for Station 1. At about 8:30 AM, she went to a stand-up meeting. Following the stand-up meeting, she read the "hot" charts. Between 9:30 AM and 10:00 AM, LVN C stated she returned from the stand-up meeting. LVN C stated she then called MD A to report Resident #1's condition. She assessed Resident#1, who was resting in bed. She stated the resident was refusing care and fought with staff after falling that night. At about 11:00 AM, LVN C stated she went back and reassessed Resident #1. The resident continued to be aggressive and resisted care. LVN C stated Resident #1 would not let her touch her. 15) A telephone interview was conducted with MD A on 11/02/12 at 9:50 AM regarding Resident #1. MD A stated she did not receive any phone calls from the facility on 10/19/12 until 10:30 AM when LVN C contacted her to inform her of Resident #1's fall. She stated she gave orders for x-rays and for Norco to be given to address the resident's pain. MD A stated she retrieved her cell phone history, and there were no calls to her cell phone on 10/19/12 prior to 10:30 AM. MD A stated she contacted the facility Administrator on several occasions, prior to the incident, to have the incorrect phone numbers corrected. She explained the phone number the facility had listed belonged to a PA who no longer worked for her. She stated she requested for all phone numbers to be updated in the residents' charts to reflect the correct phone numbers and the correct physician. On 11/02/12 at 4:00 PM, MD A contacted the surveyor and stated she had spoken with PA E, and he had received a message on his cell phone at 3:58 AM. 16) CNA H was interviewed on 11/02/12 at 10:15 AM. CNA H stated she had worked on 10/19/12 on the night shift. CNA H stated she began her employment with the facility on 10/12/12. She stated she did not take care of Resident #1 because she was assigned to another hall. Per the facility's schedule, CNA H was assigned to the hall where Resident #1 resided. 17) CNA G was interviewed on 11/02/12 at 10:00 AM. CNA G stated he assisted the nursing staff when the resident was getting x-rays, and he stated Resident #1 hit at the staff because she wanted to be left alone. 18) The Administrator was interviewed on 11/02/12 at 11:33 AM. The Administrator stated she was on vacation when Resident #1 fell . She stated she was not aware of the incident until she returned from her vacation. The Administrator was asked if she was available to the facility by phone during the vacation, and she stated she was not available via telephone. In regard to the circumstances surrounding Resident #1's fall and subsequent delay in treatment, the Administrator stated RN F was going to be terminated as a result. However, RN F voluntarily resigned prior to her termination. 19) The facility provided the survey team with an undated list of residents with bed and/or chair alarms who resided on the 100 Unit where Resident #1 resided. There were ten residents identified as requiring the use of a bed and/or chair alarm.

Based on observation, interview and record review, the facility failed to maintain an Infection Control Program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for 36 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18 (closed record), #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37 and #38) of 40 residents reviewed for infection control. The facility failed to ensure the following residents with infections were not roomed with residents, who had no infection or were roomed with residents, who had the same infectious agent: Resident #4 was infected with Acinetobacter and was in the same room with Resident #5, who had Pseudomonas. Resident #8 was infected with Beta [DIAGNOSES REDACTED] Strep and Pseudomonas. Resident #8 was a roommate of Resident #9, who was infected with Acinetobacter. Resident #5, who had Pseudomonas, was Resident #12's roommate for one day. Resident #12 had Acinetobacter. On 08/20/12, Resident #12's Acinetobacter was resolved, but she now had Pseudomonas. The facility failed to group residents infected or colonized with the same infectious agent together (cohorting). Residents #4, #5, #8, #9, #10, #12, and #13 were inappropriately cohorted. The facility failed to have an ongoing, systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risks, to try to reduce morbidity and mortality and to improve resident health status. The Infection Control Log was incomplete. The facility was not adequately and aggressively disinfecting the ventilator unit (400 hall) to combat the spread of infection through the environment. The facility was not using a disinfectant containing hypochlorite (bleach) in the[DIAGNOSES REDACTED] isolation areas and the Acinetobacter bauminnii was not using a disinfectant daily throughout the other areas. The facility failed to provide wound care, which promoted the healing of wounds. Residents #3 and #11 had their wounds contaminated with feces. LVN L donned gloves and removed old wound dressings from Resident #3's coccyx, which she placed on the resident's bed instead of a red biohazard bag. LVN L used her contaminated gloved hand to crank up the head of Resident #3's bed. LVN L dropped her cell phone into the Biohazard Box. LVN L used her contaminated gloved hand to move things around in the Biohazard Box and searched for the phone. LVN L found her contaminated phone and placed it in her pocket without any attempt at cleaning it first. LVN L continued to use the feces-contaminated measuring tape and contaminated Resident #3's wound with it. LVN L walked outside Resident #3's room wearing her isolation shoe covers before she took them off. CNA C used the same surface of a wet towel to wipe off feces from Resident #11's buttocks multiple times. LVN L dried her hands with the isolation gown and then perfomed wound treament to Resident #11. LVN L's cell phone fell on the floor in Resident #11's room. CNA C picked up the contaminated phone from the floor and placed it in her pocket. LVN L removed the contaminated wound dressing from Resident #11 and placed it on the resident's bed instead of the red biohazard bag. Respiratory Therapist O donned gloves without using any hand hygiene and then suctioned secretions from Resident #11's tracheostomy. The Interim DON identified 10 residents on Hall 400 with Acinetobacter. The lab results indicated the following: Resident #35 and Resident #16 were infected with Acinetobacter baumannii Multidrug resistant gram negative rods. Residents #23 and #16 were infected with Pseudomonas aeruginosa Multidrug resistant gram negative rods. Residents #15 and #36 were infected with Acinetobacter buamannii. The following 16 residents were infected with Pseudomonas aeruginosa: Residents #15, #21, #22, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, and #37. The following eight residents were infected with Beta [DIAGNOSES REDACTED] strep Group G: Residents #16, #21, #24, #25, #26, #34, and #38, Resident #16's Lab Results dated 08/28/12 reflected E. coli in his sputum. These failures could affect the 37 residents, who resided on Hall 400, including Residents Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37 and #38, and placed them at risk for cross-conatmination for being infected with Clostridium difficile, Acineobacter bauminnii, Beta [DIAGNOSES REDACTED] Strep Group G and Pseudomonas aeruginosa and placed them at risk for a negative impact on their health and well-being resulting in the strong potential for hospitalization and death. Findings included: Following Administrative review, this survey was re-opened. 1. Resident #18 was an [AGE] year-old female who was readmitted to the facility on [DATE], according to her Admission Record dated 07/02/12. Her Admission Record reflected her [DIAGNOSES REDACTED]. Resident #18's hospital Critical Care Progress Note dated 06/16/12 reflected, "The patients (sic) sputum Gram stain and culture is growing Acinetobacter, which is resistant to [MEDICATION NAME] and sensitive to tigecycline and [MEDICATION NAME]. The Proteus mirabilis she is growing is sensitive to meropenem, Bactrim, and [MEDICATION NAME]." Resident #18's facility Nurse's Notes dated 06/26/12 reflected she was admitted to room [ROOM NUMBER]A. Resident #18's facility admission orders [REDACTED]. Resident #18's Interim Plan of Care dated 06/26/12 did not reflect isolation precautions or active infections. Resident #18's Patient Progress Note dated 06/28/12 reflected she was on [MEDICATION NAME] and [MEDICATION NAME] for Acinetobacter. Resident #18's Care Plan initiated on 06/28/12 reflected she had Acinetobacter and the interventions included the following: bag and transport used linen according to facility protocol, collect specimens for culture and sensitivity as ordered, "CONTACT ISOLOATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry." The interventions also included: "Instruct visitors to wear disposable gloves and gown when in residents (sic) room and to wash hands before leaving room...Mask/face shield to be worn during procedures with risk of splashes or droplet contamination of bodily fluids...Observe standard precautions for infection control...Private room or cohort with appropriate rommate...Resident areas to be thoroughly cleans using disinfectants. Resident care equipment to be appropriately cleaned, disinfected or sterilized according to facility protocol." Resident #18's Physician's Telephone Order dated 07/02/12 reflected to move the resident to room [ROOM NUMBER]A. Resident #18's Physician's Telephone Order dated 07/03/12 reflected Culture and Sensivity of the sputum. Resident #18's laboratory results dated [DATE] reflected Acinetobacter bauman and "...MDR Isolated Positive Critical results called & faxed (name) at 1240 on 7/5/12...Multidrug resistant gram negative rod may require contact isolaton...." An interview with the DON, Administrator, and RN K on 09/11/12 at approximately 5:00 PM revealed Resident #18 returned to the facility on antibiotics and they knew on 07/05/12 that she had Acinetobacter. They stated they notified her physician, put her on isolation precautions, and she was on antibiotics. They revealed the physician ordered the isolation. They also revealed it was the physician's decision to put a resident in isolation. They stated they could use nursing judgment and act immediately if they thought they should. They revealed she was alone in her room. Review of Resident #18's entire closed clinical record revealed there was only one time when there was a reference to the resident being on Contact Isolation prior to the physician order [REDACTED].) Contact Isolation...." Resident #18's admission orders [REDACTED]. Resident #18's Admission Nursing assessment dated [DATE] reflected no evidence of documentation of an Acinetobacter infection or initiating Contact Isolation. Resident #2's Nurse's Notes dated 06/26/12 at 8:00 PM reflected an assessment was completed. No evidence of initating Contact Isolation was included. The Respiratory Notes dated 06/26/12 at 5:46 PM for Resident #18 reflected an initial assessment, with no indication of Contact Isolation had been implemented. Review of Resident #18's Physician's Progress Note dated 07/05/12 revealed the resident had " MDR (MultiDrug Resistant) Acinetobacter colonization of sputum, 1. Contact isolation...." Resident #18's Physician's Telephone Order dated 07/05/12 reflected Contact Isolation for Multidrug Resistant Acinetobacter. Resident #18's MDS assessment dated [DATE] reflected she did not speak, was rarely/never understood, rarely/never understands, had long and short-term memory impairment, and she never/rarely made decisions. The MDS assessment also reflected she was totally dependent on staff for bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene, and bathing. Further review of the MDS assessment revealed she was frequently incontinent of urine, was incontinent of bowel., had a Multidrug-Resistant Organism, was dependent on a respirator, had a feeding tube, had a Stage II Pressure Ulcer and five Unstageable Pressure Ulcers, and received oxygen therapy, suctioning, tracheostomy care, and was on a Ventilator or Respirator. The MDS assessment did not reflect Resident #18 was in isolation or quarantine for active infectious disease. Resident #18 was transferred to the hospital on [DATE], according to a Resident Transfer Form dated 07/11/12. An interview with RN H on 09/11/12 at approximately 3:30 PM revealed she attended the stand-up meetings and clinical meetings and obtained information regarding changes in condition of residents, critical labs, infectious disease, and anything on the 24 Hour Report which warranted attention. She stated she reviewed the Physician's Telephone Orders pink slips during the meeting daily. RN H stated with that information she was to make recommendations to the DON and Administration and sometimes the recommendations were taken to the QA meeting for consideration. She stated when Resident #18 was in the facility, she (RN H) was a new employee. RN H revealed she thought Resident #18 and Resident #20 were the first residents identified with Acinetobacter. She said she probably obtained that information during the stand-up meetings, but she was not taking minutes during the meeting. RN H also stated they discussed isolation in the meeting and looked on the internet and in policies for information regarding what type of isolation was recommended. She revealed when Resident #18 was readmitted she was placed in a private room, but it was a day or two before she was aware the resident had Acinetobacter. RN H said the DON and ADONs reviewed residents' information when the residents admitted to the facility. She stated they required the hospital to send lab work and History and Physicals. RN H revealed they did look at Resident #18's paperwork from the hospital. She stated it was a day or two before the information was discussed in the stand-up meeting. She said as she remembered they were not familiar with the Acinetobacter infection. RN H stated she printed off some information and brought it to the next meeting. Futher interview with the DON on 09/13/12 at 10:00 AM revealed he was aware that Resident #18 was in isolation in the hospital and had Acinetobacter. He stated she was readmitted to the facility on the evening shift, and the Evening Supervisor admitted her. The DON revealed the ADON followed-up with him the next day. The DON stated the ADON and the Evening Supervisor no longer worked at the facility due to job performance issues. He stated they moved Resident #18 on 07/02/12 because another resident was being readmitted to the facility in that room and they did not want them to room together due to Resident #18's infection. 2. Resident #3 was a [AGE] year-old female who was admitted to the facility on [DATE], according to her Admission Record dated 08/24/12. Her Admission Record reflected her [DIAGNOSES REDACTED]. Resident #3's admission orders [REDACTED]. Resident #3's Nurse's Notes dated 07/27/12 reflected she was admitted to room [ROOM NUMBER]A. Resident #3's Care Plan dated 07/27/12 reflected she required isolation due to a respiratory infection and the interventions included: follow facility isolation policy and inform staff and visitors of isolation requirements. Resident #3's MDS assessment dated [DATE] reflected she was cognitvely intact, needed extensive assistance with bed mobility and was totally dependent on staff for dressing, eating, toileting, personal hygiene and bathing. The assessment also reflected Resident #3 was frequently incontinent of bladder, incontinent of bowel, had Multidrug-Resistant Organism, had a feeding tube, received oxygen therapy, suctioning, tracheostomy care, was on a ventilator/respirator, but she was not in isolation or quarantine for active infectious disease. Observation at 3:53 PM on 08/18/12 revealed LVN B was in Resident #3's room without a gown or personal protective equipment. The sign on the door reflected visitors must report to the Nurse's Station before entering the room. Isolation equipment was observed hanging on the door. When asked at that time why Resident #3 was in isolation, LVN B said she did not know why Resident #3 was in isolation. On 08/18/12 CNA C was interviewed at 4:00 PM. She revealed Resident #3 had MRSA in her urine. She was not aware Resident #3 had E. Coli, MRSA, and Acinetobacter in her urine. Resident #3's laboratory results dated [DATE] reflected she had E coli (bacteria normally found in the bowel), Staphylococcus aureus, and Acinetobacter baumannii in her sputum. Resident #3's Comprehensive Plan of Care dated 08/21/12 reflected she was receiving antibiotics for E. coli, Staph aureus, and Acinetobacter baumannii in her sputum. The Plan of Care included the following interventions: isolate according to facility policy and follow universal/standard precautions to prevent cross-contamination and spread of infection. Observation on 08/22/12 at 12:00 PM revealed LVN L provided wound treatment to Resident #3. LVN L was assisted by RA Q. LVN L got her supplies: [MEDICATION NAME] cream 1%, [MEDICATION NAME] Dermicerin moisturizer cream, [MEDICATION NAME] foam dressing, Normal Saline and gauze and placed them on top of her treatment cart. LVN L transferred the supplies to Resident #3's bedside table. LVN L performed hand hygiene and donned gloves. LVN L removed the old dressing from Resident #3's coccyx. Resident #3 had respiratory problems. Resident #3 was not able to communicate. She was pointing to her head and to her neck. LVN L told RA Q to call the respiratory therapist. RA Q stood at the front door waiting to see the respiratory therapist pass by. There was a call light in the room, but LVN L and RA M did not use the call light to call for assistance. LVN L used her contaminated gloved hands and cranked the head of Resident #3's bed up. RA Q stood for 10 minutes at the front door until he saw the respiratory therapist and called the respiratory therapist into Resident #3's room. After the respiratory therapist administered oxygen to Resident #3, LVN L used the same contaminated gloved hand to measure Resident #3's wound and called out the wound measurements to the surveyor as 3.9 cm x 3.7 cm x 0.3 cm. LVN L then stuck the end of the tape in Resident #3's wound and measured the depth and called it out as 0.3. LVN L sprayed normal saline on Resident #3's coccyx wound and cleaned it with gauze. LVN L applied [MEDICATION NAME] and covered it with [MEDICATION NAME] foam. LVN L then took the leftover supplies and placed them in the Biohazard Box. LVN L left Resident #3's bedside to go to the Biohazard Box. LVN L dropped her contaminated gloves into the Biohazard Box and her cell phone fell into the Biohazard Box. LVN L donned another glove and moved contaminated gowns and gloves inside the box. LVN L removed her cell phone. LVN L placed the contaminated cell phone in her pocket. LVN L removed her glove without performing hand hygiene. LVN L used her contaminated hand to open the door and went outside the room. Observation on 08/24/12 at 11:40 AM revealed LVN L changed the dressing on Resident #3's wound. The nurse was wearing a gown, mask, shoe covers and gloves. Resident #3 was turned to the right side. Resident #3 was observed with a small amount of dark green, thick, pasty feces below the wound when turned. LVN L did not clean the feces from Resident #3 before the dressing change. LVN L removed the old, contaminated dressing from the coccyx area. The old, contaminated dressing was folded into LVN L's gloved hand. LVN L removed the glove from her hand folding the old, contaminated dressing into the glove as the glove was removed. The glove containing the contaminated dressing was placed on Resident #3's leg by LVN L. Green feces remained on Resident #3's skin below the wound after the old, contaminated dressing was removed and during the dressing change. No hand washing or hand sanitizer was used after LVN L removed the soiled dressing. New gloves were donned by LVN L. LVN L prepared to measure the wound with the paper measuring tape. LVN L measured the length first. During the measuring of the wound's length, the end of the paper measuring tape was observed to drag through the feces. A small amount of thick green feces got on the measuring tape. Three separate times LVN L held the contaminated measuring tape against the resident's open wound tissue during measuring. Three times she inserted the feces-contaminated measuring tape deep into the wound base while measuring the depth. This caused contamination of the wound with feces. LVN L did not change gloves or wash her hands after measuring the wound. Handling the contaminated measuring tape further contaminated LVN L's gloves with feces. LVN L opened a 30 ml container of sterile normal saline. LVN L moistened a 2 x 2 gauze pad with a small amount of saline. LVN L used the damp gauze pad to pat the inside center of the wound. No irrigation of the wound or other cleaning was used to remove the contamination caused when the wound was measured. LVN L then placed the normal saline container on the clean field with her other supplies. LVN L picked up the medicine cup containing [MEDICATION NAME] ointment and a cotton-tipped applicator from the clean field. LVN L applied the ointment to the center of the wound. Most of the area of the wound was not covered with the ointment. LVN L then placed the now-contaminated medicine cup and applicator back on the clean field on top of her clean gloves. LVN L then picked up the foam dressing on the clean field and applied it to the wound. LVN L did the measuring of the wound and the dressing change with gloves and a measuring tape contaminated with feces. Resident #3's Physician's Telephone Order dated 09/04/12 reflected to discontinue isolation precautions when the antibiotic was finished. There was no order to follow-up with a culture and sensitivity of the resident's sputum to determine if she was clear of the infection. 3. Resident #4 was a [AGE] year-old female, who was admitted to the facility on [DATE] and was in room [ROOM NUMBER]A, according to the Admission Record dated 08/07/12. The Admission Record reflected her [DIAGNOSES REDACTED]. A hospital Progress Note dated 07/08/12 reflected the resident had mild right lower lobe pneumonia and was currently off antibiotics. The Note also reflected Resident #4 had [MEDICATION NAME]-resistent [MEDICATION NAME], which was colonization. Resident #4's Comprehensive Plan of Care dated 07/13/12 reflected she required isolation due to a respiratory infection and the Approaches included: follow facility isolation policy, inform staff and visitors of isolation requirements. Resident #4's MDS assessment dated [DATE] reflected she was in room [ROOM NUMBER], was cognitively intact, needed extensive assistance with bed mobility, dressing, and personal hygiene and was totally dependent on staff for toileting and bathing. The assessment also reflected she had a catheter, was incontinent of bowel, received oxygen therapy, suctioning, tracheostomy care, was on a ventilator or respirator, and was not in isoloation or quarantine for an active infectious disease. Resident #4's Re-admit History and Physical dated 07/23/12 reflected a past history of Provdencia. Resident #4's laboratory results dated [DATE] reflected Providencia stuartii many colonies and Acinetobacter baumannii many colonies in her sputum. Resident #4's Nurse's Notes dated 08/14/12 reflected the antibiotic, Meropenem, one gram was ordered via IV every eight hours for 10 days and PICC line was ordered. Resident #4's Nurse's Notes dated 08/15/12 reflected the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER]A. Resident #4's laboratory results dated [DATE] reflected Acinetobacter baumannii in her sputum. The Results also reflected a handwritten note which reflected to start [MEDICATION NAME] 500 mg twice a day for 10 days and to discontinue Meropenem. Resident #4's SBAR dated 08/19/12 reflected the resident had Acinetobacter baumannii in her sputum. Resident #4's Comprehensive Plan of Care dated 08/21/12 reflected she was receiving [MEDICATION NAME] (antibiotic) for Acinetobacter in her Sputum. The Approaches included: isolate according to facility policy and follow universal/standard precautions to prevent cross-contamination and spread of infection. Interview with Physician I at 3:37 PM on 08/24/12 revealed he was the facility's Medical Director. He stated the facility certainly tried to put residents with Acinetobacter together. Physician I stated Resident #4 came from the hospital. Physician I stated he knew Resident #4 was treated for [REDACTED]. Resident #4's laboratory results dated [DATE] reflected Acinetobacter baumannii in her sputum. Review of the daily census records from the business office dated from 08/01/12 through 08/28/12 revealed Resident #4 was not in the same room with Resident #5 Review of the room roster dated 08/16/12 and printed on 08/17/12 revealed Residents #4 and #5 were roommates. Review of the facility's room roster dated 08/16/12 and printed on 08/17/12 revealed Residents #4 and #5 were roommates. Observation on 08/19/12 at 3:40 PM revealed Residents #4 and #5 were roommates. Observation at 7:37 AM on 08/20/12 revealed Residents #4 and #5 were roommates. 4. Resident #5 was an [AGE] year-old female who was admitted to the facility on [DATE] according to the Admission Record dated 08/10/12. According to the facility's Daily Census dated 08/10/12, Resident #5 did not have a roommate. Resident #5's admission orders [REDACTED]. The Orders did not reflect any antibiotics. Resident #5's Physician's Telephone Order dated 08/16/12 reflected a STAT sputum culture. Resident #5's laboratory results dated [DATE] reflected Pseudomonias aeruginosa many colonies in her sputum. Resident #5's Physician's Telephone Order dated 08/21/12 reflected [MEDICATION NAME] (antibiotic) one gram every eight hours for 10 days. Resident #5's Physician's Telephone Order dated 08/21/12 reflected to insert a PICC line. Resident #5's MDS assessment dated [DATE] reflected she did not speak, was rarely/never understood, rarely/never understands, her long and short-term memory were impaired, and she rarely/never made decisions. The assessment also reflected she was totally dependent on staff for bed mobility, dressing, eating, toileting, personal hygiene, and bathing. Further review of the MDS assessment revealed she was frequently incontinent of bladder, frequently incontinent of bowel, received oxygen therapy, suctioning, tracheostomy care and was on a ventilator or respirator. Observation on 08/24/12 at 12:12 PM revealed Resident #5 utilized a tracheostomy for breathing and a feeding tube for hydration and nutrition. Following surveyor intervention, observation on 08/24/12 revealed Resident #5 was moved to a different room and became roommates with Resident #8, who had Pseudomonas. 5. The Infection Control Log for August 2012 reflected Resident #8 had an onset date of 08/19/12 for Pseudomonas. Resident #5's Physician's Telephone Order dated 09/04/12 reflected to discontinue isolation after the resident finished antibiotics and not to repeat the sputum culture and sensitivity. 6. Resident #6 was a [AGE] year-old female, according to the laboratory results dated [DATE]. The Results also reflected she had Acinetobacter baumannii and MRSA in her sputum. Resident #6's laboratory results dated [DATE] reflected she had Acinetobacter baumannii many colonies and Proteus mirabilis in her sputum. The Results also reflected she was in room [ROOM NUMBER]B. Resident #6's Physician's Telephone Order dated 09/04/12 reflected to discontinue isolation and not to repeat a sputum culture and sensitivity. Observation at 7:37 AM on 08/20/12 revealed Residents #6 and #7 were roommates. 7. Resident #7's laboratory results dated [DATE] reflected the resident was a [AGE] year-old female, who resided in room [ROOM NUMBER]B. The Results also reflected she had Acinetobacter baumannii moderate growth in her wound. Resident #7's Physician's Telephone Order dated 08/26/12 reflected [MEDICATION NAME] (antibiotic) 4 mg via IV daily was to start on 08/27/12. Resident #7's Physician's Telephone Order dated 08/27/12 reflected to move the resident to another room. The facility's Daily Census dated 08/27/12 reflected Resident #7 became roommates with Resident #6. Reminder: Resident #6's laboratory results dated [DATE] reflected she had Acinetobacter baumannii. 8. Resident #8 was a [AGE] year-old female who was admitted to the facility on [DATE] and was in room [ROOM NUMBER]A, according to the Admission Record dated 08/24/12. The Admission Record reflected her [DIAGNOSES REDACTED]. Resident #8's MDS assessment dated [DATE] reflected she was cognitively intact, and needed extensive assistance with eating. The assessment also reflected Resident #8 was totally dependent on staff for bed mobility, dressing, toileting, personal hygiene, and bathing. Resident #8 was assessed as frequently incontinent of bowel, and she had a catheter. Further review of Resident #8's MDS assessment revealed she received oxygen therapy, suctioning, tracheostomy care, and was a ventilator or respirator. The MDS assessment reflected she was not in isolation or quarantine for active infectious disease. Resident #8's laboratory results dated [DATE] reflected Beta [DIAGNOSES REDACTED] strep group G many colonies and Pseudomonas aeruginosa moderate growth in her sputum. Resident #8's Comprehensive Plan of Care dated 08/21/12 reflected she received the antibiotic, Ceftzidime, for Beta [DIAGNOSES REDACTED] Strep and Pseudomonas in her sputum. The Plan of Care also included the Approaches to isolate the resident according to facility policy and follow universal/standard precautions to prevent cross-contamination and spread of infection. Resident #8's undated Comprehensive Plan of Care reflected she required isolation due to an infection in her sputum. The Plan of Care included the Approaches to follow facility isolation policy and inform staff and visitors of resident's isolation requirements. Review of the facility's room roster dated 08/16/12 and printed on 08/17/12 revealed Residents #8 and #9 were roommates. Observation at 7:37 AM on 08/20/12 revealed Residents #8 and #9 were roommates. 9. Resident #9 was an [AGE] year-old female who was admitted to the facility on [DATE] according to the Admission Record dated 08/28/12. The Admission Record reflected her [DIAGNOSES REDACTED]. Resident #9's laboratory results dated [DATE] reflected Acinetobacter baumannii moderate growth in her sputum. Resident #9's MDS assessment dated [DATE] reflected she was cognitively impaired, and required extensive assistance with dressing. The assessment also reflected she was totally dependent on staff for bed mobility, eating, toileting, personal hygiene, and bathing. Resident #9 was assessed as frequently incontinent of bladder and incontinent of bowel. Further review of the MDS assessment revealed she had a feeding tube, one Stage II Pressure Ulcer, one Stage IV Pressure Ulcer, and received oxygen therapy, suctioning, tracheostomy care and was on a ventilator or respirator. The MDS assessment reflected she was not in isolation or quarantine for active infectious disease. Resident #9's laboratory results dated [DATE] (four days after Resident #9 moved in) reflected not only did she still test positive for Acinetobacter baumannii many colonies, she also tested positive for she had Pseudomonas aeruginosa many colonies and Beta [DIAGNOSES REDACTED] strep not group A few colonies in her sputum (both of these were Resident #8's infectious bacteria). 10. Resident #11 was [AGE] year-old who was originally admitted to the facility on [DATE] and readmitted on [DATE] according to the Admission Record dated 08/24/12. The Admission Record reflected his [DIAGNOSES REDACTED]. Resident #11's Comprehensive Plan of Care dated 07/20/12 reflected he required isolation, but the Plan of Care did not reflect the reason for isolation. The Approaches included to follow facility isolation policy and inform staff and visitors of resident's isolation requirements. Resident #11's Comprehensive Plan of Care (date illegible) reflected he received the antibiotic, [MEDICATION NAME], for Upper Respiratory Infection/Pneumonia and Acinetobacter in his sputum. The Plan of Care Approaches included isolate according to facility policy and follow universal/standard precautions to prevent cross-contamination and spread of infection. Resident #11's MDS assessment dated [DATE] reflected he was cognitively impaired, and was totally dependent on staff for bed mobility, dressing, eating, toileting, personal hygiene, and bathing. The assessment also reflected he had an indwelling catheter, was frequentlyl incontinent of bowel, had a feeding tube, and had a Stage IV Pressure Ulcer. Further review of Resident #11's MDS assessment revealed he received oxygen therapy, suctioning, tracheostomy care, was on a ventilator or respirator, and was not in isolation or quarantine for active infectious disease. The MDS assessment also reflected he had not received an antibiotic in the last seven days. Resident #11's laboratory results dated [DATE] reflected Acinetobacter baumanii moderate growth in his sputum. Resident #11's Physician's Telephone Order dated 07/31/12 reflected the antibiotic, [MEDICATION NAME], 100 mg twice a day for 10 days. Resident #11's laboratory results dated [DATE] reflected Acinetobacter bauman

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and the plan of care of the facility. The facility failed to assess, develop and implement interventions for pain management for Residents #5, #15, and #20. 1) Resident #15 experienced excruciating pain during dressing changes on the stump of his right leg. The resident was pre-medicated with [MEDICATION NAME] 15 minutes prior to the dressing change, but the resident was crying, making hoarse squeaks around the [MEDICAL CONDITION], and flailing away at the nurses, trying to guard his right leg and keep the staff from providing wound care. [MEDICATION NAME] gel (anesthetic) was applied to the skin two inches above the wound, which made it ineffective. When LVN C and LVN D finished the dressing and switched on the wound VAC and the suction started, the resident began to shriek, flailed and attempted to pull off the dressing. ADON B held the resident's arms so he could not pull of the dressing and wound vac. 2) Resident #5 had pain "always." There was no care plan to assess and address the resident's ongoing pain. The resident had physician's orders [REDACTED]. Resident #5 also had a surgical wound from a pressure ulcer debridement along with a newly developed Stage II pressure ulcer in close proximity. LVNs C and D did not provide care in a way to promote healing and prevent cross-contamination. 3)Resident #20's pain was not adequately addressed and an unidentified LVN did not know how to use the facility pain assessment tool to assess Resident #20's pain level. Resident #20 was given Tylenol for pain. These failures resulted in inadequate pain management for Residents #5, #15, and #20, and a potential for worsening of a surgical wound for Resident #5. These failures could affect the 22 residents who were on pain management and 37 residents who lived on the 400 hall. Findings included: Based on administrative review, the facility's standard survey was reopened on 03/12/12 due to the identification of Substandard Quality of Care and the need for further investigation. 1) Resident #15 was a [AGE] year-old male who was admitted to the facility on [DATE] according to his Face Sheet dated. Resident #15's MDS assessment dated [DATE] listed [DIAGNOSES REDACTED]. Resident #15 utilized a PEG tube for food and water and had a PICC, utilized a ventilator for breathing, and utilized a urinary catheter per the MDS assessment dated [DATE]. The resident was identified as being on a pain management plan. Observation of Resident #15 during initial tour on 02/21/12 at approximately 9:00 AM revealed the resident had a wound VAC to the lower abdominal wound at 150 mm suction. Resident #15 looked very uncomfortable. He had facial grimacing and looked very sad. Observations on 02/21/12 at 2:55 PM during wound care revealed Resident #15 had one Stage III pressure ulcer on his right femur, an infected surgical wound from a lower limb above- the-knee amputation on the right leg, and an infected abdominal surgical wound. At that time, Resident #15 was receiving wound care from LVN C and LVN D. LVN C revealed Resident #15 had a wound VAC to the knee amputation. She stated, "He pulls the wound VAC off every day himself. It's supposed to be on now and put on Monday, Wednesday and Friday. Since he pulls it off all the time, we used wet-to-dry dressings." LVN C removed the wet-to-dry dressing on the right leg. The resident was crying in pain, making hoarse squeaks around the [MEDICAL CONDITION] and flailing away from the nurses. He swatted at the nurses screaming around the [MEDICAL CONDITION] during the wound care process. His face appeared in extreme pain. He kept shouting, "No! No!" and pulled his stump away from the nurses trying to hide his leg with his hands. LVN C went to the treatment cart and got [MEDICATION NAME] gel and applied it to the skin around the right stump wound about two inches above the incision site. Resident #15 continued to cry out and avoid the wound care treatment. LVN C left the room again and got the ADON. ADON B came into the room. She stated that Resident #15 was pre-medicated for pain before the dressing change. She stated, "He is just frightened. When he sees the wound it scares him so bad he starts screaming." Resident #15 continued to scream in pain and attempted to withdraw his leg. LVN C continued attempting to pack the stump wound with the white wound VAC foam. ADON B held the resident's hands to keep him from pushing the nurses away from his wounds. Resident #15 continued to attempt to guard the wound crying out whenever it was touched, flinching and keeping his leg away from the nurses. LVN C and LVN D continued to apply the dressing. When LVN C and LVN D finished the dressing and switched on the wound VAC, the suction started and the resident began to shriek, flailed and attempted to pull off the dressing. ADON B kept the resident from tearing off the dressing by holding his hands away from the dressing. Interview with LVN D on 03/04/12 at 1:10 PM revealed she rated Resident #15's pain as a "steady 8." She stated Resident #15 would let the wound nurses do all his other dressing changes, except for his stump, after receiving pain medication. She stated the resident would shield his stump and did not want the wound nurses to touch it. He grimaced when the wound nurses placed foam on his stump. He would say "stop." LVN D stated Resident #15's pain was worse after he came back from the hospital with his wound open. His wound was debrided at the hospital. LVN D stated Resident #15 had the same amount of pain throughout his stay at the facility. She stated, "Some days he would let us start his dressing change and not finish and some days he would let us complete the dressing change on his stump." She revealed Resident #15 sometimes removed the dressing from his stump. She stated wound nurses would wrap his stump with Kerlix and tape and he would remove the dressing because he could not take the pressure of the Kerlix touching his stump. LVN D stated her assessment of Resident #15's wound was that it was decreasing in size. She revealed the wound was open and the incision was not even. She stated Resident #15 would not let the wound nurses put pressure on his stump to close the wound. In an interview on 03/14/12 at 3:08 PM, CNA U revealed if she touched Resident #15's stump while providing care, the resident would say, "It hurts! It hurts!" CNA U stated she would continue providing care for the resident because, "You can't just leave him like that." She stated when she was finished providing care she would then go tell the nurse the resident was in pain and needed "pain pills." CNA U stated Resident #15 was "always" in pain due to the "gravity of the wounds." In an interview on 03/14/12 at 3:22 PM, CNA V revealed she had provided care for Resident #15. She stated Resident #15 was always in pain due to his wound and would react to care by crying and exhibiting a facial grimace which led her to believe he was in pain. She stated when Resident #15 was in pain and reacted in this manner, she would call the nurse who would give him pain medication. CNA V stated she would "wait for the medicine to settle down (take effect) and for him (Resident #15) to settle down; like about 3 or 4 minutes," and then finish providing care for him. In an interview on 03/14/12 at 3:36 PM, CNA W revealed she had provided care for Resident #15. She stated the resident was always in pain and did not want people to touch him. CNA W stated if she was in the middle of providing care and Resident #15 complained of pain, she would try to calm him down, finish providing the care and then go alert the nurse that the resident was in pain. Resident #15's February 2012 physician's orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) 100mg/5ml - Give one ml (20 mg) every three hours as needed for pain; [MEDICATION NAME]/[MEDICATION NAME] 7.5/500 mg/15 ml - Give 15 ml every four hours as needed for pain; and [MEDICATION NAME] 1 mg tablet every four hours as needed for anxiety The February 2012 MAR indicated [REDACTED]." This medication was dispensed from the pharmacy on 02/20/12. On 02/21/12 Resident #15 received [MEDICATION NAME] at 9:00 AM and at 2:30 PM (20 minutes prior to dressing change) per the narcotic administration sheet. The narcotic administration record reflected Resident #15 received [MEDICATION NAME] on 02/21/12 at 3 PM. Further review of the [MEDICATION NAME] administration record reflected Resident #15 received far more [MEDICATION NAME] than [MEDICATION NAME] or [MEDICATION NAME]. Review of the narcotic record revealed Resident #15 received this medication an average of 2 to 3 times a day. Resident #15 also had an order for [REDACTED]. ([MEDICATION NAME] an effective medication for [MEDICAL CONDITION] it is not effective for pain control.) Observation on 02/22/12 at 9:00 AM revealed Resident #15 had his teeth clenched and wrinkles in his forehead. He appeared in pain. When queried if he was in pain by the surveyor, he nodded "yes." Review of the narcotic administration record revealed Resident #15 had received [MEDICATION NAME] at 7:45 AM that morning. Observation on 02/22/12 at 11:30 AM revealed Resident #15 lying in bed with a grimace on face. When queried if he was if pain by the surveyor, he nodded "yes." The narcotic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #15's Pain Management Flow sheet for February 2012 reflected Resident #15's pain level was rated 8 to 10 on a scale of 1 to 10 on most of the entries for his right leg amputation. The pain rating score after intervention rated Resident #15's pain at zero after medication was given and comments were, "medication effective." The facility's current Pain Management Policy dated November 2009 reflected: "Appropriate pain management helps the resident to avoid pain as much as possible and it establishes a treatment plan for such episodes of acute pain/or chronic pain, if and when they occur. Intervening to treat pain before the pain becomes moderate is expected. The facility's expectation for pain management shall include but not limited to: 1) Identifying and intervening to treat pain aggressively and before the pain becomes moderate. 2) Documenting pain assessments, interventions, and evaluation activities in a clear and concise manner using the information collected to implement a multidisciplinary individualized plan of care. 3) Staff recognizing that pain medications may be given around the clock. 4) The use of non-drug interventions to assist in pain alleviation is appropriate. 5) Intervening to minimize drug side effects. 6) Implementing quality assurance/improvement standards to monitor the pain management program." 2) Resident #5 was a [AGE] year-old female who was admitted to the facility on [DATE] according to her Face Sheet dated 02/24/12. The MDS assessment dated [DATE] reflected Resident #5 was ventilator dependent, had a [MEDICAL CONDITION], utilized a [DEVICE] for feeding, and was totally dependent on staff for care. The MDS assessment also reflected Resident #5 was able to communicate with staff, was not able to identify the day of the week, but knew the month and the year. The resident was alert and oriented except for the day of the week. She was interviewable regarding her care at the facility. The assessment also reflected Resident #5 was dependent on staff for turning and all activities of daily living. [DIAGNOSES REDACTED]. An observation of Resident #5 at 9:45 AM on 02/21/12 revealed the resident was unable to turn herself. The surveyor noticed the resident had very little use of her hands and arms. The resident was not able to use her arms to position herself in bed. At that time, LVN C and LVN D were observed providing wound care to Resident #5. The DON was present and also observing. LVN D gathered the following supplies and placed them in the white plastic rectangular basket from the treatment cart: foam dressing, Puracol (a collagen, micro-scaffold product used to increase wound healing), wound gel squeezed from a tube into a plastic medicine cup, one wooden paddle applicator, an opened paper wrapped gauze package of 4 x 4 pads, scissors, and a small bottle of normal saline. LVNs C and D washed their hands and put on gloves. LVN C cleaned the bedside table with disinfecting wipes and positioned Resident #5 on her side. LVN D removed both the sacral dressing and the dressing from the left buttock and placed them in a red bag. What appeared as a large Stage IV pressure ulcer was observed on Resident #5's sacrum and a smaller Stage II pressure ulcer was observed on the resident's left buttock. LVN D removed her gloves, but did not wash her hands. She put on new gloves, opened the bottle of saline, poured some on a gauze pad, and wiped off the sacral wound. She reached into the paper package of clean gauze pads with the same contaminated gloves she had been wearing, took out a 4 x 4 and patted the wound dry. Without washing her hands and changing gloves, LVN D reached into the paper package of clean gauze pads, took out another pad, moistened it with saline, and wiped it over the left buttock pressure ulcer. She put the soiled pad into the red bag, and again reached into the opened paper bag of gauze pads, and picked up another gauze pad. LVN D then patted the buttock pressure ulcer dry and put the soiled gauze pad into the red bag. During the procedure, LVN C and LVN D measured Resident #5's sacral wound with the paper measuring tape. LVN D measured the sacral wound as 7.0 cm x 3.0 cm x 1.5 cm and stated it was a Stage IV. The surface area was 21 cm2. Muscle and fascia were observed in the wound. During the measurement, LVN D was observed allowing the paper measuring tape and her gloved fingertips to touch the open pressure ulcer. Without changing gloves and washing her hands, LVN D then measured the left buttock pressure ulcer. She used the same contaminated paper measuring tape and measured the Stage II pressure ulcer at 2 X 2 cm. (Note: The LVN touching both pressure ulcers with the tape measure and her gloved fingertips could cause cross contamination from one pressure ulcer to another.) Then, without changing her gloves and washing her hands after touching both pressure ulcers/wounds, LVN D applied wound gel to both pressure ulcers/wounds with the same wooden applicator. She repeatedly dipped the wooden applicator into the medicine cup of wound gel and she applied it to both pressure ulcers/wounds, moving from one to the other. (This method could cause cross contamination of bacteria from an infected wound to an un-infected wound.) LVN D folded the Puracol and put it into the sacral wound. Then she put the foam dressing over both wounds, washed her hands, and gathered her supplies putting them back into the plastic basket. She put the jar of opened saline into the bedside table. The plastic basket was not disinfected. The plastic basket of supplies and scissors were taken out of the room and placed back on the top of the treatment cart. LVN D wiped the scissors with an alcohol prep pad and replaced the contaminated package of gauze pads into the treatment cart drawer. Packages of disinfection wipes were observed on the treatment cart, but were not used. An interview with Resident #5 was conducted on 02/21/12 at 10:00 AM. The surveyor queried Resident #5 about how she was doing. She stated in a hoarse whisper around the [MEDICAL CONDITION], "Not so good. I'm getting worse." When the surveyor queried Resident #5 about being turned every few hours she shook her head, "No." When asked if she was in pain she nodded, "Yes." During an interview on 02/22/12 at 09:00 AM, Resident #5 was asked by surveyor if she was in pain. Resident #5 whispered, "Always." The MDS assessment dated [DATE] reflected Resident #5 had the presence of pain frequently during the last 5 days. The MDS assessment also reflected the resident had pain that limited day-to-day activities. The physician's consolidated February 2012 orders reflected, "...Monitor and record pain level ...." Resident #5's Comprehensive Plan of Care reflected the Pain Plan of Care was blank and undated. The surveyor queried ADON B about the location of current resident care plans on 02/24/12 at 2:00 PM. The ADON B stated all the care plans were in the charts and they were the most current. Review of Resident #5's Pain Management Flow Sheet for the month of February 2012 revealed documentation was done only seven times in the last 24 days. Each time the resident's pain was documented to be a 7-8 on a 0-10 pain scale. The resident was documented as crying, grimacing. Resident #5 had a physician's orders [REDACTED]. Monitor and record pain level before and after medication administration every shift." The nurse's MAR for February 2012 reflected Resident #5 received [MEDICATION NAME] five times on the day shift (February 3, 6, 17, and 19), twice on the evening shift (February 9 and 19), and 11 times on the night shift (February 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13), for the entire month of February 2012. Resident #5 received [MEDICATION NAME] on average only twice a day between the dates 02/14/12 to 02/24/12. (Resident #5 could have received pain medication up to six times a day if needed and the current doctor's order was followed.) Review of the Controlled Drug Record for Resident #5 revealed Resident #5 received [MEDICATION NAME]-APAP 5-325 twenty eight times in February. The exact dates and times were listed as follows: 02/01/12 5:00 AM 02/02/12 12:00 AM 02/02/12 10:00 AM 02/03/12 8:30 AM 02/04/12 12:00 AM 02/04/12 9:00 AM "02/02 180 (sic.)" "02/06 083 (sic.)" 02/07/12 12:00 AM 02/08/12 5:00 AM 02/09/12 12:00 AM 02/09/12 6:30 AM 02/10/12 1:00 AM 02/10/12 11:00 AM 02/10/12 9:00 PM 02/11/12 12:00 AM 02/11/12 11:00 AM 02/12/12 9:00 PM 02/17/12 8:44 AM 02/18/12 2:00 AM 02/18/12 9:00 AM 02/19/12 9:00 AM 02/19/12 6:00 PM "02/21 090 (sic.)" 02/26/12 9:00 AM 02/26/12 5:00 PM "02/28 J000 (sic.)" "02/29 J000 (sic.)" Review of the March 2012 MAR indicated [REDACTED]. There was no documented of pain monitoring on the MAR. Record review of the Controlled Drug Record for Resident #5 revealed Resident #5 received [MEDICATION NAME]-APAP 5-325 seven times in March. The exact dates and times were listed as follows: 03/03/12 12:00 AM 03/03/12 5:00 PM 03/04/12 9:00 AM 03/09/12 4:00 AM 03/10/12 1:00 PM 03/10/12 8:00 PM 03/14/12 1:30 PM Record review of the Pain Management Flowsheet for Resident #5 for the Month of March provided by the facility on 03/14/12 revealed Resident #5 had complained of leg pain on 03/03/12. Resident #5 rated the pain at an "eight." The intervention documented on the Pain Management Flowsheet was [MEDICATION NAME] 5/325. The pain rating score after intervention was a "two." Resident #5 had leg pain rated at an "eight" on 03/09/12. The intervention documented on the Pain Management Flowsheet was [MEDICATION NAME] 5/325. The pain rating score after intervention was a "two." No pain assessment was noted on the Pain Management Flowsheet for the administration of pain medication two times on 03/10/12. Interview with the DON at 11:00 AM on 03/15/12 revealed he did not have any more Pain Management Flow sheets for Resident #5. Review of the Wound Care Specialist Notes written by Physician A revealed: On 12/14/11 Resident #5's sacral surgical wound had improved and measured 8.0 x 5.0 x 1.3 cm and had a surface area of 40.00 cm2 however a pressure ulcer on the left buttock had developed. This new pressure ulcer was measured at 2.2 x 2.5 x 0.2 cm and was a Stage III. On 01/04/12 Resident #5's sacral surgical wound was noted to be improved and measured 7.6 x 4.0 x 2 cm and 30.40 cm? in surface area. The pressure ulcer on the left buttock was also improved and the measurements were 1.8 x 1.5 x 0.26 cm with a surface area on 2.70 cm2. On 01/18/12 Resident #5's sacral surgical wound measured 6.5 x 5.5 x 1.5 cm with a surface area of 35.7 cm?. The pressure ulcer on Resident #5's left buttock measured 1.5 x 1.5 x 0.2 cm and was now 2.2 cm? in surface area. On 02/15/12 Resident #5's sacral surgical wound had deteriorated. The sacral wound was measured by the wound physician as 7.5 x 5.3 x 1.5 cm with a surface area of 39.75 cm?. The left buttock pressure ulcer measured at 0.3 x 0.6 x 0.1 cm with a surface area of 0.18 cm?. Physician A indicated the reason for deterioration was noncompliance with wound care. On 02/22/12 Resident 5's sacrum wound measured as 6.5 cm x 4.5 cm x 2.0 cm and Physician A noted the pressure ulcer had improved due to decreased surface area. However, the wound was now 0.5 cm deeper. Resident #5's pressure ulcer on the left buttock measured 5.5 x 4.0 x 0.2 cm and now had a surface area of 22.00 cm?. The pressure ulcer had gotten larger. Physician A's note reflected the reason for the deterioration was the resident was unwilling or unable to adequately off load the pressure ulcer. Review of the Weekly Pressure Ulcer Healing Records for Resident #5's left buttock revealed: On 01/19/12, the record's pain section was blank; On 01/25/12, the record's pain section was blank; On 02/01/12 (reviewed 02/22/12) the record reflected Resident #5 was experiencing pain with the pressure ulcer. No information about non-verbal demonstration of pain, pain location, nature, frequency or intensity of pain was documented. (Note: The same document was again reviewed on 03/15/12, after surveyor intervention. At that time, "error" had been written under the check box for the question about whether the patient had pain related to the wound. The check box for "no" was now checked. The face was circled to indicate the intensity of the pain was zero. "Lt. Buttocks" was also added to the left side of the the page. There was no indication of a "late entry.") On 02/09/12 (reviewed 02/22/12) the record reflected the section for pain was blank. (Note: The same document was again reviewed on 03/14/12, after surveyor intervention. At that time, the check box for "no" was checked to indicate Resident #5 did not experience pain related to the wound. The face was circled to indicate the intensity of the pain was zero. There was no indication of a "late entry.") On 02/15/12 the record (reviewed on 02/22/12) reflected no documentation for pain. (Note: The same document was again reviewed on 03/14/12, after surveyor intervention. At that time, the check box was checked to indicated Resident #5 was not experiencing pain to the wound. The face was circled to indicate the intensity of the pain was zero. There was no indication of a "late entry.") Resident #5's Care Plans reviewed on 02/22/12 revealed: Pain (no date of onset) - "Acceptable Pain Level: Notify MD if level exceeds:" The care plan for Resident #5 was reviewed again on 03/15/12. The date, 02/24/12, (after surveyor intervention) had been added. The name of Resident #5 was written on the form. The pain scale circled was numeric. The pain medications listed were [MEDICATION NAME] and Tylenol. "Acceptable Pain Level: Notify MD if level exceeds" was blacked out. No "late entry" was identified on the form. Additional care plans were reviewed on 03/15/12 for Resident #5. Review of the second care plan dated both 09/28/11 and 12/28/11 revealed Resident #5 had the potential for Pain/Discomfort due to decrease in Activities of Daily Living. Review of the third care plan dated 11/16/11 revealed Resident #5 was at risk for pain due to wound care. This care plan had the following review dates: 11-30-11 "Improved" 12-07-11 "no change" 12-14-11 "Improved" 12-21-11 "no change" 12-28-11 "Improved" "1-04-11 (sic) no change" "1-11-11 (sic) no change" "1-18-11 (sic) Improved" No "late entry" was noted on these care plans. During an interview conducted on 02/24/12 at 3:10 PM, a family member stated, "The staff don't turn her (Resident #5) enough. We are very concerned about the sore. It made me sick to look at it." The interview revealed "they (the family)" had to go get staff to change the resident when she was soiled. Family interview at 12:09 PM on 03/15/12 revealed Resident #5 had pain caused by the "bed sores" on her "bottom." The family member stated Resident #5 cried because of the "bed sores." 3) Resident #20's MDS assessment reflected she was admitted to the facility on [DATE]. Her diagnosed included [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Reflux Disease, Hypertension, Diabetes Mellitus, Fracture, Dementia, Anxiety Disorder, Depression, [MEDICAL CONDITION], [DIAGNOSES REDACTED], Rhabdomyolysis, and Abnormal Gait. Staff used "facial expression" to assess the resident's pain. Review of nurse's note dated 11/08/11 revealed Resident #20 was yelling occasionally. Resident #20 was expressing facial grimace. Resident #20 was unable to communicate pain. Resident #20 was given 650 mg of Tylenol po for pain. The nurse's note did not reflect using a pain assessment tool. The nurse's note did not reflect effectiveness of the medication administered. Review of nurse's note dated 11/09/11 revealed the resident was given Tylenol 650 mg po due to facial grimace. The nurse's note reflected the resident was yelling occasionally. The nurse's note reflected Resident #20 was unable to describe the location of the pain. The pain assessment tool was not used to show the intensity of the pain. There was no documentation of the effectiveness of the medication administered. Resident #20's June 2011 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. There was no physician's telephone order for Tylenol with a start date of 06/22/11 for pain found on Resident #20's chart. The MAR indicated [REDACTED]. Review of the comprehensive care plan for Resident #20 revealed pain and comfort was not care planned. On 02/24/12, the Facility MDS Coordinator was queried and she stated she would look for the care plan. The facility MDS Coordinator returned and stated she did not find the care plan for pain, but she provided a new care plan for Resident #20's pain assessment dated [DATE]. Interview on 02/24/12 at 3:01 PM with Corporate Nurse Educator S revealed a physician's orders [REDACTED].#20's chart. Corporate Nurse Educator S stated staff might have transcribed a physician's orders [REDACTED]. Corporate Nurse Educator S stated she thought there was a physician's Tylenol order for pain. Corperate Nurse Educator S stated she thought there was another physician's Tylenol order for fever since both Tylenol had different start dates. A Pain Data Collection Tool dated 06/12/11 reflected Resident #20 had a pain scale of "3." According to scale, the pain of "3" was a mild pain and Resident #20 did not require medication. Resident #20's pain was not correctly assessed. Tylenol 650 mg was administered. An unidentified facility nurse checked the box on the form, there was no change in pain for the last 30 days. There was no other pain assessment tool found on Resident #20's chart. 4) The CMS 672 dated 02/21/12 reflected 22 residents were on pain management. The resident roster dated 02/21/12 reflected there were 37 residents who resided on the 400 hall.

Based on interview and record review, it was determined the facility staff failed to immediately consult with the physician for a change in condition or a need to alter treatment for one (Resident #2) of 13 residents reviewed. 1. Six nurses (LVN M, LVN N, LVN O, RN P, LVN L, and the DON) failed to consult with the physician when Resident #2's blood pressure was very low for 20 hours (the systolic BP was 52 to 42). Resident #2's physician said he would have sent the resident to the hospital immediately, if he had known about her low blood pressure. Resident #2 was sent to the hospital and she expired in the hospital. 2. LVNs L, N, and O failed to consult with Resident #2's physician when the resident's PEG tube site (Percutaneous Endoscopic Gastrostomy or feeding tube) was leaking so severely that a nursing instructor and her student stopped administration of tube feedings and medications. These failures caused a delay in care and medical treatment for Resident #2. These failures could affect the other 44 residents, who resided on Station 4, by placing them at risk of delay in medical care and treatment. Findings included: 1. According to the Admission Record dated [DATE], Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE]. The Admission Record reflected Resident #2 had [DIAGNOSES REDACTED]. The Nurse's Notes reflected the following information: On [DATE] at 10:00 AM, LVN N documented Resident #2's blood pressure at ,[DATE], pulse 88, respiratory rate 18, temperature 98.9 F. She further documented the PICC line (intravenous line to give her antibiotics) was not patent (line became unusable or not patent due to a blood clot or a kink in the line). The [DEVICE] was patent, and the stoma area was draining. On [DATE] at 1:00 PM, LVN N documented the resident was seen by Physician K who wrote an order to discontinue the antibiotic therapy and the PICC line. On [DATE] at 3:30 PM, LVN M documented the resident was resting in a semi-comatose state. Vital signs were: blood pressure ,[DATE], pulse 99, breathing rate 14 on the ventilator, temperature 103.1 F. LVN M gave Tylenol 650 mg for temperature. The family was notified of the change in Resident #2's condition. (Note: LVN M did not document calling the physician to notify him of the change of condition). On [DATE] at 6:00 PM, LVN M documented the vital signs were blood pressure ,[DATE], heart rate 103, respiratory rate 14, and temperature 103.6 F. LVN M gave [MEDICATION NAME] for anxiety. (Note: LVN M did not document calling the physician about the vital signs). On [DATE] at 9:00 PM, LVN M documented the resident was resting with her eyes closed. Vital signs were blood pressure ,[DATE], heart rate 96, respiratory rate 14, temperature 101.6 F. LVN M noted Tylenol was given for increased temperature, a sponge bath was given for comfort, and the family was at the bedside. On [DATE] at 1:30 AM, LVN O documented Resident #2's blood pressure at ,[DATE], heart rate 112, respiratory rate 16, and temperature 99.6 F. LVN O documented the respiratory rate was even and unlabored. [MEDICATION NAME] 1 mg, [MEDICATION NAME] ,[DATE] mg, and Tylenol 650 mg were given for elevated heart rate, pain, and elevated temperature. On [DATE] at 6:00 AM, LVN O documented Resident #2's respiratory rate was even and unlabored, fasting blood sugar was 75, and no (insulin) coverage was required. (Note: No vital signs were taken at this time.) On [DATE] at 8:30 AM, LVN N noted she was unable to administer medications, the [DEVICE] was out, the area was cleaned, and she would notify the attending physician. (Note: There were no vital signs.) On [DATE] at 9:30 AM, LVN N noted Resident #2's attending physician, Physician K, was on the unit, assessed the resident, and ordered her to be sent to the hospital to replace the [DEVICE]. (Note: There were no vital signs in this entry and no mention of the resident's blood pressure.) Resident #2's Resident Transfer Form dated [DATE] reflected she was being transferred from the facility to the local hospital to replace her [DEVICE]. Vital signs listed on the Transfer From included heart rate 95, respiratory rate 16, temperature 96.4 F. Resident #2's blood pressure was not documented on the Transfer Form. The Transfer Form was completed by RN J. The Emergency Medical Service Report reflected the following: on [DATE] at 11:53 AM, the ambulance crew arrived and began documenting Resident #2's condition. Resident #2's blood pressure was 58 by Doppler (technique reserved for the measurement of low pressures, e.g. vascular insufficiency), pulse 96, oxygen saturation 97%. They had her on a ventilator with assist control at 14, title volume 500, PEP of 5, and oxygen 40%. Resident #2's temperature was 102.4 and there were no palpable pulses, radial or femoral. At 12:00 PM the ambulance crew started an IV in Resident #2's right external jugular, gave 800 ml [MEDICATION NAME] normal saline after three attempts to start the IV. The emergency room Nurse's Notes dated [DATE] at 1:00 PM reflected Resident #2 had a blood pressure of ,[DATE], pulse 114, temp 103.1, and she was breathing at 14 with the ventilator. Resident #2's hospital lab results dated [DATE] at 1:47 PM reflected the resident's potassium was 1.8 mmol/L with the reference range of 3XXX,[DATE].0 mmol/L. Her CO 2 was 44 mmol/L and the reference range was ,[DATE] mmol/L. The results reflected Resident #2's CO 2 was "Above upper panic limits." The results reflected her chloride was 81 mmol/L with a reference range of ,[DATE] mmol/L and her blood sugar was 17 mg/dl. Resident #2's hemoglobin and hematocrit were 7.1 g/dL and 21.7%. (The hemoglobin and hematocrit are measures of the amount of blood in the body that can carry oxygen to the organs.) On [DATE] at 10:00 AM, an interview with Physician K, Resident #2's attending physician, was conducted. The surveyor and the physician reviewed Resident #2's clinical record together. The physician stated, "The nurses did not let me know about her blood pressure or fever. They did let me know about the PICC line being occluded, because I stopped the antibiotics. I felt she had enough antibiotics by that time. Reinserting a PICC line is traumatic and not without its dangers. All they told me was that the PICC line was occluded." "The nurses did not inform me of the blood pressure or the fevers. If they had, I would have sent her to the hospital right away. She was clearly in septic shock and needed more treatment. Notification of changes of condition is a frequent issue here at this facility. The nurses just don't tell a physician what he needs to know. The nurses did not let me know about the PEG tube causing problems either. I couldn't say if she was getting her tube feeding or not, but the nurses did not call and tell me about (Resident #2's) blood pressure or let me know about her change of condition. I would have sent her to the hospital when her blood pressure dropped at 3:30 PM on [DATE] by emergency ambulance because she was clearly in shock, but the staff did not recognize it." Physician K did not state the resident was on palliative care. On [DATE] at 2:20 PM, an interview with the DON was conducted. He stated, "The physician was notified of the resident's change of condition at 3:30 PM. I went in that room four or five times that day. The family only wanted palliative care. Resident #2 looked like she was dying and everybody knew about the change in condition from when she walked into the door from the hospital the last time. The SBAR should have been filled out for change of condition. The SBAR is a form that we use to document all changes of condition. I am sure that they (the staff) filled it out. It's the policy to fill out the SBAR whenever we communicate to the physician about new symptoms and signs of other changes (sic)." (Note: The DON could not produce the SBAR. He also could not produce a palliative care order or palliative care plan for Resident #2 at this time.) Resident #2's admission orders [REDACTED]. The entry reflected, "GT ([DEVICE]) Site leaking meds leaked out c (with) gravity. Chg (charge) Nurse notified feeding held-." On [DATE] at 2:45 PM, LVN L an ADON and unit manager for Station 4, was interviewed. LVN L identified the nurses charting on the MAR and on the Nurses Notes on [DATE] and [DATE]. When queried about the note on the back of the above [DATE] Administration Record he replied, "On the MAR on [DATE] at 8:00 AM these doses were circled by an instructor with a nursing student, who noted the [DEVICE] was leaking." He stated, "It is the nursing instructor who charted in the MAR about the [DEVICE]. They would have informed (LVN N)." He stated he was not aware Resident #2's blood pressure had dropped at 3:30 PM. He stated he would not have given her the [MEDICATION NAME] or [MEDICATION NAME] with such a low blood pressure. LVN L stated he was the manager of Station 4 at that time. On [DATE] at 3:30 PM, LVN M was interviewed regarding her Nurse's Note dated [DATE] at 6:00 PM. LVN M stated, "I told (LVN L), who was the unit charge, about the blood pressure. I assessed anxiety based on heart rate. I gave any medication she was supposed to be on. I just gave her all her medications. Usually a high heart rate means anxiety. I didn't call the doctor. He knew she was expected to die, so I didn't need to call. She was in very bad condition." On [DATE] at 3:45 PM, LVN L, an ADON and unit manager, stated, "Hospice would not accept (Resident #2) because of the ventilator. The hospice considers a ventilator a life-sustaining measure. We couldn't find a hospice for her. I don't have the SBAR for her change of condition. An SBAR was not done for (Resident #2)." On [DATE] at 3:45 PM, the DON was interviewed. He stated the SBAR was not in the resident's chart because Resident #2 was in such poor condition that a change of condition form was not necessary. He said staff did not do the SBAR because, "The doctor knew and everyone knew how bad she was! The doctor knew, so I didn't call him." 2. Nurse's Notes dated [DATE] at 8:00 AM reflected Resident #2's PE[DEVICE] site was leaking medications. LVN S and SN T held Resident #2's [MEDICATION NAME], Potassium, Pro-Stat, [MEDICATION NAME], the water flush, and the tube feeding that were to be given at 8:00 AM. LVN S and SN T documented the charge nurse was notified. An interview with LVN L, unit manager and ADON for Station 4, on [DATE] at 3:45 PM was conducted. LVN L revealed he was notified about the tube feeding and he did not call the doctor. He did not specify why. According to J. Fang, C. Lynch. 2004. Prevention and Management of Complications of Percutaneous Endoscopic Gastrostomy (PEG) Tubes, Practical [MEDICATION NAME], [DATE], page 70, "Leakage of a PEG tube is a significant management problem. Problems that cause excessive leakage are infection of the site, increased [MEDICAL CONDITION] acid secretion, buried bumper syndrome, and ulceration. Leaking tubes should be evaluated for evidence of infection and buried bumper." Further review of Nurse's Notes revealed LVN N documented on [DATE] at 10:00 AM that Resident #2's [DEVICE] was patent and the stoma area was draining. A Nurse's Note made by LVN N on [DATE] at 1:00 PM reflected Resident #2 was seen by Physician K. There was no documentation the physician was consulted regarding the leaking PEG tube site and holding the medication and tube feeding from earlier that day. An interview with Physician K was conducted on [DATE] at 10:00 AM. Physician K reviewed Resident #2's clinical record with the surveyor. Physician K stated the nurses did not inform him about the PEG tube causing problems. When the surveyor asked Physician K if the resident was receiving her tube feedings, he stated he could not tell from the documentation whether the tube feeding was being given or not. Resident #2's MARs for [DATE] through [DATE] reflected the resident continued to receive insulin and other medications through her PEG tube. There was no documentation if Resident #2 was receiving her tube feedings. The Hospital Emergency Department record documented Resident #2's blood sugar as 17 mg/dL when Resident #2 arrived at the hospital at 1:01 PM on [DATE]. According to A.D.A.M (A.D.A.M. Medical Encyclopedia. 2011. PubMed. retrieved [DATE] from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 23) The normal blood sugar range for adults is 80 to 100. A blood sugar of 17 would be life threatening. "The most common causes of low blood sugar in people with diabetes are, not eating enough during meals or snacks after taking insulin, taking too much insulin by mistake or taking the insulin at the wrong time. [DIAGNOSES REDACTED] is a condition that occurs when blood sugar is too low. A blood sugar below 70 mg/dL is considered low. A blood sugar at or below this level can cause harm. Low blood sugar can cause [MEDICAL CONDITIONS], coma and death. (A.D.A.M. 2011)" A family interview with Resident #2's family member was conducted on [DATE] at 10:10 AM by phone. When the family member was asked about Resident #2, he/she began to cry and sob. The family member stated he/she had just buried Resident #2 the other day. He/she stated Resident #2 passed away on [DATE] at the hospital. 3. The facility's Roster/Sample Matrix Form CMS-802 printed on [DATE] reflected 44 residents resided on Station 4.

Based on observation, interview, and record review, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for five (Residents #12, #37, #10, #4, and #3) of 13 residents and one (Resident #24) of one closed record reviewed for infection control. 1) Resident #24 had a urinary catheter without a physician's orders [REDACTED]. Facility staff were not taking care of Resident #24's catheter. These failures resulted in Resident #24 contracting a UTI and developing Sepsis. Her cause of death was Septic Shock. 2) Resident #12's urinary drainage bag was labeled with a hospital label, which indicated the catheter should be removed approximately two days after it was placed. The catheter was not removed or changed in fourteen days. There were no orders to change the urinary catheter on the MAR. 3) Resident #37's urinary drainage bag was not dated, not secured to the resident's leg, and was not changed when it was ordered to be changed. The CNA did not wash her hands before or after assisting the surveyor in seeing Resident #37's indwelling catheter. 4) Resident #10 had an order to change his supra pubic catheter monthly. Resident #10's supra pubic catheter was changed in late February, 2011, but it was not changed in [DATE] at the same time. These failures could affect the 13 residents, including Residents #10, #5, #12 and #37, who had indwelling catheters by placing them at risk of further infections and cross-contamination 5) Resident #4 had Pseudomonas and E. Coli in his sputum. RT U did not use proper hand hygiene during care for Resident #4's trach and she did not sanitize the surface area of the bedside table before and after the trach dressing changes. RT U placed the contaminated dressing on a brown paper towel on the bedside table. The same catheter was used for suctioning for 24 hours, before discarding it, but the catheter was to be used only once. These failures could affect the 26 residents, including Resident #4, who had tracheostomies, by placing them at risk of infections and cross-contamination. 6) Resident #3 was in isolation because she had[DIAGNOSES REDACTED] (Clostridium Difficile) and diarrhea, according to LVN AA. Resident #3 was listed on the Infection Control Log for an Upper Respiratory Infection and she was receiving the antibiotic, [MEDICATION NAME]. The Log also listed Resident #3 as not being isolated. A telephone order was written for Resident #3 to be in contact isolation due to[DIAGNOSES REDACTED]. Resident #3's meal trays were seen in the seat of her wheelchair three times and she was eating from the trays. The surveyors informed the DON and ADON G of this after it was seen the first time. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy," because the facility was still monitoring the Plan of Removal. This failure to establish and maintain an Infection Control Program for the facility according to the facility's policy and procedure over the last 12 months had the potential to affect all 109 residents who resided at the facility. The facility census was 109 residents. Note: DON L was employed on [DATE], however beginning [DATE], he is listed as Former DON (FDON) L. As he no longer worked in the facility. Note: this DON, was actually an ADON for the Vent Unit on the initial visit beginning [DATE]. After the investigation was re-opened on [DATE], she was the facility's only DON. Findings included: 1) Review of the current facility policy titled "Infection Prevention Manual for Long Term Care, "Section 2 Surveillance dated 2009 revealed the following: "... INFECTION PREVENTION SURVEILLANCE PURPOSE: To conduct surveillance of resident and employee infections to guide prevention activities... I. The Infection Preventionist does surveillance of healthcare-associated infections by: A. Review of culture reports and other pertinent lab data B. Nurse consultation and referral C. Chart review D. Review of the Infection Communication Form, 24 hour report, or morning stand-up meeting E. Personal consultation by employees... I. Physician consultation J. Other II. Specific definitions of healthcare-associated infections are used consistently (See "Definitions" ). Healthcare-associated infections are reported monthly on the: A. Healthcare-associated Infection Summary B. Summary of Infections by Device Days III. Surveillance documentation is maintained on the: A. Line Listing of Resident Infections... IV. Reporting of infections to the Health Department is done as required by law." "INFECTION PREVENTION PLAN... POLICY: A current written Infection Prevention plan will be implemented. The written plan will include: assessment of risk, assessment of services provided, and assessment of the population served, prioritized strategies to decrease risk, surveillance plan based on analysis of previous data. The written Infection Prevention plan will guide the activities of the Infection Prevention department. The plan will be updated at least annually and more often as needed." "HEALTHCARE-ASSOCIATED INFECTIONS AND SENTINEL EVENTS PURPOSE: To manage as sentinel events all identified cases of death and major permanent loss of function attributed to a healthcare-associated infection (i.e., except for the infection, the patient would probably not have died or suffered loss of function. PROCEDURAL GUIDELINES: I. Identification of cases to be reviewed A. During infection surveillance activities and following identification of healthcare-associated infections, the Infection Preventionist (IP) will be alert to cases of death and/or major permanent loss of function among patients having been identified as having a health-associated infection. B. The MDS Coordinator, in updating the MDS and/or identifying significant changes, will be alert to cases of death and/or major permanent loss of function among patients that may also have a healthcare-associated infection. If a potential case is identified, the MDS coordinator will communicate that information to the IP. C. All unexpected deaths occurring in a hospital following transfer from the long term care facility will be reviewed by the IP for presence of healthcare-associated infection and the potential for a sentinel event. II. Review and follow-up of potential cases A. Once alerted to the potential of a healthcare associated infection as a sentinel event, the IP will conduct a review of the patient records to determine if the case meets the definition of a healthcare-associated infection related sentinel event. It the case clearly is not a sentinel event (e.g. the patient was terminally ill prior to the infection, other life threatening events/illnesses were present, etc.), no further review in the Infection Prevention (QA/PI) committee and with the attending physician if needed to make a determination. If it is determined to be a sentinel event, the facility procedural guideline for sentinel events will be followed, including completion of root cause analysis." 2) A review of the Face Sheet dated [DATE] revealed Resident #24 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the facility's Nurse's Note, dated [DATE] at 7:30 p.m., revealed Resident #24 "...is unable to verbalize needs." A review of the facility's admission orders [REDACTED]. A review of the facility's Daily Skilled Nurse's Notes, dated [DATE] at 8:00 p.m., revealed Resident #24's admission to the facility. It further revealed incontinent care, turning and repositioning was provided, but did not document an indwelling urinary catheter. A review of the facility's Nurse's Note, dated [DATE] at 10:30 a.m., revealed Resident #24's "...F/C patent draining yellow urine...." A review of the facility's Nurse's Note, dated [DATE] at 10:30 a.m., revealed, "Resident alert trach to vent status maintained. Condition Stable. No distress noted will continue to monitor and assist as needed. VS (BP) ,[DATE]- (P) 83- (R) 97.8-(T) 18." A review of the facility's Nurse's Note dated [DATE] revealed the following: a) At 5:45 p.m., "Patient noted with abnormal breathing, staff checked vital sign. T-101.6, R-24, P-75, O 2 Sat fluctuating between ,[DATE], BP-,[DATE]. Staff noted skin cold and clammy. Notified Dr ___ (Medical Director QQ) of change of condition and received an order to transfer patient to ___ ER." b) At 6:00 p.m., "Message left for family member in the voice mail, staff called ___ EMS." c) At 7:00 p.m., "Ambulance here and transferred patient as ordered. She had BM at this time, incontinent care given. Staff called and notified on call nurse who stated 'I will let the DON know'." A review of the Emergency Medical Service (EMS) Record dated [DATE] revealed Resident #24 was transported to the emergency room at 8:13 p.m. and was coded "ALS Urgent. The Record reflected "Hypotension, Septic Shock" protocol was implemented. Resident #24's vital signs were recorded as: "6:45 p.m. - B/P ,[DATE], P 60, R 46, T 102.5, Oxygen Saturation 98% 6:55 p.m. - B/P ,[DATE], P 32, R 40, Oxygen Saturation 87% 6:58 p.m. - B/P ,[DATE], P 68, R 40, Oxygen Saturation? 7:19 p.m. - B/P ,[DATE], P 169 R 36, Oxygen Saturation 98%" This EMS Record also reflected the following narrative: "...AOS (arrived on scene) to find pt lying in bed unresponsive to all stimuli. Pt was on vent at above settings 2 (secondary to) CVA. Pt also has Foley cath that is tan brown and doesn't appear to be a new onset. Pt was also fecal incontinent. Pt looks to have had very poor care and when we requested a nurse for a report (report on resident's status) one could not be found and the only report we received was from the Respiratory Tech who said 'She doesn't have a respiratory problem. She is sating 98% although her RR (rate of respirations) is 46/min. She is go to (to go) the ER for AMS and she had blood drawn this morning and she has elevated WBC (white blood cell count). Pt was moved over to our vent. Assessment taken c BP ,[DATE], P 60, RR 46...." Resident #24's ER Face Sheet Admission/Registration Record, dated [DATE] at 10:40 p.m., revealed the admit type was "Emergency" and the reason for the visit was "Acute UTI Sepsis Acute Renal Failure." A review of Resident #24's ER Nursing Record, dated [DATE] at 8:35 p.m., revealed a temperature of 107.0 degrees F, respirations 33, blood pressure ,[DATE], pulse 188, urinary catheter - abnormal color or cloudy and Integumentary: other ____ (unable to read). Resident #24's ER Physician Record, dated [DATE] at 8:45 p.m., reflected the following: "...lack of info from nursing home... Clinical Impression: Sepsis, Fever, UTI, Acute Renal Failure, Respiratory Chronic Failure...." Resident #24's Hospital ED (Emergency Department) Transition of Care Order Set, dated [DATE] at 10:40 p.m., revealed the following Diagnoses: [REDACTED]. A review of Resident #24's ICU/Telemetry Orders Routine, dated [DATE] at 7:30 p.m., revealed a [DIAGNOSES REDACTED]. Resident #24's Hospital Admitting History and Physical dated [DATE] at 9:40 p.m. revealed Resident #24 was S/P Trach with vent dependence. "...pt reportedly had temp to 101.6 and WBC 21. In ED pt found to have temp 107 (F) ...unresponsive ...Foley in place, thick, brownish ...Plan of Care HTN, DM, ...Sepsis ,[DATE] (secondary to) UTI." Resident #24's Hospital Communication Flowsheet dated [DATE] revealed the following: "Physician Call ... Made aware of urine output, hematuria, and filth of previous catheter (from nursing home)." Resident #24's Hospital Discharge Summary dated [DATE] reflected her admitting [DIAGNOSES REDACTED]. Resident #24 was discharged to inpatient hospice. Resident #24's condition upon discharge was "Dying." Resident #24's Hospital Authorization for Release of deceased Patient dated [DATE] at 12:35 p.m., reflected the resident was pronounced dead on [DATE] at 8:55 a.m. with a [DIAGNOSES REDACTED]. A review of the Certification of Vital Record, County of Dallas Texas, State of Texas, Certificate of Death received by local Registrar on [DATE] revealed the following information regarding Resident #24: The date of Resident #24's death was [DATE] and cause was Septic Shock. The underlying cause, which initiated the event resulting in Resident #24's death was Pyelonephritis. A review of Resident #24's complete clinical record, received from the DON, revealed no evidence of the provision of catheter/peri care. On [DATE] at 1:15 p.m., an interview was conducted with the DON. She was asked to provide a copy of their documentation for the facility Infection Control Program. She stated, "I am trying to locate them. The sheet (24 Hour Report Sheet) I copied for you is what I started. It's been find a pile and dig through it." On [DATE] at 2:00 p.m., an interview was conducted with DON L. He stated he had only been in the position for three months, and was trying to establish and maintain an Infection Control Program, but it was still a work in progress. DON L stated the DON before him had no Infection Control Program in place. The surveyor asked to review a copy of the Infection Control Program Policy/Procedure and the program's documentation established while he was the DON. On [DATE] at 2:30 p.m., an interview was conducted with DON L. He stated the Infection Control Logs should be here for all the units, but "I haven't gotten to the recap yet." The surveyor asked him if he had gotten to tracking and trending facility infections. He stated, "We aren't trending and tracking." 3) Resident #4 was a [AGE] year-old male, admitted to the facility on [DATE], per the Face Sheet dated [DATE]. Resident #4 had [DIAGNOSES REDACTED]. Review of a Comprehensive Plan of Care for Resident #4 initiated on [DATE] revealed, "Resident has a Tracheostomy and is at risk for increased secretions/congestion and infections due to respiratory failure... Approach: ...3) Give meds per order-monitor labs/xrays-report abns to M.D... 5) Monitor for s/s of infection, report to M.D...." Review of a physician's telephone order for Resident #4 dated [DATE] revealed, "Sputum c&s." Interview on [DATE] at 8:35 p.m. with the Respiratory Therapy Director revealed Resident #4 did have a sputum culture ordered on [DATE]. He stated it was completed on [DATE]. The Respiratory Therapy Director confirmed the results were not able to be located in the clinical record. ADON CC located the results in the physician's folder. The Respiratory Therapy Director confirmed it was not normal to have E. coli in the sputum. Review of a Lower Respiratory Tract culture, finalized on [DATE], for Resident #4 revealed he had Pseudomonas aeruginosa Moderate Growth that was Multidrug resistant gram negative rod, and Escherichia coli in the sputum sample. Observation on [DATE] at 12:25 p.m. revealed Resident #4's trach collar had a moderate amount of thick, gray mucus in it. RT U was informed of the observation. RT U did not wash her hands after entering the room. When asked about the most recent sputum culture for Resident #4, RT U stated she thought it was, "clear." RT U suctioned Resident #4 with an opened, single-use only catheter that was laying in the original opened package, on the dresser next to the bed. After suctioning Resident #4, RT U removed the mucus-soiled gauze from the trach site, and laid it on top of a recycled brown paper towel (the ones that are in the paper towel dispensers to dry your hands with after washing), that was laying on top of the bedside table. RT U did not sanitize the bedside table before or after the entire procedure. Observation of Resident #4 on [DATE] at 7:20 a.m. revealed a suctioning catheter was at the bedside, in an open package, on the bedside dresser. Observation on [DATE] at 2:10 p.m. of Resident #4 revealed there was an opened suction catheter on the bedside dresser. Resident #4 was observed to be suctioned at that time, with the opened suction catheter by the Respiratory Therapy Director. Review of Respiratory Notes for Resident #4 dated [DATE] at 6:34 a.m. revealed, "Received pt in T/C with 3 L of O2, Sp 02 99%, HR 124, RR 22 bpm, patient coughed out moderate amount of brown _____ ...08:45 am informed nurse @ now, HR 120 @ now. Nurse called Dr. Pt cannot communicate what is going on... 09:40 am EMS came and took patient to hospital for tachycardia and difficulty breathing." Review of Daily Skilled Nurse's Notes for Resident #4, dated [DATE] at 8:10 a.m., revealed "Nurse contacted physician regarding chest x-ray. No answer by physician. Voicemail left. MD returned call at 0825 ...08:23 am noted resident this am, sweating, having difficulty breathing, lungs crackled bilaterally to lower lobe. Coughing brownish thick mucous, resident suctioned, Tylenol given for increased temp 99, o2 sat 99% via oxygen, B/P ,[DATE], HR 107... 09:00 placed call to (Physician T) regarding res change in condition, written order to send resident to (hospital), or hospital of choice per family... 09:26 am Resident made comfortable in bed, continued to have difficulty breathing." Review of a Patient Transfer Form dated [DATE] revealed Resident #4 had SOB and Tachycardia at time of transfer to a local hospital's ER. Pulse charted as 107. 4) A review of the Face Sheet dated [DATE] revealed Resident #10 was a [AGE] year-old-male, who was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. A review of the comprehensive MDS assessment dated [DATE] revealed Resident #10 was totally dependent in bed mobility, dressing, eating, toilet use and personal hygiene, had an indwelling catheter and an ostomy (including [MEDICATION NAME], ileostomy and colostomy). The MDS assessment also reflected he was at risk for developing a pressure ulcer, he had one or more unhealed pressure ulcers and he had four Stage IV Pressure Ulcers. The MDS assessment reflected he also received oxygen therapy, suctioning, tracheostomy care, and ventilator or respirator treatments. A review the Comprehensive Plan of Care revealed the following regarding Resident #10: Problem: [DATE] - Resident requires Isolation AEB (as evidenced by) MRSA to wound. Approach: Follow facility isolation policy. Problem: [DATE] -Resident has a supra pubic catheter. Approach: Change Foley cath, tubing and bag per order. Monitor urine for odor, color, sediments, and amount of urine, etc. and report abnormal to MD. Keep tubing/bag below the bladder, do not kink tubing. Cath care per order. Problem: [DATE] - Resident has a Tracheostomy and is at risk for increased secretions/congestion and infections due to Respiratory Failure. Approach: Provide for support to prevent anxiety if episodes of SOB occurs. Monitor for s/s of infection- report to MD. On [DATE] at 11:50 a.m., CNA O assisted the surveyor in observing the indwelling urinary catheter of Resident #10. The urinary drainage bag was not dated and not secured to the resident's leg. The indwelling urinary catheter was observed with a dark brown, linear substance on the catheter tubing near the insertion site. Resident #10's Treatment Administration Record provided by the facility, dated February 2011, did not address changing the indwelling. Observation on [DATE] at 7:14 p.m. revealed Resident #10 was in his bed. His Foley catheter bag had a moderate amount of thick, white sediment in the tubing and in the urinary collection bag. There was blood noted on the resident's gown, near the supra-pubic catheter insertion site. Resident #10 stated a CNA told him he was bleeding. There was a bath towel in between the abdominal fold near the supra-pubic catheter site. Interview on [DATE] at 8:21 p.m. with Resident #10 revealed staff never cleaned his catheter tubing. He stated he began to experience bladder spasms and asked for medication. He stated the medications were increased for the spasms, but it did not help. He stated he asked the night nurse about it about one week ago, and asked for a urinalysis. Resident #10 stated he felt like he had a UTI or a Kidney infection. Observation on [DATE] at 11:30 p.m. revealed Resident #10's suction tubing (not attached to his inline suction catheter), was on the floor of the room. Interview on [DATE] at 12:10 a.m. with the DON revealed she was not able to determine that Resident #10's catheter was changed at all in [DATE], and had not been changed as of this interview on [DATE]. When asked if she had assessed the catheter, the DON stated she observed "some drainage" and "redness at the site." The DON was asked to locate any orders to clean the catheter, for Resident #10. She was not able to locate any. A review of Resident #10's Telephone Orders dated [DATE] revealed, "C&S of Lt foot wounds." This order was not signed or dated by a physician. A review of Resident #10's Telephone Orders dated [DATE] revealed, "Contact Isolation -[DIAGNOSES REDACTED] Colitis." This order was not signed or dated by a physician. A review of Resident #10's Telephone Orders dated [DATE] revealed, "Change Supra Pubic cath q month." This order was not signed and dated by a physician. A review of Resident #10's Telephone Orders dated [DATE] revealed, "C&S of Lt foot wound." This order was not signed and dated by a physician. A review of Resident #10's Telephone Orders dated [DATE] revealed, "Add: Supra pubic cath care with soap & H2O (water) q (every) shift. Change SP catheter monthly c drain bag/tubing change." A review of Resident #10's Telephone Orders dated [DATE] revealed, "Replace current supra pubic foley (Foley) cath (catheter) 30 fr (French) 30 cc c (with) new silver impregnated S/P (status [REDACTED].Change silver impreg. (impregnated) Cath PRN to maintain patency. D/C (discontinue) order to change SP foley catheter Q month." A review of an Order Detail/PO Confirmation dated [DATE] at 10:07 a.m. revealed the following catheters were ordered by the facility: Silver Catheter sizes ,[DATE]cc, ,[DATE]cc, ,[DATE]cc, and ,[DATE]cc. This order did not reflect an order for [REDACTED].#10. A review of Resident #10's Telephone Orders dated [DATE] revealed, "Cleanse supra pubic site with normal saline, pat dry, apply [MEDICATION NAME] Ointment and cover with a dressing daily." A review of Resident #10's Nurse's Notes dated [DATE] at 11:00 p.m. revealed, "...Supra pubic patient. Urine amber colored. No sediments noted...." A review of Resident #10's Telephone Orders dated [DATE] at "0040" revealed, "N/O (new order) D/C order for Silver Impregnated. Insert Supra Pubic Cath. Foley care q shift change PRN/Patency. Get UA C&S Poss UTI...." A review of Resident #10's Nurse's Notes dated [DATE] at "0140" revealed, "Late entry (0830) NP _____ notified of bloody discharged from supra pubic catheter site. Nurse also informed NP that resident has some sediment in his catheter. New order for UA c C&S noted a, and to change the foley catheter...." A review of Resident #10's Nurse's Notes dated ____ (immediately following the above Nurses Note entry) at 1:55 a.m. revealed, "Foley Cath #28 c 30 cc bulb using sterile tech tol well. Bag contain 200 cc of clear amber urine. Positioned for comfort call light in reach. Charge nurse informed." A review of Resident #10's Nurses Note dated [DATE] at 5:00 a.m. revealed, "...Has his supra pubic foley catheter changed this shift with #28 Fr Catheter. Same draining well of clear amber colored urine." A review of Resident #10's Nurse's Note dated [DATE] at "06:00" a.m. revealed, "...Supra pubic foley catheter in place draining clear urine...." 5) According to the Face Sheet dated [DATE], Resident #3 was [AGE] year-old female, who was admitted on [DATE], with [DIAGNOSES REDACTED]. On [DATE] at 10:35 a.m., Resident #3 was observed on initial rounds asleep in bed with oxygen in use. A small three-drawer container with gloves and yellow gowns was observed just outside Resident #3's room in the hall. LVN AA stated the resident was on isolation precautions due to[DIAGNOSES REDACTED] and Diarrhea. Resident #3's MDS assessment, dated [DATE], reflected Resident #3 had no cognition problems and was independent with her ADLs. Resident #3's care plan, dated [DATE], reflected nothing about[DIAGNOSES REDACTED], URI, or Contact Isolation Precaution. The tracking and trending log the DON provided for the facility's infection control program she had composed thus far for [DATE] was reviewed. Resident #3 was listed and the reason was "URI" (upper respiratory infection). [MEDICATION NAME] was listed as the antibiotic and the "isolated yes or no" column was checked "no." ADON G was questioned on [DATE] at 5:35 p.m. about Resident #3 and the infection control log reflecting the resident was listed due to a URI and not[DIAGNOSES REDACTED] and the fact she was checked "no" for "isolated." She stated Resident #3 was recently sent out to the hospital with Pneumonia and came back with a URI. She stated the [DIAGNOSES REDACTED]. The local hospital records dated [DATE] reflected Resident #3 was admitted with [DIAGNOSES REDACTED]. The local hospital's physician progress notes [REDACTED].? PNA.) The nurse's notes dated [DATE] reflected Resident #3 was readmitted with [DIAGNOSES REDACTED]." Nurse's notes dated [DATE] reflected "initial dose of [MEDICATION NAME] 500 mg po from the ER kit. Remains on MCR (medicare) charting for[DIAGNOSES REDACTED] and COPD exacerbation." "[MEDICATION NAME] 125 mg give for the dx of[DIAGNOSES REDACTED] & diarrhea." "Also order for contact isolation precaution for[DIAGNOSES REDACTED]." Nurse's notes dated [DATE] reflected " ...on MCR for pneumonia,[DIAGNOSES REDACTED], COPD exacerbation- A-Fib, cont isolation ...." Nurse's notes dated [DATE] reflected "Res. Remains on MCR skilled services for- pneumonia,[DIAGNOSES REDACTED], COPD exacerbation, A-fib...." Resident #3's telephone order dated [DATE] reflected "Send Resident to ER for SOB (short of breath)." Telephone order dated [DATE] reflected "Readmit resident...." Telephone order dated [DATE] reflected "[MEDICATION NAME] 500 mg 1 tab po TID X 4 wks., [MEDICATION NAME] 125 mg po QID (four times a day) X 2 wks...." Telephone order dated [DATE] reflected "Contact Isolation Precaution for[DIAGNOSES REDACTED]." Review of Resident #3's [DATE] MAR revealed Resident #3 was receiving [MEDICATION NAME] 500 mg three times a day for four weeks and [MEDICATION NAME] 125 mg four times a day for the weeks. These medications were traditional treatment for [REDACTED]. On [DATE] at 12:23 p.m., Resident #3's lunch tray was observed to be served in her room on the seat of her wheelchair next to her bed. Resident #3 was observed eating her lunch in this situation at 12:55 p.m. On [DATE] at 5:30 p.m., the DON and ADON G were informed Resident #3's lunch tray was served in the seat of the wheelchair and she had a [DIAGNOSES REDACTED]. On [DATE] at 12:30 p.m., Resident #3's lunch tray was observed to be served in her room on the seat of her wheelchair next to her bed. Resident #3 stated she ate her lunch from this position. On [DATE] at 8:06 a.m., Resident #3's breakfast tray was observed to be served in her room on the seat of her wheelchair next to her bed. 6) Review of Resident #12's face sheet dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's admission MDS assessment dated [DATE] revealed the resident was always incontinent of bowel and had an indwelling urinary catheter. Resident #12 was totally dependent on two or more staff for transfers, dressing, toilet use and personal hygiene. On [DATE] at 11:30 a.m., the DON assisted the surveyor in observing the indwelling urinary catheter of Resident #12. The urinary drainage bag was label with a Hospital label that read: "Placement [DATE] at 21 Hrs. Due for removal [DATE]. Reason- Septic Shock, Renal Failure and Vent Support." The DON was asked if everyone on a vent needs an indwelling urinary catheter. She stated, "Everyone does not need a Foley catheter who is on the vent." She further stated they use the federal regulation guideline for urinary justification. A review of Resident #12's clinical record revealed no order to change the urinary catheter on the MAR. Interview with LVN E during initial tour on [DATE] at 11:10 a.m. revealed Resident #12 was bedfast, received nourishment through a gastrostomy tube, was incontinent of bowel, had an indwelling urinary catheter, had a tracheostomy, was on a ventilator for breathing and had a pressure ulcer on her coccyx. Observation on [DATE] at 1:50 p.m. revealed CNA JJ provided incontinent care for Resident #12. CNA JJ did not open the labia to visualize the urinary meatus. CNA JJ blindly wiped the urinary meatus with a pre-moistened cleansing cloth, and did not clean any other areas of Resident #12's vaginal or inguinal areas. Without sanitizing her hands or changing her gloves, CNA JJ assisted Resident #12 onto her right side. CNA JJ wiped feces from Resident #12's perineum, then over her anus, over her left and right buttocks, and back over her anus with a smearing effect. Without sanitizing her hands or changing her feces-soiled gloves, CNA JJ closed the container of clean, pre-moistened cleansing cloths, repositioned Resident #12 in bed, placed a clean pad under Resident #12's legs, turned a handle to raise the head of the bed, [MEDICATION NAME] the resident's hair when placing a clean pillow under her head, and patted the resident on her shoulder. F441 CONTINUED IN F9999 ON PAGE 211

Based on observation, interview, and record review, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for five (Residents #12, #37, #10, #4, and #3) of 13 residents and one (Resident #24) of one closed record reviewed for infection control. 1) Resident #24 had a urinary catheter without a physician's orders [REDACTED]. Facility staff were not taking care of Resident #24's catheter. These failures resulted in Resident #24 contracting a UTI and developing Sepsis. Her cause of death was Septic Shock. 2) Resident #12's urinary drainage bag was labeled with a hospital label, which indicated the catheter should be removed approximately two days after it was placed. The catheter was not removed or changed in fourteen days. There were no orders to change the urinary catheter on the MAR. 3) Resident #37's urinary drainage bag was not dated, not secured to the resident's leg, and was not changed when it was ordered to be changed. The CNA did not wash her hands before or after assisting the surveyor in seeing Resident #37's indwelling catheter. 4) Resident #10 had an order to change his supra pubic catheter monthly. Resident #10's supra pubic catheter was changed in late February, 2011, but it was not changed in [DATE] at the same time. These failures could affect the 13 residents, including Residents #10, #5, #12 and #37, who had indwelling catheters by placing them at risk of further infections and cross-contamination 5) Resident #4 had Pseudomonas and E. Coli in his sputum. RT U did not use proper hand hygiene during care for Resident #4's trach and she did not sanitize the surface area of the bedside table before and after the trach dressing changes. RT U placed the contaminated dressing on a brown paper towel on the bedside table. The same catheter was used for suctioning for 24 hours, before discarding it, but the catheter was to be used only once. These failures could affect the 26 residents, including Resident #4, who had tracheostomies, by placing them at risk of infections and cross-contamination. 6) Resident #3 was in isolation because she had[DIAGNOSES REDACTED] (Clostridium Difficile) and diarrhea, according to LVN AA. Resident #3 was listed on the Infection Control Log for an Upper Respiratory Infection and she was receiving the antibiotic, [MEDICATION NAME]. The Log also listed Resident #3 as not being isolated. A telephone order was written for Resident #3 to be in contact isolation due to[DIAGNOSES REDACTED]. Resident #3's meal trays were seen in the seat of her wheelchair three times and she was eating from the trays. The surveyors informed the DON and ADON G of this after it was seen the first time. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy," because the facility was still monitoring the Plan of Removal. This failure to establish and maintain an Infection Control Program for the facility according to the facility's policy and procedure over the last 12 months had the potential to affect all 109 residents who resided at the facility. The facility census was 109 residents. Note: DON L was employed on [DATE], however beginning [DATE], he is listed as Former DON (FDON) L. As he no longer worked in the facility. Note: this DON, was actually an ADON for the Vent Unit on the initial visit beginning [DATE]. After the investigation was re-opened on [DATE], she was the facility's only DON. Findings included: 1) Review of the current facility policy titled "Infection Prevention Manual for Long Term Care, "Section 2 Surveillance dated 2009 revealed the following: "... INFECTION PREVENTION SURVEILLANCE PURPOSE: To conduct surveillance of resident and employee infections to guide prevention activities... I. The Infection Preventionist does surveillance of healthcare-associated infections by: A. Review of culture reports and other pertinent lab data B. Nurse consultation and referral C. Chart review D. Review of the Infection Communication Form, 24 hour report, or morning stand-up meeting E. Personal consultation by employees... I. Physician consultation J. Other II. Specific definitions of healthcare-associated infections are used consistently (See "Definitions" ). Healthcare-associated infections are reported monthly on the: A. Healthcare-associated Infection Summary B. Summary of Infections by Device Days III. Surveillance documentation is maintained on the: A. Line Listing of Resident Infections... IV. Reporting of infections to the Health Department is done as required by law." "INFECTION PREVENTION PLAN... POLICY: A current written Infection Prevention plan will be implemented. The written plan will include: assessment of risk, assessment of services provided, and assessment of the population served, prioritized strategies to decrease risk, surveillance plan based on analysis of previous data. The written Infection Prevention plan will guide the activities of the Infection Prevention department. The plan will be updated at least annually and more often as needed." "HEALTHCARE-ASSOCIATED INFECTIONS AND SENTINEL EVENTS PURPOSE: To manage as sentinel events all identified cases of death and major permanent loss of function attributed to a healthcare-associated infection (i.e., except for the infection, the patient would probably not have died or suffered loss of function. PROCEDURAL GUIDELINES: I. Identification of cases to be reviewed A. During infection surveillance activities and following identification of healthcare-associated infections, the Infection Preventionist (IP) will be alert to cases of death and/or major permanent loss of function among patients having been identified as having a health-associated infection. B. The MDS Coordinator, in updating the MDS and/or identifying significant changes, will be alert to cases of death and/or major permanent loss of function among patients that may also have a healthcare-associated infection. If a potential case is identified, the MDS coordinator will communicate that information to the IP. C. All unexpected deaths occurring in a hospital following transfer from the long term care facility will be reviewed by the IP for presence of healthcare-associated infection and the potential for a sentinel event. II. Review and follow-up of potential cases A. Once alerted to the potential of a healthcare associated infection as a sentinel event, the IP will conduct a review of the patient records to determine if the case meets the definition of a healthcare-associated infection related sentinel event. It the case clearly is not a sentinel event (e.g. the patient was terminally ill prior to the infection, other life threatening events/illnesses were present, etc.), no further review in the Infection Prevention (QA/PI) committee and with the attending physician if needed to make a determination. If it is determined to be a sentinel event, the facility procedural guideline for sentinel events will be followed, including completion of root cause analysis." 2) A review of the Face Sheet dated [DATE] revealed Resident #24 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the facility's Nurse's Note, dated [DATE] at 7:30 p.m., revealed Resident #24 "...is unable to verbalize needs." A review of the facility's admission orders [REDACTED]. A review of the facility's Daily Skilled Nurse's Notes, dated [DATE] at 8:00 p.m., revealed Resident #24's admission to the facility. It further revealed incontinent care, turning and repositioning was provided, but did not document an indwelling urinary catheter. A review of the facility's Nurse's Note, dated [DATE] at 10:30 a.m., revealed Resident #24's "...F/C patent draining yellow urine...." A review of the facility's Nurse's Note, dated [DATE] at 10:30 a.m., revealed, "Resident alert trach to vent status maintained. Condition Stable. No distress noted will continue to monitor and assist as needed. VS (BP) ,[DATE]- (P) 83- (R) 97.8-(T) 18." A review of the facility's Nurse's Note dated [DATE] revealed the following: a) At 5:45 p.m., "Patient noted with abnormal breathing, staff checked vital sign. T-101.6, R-24, P-75, O 2 Sat fluctuating between ,[DATE], BP-,[DATE]. Staff noted skin cold and clammy. Notified Dr ___ (Medical Director QQ) of change of condition and received an order to transfer patient to ___ ER." b) At 6:00 p.m., "Message left for family member in the voice mail, staff called ___ EMS." c) At 7:00 p.m., "Ambulance here and transferred patient as ordered. She had BM at this time, incontinent care given. Staff called and notified on call nurse who stated 'I will let the DON know'." A review of the Emergency Medical Service (EMS) Record dated [DATE] revealed Resident #24 was transported to the emergency room at 8:13 p.m. and was coded "ALS Urgent. The Record reflected "Hypotension, Septic Shock" protocol was implemented. Resident #24's vital signs were recorded as: "6:45 p.m. - B/P ,[DATE], P 60, R 46, T 102.5, Oxygen Saturation 98% 6:55 p.m. - B/P ,[DATE], P 32, R 40, Oxygen Saturation 87% 6:58 p.m. - B/P ,[DATE], P 68, R 40, Oxygen Saturation? 7:19 p.m. - B/P ,[DATE], P 169 R 36, Oxygen Saturation 98%" This EMS Record also reflected the following narrative: "...AOS (arrived on scene) to find pt lying in bed unresponsive to all stimuli. Pt was on vent at above settings 2 (secondary to) CVA. Pt also has Foley cath that is tan brown and doesn't appear to be a new onset. Pt was also fecal incontinent. Pt looks to have had very poor care and when we requested a nurse for a report (report on resident's status) one could not be found and the only report we received was from the Respiratory Tech who said 'She doesn't have a respiratory problem. She is sating 98% although her RR (rate of respirations) is 46/min. She is go to (to go) the ER for AMS and she had blood drawn this morning and she has elevated WBC (white blood cell count). Pt was moved over to our vent. Assessment taken c BP ,[DATE], P 60, RR 46...." Resident #24's ER Face Sheet Admission/Registration Record, dated [DATE] at 10:40 p.m., revealed the admit type was "Emergency" and the reason for the visit was "Acute UTI Sepsis Acute Renal Failure." A review of Resident #24's ER Nursing Record, dated [DATE] at 8:35 p.m., revealed a temperature of 107.0 degrees F, respirations 33, blood pressure ,[DATE], pulse 188, urinary catheter - abnormal color or cloudy and Integumentary: other ____ (unable to read). Resident #24's ER Physician Record, dated [DATE] at 8:45 p.m., reflected the following: "...lack of info from nursing home... Clinical Impression: Sepsis, Fever, UTI, Acute Renal Failure, Respiratory Chronic Failure...." Resident #24's Hospital ED (Emergency Department) Transition of Care Order Set, dated [DATE] at 10:40 p.m., revealed the following Diagnoses: [REDACTED]. A review of Resident #24's ICU/Telemetry Orders Routine, dated [DATE] at 7:30 p.m., revealed a [DIAGNOSES REDACTED]. Resident #24's Hospital Admitting History and Physical dated [DATE] at 9:40 p.m. revealed Resident #24 was S/P Trach with vent dependence. "...pt reportedly had temp to 101.6 and WBC 21. In ED pt found to have temp 107 (F) ...unresponsive ...Foley in place, thick, brownish ...Plan of Care HTN, DM, ...Sepsis ,[DATE] (secondary to) UTI." Resident #24's Hospital Communication Flowsheet dated [DATE] revealed the following: "Physician Call ... Made aware of urine output, hematuria, and filth of previous catheter (from nursing home)." Resident #24's Hospital Discharge Summary dated [DATE] reflected her admitting [DIAGNOSES REDACTED]. Resident #24 was discharged to inpatient hospice. Resident #24's condition upon discharge was "Dying." Resident #24's Hospital Authorization for Release of deceased Patient dated [DATE] at 12:35 p.m., reflected the resident was pronounced dead on [DATE] at 8:55 a.m. with a [DIAGNOSES REDACTED]. A review of the Certification of Vital Record, County of Dallas Texas, State of Texas, Certificate of Death received by local Registrar on [DATE] revealed the following information regarding Resident #24: The date of Resident #24's death was [DATE] and cause was Septic Shock. The underlying cause, which initiated the event resulting in Resident #24's death was Pyelonephritis. A review of Resident #24's complete clinical record, received from the DON, revealed no evidence of the provision of catheter/peri care. On [DATE] at 1:15 p.m., an interview was conducted with the DON. She was asked to provide a copy of their documentation for the facility Infection Control Program. She stated, "I am trying to locate them. The sheet (24 Hour Report Sheet) I copied for you is what I started. It's been find a pile and dig through it." On [DATE] at 2:00 p.m., an interview was conducted with DON L. He stated he had only been in the position for three months, and was trying to establish and maintain an Infection Control Program, but it was still a work in progress. DON L stated the DON before him had no Infection Control Program in place. The surveyor asked to review a copy of the Infection Control Program Policy/Procedure and the program's documentation established while he was the DON. On [DATE] at 2:30 p.m., an interview was conducted with DON L. He stated the Infection Control Logs should be here for all the units, but "I haven't gotten to the recap yet." The surveyor asked him if he had gotten to tracking and trending facility infections. He stated, "We aren't trending and tracking." 3) Resident #4 was a [AGE] year-old male, admitted to the facility on [DATE], per the Face Sheet dated [DATE]. Resident #4 had [DIAGNOSES REDACTED]. Review of a Comprehensive Plan of Care for Resident #4 initiated on [DATE] revealed, "Resident has a Tracheostomy and is at risk for increased secretions/congestion and infections due to respiratory failure... Approach: ...3) Give meds per order-monitor labs/xrays-report abns to M.D... 5) Monitor for s/s of infection, report to M.D...." Review of a physician's telephone order for Resident #4 dated [DATE] revealed, "Sputum c&s." Interview on [DATE] at 8:35 p.m. with the Respiratory Therapy Director revealed Resident #4 did have a sputum culture ordered on [DATE]. He stated it was completed on [DATE]. The Respiratory Therapy Director confirmed the results were not able to be located in the clinical record. ADON CC located the results in the physician's folder. The Respiratory Therapy Director confirmed it was not normal to have E. coli in the sputum. Review of a Lower Respiratory Tract culture, finalized on [DATE], for Resident #4 revealed he had Pseudomonas aeruginosa Moderate Growth that was Multidrug resistant gram negative rod, and Escherichia coli in the sputum sample. Observation on [DATE] at 12:25 p.m. revealed Resident #4's trach collar had a moderate amount of thick, gray mucus in it. RT U was informed of the observation. RT U did not wash her hands after entering the room. When asked about the most recent sputum culture for Resident #4, RT U stated she thought it was, "clear." RT U suctioned Resident #4 with an opened, single-use only catheter that was laying in the original opened package, on the dresser next to the bed. After suctioning Resident #4, RT U removed the mucus-soiled gauze from the trach site, and laid it on top of a recycled brown paper towel (the ones that are in the paper towel dispensers to dry your hands with after washing), that was laying on top of the bedside table. RT U did not sanitize the bedside table before or after the entire procedure. Observation of Resident #4 on [DATE] at 7:20 a.m. revealed a suctioning catheter was at the bedside, in an open package, on the bedside dresser. Observation on [DATE] at 2:10 p.m. of Resident #4 revealed there was an opened suction catheter on the bedside dresser. Resident #4 was observed to be suctioned at that time, with the opened suction catheter by the Respiratory Therapy Director. Review of Respiratory Notes for Resident #4 dated [DATE] at 6:34 a.m. revealed, "Received pt in T/C with 3 L of O2, Sp 02 99%, HR 124, RR 22 bpm, patient coughed out moderate amount of brown _____ ...08:45 am informed nurse @ now, HR 120 @ now. Nurse called Dr. Pt cannot communicate what is going on... 09:40 am EMS came and took patient to hospital for tachycardia and difficulty breathing." Review of Daily Skilled Nurse's Notes for Resident #4, dated [DATE] at 8:10 a.m., revealed "Nurse contacted physician regarding chest x-ray. No answer by physician. Voicemail left. MD returned call at 0825 ...08:23 am noted resident this am, sweating, having difficulty breathing, lungs crackled bilaterally to lower lobe. Coughing brownish thick mucous, resident suctioned, Tylenol given for increased temp 99, o2 sat 99% via oxygen, B/P ,[DATE], HR 107... 09:00 placed call to (Physician T) regarding res change in condition, written order to send resident to (hospital), or hospital of choice per family... 09:26 am Resident made comfortable in bed, continued to have difficulty breathing." Review of a Patient Transfer Form dated [DATE] revealed Resident #4 had SOB and Tachycardia at time of transfer to a local hospital's ER. Pulse charted as 107. 4) A review of the Face Sheet dated [DATE] revealed Resident #10 was a [AGE] year-old-male, who was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. A review of the comprehensive MDS assessment dated [DATE] revealed Resident #10 was totally dependent in bed mobility, dressing, eating, toilet use and personal hygiene, had an indwelling catheter and an ostomy (including [MEDICATION NAME], ileostomy and colostomy). The MDS assessment also reflected he was at risk for developing a pressure ulcer, he had one or more unhealed pressure ulcers and he had four Stage IV Pressure Ulcers. The MDS assessment reflected he also received oxygen therapy, suctioning, tracheostomy care, and ventilator or respirator treatments. A review the Comprehensive Plan of Care revealed the following regarding Resident #10: Problem: [DATE] - Resident requires Isolation AEB (as evidenced by) MRSA to wound. Approach: Follow facility isolation policy. Problem: [DATE] -Resident has a supra pubic catheter. Approach: Change Foley cath, tubing and bag per order. Monitor urine for odor, color, sediments, and amount of urine, etc. and report abnormal to MD. Keep tubing/bag below the bladder, do not kink tubing. Cath care per order. Problem: [DATE] - Resident has a Tracheostomy and is at risk for increased secretions/congestion and infections due to Respiratory Failure. Approach: Provide for support to prevent anxiety if episodes of SOB occurs. Monitor for s/s of infection- report to MD. On [DATE] at 11:50 a.m., CNA O assisted the surveyor in observing the indwelling urinary catheter of Resident #10. The urinary drainage bag was not dated and not secured to the resident's leg. The indwelling urinary catheter was observed with a dark brown, linear substance on the catheter tubing near the insertion site. Resident #10's Treatment Administration Record provided by the facility, dated February 2011, did not address changing the indwelling. Observation on [DATE] at 7:14 p.m. revealed Resident #10 was in his bed. His Foley catheter bag had a moderate amount of thick, white sediment in the tubing and in the urinary collection bag. There was blood noted on the resident's gown, near the supra-pubic catheter insertion site. Resident #10 stated a CNA told him he was bleeding. There was a bath towel in between the abdominal fold near the supra-pubic catheter site. Interview on [DATE] at 8:21 p.m. with Resident #10 revealed staff never cleaned his catheter tubing. He stated he began to experience bladder spasms and asked for medication. He stated the medications were increased for the spasms, but it did not help. He stated he asked the night nurse about it about one week ago, and asked for a urinalysis. Resident #10 stated he felt like he had a UTI or a Kidney infection. Observation on [DATE] at 11:30 p.m. revealed Resident #10's suction tubing (not attached to his inline suction catheter), was on the floor of the room. Interview on [DATE] at 12:10 a.m. with the DON revealed she was not able to determine that Resident #10's catheter was changed at all in [DATE], and had not been changed as of this interview on [DATE]. When asked if she had assessed the catheter, the DON stated she observed "some drainage" and "redness at the site." The DON was asked to locate any orders to clean the catheter, for Resident #10. She was not able to locate any. A review of Resident #10's Telephone Orders dated [DATE] revealed, "C&S of Lt foot wounds." This order was not signed or dated by a physician. A review of Resident #10's Telephone Orders dated [DATE] revealed, "Contact Isolation -[DIAGNOSES REDACTED] Colitis." This order was not signed or dated by a physician. A review of Resident #10's Telephone Orders dated [DATE] revealed, "Change Supra Pubic cath q month." This order was not signed and dated by a physician. A review of Resident #10's Telephone Orders dated [DATE] revealed, "C&S of Lt foot wound." This order was not signed and dated by a physician. A review of Resident #10's Telephone Orders dated [DATE] revealed, "Add: Supra pubic cath care with soap & H2O (water) q (every) shift. Change SP catheter monthly c drain bag/tubing change." A review of Resident #10's Telephone Orders dated [DATE] revealed, "Replace current supra pubic foley (Foley) cath (catheter) 30 fr (French) 30 cc c (with) new silver impregnated S/P (status [REDACTED].Change silver impreg. (impregnated) Cath PRN to maintain patency. D/C (discontinue) order to change SP foley catheter Q month." A review of an Order Detail/PO Confirmation dated [DATE] at 10:07 a.m. revealed the following catheters were ordered by the facility: Silver Catheter sizes ,[DATE]cc, ,[DATE]cc, ,[DATE]cc, and ,[DATE]cc. This order did not reflect an order for [REDACTED].#10. A review of Resident #10's Telephone Orders dated [DATE] revealed, "Cleanse supra pubic site with normal saline, pat dry, apply [MEDICATION NAME] Ointment and cover with a dressing daily." A review of Resident #10's Nurse's Notes dated [DATE] at 11:00 p.m. revealed, "...Supra pubic patient. Urine amber colored. No sediments noted...." A review of Resident #10's Telephone Orders dated [DATE] at "0040" revealed, "N/O (new order) D/C order for Silver Impregnated. Insert Supra Pubic Cath. Foley care q shift change PRN/Patency. Get UA C&S Poss UTI...." A review of Resident #10's Nurse's Notes dated [DATE] at "0140" revealed, "Late entry (0830) NP _____ notified of bloody discharged from supra pubic catheter site. Nurse also informed NP that resident has some sediment in his catheter. New order for UA c C&S noted a, and to change the foley catheter...." A review of Resident #10's Nurse's Notes dated ____ (immediately following the above Nurses Note entry) at 1:55 a.m. revealed, "Foley Cath #28 c 30 cc bulb using sterile tech tol well. Bag contain 200 cc of clear amber urine. Positioned for comfort call light in reach. Charge nurse informed." A review of Resident #10's Nurses Note dated [DATE] at 5:00 a.m. revealed, "...Has his supra pubic foley catheter changed this shift with #28 Fr Catheter. Same draining well of clear amber colored urine." A review of Resident #10's Nurse's Note dated [DATE] at "06:00" a.m. revealed, "...Supra pubic foley catheter in place draining clear urine...." 5) According to the Face Sheet dated [DATE], Resident #3 was [AGE] year-old female, who was admitted on [DATE], with [DIAGNOSES REDACTED]. On [DATE] at 10:35 a.m., Resident #3 was observed on initial rounds asleep in bed with oxygen in use. A small three-drawer container with gloves and yellow gowns was observed just outside Resident #3's room in the hall. LVN AA stated the resident was on isolation precautions due to[DIAGNOSES REDACTED] and Diarrhea. Resident #3's MDS assessment, dated [DATE], reflected Resident #3 had no cognition problems and was independent with her ADLs. Resident #3's care plan, dated [DATE], reflected nothing about[DIAGNOSES REDACTED], URI, or Contact Isolation Precaution. The tracking and trending log the DON provided for the facility's infection control program she had composed thus far for [DATE] was reviewed. Resident #3 was listed and the reason was "URI" (upper respiratory infection). [MEDICATION NAME] was listed as the antibiotic and the "isolated yes or no" column was checked "no." ADON G was questioned on [DATE] at 5:35 p.m. about Resident #3 and the infection control log reflecting the resident was listed due to a URI and not[DIAGNOSES REDACTED] and the fact she was checked "no" for "isolated." She stated Resident #3 was recently sent out to the hospital with Pneumonia and came back with a URI. She stated the [DIAGNOSES REDACTED]. The local hospital records dated [DATE] reflected Resident #3 was admitted with [DIAGNOSES REDACTED]. The local hospital's physician progress notes [REDACTED].? PNA.) The nurse's notes dated [DATE] reflected Resident #3 was readmitted with [DIAGNOSES REDACTED]." Nurse's notes dated [DATE] reflected "initial dose of [MEDICATION NAME] 500 mg po from the ER kit. Remains on MCR (medicare) charting for[DIAGNOSES REDACTED] and COPD exacerbation." "[MEDICATION NAME] 125 mg give for the dx of[DIAGNOSES REDACTED] & diarrhea." "Also order for contact isolation precaution for[DIAGNOSES REDACTED]." Nurse's notes dated [DATE] reflected " ...on MCR for pneumonia,[DIAGNOSES REDACTED], COPD exacerbation- A-Fib, cont isolation ...." Nurse's notes dated [DATE] reflected "Res. Remains on MCR skilled services for- pneumonia,[DIAGNOSES REDACTED], COPD exacerbation, A-fib...." Resident #3's telephone order dated [DATE] reflected "Send Resident to ER for SOB (short of breath)." Telephone order dated [DATE] reflected "Readmit resident...." Telephone order dated [DATE] reflected "[MEDICATION NAME] 500 mg 1 tab po TID X 4 wks., [MEDICATION NAME] 125 mg po QID (four times a day) X 2 wks...." Telephone order dated [DATE] reflected "Contact Isolation Precaution for[DIAGNOSES REDACTED]." Review of Resident #3's [DATE] MAR revealed Resident #3 was receiving [MEDICATION NAME] 500 mg three times a day for four weeks and [MEDICATION NAME] 125 mg four times a day for the weeks. These medications were traditional treatment for [REDACTED]. On [DATE] at 12:23 p.m., Resident #3's lunch tray was observed to be served in her room on the seat of her wheelchair next to her bed. Resident #3 was observed eating her lunch in this situation at 12:55 p.m. On [DATE] at 5:30 p.m., the DON and ADON G were informed Resident #3's lunch tray was served in the seat of the wheelchair and she had a [DIAGNOSES REDACTED]. On [DATE] at 12:30 p.m., Resident #3's lunch tray was observed to be served in her room on the seat of her wheelchair next to her bed. Resident #3 stated she ate her lunch from this position. On [DATE] at 8:06 a.m., Resident #3's breakfast tray was observed to be served in her room on the seat of her wheelchair next to her bed. 6) Review of Resident #12's face sheet dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's admission MDS assessment dated [DATE] revealed the resident was always incontinent of bowel and had an indwelling urinary catheter. Resident #12 was totally dependent on two or more staff for transfers, dressing, toilet use and personal hygiene. On [DATE] at 11:30 a.m., the DON assisted the surveyor in observing the indwelling urinary catheter of Resident #12. The urinary drainage bag was label with a Hospital label that read: "Placement [DATE] at 21 Hrs. Due for removal [DATE]. Reason- Septic Shock, Renal Failure and Vent Support." The DON was asked if everyone on a vent needs an indwelling urinary catheter. She stated, "Everyone does not need a Foley catheter who is on the vent." She further stated they use the federal regulation guideline for urinary justification. A review of Resident #12's clinical record revealed no order to change the urinary catheter on the MAR. Interview with LVN E during initial tour on [DATE] at 11:10 a.m. revealed Resident #12 was bedfast, received nourishment through a gastrostomy tube, was incontinent of bowel, had an indwelling urinary catheter, had a tracheostomy, was on a ventilator for breathing and had a pressure ulcer on her coccyx. Observation on [DATE] at 1:50 p.m. revealed CNA JJ provided incontinent care for Resident #12. CNA JJ did not open the labia to visualize the urinary meatus. CNA JJ blindly wiped the urinary meatus with a pre-moistened cleansing cloth, and did not clean any other areas of Resident #12's vaginal or inguinal areas. Without sanitizing her hands or changing her gloves, CNA JJ assisted Resident #12 onto her right side. CNA JJ wiped feces from Resident #12's perineum, then over her anus, over her left and right buttocks, and back over her anus with a smearing effect. Without sanitizing her hands or changing her feces-soiled gloves, CNA JJ closed the container of clean, pre-moistened cleansing cloths, repositioned Resident #12 in bed, placed a clean pad under Resident #12's legs, turned a handle to raise the head of the bed, [MEDICATION NAME] the resident's hair when placing a clean pillow under her head, and patted the resident on her shoulder. F441 CONTINUED IN F9999 ON PAGE 211

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five (Residents #5, #7, #10 #24, and #39) of 22 residents reviewed for quality of care. 1. Resident #24 had an indwelling urinary catheter without a physician's order and there were no orders for the care and maintenance of the catheter. Facility staff was not taking care of Resident #24's catheter. The facility failed to provide timely EMS for Resident #24 who required Advanced Life Support (ALS) Urgent Service for her condition. 911 service was not called for Resident #24. These failures resulted in Resident #24 developing a Urinary Tract Infection which resulted in Septic Shock and Death. Resident #24 waited 2 hours and 35 minutes from the time EMS was called to the time she arrived in the ER to receive Emergency Department Services. Resident #24's immediate cause of death was Septic Shock. 3. Resident #10's indwelling urinary catheter was not changed as ordered and the catheter tubing was not secured to his inner thigh. Resident #10 said he was having bladder spasms and discomfort related to his catheter. 4. Resident #12's catheter had not been changed. There were no physician's order to change it. 4. Residents #5, #7, and #37 indwelling urinary catheter/tubing was not secured to the resident's inner thigh. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 12:10 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and severity level of "actual harm that is not Immediate Jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the 13 residents who had a urinary catheter, including Residents #5, #37, and #10 by placing them at risk for the potential traumatic injury to the bladder/urinary tract and/or urinary tract infections. Findings included: 1) A review of the Face Sheet dated [DATE] revealed Resident #24 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the facility's Nurse's Notes, dated [DATE] at 7:30 p.m., revealed Resident #24 was "...unable to verbalize needs." A review of the facility's Physician's Telephone Order, dated [DATE] at 10:00 a.m., revealed Resident #24 was transferred to the ER for evaluation for [MEDICAL CONDITION] Flutter. Resident #24's admission orders [REDACTED]. The orders did not reflect the resident had an indwelling urinary catheter. A review of the facility's Daily Skilled Nurse's Notes, dated [DATE] at 8:00 p.m., revealed Resident #24's admission to the facility. It further revealed incontinent care, turning, and repositioning were provided, but there was no documentation regarding an indwelling urinary catheter. A review of the facility's Daily Skilled Nurse's Notes, dated [DATE] at 1:00 a.m., revealed Resident #24 was "voiding (urinating) freely." Daily nurse's notes for [DATE] and [DATE] did not address Resident #24's urinary output or the presence of an indwelling urinary catheter. The facility's Nurse's Notes dated [DATE] at 8:10 a.m. reflected Resident #24 had an indwelling urinary catheter. The note reflected, "...Foley catheter patent, yellow and clear urine ...." (Note: This was the first note that identified the resident had a urinary catheter.) A review of Resident #24's Nurse's Notes dated [DATE] at 08:30 a.m. revealed, "...Foley catheter patent, yellow and clear urine. V/S DT (unknown abbreviation) 98 F... No distress. Will continue to monitor...." Daily Nurse's Notes on [DATE], [DATE], and [DATE] confirmed Resident #24 had a urinary catheter "draining yellow urine ...." A review of Resident #24's Nurse's Notes dated [DATE] at 10:30 a.m. revealed, "Resident [MEDICAL CONDITION] vent status maintained. Condition Stable. No distress noted will continue to monitor and assist as needed. VS (BP) ,[DATE]- (P) 83- (R) 97.8-(T) 18." A review of the facility's Nurse's Note's dated [DATE] revealed the following regarding Resident #24: a) At 5:45 p.m., "Patient noted with abnormal breathing, staff checked vital sign, T-101.6, R-24, P-75, O 2 Sat fluctuating between ,[DATE], BP-,[DATE]. Staff noted skin cold and clammy. Notified Dr ___ (Medical Director QQ) of change of condition and received an order to transfer patient to ___ (hospital name) ER." b) At 6:00 p.m., "Message left for ___ (Resident #24's family member) in the voice mail, staff called ___ (name of EMS) EMS." c) At 7:00 p.m., "Ambulance here and transferred patient as ordered. She had BM at this time, incontinent care given. Staff called and notified on call nurse who stated 'I will let the DON know.'" A review of the Emergency Medical Service (EMS) record for Resident #24 dated [DATE] revealed a call was received from the facility and dispatched at 6:58 p.m. EMS arrived at the facility at 7:24 p.m. Resident #24 was transported to the emergency room at 8:13 p.m. and call was cleared at 9:30 p.m. This record was coded "ALS Urgent" and the "[MEDICAL CONDITION], Septic Shock" protocol was implemented. The EMS record reflected the following vital signs for Resident #24: "6:45 p.m. - B/P ,[DATE], P 60, R 46, T 102.5, Oxygen Saturation 98% 6:55 p.m. - B/P ,[DATE], P 32, R 40, Oxygen Saturation 87% 6:58 p.m. - B/P ,[DATE], P 68, R 40, Oxygen Saturation? 7:19 p.m. - B/P ,[DATE], P 169 R 36, Oxygen Saturation 98%." This EMS Record also reflected the following narrative for Resident #24: "...AOS (arrived on scene) to find pt lying in bed unresponsive to all stimuli. Pt was on vent at above settings 2 (secondary to) [MEDICAL CONDITION]. Pt also has Foley cath that is tan brown and doesn't appear to be a new onset. Pt was also fecal incontinent. Pt looks to have had very poor care and when we requested a nurse for a report (report on resident's status) one could not be found and the only report we received was from the Respiratory Tech who said 'She doesn't have a respiratory problem. She is sating 98% although her RR (rate of respirations) is 46/min. She is go to (to go) the ER for AMS and she had blood drawn this morning and she has elevated WBC (white blood cell count). Pt was moved over to our vent. Assessment taken c BP ,[DATE], P 60, RR 46. Pt was moved over to the stretcher and secured by rails (up) X (times) 2, straps X3, Pt loaded into MICU and IV established. D-stick (blood glucose level) taken as well as tympanic temp, fluid [MEDICATION NAME] of 500 cc and placed in Trendelenburg position (Position where the patient's head was low and the body and legs were on an elevated and inclined place) and TXP (transported) to (Hospital Name) Emergency and pt care was TXF (transferred) to RN." A review of Resident #24's Hospital Emergency Department Nursing Record, dated [DATE] at 8:35 p.m., revealed a temperature of 107.0 F, respirations 33, blood pressure ,[DATE], pulse 188, urinary catheter - abnormal color or cloudy and Integumentary: other ____ (unable to read). A review of Resident #24's Hospital Emergency Physician Record, dated [DATE] at 8:45 p.m., revealed the following: "...Chief complaint: Fever ... unable to obtain further ___ (unable to read) ans (unknown abbreviation), lack of info from nursing home .... Clinical Impression: [MEDICAL CONDITION], Fever, UTI, Acute [MEDICAL CONDITION], Respiratory Chronic Failure...." A review of Resident #24's Hospital ED (Emergency Department) Transition of Care Order Set, dated [DATE] at 10:40 p.m., revealed the following Diagnoses: [REDACTED]. A review of Resident #24's ICU/Telemetry Orders Routine, dated [DATE] at 7:30 p.m., revealed a [DIAGNOSES REDACTED]. A review of Resident #24's Hospital Admitting History and Physical, dated [DATE] at 9:40 p.m., revealed Resident #24 was S/[MEDICAL CONDITION] vent dependence. "...pt reportedly had temp to 101.6 and WBC 21. In ED pt found to have temp 107... unresponsive ...Foley in place, thick, brownish ...Plan of Care HTN, DM, ...Sepsis ,[DATE] (secondary to) UTI." A review of Resident #24's Hospital [MEDICAL CONDITION] Flowsheet, dated [DATE] at 11:45 p.m., revealed the following: "Urethral Catheter Removal: urethral catheter removed; tubing intact; physician notified. Removal Indication: site symptomatic; urine tubing and amp (unknown abbreviation); meter filthy,[MEDICAL CONDITION] dx (diagnosis)." A review of Resident #24's Hospital Communication Flowsheet, dated [DATE] and signed by a registered nurse revealed the following: "Physician Call ...Made aware of urine output, hematuria, and filth of previous catheter." A review of Resident #24's Hospital Discharge Summary with discharge date of [DATE] revealed her admitting [DIAGNOSES REDACTED]. Consults reflected palliative care and Resident #24 was discharged to inpatient hospice. Resident #24's condition upon discharge was "Dying." Resident #24's Hospice Physician's Orders, dated [DATE] at 8:15 p.m., reflected a [DIAGNOSES REDACTED]. Resident #24's Hospital Authorization for Release of deceased Patient, dated [DATE] at 12:35 p.m., reflected Resident #24 was pronounced dead on [DATE] at 8:55 a.m. with a [DIAGNOSES REDACTED]. On [DATE] at 11:00 a.m., an interview was conducted with Medical Director QQ who stated he had concerns regarding the care that was being provided by the facility. At that time, Medical Director QQ revealed he was the Medical Director of [MEDICAL CONDITION] at the facility. He stated, "Several patients here have multi-resistant drug germs. These patients are very risky to contaminate other patients." The surveyor asked Medical Director QQ if he had any concerns about the facility's ability to manage indwelling catheters. Medical Director QQ stated, "I have been concerned about _____ (resident's name) Foley catheter management for a long, long time. He had [MEDICAL CONDITION]." He stated he told Nurse ____ to send Res ___ out to the emergency room for evaluation, but the nurse called back to say she talked to somebody (non-medical doctor) who said they would re-evaluate the patient and did not send the patient out immediately. Medical Director QQ stated, "I called and talked with (ADON B) and she (ADON B) said she (ADON B) never said to reassess the patient, but told her (charge nurse) to send the patient to the hospital." Medical Director QQ stated, "The nursing situation here is very dangerous." Medical Director QQ stated he was concerned about the care that was provided by the facility and he had a moral and ethical obligation to report his concerns. On [DATE] at 12:00 p.m., an interview was conducted with the current DON regarding some of the residents' care concerns held by Medical Director QQ. She stated, "I know that Dr. ___ (Medical Director QQ) has resigned. He has been increasingly difficult to the staff, cursing and yelling at them." When the DON was asked if Medical Director QQ was cursing and yelling at the residents, she stated, "I don't believe he's being disrespectful to the residents." On [DATE] at 4:05 p.m., an interview was conducted with the current DON, and Resident #24's complete clinical record was requested. After review of the clinical record, the surveyor was unable to locate evidence of the provision of catheter/peri care. On [DATE] at 10:30 a.m., an interview was conducted with the EMS Director of Operation. He was asked to explain the difference in using his company's EMS versus calling 911. He stated the basic difference between the two would be in the response time. He stated the ETA (estimated time of arrival) would be based on where the transport vehicle was coming from. He further stated, "We leave it up to the facility to determine who they call based on ETA." The EMS Director of Operation was asked if a resident presented with vital signs of B/P ,[DATE], P 60, R 46, T 102.5, Oxygen Saturation 98%, would an hour wait for emergency service be considered a long time to wait. He stated, "That would be a long time to wait with the conditions you described." 2) Resident #10's Face Sheet dated [DATE] reflected an admitted d of [DATE] with the following Diagnoses: [REDACTED]. The Telephone Orders dated [DATE] for Resident #10 reflected the following: "Change Supra Pubic cath q month." This order was not signed and dated by a physician. A review of the facility's Additional Nurse's Notes dated [DATE] at "_435" revealed "...Foley cath changed..." The clinical record did not reflect monthly Foley catheter changes thereafter, nor was this information provided by the facility. A review of the comprehensive MDS assessment dated [DATE] revealed Resident #10 sometimes made himself understood, he usually understood others, he was moderately impaired in his cognitive skills for daily decision making, and he was short-tempered and easily annoyed. The MDS assessment also reflected he had verbal behavioral symptoms directed toward others and he rejected care (behavior of this type occurred four to six days per week, but less than daily). The MDS assessment reflected he was totally dependent in bed mobility, dressing, eating, toilet use and personal hygiene, had an indwelling catheter and an ostomy (including [MEDICATION NAME], [MEDICAL CONDITION] and [MEDICAL CONDITION]). On [DATE] at 11:50 a.m., CNA O assisted the surveyor in observing the indwelling urinary catheter of Resident #10. The urinary drainage bag was not dated and was not secured to the resident's leg. The indwelling urinary catheter was observed with a dark brown linear substance on the catheter tubing near the insertion site. A review of Resident #10's TAR provided by the facility dated February 2011 did not address changing the indwelling catheter. A review the Comprehensive Plan of Care revealed the following regarding Resident #10: Problem: [DATE] - Resident ADL functions - total dependence in bed mobility, dressing, eating, toileting, personal hygiene and bathing. Approach: Assist with ADLs as needed. Problem: [DATE] -Resident has a supra pubic catheter. Approach: Change Foley cath, tubing and bag per order. Monitor urine for odor, color, sediments, and amount of urine, etc. and report abnormal to MD. Keep tubing/bag below the bladder, do not kink tubing. Cath care per order. A review of the Telephone Orders dated [DATE] for Resident #10 revealed the following: "Add: Supra pubic (SP) cath care with soap & H2O (water) q shift. Change SP catheter monthly c drain bag/tubing change." The Telephone Orders dated [DATE] for Resident #10 reflected the following: Replace current supra pubic Foley catheter 30 French - 30 cc with new silver impregnated supra pubic Foley 30 French - 30 cc, when available, to reduce bio-load. (Diagnoses: [REDACTED]. Change silver impregnated catheter as needed to maintain patency. Discontinue order to change supra pubic Foley catheter every month. A review of an Order Detail/PO Confirmation (invoice) dated [DATE] at 10:07 a.m. revealed the order did not reflect an order for [REDACTED]. On [DATE] at 7:14 p.m., Resident #10 was observed lying in bed awake. His indwelling urinary catheter was observed by two surveyors with gross sedimentation present. At this time, the surveyors received permission from Resident #10 to observe his supra pubic indwelling catheter insertion site. When the surveyors observed the insertion site, a white wash cloth with red discoloration on it was observed positioned over the insertion site. Resident #10 was asked why the white wash cloth was over his insertion site. He stated the red discoloration on the wash cloth was blood that came from his catheter site. He was asked if he had notified the staff of this bleeding. He stated the CNA had put the towel there and was supposed to tell the nurse. Resident #10 was asked what time did this occur. He stated at 10:00 a.m. He was asked if anyone had come to assess the insertion site or the source of the bleeding. Resident #10 stated no one had checked the supra pubic catheter yet. Resident #10 was asked if the facility staff cleaned his catheter on a regular basis. Resident #10 stated, "No, staff does not clean my catheter." Resident #10 also stated he told the nurse he was having bladder spasms and thought he might have a kidney infection. Resident #10 added he asked the nurse for a "UA a week ago," but it was not done. On [DATE] at 8:45 p.m., ADON CC was interviewed. He was asked why Resident #10's supra pubic indwelling urinary catheter was not changed on [DATE] (when the order was written). He stated, "We are waiting for it (catheter) to come in." On [DATE] at 8:50 p.m., LVN D was interviewed. She was asked if Resident #10's supra pubic indwelling urinary catheter was changed anytime after [DATE]. She stated, "I don't see where it was changed." On [DATE] at 8:55 p.m., the Ancillary Director/Staffing Coordinator was interviewed and asked in the presence of the current DON, if Resident #10's catheter had been ordered. She stated, "Yes, I tried to order it but it doesn't come in a 28 (size) or 30 (size)." She was asked if she had notified anyone of her findings regarding the catheter for Resident #10. In the presence of the DON, she stated she had told the DON. The current DON was then asked if she had been notified the catheter size the physician ordered for Resident #10 was not manufactured in the ordered size. The DON stated, "Yes, you told me this morning." The DON was asked if the physician had been notified the catheter was not manufactured in the size ordered. The DON stated, "No, I don't see it, according to the clinical record." The DON was asked when was the last time Resident #10's supra pubic catheter was changed. After review of the clinical record, the DON stated, "February 22, 2011." A review of the Nurse's Notes dated [DATE] at 11:00 p.m. revealed the following regarding Resident #10: "...Supra pubic patent. Urine amber colored. No sediments noted...." On [DATE] at 11:35 p.m., Resident #10 was interviewed. He was asked if the facility staff had come to assess the bleeding to his supra pubic indwelling catheter. He stated, "Nobody has come to check my catheter. The nurse came to change my [MEDICAL CONDITION], the bag busted. He (the nurse) got the CNA to clean (the feces from the busted [MEDICAL CONDITION] bag) me up." The resident was asked who moved the white wash cloth with the red discoloration on it. Resident #10 stated the CNA moved the wash cloth, when the CNA cleaned him, because the wash cloth had feces on it. Resident #10 stated, "That's how it (wash cloth) got moved." The resident was asked if the nurse assessed his supra pubic insertion site. Resident #10 stated, "The nurse did not check my catheter." On [DATE] at 11:40 p.m., CNA BBB was observed assisting Resident #10 with positioning. CNA AAA lifted Resident #10's urinary drainage bag and put it on the top of the bed, while she waited for approximately two minutes for Resident #10 to recover from a muscle spasm. On [DATE] at 11:43 p.m., LVN H was interviewed regarding Resident #10. He was asked if the CNA had informed him of possible bleeding from the supra pubic catheter site. He stated, "No, the CNA didn't tell me." On [DATE] at 12:10 a.m., an interview was conducted with the DON, ADON B, BOM, Ancillary Director/Staffing Coordinator, LVN G, Medical Records, Environmental Supervisor, Regional Director, ADON A, LVN D, and RT Q. The above observations were discussed regarding Resident #10, including the physician not being notified of Resident #10's current catheter observations. The DON stated, "I looked at his catheter. He's got some redness and irritation." At this time ([DATE] at 12:10 a.m.), an IJ situation was identified in the areas of Quality of Care, Infection Control and Administration on [DATE] at 12:10 a.m. A Plan of Removal was requested at that time. A review of the Telephone Orders dated "[DATE]" at "1225" for Resident #10 revealed the following: "Cleanse supra pubic site with normal saline, pat dry, apply [MEDICATION NAME] Ointment and cover with a dressing daily." A review of the Telephone Orders dated "[DATE]" at "0040" for Resident #10 revealed the following: New Order: Discontinue the order for the silver impregnated supra pubic urinary catheter. Insert supra pubic catheter. Foley care every shift change as needed/patency. Get urinalysis and culture & sensitivity. Possible Urinary Tract Infection. French Cath size 28 - 30 cc balloon. Resident #10's Nurse's Notes reflected the following: [DATE] at 1:40 AM - Late entry 8:30 AM - NP notified of bloody discharge from catheter site and sediment in catheter tubing. Order for UA with C&S received and to change catheter. At 1:55 AM - Foley catheter changed. [DATE] at 5:00 AM - catheter changed; draining well with clear amber urine. [DATE] at 6:00 AM - catheter in place, draining clear urine. 3) A review of Resident #39's undated admission face sheet revealed she was a [AGE] year-old resident who was admitted to the facility on [DATE]. A review of Resident #39's [DATE] MAR indicated [REDACTED]. A review of Resident #39's comprehensive plan of care dated [DATE] revealed Resident #39 had a Foley catheter and was at risk of Urinary Tract Infections. The goal reflected the catheter would remain patent and he would not develop UTIs. Approaches reflected to: 1) Change Foley cath, tubing and bag per order. 2) Monitor urine for odor, color, sediments, and amount of urine, etc, and reports abn (Abnormal labs) to MD. 3) Encourage p.o and fluid intake with in dietary limits 4) Keep tubing/bag below the bladder, do not kink tubing. 5) Cath. care per order." An observation on [DATE] at 11:25 a.m. with MA N of Resident #39's catheter and tubing revealed the tubing was cloudy in areas. In the middle area from the resident to the catheter, the tubing was not able to be seen, because it was white and encrusted. MA N removed the catheter from the catheter cover and turned the bag over. MA N stated "Oh my God." The surveyor asked the date on the bag, MA N replied it is "[DATE]." A review of a physician's order dated [DATE] revealed, "Computer update change Foley cath q mos on the 15th." A review of Resident #39's MAR indicated [REDACTED]. A review of Resident #39's [DATE] MAR indicated [REDACTED]." A review of Resident #39's nurse's notes from admission to [DATE] revealed there was no documentation the facility staff had attempted to change Resident #39's catheter. 4) A review of Resident #12's admission orders [REDACTED]. A review of Resident #12's MAR for [DATE] revealed orders for catheter care every shift, but no orders to routinely change the urinary catheter. On [DATE] at 11:30 a.m., the surveyor and the DON observed the indwelling urinary catheter of Resident #12. The urinary drainage bag was labeled with a Hospital label, which reflected, "Placement [DATE] at 21 Hrs. Due for removal [DATE]. Reason- Septic Shock, [MEDICAL CONDITION] and Vent Support." At that time, the DON was asked if everyone on a vent needed an indwelling urinary catheter. She stated, "Everyone does not need a Foley catheter who is on the vent." She further stated they used the federal regulation guidelines for urinary justification. 5) A review of Resident #37's TAR dated [DATE] revealed the following treatment: "Foley catheter Fr 18 with 30 ml and urinary drainage bag. Change every month on the 15th ,[DATE] (10:00 p.m. to 6:00 a.m. shift) and PRN." The [DATE] column was not signed to reflect the catheter was changed. On [DATE] at 11:40 a.m., CNA O assisted the surveyor in observing the indwelling urinary catheter of Resident #37. The urinary drainage bag was not dated and not secured to the resident's leg. The CNA was not observed to wash her hands before or after assisting the surveyor in observing Resident #37 indwelling catheter. 6) On [DATE] at 11:45 a.m., CNA O assisted the surveyor in observing the indwelling urinary catheter of Resident #5. The urinary drainage bag was dated [DATE], but was not secured to the resident's leg. Without washing her hands, CNA O leaned forward to lift the resident's dress. Resident #5 stopped her and asked her to put gloves on. A review of a list of current residents with UTIs, provided on [DATE] by the DON, revealed Resident #5 was currently receiving antibiotic treated for [REDACTED]. 7) On [DATE] at 6:50 p.m., Resident #7's indwelling urinary catheter was observed not secured to the resident's leg. 8) On [DATE] at 4:30 p.m., an interview was conducted with the Administrator, DON, and Nurse Consultant. The above observations were discussed/reviewed. When they were asked if they were aware of Resident #24's death, the RN Consultant stated they were currently working on the facility's Urinary Catheter Management Program and also stated they were not aware of Resident #24's developing Septic Shock resulting in death. 9) The Plan of Removal, which was accepted on [DATE] at 7:30 a.m., reflected: 1. Resident #10's physician was notified and his catheter replaced on the morning of ,[DATE]. A STAT (immediate) lab was ordered. Lab values were better than previously per the physician. Assessments of Resident #10 have yielded no issues regarding his catheter. The physician will be notified of abnormals. 2. Resident #10 and all residents with catheters have been assessed with [REDACTED]. 3. All urinary catheters have been changed on the residents. 4. Resident #10 and all residents with indwelling foley catheters/supra-pubic catheters have been fully assessed with [REDACTED]. Negative findings will be documented and reported to attending physician. Abnormal labs will be followed up. 5. Training on Urinary Catheter Management, Catheter Care and Supra-pubic Catheter Care being provided before current nurses and CNAs are allowed to work for any upcoming shifts and this will continue ongoing until all are trained. New nurses will be trained within three days of hire. 6. Staff proficiency on Urinary Catheter Management, Catheter Care on Indwelling and Supra-pubic will be conducted by Nurse Managers. Any deficient care will be addressed immediately and the employee will be retrained. 7. Nurse Managers will monitor any change in foley catheter orders and will monitor physician orders to ensure they are changed per physician orders/patency/signs of UTI. 8. The DON will ensure compliance with physician orders and the Urinary Catheter Management Guidelines. Any deficient practice or care will be addressed immediately and an off cycle QA will be conducted with the Medical Director. Interviews on [DATE] from 12:30 p.m. to 4:10 p.m. with the Activity Assistant, ADON A, ADON CC, CNA KK, CNA LL, CNA MM, CNA PP, LVN D, LVN F, LVN H, LVN V, LVN Z, LVN NN, and MA Y revealed they answered questions appropriately regarding catheters. Interview with CNA OO on [DATE] at 12:55 p.m. revealed failure to identify the proper positioning of a Foley bag to prevent backflow. 10) The CDC (Centers for Disease Control and Protection) Guidelines for Prevention of Catheter-Associated Urinary Tract Infections dated [DATE] reflected, "...d. Indwelling catheters should be properly secured after insertion to prevent movement and urethral traction....collecting bags should always be kept below the level of the bladder." According to <http://www.emedicine.com/med/topic3176.htm> retrieved on [DATE], "In spite of its apparent advantages, the use of a Foley catheter for a prolonged period of time (eg, months to years) is strongly discouraged. Chronic dependence on these catheters is extremely risky because long-term use of urethral catheters poses significant health hazards. Indwelling urethral catheters are a significant cause of urinary tract infections that involve the urethra, bladder, and kidneys. Within ,[DATE] weeks after catheter insertion, bacteria will be present in the bladder of most women. Asymptomatic bacterial colonization is common and does not pose a health hazard. However, untreated symptomatic urinary tract infections may lead to urosepsis and death. The death rate of nursing home residents with urethral catheters has been found to be 3 times higher than that of residents without catheters; this may be more a reflection of the severity of comorbid conditions that lead to the clinical decision to use chronic bladder drainage than causation from the use of chronic bladder drainage. " 11) A review of the facility's current policy entitled Urinary Catheter Management, origination date [DATE], revealed, "... 2. Use a catheter-anchoring device such as a catheter strap or adhesive device to prevent tension on the catheter and dislodgement of the catheter, thus minimizing urethral bladder friction and trauma. The catheter-anchoring device should be on the same side of the body as the drainage bag. 3. Properly position drainage bag and tubing below the level of the bladder and in a dependent position to facilitate flow of urine... 7. Provide perineal/catheter care with a perineal cleanser or mild soap and water at least once daily and promptly after fecal soiling to reduce the potential for bacterial contamination. Fecal matter should be cleansed away from the urethral meatus.... 10. Indwelling catheters do not need to be changed routinely. Frequency of change shall be based on the resident's individual assessment of factors such as rate of encrustation, occurrence of obstruction, leakage, or other complications; catheters may be changed more or less than every 30 days... 11. Monitor for potential catheter complications and provide appropriate nursing interventions to resolve the problem and/or change catheter if indicated... 12. Recognize the signs and symptoms of asymptomatic UTI... 13. For a suspected UTI, remove current catheter and insert a new catheter... 14. Treat symptomatic UTIs only...Monitor and ensure that proper perineal and catheter care is provided. Monitor and ensure the catheter drainage system is properly maintained...." 12) The ADM was notified on [DATE] at 7:17 p.m. that the IJ situation was removed on [DATE]. The facility remained out of compliance at a scope of "pattern" and severity level of "actual harm that is not Immediate Jeopardy" because the facility was still monitoring the Plan of Removal. 13) Review of the Resident Census and Condition of Residents dated [DATE] and signed by the DON revealed the following: total residents with indwelling or external catheter were 13; and total residents receiving antibiotics were 18.

Based on observation, interview and record review, it was determined the facility failed to follow a resident's formulated advance directive for one (Resident #10) of 22 residents reviewed for advance directives. Resident #10 was ventilator dependent. He made his mark on the facility's paperwork, which was witnessed by a former facility SW. Resident #10 chose to be resuscitated. The facility obtained a physician's orders [REDACTED]. Resident #10 said he was young and he wanted to live. He said he did not tell staff he did not want to be resuscitated. An Immediate Jeopardy (IJ) was identified on [DATE] at 6:00 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm," because the facility was still monitoring the Plan of Removal. This failure could have affected the facility's 62 residents, including Resident #10, by placing them at risk not receiving treatment they wanted or receiving treatment they did not want. Findings included: A review of the Face Sheet dated [DATE] revealed Resident #10 was a [AGE] year-old male, who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. This face sheet reflected Resident #10 was coded as a "DNR" (Do Not Resuscitate) and his family member was his POA (Power of Attorney). A review of the facility's "Acknowledgement of Self Determination Information" dated [DATE] for Resident #10 revealed, "I/family do not wish to make a decision at this time, and understand that should [MEDICAL CONDITION] occur, every measure will be taken to resuscitate. I reserve the right to execute an Advance Care Planning at a later time. RESIDENT IS FULL CODE STATUS." Resident #10 made his mark on the document, and it was witnessed by a former SW. A review of the Social Services Progress Notes dated [DATE] for Resident #10 revealed, "... Res (resident) remains in bed, but is dressed and groomed appropriately. Res utilizes his computer, enjoys watching TV and listening to music ...Res chooses to be full code & chart is flagged full code...." A review of the comprehensive MDS assessment dated [DATE] revealed Resident #10 sometimes made himself understood, he usually understood others, he was moderately impaired in his cognitive skills for daily decision making, and he was short-tempered and easily annoyed. The MDS assessment reflected Resident #10 did not have [MEDICAL CONDITION] or Hallucinations. The MDS assessment also reflected he had verbal behavioral symptoms directed toward others and he rejected care (behavior of this type occurred four to six days per week, but less than daily). The MDS assessment reflected he was totally dependent in bed mobility, dressing, eating, toilet use and personal hygiene, had an indwelling catheter and an ostomy (including [MEDICATION NAME], [MEDICAL CONDITION] and [MEDICAL CONDITION]). The MDS assessment also reflected he was at risk for developing a pressure ulcer, he had one or more unhealed pressure ulcers and he had four Stage IV Pressure Ulcers. The MDS assessment reflected he also received oxygen therapy, suctioning, [MEDICAL CONDITION] care, and ventilator or respirator treatments. A review of Resident #10's Comprehensive Plan of Care revealed the following: Problem: [DATE]-Resident requests Code Status of "No CPR." Approach: Inform staff of code status. Monitor for change of condition - report to MD and responsible party. A review of all the active orders for [DATE] (monthly orders) revealed Resident #10 had a DNR. A review of an audit to confirm/verify correct Code Status on all facility residents received from the SW on [DATE] revealed Halls 100, 200, and 300 were completed. The audit reflected Hall 400, the Vent Unit, had not been fully completed. On [DATE] at 4:40 p.m., an interview was conducted with Resident #10. Resident #10 was made aware of the discrepancy in the documentation regarding his code status. Resident #10 was told his signed "Acknowledgement of Self-Determination Information reflected "RESIDENT IS A FULL CODE STATUS," but the monthly physician's orders [REDACTED]. He was asked what his wish was related to code status. Resident #10 stated, "I want to be resuscitated. I am too young. That's wrong. I never told them I wanted to die. I am not that depressed." On [DATE] at 5:20 p.m., an interview was conducted with the facility's SW. She was asked to review a SS Note in Resident #10's clinical record dated [DATE], which reflected Resident #10's desire to be a full code. The SW stated, "I was not here that date. That's not my writing." She stated she had been employed at the facility for two weeks. The SW was shown the discrepancies in the clinical record of Resident #10 regarding his Advance Directives. She was asked if she was aware of this discrepancy. She stated, "I was training last week with _____, one of the other Social Workers, because we discovered a chart that the old Social Worker had a resident as a DNR, when the (family member) wanted full code." She was asked when was this error determined. The SW stated, "We determined that about a week ago." When asked for a specific date, she stated, "[DATE]th (2011)." The surveyor asked why she waited a week before starting to assess/correct residents' code status. The SW stated, "I was trying to do all the things I needed to to." She was asked if she made the ADM aware of this concern. The SW stated, "I told the ADM at the beginning of the week." The SW was asked how many residents still needed an audit of their advance directives. After reviewing her audit information, she stated, "24 people on the vent unit have not been done," which included Resident #10. At the time of this interview, the SW was observed to hand write Resident #10's correct Advance Directive information on her audit sheet. A review of an audit to confirm/verify correct Code Status on all facility residents received from the Social Worker on [DATE] revealed Halls 100, 200, and 300 were completed. The audit reflected Hall 400, the Vent Unit, had not been fully completed. On [DATE] at 5:55 p.m., the ADM, DON and RN Consultant were interviewed regarding Advance Directives for residents residing at the facility. The Code Status for Resident #10 was reviewed with the facility staff present. The ADM was asked why the SW was conducting an audit of Advance Directives. The ADM stated, "The Social Worker is going through and auditing them because I wanted them audited." The surveyor informed the facility staff the SW was interviewed and stated Resident #10's family identified his DNR was incorrect. The surveyor asked the ADM why he waited a week to make sure all the residents' Advance Directives were correct. The ADM stated, "She was in training last week. She was working with ____. The one that was identified was fixed." The ADM, DON, and RN Consultant were informed on [DATE] at 6:00 p.m. that the IJ situation was extended into Advance Directives. A plan of removal was requested at that time. A review of the facility's Plan of Removal, which was accepted on [DATE] at 7:30 a.m., revealed: 1. Resident #10's advance directive was clarified on his chart. All other residents on unit 4 had their advance directives clarified to reflect their preferences. 2. The facility conducted a full house audit of out-of- hospital DNRs and ensured residents' current preferences were reflected in the documentation in the clinical record. A red flag sheet meant DNR and a green flag sheet meant full code. 3. Red/green DNR/full code flags were updated in each chart and face sheets were updated to reflect the appropriate code status. 4. Facility licensed staff were inserviced on the resident's right to formulate advance directives. The inservice included information on the red or green flag sheet used in an emergency to quickly determine a resident's code status, and out-of-hospital DNRs. Information on how to use these things to determine code status was included. This training was conducted by the Case Mix Managers. The CMM's were trained by the RN Regional Nurse Consultant. The training was ongoing until all nursing staff were trained. New staff will be trained and checked off in these areas within 72 hours of employment. 5. Future compliance with full code/DNR policies will be monitored via a three check method. The three check method included the following: a) Full code/DNR status will be verified when monthly orders are checked; b) Full code/DNR status will be verified during quarterly social worker assessments; and c) Full code/DNR status will be discussed in quarterly care plans with family members or updated with them telephonically. Deficient areas will be corrected immediately. 6. Any deficient practices will be addressed immediately and addressed during the next scheduled QA meeting that is attended by the facility Medical Director. 7. The facility Medical Director was notified of the alleged issue with advance directives as well as the placement of the facility in IJ status for failure to follow policy and procedure. 8. In the future event a licensed nurse received a DNR order from the resident's physician, but there was no Out-of-Hospital DNR order executed in accordance with Chapter 166 of the Texas Health and Safety Code in the resident's chart, the licensed nurse will immediately notify the Social Worker, DON or the Administrator. The resident and/or responsible party and the physician will be immediately notified that an Out-of-Hospital DNR order executed in accordance with Chapter 166 was required in order for a DNR order from a physician to be honored by the facility. They will also be notified that the resident will stay at current status until the Out-of-Hospital DNR was fully executed and received by the facility. 9. The facility will honor advance directives, durable powers of attorney, living wills, and out-of-hospital DNRs. Interviews on [DATE] from 12:30 p.m. to 4:10 p.m. with the Activity Assistant, ADON A, ADON CC, CNA KK, CNA LL, CNA MM, CNA PP, LVN D, LVN F, LVN H, LVN V, LVN Z, LVN NN, and MA Y revealed they answered the questions correctly regarding Advance Directives. The ADM was informed on [DATE] at 7:17 p.m. during the Exit Conference that the IJ was removed on [DATE]. The facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm," because the facility was still monitoring the Plan of Removal. A review of the Resident Census and Condition of Residents form dated [DATE] and signed by the DON revealed a total census of 109 residents and 62 residents had advance directives.

Based on observation, interview and record review, it was determined the facility failed to follow a resident's formulated advance directive for one (Resident #10) of 22 residents reviewed for advance directives. Resident #10 was ventilator dependent. He made his mark on the facility's paperwork, which was witnessed by a former facility SW. Resident #10 chose to be resuscitated. The facility obtained a physician's orders [REDACTED]. Resident #10 said he was young and he wanted to live. He said he did not tell staff he did not want to be resuscitated. An Immediate Jeopardy (IJ) was identified on [DATE] at 6:00 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm," because the facility was still monitoring the Plan of Removal. This failure could have affected the facility's 62 residents, including Resident #10, by placing them at risk not receiving treatment they wanted or receiving treatment they did not want. Findings included: A review of the Face Sheet dated [DATE] revealed Resident #10 was a [AGE] year-old male, who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. This face sheet reflected Resident #10 was coded as a "DNR" (Do Not Resuscitate) and his family member was his POA (Power of Attorney). A review of the facility's "Acknowledgement of Self Determination Information" dated [DATE] for Resident #10 revealed, "I/family do not wish to make a decision at this time, and understand that should [MEDICAL CONDITION] occur, every measure will be taken to resuscitate. I reserve the right to execute an Advance Care Planning at a later time. RESIDENT IS FULL CODE STATUS." Resident #10 made his mark on the document, and it was witnessed by a former SW. A review of the Social Services Progress Notes dated [DATE] for Resident #10 revealed, "... Res (resident) remains in bed, but is dressed and groomed appropriately. Res utilizes his computer, enjoys watching TV and listening to music ...Res chooses to be full code & chart is flagged full code...." A review of the comprehensive MDS assessment dated [DATE] revealed Resident #10 sometimes made himself understood, he usually understood others, he was moderately impaired in his cognitive skills for daily decision making, and he was short-tempered and easily annoyed. The MDS assessment reflected Resident #10 did not have [MEDICAL CONDITION] or Hallucinations. The MDS assessment also reflected he had verbal behavioral symptoms directed toward others and he rejected care (behavior of this type occurred four to six days per week, but less than daily). The MDS assessment reflected he was totally dependent in bed mobility, dressing, eating, toilet use and personal hygiene, had an indwelling catheter and an ostomy (including [MEDICATION NAME], [MEDICAL CONDITION] and [MEDICAL CONDITION]). The MDS assessment also reflected he was at risk for developing a pressure ulcer, he had one or more unhealed pressure ulcers and he had four Stage IV Pressure Ulcers. The MDS assessment reflected he also received oxygen therapy, suctioning, [MEDICAL CONDITION] care, and ventilator or respirator treatments. A review of Resident #10's Comprehensive Plan of Care revealed the following: Problem: [DATE]-Resident requests Code Status of "No CPR." Approach: Inform staff of code status. Monitor for change of condition - report to MD and responsible party. A review of all the active orders for [DATE] (monthly orders) revealed Resident #10 had a DNR. A review of an audit to confirm/verify correct Code Status on all facility residents received from the SW on [DATE] revealed Halls 100, 200, and 300 were completed. The audit reflected Hall 400, the Vent Unit, had not been fully completed. On [DATE] at 4:40 p.m., an interview was conducted with Resident #10. Resident #10 was made aware of the discrepancy in the documentation regarding his code status. Resident #10 was told his signed "Acknowledgement of Self-Determination Information reflected "RESIDENT IS A FULL CODE STATUS," but the monthly physician's orders [REDACTED]. He was asked what his wish was related to code status. Resident #10 stated, "I want to be resuscitated. I am too young. That's wrong. I never told them I wanted to die. I am not that depressed." On [DATE] at 5:20 p.m., an interview was conducted with the facility's SW. She was asked to review a SS Note in Resident #10's clinical record dated [DATE], which reflected Resident #10's desire to be a full code. The SW stated, "I was not here that date. That's not my writing." She stated she had been employed at the facility for two weeks. The SW was shown the discrepancies in the clinical record of Resident #10 regarding his Advance Directives. She was asked if she was aware of this discrepancy. She stated, "I was training last week with _____, one of the other Social Workers, because we discovered a chart that the old Social Worker had a resident as a DNR, when the (family member) wanted full code." She was asked when was this error determined. The SW stated, "We determined that about a week ago." When asked for a specific date, she stated, "[DATE]th (2011)." The surveyor asked why she waited a week before starting to assess/correct residents' code status. The SW stated, "I was trying to do all the things I needed to to." She was asked if she made the ADM aware of this concern. The SW stated, "I told the ADM at the beginning of the week." The SW was asked how many residents still needed an audit of their advance directives. After reviewing her audit information, she stated, "24 people on the vent unit have not been done," which included Resident #10. At the time of this interview, the SW was observed to hand write Resident #10's correct Advance Directive information on her audit sheet. A review of an audit to confirm/verify correct Code Status on all facility residents received from the Social Worker on [DATE] revealed Halls 100, 200, and 300 were completed. The audit reflected Hall 400, the Vent Unit, had not been fully completed. On [DATE] at 5:55 p.m., the ADM, DON and RN Consultant were interviewed regarding Advance Directives for residents residing at the facility. The Code Status for Resident #10 was reviewed with the facility staff present. The ADM was asked why the SW was conducting an audit of Advance Directives. The ADM stated, "The Social Worker is going through and auditing them because I wanted them audited." The surveyor informed the facility staff the SW was interviewed and stated Resident #10's family identified his DNR was incorrect. The surveyor asked the ADM why he waited a week to make sure all the residents' Advance Directives were correct. The ADM stated, "She was in training last week. She was working with ____. The one that was identified was fixed." The ADM, DON, and RN Consultant were informed on [DATE] at 6:00 p.m. that the IJ situation was extended into Advance Directives. A plan of removal was requested at that time. A review of the facility's Plan of Removal, which was accepted on [DATE] at 7:30 a.m., revealed: 1. Resident #10's advance directive was clarified on his chart. All other residents on unit 4 had their advance directives clarified to reflect their preferences. 2. The facility conducted a full house audit of out-of- hospital DNRs and ensured residents' current preferences were reflected in the documentation in the clinical record. A red flag sheet meant DNR and a green flag sheet meant full code. 3. Red/green DNR/full code flags were updated in each chart and face sheets were updated to reflect the appropriate code status. 4. Facility licensed staff were inserviced on the resident's right to formulate advance directives. The inservice included information on the red or green flag sheet used in an emergency to quickly determine a resident's code status, and out-of-hospital DNRs. Information on how to use these things to determine code status was included. This training was conducted by the Case Mix Managers. The CMM's were trained by the RN Regional Nurse Consultant. The training was ongoing until all nursing staff were trained. New staff will be trained and checked off in these areas within 72 hours of employment. 5. Future compliance with full code/DNR policies will be monitored via a three check method. The three check method included the following: a) Full code/DNR status will be verified when monthly orders are checked; b) Full code/DNR status will be verified during quarterly social worker assessments; and c) Full code/DNR status will be discussed in quarterly care plans with family members or updated with them telephonically. Deficient areas will be corrected immediately. 6. Any deficient practices will be addressed immediately and addressed during the next scheduled QA meeting that is attended by the facility Medical Director. 7. The facility Medical Director was notified of the alleged issue with advance directives as well as the placement of the facility in IJ status for failure to follow policy and procedure. 8. In the future event a licensed nurse received a DNR order from the resident's physician, but there was no Out-of-Hospital DNR order executed in accordance with Chapter 166 of the Texas Health and Safety Code in the resident's chart, the licensed nurse will immediately notify the Social Worker, DON or the Administrator. The resident and/or responsible party and the physician will be immediately notified that an Out-of-Hospital DNR order executed in accordance with Chapter 166 was required in order for a DNR order from a physician to be honored by the facility. They will also be notified that the resident will stay at current status until the Out-of-Hospital DNR was fully executed and received by the facility. 9. The facility will honor advance directives, durable powers of attorney, living wills, and out-of-hospital DNRs. Interviews on [DATE] from 12:30 p.m. to 4:10 p.m. with the Activity Assistant, ADON A, ADON CC, CNA KK, CNA LL, CNA MM, CNA PP, LVN D, LVN F, LVN H, LVN V, LVN Z, LVN NN, and MA Y revealed they answered the questions correctly regarding Advance Directives. The ADM was informed on [DATE] at 7:17 p.m. during the Exit Conference that the IJ was removed on [DATE]. The facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm," because the facility was still monitoring the Plan of Removal. A review of the Resident Census and Condition of Residents form dated [DATE] and signed by the DON revealed a total census of 109 residents and 62 residents had advance directives.

Based on observation, interview and record review, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as possible for all 109 residents residing in the facility. 1) There were numerous hazardous items (cleaners, mouthwash, lotions, skin care items, hair products, deodorant, razors, shaving cream and alcohol hand gel/cleaner) unlocked on the Secured Unit for two days. The facility was notified of the hazards on the Secured Unit the first day the surveyors saw them, but the facility did not secure the items. The residents were able to obtain/reach the hazardous items and possibly ingest them or handle them. Hazardous items were found behind the Nurse's Station and one resident was seen behind the Station and there was not a nurse present at the Nurse's Station to intervene. An Immediate Jeopardy (IJ) was identified on 04/13/11. While the IJ was removed on 04/15/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm" because the facility was still monitoring the Plan of Removal. These failures could affect the 31 cognitively impaired residents, who resided on the Secured Unit, by placing them at risk of stomach upset, gastrointestinal bleeding, kidney failure and death from ingesting the hazardous items. 2) The shower room on the Vent Unit was not locked and there was a pooling of water in the center of the room. The call light next to the toilet did not work. The shower room also had bottles of shaving cream and body wash/shampoo in the shower room unsecured. A cabinet on the wall in the shower room had a latch and key secured to the cabinet, but the cabinet was unlocked and opened. 3) There was a wet floor, near the kitchen, that did not have a wet floor sign to alert residents. These failures could affect the 56 residents, who could independently ambulate or who ambulated with assistive devices, by placing them at risk of falling and suffering lacerations, bruises, and/or fractures and ingesting hazardous items. Findings included: 1) An observation of the Secured Unit on 04/12/11 at 10:12 a.m. revealed a housekeeping cart was unattended and unsecured with five spray bottles of cleaner on the cart. All the bottles of cleaners had labels that stated the contents were to be kept out of the reach of children. An observation of the Secured Unit on 04/12/11 at 10:15 a.m. revealed a storage closet near the nurse's station was unlocked, with the following items inside: 19 bottles of mouthwash 3 bottles of lotion 14 bottles of deodorant 4 loose razors and 3 full boxes of razors 5 cans of shaving cream 1 bottle of Sensicare (Toothpaste) 2 bottles of Soothe and Cool (Skin Barrier Cream) All of the above items' labels reflected either "Keep out of reach of children" or "For external use only." An observation of the Secured Unit on 04/12/11 at 10:21 a.m. revealed the clean linen room was not locked. The room contained a can of shaving cream and the label reflected to, "Keep out of reach of children." An observation of the Secured Unit on 04/12/11 at 10:27 a.m. revealed a medication cart behind the nurse's station was not locked. The nurse's station was not secured and was unattended. The medication room door was not locked and open to any resident, who wandered inside it. ADON A was made aware of all hazards at this time. An observation of the Secured Unit on 04/12/11 at 12:45 p.m. revealed hand hygiene sanitizer on top of the nurse's cart. The label on the hand sanitizer reflected, "For external use only." An observation of the Secured Unit on 04/13/11 at 7:30 a.m. revealed hand gel/sanitizer with a label which reflected, "For external use only" in Room #122. An observation of the Secured Unit on 04/13/11 at 07:31 a.m. revealed an unidentified resident wandering behind the nurse's station. There was not a nurse behind the nurse's station. An observation behind the nurse's station on the Secured Unit on 04/13/11 at 07:32 a.m. revealed the following items: 1) two containers of Soothe and Cool; 2) two bottles of Epiclenz -hand foam/sanitizer (on the medication cart); and 3) a can of Val Foam (volumizing hair product) spray. All the labels reflected to keep out of the reach of children or for external use only. An observation in the Secured Unit on 04/13/11 at 7:35 a.m. revealed the following items: 1) Mouthwash, 2) Soothe and Cool, 3) lotion and 4) Ampro pro style (hair product). All of the items' labels reflected to either "keep out of reach of children" or "for external use only." An observation of the medication cart in the hall of the Secured Unit on 04/13/11 at 07:40 a.m. revealed Epidemz and the label reflected to keep out of reach of children. An observation of Room 126 in the Secured Unit on 04/13/11 at 7:41 a.m. revealed lotion and Soothe and Cool. All of the items' labels reflected to either "keep out of reach of children" or "for external use only." 2) An observation on 04/08/11 at 7:35 p.m. in the shower room on Hall 400 (Vent Unit) near the respiratory therapy office, revealed the shower room door was not locked. There was water pooled in the center of the room and there was not a wet floor sign. The call light at the toilet was not working. An interview with an unknown staff member revealed the door was usually locked and no residents used the toilet unattended. On 04/12/11 at 12:00 p.m., a tour of the shower room on the Vent Unit was conducted with ADON CC and the following was observed: a) An emergency call light was observed positioned next to the toilet on the wall, but it did not work when the cord was pulled by the surveyor. b) A BSC (bedside commode) was observed positioned directly over the toilet and had a dark brown substance on it. c) A trash receptacle was observed full of trash with additional trash debris noted laying on the floor surrounding the trash receptacle. A sign was observed posted on the wall in the area of the trash receptacle which reflected, "This area is to stay clean. No excuses." d) Bottles of shaving cream, body wash/shampoo were out in the shower room unsecured. e) A cabinet on the wall in this shower room was observed with a latch and key secured to the cabinet, but the cabinet was observed opened and unlocked. f) A shower head holder was observed broken and the shower head was observed hanging on the floor; standing water was also observed on the shower room floor. ADON CC was interviewed at this time. He was asked who utilized the toilet in the Shower Room on the Vent Unit. He stated, "This toilet is supposed to be for the residents." He was asked if it was the facility policy and/or procedure to keep shaving cream, body wash and shampoo unsecured. ADON CC stated, "Toiletries should be put away." ADON CC was asked what the dark brown substance was on the seat of the BSC. He stated, "Looks like feces." ADON CC was asked if the shower head holder was broken. He stated it appeared to be. On 04/12/11 at 12:45 p.m., an interview was conducted with Resident #43. She was asked if she used the shower on the Vent Unit. She stated she did. She was asked if she ever used this shower/shower room unattended by staff. She stated, "I went in there one time, but I thought 'Should I?'" 3) The facility was informed on 04/13/11 at 11:30 a.m. that the IJ situation had been extended into the area of Hazards. A Plan of Removal was requested at that time. 4) An observation of the Secured Unit on 04/13/11 at 12:40 p.m. revealed an unattended nurse's cart that was unlocked. LVN V was standing next to the surveyor and she closed and locked the cart. An observation of a housekeeping cart on the Secured Unit on 04/13/11 at 1:24 p.m. revealed it was unlocked with cleaning chemicals in it. The labels on the chemicals reflected to keep out of reach of children and poison control information. 5) On 04/13/11 at 1:30 p.m., a surveyor was walking in the corridor with ADON CC. As the surveyor and ADON CC passed the kitchen, in the corridor frequently used by residents, the surveyor slipped in water and landed on her left knee and twisted her right ankle. Both the surveyor and ADON CC observed there was water on the floor, and no "wet floor" sign was observed. 6) An observation in the non-functional shower room on Hall 200 on 04/13/11 at 3:33 p.m. revealed it was unlocked and the following items were in an open cabinet: One 8-oz. can of Instant foam Hand Antiseptic, One 24-oz. spray bottle of Non-acid Bowl and Bathroom Disinfectant with 3-oz. of clear liquid in the bottle, Eight packages of razors, and Four 11-oz. cans of shaving cream. All of the above items' labels reflected either "keep out of reach of children" or "for external use only." An interview with the ADM on 04/13/11 at 3:43 p.m. revealed, "Ladies I'm going to get everything out of there and put it in the garbage. I swear that door has been locked everyday. The Life Safety Code people must have left it unlocked." 7) A review of the facility's Plan of Removal, which was accepted on 04/14/11 at 7:25 a.m., revealed: "1. Emergency call light in station 4 shower room was repaired on 04/12/11. Facility monitored call lights on units via the TELS system on a monthly basis. Station 1 Unit Manager was inserviced regarding timely response informing supervisors and following up to ensure issues do not occur. 2. Secured Unit and all other units have been searched for chemicals, keep out of reach items, and other hazards and the items were removed or secured in a locked closet, drawer, or cabinet as appropriate. Unlocked doors have been secured. Housekeeping carts have been secured or are attended. Water in hall was cleaned up immediately. 3. Facility staff will be inserviced on hazards to include chemicals in residents' rooms, keep out of reach of children items, housekeeping carts being secured, storage rooms locked where appropriate, chemical storage, med carts being locked and secured, and chemicals being stored behind nurse's stations. Staff will also be inserviced on the use of wet floor signs when mopping. This training was conducted by Nurse Managers and/or other Department Heads. This training will be ongoing until all staff are trained. New staff will be trained and checked off in these areas within 72 hours of employment. 4. Compliance with inservices will be monitored via rounds by Department Managers. Deficient areas will be corrected immediately and staff responsible will be inserviced on the spot. 5. Any deficient practices will be addressed immediately and addressed during the next scheduled QA meeting. The facility's Medical Director attended the QA meetings. These items will be addressed today in our QA meeting." Interviews on 04/15/11 from 12:30 p.m. to 4:10 p.m. with the Activity Assistant, ADON A, ADON CC, CNA KK, CNA LL, CNA MM, CNA PP, LVN D, LVN F, LVN H, LVN V, LVN Z, LVN NN, and MA Y revealed they answered the questions regarding hazards and the Plan of Removal correctly. 8) The ADM was notified on 04/15/11 that the IJ situation was removed. The facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm," because the facility was still monitoring the Plan of Removal. 9) The CMS-672 dated 04/13/11 provided and signed by the DON reflected a census of 109 residents with were 31 residents residing on the Secured Unit. The CMS-672 also reflected 56 residents ambulated independently and with assistive devices.

Based on observation, interview and record review, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as possible for all 109 residents residing in the facility. 1) There were numerous hazardous items (cleaners, mouthwash, lotions, skin care items, hair products, deodorant, razors, shaving cream and alcohol hand gel/cleaner) unlocked on the Secured Unit for two days. The facility was notified of the hazards on the Secured Unit the first day the surveyors saw them, but the facility did not secure the items. The residents were able to obtain/reach the hazardous items and possibly ingest them or handle them. Hazardous items were found behind the Nurse's Station and one resident was seen behind the Station and there was not a nurse present at the Nurse's Station to intervene. An Immediate Jeopardy (IJ) was identified on 04/13/11. While the IJ was removed on 04/15/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm" because the facility was still monitoring the Plan of Removal. These failures could affect the 31 cognitively impaired residents, who resided on the Secured Unit, by placing them at risk of stomach upset, gastrointestinal bleeding, kidney failure and death from ingesting the hazardous items. 2) The shower room on the Vent Unit was not locked and there was a pooling of water in the center of the room. The call light next to the toilet did not work. The shower room also had bottles of shaving cream and body wash/shampoo in the shower room unsecured. A cabinet on the wall in the shower room had a latch and key secured to the cabinet, but the cabinet was unlocked and opened. 3) There was a wet floor, near the kitchen, that did not have a wet floor sign to alert residents. These failures could affect the 56 residents, who could independently ambulate or who ambulated with assistive devices, by placing them at risk of falling and suffering lacerations, bruises, and/or fractures and ingesting hazardous items. Findings included: 1) An observation of the Secured Unit on 04/12/11 at 10:12 a.m. revealed a housekeeping cart was unattended and unsecured with five spray bottles of cleaner on the cart. All the bottles of cleaners had labels that stated the contents were to be kept out of the reach of children. An observation of the Secured Unit on 04/12/11 at 10:15 a.m. revealed a storage closet near the nurse's station was unlocked, with the following items inside: 19 bottles of mouthwash 3 bottles of lotion 14 bottles of deodorant 4 loose razors and 3 full boxes of razors 5 cans of shaving cream 1 bottle of Sensicare (Toothpaste) 2 bottles of Soothe and Cool (Skin Barrier Cream) All of the above items' labels reflected either "Keep out of reach of children" or "For external use only." An observation of the Secured Unit on 04/12/11 at 10:21 a.m. revealed the clean linen room was not locked. The room contained a can of shaving cream and the label reflected to, "Keep out of reach of children." An observation of the Secured Unit on 04/12/11 at 10:27 a.m. revealed a medication cart behind the nurse's station was not locked. The nurse's station was not secured and was unattended. The medication room door was not locked and open to any resident, who wandered inside it. ADON A was made aware of all hazards at this time. An observation of the Secured Unit on 04/12/11 at 12:45 p.m. revealed hand hygiene sanitizer on top of the nurse's cart. The label on the hand sanitizer reflected, "For external use only." An observation of the Secured Unit on 04/13/11 at 7:30 a.m. revealed hand gel/sanitizer with a label which reflected, "For external use only" in Room #122. An observation of the Secured Unit on 04/13/11 at 07:31 a.m. revealed an unidentified resident wandering behind the nurse's station. There was not a nurse behind the nurse's station. An observation behind the nurse's station on the Secured Unit on 04/13/11 at 07:32 a.m. revealed the following items: 1) two containers of Soothe and Cool; 2) two bottles of Epiclenz -hand foam/sanitizer (on the medication cart); and 3) a can of Val Foam (volumizing hair product) spray. All the labels reflected to keep out of the reach of children or for external use only. An observation in the Secured Unit on 04/13/11 at 7:35 a.m. revealed the following items: 1) Mouthwash, 2) Soothe and Cool, 3) lotion and 4) Ampro pro style (hair product). All of the items' labels reflected to either "keep out of reach of children" or "for external use only." An observation of the medication cart in the hall of the Secured Unit on 04/13/11 at 07:40 a.m. revealed Epidemz and the label reflected to keep out of reach of children. An observation of Room 126 in the Secured Unit on 04/13/11 at 7:41 a.m. revealed lotion and Soothe and Cool. All of the items' labels reflected to either "keep out of reach of children" or "for external use only." 2) An observation on 04/08/11 at 7:35 p.m. in the shower room on Hall 400 (Vent Unit) near the respiratory therapy office, revealed the shower room door was not locked. There was water pooled in the center of the room and there was not a wet floor sign. The call light at the toilet was not working. An interview with an unknown staff member revealed the door was usually locked and no residents used the toilet unattended. On 04/12/11 at 12:00 p.m., a tour of the shower room on the Vent Unit was conducted with ADON CC and the following was observed: a) An emergency call light was observed positioned next to the toilet on the wall, but it did not work when the cord was pulled by the surveyor. b) A BSC (bedside commode) was observed positioned directly over the toilet and had a dark brown substance on it. c) A trash receptacle was observed full of trash with additional trash debris noted laying on the floor surrounding the trash receptacle. A sign was observed posted on the wall in the area of the trash receptacle which reflected, "This area is to stay clean. No excuses." d) Bottles of shaving cream, body wash/shampoo were out in the shower room unsecured. e) A cabinet on the wall in this shower room was observed with a latch and key secured to the cabinet, but the cabinet was observed opened and unlocked. f) A shower head holder was observed broken and the shower head was observed hanging on the floor; standing water was also observed on the shower room floor. ADON CC was interviewed at this time. He was asked who utilized the toilet in the Shower Room on the Vent Unit. He stated, "This toilet is supposed to be for the residents." He was asked if it was the facility policy and/or procedure to keep shaving cream, body wash and shampoo unsecured. ADON CC stated, "Toiletries should be put away." ADON CC was asked what the dark brown substance was on the seat of the BSC. He stated, "Looks like feces." ADON CC was asked if the shower head holder was broken. He stated it appeared to be. On 04/12/11 at 12:45 p.m., an interview was conducted with Resident #43. She was asked if she used the shower on the Vent Unit. She stated she did. She was asked if she ever used this shower/shower room unattended by staff. She stated, "I went in there one time, but I thought 'Should I?'" 3) The facility was informed on 04/13/11 at 11:30 a.m. that the IJ situation had been extended into the area of Hazards. A Plan of Removal was requested at that time. 4) An observation of the Secured Unit on 04/13/11 at 12:40 p.m. revealed an unattended nurse's cart that was unlocked. LVN V was standing next to the surveyor and she closed and locked the cart. An observation of a housekeeping cart on the Secured Unit on 04/13/11 at 1:24 p.m. revealed it was unlocked with cleaning chemicals in it. The labels on the chemicals reflected to keep out of reach of children and poison control information. 5) On 04/13/11 at 1:30 p.m., a surveyor was walking in the corridor with ADON CC. As the surveyor and ADON CC passed the kitchen, in the corridor frequently used by residents, the surveyor slipped in water and landed on her left knee and twisted her right ankle. Both the surveyor and ADON CC observed there was water on the floor, and no "wet floor" sign was observed. 6) An observation in the non-functional shower room on Hall 200 on 04/13/11 at 3:33 p.m. revealed it was unlocked and the following items were in an open cabinet: One 8-oz. can of Instant foam Hand Antiseptic, One 24-oz. spray bottle of Non-acid Bowl and Bathroom Disinfectant with 3-oz. of clear liquid in the bottle, Eight packages of razors, and Four 11-oz. cans of shaving cream. All of the above items' labels reflected either "keep out of reach of children" or "for external use only." An interview with the ADM on 04/13/11 at 3:43 p.m. revealed, "Ladies I'm going to get everything out of there and put it in the garbage. I swear that door has been locked everyday. The Life Safety Code people must have left it unlocked." 7) A review of the facility's Plan of Removal, which was accepted on 04/14/11 at 7:25 a.m., revealed: "1. Emergency call light in station 4 shower room was repaired on 04/12/11. Facility monitored call lights on units via the TELS system on a monthly basis. Station 1 Unit Manager was inserviced regarding timely response informing supervisors and following up to ensure issues do not occur. 2. Secured Unit and all other units have been searched for chemicals, keep out of reach items, and other hazards and the items were removed or secured in a locked closet, drawer, or cabinet as appropriate. Unlocked doors have been secured. Housekeeping carts have been secured or are attended. Water in hall was cleaned up immediately. 3. Facility staff will be inserviced on hazards to include chemicals in residents' rooms, keep out of reach of children items, housekeeping carts being secured, storage rooms locked where appropriate, chemical storage, med carts being locked and secured, and chemicals being stored behind nurse's stations. Staff will also be inserviced on the use of wet floor signs when mopping. This training was conducted by Nurse Managers and/or other Department Heads. This training will be ongoing until all staff are trained. New staff will be trained and checked off in these areas within 72 hours of employment. 4. Compliance with inservices will be monitored via rounds by Department Managers. Deficient areas will be corrected immediately and staff responsible will be inserviced on the spot. 5. Any deficient practices will be addressed immediately and addressed during the next scheduled QA meeting. The facility's Medical Director attended the QA meetings. These items will be addressed today in our QA meeting." Interviews on 04/15/11 from 12:30 p.m. to 4:10 p.m. with the Activity Assistant, ADON A, ADON CC, CNA KK, CNA LL, CNA MM, CNA PP, LVN D, LVN F, LVN H, LVN V, LVN Z, LVN NN, and MA Y revealed they answered the questions regarding hazards and the Plan of Removal correctly. 8) The ADM was notified on 04/15/11 that the IJ situation was removed. The facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm," because the facility was still monitoring the Plan of Removal. 9) The CMS-672 dated 04/13/11 provided and signed by the DON reflected a census of 109 residents with were 31 residents residing on the Secured Unit. The CMS-672 also reflected 56 residents ambulated independently and with assistive devices.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five (Residents #5, #7, #10 #24, and #39) of 22 residents reviewed for quality of care. 1. Resident #24 had an indwelling urinary catheter without a physician's order and there were no orders for the care and maintenance of the catheter. Facility staff was not taking care of Resident #24's catheter. The facility failed to provide timely EMS for Resident #24 who required Advanced Life Support (ALS) Urgent Service for her condition. 911 service was not called for Resident #24. These failures resulted in Resident #24 developing a Urinary Tract Infection which resulted in Septic Shock and Death. Resident #24 waited 2 hours and 35 minutes from the time EMS was called to the time she arrived in the ER to receive Emergency Department Services. Resident #24's immediate cause of death was Septic Shock. 3. Resident #10's indwelling urinary catheter was not changed as ordered and the catheter tubing was not secured to his inner thigh. Resident #10 said he was having bladder spasms and discomfort related to his catheter. 4. Resident #12's catheter had not been changed. There were no physician's order to change it. 4. Residents #5, #7, and #37 indwelling urinary catheter/tubing was not secured to the resident's inner thigh. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 12:10 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and severity level of "actual harm that is not Immediate Jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the 13 residents who had a urinary catheter, including Residents #5, #37, and #10 by placing them at risk for the potential traumatic injury to the bladder/urinary tract and/or urinary tract infections. Findings included: 1) A review of the Face Sheet dated [DATE] revealed Resident #24 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the facility's Nurse's Notes, dated [DATE] at 7:30 p.m., revealed Resident #24 was "...unable to verbalize needs." A review of the facility's Physician's Telephone Order, dated [DATE] at 10:00 a.m., revealed Resident #24 was transferred to the ER for evaluation for [MEDICAL CONDITION] Flutter. Resident #24's admission orders [REDACTED]. The orders did not reflect the resident had an indwelling urinary catheter. A review of the facility's Daily Skilled Nurse's Notes, dated [DATE] at 8:00 p.m., revealed Resident #24's admission to the facility. It further revealed incontinent care, turning, and repositioning were provided, but there was no documentation regarding an indwelling urinary catheter. A review of the facility's Daily Skilled Nurse's Notes, dated [DATE] at 1:00 a.m., revealed Resident #24 was "voiding (urinating) freely." Daily nurse's notes for [DATE] and [DATE] did not address Resident #24's urinary output or the presence of an indwelling urinary catheter. The facility's Nurse's Notes dated [DATE] at 8:10 a.m. reflected Resident #24 had an indwelling urinary catheter. The note reflected, "...Foley catheter patent, yellow and clear urine ...." (Note: This was the first note that identified the resident had a urinary catheter.) A review of Resident #24's Nurse's Notes dated [DATE] at 08:30 a.m. revealed, "...Foley catheter patent, yellow and clear urine. V/S DT (unknown abbreviation) 98 F... No distress. Will continue to monitor...." Daily Nurse's Notes on [DATE], [DATE], and [DATE] confirmed Resident #24 had a urinary catheter "draining yellow urine ...." A review of Resident #24's Nurse's Notes dated [DATE] at 10:30 a.m. revealed, "Resident [MEDICAL CONDITION] vent status maintained. Condition Stable. No distress noted will continue to monitor and assist as needed. VS (BP) ,[DATE]- (P) 83- (R) 97.8-(T) 18." A review of the facility's Nurse's Note's dated [DATE] revealed the following regarding Resident #24: a) At 5:45 p.m., "Patient noted with abnormal breathing, staff checked vital sign, T-101.6, R-24, P-75, O 2 Sat fluctuating between ,[DATE], BP-,[DATE]. Staff noted skin cold and clammy. Notified Dr ___ (Medical Director QQ) of change of condition and received an order to transfer patient to ___ (hospital name) ER." b) At 6:00 p.m., "Message left for ___ (Resident #24's family member) in the voice mail, staff called ___ (name of EMS) EMS." c) At 7:00 p.m., "Ambulance here and transferred patient as ordered. She had BM at this time, incontinent care given. Staff called and notified on call nurse who stated 'I will let the DON know.'" A review of the Emergency Medical Service (EMS) record for Resident #24 dated [DATE] revealed a call was received from the facility and dispatched at 6:58 p.m. EMS arrived at the facility at 7:24 p.m. Resident #24 was transported to the emergency room at 8:13 p.m. and call was cleared at 9:30 p.m. This record was coded "ALS Urgent" and the "[MEDICAL CONDITION], Septic Shock" protocol was implemented. The EMS record reflected the following vital signs for Resident #24: "6:45 p.m. - B/P ,[DATE], P 60, R 46, T 102.5, Oxygen Saturation 98% 6:55 p.m. - B/P ,[DATE], P 32, R 40, Oxygen Saturation 87% 6:58 p.m. - B/P ,[DATE], P 68, R 40, Oxygen Saturation? 7:19 p.m. - B/P ,[DATE], P 169 R 36, Oxygen Saturation 98%." This EMS Record also reflected the following narrative for Resident #24: "...AOS (arrived on scene) to find pt lying in bed unresponsive to all stimuli. Pt was on vent at above settings 2 (secondary to) [MEDICAL CONDITION]. Pt also has Foley cath that is tan brown and doesn't appear to be a new onset. Pt was also fecal incontinent. Pt looks to have had very poor care and when we requested a nurse for a report (report on resident's status) one could not be found and the only report we received was from the Respiratory Tech who said 'She doesn't have a respiratory problem. She is sating 98% although her RR (rate of respirations) is 46/min. She is go to (to go) the ER for AMS and she had blood drawn this morning and she has elevated WBC (white blood cell count). Pt was moved over to our vent. Assessment taken c BP ,[DATE], P 60, RR 46. Pt was moved over to the stretcher and secured by rails (up) X (times) 2, straps X3, Pt loaded into MICU and IV established. D-stick (blood glucose level) taken as well as tympanic temp, fluid [MEDICATION NAME] of 500 cc and placed in Trendelenburg position (Position where the patient's head was low and the body and legs were on an elevated and inclined place) and TXP (transported) to (Hospital Name) Emergency and pt care was TXF (transferred) to RN." A review of Resident #24's Hospital Emergency Department Nursing Record, dated [DATE] at 8:35 p.m., revealed a temperature of 107.0 F, respirations 33, blood pressure ,[DATE], pulse 188, urinary catheter - abnormal color or cloudy and Integumentary: other ____ (unable to read). A review of Resident #24's Hospital Emergency Physician Record, dated [DATE] at 8:45 p.m., revealed the following: "...Chief complaint: Fever ... unable to obtain further ___ (unable to read) ans (unknown abbreviation), lack of info from nursing home .... Clinical Impression: [MEDICAL CONDITION], Fever, UTI, Acute [MEDICAL CONDITION], Respiratory Chronic Failure...." A review of Resident #24's Hospital ED (Emergency Department) Transition of Care Order Set, dated [DATE] at 10:40 p.m., revealed the following Diagnoses: [REDACTED]. A review of Resident #24's ICU/Telemetry Orders Routine, dated [DATE] at 7:30 p.m., revealed a [DIAGNOSES REDACTED]. A review of Resident #24's Hospital Admitting History and Physical, dated [DATE] at 9:40 p.m., revealed Resident #24 was S/[MEDICAL CONDITION] vent dependence. "...pt reportedly had temp to 101.6 and WBC 21. In ED pt found to have temp 107... unresponsive ...Foley in place, thick, brownish ...Plan of Care HTN, DM, ...Sepsis ,[DATE] (secondary to) UTI." A review of Resident #24's Hospital [MEDICAL CONDITION] Flowsheet, dated [DATE] at 11:45 p.m., revealed the following: "Urethral Catheter Removal: urethral catheter removed; tubing intact; physician notified. Removal Indication: site symptomatic; urine tubing and amp (unknown abbreviation); meter filthy,[MEDICAL CONDITION] dx (diagnosis)." A review of Resident #24's Hospital Communication Flowsheet, dated [DATE] and signed by a registered nurse revealed the following: "Physician Call ...Made aware of urine output, hematuria, and filth of previous catheter." A review of Resident #24's Hospital Discharge Summary with discharge date of [DATE] revealed her admitting [DIAGNOSES REDACTED]. Consults reflected palliative care and Resident #24 was discharged to inpatient hospice. Resident #24's condition upon discharge was "Dying." Resident #24's Hospice Physician's Orders, dated [DATE] at 8:15 p.m., reflected a [DIAGNOSES REDACTED]. Resident #24's Hospital Authorization for Release of deceased Patient, dated [DATE] at 12:35 p.m., reflected Resident #24 was pronounced dead on [DATE] at 8:55 a.m. with a [DIAGNOSES REDACTED]. On [DATE] at 11:00 a.m., an interview was conducted with Medical Director QQ who stated he had concerns regarding the care that was being provided by the facility. At that time, Medical Director QQ revealed he was the Medical Director of [MEDICAL CONDITION] at the facility. He stated, "Several patients here have multi-resistant drug germs. These patients are very risky to contaminate other patients." The surveyor asked Medical Director QQ if he had any concerns about the facility's ability to manage indwelling catheters. Medical Director QQ stated, "I have been concerned about _____ (resident's name) Foley catheter management for a long, long time. He had [MEDICAL CONDITION]." He stated he told Nurse ____ to send Res ___ out to the emergency room for evaluation, but the nurse called back to say she talked to somebody (non-medical doctor) who said they would re-evaluate the patient and did not send the patient out immediately. Medical Director QQ stated, "I called and talked with (ADON B) and she (ADON B) said she (ADON B) never said to reassess the patient, but told her (charge nurse) to send the patient to the hospital." Medical Director QQ stated, "The nursing situation here is very dangerous." Medical Director QQ stated he was concerned about the care that was provided by the facility and he had a moral and ethical obligation to report his concerns. On [DATE] at 12:00 p.m., an interview was conducted with the current DON regarding some of the residents' care concerns held by Medical Director QQ. She stated, "I know that Dr. ___ (Medical Director QQ) has resigned. He has been increasingly difficult to the staff, cursing and yelling at them." When the DON was asked if Medical Director QQ was cursing and yelling at the residents, she stated, "I don't believe he's being disrespectful to the residents." On [DATE] at 4:05 p.m., an interview was conducted with the current DON, and Resident #24's complete clinical record was requested. After review of the clinical record, the surveyor was unable to locate evidence of the provision of catheter/peri care. On [DATE] at 10:30 a.m., an interview was conducted with the EMS Director of Operation. He was asked to explain the difference in using his company's EMS versus calling 911. He stated the basic difference between the two would be in the response time. He stated the ETA (estimated time of arrival) would be based on where the transport vehicle was coming from. He further stated, "We leave it up to the facility to determine who they call based on ETA." The EMS Director of Operation was asked if a resident presented with vital signs of B/P ,[DATE], P 60, R 46, T 102.5, Oxygen Saturation 98%, would an hour wait for emergency service be considered a long time to wait. He stated, "That would be a long time to wait with the conditions you described." 2) Resident #10's Face Sheet dated [DATE] reflected an admitted d of [DATE] with the following Diagnoses: [REDACTED]. The Telephone Orders dated [DATE] for Resident #10 reflected the following: "Change Supra Pubic cath q month." This order was not signed and dated by a physician. A review of the facility's Additional Nurse's Notes dated [DATE] at "_435" revealed "...Foley cath changed..." The clinical record did not reflect monthly Foley catheter changes thereafter, nor was this information provided by the facility. A review of the comprehensive MDS assessment dated [DATE] revealed Resident #10 sometimes made himself understood, he usually understood others, he was moderately impaired in his cognitive skills for daily decision making, and he was short-tempered and easily annoyed. The MDS assessment also reflected he had verbal behavioral symptoms directed toward others and he rejected care (behavior of this type occurred four to six days per week, but less than daily). The MDS assessment reflected he was totally dependent in bed mobility, dressing, eating, toilet use and personal hygiene, had an indwelling catheter and an ostomy (including [MEDICATION NAME], [MEDICAL CONDITION] and [MEDICAL CONDITION]). On [DATE] at 11:50 a.m., CNA O assisted the surveyor in observing the indwelling urinary catheter of Resident #10. The urinary drainage bag was not dated and was not secured to the resident's leg. The indwelling urinary catheter was observed with a dark brown linear substance on the catheter tubing near the insertion site. A review of Resident #10's TAR provided by the facility dated February 2011 did not address changing the indwelling catheter. A review the Comprehensive Plan of Care revealed the following regarding Resident #10: Problem: [DATE] - Resident ADL functions - total dependence in bed mobility, dressing, eating, toileting, personal hygiene and bathing. Approach: Assist with ADLs as needed. Problem: [DATE] -Resident has a supra pubic catheter. Approach: Change Foley cath, tubing and bag per order. Monitor urine for odor, color, sediments, and amount of urine, etc. and report abnormal to MD. Keep tubing/bag below the bladder, do not kink tubing. Cath care per order. A review of the Telephone Orders dated [DATE] for Resident #10 revealed the following: "Add: Supra pubic (SP) cath care with soap & H2O (water) q shift. Change SP catheter monthly c drain bag/tubing change." The Telephone Orders dated [DATE] for Resident #10 reflected the following: Replace current supra pubic Foley catheter 30 French - 30 cc with new silver impregnated supra pubic Foley 30 French - 30 cc, when available, to reduce bio-load. (Diagnoses: [REDACTED]. Change silver impregnated catheter as needed to maintain patency. Discontinue order to change supra pubic Foley catheter every month. A review of an Order Detail/PO Confirmation (invoice) dated [DATE] at 10:07 a.m. revealed the order did not reflect an order for [REDACTED]. On [DATE] at 7:14 p.m., Resident #10 was observed lying in bed awake. His indwelling urinary catheter was observed by two surveyors with gross sedimentation present. At this time, the surveyors received permission from Resident #10 to observe his supra pubic indwelling catheter insertion site. When the surveyors observed the insertion site, a white wash cloth with red discoloration on it was observed positioned over the insertion site. Resident #10 was asked why the white wash cloth was over his insertion site. He stated the red discoloration on the wash cloth was blood that came from his catheter site. He was asked if he had notified the staff of this bleeding. He stated the CNA had put the towel there and was supposed to tell the nurse. Resident #10 was asked what time did this occur. He stated at 10:00 a.m. He was asked if anyone had come to assess the insertion site or the source of the bleeding. Resident #10 stated no one had checked the supra pubic catheter yet. Resident #10 was asked if the facility staff cleaned his catheter on a regular basis. Resident #10 stated, "No, staff does not clean my catheter." Resident #10 also stated he told the nurse he was having bladder spasms and thought he might have a kidney infection. Resident #10 added he asked the nurse for a "UA a week ago," but it was not done. On [DATE] at 8:45 p.m., ADON CC was interviewed. He was asked why Resident #10's supra pubic indwelling urinary catheter was not changed on [DATE] (when the order was written). He stated, "We are waiting for it (catheter) to come in." On [DATE] at 8:50 p.m., LVN D was interviewed. She was asked if Resident #10's supra pubic indwelling urinary catheter was changed anytime after [DATE]. She stated, "I don't see where it was changed." On [DATE] at 8:55 p.m., the Ancillary Director/Staffing Coordinator was interviewed and asked in the presence of the current DON, if Resident #10's catheter had been ordered. She stated, "Yes, I tried to order it but it doesn't come in a 28 (size) or 30 (size)." She was asked if she had notified anyone of her findings regarding the catheter for Resident #10. In the presence of the DON, she stated she had told the DON. The current DON was then asked if she had been notified the catheter size the physician ordered for Resident #10 was not manufactured in the ordered size. The DON stated, "Yes, you told me this morning." The DON was asked if the physician had been notified the catheter was not manufactured in the size ordered. The DON stated, "No, I don't see it, according to the clinical record." The DON was asked when was the last time Resident #10's supra pubic catheter was changed. After review of the clinical record, the DON stated, "February 22, 2011." A review of the Nurse's Notes dated [DATE] at 11:00 p.m. revealed the following regarding Resident #10: "...Supra pubic patent. Urine amber colored. No sediments noted...." On [DATE] at 11:35 p.m., Resident #10 was interviewed. He was asked if the facility staff had come to assess the bleeding to his supra pubic indwelling catheter. He stated, "Nobody has come to check my catheter. The nurse came to change my [MEDICAL CONDITION], the bag busted. He (the nurse) got the CNA to clean (the feces from the busted [MEDICAL CONDITION] bag) me up." The resident was asked who moved the white wash cloth with the red discoloration on it. Resident #10 stated the CNA moved the wash cloth, when the CNA cleaned him, because the wash cloth had feces on it. Resident #10 stated, "That's how it (wash cloth) got moved." The resident was asked if the nurse assessed his supra pubic insertion site. Resident #10 stated, "The nurse did not check my catheter." On [DATE] at 11:40 p.m., CNA BBB was observed assisting Resident #10 with positioning. CNA AAA lifted Resident #10's urinary drainage bag and put it on the top of the bed, while she waited for approximately two minutes for Resident #10 to recover from a muscle spasm. On [DATE] at 11:43 p.m., LVN H was interviewed regarding Resident #10. He was asked if the CNA had informed him of possible bleeding from the supra pubic catheter site. He stated, "No, the CNA didn't tell me." On [DATE] at 12:10 a.m., an interview was conducted with the DON, ADON B, BOM, Ancillary Director/Staffing Coordinator, LVN G, Medical Records, Environmental Supervisor, Regional Director, ADON A, LVN D, and RT Q. The above observations were discussed regarding Resident #10, including the physician not being notified of Resident #10's current catheter observations. The DON stated, "I looked at his catheter. He's got some redness and irritation." At this time ([DATE] at 12:10 a.m.), an IJ situation was identified in the areas of Quality of Care, Infection Control and Administration on [DATE] at 12:10 a.m. A Plan of Removal was requested at that time. A review of the Telephone Orders dated "[DATE]" at "1225" for Resident #10 revealed the following: "Cleanse supra pubic site with normal saline, pat dry, apply [MEDICATION NAME] Ointment and cover with a dressing daily." A review of the Telephone Orders dated "[DATE]" at "0040" for Resident #10 revealed the following: New Order: Discontinue the order for the silver impregnated supra pubic urinary catheter. Insert supra pubic catheter. Foley care every shift change as needed/patency. Get urinalysis and culture & sensitivity. Possible Urinary Tract Infection. French Cath size 28 - 30 cc balloon. Resident #10's Nurse's Notes reflected the following: [DATE] at 1:40 AM - Late entry 8:30 AM - NP notified of bloody discharge from catheter site and sediment in catheter tubing. Order for UA with C&S received and to change catheter. At 1:55 AM - Foley catheter changed. [DATE] at 5:00 AM - catheter changed; draining well with clear amber urine. [DATE] at 6:00 AM - catheter in place, draining clear urine. 3) A review of Resident #39's undated admission face sheet revealed she was a [AGE] year-old resident who was admitted to the facility on [DATE]. A review of Resident #39's [DATE] MAR indicated [REDACTED]. A review of Resident #39's comprehensive plan of care dated [DATE] revealed Resident #39 had a Foley catheter and was at risk of Urinary Tract Infections. The goal reflected the catheter would remain patent and he would not develop UTIs. Approaches reflected to: 1) Change Foley cath, tubing and bag per order. 2) Monitor urine for odor, color, sediments, and amount of urine, etc, and reports abn (Abnormal labs) to MD. 3) Encourage p.o and fluid intake with in dietary limits 4) Keep tubing/bag below the bladder, do not kink tubing. 5) Cath. care per order." An observation on [DATE] at 11:25 a.m. with MA N of Resident #39's catheter and tubing revealed the tubing was cloudy in areas. In the middle area from the resident to the catheter, the tubing was not able to be seen, because it was white and encrusted. MA N removed the catheter from the catheter cover and turned the bag over. MA N stated "Oh my God." The surveyor asked the date on the bag, MA N replied it is "[DATE]." A review of a physician's order dated [DATE] revealed, "Computer update change Foley cath q mos on the 15th." A review of Resident #39's MAR indicated [REDACTED]. A review of Resident #39's [DATE] MAR indicated [REDACTED]." A review of Resident #39's nurse's notes from admission to [DATE] revealed there was no documentation the facility staff had attempted to change Resident #39's catheter. 4) A review of Resident #12's admission orders [REDACTED]. A review of Resident #12's MAR for [DATE] revealed orders for catheter care every shift, but no orders to routinely change the urinary catheter. On [DATE] at 11:30 a.m., the surveyor and the DON observed the indwelling urinary catheter of Resident #12. The urinary drainage bag was labeled with a Hospital label, which reflected, "Placement [DATE] at 21 Hrs. Due for removal [DATE]. Reason- Septic Shock, [MEDICAL CONDITION] and Vent Support." At that time, the DON was asked if everyone on a vent needed an indwelling urinary catheter. She stated, "Everyone does not need a Foley catheter who is on the vent." She further stated they used the federal regulation guidelines for urinary justification. 5) A review of Resident #37's TAR dated [DATE] revealed the following treatment: "Foley catheter Fr 18 with 30 ml and urinary drainage bag. Change every month on the 15th ,[DATE] (10:00 p.m. to 6:00 a.m. shift) and PRN." The [DATE] column was not signed to reflect the catheter was changed. On [DATE] at 11:40 a.m., CNA O assisted the surveyor in observing the indwelling urinary catheter of Resident #37. The urinary drainage bag was not dated and not secured to the resident's leg. The CNA was not observed to wash her hands before or after assisting the surveyor in observing Resident #37 indwelling catheter. 6) On [DATE] at 11:45 a.m., CNA O assisted the surveyor in observing the indwelling urinary catheter of Resident #5. The urinary drainage bag was dated [DATE], but was not secured to the resident's leg. Without washing her hands, CNA O leaned forward to lift the resident's dress. Resident #5 stopped her and asked her to put gloves on. A review of a list of current residents with UTIs, provided on [DATE] by the DON, revealed Resident #5 was currently receiving antibiotic treated for [REDACTED]. 7) On [DATE] at 6:50 p.m., Resident #7's indwelling urinary catheter was observed not secured to the resident's leg. 8) On [DATE] at 4:30 p.m., an interview was conducted with the Administrator, DON, and Nurse Consultant. The above observations were discussed/reviewed. When they were asked if they were aware of Resident #24's death, the RN Consultant stated they were currently working on the facility's Urinary Catheter Management Program and also stated they were not aware of Resident #24's developing Septic Shock resulting in death. 9) The Plan of Removal, which was accepted on [DATE] at 7:30 a.m., reflected: 1. Resident #10's physician was notified and his catheter replaced on the morning of ,[DATE]. A STAT (immediate) lab was ordered. Lab values were better than previously per the physician. Assessments of Resident #10 have yielded no issues regarding his catheter. The physician will be notified of abnormals. 2. Resident #10 and all residents with catheters have been assessed with [REDACTED]. 3. All urinary catheters have been changed on the residents. 4. Resident #10 and all residents with indwelling foley catheters/supra-pubic catheters have been fully assessed with [REDACTED]. Negative findings will be documented and reported to attending physician. Abnormal labs will be followed up. 5. Training on Urinary Catheter Management, Catheter Care and Supra-pubic Catheter Care being provided before current nurses and CNAs are allowed to work for any upcoming shifts and this will continue ongoing until all are trained. New nurses will be trained within three days of hire. 6. Staff proficiency on Urinary Catheter Management, Catheter Care on Indwelling and Supra-pubic will be conducted by Nurse Managers. Any deficient care will be addressed immediately and the employee will be retrained. 7. Nurse Managers will monitor any change in foley catheter orders and will monitor physician orders to ensure they are changed per physician orders/patency/signs of UTI. 8. The DON will ensure compliance with physician orders and the Urinary Catheter Management Guidelines. Any deficient practice or care will be addressed immediately and an off cycle QA will be conducted with the Medical Director. Interviews on [DATE] from 12:30 p.m. to 4:10 p.m. with the Activity Assistant, ADON A, ADON CC, CNA KK, CNA LL, CNA MM, CNA PP, LVN D, LVN F, LVN H, LVN V, LVN Z, LVN NN, and MA Y revealed they answered questions appropriately regarding catheters. Interview with CNA OO on [DATE] at 12:55 p.m. revealed failure to identify the proper positioning of a Foley bag to prevent backflow. 10) The CDC (Centers for Disease Control and Protection) Guidelines for Prevention of Catheter-Associated Urinary Tract Infections dated [DATE] reflected, "...d. Indwelling catheters should be properly secured after insertion to prevent movement and urethral traction....collecting bags should always be kept below the level of the bladder." According to <http://www.emedicine.com/med/topic3176.htm> retrieved on [DATE], "In spite of its apparent advantages, the use of a Foley catheter for a prolonged period of time (eg, months to years) is strongly discouraged. Chronic dependence on these catheters is extremely risky because long-term use of urethral catheters poses significant health hazards. Indwelling urethral catheters are a significant cause of urinary tract infections that involve the urethra, bladder, and kidneys. Within ,[DATE] weeks after catheter insertion, bacteria will be present in the bladder of most women. Asymptomatic bacterial colonization is common and does not pose a health hazard. However, untreated symptomatic urinary tract infections may lead to urosepsis and death. The death rate of nursing home residents with urethral catheters has been found to be 3 times higher than that of residents without catheters; this may be more a reflection of the severity of comorbid conditions that lead to the clinical decision to use chronic bladder drainage than causation from the use of chronic bladder drainage. " 11) A review of the facility's current policy entitled Urinary Catheter Management, origination date [DATE], revealed, "... 2. Use a catheter-anchoring device such as a catheter strap or adhesive device to prevent tension on the catheter and dislodgement of the catheter, thus minimizing urethral bladder friction and trauma. The catheter-anchoring device should be on the same side of the body as the drainage bag. 3. Properly position drainage bag and tubing below the level of the bladder and in a dependent position to facilitate flow of urine... 7. Provide perineal/catheter care with a perineal cleanser or mild soap and water at least once daily and promptly after fecal soiling to reduce the potential for bacterial contamination. Fecal matter should be cleansed away from the urethral meatus.... 10. Indwelling catheters do not need to be changed routinely. Frequency of change shall be based on the resident's individual assessment of factors such as rate of encrustation, occurrence of obstruction, leakage, or other complications; catheters may be changed more or less than every 30 days... 11. Monitor for potential catheter complications and provide appropriate nursing interventions to resolve the problem and/or change catheter if indicated... 12. Recognize the signs and symptoms of asymptomatic UTI... 13. For a suspected UTI, remove current catheter and insert a new catheter... 14. Treat symptomatic UTIs only...Monitor and ensure that proper perineal and catheter care is provided. Monitor and ensure the catheter drainage system is properly maintained...." 12) The ADM was notified on [DATE] at 7:17 p.m. that the IJ situation was removed on [DATE]. The facility remained out of compliance at a scope of "pattern" and severity level of "actual harm that is not Immediate Jeopardy" because the facility was still monitoring the Plan of Removal. 13) Review of the Resident Census and Condition of Residents dated [DATE] and signed by the DON revealed the following: total residents with indwelling or external catheter were 13; and total residents receiving antibiotics were 18.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for three (Residents #11, #12 and #13) of three residents observed during the provision of wound care and reviewed for pain management. Resident #13 was stiffening and pulling away from LVN H every time she touched the resident when providing wound care. LVN H stated the resident was having pain and requested the nurse to give the resident pain medication. The medication was not administered until after the dressing change was completed. Resident #11 was grimacing and shaking her head back and forth as LVN H removed the dressing from her arm, pulling the resident's skin off with the dressing. When finished, LVN H told the resident's nurse to give the resident some pain medication. Resident #12 was tense and turned to watch LVN H when she was packing his wound during the dressing change. Resident #12 said it was painful when his dressing was changed. Residents #11, #12, and #13 experienced unnecessary pain and suffering during wound treatments, which could affect any of the 14 additional residents, who received wound care from LVN H, and placed them all at risk for sleep disturbances, depression, fear, increased blood pressure, withdrawal from activities or relationships, changes in mood/emotions, a decrease in physical activity, increased respirations and an increased demand for oxygen by the body's vital organs. Findings included: 1) Resident #13, according to a face sheet dated 08/03/10, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]." A care plan for Resident #13 initiated 08/20/10 and updated 11/12/10 and 02/10/11 revealed the following: "Problem - Resident complaints of increased pain. Staff to monitor facial expressions due to pt. (patient) being semi comatose. Approach - 1. Monitor for s/s (signs and symptoms) of increased pain/ discomfort - assess resident for possible causes, give meds, tx's (treatments), physical and relaxation modalities, etc - assess for relief...." A progress note by the wound care physician dated 02/17/11 reflected the resident had pain in the wound area and a Stage IV Sacral Wound (A Stage IV wound extends through the skin and involves underlying muscle, tendons and bone.) Resident #13's MDS assessment dated [DATE] reflected the resident was in a persistent vegetative state. A Pain assessment dated [DATE] for Resident #13 revealed the following: "Onset of pain > 3 mos (months), pain intensity 7 out of 10, ( Resident #13 has experienced due to pain) Withdrawal from activities or relationships and a decrease in physical activity." On 03/01/11 at 10:45 AM, LVN H, CNA J and RN K were observed providing wound care to Resident #13. Resident #13 was ventilator-dependent. The resident was turned to his right side to reveal a wound vac applied to a large sacral wound. LVN H removed the wound vac and placed her fingers into the resident's wound to remove foam material. At this point, the resident was observed to stiffen and pull away from her. When LVN H was asked, she confirmed the resident was pulling away from her, and she asked RN K to ask the resident's nurse for pain medication. RN K left the room and LVN H continued with the wound care treatment despite the resident's response. CNA J stated to LVN H, "That's hurting him. He needs a pain pill. Everything you touch on him. He makes a face." When LVN H had completed the dressing change and had repositioned the resident, the nurse returned to Resident #13's room with the pain medication. However, she did not administer the medication and left the room. She later returned to administer the medication. 2) Resident #11, according to a face sheet dated 03/10/11, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]." On 02/28/11 at approximately 11:00 AM, LVN H and CNA I were observed providing wound care to Resident #11. The resident was ventilator-dependent. Resident # 11 was turned to her side for the treatment to her coccyx wound. When the resident was turned onto her back, LVN H noted blood on the dressing covering skin tears (Skin tears are traumatic wounds that result from a separation of the two major layers of human skin, the epidermis and the dermis) on Resident #11's right arm. LVN H stated she would not normally change the dressings on the resident's arm, because the charge nurse would be responsible for skin tears. However, LVN H began to remove the dressing on the wounds. As she removed the dressings, the resident, who had been laying with her eyes closed, began to grimace and turned her head back and forth as if she were saying, "No." LVN H and CNA I were asked by the surveyor if they thought Resident #11 was hurting. CNA I responded, "Yeah. She looks like it." LVN H did not respond, but continued to remove the dressing. As Resident #11 continued shaking her head back and forth, LVN H then stated, "Ok mama. I'm sorry. We're still taking your skin off." When the dressing was removed, Resident #11's arm was observed with five large skin tears, the largest measuring four inches long. As LVN H cleaned the wounds, Resident #11 continued to shake her head back and forth. The surveyor then asked LVN H and CNA I what they thought her shaking her head meant. CNA I stated, "She's probably in pain." LVN H responded by saying to the resident, "I'm almost through." As LVN H re-dressed the wounds, she made the comment she would see if she could get vaseline gauze ordered for the resident, because the dressings were pulling her skin off when they were removed. When LVN H left Resident #11's room, she approached the charge nurse and asked her to give Resident #11 something for pain. 3) Resident # 12, according to a face sheet dated 02/17/11, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #12's Physician orders [REDACTED]. APAP ([MEDICATION NAME]) 650 mg per peg tube every 4 hours as needed for pain." A Weekly Pressure Ulcer Log dated 02/16/11 reflected Resident #12's pressure ulcer was a Stage III pressure ulcer located on the coccyx. (A Stage III pressure ulcer has full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.) On 03/01/11 at 10:20 AM, LVN H and CNA I were observed providing wound care to Resident #12. The resident was ventilator-dependent. Resident #12 was turned on his left side for the treatment, and his face was not visible to the nurse or the surveyor. The resident was observed to tense up and turn his head toward LVN H when she packed his wound. LVN H said, "OK. I'm sorry." On 03/01/11 at 2:30 PM, Resident #12 was asked if it was painful when his dressing was changed, and the resident nodded his head, "Yes." A pain assessment for Resident #12 dated 03/02/11 reflected the following, "Onset of pain 10/11/10, pain intensity 5 out of 10, (Resident #12 experienced the following due to pain:) Withdrawal from activities or relationships, changes in mood. emotions, and a decrease in physical activity." 4) On 03/01/11 at 12:51 PM, LVN H was interviewed. She stated she did 35 dressing changes a day and worked throughout the entire building treating residents with Stage II, III and Stage IV wounds. She was asked if she felt Residents #11, #12 and #13 was in pain during his dressing changes. She agreed they were having pain. She specifically addressed Resident #13 and stated she would have rated his pain at a six or seven on a 1 -10 scale. LVN H was asked about providing pre-treatment pain medications for residents. LVN H stated, "If they have an order for [REDACTED]. 3) Review of the facility's current policy entitled "Pain Management" dated February 2009 revealed the following: "Residents who have pain symptoms or who have the potential for pain shall be appropriately monitored, receive treatment for [REDACTED]. Staff will: Recognize when the residents are experiencing pain and be able to identify circumstances when pain can be anticipated. Evaluate pain and it's cause(s); and Manage and /or prevent pain. ...In addition, pain may be anticipated during specific procedures, care, or treatment. It is important that residents be monitored for the presence of pain and be evaluated when there are circumstances when pain can be anticipated. ...Incident pain refers to pain that is typically predictable and is related to an event such as movement or certain actions (e.g. ...wound care) ...Any resident experiencing pain should be immediately reviewed and offered treatment...." 4) A Resident List Report dated 02/28/11 reflected Hall 400 had 42 residents. 5) A Weekly Pressure Ulcer Log dated 02/23/11 reflected 17 residents received wound care from LVN H.