Every finding on record at Ambrosio Guillen Texas State Veterans Home

Based on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 14 residents (Resident #63, Resident #65, and Resident #148) reviewed for ADL care.- The facility failed on 04/2026 to ensure Resident #63's, Resident #65's and Resident #148's fingernails were clean and trimmed.This failure could place residents who required assistance with ADLs at risk for unmet care needs.Findings include: Resident #63 Record review of Resident #63's admission Sheet dated 04/08/26 revealed a [AGE] year-old male with admission date 07/31/2020. Record review of Resident #63's Health and Physical dated 03/13/26 revealed a medical history of Congestive Heart Failure (the heart becomes unable to pump efficiently to meet the body's needs), and Muscle Weakness. Record review of Resident #63's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating Resident #63 were cognitively intact. Under Section GG-Functional Abilities, it was noted Resident #63 was dependent with personal hygiene, meaning the helper does all the effort and the resident does none of the effort, to complete the task. Record review of Resident #63's Care Plan with revision date 10/01/25 revealed Resident #63 was ADL (Activities of Daily Living) self-care performance deficit. Staff interventions stated Resident #63 was totally dependent on 2 staff assistance with personal hygiene. In an observation on 04/07/26 at 9:29 AM, Resident #63 was observed with long nails measuring quarter of an inch past the finger tips on both hands. Resident #63 stated he would like to have them trimmed, and he had not had his nails trimmed in 1 month. Resident #65 Record review of Resident #65's admission Sheet dated 04/09/26 revealed a [AGE] year-old male with admission date 02/07/2022. Record review of Resident #65's Health and Physical dated 02/03/26 revealed a medical history of Cerebral Infarction (Stroke), and Type II Diabetes Mellitus (a chronic condition affecting the body's ability to make insulin and control blood sugar levels). Record review of Resident #65's Comprehensive MDS dated [DATE] revealed a BIMS score of 14, indicating the resident was cognitively intact. Under Section GG- Functional Abilities, it was noted that Resident #65 required substantial/maximal assistance with personal hygiene. This meant the helper does more than half the effort to complete the task. Record review of Resident #63's Care plan with revision date 10/20/25 revealed Resident #63 had an ADL self-care performance deficit. Staff interventions noted Resident #63 was dependent on 2 staff to assist with personal hygiene. In an observation on 04/07/26 at 2:06 PM, Resident #65 was observed with long nails approximately a quarter of an inch long, past his fingertips, to his left hand. He was observed with a left-hand contracture (meaning the skin of the palm of the hand thickens causing the fingers to curl). He stated he would like to have his nails trimmed and was unable to recall last time his nails were trimmed. Resident #148 Record review of Resident #148's admission record revealed an [AGE] year-old male with an admission date on 10/17/2024. Record review of Resident #148's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15 with the significance being the resident was cognitively intact. Under section GG for functional abilities of self-care the resident was coded for being substantial/maximal assistance required for personal hygiene. Under Section I active diagnoses, the resident was coded for Diabetes mellitus (chronic metabolic disorder characterized by high blood sugar resulting from inadequate insulin production) and cerebrovascular disease (includes conditions that affect blood flow to the brain, such as stroke). Record review of the Resident #148's care plan dated 04/09/2026 had a focus area for ADL self-care performance with intervention of 1 person assist for personal hygiene. During an interview and observation on 04/08/2026 at 8:33 AM with Resident #148, he stated he wanted his nails cut but had to wait a long time for service because only the nurse could cut his nails due to his diabetes diagnosis. He stated he had asked last week but did not have his request fulfilled. He stated that his contracted right-hand nails were longer. Observation of Resident #148's right hand nails revealed to be 1 inch longer left hand nails. During an interview on 04/09/2026 at 11:10 AM CNA D stated her responsibilities were to assist residents with adjustments, transfers, incontinent changes, change clothes, hygiene, nail trimming, and brushing teeth/hair. She stated that if a resident was diabetic the nurse needed to cut the resident's nails but CNAs could use the nail file for residents who were diabetic. She stated if a resident notified her that they wanted their nails trimmed but were diabetic she would notify the nurse promptly to have the services provided. She stated she would follow-up with the resident to see if it was completed. She stated that long nails affected the resident because they could not get the services they needed. She stated that a resident with limited range of motion needed assistance for nail trimming. She stated she did not remember the last in-service she received for nail cutting or nail filing. During an interview on 04/09/2026 at 11:38 AM LVN G she stated the Nurse and CNA could provide nail trimming services to residents. She stated that the nurse needed to observe or provide it if there was a skin integrity issue. She stated that the CNAs could not trim or file nails if a resident was diabetic. She stated that any nurse RN or LVN could cut the nails and needed to further monitor for infections or bleeding that could be exacerbated by the diabetic diagnosis. She stated that a CNA needed to notify her immediately if a resident wanted their nails cut and the nurse would follow up immediately as well. She stated there was only one resident she was aware of who could be resistant for ADL care and added the other residents in her hall were receptive of the services. She stated that a resident with long fingernails could scratch themselves, cause infection, and could be left without the services they were asking for. She stated that nail care was routinely conducted on Sundays for residents with diabetic diagnosis and as needed. She stated the nurse was responsible for ensuring the residents' nails were trimmed. She stated the last in-service she received for ADLs and nail cutting March 2026. During an interview on 04/09/2026 at 2:41 PM the DON she stated that nail care could be provided by CNAs and nurses. She stated that if a resident was diabetic then the nurses needed to complete it. She stated that the CNA should notify the nurse as soon as feasible if a resident with diabetes wanted their nails trimmed. She stated that it was a hygiene issue. She stated there was a concern for compromising skin integrity and infection for long nails. She stated that the CNAs observed residents' nails on Sunday as a scheduled routine and for those that were diabetic the nurse would provide that care. She stated that the nurse was responsible for ensuring nail care was provided to the resident. She stated the last in-service/training staff received in November 2025 for ADL assistance. Record review of the facility's Nail Care (Fingernails/Toenails) Policy, revised on 09/02/25, revealed in part: Purpose: Nail care will be provided to resident, with diabetic residents referred to the licensed nurse or podiatrist.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage. -The facility failed on 04/07/2026 to ensure leftover food was properly covered and sealed in the walk-in refrigerator.-The facility failed on 04/07/2026 to ensure dietary staff maintained proper hygiene, as evidenced by a torn hairnet that allowed hair exposure during meal handling.-The facility failed on 04/07/2026 to ensure dietary staff practiced hand hygiene and glove changes per the facility policy after their hands became contaminated. These failures had the potential to place all residents who received meals from the kitchen at risk for foodborne illness due to improper food storage and handling practices. Findings included: In an observation and interview on 04/07/2026 at 8:36 a.m. with the Dietary Director, revealed a zip top bag containing boiled eggs was observed open and not properly sealedinside the walk-in refrigerator; the bag had a date of 04/06/2026. Adjacent to the refrigerator door, revealed on a metal rack, a plastic container holding fruit salad was also observed unsealed; the plastic wrapping covering the container had a visible opening at one corner, leaving the contents exposed. The Dietary Director stated that both the zip top bag containing boiled eggs and the plastic container with fruit salad had not been properly sealed. The Dietary Director stated that storing food in an unsealed condition inside the refrigerator increased the risk of contamination, including potential exposure to insects and other environmental factors such as frost bite. The Dietary Director stated that such practices could result in food spoilage and, if served to residents, posed a risk of gastrointestinal illness, including symptoms such as diarrhea and vomiting. In a follow-up interview on 04/09/2026 at 4:29 PM, the Dietary Director stated that the proper prevention for cross contamination included staff wearing gloves, utilizing hairnets, and practicing hand hygiene. The Dietary Director stated that staff needed to change their gloves whenever they touched something that wasn't food or in the serving process. The Dietary Director stated that staff needed to practice hand hygiene and change their gloves if they were to touch the door handle and before resuming meal service. The Dietary Director stated it was cross contamination that could potentially make the resident sick. During an observation and interview on 04/07/2026 at 11:38 a.m., LVN A was observed inside the kitchen handling meal trays that were scheduled for distribution to residents during lunch service. LVN A was noted to be wearing a torn hairnet, which left his hair exposed on the right side of his head. The Dietary Director stated that all personnel entering the kitchen were required to wear appropriate hair restraints, including hairnets and beard guards when applicable. The Dietary Director stated that the use of a torn hairnet compromised infection control standards, as it increased the likelihood of hair falling into food, potentially contaminating meal trays. The Dietary Director stated that if contaminated food were consumed by residents, it could result in gastrointestinal illness, including symptoms such as diarrhea and vomiting, and could also present a choking hazard. During an interview on 04/07/2026 at 11:59 a.m. with LVN A, he stated he was responsible for verifying meal tickets on residents' trays to ensure accuracy of diet orders and consistency requirements. LVN A stated he had been informed by the Dietary Manager that his hairnet was torn and that his hair was exposed. LVN A stated that wearing a torn hairnet inside the kitchen environment was not acceptable, as it increased the risk of hair falling into residents' meals, which could lead to contamination. LVN A stated that such contamination could potentially cause residents to become ill with gastrointestinal symptoms and could also pose a choking risk. During an observation on 04/07/2026 at 11:53 AM in the memory unit dining room during meal service, the Dietary staff was observed exiting and reentering into the kitchen three times while wearing serving gloves. Dietary Staff did not practice hand hygiene before reentering the meal serving area. The Dietary staff was observed grabbing bread rolls with gloves contaminated by door handle and touching surfaces outside of the food service area for approximately 20 residents who were served in the memory unit side. During an interview on 04/09/2026 at 10:00 a.m. with the ADD, she stated that leftover food posed a risk when not properly sealed, as exposure could allow insects to come into contact with items such as the boiled eggs or other stored foods, leading to contamination. The ADD stated there was also a risk of cross-contamination when food remained open. The ADD stated that if residents consumed contaminated food, it could result in gastrointestinal illness, including diarrhea or vomiting, which could further lead to dehydration and exacerbate existing health conditions. Regarding hair restraints, ADD stated that all individuals entering the kitchen were required to wear hairnets and beard guards as applicable. She explained that hairnets served as a preventive measure to minimize the risk of hair falling into food, which could otherwise result in contamination and potentially cause residents to become ill. During an interview on 04/09/2026 at 10:27 a.m. with the Administrator, he stated that all staff entering the kitchen were expected to wear appropriate hair restraints, including hairnets and beard guards, when necessary, to maintain infection control standards. The Administrator stated that the purpose of these measures was to prevent hair from entering food and compromising cleanliness and safety within the kitchen environment. The Administrator stated that failure to utilize PPE could lead to contamination and increase the risk of residents developing gastrointestinal symptoms. The Administrator stated that while all staff shared responsibility for adhering to these practices, the Dietary Manager was responsible for ensuring compliance. Regarding left over food, the Administrator stated that all food items were required to be properly sealed and stored to prevent spoilage, maintain quality, and avoid contamination. He stated that if exposed or improperly stored food were served, it could result in illness or reduced palatability for residents. In a follow-up interview on 04/09/2026 at 4:35 PM he stated the facility used hand hygiene and glove changing as needed during meal service. The Administrator stated that when staff touched something that wasn't food like a door handle hand hygiene needed to be adhered to. The Administrator stated that they needed to remove gloves, practice hand hygiene, and reapply gloves when touching an unclean surface. The Administrator stated that Dietary Manager and Assistant Dietary Manager were responsible for overseeing the dietary staff and ensuring hand hygiene protocol was followed. The Administrator stated that the food could be contaminated, spread germs, and the resident could feel ill or sick from eating cross-contaminated foods. During an interview on 04/09/2026 at 10:42 a.m. with the DON, she stated that hairnets were considered part of infection control practices and were used to prevent cross-contamination during food preparation. The DON stated that if hair were to fall into food, it could compromise the integrity of the meal and potentially result in residents experiencing gastrointestinal illness, including symptoms such as vomiting or diarrhea. The DON stated that leftover food was required to be adequately covered and stored to prevent bacterial growth and spoilage. She indicated that failure to properly store food could lead to contamination and increase the likelihood of residents developing infections or becoming ill after consumption. During an interview on 04/09/2026 at 11:41 a.m. with the Cook, she stated that hairnets were utilized to maintain hygiene and reduce the risk of contamination during food preparation. She explained that if hair were to fall into prepared meals, it could contaminate the food and present both a choking hazard and a risk of illness for residents. The [NAME] stated that leftover food needed to be cooled to appropriate temperatures, properly sealed, labeled, and dated to ensure safety and quality. The cook stated that failure to store food correctly could result in spoilage or bacterial growth, and if such food were served to residents, it could lead to gastrointestinal illness and other health complications. During an interview on 04/09/2026 at 12:31 PM the Dietary Staff stated that hairnets needed to be worn all the time in the kitchen. He stated beard guards need to be worn, and nursing staff needed to wear a hair net whenever they entered the kitchen. He stated that there were hairnets by the entry that staff could use and apply at any time before entering the kitchen. He stated he would tell the staff member to exit and reapply the hairnet before entering. He stated that there was potential for loose hair to get in the cooking/serving area which would contaminate the food. He stated that it was all Dietary departments' responsibility to prevent cross contamination but the dietary director's responsibility to ensure it was completed. He stated the last in-service was in February 2026. He stated he was grabbing the bread rolls with a gloved hand. He stated he did not practice hand hygiene or change gloves and continued serving bread after all exits and reentries into the meal serving area. He stated he went into the room to access the warmer for food and plates. He stated he should have removed gloves, practiced hand hygiene and applied new gloves before resuming work. He stated this needed to be done to prevent cross contamination. He stated that the residents were affected if it was not adhered to. He stated that last time he received hand hygiene training was in February 2026. He stated the process of washing hands was to wash hands for 20 seconds front and back and exposed wrist and turn off the faucet with the paper towel. Record review of the facility's policies and procedures titled Policy and Procedure Manual, Chapter 3: Food Production and Food Safety, dated 2023, revealed in part: 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2022 Federal Food Code. (Also see policy on Use of Leftovers later in this chapter.) Check state regulations as some states may allow shorter time frames for the use of leftovers. f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. Record review of the facility's policies and procedures titled Policy and Procedure Manual, Chapter 4: Employee Hygiene for Food Safety, revealed in part: Policy: All food and nutrition services employees will practice good personal hygiene and safe food handling procedures. Procedure: 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. Record review of the facility's policy and procedure titled policy and procedure manual bare hand contact with food and use of plastic gloves revealed in part: Single use gloves or other barriers will be used when handling food directly with hands to assure that bacteria are not transferred from the food handles hands to the food product being served .Single use gloves shall be used for only one task such as working with ready to eat food or with raw animal food, used for no other purpose and discarded when damaged, or soiled, or when interruptions occur in the operations Hands are to be washed when entering the kitchen before putting on the single use gloves Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed and hands must be washed

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident; and failed to have an established system in place for accurate reconciliation for 1 (East wing) of 2 medication carts that had residents with orders for controlled substances.The facility failed to ensure LVN C signed the form after counting and verifying that all controlled substances in the medication cart had been accounted for with the Controlled Medication Accountability Record on 04/09/26.The facility failed to ensure Resident #157's Lidocaine Patch was removed per Physician's Order.This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances.Findings include:Record review of Resident #157's admission date 04/09/26 revealed an [AGE] year-old male resident with admission date 09/16/25.Record review of Resident #157's Health and Physical dated 03/31/26 revealed a medical history of Rheumatoid Arthritis (chronic condition of inflammation of the joints causing stiffness and pain).Record review of Resident #157's Quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating Resident #157 was cognitively intact. Record review of Resident #157's care plan last revised 01/22/26, revealed the resident was at risk for alteration of comfort/pain related to arthritis. The staff interventions included to administer medications as ordered.Record review of Resident #157's medication order revealed: Lidocaine External Patch 4% Apply to Affected area topically in the morning for pain and remove per schedule with start date 01/20/26.Record review of Resident #157's Medication Administration Record for April 2026, dated 04/09/26, revealed the medication order: Lidocaine External Patch 4% Apply to Affected area topically in the morning for pain and remove per schedule with start date 01/20/26, with Administration Time at 08:00 AM, and Removal at 08:00 PM. The Lidocaine External Patch 4% was marked as removed on 04/08/26 at 08:00 PM by LVN J.An observation was made on 04/09/26 at 08:30 AM of LVN H removing the Lidocaine Patch from Resident #157's right shoulder that was dated 04/08/26. LVN C then administered a new Lidocaine patch dated 04/09/26 to Resident #157's right shoulder. Resident #157 was assessed for pain by LVN H, which Resident #157 denied. The skin of the right shoulder was observed to be free of redness or inflammation.In an review and interview on 04/09/26 at 11:20 AM of the Controlled Medication Accountability Record with LVN C, it revealed she failed to sign the record when she started her shift. She stated nurses were supposed to sign the Controlled Medication Accountability Record at the beginning of the shift, but she did not because she usually did it in the middle of her shift. She stated she did that in case she received more medications that needed to be accounted for during her shift.In an interview on 04/09/26 at 11:20 AM with LVN H, he stated Resident #157's Lidocaine patch was to be removed at night per the physician's order. He stated the nurse that signed off on the Medication Administration Record was responsible for removing the patch per physician's order. He stated the potential risk of not following the physician's order, such as not removing the lidocaine patch, including possible skin irritation for a resident.In a follow up interview on 04/09/26 at 2:20 PM with LVN C, she stated nurses that were incoming onto the shift were responsible for signing the Controlled Medication Accountability Record. She stated the purpose for signing when coming onto the shift was to confirm the count and accuracy of the narcotic medications. She stated the potential risk of not signing per policy included residents not obtaining their medications. She stated nursing supervisors did random checks of the narcotic books daily. LVN C stated the nurse on shift administering or removing the medication was responsible for following the physician's orders. She stated the DON monitored nurses' medication administration compliance once a week. She stated the potential risk for residents having a topical medication longer than the physician's order included skin irritation.In an interview on 04/09/26 at 2:37 PM with LVN E, she stated the nurses coming onto shift were responsible for signing the Controlled Medication Accountability Record after they finished counting the narcotic medications at the beginning of the shift. She stated nurses were to sign their name and date after confirming medication count. She stated the nursing supervisors reviewed and monitored the narcotic book and logs every shift. She stated the potential risk of nurses not signing the Controlled Medication Accountability Record included residents having limited medication availability for residents which could depend on the medications of the residents.In an interview on 04/09/26 at 3:38 PM with the DON, she stated nurses were responsible for following physician orders. She stated if nurses were to report any concerns regarding medications including a topical medication patch not being removed per physician order. She stated there was no monitoring system in place, but Supervisors were notified of any concerns and the Supervisors or self as the DON, would follow up. She stated she did not believe there was potential risk to the resident since the Lidocaine Patch was removed within 24 hours. The DON stated the pharmacy nurse completed a comprehensive review of the facility's medication carts monthly including the narcotic books. She stated the potential risk of not signing the narcotic books per policy included drug diversion.Record review of the facility's policy Medication Administration with revision date 07/01/26, revealed in part: Purpose: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on observation, interview and record review, the facility failed to review and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #24) reviewed for care plan accuracy. -The facility failed to have a comprehensive person-centered care plan for Resident #24 that was completed within the previous 3 months.These failures could affect residents and put them at risk of not receiving care and services to meet their needs.Findings include:Resident #24Record review of Resident #24's admission record dated 04/09/2026 revealed an [AGE] year-old male with an original admission date on 04/05/2021 and readmission on [DATE]. Record review of Resident #24's annual MDS dated [DATE] revealed the resident had a BIMS score of 09 with the significance being the resident had mild cognitive impairment. Under section I the resident had an active diagnosis for dementia (irreversible neurodegenerative disease characterized by cognitive decline, memory loss, and behavioral changes), depression (serious mental health disorder characterized by persistent sadness, loss of interest in activities, and reduced energy) and other symptoms and signs with cognitive functions and awareness (referring to non-specific issues like memory lapses, confusion, poor concentration, and altered awareness). Record review of Resident #24's Physical and Health dated 04/02/2026 revealed the resident had been complaining about his POA guardian not giving him enough money. Record review of Resident #24's published care plan dated 07/2025 with a target completion date of 10/23/2025 revealed the resident had a focus area for being at risk for increased confusion and disorientation related to diagnosis of dementia with specific behavior listed as, asking staff to take him to border city in neighboring country resident is bribing staff to take him to border city with anything they want including money. Additionally, the resident had a focus area to address diagnosis of major depressive disorder with intervention to observe for change in mental status. During an interview and observation on 04/07/2026 at 2:05 PM revealed Resident #24 was continuously fixated on his money, family member, and spouse in Mexico. Resident #24 was observed expressing signs of restlessness, difficulty regulating emotions, and frustration. Follow-up interviews and observations completed on 04/08/2026 at 9:57 AM and 04/09/2026 at 11:17 AM revealed Resident #24 was still fixated on recent stressors. During an over the phone interview on 04/08/2026 at 12:09 PM with Resident #24's guardian, he stated he had not participated in a care plan for Resident #24 within the 4 months of guardianship and had not been contacted by the facility to schedule a future care plan meeting. During an interview on 04/09/2026 at 11:47 AM LVN G stated that care plans needed to be updated when there was a change in condition, dietary changes, and change in behaviors. She stated whenever a significant finding or event occurred the care plan needed to be updated immediately. She stated that a care plan that was last completed October 2025 was not up to date. She identified the care plan team was comprised of the DON, Social Worker, Administrator, and nursing supervisors. She stated she has a floor nurse did not directly participate in the care plan meetings. During an interview on 04/09/2026 at 2:03 PM the Social Worker stated the IDT was comprised of nursing (MDS), the activities department, and dietary department. He stated that the care plan needed to be updated quarterly, on admission, and change of condition. He stated that the facility had a corporate facilitator who would be providing a care plan meeting within the coming weeks. He stated that Resident #24's care plan needed to be updated since July of 2025, since the target completion was scheduled for October 2025. He stated that care concerns could arise, and appropriate care could not be provided if the care plan was not updated or accurate. He added that care might not be continued because there were other issues that were not being updated. During an interview on 04/09/2026 at 2:56 PM the DON stated that MDS developed the care plan and there were 2 individuals who managed the care plans for all the residents within the facility. She stated that care plans were updated when there was a fall, standards of care (gastro tubes [a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications when oral intake is not possible], Foley catheter [a flexible, indwelling tube inserted through the urethra into the bladder to drain urine], transmission based precautions) once a week as needed. She added that care plans and MDSs were routinely completed quarterly, when a significant change occurred, on admission, discharge, and readmission. She stated that a resident's care plan not being updated since July (2025) would not meet the expectations of the facility. She stated that MDS was responsible for ensuring care plans were accurate, comprehensive, and updated. She identified social services, dietary, and the activities departments were individuals who participated in the development of care plan. She stated there could be potential missing pieces for comprehensive care of the residents and a potential failure to meet their needs. She stated the Administrator had documentation for training with MDS for care plans. She stated she suspected it had been completed in January 2026. Record review of the facility's Care Plans (Comprehensive) Policy dated 06/2019, revealed in part: Purpose: To develop an interdisciplinary resident centered comprehensive care plan to meet the individual needs of each resident. Under Policy Explanation and Compliance Guidelines, it continued: 1. An interdisciplinary team develops and maintains a comprehensive care plan for each resident. 2. The comprehensive care plan has been designed to: a. Identify care needs that include resident's strengths, history, and preferences; b. Incorporate risk factors. 3. The resident's comprehensive care plan is developed within seven (7) days after the completion of the MDS assessment. New residents will have a comprehensive care plan within seven (7) days after the completion of the MDS assessment, not to exceed twenty-one (21) days from the date of admission. a. Care plans are revised as changes are indicated.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 2 of 6 residents (Resident #14 and Resident #24) reviewed for dementia care.-The facility failed to have a comprehensive person-centered care plan for Resident #14 by not including a diagnosis and focus area for dementia and dialysis diagnosis.-The facility failed to have a comprehensive person-centered care plan for Resident #24 that was completed within the previous 3 months.These failures could affect residents and put them at risk of not receiving care and services to meet their needs.Findings include: Resident #14 Record review of Resident #14's admission record dated 04/08/26 revealed an admission date 10/06/2020. Resident #14's Primary Diagnosis was noted as Unspecified Dementia, mild. Record review of Resident #14's Quarterly MDS dated [DATE] revealed Resident #14 was unable to participate in a BIMS. Under Section I, Resident #14 was noted to have Non-Alzheimer's Dementia (the loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform their usual personal, social, or occupational activities). Record review of Resident #14's Health and Physical dated 03/23/26 revealed a medical history of dementia under date of service 02/10/26. Record review of Resident #14's care plan last revised 03/17/2026, revealed Dementia was not included. Resident #24 Record review of Resident #24's admission record dated 04/09/2026 revealed an [AGE] year-old male with an original admission date on 04/05/2021 and readmission on [DATE]. Record review of Resident #24's annual MDS dated [DATE] revealed the resident had a BIMS score of 09 with the significance being the resident had mild cognitive impairment. Under section I the resident had an active diagnosis for dementia (irreversible neurodegenerative disease characterized by cognitive decline, memory loss, and behavioral changes), depression (serious mental health disorder characterized by persistent sadness, loss of interest in activities, and reduced energy) and other symptoms and signs with cognitive functions and awareness (referring to non-specific issues like memory lapses, confusion, poor concentration, and altered awareness). Record review of Resident #24's Physical and Health dated 04/02/2026 revealed the resident had been complaining about his POA guardian not giving him enough money. Record review of Resident #24's published care plan dated 07/2025 with a target completion date of 10/23/2025 revealed the resident had a focus area for being at risk for increased confusion and disorientation related to diagnosis of dementia with specific behavior listed as, asking staff to take him to border city in neighboring country resident is bribing staff to take him to border city with anything they want including money. Additionally, the resident had a focus area to address diagnosis of major depressive disorder with intervention to observe for change in mental status. During an interview and observation on 04/07/2026 at 2:05 PM revealed Resident #24 was continuously fixated on his money, family member, and spouse in Mexico. Resident #24 was observed expressing signs of restlessness, difficulty regulating emotions, and frustration. Follow-up interviews and observations completed on 04/08/2026 at 9:57 AM and 04/09/2026 at 11:17 AM revealed Resident #24 was still fixated on recent stressors. During an over the phone interview on 04/08/2026 at 12:09 PM with Resident #24's guardian, he stated he had not participated in a care plan for Resident #24 within the 4 months of guardianship and had not been contacted by the facility to schedule a future care plan meeting. During an interview on 04/09/2026 at 11:47 AM LVN G stated that care plans needed to be updated when there was a change in condition, dietary changes, and change in behaviors. She stated whenever a significant finding or event occurred the care plan needed to be updated immediately. She stated that a care plan that was last completed October 2025 was not up to date. She identified the care plan team was comprised of the DON, Social Worker, Administrator, and nursing supervisors. She stated she has a floor nurse did not directly participate in the care plan meetings. During an interview on 04/09/2026 at 2:03 PM the Social Worker stated the IDT was comprised of nursing (MDS), the activities department, and dietary department. He stated that the care plan needed to be updated quarterly, on admission, and change of condition. He stated that the facility had a corporate facilitator who would be providing a care plan meeting within the coming weeks. He stated that Resident #24's care plan needed to be updated since July of 2025, since the target completion was scheduled for October 2025. He stated that a resident who was missing a dialysis diagnosis needed to be care planned. He stated that care concerns could arise, and appropriate care could not be provided if the care plan was not updated or accurate. He added that care might not be continued because there were other issues that were not being updated. During an interview on 04/09/2026 at 2:56 PM the DON stated that MDS developed the care plan and there were 2 individuals who managed the care plans for all the residents within the facility. She stated that care plans were updated when there was a fall, standards of care (gastro tubes [a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications when oral intake is not possible], Foley catheter [a flexible, indwelling tube inserted through the urethra into the bladder to drain urine], transmission based precautions) once a week as needed. She added that care plans and MDSs were routinely completed quarterly, when a significant change occurred, on admission, discharge, and readmission. She stated that a resident's care plan not being updated since July (2025) would not meet the expectations of the facility. She stated that if a resident's care plan was missing a dementia diagnosis, then the facility could not create a plan of care. She stated the facility would not be able to address the behaviors and implications of dementia. She stated the care plan would signify to the care team what their needs were for the dialysis diagnosis. She stated that MDS was responsible for ensuring care plans were accurate, comprehensive, and updated. She identified social services, dietary, and the activities departments were individuals who participated in the development of care plan. She stated there could be potential missing pieces for comprehensive care of the residents and a potential failure to meet their needs. She stated the Administrator had documentation for training with MDS for care plans. She stated she suspected it had been completed in January 2026. Record review of the facility's Care Plans (Comprehensive) Policy dated 06/2019, revealed in part: Purpose: To develop an interdisciplinary resident centered comprehensive care plan to meet the individual needs of each resident. Under Policy Explanation and Compliance Guidelines, it continued: 1. An interdisciplinary team develops and maintains a comprehensive care plan for each resident. 2. The comprehensive care plan has been designed to: a. Identify care needs that include resident's strengths, history, and preferences; b. Incorporate risk factors. 3. The resident's comprehensive care plan is developed within seven (7) days after the completion of the MDS assessment. New residents will have a comprehensive care plan within seven (7) days after the completion of the MDS assessment, not to exceed twenty-one (21) days from the date of admission. a. Care plans are revised as changes are indicated.

Based on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 8 residents reviewed for accommodation of needs. The facility failed to ensure resident call lights were within reach for Resident # 15 on 04/07/2026.This failure placed residents at risk of having their needs unmet when they were unable to contact staff.Findings included:Record review of Resident #15's admission record dated 04/09/2026 revealed and original admission date of 09/19/2025 and a readmission date of 09/25/2025.Record review of Resident #15's history and physical dated 03/03/2026 revealed a diagnosis of multiple sclerosis (a disease that causes breakdown of the protective covering of nerves).Record review of Resident #15's comprehensive MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive function. Section GG indicated Resident #15 was dependent with toileting and hygiene. It also indicated resident was dependent for bed mobilityRecord review of Resident #15's care plan revised on 03/23/2026 revealed Resident #15 was at risk for injury/ falls related to impaired mobility, general weakness related to multiple sclerosis. Intervention included keeping the call light within reach when in bed.An observation and interview on 04/07/2026 at 10:19 a.m., revealed Resident #15 was lying in bed, and the call light was behind the chair to the right of her bed. She stated that she did not know how the call bell got there, but that she could not reach it. she stated that she does use the call light to ask the staff for help.In an interview on 04/09/2026 at 1:53 p.m., with CNA B revealed that the purpose of a call light was for the residents to be able to call for assistance. She stated that it was usually clipped to their sheets where the resident could reach it. She stated that it was necessary to be kept within reach so that the resident could call for assistance when needed. She stated that if the call light was not within reach the resident could be at risk for needs not being met. She stated that it was the responsibility of the nurses and the CNAs to ensure that call lights were within reach.In an interview on 04/09/2026 at 2:05 PM with LVN C revealed that the purpose of a call light was so the residents could let staff know when they needed assistance. She stated that the call light should always be kept within reach to ensure residents get their needs met in a timely manner. She stated that if the call light was not within reach, the resident was at risk for falls. She stated that all staff were responsible for ensuring call lights were within reach at all times.In an interview on 04/09/2026 at 3:41 PM with the DON revealed that the purpose of the call light was for residents to be able to call staff for assistance. She stated that it was to be kept within reach to ensure residents had accessibility to ask for help. She stated that a risk of the call light not being readily accessible would be the residents' needs not being met. She stated that it was the responsibility of all staff to ensure call lights were within reach.In an interview on 04/09/2026 at 4:16 PM with the Administrator revealed that the purpose of the call light was for residents to signal for help, therefore it was to be kept within reach. The risk of the call light not being within reach was that the residents would not get the assistance needed. He stated that all staff were responsible for ensuring that the call light was within reach. Review of the facility policy titled Call Light System generated on 10/2019 revealed in part Staff will receive education related to the mechanism of the call light system and call light availability/ placement for the resident.

Based on observation, interview, and record review the facility failed to treat the resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 3 residents (Resident #127) reviewed for dignity. -The facility failed on 04/07/2026 to ensure Resident #127's Foley catheter bag had a privacy bag. The deficient practice could affect residents by contributing to poor self-esteem, dignity issues, and diminished quality of life.The findings include:Record review of Resident #127's face sheet dated 04/09/2026 revealed a [AGE] year-old male with an original admission date of 12/05/2025. Record review of Resident #127's physical and health dated 03/07/2025 revealed the resident was diagnosed with Alzheimer's dementia (irreversible neurodegenerative disease characterized by cognitive decline, memory loss, and behavioral changes), overactive bladder (uncontrollable urges to urinate and high frequency of urinating), benign prostatic hyperplasia without lower urinary tract symptoms (an incidentally found enlarged prostate that is not causing functional bladder issues or distress). Plan of care under physical and health revealed Resident #127 was to follow up with urologist and provide foley care. Record review of Resident #127's MDS dated [DATE] revealed under section C, a BIMS score of 3 the significance meaning he had severe cognitive impairment. Record review of Resident #127's care plan dated 12/18/2025 revealed the resident had a focus area related to disorientation from dementia. Interventions in place included to provide choices for the resident and assist with decision making.Record review of Resident #127's March 2026 MAR/TAR revealed the resident had an indwelling catheter with instruction to keep the Foley bag below the bladder and utilize a privacy bag in place.During an observation and interview attempt on 04/07/2026 at 3:01 PM, Resident #127 was observed in the common area watching TV while seated in his wheelchair and a clear Foley catheter bag exposed underneath his wheelchair without a privacy cover in place. Follow up observation completed at 4:07 PM, revealed the resident was still in the common area watching TV with his Foley catheter bag still exposed. Resident #127 was unable to participate in an interview due to dementia diagnosis and continuous confusion. In a follow up observation on 04/08/2026 at 9:42 AM revealed the Resident #127's clear Foley catheter bag was placed in a privacy bag suspended under his wheelchair. In an interview on 04/09/2026 at 11:20 AM CNA D stated that the privacy bag was used to hold the residents' Foley catheter bag when the resident was in their wheelchair. She stated that the purpose of the privacy bag was so that other residents could not see the urine output or color since Foley catheter bags were transparent. She stated that CNAs and nurses were responsible for ensuring residents had their Foley catheter bag in the privacy bag. She stated that residents in the memory care unit needed to have their Foley catheter bags covered as well. She stated it affected the resident by exposing the color and amount of urine the resident was releasing and was a dignity issue. She stated she could not remember the last training she received for dignity or resident rights. In an interview on 04/09/2026 at 1:18 PM LVN C stated that Foley catheter care included ensuring the catheter line was not backed up, kinked, off the floor, and a privacy bag was being utilized. She stated the privacy bags were white on the back and had a blue flap on the front. She stated that she did not know if there was another version of privacy bags the facility used for Foley catheter bags. She stated that the Foley catheter bag would receive a satchel with fabric strips for Foley catheter bags without hooks. She stated that the privacy flap on the Foley catheter bag provided privacy to the residents who had an indwelling catheter in place. She stated the Foley b catheter ag needed to be covered for the privacy of the resident. She stated the color and the amount of urine could be exposed to other residents. She stated that a resident would be affected by not having their privacy and dignity respected. She stated the last in-service for privacy and dignity was a couple weeks ago, and added all employees were responsible for upholding the resident's privacy and dignity. In an interview on 04/09/2026 at 1:18 PM LVN F stated that residents were provided the privacy bag once the facility was made aware of the different Foley catheter bag or indwelling catheter in place. She stated the privacy bag could be provided by the nurses, nursing supervisors, DON, or Unit managers. She stated that it needed to be provided immediately. She stated that it affected a resident by compromising their privacy. She stated the color of the urine could be exposed if they did not have a privacy bag. She stated that she observed residents' Foley catheter bags for privacy whenever they were in the common area. She stated the last in-service for privacy, dignity, and resident rights was two weeks prior. In an interview on 04/09/2026 at 2:48 PM the DON stated that the flap on the Foley catheter bag provided privacy to the residents' urine output. She stated if a resident had a clear Foley catheter bag the facility usually switched it to the white with blue flap Foley catheter bag version when they come back from the hospital. She stated that the facility had a privacy bag in place for residents that did not have the foley bag with the privacy flap. She stated the dignity of a resident was compromised and the residents' right to privacy if their Foley catheter bag did not have privacy cover. She stated all staff were responsible for upholding residents' dignity and any nurse could change out the Foley catheter bag to the white with blue flap Foley catheter bag and added anyone could provide the privacy satchel. In an observation and interview on 04/09/2026 at approximately 3:15 PM, revealed LVN F observed the Foley catheter bag of Resident #127 in his private restroom and confirmed the Foley catheter bag inside the privacy satchel was clear and not the facility's standard issued white with blue privacy flap. In an interview on 04/09/2026 at 4:11 PM the Administrator stated he wanted to defer comments on the Foley catheter bag to his DON due to his limited knowledge on the topic. Record review of the facility's policy titled Resident's Rights dated 10/2022 revealed in part, Purpose: To ensure the facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility 3. Planning and implementing care: b. the right to participate in the development and implementation of his or her person-centered plan of care 5. Respect and dignity: the resident has a right to be treated with respect and dignity including 8. Privacy and confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment Record review of the facility's in-service titled Resident's Rights dated 03/23/2026 revealed CNA D and LVN C were educated and acknowledged about providing privacy for the residents and residents rights.

Based on observation, interviews, and record review, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (300-hall) viewed for pharmacy services.The facility failed to ensure the 300-hall medication cart was clean and free from dried drippings, pieces of paper and a loose tablet.This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.The findings include:In an observation on 04/09/26 at 11:05 AM of the medication cart located in the 300-hall with LVN I, revealed the second drawer contained blister packet medications with pieces of paper from the blister packets and a loose tablet medication on the bottom of the drawer. It also revealed a dried deep-yellow dripping on the first drawer of the right side when facing the medication cart.In an interview on 04/09/25 at 2:17 PM with LVN C, she stated the nurse or medication aide that had the cart that shift was responsible for cleanliness of the cart. She stated nursing staff were to clean and maintain the cart every shift. She stated potential risk of loose tablets and dried drippings in a medication cart included residents' medications being exposed to unknown substances causing unknown reactions.In an interview on 04/09/26 at 3:38 PM with the DON, she stated the pharmacy nurse completed a comprehensive review of the facility's medication carts monthly. She stated the pharmacy nurse reviewed medications and the cart for cleanliness. She stated the purpose of cleaning the medication cart and keeping it free from dried drippings, loose tablets, and small loose pieces of paper was for hygiene purposes and was an infection control issue.Record review of the facility's policy Medication Administration with revision date 07/01/26, revealed in part: Purpose: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under Procedure, it read in part: Keep medication cart clean, organized, and stocked with adequate supplies.

Based on observation, interview, 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 promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 9 residents (Resident #1 Resident #2, Resident #3, and Resident #4) reviewed for dignity.-The facility failed on 3/18/2026 to provide glucose reading for Resident #1, Resident #2, Resident #3, and Resident #4 in a private setting.-The facility failed on 3/18/2026 to provide insulin injection for Resident #1, Resident #2, Resident #3, and Resident #4 in a private setting.The deficient practice could affect residents by contributing to poor self-esteem, dignity issues, diminished quality of life, and leaking of protected health information.The findings include:Record review of Resident #1's face sheet dated 3/18/2026 revealed a [AGE] year-old male with an original admission date of 12/05/2025.Record review of Resident #1's MDS dated [DATE] revealed under section C, a BIMS score of 3 the significance meaning he had severe cognitive impairment. Under Section I, the resident had an active diagnosis of diabetes mellitus (a condition of high blood sugar from inadequate insulin production). Under section N revealed the resident required insulin injections every day.Record review of Resident #1's care plan dated 12/16/2025 revealed the resident had focus area related to disorientation from dementia. Interventions in place included to provide choices for the resident and assist with decision making. Record review of Resident #1's physical and health dated 12/11/2025 revealed the resident was diagnosed with Alzheimer's dementia and diabetes type 2.Record review of Resident #2 face sheet dated 3/19/2026 revealed a [AGE] year-old male with an original admission date of 5/3/2022 and readmission date of 5/8/2023.Record review of Resident #2's MDS dated [DATE] revealed under section C, a BIMS score of 6 the significance meaning he had severe cognitive impairment. Under Section I, the resident had an active diagnosis of diabetes mellitus (a condition of high blood sugar from inadequate insulin production).Record review of Resident #2's care plan dated 12/5/2025 revealed the resident had a focus area related to impaired communication with interventions to allow adequate time for the resident to respond and evaluate resident's ability to comprehend.Record review of Resident #2's physical and health dated 2/10/2026 revealed the resident was diagnosed with diabetes type 2, dementia and bipolar disorder (a psychiatric mood disorder characterized by episodes of depression and manic behavior).Record review of Resident #3's face sheet dated 3/19/2026 revealed an [AGE] year-old male with an admission date of 6/21/2024.Record review of Resident #3's MDS dated [DATE] revealed under section C, a BIMS score of 4 the significance meaning he had severe cognitive impairment. Under Section I, the resident had an active diagnosis of diabetes mellitus (a condition of high blood sugar from inadequate insulin production). Under section N revealed the resident required insulin injections every day.Record review of Resident #3's care plan dated 1/26/2026 revealed the resident had a focus area for diabetes mellitus concerns with interventions of observe for signs and symptoms of hyper/hypoglycemia (symptoms related to low and high blood sugar), rotate injection sites, and monitor food intake.Record review of Resident #3's physical and health dated 6/6/2025 revealed the resident was diagnosed with dementia and diabetes type 2.Record review of Resident #4 face sheet dated 3/19/2026 revealed a [AGE] year-old male with an original admission date of 10/22/2025 and a readmission date of 2/11/2026.Record review of Resident #4 MDS dated [DATE] revealed under section C, a BIMS score of 11 the significance meaning he had moderate cognitive impairment. Under Section I, the resident had an active diagnosis of diabetes mellitus (a condition of high blood sugar from inadequate insulin production). Under section N revealed the resident required insulin injections every day.Record review of Resident #4's care plan dated 11/11/2025 revealed the resident had a focus area for at risk weight loss related to diagnosis. The resident's care plan addressed a care area of cognition with interventions of ask simple questions, do not rush the resident, and explain procedures to the resident. Record review of Resident #4's physical and health dated 10/27/2025 revealed the resident had a diagnosis of hearing loss, diabetes type 2, and dementiaDuring an observation on 3/18/2026 at 11:05 AM, it was observed that RN A completed a glucose check and an insulin injection in the TV room area for Resident #1. At 11:116 AM, RN A completed a glucose check and an insulin injection in the TV room area for Resident #2. At 11:29 AM, RN A completed a glucose check and an insulin injection in the TV room area for Resident #3. At 11:42 AM, RN A completed a glucose check and an insulin injection in the TV room area for Resident #4. There were more than 15 other residents in close proximity present while Resident #1, Resident #2, Resident #3, and Resident #4 received treatment.During an interview on 3/19/2026 at 11:55 AM with the Supervisor RN, she stated that when checking a resident's glucose staff had to ensure the resident was in their room and not in the open. She stated that needed to be done to uphold a resident's dignity. She stated a resident's blood sugar, insulin brand, and number of units could be overheard by residents nearby if it was completed out in the open. She stated a resident could feel embarrassed if they received care in the open for others to see. She stated that herself, nursing leadership, and the Administrator were the individuals responsible for ensuring staff provided care to the resident inside their bedroom. She stated that she would have instructed RN A to take the residents back to their room when checking glucose levels and injecting insulin. She stated the last in-service for resident rights was last week.During an interview on 3/19/2026 at 12:53 PM with the Unit Manager, she stated a blood sugar level reading and insulin injection were a treatment that needed to be completed in a resident's room to protect their privacy. Sh stated she did observe RN A conduct glucose readings and administer insulin in the common area on 3/18/2026. She stated that after the observation she instructed RN A she could not provide care in the open and needed to administer it in the resident's bedroom. She stated all patient related care should be completed in the residents' rooms. She stated it affected residents because it took away a factor of privacy, and a resident could feel embarrassed. She added that the residents' dignity needed to be upheld by staff even if the resident was in the memory unit. She stated the last in-service for resident rights was a week ago.During an interview on 3/19/2026 at 2:34 PM with the ADON, she stated that the residents needed to be in their rooms to receive care for a glucose reading and insulin injection because skin would be exposed. She stated it was a dignity and HIPAA concern if staff provided care in the open for other residents to see. She stated by conducting treatment for diabetes out in the open the residents' glucose readings, skin, diagnosis, dosage, and type of insulin would be disclosed for others to see and hear. She stated that all staff were responsible for protecting residents' information. She stated it affected a resident because they could feel embarrassed and humiliated if they received care in a common area. During an interview on 3/19/2026 at 4:15 PM with the Administrator, he stated the facility upheld residents' dignity by ensuring the residents felt heard, following up on grievances, and provided privacy when receiving care. He stated that it was a privacy concern and added it was essential residents received care in a private setting when appropriate. He stated if staff provided treatment or care in the open it could disrupt the resident's activity or be disruptive to other residents. He stated that a diagnosis, medications, glucose levels, vitals, and residents' stomachs would be exposed to other residents due to recieving diabetic related treatment in the open. He stated that everyone in the building was responsible for upholding a resident's dignity. He stated it affected a resident because they would feel unappreciated or person-centered in th care they received.Record review of the facility's policy titled Resident's Rights dated 10/2022 revealed in part, Purpose: To ensure the facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility 3. Planning and implementing care: b. the right to participate in the development and implementation of his or her person-centered plan of care 5. Respect and dignity: the resident has a right to be treated with respect and dignity including 8. Privacy and confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment

Based on observation, interview, and record review the facility failed to maintain an infection prevention program designed to provide safe, sanitary, and prevent the development and transmission of communicable diseases and infections for 5 of 12 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for transmission-based precautions.-LVN G failed to perform hand hygiene and change gloves after disposing the dirty wound dressings, disposing his PPE gown, and before cleaning the wound, and applying the new wound dressing on 03/14/2026.-LVN G failed to secure his PPE gown before wound care and disposed of it without putting on a new one while providing wound care on 03/14/2026.-RN A failed on 3/18/2026 to practice proper hand hygiene during glucose measuring and insulin injection.The failures placed residents at risk for developing a preventable infection during patient care.The findings include:Record review of Resident #1's face sheet dated 3/18/2026 revealed a [AGE] year-old male with an original admission date of 12/05/2025.Record review of Resident #1's MDS dated [DATE] revealed under section C, a BIMS score of 3 the significance meaning he had severe cognitive impairment. Under Section I, the resident had an active diagnosis of diabetes mellitus (a condition of high blood sugar from inadequate insulin production). Under section N revealed the resident required insulin injections every day.Record review of Resident #1's care plan dated 12/16/2025 revealed the resident had focus area related to disorientation from dementia. Interventions in place include to provide choices for the resident and assist with decision making. Further interventions related to diet included: provide snacks, offer alternate meals if refused, and encourage food related activities.Record review of Resident #1's physical and health dated 12/11/2025 revealed the resident was diagnosed with Alzheimer's dementia, chronic kidney disease (long-term loss of kidney function preventing the filtration of blood and waste), and diabetes type 2.Record review of Resident #2 face sheet dated 3/19/2026 revealed a [AGE] year-old male with an original admission date of 5/3/2022 and readmission date of 5/8/2023.Record review of Resident #2's MDS dated [DATE] revealed under section C, a BIMS score of 6 the significance meaning he had severe cognitive impairment. Under Section I, the resident had an active diagnosis of diabetes mellitus (a condition of high blood sugar from inadequate insulin production).Record review of Resident #2's care plan dated 12/5/2025 revealed the resident had a focus area related to impaired communication with interventions of allow adequate time for the resident to respond and evaluate resident's ability to comprehend. A focus area for risk for skin integrity due to dementia and g tube site with an intervention to observe the resident for signs and symptoms of infections.Record review of Resident #2's physical and health dated 2/10/2026 revealed the resident was diagnosed with diabetes type 2, dementia and bipolar disorder (a psychiatric mood disorder characterized by episodes of depression and manic behavior).Record review of Resident #3's face sheet dated 3/19/2026 revealed an [AGE] year-old male with an admission date of 6/21/2024.Record review of Resident #3's MDS dated [DATE] revealed under section C, a BIMS score of 4 the significance meaning he had severe cognitive impairment. Under Section I, the resident had an active diagnosis of diabetes mellitus (a condition of high blood sugar from inadequate insulin production). Under section N revealed the resident required insulin injections every day.Record review of Resident #3's care plan dated 1/26/2026 revealed the resident had a focus area for diabetes mellitus concerns with interventions of observe for signs and symptoms of hyper/hypoglycemia (symptoms related to low and high blood sugar), rotate injection sites, and monitor food intake. A focus area for risk for skin integrity due to fragile skin with an intervention to observe the resident for signs and symptoms of infections. Wound management was a focus area with concerns for ulcer development and infection.Record review of Resident #3's physical and health dated 6/6/2025 revealed the resident was diagnosed with dementia, recurrent pneumonias (a serious lung infection caused by bacterias, viruses or fungi) and diabetes type 2.Record review of Resident #4 face sheet dated 3/19/2026 revealed a [AGE] year-old male with an original admission date of 10/22/2025 and a readmission date of 2/11/2026.Record review of Resident #4 MDS dated [DATE] revealed under section C, a BIMS score of 11 the significance meaning he had moderate cognitive impairment. Under Section I, the resident had an active diagnosis of diabetes mellitus (a condition of high blood sugar from inadequate insulin production). Under section N revealed the resident required insulin injections every day.Record review of Resident #4's care plan dated 11/11/2025 revealed the resident had a focus area for at risk weight loss related to diagnosis. Interventions in place included to allow the resident time to finish meals, offer resident food alternatives. An additional care area focus for communication with interventions of allow resident time to prepare/finish thoughts. The resident's care plan addressed a care area of cognition with interventions to ask simple questions, do not rush the resident, and explain procedures to the resident.Record review of Resident #4's physical and health dated 10/27/2025 revealed the resident had a diagnosis of hearing loss, diabetes type 2, chronic kidney disease (long-term loss of kidney function preventing the filtration of blood and waste) and dementia.Record review of Resident #5's admission record dated 03/14/2026 revealed an [AGE] year-old male with admission date 10/13/2022.Record review of Resident #5's Nursing Home Discharge MDS dated [DATE] revealed resident was unable to participate and score a BIMS score as he was rarely/never understood per MDS. Section M-Skin Conditions notated Resident #5 had 1 unstageable pressure ulcer.Record review of Resident #5's care plan revised on 01/23/2025 revealed Resident #5 had a Stage 4 pressure injury to the Sacrum (lower part of the spine). The staff intervention included to administer treatments as ordered and monitor for effectiveness, and to monitor as needed any changes in skin status.Record review of Resident #5's Wound Care progress note dated 02/12/2026 revealed the resident had a wound to his sacrum (lower part of the spine). It also noted the following wound care orders: 1) Primary Dressing- Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged. 2) Secondary Dressing- Gauze island with bdr apply once daily and as needed: if soiled or dislodged.In an observation and interview on 03/14/2026 at 3:30 PM revealed wound care was provided to Resident #5's sacrum by LVN G. LVN G was observed putting on a PPE gown but did not secure the back or neck ties. LVN G was observed disposing of Resident #5's soiled wound dressing and continued to clean the wound without performing hand hygiene and changing gloves. LVN G removed his PPE gown after cleaning the wound and stated it was getting in his way. LVN G disposed the PPE gown into the trash and continued to clean the wound on the sacrum. LVN G was observed opening the new dressing to apply on Resident #5's sacrum wound, when stopped by the State Surveyor and was asked about hand hygiene. LVN G stated he was to perform hand hygiene before placing the new dressing and performed hand hygiene and changed gloves. He was observed completing wound care without a PPE gown. After wound care was performed, LVN G stated he forgot to wash his hands and change his gloves after disposing the dirty dressing and cleaning the wound. He stated he was also expected to wash his hands after cleaning the wound and before applying the new dressing on Resident #5. He stated he forgot to wash his hands as he did not typically provide wound care and had not done so in some time as the facility had a designated Wound Care Nurse providing wound care. He stated nurses were able and expected to provide wound care when the Wound Care Nurse was unable to. He stated he removed his PPE gown because it was not secured and kept getting in his way while he provided wound care. He stated it was not secured because it was too small for him. He stated he required a larger size which the facility had provided approximately 1 month ago but had run out recently. He stated he was to notify the Nurse Supervisor when the staff were low on PPE. He stated the purpose of wearing PPE was infection control and not having a PPE gown on during wound care, or performing hand hygiene, put the resident at potential risk for infection.During an observation on 3/18/2026 at 11:05 AM, revealed RN A was providing glucose measuring and insulin administration to Resident #1. RN A did not utilize hand hygiene sanitization between completing glucose measuring and filing the syringe with insulin. RN A failed to sanitize after administering insulin, disposing of sharps and gloves and touched the medication cart drawer and a residents door handle. At 11:16 AM, RN A proceeded to complete glucose measuring and insulin administration on Resident #2. After completing glucose measuring RN A failed to utilize hand hygiene sanitization before filling the syringe with insulin. RN A continued to put on gloves without practicing hand hygiene and administered insulin into Resident #2's stomach and sanitized at the conclusion of discarding the sharp and glove removal. At 11:29 AM, RN A conducted glucose measuring and insulin administration on Resident #3. RN A did not utilize hand hygiene sanitization between completing glucose measuring and filing the syringe with insulin. RN A applied new gloves without practicing hand hygiene and administered medication to Resident #3. RN A failed to sanitize her hands after removing her gloves following Resident #3's treatment. At 11:42 AM, RN A proceeded to provide glucose measuring for Resident #4 without hand sanitizing after Resident #3. RN A did not utilize hand hygiene sanitization following the glucose reading for Resident #4. During an interview on 3/18/2026 at 3:20 PM with RN A, she stated she did not use the sanitizer solution on her cart and opted for the wall mounted sanitizers instead. She stated she should sanitize before and after every glove application and added she did not think she adhered to that standard. She stated she did not know why she did not sanitize her hands between glucose measuring and insulin administration and attributed it to not having hand sanitizer readily accessible on her cart. She stated that there was potential for contaminants in the blood to be exposed and needed to practice hand hygiene between care and for every glove change. She stated it affected residents because if they had an infection it could spread because staff were not sanitizing properly. She stated she was responsible for practicing infection control during patient care. She identified the Infection Preventionist as the individual responsible for ensuring all nurses were adhering to infection control practices. She stated glucose measuring and injections were considered an invasive procedure because they exposed blood. She asked for clarification if she had to sanitize multiple times if she was still working with the same resident.During an interview on 3/19/2026 at 10:50 AM with LVN C, she stated the procedure to checking glucose levels and administering insulin while adhering to infection control was to: wash hands, apply gloves, disinfect the glucose meter, sterilize the resident's finger, remove gloves, practice hand hygiene, reapply gloves, clean the insertion site, sterilize the injection site, discard sharps and gloves, and practice hand hygiene. She stated there should be 3 to 4 opportunities for nurses to practice hand hygiene during the process. She stated that needed to be completed for infection prevention practices while handling blood. She stated it was the charge nurse's responsibility to ensure that was being completed. She stated there was potential to infect the resident by not adhering to hand hygiene practices. She stated staff needed to practice hand hygiene before proceeding to another resident to prevent cross contamination between residents. She stated sometimes the nursing supervisors conducted observations on skills randomly and had an annual test for all nursing skills and with return demonstrations.During an interview on 3/19/2026 at 12:10 PM with the Supervisor RN, she stated staff needed to sanitize the glucose meter before beginning services with the resident. She stated they needed to apply gloves, sanitize the prick site, remove gloves, practice hand hygiene, prepare the insulin, practice hand hygiene, apply gloves, administer the insulin, discard the sharp, remove gloves and practice hand hygiene. She stated they needed to sanitize 3 to 4 times during glucose measuring. She stated that needed to be done to prevent an infection between residents. She stated that all staff members were responsible for practicing good infection control practices to prevent infections. She stated it affected the residents because they could be exposed to an infection by staff members. She stated as resident with an infection could present symptoms in the form of skin rash, fever, pain, discomfort, coughing. She stated that nursing administration was responsible for ensuring nurses were using proper practices.During an interview on 3/19/2026 at 1:20 PM with the Unit Manager, she stated the Infection Preventionist was the individual who oversaw infection control and added it was a shared responsibility amongst all staff to uphold the standards. She stated clinical supervisors educated nurses around the year on topics like infection prevention. She stated some examples of staff using infection prevention procedures during glucose measuring and insulin administration were to practice hand hygiene and change gloves when providing care. She stated when a nurse provided glucose monitoring care they should wash or sanitize their hands, disinfect the glucose meter, change gloves after checking the glucose levels, sanitize their hands, clean the lid to the insulin vial, sanitize their hands, apply gloves, administer insulin, discard the sharp, discard the gloves, sanitize their hands and wipe their work area. She stated they should sanitize 3 to 4 times for the duration of the process. She stated it was for cleanliness reasons and to prevent the transfer of bodily fluids. She stated there could be a transfer of bodily fluids if hand hygiene was not conducted. She stated residents could be contaminated and affected them by resulting in an infection. She stated they could experience symptoms like fever, rash, swelling, warm to touch, discomfort. She identified the nursing supervisors were responsible for ensuring that staff was adhering to infection control practices. She stated the last in-service and training for infection control was during the skills fair hosted in October/November of 2025.During an interview on 3/19/2026 at 2:45 PM with the ADON, she stated everybody was responsible for infection prevention of practices. She stated examples would include hand hygiene, standard precautions, wearing gloves, sanitizing between residents, washing hands if physically soiled, wearing the proper PPE, ensuring residents on isolation precautions remain isolated. She stated that if the process involved blood and inserting into the skin infection prevention needed to be adhered to. She stated that the resident could be exposed to blood-borne pathogens and bacterial infections if not followed. She stated a resident could experience fevers, become hospitalized , chills, altered mental status, spread to organs, or could become septic or potentially spread to other residents. She stated that the Infection Preventionist oversaw the infection control efficacy of the facility. She stated the last in-service for infection control was a couple weeks ago facility wide. She stated there were 3 to 4 instances of potential hand hygiene applications during glucose measuring and insulin administration. She stated staff were expected to sanitize before the next resident.During an interview on 3/19/2026 at 4:25 PM with the Administrator, he stated that staff should be always sanitizing and preventing infections. He stated this included sanitizing equipment and following the facility hand hygiene procedure. He stated if staff were not following hand hygiene procedures it could lead to infections. He tated that a resident who contracted an infection could experience symptoms of fever, cough, sneezing, and discomfort. He stated it was all of staff's responsibility to adhere to infection preventions. He stated that the facility had multiple supervisors who oversaw the nursing department and provided coaching as needed for infection prevention. He identified unit managers, ADON, DON, and clinical RNs, and the Infection Preventionist that provided coaching.During an interview on 3/18/2026 at 9:08 AM with the DON, she stated she had been the DON for 10 months and RN 14 years. She added she had previous experience as a DON. She stated PPE was to ensure nothing was introduced into the resident's wound when performing wound care and to protect staff. She stated staff were to don the gown and gloves at minimum when providing the wound care. She stated it was appropriate to switch gloves during the wound care procedure; however, it was not appropriate to remove the gown during wound care. She stated if the gown was removed, it needed to be reapplied by the nurse. She stated she was not aware of any staff member requiring a larger sized gown. She stated the facility used the one size fits all and had not heard any complaints about staff not fitting into the appropriate PPE. She stated it was nursing administration and central supply's responsibility to ensure the facility had enough PPE. She stated all staff were responsible for reporting any shortages of PPE and nursing supervisors oversaw the operation and reviewed with central supply weekly for PPE orders. She stated that was a daily practice that all staff and supervisors participated in. She stated staff needed to practice hand hygiene before applying PPE, before beginning wound care, when changing gloves during wound care, and before applying the new wound dressing. She stated hand hygiene needed to be practiced during ever gloves change which would be 3 to 4 times. She stated hand hygiene needed to be practiced usually with hand sanitizer, unless their hands were visibly soiled then it required soap and water. She stated anytime staff didn't adhere to hand hygiene or PPE standards there was a risk for infection or systemic infection. She stated nursing administration and wound LVN D and LVN E were responsible for ensuring nursing staff was providing wound care per protocol. She stated that return demonstration for wound care was during orientation, as needed, with annuals, or if issues identified. She added that there was a skills fair which was hosted in October/November 2025 in the facility. She stated LVN F was the staff development coordinator who provided service to all RN supervisors. She stated that the last in-service for infection control was in the evening on 3/14/2026 to ensure they were confident to teach other fellow nurses on how to complete wound care.Record review of the facility's policy titled Hand Hygiene dated 02/2020 revealed in part, it is the policy of this facility that staff will perform hand hygiene to aide in the prevention of the transmission of infections Hand hygiene with waterless hand sanitizer may be used when hands are not visibly soiled and is the preferred method per CDC guidelines Record review of the facility's policy titled Infection Prevention and Control dated 04/2025 revealed in part, It is the policy of the facility to comply with all OSHA and CDC guidelines related to infection prevention and control practices. The facility has established and maintains an infection prevention and control program designed to provide safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections 4. Standard Precautions Hand hygiene shall be performed in accordance with facility's established hand hygiene procedures. Staff shall use personal protective equipment (PPE) according to established facility governing use of (PPE) when providing resident care activities It also read: Policy Explanation and Compliance Guidelines: 4. Standard Precautions: Hand hygiene shall be performed in accordance with facility's established hand hygiene procedures. Staff shall use personal protective equipment (PPE) according to established facility governing use of PPE when providing resident care activities.

Based on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 1 of 1 (Resident #1) resident reviewed for accuracy and completeness of medical records.-The facility failed to document notification to NP/MD of osteomyelitis for Resident #1 on 12/10/25.These failures could place residents at risk of not receiving needed services.Findings included: Record review of Resident #1's admission Record dated 02/03/26, revealed an [AGE] year-old male with an admission date of 02/27/25 to the facility and a discharge date of 01/25/2026. Record review of Resident #1 's local hospital history and physical dated 02/12/25, revealed, a medical history of open wound of foot, open wound of left great toe and diabetes mellitus with hyperglycemia (elevated blood sugar). Per assessment plan, Resident was referred to local hospital on 12.12.25 due to concern of osteomyelitis in the left foot. MRI imaging was consistent with left-sided calcaneal osteomyelitis (infection of the heel bone), possible left 5th toe osteomyelitis. Record review of hospital notes revealed resident was admitted on [DATE] for management of a urinary tract infection and left open wound concerning for osteomyelitis. Plan was for resident to be started on antibiotic therapy before being discharged back to nursing facility. Hospital records noted calcaneal osteomyelitis( bone infection of the heel) of the left foot. Record review of Resident #1's discharge MDS dated [DATE], revealed, no BIMS score. Section C- Cognitive Patterns revealed Resident #1's Cognitive Skills for Daily Decision Making coded at a 2 meaning resident was moderately impaired- decisions poor; cues/supervision required.Record review of Resident #1's progress note dated 12/9/2025 revealed Resident #1 had a podiatrist appointment at 1:00 p.m.Record review of Resident #1's progress notes dated 12/10/2025 revealed no information regarding podiatrists' progress note detailing osteomyelitis diagnosis or notification to nurse practitioner of diagnosis.Progress note dated 12/12/2025 revealed Resident was sent out to hospital for further evaluation regarding osteomyelitis due to veterans affairs infectious disease doctor scheduling appointment taking long to schedule resident.Record review of a podiatrist progress noted not dated revealed erosion of left 5th toe indicated osteomyelitis, will consult infectious disease today as toe is stable.Record review of Resident #1's care plan cancellation date 01/27/26, revealed, Resident #1 Required IV therapy related to osteomyelitis. Interventions included administering IV fluid per order, Auscultating lung sounds as indicated, check site routinely for signs and symptoms of infection, and notifying physician of signs and symptoms of infection at site and or complications. In an interview on 02/03/2026 at 11:20 a.m., LVN A revealed that when a resident attended an outside appointment, and brings back a progress note, the nurses were responsible for relaying any new orders and or diagnosis to the nurse practitioner or medical doctor. She stated that once they were notified, then a progress note was input in the system. She stated that the importance of reporting any new orders or diagnosis to the nurse practitioner would be continuity of care so that the team was aware of what was going on with the resident. She stated that documenting a progress note after notifying the nurse practitioner was also important because that way everyone was aware of what each nurse did with the resident. She stated that it was the responsibility of the nurse receiving the resident back from the appointment and whoever reviewed the progress note to inform the nurse practitioner immediately as soon as the changes were noted and to document it. She stated that the risk to the resident would be a delay in care and miscommunication. She stated that she could not recall the last Inservice over notifying nurse practitioner and that the documentation in-services were done monthly.In an interview on 02/03/2026 at 12:00 p.m., LVN B revealed that he was not aware of Resident #1's diagnosis of osteomyelitis, He stated that he was informed on 12/12/25 by Resident #1's POA. He stated that when a resident came back from an outside appointment, the nurses were to review any new orders/changes, and they were to notify the nurse practitioner immediately as soon as they were aware of changes. He stated that it was the receiving nurse's responsibility to report any changes to the nurse practitioner and to document that it was reported. He stated that he did not always document a progress note when residents came back from an appointment if there were no new orders to report. He stated that the importance of reporting and documenting was for continuity of care of the residents and so all the nurses caring for the resident could be informed. He stated that the risk to the resident would be a delay in care if changes were not relayed to the nurse practitioner. He stated that the last Inservice over reporting changes to the nurse practitioner was about a month ago and documentation in-service was this morning 02/03/2026. In an interview on 02/03/2026 at 12:58 p.m., the DON revealed that staff was to report any new orders or change in condition/new diagnosis immediately to nurse practitioner and document a progress note. She stated that since Resident #1s podiatrist progress note did not contain any orders, and it stated that the podiatrist was referring Resident #1 to infectious disease doctor and that the condition was stable, therefore there was nothing to act on at that time. She stated that nurse practitioner did not need to be notified immediately of osteomyelitis diagnosis in this case as it was stable. She stated that it was acceptable for the nurses to notify the nurse practitioner the following day. She stated that if the staff failed to notify the nurse practitioner of any new orders, then that would cause a delay in care, but not in this case as there were no new orders. She stated that the nurse receiving the report was responsible for notifying the nurse practitioner. She stated that the last Inservice over notification and documentation were held periodically with the last one being in [DATE].In an interview on 02/03/2026 at 4:00 p.m., the Administrator revealed that whenever a resident was brought back from an outside appointment with a progress note detailing any new orders or changes to diagnosis the staff was to notify nursing supervisor, and nurse practitioner immediately and document a progress note. He stated that the risk of not notifying the nurse practitioner of these changes would cause an opportunity for miscommunication and care could be delayed and or missed; incorrect information could be given. He stated that the receiving nurse was responsible for notifying the nurse practitioner and documenting the progress note. He stated that the clinical team including the DON and corporate compliance team also oversee documentation. The DON oversees documentation daily and the corporate compliance team oversees documentation once a week. He could not recall the last in-service held regarding notification to nurse practitioner.Review of the facility policy and procedure titled Medical Record Documentation dated October 2021 read in part Licensed staff and interdisciplinary team members shall document observation and services provided in the resident's medical record in accordance with state law .

Based on observation, interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 (Resident #1) of 5 residents reviewed for accuracy of MDS assessment, in that: Resident #1's Discharge MDS dated [DATE] did not accurately reflect the residents' diagnosis of Osteomyelitis (infection of the bone).This failure could place residents at risk of not receiving necessary care . Findings included:Record review of Resident #1's admission Record dated 02/03/26, revealed an [AGE] year-old male with an admission date of 02/27/25 to the facility and a discharge date of 01/25/2026.Record review of Resident #1's local hospital history and physical dated 02/12/25, revealed, a medical history of open wound of foot, open wound of left great toe and diabetes mellitus with hyperglycemia (elevated blood sugar). Per assessment plan, Resident was referred to local hospital on 12.12.25 due to concern of osteomyelitis in the left foot. MRI imaging was consistent with left-sided calcaneal osteomyelitis (infection of the heel bone), possible left 5th toe osteomyelitis.Record review of hospital notes revealed resident was admitted on [DATE] for management of a urinary tract infection and left open wound concerning for osteomyelitis. Plan was for resident to be started on antibiotic therapy before being discharged back to nursing facility. Hospital records noted calcaneal osteomyelitis( bone infection of the heel) of the left foot.Record review of Resident #1's discharge MDS dated [DATE], revealed, no BIMS score. Section C- Cognitive Patterns revealed Resident #1's Cognitive Skills for Daily Decision Making coded at a 2 meaning Resident was moderately impaired- decisions poor; cues/supervision required. MDS did not include osteomyelitis diagnosis.Record review of Resident #1's care plan with a target date of 01/26/26, revealed, Resident #1 Required IV therapy related to osteomyelitis. Interventions included administering IV fluid per order, Auscultating lung sounds as indicated, check site routinely for signs and symptoms of infection, and notifying physician of signs and symptoms of infection at site and or complications. In an interview on 02/03/2026 at 2:40 p.m., the MDS LVN revealed that the MDS assessment paints a picture of the residents' care that was being provided at the facility while a resident. He stated that all active diagnoses should have been included. He stated that the floor nurses was responsible for updating the MDS assessment upon initiation of a new diagnosis. He stated that he only reviewed the MDS quarterly. He stated that if the MDS was missing a diagnosis, this did not pose a risk to resident care; rather it was a reimbursement issue affecting the facility. He stated that he had not received any in-services over accurate MDS completion.In an interview on 02/03/2026 at 4:00 p.m., the Administrator revealed that the MDS was an assessment of the resident's functional cognitive state. He mainly looks at the BIMS score. He stated that he was not sure if the resident's diagnosis had to be included in the MDS assessment. He stated that if medical diagnosis were not included, it would not be showing the resident's full clinical picture. He stated that the floor nurses and MDS nurses was responsible for ensuring the MDS assessment was completed accurately. He stated that he could not recall the last IInservice provided.Review of facility policy titled Resident Assessment revised April 2025 read in part . A comprehensive assessment will be completed when a significant change is determined based upon the criteria outlined in the RAI manual .

Based on interview and record review the facility failed to immediately notify and consult with the resident's physician when a significant change in a residents physical, mental, or psychosocial status (that was a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 3 residents reviewed for change in condition.The facility failed to immediately inform the NP/MD on 12/10/25 of Resident #1's new diagnosis of osteomyelitis (bone infection).This failure could place residents at risk of serious decrease in health related to delayed treatment. Findings include:Record review of Resident #1's admission Record dated 02/03/26, revealed an [AGE] year-old male with an admission date of 02/27/25 to the facility and a discharge date of 01/25/2026.Record review of Resident #1's discharge MDS dated [DATE], revealed, no BIMS score. Section C- Cognitive Patterns revealed Resident #1's Cognitive Skills for Daily Decision Making coded at a 2 meaning resident was moderately impaired- decisions poor; cues/supervision required.Record review of Resident #1 's local hospital history and physical dated 02/12/25, revealed, a medical history of open wound of foot, open wound of left great toe and diabetes mellitus with hyperglycemia (elevated blood sugar). Per assessment plan, Resident was referred to local hospital on 12.12.25 due to concern of osteomyelitis in the left foot. MRI imaging was consistent with left-sided calcaneal osteomyelitis (infection of the heel bone), possible left 5th toe osteomyelitis.Record review of Resident #1's progress note dated 12/9/2025 revealed Resident #1 had a podiatrist appointment at 1:00 pm.Record review of a progress note dated 12/10/2025, revealed no information regarding Resident #1's podiatrists' progress note detailing osteomyelitis diagnosis or notification to nurse practitioner of diagnosis.Progress note dated 12/12/2025 revealed Resident was sent out to hospital for further evaluation regarding osteomyelitis due to veterans affairs infectious disease doctor scheduling appointment taking long to schedule resident. Record review of a podiatrist progress noted not dated revealed erosion of left 5th toe indicated osteomyelitis, will consult infectious disease today as toe is stable.Record review of hospital notes revealed resident was admitted on [DATE] for management of a urinary tract infection and left open wound concerning for osteomyelitis. Plan was for resident to be started on antibiotic therapy before being discharged back to nursing facility. Hospital records noted calcaneal osteomyelitis( bone infection of the heel) of the left foot.Record review of Resident #1's care plan with a target date of 01/26/26, revealed, Resident #1 Required IV therapy related to osteomyelitis. Interventions included administering IV fluid per order, Auscultating lung sounds as indicated, check site routinely for signs and symptoms of infection, and notifying physician of signs and symptoms of infection at site and or complications. In an interview on 02/03/2026 at 11:20 a.m., LVN A revealed that when a resident attends an outside appointment, and brings back a progress note, the nurses was responsible for relaying any new orders and or diagnosis to the nurse practitioner or medical doctor. She stated that once they were notified, then a progress note was input in the system. She stated that the importance of reporting any new orders or diagnosis to the nurse practitioner would be continuity of care so that the team was aware of what was going on with the resident. She stated that it was the responsibility of the nurse receiving the resident back from the appointment and whoever reviewed the progress note to inform the nurse practitioner immediately as soon as the changes were noted. She stated that the risk to the resident would be a delay in care and miscommunication. She stated that she could not recall the last Inservice over notifying the nurse practitioner.In an interview on 02/03/2026 at 11:40 a.m., the Nurse Practitioner revealed that she was not notified of Resident #1's diagnosis of osteomyelitis by the nurses, she was notified by the residents family member on 12/12/2026, she stated that it was nice to know when there was changes to residents diagnosis or any new orders from outside doctors. She stated that there was always a risk for residents when the nurse practitioner was not notified in a timely manner that could result in a delay of care.In an interview on 02/03/2026 at 12:00 p.m., LVN B revealed that he was not aware of Resident #1's diagnosis of osteomyelitis, he stated that he was informed on 12/12/25 by Resident #1's POA. He stated that when a resident came back from an outside appointment, the nurses was to review any new orders/changes, and they were to notify the nurse practitioner immediately as soon as they were aware of changes. He stated that it was the receiving nurse's responsibility to report any changes to the nurse practitioner. He stated the importance of this was for continuity of care of the residents and so all the nurses caring for the resident could be informed. He stated that the risk to the resident would be a delay in care if changes wase not relayed to the nurse practitioner. He stated that the last Inservice over reporting changes to the nurse practitioner was about a month ago. In an interview on 02/03/2026 at 12:58 p.m., the DON revealed that staff was to report any new orders or change in condition/new diagnosis immediately to the nurse practitioner and document a progress note. She stated that since Resident #1's podiatrist progress note did not contain any orders, and it stated that the podiatrist was referring Resident #1 to the infectious disease doctor, and that the condition was stable, therefore there was nothing to act on at that time. She stated that the nurse practitioner did not need to be notified immediately of the osteomyelitis diagnosis in this case as it was stable. She stated that it was acceptable for the nurses to notify the nurse practitioner the following day. She stated that if the staff failed to notify the nurse practitioner of any new orders, then that would cause a delay in care, but not in this case as there was no new orders. She stated that the nurse receiving the report was responsible for notifying the nurse practitioner. She stated that the last Inservice over notification and documentation was held periodically with the last one being in November 2025.In an interview on 02/03/2026 at 4:00 p.m., the Administrator revealed that whenever a resident was brought back from an outside appointment with a progress note detailing any new orders or changes to diagnosis the staff was to notify the nursing supervisor, and nurse practitioner immediately. He stated that the risk of not notifying the nurse practitioner of these changes would cause an opportunity for miscommunication and care could be delayed and or missed; incorrect information could be given. He stated that the receiving nurse was responsible for notifying the nurse practitioner. He could not recall the last in-service held regarding notification to nurse practitioner.Review of facility policy titled Change in Resident Condition Notification revised February 2020 read in part . In the following situations: residents attending physician or designee and resident representative will be notified by the licensed nurse Situations which would require a change in medication or treatment regimen: (examples not limited to) need for restraints, exacerbation of known condition, onset of new condition, abnormal lab values, behavior, weight loss, appointments, elopement, skin issues, elimination changes, vital sign changes and physical functioning.

Based on interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, includinginjuries of unknown source, were reported immediately to the State Survey Agency, for 1 of 4 residents (Resident #1) reviewed for abuse/neglect. The nursing facility failed to report Resident #1's allegation of abuse, alleging LVN B squeezed her left-hand, on 10/01/25 to the state survey agency within 2 hours of learning of the allegation. This failure could place residents at risk for abuse and neglect and result in increased risk of abuse andneglect not being reported within 24 hours to the State Agency to ensure appropriate investigation and corrective actions were taken.Findings includeRecord review of Resident #1's face-sheet dated 10/27/25 revealed she was an [AGE] year-old female with admission date 10/06/23.Record review of Resident #1's history and physical dated 10/10/25 revealed the resident's following medical history: Venous Insufficiency (a condition where the veins in your legs do not efficiently return blood to the heart, leading to blood pooling in the legs), Generalized Anxiety disorder (disorder causing excessive worrying about everyday life), Delusional disorders (mental illness characterized by one or more persistent delusions that last a at least month), Muscle wasting and atrophy (loss or thinning of muscle tissue leading to decrease in muscle mass and strength), muscle weakness, and Heart Failure (condition where the heart cannot pump blood efficiently enough to meet the body's need for blood). The document noted the Resident #1's Chief Complaint was aggression and foul urine odor; it noted Resident #1 was seen for aggression and refusal of labs. History and Physical noted [Resident #1] had been trying to hit staff and verbally aggressive towards staff and refusing medications at times and refusing care. She had been yelling 'people want to hurt her at times and put poison in food.' Patient also with foul smelling urine and being treated empirical with Cefdinir [antibiotic] as she is refusing labs and UA [urine analysis]. She was also started on Risperidone yesterday due to delusional disorder and is on Valproic Acid [an anticonvulsant drug used to treat seizures, bipolar disorder, and migraine headaches]; she follows up with psych team. The History and Physical medication list revealed Resident #1 was not on anticoagulants.Record review of Resident #1's Annual MDS dated [DATE] revealed no BIMS score. The Annual MDS noted resident was unable to participate or complete the Brief Interview for Mental Status (BIMS).Record review of Resident #1's care plan dated with revision date 07/14/25 revealed the resident was at risk for skin tears or discoloration related to her thin, fragile skin which included staff intervention if the resident was agitated staff were to provide patient safety and leave resident alone for a while and come back. The care plan also included Resident #1 exhibited mood/behavior problems of physical contact with staff with the last revision date 10/03/25. The staff interventions included approaching the resident warmly and positively at all times, consult with family as needed, notify the MD as needed, and they were to provide for safety of the resident during times of combativeness.Record review of Resident #1's incident report dated 10/01/25 prepared by LVN B revealed the following: IDT (Interdisciplinary team) reviewed circumstances surrounding resident skin integrity issue. DON went to look at resident's skin, three bruises noted to left hand, two approximately 2cm by 2cm with light purple and yellow discoloration, one 1cm by 3cm dark purple in color. Resident #1 was asked if she knew how bruise occurred. Resident shook her head no. Resident stated she had mild pain to hand. ROM [Range of Motion] WNL [Within Normal Limits], no swelling noted. Resident #1 reported that the night nurse from the previous shift tried to take away resident's medications, which were hers since she had paid for them, so the medications belonged to her. Resident #1 noted with mild confusion. Psychiatric NP notified about behavior from night shift and confusion this am. Lab work and UA order obtained, order for anxiety medication also obtained. Order for aricare ointment for bruise ordered from NP, which was an ointment used to temporarily treat pain and bruises. Facility does not suspect abuse, neglect, or exploitation. Incident Report, under Incident Description, Nursing Description: Noticed bruising to her left hand after the resident with aggressive behavior was throwing punches towards staff as she hit the table and side rail several times. Resident Description: Resident voicing staff was taking advantage of resident. The document reflected, the resident refused care for her bruising, and she was not taken to the hospital. Incident Report noted under Injuries Observed at Time of Incident Abrasion, back of left hand.Record review of Resident #1's progress notes dated 10/01/25 at 10:58 AM documented by LVN A revealed: Several bruises noted to resident's left hand this morning. Bruises to front of hand and on side of hand. Resident voiced pain to hand. Resident stated her hand was 'squeezed' early this morning when she did not want to give back the nurse a pill she had given her. This nurse notified RN Supervisor and NP. [RN Supervisor D] notified DON and DON notified administrator. NP gave order for XRAY to left hand. [POA] notified. Pending x-ray to be done. Resident [#1] notified of orders. This nurse tried to do head to toe assessment on Resident [#1] but resident refused. Resident is stable at this time. Refused Valproic Acid [medication used to treat seizures, migraines, and bipolar disorder which was a mental condition that is characterized by extreme mood swings] capsule this morning but did take the rest of her medications. Compliant with care. Record review of Resident #1's progress notes dated 10/01/25 at 3:23 PM documented by LVN C, revealed x-ray results of no acute fractures or findings.On 10/27/25 at 10:23 AM, the investigator attempted to interview Resident #1, and she declined.In an interview on 10/27/25 at 11:37 AM, LVN A stated she received a report from LVN B during shift change on day of the incident, 10/01/25. LVN A stated LVN B reported Resident #1 had a bruise on her left hand. LVN A stated LVN B reported Resident #1 refused to take her medications that were in a medication cup on the table, and Resident #1 stated she paid for medications, so she refused to give them back to LVN B and Resident #1 refused to take them. LVN A stated LVN B reported Resident #1 attempted to hit LVN B and hit herself on the side rail or the side table. LVN A stated she observed Resident #1 visibly upset that morning 10/01/25 at approximately and LVN A asked the resident what was wrong. LVN A stated Resident #1 reported the night nurse squeezed the resident's hand to take the medications Resident #1 had. LVN A stated Resident #1 physically demonstrated how her hand was grabbed which LVN A believed consisted with the bruises observed on Resident #1's left hand. When asked of the sizes of the bruises by, LVN A stated the 3 bruises on top of Resident #1's left hand looked like fingerprints, and all 3 bruises were purple in color. During a follow up interview on 10//27/25 at 3:17 PM, LVN A stated she attempted to notify the Administrator of Resident #1's allegation against LVN B. She stated the Administrator was the Abuse Coordinator and he was to be notified of all abuse, neglect, and exploitation allegations immediately. LVN A stated she called the Administrator that morning on 10/01/25 immediately after Resident #1 made her allegation of abuse, but he did not answer at that time which was approximately 7 AM. She stated she notified RN Supervisor D, and she notified the DON and the DON notified the Administrator immediately. LVN A stated the DON was aware of Resident #1's allegation against LVN B, alleging LVN B squeezed her hand and there was a bruise. LVN A stated allegations of abuse or neglect were to be immediately reported to the Abuse Coordinator or the immediate supervisor, and the alleged preparator was to be removed off the facility and suspended pending investigation. LVN A stated she observed LVN B arrive on her assigned night shift the following day.During a telephone interview on 10/27/25 at 1:15 PM, LVN B stated it was approximately 5:30 AM and she tried to administer Resident #1's medications. LVN B stated Resident #1 stated she would take the medications when she wanted to. LVN B stated she would not be able to leave the medications unattended and that Resident #1 left the medication cup with the medications on the side table. LVN B stated the side table was located at Resident #1's left side in front of her while the resident was in bed. LVN B stated she attempted to reach for the medication cup and Resident #1 began to scream and swinging, and thought Resident #1 could have got her bruises from the side rail or the table because Resident #1 swung her arms. LVN B stated Resident #1 was screaming and punching LVN B, which connected and resulted in a bruise on LVN B. She stated she called RN Supervisor E via phone while LVN B continued to be at Resident #1's bedside. LVN B denied ever touching the resident, including her hand or wrist. LVN B stated Resident #1 was screaming while LVN B was on the phone with RN Supervisor E. She stated RN Supervisor E came into Resident #1's room and LVN B removed herself from the situation. LVN B stated she was documenting that morning 10/01/25 when she was made aware by DON that Resident #1 alleged LVN B squeezed her hand. LVN B stated she notified the DON of the incident, Resident #1's behavior which included the swinging of arms. She stated there was an internal investigation conducted. LVN B stated the nursing facility conducted weekly or bi-weekly abuse, neglect, or exploitation in-services, and her most recent ANE in-service was last week. She stated the Administrator was the Abuse Coordinator. She stated she observed 2 bruises by the knuckles and the other bruise was on top of the hand; all 3 bruises were smaller than a penny. LVN B stated the bruises were all purple from what she could recall, but it had been a month since the incident and the investigator could refer to her documentation. In an interview on 10/27/25 at 2:22 PM with the Director of Human Resources, she stated LVN B was not suspended at any time after Resident #1 made the abuse allegation on 10/01/25.In a phone interview on 10/27/25 at 2:39 PM with Resident #1's Power of Attorney (POA), she stated she was called and notified of the incident regarding the resident's behavior. She stated she was also notified by the nursing facility staff of Resident #1's allegation. The POA stated she offered to assist the facility staff by being present as Resident #1 calmed down and did well when family was present at the bedside. The POA stated the staff agreed and she was there that morning but unable to recall the time. The POA stated she was there at Resident #1's bedside that morning of 10/01/25, and she observed Resident #1 being uncooperative with nursing staff when they attempted to assist Resident #1 with changing her shirt. The POA stated Resident #1 was upset and informed the POA of her allegation, but the POA stated Resident #1 did not cooperate with staff. She stated she had observed Resident #1 being agitated when uncooperative with nursing staff for some weeks before 10/01/25, which she believed contributed to Resident #1's bruising on her left hand. The POA stated she did not examine the bruising because Resident #1 was agitated, but the bruises were all the colors of bruises. all the purples and greens. The POA denied concern with Resident #1's care provided by the nursing facility, and she denied concerns regarding abuse.In an interview on 10/27/25 at 3:27 PM with the DON, she stated she was notified by RN Supervisor D that Resident #1 reported someone had squeezed Resident #1's hand and there was a bruise. The DON stated she spoke with Resident #1 and had LVN A present. The DON stated Resident #1 did not report any allegations of abuse to her and the resident declined to speak with the DON about her bruise. The DON stated she did not observe the resident distressed. The DON stated the police were notified of Resident #1's allegation, but they did not take the case. The DON stated there were a total of 4 bruises observed on Resident #1's left hand, and they were in different stages of healing. She stated 2 bruises, one on the top of the left hand and the other on the side of hand, were deep purple. She stated another bruise on the hand was yellow, and the last bruise on the hand was red and purple. She stated the 3 bruises on the top of the left hand were small circles, approximately 2 cm. The DON stated she did not think the incident was to be reported to the State Survey Agency since LVN B documented the resident's combative behavior during medication administration that morning 10/01/25. The DON stated Resident #1's POA, and Physician were notified of the behaviors and of the allegation. She stated there was an order for x-ray for Resident #1's left hand which there were no acute findings or fractures. The DON stated the facility conducted a safe survey for residents on 10/13/25 and conducted an ANE in-service for the nursing facility staff on 10/13/25. The DON stated she and the Administrator became aware that an employee called the facility's corporate hotline for employees due to an anonymous employee was concerned about the lack of reporting, investigation, and suspension of the alleged perpetrator, LVN B, after Resident #1 made an abuse allegation. The DON stated she was aware that Resident #1 alleged to LVN A that LVN B had squeezed Resident #1's hand on 10/01/25, but it was not presented as an allegation of abuse. The DON stated she discussed the allegation of Resident #1's hand being squeezed with the Administrator and corporate, which was deemed not as abuse because of LVN B's documentation of Resident #1's behaviors. She stated the behaviors made sense as being a possible cause for the bruises, as Resident #1 had behaviors for approximately 1-2 months before 10/01/25. The DON stated LVN B was not suspended during the self-report on 10/13/25, nor on day of the allegation on 10/01/25, because the facility staff, the DON and Administrator had evidence to unsubstantiate Resident #1's allegation. The DON stated the Administrator was the Abuse Coordinator and he was responsible for reporting all allegations of ANE to the State Survey Agency per the policy's time frame. She stated if he were unable to, it would be her responsibility to as the DON. She stated the purpose of reporting allegations of ANE to the State Survey Agency were to protect the residents and to ensure the residents were free from ANE. In an interview on 10/27/25 at 4:00 PM with the Administrator, he stated he was notified of Resident #1's allegation of bruise and her hand being squeezed on 10/01/25 by RN Supervisor D. The Administrator stated the DON spoke and assessed Resident #1, which the DON did not identify any concerns. He stated Resident #1 did not report concerns or allegations of abuse to the DON. He stated himself and the DON were not notified of allegations of abuse but were made aware of Resident #1 alleged her hand was squeezed by LVN B on 10/01/25. He stated himself and the DON reviewed documentation which LVN B noted Resident #1's combative behavior on 10/01/25 during that night shift. He stated no issues were identified. The Administrator stated he was notified by the corporate compliance line of an employee reporting their concern that Resident #1's alleged perpetrator was not suspended after Resident #1's allegation. He stated that was when it was presented as abuse. The Administrator reviewed the nursing facility abuse policy and read it was the responsibility of the facility to report allegations of abuse with no serious injury within 24 hours from allegation was made. He stated he was the Abuse Coordinator. He stated safe surveys for residents were completed after self-reporting on 10/13/25, and no issues were identified. He stated no allegations of ANE were reported to him or the DON on 10/01/25. The Administrator stated staff were trained to report allegations of ANE to himself as the Abuse Coordinator, the DON, and their immediate supervisor. He stated LVN B was not suspended because the initial and the 5-day paperwork were submitted within 30 minutes on 10/13/25. He stated that himself and the DON investigated there was no abuse on 10/01/25 by reviewing progress notes, speaking with LVN B, and Resident #1 did not report allegations of abuse and Resident #1 denied that her hand was squeezed on 10/01/25, though the Administrator stated he did not speak with Resident #1 on 10/01/25.Record review of the nursing facility's policy Abuse dated October 2022, revealed the purpose of the policy was to identify, prohibit, and prevent resident abuse. Under procedure, Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual including caretaker, of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being. It reflected, 4. The facility will ensure the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The policy reflected, 6. Any allegation of abuse will be immediately reported to the Administrator. The facility will designate an Abuse Prevention Coordinator who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency, law enforcement, and other officials in accordance with state law. The policy also reflected 8.a. Any reasonable suspicion of a crime will be reported to the state agency and law enforcement immediately, but no later than 2 hours after forming the suspicion if results in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Lastly, the policy reflected 9. Covered individual is anyone who is an owner, operator, employee, manager, or agent or contractor of facility. The covered individual will report the suspicion of a crime to the state agency and law enforcement within the required regulatory timeframes.Record review of the nursing facility policy Abuse Reporting with revision date October 2022, revealed the purpose of abuse reporting was to ensure allegations of abuse are reported immediately to the Administrator and/or Director of Nursing and required Agencies. Under procedure, it noted: 1. The facility will designate an Abuse Prevention Coordinator who is responsible for reporting allegations of abuse to the state agencies, law enforcement, and other officials in accordance with state law. It also reflected, 4. The facility will have a process in place to report allegations of abuse, neglect, exploitation, or mistreatment including injuries of unknown origin and misappropriation of resident property, and suspected crimes to the required agencies within twenty-four (24) hours of identification if the events that cause the allegation do not involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 2 of 10 employees (CNA A and CNA B) reviewed for annual employee misconduct registry and nurse aide registry screenings, in that: The facility had failed to complete annual employee misconduct registry and annual nurse aide registry screenings for CNA A and CNA B. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings included:-Record review of facility's policy undated on Abuse, Neglect and Exploitation revealed, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The components of the facility abuse prohibition plan include Screening-Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Screening may be conducted by the facility itself, third-party agency or academic institution. The facility will maintain documentation of proof that the screening occurred. -An interview and record review on 09/12/25 at 3:59 p.m., with the HR Resource Assistant, revealed CNA A was hired on 03/26/24 and the last EMR/NAR screening was completed on 03/20/2024. She said, We do not have any other EMR/NAR screening in the CNA's employee file to show that the annual EMR/NAR screening was completed according to facility policy. She said EMR/NR screening should be completed upon hire and annually. -An interview and record review on 09/12/25 at 4:04 p.m., with the HR Resource Assistant, revealed CNA B was hired on 05/01/18 and the last EMR/NAR screening was completed on 01/31/24. She said, We do not have any other EMR/NAR screening in the CNA's employee file to show that the annual EMR/NAR screening was completed according to facility policy. -During an interview and record review on 09/15/25 at 9:59 a.m., with the HR Business Partner, confirmed annual EMR/NAR screenings had not been completed on CNA A and CNA B. She said, EMR/NAR checks should be completed upon hire and annually according to facility policy.-During an interview on 09/15/25 at 11:30 a.m., with the Administrator in the presence of HR Business Partner revealed, EMR/NAR checks should be completed upon hire and annually according to facility's policy and best practice.

Based on observation, interview, and record review, the facility failed to ensure that residents environment remained as free of accidents and hazards as possible, and each resident received adequate supervision to prevent accidents for 2 (Resident #2 and Resident #12) of 5 residents reviewed for quality of care.1. The facility failed to ensure the call light was within reach, assist bars were in place, and the bedside table was positioned away from Resident #2 on 8/28/25.2. The facility failed to ensure an PT/OT evaluation was completed for Resident #12, who required an assessment for assist bars to support bed mobility.These failures could place residents at risk for falls, injuries, loss of independence, and unmet care needs, which may result in a decline in overall health, safety, and quality of life. Findings included: 1. Record review of Resident #2's face sheet dated 9/11/25 revealed [AGE] year-old male was admitted to the facility on [DATE]. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed his cognition was severely impaired. For rolling left and right Resident #2 required substantial/ maximal assistance. Record review of Resident #2's history and physical dated 10/1/24 revealed a diagnosis of right sided hemiparesis (weakness on the right side of the body) seizure (sudden surge of electrical activity in the brain that can cause shaking, staring spells, confusion, or loss of awareness for a short period), vascular dementia (memory loss and difficulty thinking caused by poor blood flow in the brain, often after strokes or mini-strokes), hemorrhagic stroke (type of stroke that happens when a blood vessel in the brain bursts, causing bleeding and damage to brain cells), BPH (enlarged prostate gland (not cancer) that can make urination slow, frequent, or difficult, usually in older men). Record review of Resident #2's care plan dated 5/1/25 revealed a focus area of ADL self-care performance deficit related to Hemiplegia and risk for falls and interventions that included the resident requires (maximal assistance) by x1 staff to turn and reposition in bed every 2 hours and as necessary and assist Resident with ambulation and transfers, utilizing therapy recommendations. At risk for injury/falls r/t Traumatic hemorrhage, fall prior to admission with interventions that included Call light within reach when in bed and provide assistive devices for mobility as indicated. Record review of Resident #2's side rail assessment dated [DATE] revealed consideration due to medical needs and mobility/transfer assistance; benefits included assist resident with movement while in bed, assists with positioning/turning side to side in bed, provides with feeling of comfort and security in bed, defines bed parameters; no risks were identified; siderail were recommended at the time for medical reason; resident and resident RP were marked notified and discussed the risks and benefits from using siderails. Record review of Resident #2's electronic medical records for August and September 2025 revealed no side rail assessment was completed.Record review of Resident #2 video picture dated 8/28/25 at 4:22 pm, call light does not appear within reach, and bedside table was arm's length from the bed, and side rails were not in place. Record review of Resident #2's progress note dated 8/28/25 written by LVN Unit Manager F read in part 1625 hours Nurse was notify by CNA that resident was on the floor at principal for pain on left hip, hospice, to inform that resident situation, and has previous hip surgery. RN supervisor perform head to toe assessment, resident complain of pain on left hip, ambulance was the same place, ok sent him to hospital, call 911 at 1630, and leave facility at 1700 to [local hospital] main campus notify ADON DON, RN, we continue as protocol of this facility.Record review of Resident #2's progress note dated 8/28/25 written by DON Was notify by floor nurse that resident was on the floor, resident was on his left side scooting around, resident was partially off the floor matt. Resident alert and oriented times 1 left hip, unable to move extremity, resident unable to fully extend upper extremity and noticed abrasions to shin area. Resident unable to fully extend the upper extremity, normal baseline noticed. Called [family member] to notify of incident, [family member] stated he will call hospice. Floor nurse called hospice and got okay to send him to hospital for further treatment. Record review of Resident #2's local EMS care report dated 8/28/25 revealed cause of injury was fall from bed and height of fall was 2 feet tall. The narrative read in part he was normal baseline, GCS of 13, history of dementia, distal pulses (heartbeat felt farthest from the heart) present, and lung sounds clear. The patient sustained a bedside fall, no LOC, no blood thinners, but was found to be trauma hypotensive with systolic of 105. He denied any pain. Record review of Resident #2's local hospital note dated 8/28/25 revealed a [AGE] year-old male with a history of vascular dementia, prior hemorrhagic stroke with right-sided weakness, seizures, and BPH, was admitted to the hospital on [DATE] after an unwitnessed fall from bed at the nursing facility. On arrival, he was confused but hemodynamically stable with a GCS of 13. A CT scan of the brain showed no acute bleeding or injury but revealed chronic changes, including left frontal lobe scarring, brain shrinkage, and small-vessel disease. The pelvis X-ray showed no fractures or dislocations. It did show weaker bones, moderate arthritis in both hips. He was managed as a trauma case, received IV fluids, and continued home medications including Keppra, lorazepam, and morphine as needed. On 8/29/25, his son requested discharge back to the nursing facility despite risks being explained, and [Resident #2] was discharged against medical advice.2. Record review of Resident #12's face sheet dated 9/12/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, his cognition was intact. For rolling left and right, Resident #12 was marked as requiring substantial/ maximal assistance. Record review of Resident #12's history and physical dated 5/6/15 revealed diagnoses of morbid obesity, unspecified osteoarthritis, and COPD (lung disease that block airflow and make it difficult to breathe). Record review of Resident #12's care plan dated 5/29/25 revealed focus area for ADL self-care performance deficit related to impaired balance, spinal stenosis (happens when the space inside the backbone is too small), artificial right knee; prefers call light for easier accessibility to be wrapped on his bed side rail with interventions that included bed mobility: requires dependent assistance by x2 staff to turn and reposition in bed every 2 hours and as necessary and SIDE RAILS: 1/4 side rails up as per doctor's order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition every 2 hours and as necessary to avoid injury was resolved/ discontinued on 8/27/25. Record review of Resident #12's electronic medical records for revealed there was no side rail assessment completed. During an interview on 9/11/25 at 10:36 am, LVN Unit Manager F stated therapy had begun evaluating all residents for the use of assist bars as of the previous week. Prior to that, admissions would ask residents if they wanted assist bars and would place them. He stated that after admission, if a resident requested assist bars, the nurse would conduct a side rail assessment and proceed from there. He stated he was familiar with Resident #2 and that a side rail assessment had been completed for him on 7/2/25, which indicated medical necessity for a side rail. He stated that later in August, the facility received new beds and were pending therapy assessments to determine who required them. Because of this, not many residents had bed rails at that time. He referred to the notes from 7/27/25 and stated he had written a note after Resident #2's family member requested full bed rails. He stated he educated the family member that only quarter assist bars could be provided, which Resident #2 had prior to receiving the new bed. He stated that full assist bars would have been considered a restraint since Resident #2 would not have been able to get out of bed. He explained that when a side rail assessment warranted rails, an order would be placed in the electronic health records, and maintenance, through the DOR, would install them. He was shown the picture and the date and stated that during that week the new beds had been delivered, which was why assist bars were not in place. He stated Resident #2 had a history of falls, and interventions included a low bed, floor mat, and call light within reach. He stated the bedside table should not have been placed close to Resident #2 because he could have attempted to lean over to grab items, increasing the fall risk. He stated CNAs and nurses were responsible for ensuring fall precautions were in place, and rounds were conducted every two hours at a minimum. He stated failure to follow interventions could result in falls, as in the incident where Resident #2 fell and was sent to the hospital. Based on the picture, he stated the call light was not in reach and the bedside table was too close.During an interview on 9/11/25 at 11:06 am, CNA J stated she was familiar with Resident #2 and recalled he was a high fall risk. She stated interventions included a low bed, floor mats, and a call light within reach. She stated Resident #2 had assist bars, but they were removed about 2-3 weeks earlier. She stated he sometimes used them. She stated that because Resident #2 was confused and had very few belongings, which were kept on his dresser, the bedside table did not need to be close. She stated that if placed too close, Resident #2 would have been tempted to reach over and possibly fall. She stated she had worked on 8/28/25 and was the CNA assigned. After being shown the picture, she stated she could not see the call light and that it was not in reach. She also stated the table should not have been placed close. She stated Resident #2 was at risk for falls, though she did not recall whether he fell that day. She did not know why the call light was not in reach or why the table was placed that way. She stated she had received training on fall precautions.During an interview on 9/12/25 at 11:22 am, the DON stated that when she met Resident #2, he did not need assist bars. She stated the rails were intended to aid in mobility, and he was not conscious enough to use them for that purpose. She stated any intentional movement had to be assisted by staff. She stated she had started in early June of 2025. She reviewed the side rail assessment dated [DATE] and stated that in her personal observation, he did not need assist bars. She stated the floor nurses were responsible for assessments. She also stated that at the end of July 2025, therapy began evaluating residents to determine their need for assist bars, though Resident #2 had not yet been evaluated by therapy. She explained that when the beds were replaced, the old assist bars were not compatible with the new ones, so no rails were installed. She stated Resident #2 had a seizure diagnosis, which increased his risk for injury. She explained that interventions included keeping the bed in a low position, using mats, and checking on him every hour due to family involvement. She stated that during the fall on 8/28/25, Resident #2 had been restless. She recalled seeing him on the floor and that EMS had placed him back in bed. She stated he did not appear to be in pain and had no visible head injury when he returned. She stated the call light was not visible in the picture. She noted that policy required items to remain within reach, but the bedside table did not specifically care planned to be away from him. She stated that with restless residents, staff could add care plan interventions to remove or reposition tables if needed.During an interview on 9/12/25 at 2:05 am, the DOM stated he did not know which residents required side assistance bars, as he was waiting on PT evaluations. He stated all new beds were installed the last week of August 2025, and the assist bars were placed in storage pending therapy's list for installation.During an observation and interview on 9/12/25 at 2:33 pm, Resident #12, Alert and Oriented x4, was in bed and no assist bars were noted. He stated his bed rails were removed about 2-3 weeks ago when the new beds arrived. He stated he had used them for bed mobility, but now had to wait for staff assistance. He stated this change affected his independence. He stated he had asked about it and was only told they were waiting for the new bed rails to arrive.During an interview on 9/12/25 at 3:23 pm, the DOR stated PT and OT completed evaluations to determine their need and this would take about 30 minutes. He stated the bars were meant to assist with bed mobility and transfers for ADLs. He stated the new beds were installed about two weeks earlier. He stated approximately 71 evaluations had been completed, a little less than half of the residents. Some residents did not yet have bars because the assist bars were not available. He stated once evaluations were complete, physicians had to approve the orders, including those for enablers.During a follow up interview on 9/12/25 at 4:16 pm, the DON stated Resident #12 was still pending evaluation. She stated she had been told the therapy evaluations took about 30 minutes but had seen little progress in three weeks. During an interview on 9/15/25 at 9:34 am, the Administrator stated clinical leadership, unit managers, and DONs were responsible for prevention, call light placement, and ensuring staff were aware of fall risks. He stated post-fall risk meetings were held to identify causes and implement interventions such as footwear, low beds, and call lights. He stated he was familiar with Resident #2, describing him as paralyzed and later confused. He stated a fall mat was in place, the bed was in the lowest position, and although a call light was expected to be within reach, it could not be seen in the picture. He stated if the call light was thrown off the bed, frequent rounding should have ensured it was replaced. He stated the bedside table could obstruct pathways unless specifically care planned to be removed. Regarding assist bars, he stated this was a new process with the new beds and therapy assessments were pending. He stated the facility already had the bars but had not made progress on installations. He stated frequent rounding and call light placement were the main interventions, though ideally the bars would enhance independence.Record review of the facility's Fall Prevention and Reduction Program policy not dated revealed in part A fall is defined as the act of unintentionally coming to rest on the ground, floor, or other lower level (e.g., onto a bed, chair, or bedside mat) but not as a result of an overwhelming external force (e.g., a resident pushes another resident). The fall may be witnessed, reported by the resident or an observer, or identified when a resident is observed on the floor or ground and can occur anywhere. A near miss or an episode where a resident lost his or her balance and almost fell is also considered a fall, as well as a fall that does not result in injury. Individualized approaches may include, but are not limited to: evaluating the resident for recent change in medication; evaluating the resident for changes (mental/physical); therapy referral for evaluation; toileting plan to include before meals and bedtime; use of bed and chair alarms; non-restrictive Velcro alarming seatbelt; protective equipment such as non-skid material to wheelchair or anti-tippers; non-skid socks; properly fitted shoes; bed in low position; bed on floor if feasible; bed against the wall; defined perimeter mattress; use of side rails to aid in bed mobility and to define bed perimeter; and equipment to aid with access to items in room.Record review of the facility's Side Rail/ Bed Rails policy not dated read in part Purpose: To utilize a person-centered approach when determining the use of side rails/bed rails and enhance resident's mobility and functional independence. Procedure: Side rail screen to be completed prior to use of side rail(s) which will address alternatives attempted and how those alternatives failed to meet the resident's assessed needs. Facility will assess if the side rail(s) meets the definition of a restraint. Refer to restraint screen as indicated. Review the risk/benefits and reason for the use of side rail(s) with the resident and/or resident representative. Obtain informed consent prior to installation/use of side rail(s). Use of side rail will be demonstrated to the resident/resident representative.

Based on interview and record review, the facility failed to ensure sufficient nursing staff possess the competencies and skill sets necessary to provide nursing services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 1 of 1 staff member (RN C) reviewed for nursing services. 1. The facility failed to ensure RN C followed the facility's policy on blood sugar checks for Resident #6 by delegating the task to Certified Nurse Aide.2. The facility failed to ensure RN C administered injections according to the facility's policy and procedures to Resident #7.These failures could place residents at risk of being cared for not receiving nursing services by adequately trained and licensed staff, which could result in injury and infection. Findings included:Resident #6 -Review of Resident #6's admission Record, dated 09/10/25, revealed resident was admitted to the nursing facility on 06/06/25. -Review of History & Physical dated on 06/11/25 for Resident #6 revealed, [AGE] year-old male with history of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), delusional disorder (is a type if mental health condition in which a person can't tell what's real from what's imagined), type 2 DM (a condition where the body has trouble using insulin, a hormone that helps cells use glucose for energy. This leads to high blood sugar levels because the body doesn't respond well to insulin). -Review of Resident #6's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed short-term/long-term memory problems. Unclear speech. Active Diagnoses: Diabetes Mellitus. Section N - Medications: N0300. Injections. Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days - 7. N0415. High-Risk Drug Classes: Use and Indication: J. Hypoglycemic (including insulin). -Review of Care Plan of Resident #6's Care Plan dated 06/07/25 revealed, at risk for hyper/hypoglycemia related to diagnosis of diabetes mellitus. Interventions/Tasks: Observe percentages of food eaten and report food not eaten. Observe for s/s of hyper/hypoglycemia (i.e. Sweating, tremor, pallor, nervousness, headache, double vision, confusion, lack of coordination etc.), FSBS as ordered by physician. Rotate injection sites. Medication as ordered. FSBS as ordered by physician. -Review of Physician Order Summary for Resident #6 dated 09/11/25 revealed, Insulin Aspart Injection Solution 100 unit/ml inject as per sliding scale: if 0-160 = 0 if BS less than 70 initiate hypoglycemic protocol and notify MD/NP; 161-200 = 4; 201 - 250 = 8; 251 - 300 = 12; 301 - 350 = 16; 351 - 400 = 20; 400+ notify MD/NP for further orders, subcutaneously before meals related to Type 2 Diabetes Mellitus.-Review of Medication Administration Record (MAR) for Resident #6 dated July 2025 revealed, Humalog Injection Solution 100 unit/ml (Insulin Lispro) Inject as per sliding scale: If 0-160 = 0. 161-200 = 4 units. 201 - 250 = 8 units.251 - 300 = 12 units.301 - 350 = 16 units.351 - 400 = 20 units.400+ notify MD/NP for further orders, subcutaneously before meals related to Type 2 Diabetes Mellitus. BS at 7:30 AM; BS at 11:30 AM, BS at 5:00 PM. -Review of Resident #6's Medication Administration Record (MAR) dated July 2025 revealed, RN C had administered Humalog Injection Solution 100 unit/ml (Insulin Lispro) Inject as per sliding scale, on 07/19/25 at 11:30 AM for Blood Sugar Level of 238, administered 8 units of insulin Lispro subcutaneously before meals; 5:00 PM for Blood Sugar Level of 337 administered 16 units subcutaneously before meals. -Review of In-Service Training Sign-in Sheet provided by the DON on 09/15/25 revealed the Staff Development Coordinator had in-serviced Certified Nurse Aides on 09/12/25 at 12:00 noon, Topic: CNAs are NOT authorized to check blood sugars in this facility. Failure to comply with the above will result in disciplinary action. -Review of Review of copy of Text Message provided by DON on 09/15/25 revealed, Text Message was sent to Licensed Staff and Certified Nurse Aides on 09/12/25 at 4:47 pm, by Staff Development Coordinator to 148 recipients. Details of Message documented, ATTN: ALL NURSING STAFF-CNAS are NEVER to check sugars in this facility. Failure to comply will result in disciplinary action. If you are receiving this message, PLEASE contact Staff Development Coordinator from 0800-1700 Monday-Friday and/or RN Supervisor after hours and weekend.-Review of Review of Note to File provided by DON on 09/15/25 revealed, Subject: RN C. Author was left blank. Other participants and witnesses were left blank. Date/time event took place 07/19/25. Date/time note was written 09/10/25. On 07/21/25 Unit Manger F and RN ADON E, had a phone conversation with RN C regarding an incident in which he delegated to a CNA to check blood sugar for him on 07/19/25. RN C was educated on how within long term care nursing assistants and medication aids are not allowed to check blood sugar and that it is strictly the charge nurse responsibility to perform that check. RN C verbalized an understanding with no further questions or concerns. The Note to File was signed on 09/10/25 by RN ADON E, assigned to the Traditional Unit. -Review of Review of Medication Administration Competency Checklist for RN C dated 01/17/25 provided by DON 09/12/25 revealed, Met - Administers injections using proper technique.-During an interview on 09/09/25 at 9:15 AM, with CNA I revealed the CNAs had rotating schedules, so she occasionally worked on the weekends and at times was assigned to work on the 300 Hall. She said, the nursing administration had investigated an incident involving CNA H who worked on the weekends because she had done a blood glucose check for RN C on one of the residents. She said that she did not know the resident's name. She said LVN Unit Manager F, and the DON were aware of this. She said that this happened approximately one month ago. She said, I do not know what was done by LVN Unit Manager or the DON, because CNAs are not to be doing finger sticks. -During an interview on 09/09/25 at 2:10 PM, with LVN Unit Manager F assigned to the Traditional Unit revealed, said he was not aware of any concerns related to CNA doing blood glucose checks on the weekends. He said CNAs were not allowed to do blood glucose checks at the nursing home. -During an interview on 09/09/25 at 2:21 PM, with RN G Supervisor revealed, she rotated working on the weekends. She said, Restorative CNA B, had reported to her that CNA H was doing blood glucose checks for RN C who was assigned to the 300 Hall on the weekends. She said, I immediately reported this to the DON, on that day. I also talked to RN C and CNA H on that day, and he said he was sorry; he had asked CNA H to check the blood sugar on one of the residents. She said, I did not ask RN C or CNA H when I talked to them, who was the resident that she had checked the blood glucose, and I did not check the resident on that day. I know that DON investigated this, and it has not happened again. I know the nurses are always rushing to do the blood glucose checks prior to the residents eating their meals to administer the insulins according to physician's order, but I have never seen the CNAs doing the blood glucose checks for the nurses. -During an interview on 09/09/25 at 2:29 PM, with the DON revealed, RN G Supervisor assigned to the Traditional Unit called her to report CNA H, who worked on the weekends, had checked the blood glucose on a resident. She said, I did not ask RN G who was the resident. She said, RN G talked to RN C and CNA H and told them not to do it again. She said RN ADON E, had discussed this with RN C that CNAs were not allowed blood glucose checks per facility policy. The DON, said, We do not have any written documentation of the conversation between the RN ADON E and RN C related to him directing CNA H to check the blood glucose on the resident. We also do not have any documentation of in-service training provided to RN C about not delegating blood glucose checks to the CNAs. The DON said she could not remember if she had reported to the Administrator, that RN C had asked CNA H on one occasion to check the blood glucose on a resident in the 300-Hall. The DON said, I do not recall if this was mentioned during the morning meeting or just mentioned it to him on passing. - During an interview on 09/09/25 at 2:39 PM, with DON, RN Supervisor G, LVN Unit Manager F and RN ADON E assigned to the Traditional Unit revealed, RN Supervisor G did not recall when she had notified the DON, that CNA H had been seen on one occasion checking the blood glucose on one of the residents. RN Supervisor G said, she remembered talking to RN C and CNA H on that day and informed them that CNAs were not allowed to check blood glucose on the residents at the nursing home. RN Supervisor G said, RN C said he was sorry that he had asked CNA H to check the blood sugar on one of the residents and that she had told CNA H, CNAs were not allowed to do blood glucose checks in the nursing and did not have any written documentation related to this incident. The DON said it was an isolated occurrence, and they had not asked who the resident was or who was involved in this matter. RN ADON E said she had completed re-education with RN C and CNA H, and she had informed them that the nurses were not allowed to delegate blood glucose checks to the CNAs. She said she had not documented the conversation that she had with RN C or CNA H on that day. The DON said she did not remember if this had been reported to the Administrator. RN Supervisor G and RN ADON E said that after that incident nursing administration randomly checked during rounds that the nurses were doing the blood glucose checks, but did not have any written documentation of the random audits. The DON, said, they immediately took corrective action but did not have any written documentation of the conversations that were done with RN C and CNA H. RN ADON E said the DON, had reported to her on Monday 07/21/25, RN C had delegated to CNA H to check the blood glucose on a resident and corrective action was immediately addressed with the nurse and the CNA involved in this matter but did not have any written documentation. The nursing administration team reported they had not consulted with HR to determine what type of documentation needed to be completed to address this issue. The DON said they had been trained to consult with HR to determine what corrective action needed to be taken to address failure to follow facility policies and procedures.- During an interview on 09/09/25 at 3:48 PM, with the Administrator, revealed he was not aware RN C had instructed a CNA H to do a blood sugar check on one of the residents. He said he expected the nursing administration to immediately report to him situations like this, because this could harm the resident by allowing staff that had not been trained or qualified to perform nursing tasks. He said the nurses could not delegate tasks that were not within the scope of practice to the CNAs. He said he was not aware if the nursing administration had re-educated the staff, investigated the occurrence or if they had obtained written statements from the RN C and CNA H. He said, the nursing administration should have consulted with HR, for guidance on how to handle this situation to prevent it from reoccurring. -During a telephone interview on 09/09/25 at 4:42 PM, with CNA H, revealed RN C had asked her to do a blood glucose on Resident #6 on 07/19/25 during the weekend. She said, RN C knew that she had worked in the hospital and that CNAs were trained and were allowed to do blood glucose checks. She said, I was not aware that CNAs in the nursing homes were not allowed to do blood glucose checks. RN Supervisor G, informed me on that day, that CNAs were not allowed to do blood glucose checks in the nursing home and was told not to do it again. -During an interview on 09/10/25 at 8:51 AM, with RN C Charge Nurse on the 300 Hall, revealed he had 9 years of experience working in the Acute Hospital setting and that the CNAs were trained and allowed to perform Blood Glucose Checks on the patients. He said he had started working in a supervisory position at the nursing facility and had started working as a floor nurse a month ago. He said he was given a 2-3-day orientation before he started working on the floor independently. He said the staffing pattern was different on the weekends. He said, So sometimes we do not have a Medication Aide, so we are rushing to do blood glucose checks and administer insulin before meals. He said, I knew that CNA H had worked in acute care, so I asked her on one occasion to check the blood sugar on Resident #6, but do not remember the exact date. This was a couple of months ago. I was not aware that the CNAs were not allowed to do blood glucose checks at the nursing homes. On that day, RN Supervisor G was on duty, and she informed me later during the shift that CNAs were not allowed to do blood glucose checks in the nursing homes. He said, LVN Unit Manager F called me on Monday or Tuesday to inform me that CNAs were not allowed to perform blood glucose checks at the nursing home. I was very honest with him and confirmed that I had asked CNA H to help me check the blood glucose on Resident #6, and I reassured him that it would not happen again. He said, on that day Resident #6 was already in the main dining room. He said that sometimes the CNAs wheeled the residents to the dining room before he checked the blood glucose before meals according to physician's orders. He said, I remember that on that day, Restorative Aide C, had wheeled Resident #6 to his room, before I had done the blood glucose check, and that is why I asked CNA H to go do the blood glucose check for Resident #6. I remember that I administered insulin to the resident on that day, after I got the blood glucose level from CNA H. The resident did not have any adverse reaction to the insulin on that day. He said that he had never asked other CNAs to do blood glucose checks and that he had only asked CNA H to do a blood glucose check only on one occasion. - During an interview on 09/15/25 at 10:45 AM, DON said, I do not have anything in writing for RN C when he asked CNA H to check the blood sugar check on Resident #6 or about injecting Resident #7 over the shirt, but I did confirm that RN ADON E, LVN Unit Manager F, and RN Supervisor G had talked to RN C.Resident #7 -Review of Resident #7's admission Record, dated 09/11/25, revealed resident was admitted to the nursing facility on 08/15/24. -Review of History & Physical dated on 08/13/25 for Resident #7 revealed, [AGE] year-old male with Past Medical History of diabetes. -Review of Resident #7's Annual Minimum Data Set (MDS) dated [DATE], revealed, Brief Interview for Mental Status (BIMS) documented a BIMS Score of 14 (cognitively intact); Section I - Active Diagnoses Diabetes Mellitus. Section N - Medications - N0350. Insulin administered during the last 7 days. N0415. High-Risk Drug Classes: Use and Indication - Hypoglycemic (including insulin). -Review of Resident #7's Care Plan revised on 08/16/24 revealed, at risk for hyper/hypoglycemia related to diagnosis of diabetes mellitus. Interventions/Tasks: Rotate injection sites. Observe percentages of food eaten and report food not eaten. Observe signs and symptoms of hyper/hypoglycemia (i.e. Sweating, tremor, pallor nervousness, headache, double vision, confusion, lack of coordination, etc.). Medication as ordered. FSBS as ordered by physician. -Review of Resident #7's Physician Order Summary dated 09/11/25 revealed, Insulin Aspart Injection Solution 100 Unit/ML inject as per sliding scale: If 90-140 = 2; 141 - 200 = 3; 201-275 = 4 276-350 = 5. If above 401 notify NP for further orders, subcutaneously before meals related to Type 1 Diabetes Mellitus. -Review of Resident #7's MAR dated September 2025 revealed, Insulin Aspart Injection Solution 100 Unit/ML inject as per sliding scale: If 90-140 = 2141 - 200 = 3 201-275 = 4 276-350 = 5. If above 401 notify NP for further orders, subcutaneously before meals related to Type 1 Diabetes Mellitus. -During a confidential interview on 09/09/25 at 10:25 AM, Restorative CNA B had said that she had seen RN C give an insulin injection to Resident #7 in the main dining room area. Restorative CNA B said RN C had stuck the needed through the shirt and had not cleaned the injection site prior to giving the insulin injection. Restorative CNA B said she had reported this to the RN Supervisor G that worked on that weekend, and she had said, Don't tell me, that is not my problem. The administration said they would handle this problem internally. -Telephone interview on 09/09/25 at 10:54 AM, with RN C, revealed he was rushing to administer insulin to Resident #7, because he was already in the dining room and he administered the insulin through the shirt, because he had on a long sleeve shirt and did not want to roll the sleeve up in the dining room to give him his insulin. He said he could not recall the date when he had done this. He said, I remember that RN Supervisor G and LVN Unit Manager F informed me when they called me on that day, to let me know that insulins could not be administered in the dining room. He said, he had not followed the technique on insulin administration like he was trained to do in nursing school. I know that the injection site needs to be cleaned prior to administering the injections. He said he was also trained in nursing school not to administer insulin through the clothes. He said, this could place the resident at risk for infection. -During an interview on 09/09/25 at 1:53 PM, with Restorative CNA B revealed, she had reported to RN G who was the week-end Supervisor on that weekend that she had seen RN C inject insulin to a resident in the main dining room through the clothing, and that RN C was passing by the resident and did not tell the resident he was going to give him an insulin injection and just poked the resident with the needle through his shirt. She said the resident was startled when RN C had done this to him. I don't think that what RN C did to the resident was right, because he had not cleaned the area on the arm prior to injecting the insulin to the resident, and that placed the resident at risk for infection. This happened more than a month ago on the weekend, and I do not remember who the resident was. I later followed up with RN G, to see what had been done about my concern and all she said was that she had reported this to the DON. -During an interview on 09/09/25 at 2:29 PM, with the DON revealed, she was not aware that Restorative CNA B had reported to RN Supervisor G that she had seen RN C inject a resident through his T-Shirt in the main dining room. The DON said The RN Supervisor G should have reported this to me or to RN ADON E and LVN Unit Manager F right away, to immediately address this concern to prevent it from reoccurring. This practice could place the resident at risk of infection. -During an interview and record review on 09/12/25 at 11:30 AM, with the DON revealed the facility did not have a Skills Checklist on Insulin Administration for the licensed staff. She informed the state surveyor she had found a Skills Checklist on Insulin Administration in one of the facility's Manuals that she was going to start using to check licensed staff on Insulin Medication Administration. She said the checklist documented, to select an appropriate injection site, free from edema, induration, tenderness, or skin irritation. Cleanse site with alcohol swab beginning at center of site and rotating outward approximately 2 inches. Allow skin to dry completely; do not fan or blow on site. With non-dominant hand, spread skin across injection site or pinch skin around injection site. Inform resident he/she will feel a slight pinch, pressure, or stinging sensation as the insulin is injected. She said, This will ensure licensed staff do not inject insulin over the clothes without cleaning the injection site, prior to administering the insulin. She said she was still looking for a policy & procedure on insulin administration and would provide the state surveyor a copy of the policy if she found one. The surveyor requested a copy of Nursing Policy & Procedures on Injection Administration. The DON did not provide the requested document before exit. The surveyor requested a copy of Pharmacy Policy & Procedures on Injection Administration. The DON did not provide the requested document before exit. Review of the facility's policy and procedures on Medication Administration revised July 1, 2025, revealed administer medications as ordered in accordance with manufacturer specifications. According to Manufacturer's specifications obtained on 09/10/25 at https://www.novo-pi.com Subcutaneous injection: inject subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm.

Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for 1 (Resident #6) of 2 residents reviewed for pharmaceutical services.-The facility failed to administer insulin to Resident #6 according to physician orders.-The facility failed to ensure LVN D administered insulin to Resident #6 according to Manufacturer's Specifications. This deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health.The findings include: -Review of Resident #6's admission Record, dated 09/10/25, revealed resident was admitted to the nursing facility on 06/06/25. -Review of History & Physical dated on 06/11/25 for Resident #6 revealed, [AGE] year-old male with history of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), delusional disorder (is a type if mental health condition in which a person can't tell what's real from what's imagined), type 2 DM (a condition where the body has trouble using insulin, a hormone that helps cells use glucose for energy. This leads to high blood sugar levels because the body doesn't respond well to insulin). -Review of Resident #6's Annual Minimum Data Set (MDS) dated [DATE], revealed short-term/long-term memory problems. Unclear speech. Active Diagnoses: Diabetes Mellitus. Section N - Medications: N0300. Injections. Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days - 7. N0415. High-Risk Drug Classes: Use and Indication: J. Hypoglycemic (including insulin). -Review of Care Plan of Resident #6's Care Plan dated 06/07/25 revealed, at risk for hyper/hypoglycemia related to diagnosis of diabetes mellitus. Interventions/Tasks: Observe percentages of food eaten and report food not eaten. Observe for s/s of hyper/hypoglycemia (ie. Sweating, tremor, pallor, nervousness, headache, double vision, confusion, lack of coordination etc.), FSBS as ordered by physician. Rotate injection sites. Medication as ordered. FSBS as ordered by physician. -Review of Physician Order Summary for Resident #6 dated 09/11/25 revealed, Insulin Aspart Injection Solution 100 unit/ml inject as per sliding scale: if 0-160 = 0 if BS less than 70 initiate hypoglycemic protocol and notify MD/NP; 161-200 = 4; 201 - 250 = 8; 251 - 300 = 12; 301 - 350 = 16; 351 - 400 = 20; 400+ notify MD/NP for further orders, subcutaneously before meals related to Type 2 Diabetes Mellitus. -Review of facility's mealtimes revealed Breakfast was served at 7:00 a.m., Lunch at 11:30 a.m., and Dinner at 5:00 p.m. -Review of Medication Administration Record dated September 2025 for Resident #6 revealed LVN D had not checked Resident #6's Blood Glucose on 09/09/25 at 5:00 PM before meals according to physician's order. -Review of Resident #6's Nursing Progress Note dated 09/09/25 at 6:47 p.m. written by LVN D, revealed Resident was in activities and went straight to the dining room. -Review of Note to File dated 09/09/25 at 6:30 PM written by RN ADON E, revealed LVN D was educated by LVN Unit Manager F on 09/09/25 regarding proper documentation and timely administration of insulin. LVN D was also educated on following orders for residents regarding assessment of blood glucose levels prior to mealtimes. LVN D verbalized an understanding at this time. -Review of Medication Error Report dated 09/09/25 at 6:45 PM, written by DON revealed, Incident Description: On 09/09/25 approximately 6:45 p.m., Resident #6 did not have his blood glucose checked prior to dinner and therefore did not receive any sliding scale coverage for his dinner. Immediate Action Taken: Upon discovery of incident, Unit Manager assessed resident. Morning BGL 181. The resident was covered with 4 units of short acting insulin and scheduled dose of long-acting insulin. The Resident did not exhibit any signs of hyper/hypoglycemia. NP notified - no new orders obtained. Notes: Resident #6 is an [AGE] year-old male admitted [DATE]. Resident diagnosis includes dementia and type 2 diabetes. DON identified medication error made night prior - resident was not administered sliding scale insulin because resident did not get his blood glucose read prior to dinner. NP notified of findings in morning and reported most recent BGL in am and that resident did not exhibit any signs of hypo or hyperglycemia. No new orders obtained from NP. Resident POA notified about incident. LVN D educated about proper procedure if resident blood glucose not checked prior to dinner - call NP that blood glucose was not checked prior to dinner and obtain orders for how to proceed. Nurse verbalized understanding. -Review of Resident #6's Nursing Progress Note dated 09/10/25 at 8:30 AM, written by LVN Unit Manager F revealed, Spoke with NP regarding blood sugar not being checked yesterday evening. His BS this morning was 181, given 4 units of Novolog for sliding scale coverage and 23 units of insulin Glargine scheduled. No new orders given. No s/s of hypo/hyperglycemia. Will continue to monitor. -Review of Medication Administration Record for September 2025 for Resident #6 revealed, LVN D documented on 09/09/25 blood glucose had not been completed at 5:00 PM and had not administered Aspart insulin according to sliding scale coverage as ordered by the attending physician. LVN D documented, on 09/10/25 BS at 5:00 PM was 242 and had administered 8 units of Aspart insulin according to sliding scale coverage. -Review of In-Service Training Sign-in Sheet dated 09/10/25 at 6:20 PM presented by LVN K Staff Development Coordinator, revealed Oral Presentation: All Licensed Staff. SNACKS/MEAL POST SLIDING SCALE COVERAGE: Sliding Scale Coverage MUST be given within 30 minutes after checking a resident's blood sugar. A snack/meal tray MUST also be given within 15 minutes of sliding scale insulin administration. If the resident refuses the snack/meal tray. The refusal must be documented in resident's clinical record. -Review of Note to File dated 09/10/25 at 6:22 PM, written by RN ADON E, revealed LVN D was educated on informing the NP of any time medications, including insulin is held was educated on reporting whenever BGL is unavailable/she is unable to assess to the nurse practitioner. She was also educated at this time on providing a substantial snack or assure their tray will be in front of them within 15 minutes of insulin administration. LVN D verbalized understanding. -Review of Medication Error Report dated 09/10/25 at 6:39 PM, written by RN ADON E revealed, Incident Description: Resident #6 was administered Insulin Aspart 8 units at 4:08 p.m., and received his dinner tray at approximately 5:15 PM. Immediate Action Taken: Resident was observed to be asymptomatic and noted to consume dinner with no issues. Notes: Resident #6 is an [AGE] year-old male admitted [DATE]. Resident diagnosis includes dementia and type 2 diabetes. LVN D was observed to have administered 8 units of insulin Aspart to the resident with a BGL of 242 at approximately 4:08 PM prior to dinner time. Resident received his tray at approximately 5:15 PM. LVN D reeducated at this time on providing a substantial snack or assure their tray will be in front of them within 15 minutes of insulin administration. Charge nurse verbalized an understanding of this procedure. DON, ADON, Administrator, POA and NP notified.Record review of Pharmacy Consultant reports dated May - August did not reveal any concerns related to insulin administration. During an interview on 09/09/25 at 4:00 PM, with LVN D, revealed she had already administered insulin to her assigned residents. During an observation and interview on 09/09/25 at 5:01 PM, with the CNA L revealed Resident #6 was sitting in the dining room at the assisted feeding table waiting for dinner to be served. The CNA informed the state surveyor, the resident was hard of hearing and occasionally answered simple questions. Resident did not respond to the surveyor when asked simple questions. During an interview and record review on 09/09/25 at 5:13 PM, with RN, ADON E revealed, Medication Administration Record dated July 2025 for Resident #6 revealed LVN D, had documented she had checked the resident's blood glucose level before meals according to physician's orders. During an observation on 09/09/25 at 5:23 PM, revealed Resident #6 was served his meal tray and CNA started to spoon feed the resident. During an interview on 09/09/25 at 5:25 PM, with LVN D, revealed, she had not checked the blood sugar for Resident #6 before dinner according to physician's orders, because she was busy handling a medical emergency with another resident. During an interview on 09/09/25 at 5:26 PM, with CNA L, revealed she was new and did not know which residents got insulin before meals. She said, there is always a tray with snacks at the nurse's station to give to the residents as needed until dinner is served. During an interview and record review on 09/09/25 at 5:31 PM, LVN Unit Manager F revealed, Licensed Staff had been trained to check blood sugar according to physician's order. He said, LVN D, should have checked the blood sugar ac dinner so insulin could be administered to physician's orders. During an interview on 09/09/25 at 5:33 PM, with DON revealed Licensed Staff had been trained to check blood glucose ac meals according to physician's order, to ensure insulin was administered according to physician's order. During an observation on 09/10/25 at 5:00 PM, revealed Resident #6 was in dining room waiting for dinner to be served. During an observation on 09/10/25 at 5:14 PM, revealed Resident #6 was served his dinner tray and the CNA started to spoon feed the resident. During an observation and interview on 09/11/25 at 1:29 PM with LVN MDS Nurse M revealed, Resident #6 was a diabetic on insulin and had orders for blood sugars to be done before meals and had orders to administer Aspart insulin according to sliding scale coverage according to physician's orders. During Telephone interview on 09/12/25 at 9:52 AM, with Pharmacy Consultant Pharmacist in the presence of supervisor, revealed she did not have the records for her visits to know if there were any issues related to insulin administration and could not reply to the surveyor's question. She said if a resident had an order for blood glucose checks ac meals, she was not aware of a timeframe as to when glucose checks should be done, because it would be facility specific due to the times that meals are served. She said that physician's orders for sliding scale coverage are for Rapid Acting Insulins such as Insulin Aspart or Lispro. She said if blood glucose checks were not done as ordered and sliding scale insulin was not administered due to that, it would be considered an omission. This could be because a resident was out on an appointment and/or not in the room or under other circumstances. During an interview on 09/12/25 at 2:17 PM, with LVN D in the presence of the DON revealed, Resident #6 was non-verbal and would only say a word or two. She said she had not checked Resident's blood sugar on 09/09/25 at 5:00 PM, before dinner according to MD order, so she had not covered the resident with Aspart sliding scale coverage as ordered. She said they had been trained to do blood glucose checks prior to meals and administer insulin according to physician's orders. She said, On that day the resident was taken to the dining room prior to her checking the blood sugar. LVN D said she had administered 8 units of Insulin Aspart to Resident #6 at 4:08 PM on 09/10/25 and did not given the resident a snack within 15 minutes of administering the insulin to the resident. She said Insulin Aspart is Rapid Acting, and residents should be given a snack if the meal tray is not served within 15 minutes of administering the insulin to prevent hypoglycemia. Review of facility's policy and procedure on Medication Administration Revised July 1, 2025, revealed administer medications as ordered in accordance with manufacturer specifications. Medication times may vary based upon facility or location. Medication times/periods should remain consistent with standards of practice and resident needs. Specific medications may not be able to be generalized (such as insulins, etc.) depending upon the desired outcome and/or need to maintain a consistent level. Review of facility's policy and procedure on Medication Administration Times revised 11/15/24, revealed Policy: Sets forth the procedures related to medication administration times. Procedure: Facility should ensure that authorized personnel, as determined by Applicable Law, administer medications according to times of administration as determined by Facility's pharmacy committee and/or Physician/Prescriber. Facility staff should refer to Facility's medication administration policy to determine whether certain medications require different administration times.

Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the state survey agency, in accordance with State law through established procedures for 1 of 3 residents (Residents #10) reviewed for misappropriation of property. The facility failed to report to the State Survey Agency when Resident #10 reported to the facility that his wallet that had his SS card, ID, approximately $180, and a check book was missing on 3/28/25. This failure could place residents at risk of vulnerability for unauthorized financial transactions, potential identity theft, and emotional distress. Findings include: 1. Record review of Resident #10's face sheet, dated 4/1/25, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. He was documented as his own RP. Record review of Resident #10's history and physical, dated 8/5/24, revealed diagnoses which included: DM: A condition that causes high blood sugar levels; HLD: High levels of fats (like cholesterol) in the blood; HTN: High blood pressure; GERD:A condition where stomach acid frequently flows back into the tube connecting the mouth and stomach, causing heartburn and other symptoms. Record review of Resident #10's quarterly MDS assessment, dated 1/1/25, revealed a BIMS score of 15, which indicated his cognition was intact. Record review of progress note, dated 3/21/25, written by LVN B, revealed: [Resident #10] the CNA reported that spouse (Resident #11) had misplaced his wallet with his ID and social security card. Searched their room and unable to locate items. Missing items paper filled out and left under social workers door. RN supervisor aware. Record review of Resident #10's grievance, dated 3/21/25, revealed missing items which included the ID and Social Security card, which were marked as lost that morning. The items were later found with a note that read: SW found in residents (Resident #10's) second drawer of dresser, and was signed by the Social Worker (SW), Administrator, and OSR. The second page of the grievance, dated 3/28/25, documented additional missing items reported by Resident #10, including a brown soft leather wallet, checkbook, ID, healthcare card, Social Security card, Medicare card, and approximately $180, all in $20 bills. These items were marked as not found and the form was signed by the SW, Administrator, and OSR. Additional information read: Resident reports to social worker, his spouse misplaced his wallet. Social worker searched the room for his items, could not locate. Social worker and CNA A also searched the 500 Hall unit. Resident's rooms for missing items, could not locate. Social worker searched laundry, lost and found. Aide advised the missing item was not found in linen or laundry today. Social worker updated him and advised administrator to above. Social worker requested staff to keep eye open for missing item. Wallet has not been located. Resident aware staff will continue to keep an eye out for resident's wallet. Resident did advise there has been no activity on cards, one transaction in his bank and did alert and closed accounts. 2. Record review of Resident #11's face sheet, dated 4/1/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. She was documented as her own responsible party (RP). Record review of Resident #11's history and physical, dated 3/18/25, revealed a diagnosis which included unspecified dementia, which is a condition that affects memory, thinking, and behavior. It causes confusion, forgetfulness, and difficulty in communication or daily functioning, and it worsens over time. Record review of Resident #11's admission MDS assessment, dated 3/24/25, revealed a BIMS score of 3, which indicated her cognition was severely impaired. Record review of Resident #11's care plan, dated 3/21/25, revealed a focus area for wanders aimlessly about the facility with interventions that included: observe whereabouts frequently when out of bed, redirect as needed, observe appropriate footwear. Record review of Resident #11's progress note, dated 3/24/25, written by the Social Worker, revealed: SW advised resident will be moving to memory care unit. SW met with [Resident #10] and agreed to room change. During an interview on 4/1/25 at 10:39 AM, the Social Worker stated Resident #10's grievance was reported by staff on 3/21/25, although no description of the wallet was included in the initial report. The SW stated the wallet contained an ID, a Social Security card, and a checkbook. The SW stated when she followed up with Resident #10, he was reportedly in the bathroom at the time. The SW stated she asked Resident #11 (his wife), who was his roommate at the time, for permission to search for the wallet in which it was consented to and found in the drawer on Resident #10's side and informed him through the door. The SW stated she later followed up with Resident #10 (3/28/25) after staff continued to report the wallet as missing and obtained a proper description. The SW stated she and CNA A searched the 500 hall with resident's permission, but did not locate the wallet. She stated she followed up with laundry and the med carts where it had not been located. The SW stated she reported this to Resident #10 and he was understanding of the situation. The SW stated Resident #10 had been monitoring his bank account and had already closed the account and begun replacing his cards. The SW reported the matter to the Administrator and Onsite Representative, the VA representative, provided the final signature for the grievance. The SW stated the risk of the wallet not been located was a concern that someone could potentially use the lost items. The SW stated they had been following up daily with Resident #10 for any activity on his account, but none was reported. The SW stated she also searched Resident #11 room (she had been moved to memory care) and found nothing. As of today, the wallet and checkbook had still not been found. During an interview on 4/1/25 at 10:45 AM, The Administrator stated according to the provider letter , any allegation involving a missing item must be reported to State Operations. He reported Resident #10's wallet was reported missing a second time on 3/28/25, which contained identification, a Social Security card, money, and a checkbook. The Administrator stated medication carts and the laundry area were checked, but nothing had been found. He stated since there was no alleged perpetrator identified by Resident #10, the incident did not meet the criteria for misappropriation of property. He referenced the provider letter, which indicated deliberate misplacement must be present to consider it misappropriation and reiterated the resident did not accuse anyone of taking the wallet. During an interview on 4/1/25 at 1:23 PM, CNA A stated the Social Worker approached her and asked for assistance in locating Resident #10's missing wallet on 3/28/25. CNA A reported, prior to Resident #11, Resident #10's wife, being placed with him, he had not reported any missing items. CNA A stated she received a report which indicated Resident #11 had been taking Resident #10's belongings and placing them in different locations. CNA A stated Resident #11 was subsequently moved to the memory care unit. CNA A stated when she followed up with Resident #11 regarding the wallet, she did not recall taking it. CNA A reported even Resident #10 asked Resident #11where she had left the wallet, and the wife responded she did not know. CNA A recalled Resident #10 describing the wallet as being able to open 180 degrees and long enough to fit a checkbook. CNA A stated she assisted the SW in searching all the rooms in the 500 hall, with the resident's permission, and the wallet was not located. CNA A reported the SW also followed up with the laundry department, but the wallet was not found. During an interview on 4/1/25 at 1:46 PM, Resident #10 stated his wallet had been missing since last Friday (3/28/25). Resident #10 stated he suspected Resident #11, whom he identified as his wife, may had taken it without his consent, as she had recently become his roommate and had a history of wandering behavior, particularly at night. Resident #10 stated he recalled his shoes had been found in another resident's room on the day of Resident #11's arrival, which reinforced his concern. Resident #10 stated his wallet contained the following items: Identification Card, Social Security card, Medicare card, VA card, shot record, MasterCard, debit card, checkbook, and approximately $180 in $20 bills. Resident #10 stated he did not give Resident #11 permission to take the wallet and is uncertain if she is even aware that she took it. Resident #10 stated he had been monitoring his bank accounts daily and reported no abnormal activity. Resident #10 stated he canceled both his MasterCard and debit card two days ago after confirming a check written to his daughter had cleared. Resident #10 stated he experienced significant stress due to concerns about unauthorized use of his financial information. Resident #10 stated the facility informed him all resident rooms in the hallway, laundry areas, and other common locations were searched, but the wallet had not been found. Resident #10 stated he was offered assistance in replacing his identification documents but was currently struggling with the process due to having no identification in his possession. During an interview on 4/1/25 at 2:35 PM, Resident #11 was alert and oriented to person only and did not answer questions asked. During a follow up interview on 4/1/25 at 3:41 PM, the Administrator stated the situation which involved Resident #10's missing wallet was complex due to Resident #11, whom Resident #10 identified as his wife, having a low BIMS score and not being cognitively intact or capable of meaningful communication. The Administrator stated, because of this, Resident #11 was not considered interviewable and may not have fully understood or recalled her actions. The Administrator stated, based on how the allegation was presented, specifically the wallet was described as misplaced rather than definitively taken, it did not meet the threshold for misappropriation in his judgment. The Administrator stated if Resident #10 had clearly reported Resident #11 took his belongings and refused to return them, it would have warranted a report to State Operations. The Administrator stated the available information reflected uncertainty and shared living arrangements, which complicated the interpretation of the situation. The Administrator also stated Resident #10 and Resident #11 shared a room and possibly shared belongings, adding another layer of difficulty in determining intent or ownership boundaries . Record review of the facility's Abuse, Neglect, and Exploitation, dated 2024, read in part Definition: Misappropriation of Resident Property (Page 1) Defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Policy Expectations on Investigation and Reporting (Page 4-5) V. Investigation of Alleged Abuse, Neglect, and Exploitation An immediate investigation is required when there is suspicion or a report of: Abuse, Neglect, Exploitation, Misappropriation of resident property. VII. Reporting / Response (Page 4-5) Written procedures must include: Reporting of all alleged violations to the Administrator, State agency, Adult Protective Services, and other required agencies.

Based on observation, interview, 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 promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 7 of 15 residents reviewed for residents' rights, in that: -In the memory care unit, facility failed to serve 7 of 15 residents their meals at the same time as their tablemates, causing them to watch their tablemates eat while they waited up to 30 minutes for their meal. This failure could affect residents' self-esteem and dignity. The findings include: During an Observation on 1/27/25 at 11:30 AM, residents were observed sitting in dining area located in the memory care unit. The first meal cart containing the resident's lunch trays arrived at the memory care unit at 12:19 PM. The second meal cart containing the resident's lunch trays is observed to arrive to the unit at 12:27 PM. There are 2 of 4 residents observed in the first table not served while the other residents in table are eating their meal with 50% of meal observed eaten. The third meal cart containing the resident's lunch tray is observed to arrive to the unit at 12:41 PM. The fourth meal cart containing the resident's lunch tray arrived at 12:46 PM. At 12:47 PM, a second table observed with 1 of 4 residents ate his meal at 100% while the 3 of 4 at same table have not yet been served. At 12:48 PM, observation of the third table with 1 of 3 residents was eating meal with more than 25% of meal consumed, and the 2 of 3 residents at the same table were not served. During an interview with DON on 1/30/25 at 3:24 PM, she stated the nursing team needs to check the meal carts and observe who is in the dining room. She stated, The CNA's or the nurse hands the kitchen staff the tickets of the residents who are present in the dining room, so they are served at the same time. DON states The concern with the residents not eating at the same time is unfair to stare at someone else eating while they are not. The DON also stated, It shouldn't happen. The DON stated the nursing staff is responsible for notifying the kitchen for any pending trays, so all residents are served at the same time at the same table. During an interview on 1/30/25 at 04:24 PM with Pharmacy Nurse LN she states there is a seating chart for the dining room in the memory care unit that is updated with admissions, discharges, need for assistance, or preference. She states that residents unfortunately come back and forth from the dining area when waiting for their meal. She states the responsibility to ensure residents are all served at the same time at the same table is whoever is passing the trays such as nursing staff. Pharmacy Nurse LN states that the nursing staff also get assistance from the administrative staff to pass trays, so they are also responsible if they assist. During an interview with Interim CDM on 1/30/25 at 4:43 PM, he states the CNA's or nurses are responsible for ensuring that residents at the same table should be served and eat at the same time. He states nursing staff and kitchen staff work together to ensure residents are served their meals together. He states the risks of residents not being served at the same time include a personal attack or the resident may feel singled out. He denies having concerns regarding residents in the dining room not being served at the same time being reported to him . Record Review of the facility's policy named Resident Rights dated February 2020 read in part: The resident has the right to be treated with respect and dignity, including: The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.

Based on interview and record review, the facility failed to ensure the physician was informed of a significant change in the resident's physical, mental, or psychosocial status for 1 of 10 residents (Resident #1) reviewed for physician notification. The facility failed to consult with the attending physician on [DATE] when Licensed Vocational Nurse (LVN) K on the 2:00 PM to 10:00 PM shift noted pin point spots of blood on Resident #1's brief. On [DATE] failed to administer [MEDICATION NAME] (antibiotic) as ordered for hematuria (blood in urine). Failed to consult with the attending physician when Resident #1 displayed signs of a change in condition. On [DATE] Resident #1's condition worsened, including a significant decline in physical functioning and decreased level of consciousness, the facility failed to consult with Resident #1's physician. On [DATE], Resident #1 was sent to the emergency room (ER) where he died . This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE]. While the IJ was lowered on [DATE] at 2:00 PM the non-compliance continued at a level of actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate and monitor the effectiveness of their corrective action system. This failure has the potential to affect 21 residents that reside on the Special Care Unit (where Resident #1 resided) by placing them at risk of potential medical complications, hospitalization , or even death related to changes in condition. Findings included: RESIDENT #1 Review of Resident #1's Electronic Medical Record (EMR) undated Face Sheet documented Resident #1 was a [AGE] year-old male readmitted to the facility on [DATE]. Review of Resident #1's most recent History and Physical dated [DATE] documented in part; Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] documented, in part: Hearing adequate Speech clear Made himself understood Understood others Brief Interview for Mental Status (BIMS) score 13 which indicated he was cognitively intact Independent for eating Required one staff and extensive assistance for transfer and toilet use. Used a wheelchair for mobility Review of Nurse's Notes documented, in part: [DATE] at 11:28 PM the nurse going off duty documented: This nurse observed several pin point size spots of blood on the brief when the resident was being changed. Brief wet at this time with urine. Reported to oncoming nurse to monitor for any further changes. Signed by LVN K. [DATE] at 10:15 PM the nurse going off duty documented: Resident noted to have hematuria X 2. Observed blood tinged urine on his brief during the last two changes. Call placed to physician and orders received to get urinalysis for culture and sensitivity, Complete blood count (CBC) and give a one-time dose of [MEDICATION NAME] (antibiotic) 1-gram Intra Muscular (IM). Signed by LVN K. (No documentation of Resident #1 receiving [MEDICATION NAME].) [DATE] at 5:20 AM resident noted with abdominal distention, no urine output throughout shift, last void was yesterday at 8:00PM. Resident complained of discomfort to lower abdomen. This nurse offered pain medication, resident denied. Call placed to physician. Vital Signs (VS) ,[DATE] (blood pressure), 86 (pulse), 18 (respirations), 94% oxygen saturation on 2 L/M (liters per minute), 98.9 temporal temperature. Will pass on report, continue to monitor. Signed by LVN J. [DATE] at 5:47 AM physician called back and ordered in and out catheter. Urine output 850ml (milliters). Pending call back from physician to report urine output, will pass on in report. Signed by LVN J. [DATE] at 7:01 AM per ,[DATE] nurse pending call back from physician to report urine output, will continue to monitor. Signed by LVN A [DATE] at 9:52 AM resident noted to be very weak and physical appearance out of the norms. VS ,[DATE] (blood pressure), 86 (pulse), 19 (respirations), 97.6 (temperature), oxygen saturation 85 on room air, blood sugar 62. Nurse administered as needed oxygen via nasal cannula and oxygen saturation increased to 95%. Nurse also gave orange juice and blood sugar up to 110. Resident refused to take his [MEDICATION NAME]due to low blood sugar, will continue to monitor. Signed by LVN A [DATE] at 1:51 PM resident assessed with [REDACTED]. Resident stated, I peed today . Bladder scan performed and found 29mls of urine, will continue to monitor. Signed by LVN A. [DATE] at 7:49 PM This nurse placed call (to physician) to report in and out of the morning. Pending call back. Signed by LVN A. [DATE] at 5:00 AM at this time resident noted with labored breathing, VS ,[DATE], 112, 30, 101.8 and oxygen saturation 92% with oxygen on, blood sugar 122. Resident unable to answer any questions, unable to swallow water. Signed by LVN L. [DATE] at 5:15 AM On call MD returned call back with new order to send resident out to hospital, 911 call placed by this nurse. Signed by LVN L. [DATE] at 5:35 AM resident leaving facility via ambulance. Signed by LVN L. During an interview on [DATE] at 1:58 PM CNA C said Resident #1 would always stand and pivot when transferring. On [DATE], (Sunday morning) when she went in to get him ready for breakfast, he was not himself. She said Resident #1 could not help her get him up and she had to physically slide him into his wheelchair to transfer him; she then took him to the dining room. CNA C said Resident #1 was very weak and couldn't eat anything, she went and told LVN A and LVN A came and took his blood sugar. CNA C said LVN A told her the blood sugar was low, so she gave him apple juice with sugar in it. LVN A checked again, and his blood sugar had come up, but he remained very weak and could hardly sit up. CNA C said she took him back to bed and he was so bad she could not get him back by herself. She said she had to get another CNA (CNA G) to help her put him in bed. He stayed in bed the remainder of the weekend. CNA C said she told LVN A how bad he was, and that he needed to go to the hospital and she should call 911. LVN A said she had to call the doctor first because that was protocol. CNA C said the resident did not urinate or have a bowel movement for the entire weekend. She was very worried about him because he was always up and ate everything, and this was a big change. She said all total that day Resident #1 was up for maybe 10 minutes. During an interview on [DATE] at 3:11 PM RN Supervisor D said the last few days before Resident #1 went out to the hospital the CNA's had reported he was weaker. In an interview on [DATE] at 2:18 PM CNA F said she worked on Friday ([DATE]), Saturday ([DATE]) and Sunday ([DATE]). She said one of the last days Resident #1 was in dining room, probably Friday, she noticed he didn't eat very much; he had just picked at his food. CNA F said she reported it to the LVN because Resident #1 usually ate everything. In an interview on [DATE] at 9:25 AM CNA G said on Friday, [DATE], Resident #1 seemed fine. She said on Saturday, [DATE], he was a little quiet but, he went to the dining room and ate everything for breakfast and a little lunch. CNA G said she changed his brief and he had urine and it was not bloody. She said Resident #1 called his wife as he did every day. CNA G said on Sunday [DATE] Resident #1 had a big, big change and he couldn't even stand up. CNA G said at the dining room CNA C told LVN A to check Resident #1 because he could not stand up, he did not eat, and he was very weak. CNA G said LVN A said his sugar was low. CNA G said she helped CNA C get Resident #1 back in bed after breakfast. She said CNA C told LVN A that Resident #1 was not feeling good, did not eat anything, did not have any urine all day and he was not talking. CNA G said she was with CNA C when CNA C reported Resident #1's bad condition to the RN Supervisor B, they were together. In an interview on [DATE] at 4:22 PM LVN A said she worked weekends from 6:00 AM until 10:00 PM on the Special Care Unit, and Resident #1 was her resident. She said she remembered on Saturday morning ([DATE]) the night nurse told her the [MEDICATION NAME] was pending delivery from the pharmacy. LVN A said the medication was never delivered and she did not call the pharmacy to check on it. LVN A said on Sunday ([DATE]) Resident #1's appearance was off; he got up but looked fatigued. She said his oxygen saturation and blood sugar were low, she gave him PRN oxygen and held his morning and afternoon insulin. LVN A said she thinks she told RN Supervisor B, but she did not notify the physician. LVN A said the night nurse had done an in and out catheter because the resident had not voided all night. LVN A said when Resident #1 had not voided by around noon on Sunday ([DATE]) she was going to do another in and out catheter, but RN Supervisor B told her not to. He said he would come and do a bladder scan. She said Resident #1 stayed in bed all day. LVN A said she remembered CNA C reporting to her Resident #1's drastic change and CNA C wanted her to call 911. LVN A said she told the CNA that it was just because of his blood sugar. In a telephone interview on [DATE] at 2:58 PM RN Supervisor B said at about 3:00 PM on Sunday ([DATE]) LVN A told him Resident #1 had not had any urine output and she was going to do an in and out catheter. He said he told LVN A he would go and do a bladder scan, which he did. RN Supervisor B said when he did the scan Resident #1 only had about 30ml of urine in his bladder. He said the resident told him he had peed . The resident told him he had peed, and he thought the resident should know better than the CNA's. RN Supervisor B said he did not go back later to check on the resident. RN Supervisor B said Resident #1 was usually up in his wheelchair propelling himself throughout the facility but on [DATE] Resident #1 was in bed. RN Supervisor B said he did not think it was strange that he was in bed and not up because sometimes old people do that. RN Supervisor B said he was not aware of an order for [REDACTED].>In a telephone interview on [DATE] at 2:55 PM the Pharmacy Manager said they received an order for [REDACTED]. The Pharmacy Manager said the pharmacy did not call to notify the facility because all nurses are supposed to know what medications were in the automated medication dispenser. In an interview on [DATE] at 3:05 PM the Director of Nursing (DON) said she did not see that anything was done wrong concerning Resident #1's care from [DATE] until [DATE]. The DON said because she did not find anything wrong, no in-services were done. There was not an incident report for that time period. In an interview on [DATE] at 1:10 PM the Director of Nursing (DON) said the resident's physician informed her Resident #1's cause of death was due [MEDICAL CONDITION], pneumonia and acute [MEDICAL CONDITION]. The DON said she wasn't there and it wasn't her making the decisions about calling the physician for Resident #1. The DON said the Licensed Vocational Nurse (LVN) used her clinical judgement; and if she didn't call the physician it was because she didn't think she should call. The DON said the physician did not need to be called when Resident #1's blood sugar and oxygen saturation were low, even though it had not been that low before, because the nurse had PRN orders to use. The DON said the physician did not need to be notified when there was only 29ml of urine in Resident #1's bladder after not voiding for eight hours, because it would depend on the resident's intake. The DON said the low level of urine would not necessarily make her think [MEDICAL CONDITION] because nurses can't diagnose. The DON said she wasn't there and could not say what should have been done because the nurses used their clinical judgement. The DON said the [MEDICATION NAME] was never administered, the nurses did not check the automated medication dispenser or call the pharmacy. In an interview on [DATE] at 1:30 PM the Administrator said he stood by the DON's investigation of Resident #1 and agreed with her conclusion. In an interview on [DATE] at 2:00 PM the attending physician for Resident #1, Medical Doctor (MD) I, said there was a Physician on call each weekday from 5:00 PM until 7:00 AM and 24 hours a day on weekends. MD I said she should have been notified if an oxygen saturation was low and it was necessary to give PRN oxygen. MD I said when Resident #1's bladder scan revealed 29ml of urine and the staff reported no urine for the past eight hours the staff should have notified the on-call physician. MD I said at that time Resident #1 should have been sent to the emergency room to be evaluated by a physician in person. MD I said all of the factors and facility failures could have contributed to Resident #1's condition getting worse and resulted in his death. Review of the Fire Department Emergency Medical Services (EMS) Prehospital Care Report, dated [DATE], documented they arrived at the patient at 5:30 AM. They documented on assessment Resident #1 was unresponsive, had hot skin, his pulse was elevated at 108 - 116, respirations were labored and elevated at 31 - 42, he had no eye movement, no motor response, and no verbal or vocal response. The report documented EMS arrived on scene to find the resident laying in bed with labored belly breathing. The report documented the staff reported he had altered mental status for 30 minutes, he had a urinary tract infection, and they were waiting for medication from the pharmacy. EMS documented they were unable to obtain IV access in the facility, and the resident was transported to the closest hospital. Review of hospital emergency room notes, dated [DATE], documented Resident #1 arrived in severe distress and ill appearing with an obviously altered mental status and sonorous (an abnormal snoring sound) respirations at a rate of 30 - 40 and hypotensive (low blood pressure). Resident #1 had [MEDICAL CONDITION] (fast heartbeat) which was treated and resolved. The physician discussed the poor prognosis with the wife and given he was breathing 30 - 40 times a minute she was told that he likely was not going to survive much longer. He did not survive to make it to a hospital bed and died while in the emergency department. Resident #1's death was pronounced at 9:33 AM. Review of Resident #1's death certificate documented the cause of death was urinary tract infection, pneumonia,[MEDICAL CONDITION] and acute [MEDICAL CONDITION] due to infection. Review of Policy and Procedure, Change in Resident Condition or Status dated (MONTH) 2012 documented in part: Purpose: to establish guidelines for determining changes in resident status (condition) Change in Resident Condition or Status 1. Changes in usual bladder elimination patterns 2. No urine output for eight (8) hours/one (1) shift 3. Change in limb movement 4. Changes in: transfer and ambulation, dressing, bathing and/or grooming, eating, chewing and/or swallowing, toileting 5. Changes in range of motion 6. Sudden onset or worsening of lethargy (sluggishness, difficult to arouse and little body movement) Review of Policy and Procedure, Change of Status Notification dated (MONTH) 2012 documented in part: Purpose: To notify the resident's attending physician of change in the resident's condition or status. Procedure: In the following situations the resident's attending physician or designee will be notified 1. A sudden or unexpected change or deterioration in resident's physical, mental or emotional status 2. Any situation which requires a change in medication or treatment such as onset of a new condition On [DATE] at 10:00 AM the Administrator, DON and Assistant Director of Nursing (ADON) were informed an Immediate Jeopardy had been identified. The facility's 3rd Plan of Removal was accepted on [DATE]. Review of the facility's Plan of Removal, accepted [DATE], documented: Criteria #1: 1. Resident X was discharged (MONTH) 21, (YEAR). Criteria #2: 1. DON will generate the 24-hour reports from (MONTH) 26, (YEAR) to present in order to identify any residents that have experienced change in condition beginning (MONTH) 26, (YEAR) and completed [DATE]. 2. For any residents identified with change in condition, the change in condition/notification policy will be followed in its entirety. This will be overseen by the DON/designee on a daily basis beginning [DATE]. This includes: There is an incident or accident involving the resident. A sudden or unexpected change or deterioration in resident's physical, mental or emotional status (psychosocial) Appetite/Fluid Consumption: 1. Frequent deviation from therapeutic diet. Hydration: 1. Unexpected signs/symptoms of dehydration such as dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, fever, abnormal laboratory values such as elevated hemoglobin and hematocrit, potassium, chloride, sodium, [MEDICATION NAME], blood urea nitrogen (BUN) or urine specific gravity Nutrition: 1. Unexpected signs/symptoms of malnutrition such as pale skin, dull eyes, swollen lips, swollen gums, swollen and/or dry tongue with scarlet or magenta hue, poor skin turgor, cachexia, bilateral [MEDICAL CONDITION] and muscle wasting. Weight: 1. Significant unexpected weight change of: a. 5% in 30 days b. 7.5% in 90 days c. 10% in 180 days Elimination Habits Habits/Patterns (Bowel and Bladder): Bowel: 1. Changes in usual bowel elimination pattern. 2. Changes in color, consistency, odor, and/or frequency of bowel movements. 3. Two (2) or more loose stools in an eight (8) hour period. 4. Absence of bowel movements for three (3) or more consecutive days. Bladder: 1. Changes in usual bladder elimination patterns. 2. Changes in color, clarity, odor, pain/burning, urgency and/or frequency in urinary output. 3. No urine output for eight (8) hours/one (1) shift. Neurological: 1. Change in orientation (person, time, place). 2. Sudden onset or worsening of: a. Disorientation b. Stupor or coma c. Level of arousal, including painful stimuli. 3. Loss of consciousness. 4. Pupillary response 5. Limb movement Cardiovascular: 1. New onset of chest pain. 2. New onset of dependent, [MEDICAL CONDITION]. 3. Capillary refill time of three (3) seconds. 4. New onset of pallor or cyanosis. Vital Signs: 1. Change in resting pulse rate that is = or < 60 or = > 100. 2. Change in blood pressure. 3. Oral temperature <96 or >100. 4. Axillary temperature <95 or >99. 5. Resting respiratory rate <10 or >24 Digestive System: 1. Sudden onset, worsening, or reports of: a. Indigestion/heartburn or flatulence. b. Nausea/vomiting c. Bloating/abdominal distention or constipation. d. Appearance of blood in stools or vomitus. e. Glucose testing - follow physician's protocol or orders. Respiratory Status: 1. Change in rhythm (regularity). 2. New onset of chest pain. 3. Changes in breath sounds including wheezing, crackles, rales, and/or rhonchi. 4. New onset of cough. 5. Complaints or reports of dyspnea or shortness of breath. 6. Pulse oximetry reading of 92% or less. Pain: 1. Sudden onset of pain and/or expression of pain (verbal or nonverbal). 2. Change in duration, location, intensity, character, quality of pain. Physical Functioning: 1. Changes in: a. Transfer and ambulation b. Dressing, bathing and/or grooming. c. Eating, chewing and/or swallowing. d. Toileting. e. Use of speech, language, or other functional communication system. f. Vision and hearing 2. Range of motion: a. Limitations b. Changes and/or alterations. Skin Integrity: 1. New onset of Stage I or greater nosocomial pressure ulcers. 2. New onset of rashes, blisters or denuded skin. Behavior (certain behaviors may be indicative of an altered mental status): 1. Sudden onset or worsening of inappropriate behaviors that cannot be easily redirected such as: a. Wandering (moving with no rational purpose, seemingly oblivious to needs or safety). b. Verbally abusive (screaming at, cursing at, or threatening others). c. Socially inappropriate/disruptive behavior (makes disrupting sounds, noisy, screams, self-negative acts, inappropriate sexual behavior, disrobing in public, smearing/throwing food/feces, hoarding, rummaging through others' belongings). d. Resisting care (taking medications/injections and or resisting ADL assistance). e. Hallucinations/delusions. f. Poor self-care. g. Unsociable behavior. h. Periods of restlessness (fidgeting or picking at skin, clothing, napkins, etc.; frequent position changes; repetitive physical movements or calling out). i. Uncooperativeness. j. Agitated behaviors that may or may not represent a danger to the resident or others. Sudden onset or worsening of changes in cognition such as: 1. Impaired memory. 2. Disordered thinking that may be manifested by rambling, irrelevant, or incoherent speech. Sudden onset or worsening of mood and behavior patterns such as: 1. Anxiety; 2. Depression; 3. [MEDICAL CONDITION]; 4. Sense of initiative and involvement; 5. Loss of interest and/or isolation; or 6. Indifference to surrounding; or 7. Verbal expressions of distress (increased or decreased numbers, frequency, or intensity of expressions of signs of distress). 8. Sudden onset or worsening of lethargy (sluggishness, staring into space; difficult to arouse; little body movement). *Any situation which requires a change in medication or treatment regime, i.e., need for restraints, exacerbation of known condition, onset of new condition, abnormal lab values, behavior, weight loss, appointments, elopement and skin breakdown. *When the resident leaves against medical advice. *Any resident-to-resident altercation. *When the decision to transfer or discharge the resident from the facility has been made or in the event of resident death. *The charge nurse on the unit is responsible with assistance from RN Supervisor. 3. 24-hour reports will be reviewed daily by DON, ADON, and RN Supervisors beginning (MONTH) 26,2018 in order to identify change in condition and to ensure policies are followed. This over-site to be provided by the Regional Clinical Nurse Consultant beginning (MONTH) 27, (YEAR). These policies include: There is an incident or accident involving the resident. A sudden or unexpected change or deterioration in resident's physical, mental or emotional status (psychosocial). Appetite/Fluid Consumption: 1. Frequent deviation from therapeutic diet. Hydration: 1. Unexpected signs/symptoms of malnutrition such as pale skin, dull eyes, swollen lips, swollen gums, swollen and/or dry tongue with scarlet or magenta hue, poor skin turgor, cachexia, bilateral [MEDICAL CONDITION], muscle wasting. Nutrition: 1. Unexpected signs/symptoms of malnutrition such as pale skin, dull eyes, swollen lips, swollen gums, swollen and/or dry tongue with scarlet or magenta hue, poor skin turgor, cachexia, bilateral [MEDICAL CONDITION] and muscle wasting. Weight: 1. Significant unexpected weight change of: a. 5% in 30 days b. 7.5% in 90 days c. 10% in 180 days Elimination Habits Habits/Patterns (Bowel and Bladder): Bowel: 1. Changes in usual bowel elimination pattern. 2. Changes in color, consistency, odor, and/or frequency of bowel movements. 3. Two (2) or more loose stools in an eight (8) hour period. 4. Absence of bowel movements for three (3) or more consecutive days. Bladder: 1. Changes in usual bladder elimination patterns. 2. Changes in color, clarity, odor, pain/burning, urgency and/or frequency in urinary output. 3. No urine output for eight (8) hours/one (1) shift. Neurological: 1. Change in orientation (person, time, place). 2. Sudden onset or worsening of: a. Disorientation b. Stupor or coma c. Level of arousal, including painful stimuli. 3. Loss of consciousness. 4. Pupillary response 5. Limb movement Cardiovascular: 1. New onset of chest pain. 2. New onset of dependent, [MEDICAL CONDITION]. 3. Capillary refill time of three (3) seconds. 4. New onset of pallor or cyanosis. Vital Signs: 1. Change in resting pulse rate that is = or < 60 or = > 100. 2. Change in blood pressure. 3. Oral temperature <96 or >100. 4. Axillary temperature <95 or >99. 5. Resting respiratory rate <10 or >24 Digestive System: 1. Sudden onset, worsening, or reports of: a. Indigestion/heartburn or flatulence. b. Nausea/vomiting c. Bloating/abdominal distention or constipation. d. Appearance of blood in stools or vomitus. e. Glucose testing - follow physician's protocol or orders. Respiratory Status: 1. Change in rhythm (regularity). 2. New onset of chest pain. 3. Changes in breath sounds including wheezing, crackles, rales, and/or rhonchi. 4. New onset of cough. 5. Complaints or reports of dyspnea or shortness of breath. 6. Pulse oximetry reading of 92% or less. Pain: 1. Sudden onset of pain and/or expression of pain (verbal or nonverbal). 2. Change in duration, location, intensity, character, quality of pain. Physical Functioning: 1. Changes in: a. Transfer and ambulation b. Dressing, bathing and/or grooming. c. Eating, chewing and/or swallowing. d. Toileting. e. Use of speech, language, or other functional communication system. f. Vision and hearing 2 Range of motion: a. Limitations b. Changes and/or alterations. Skin Integrity: 1. New onset of Stage I or greater nosocomial pressure ulcers. 2. New onset of rashes, blisters or denuded skin. Behavior (certain behaviors may be indicative of an altered mental status): 1. Sudden onset or worsening of inappropriate behaviors that cannot be easily redirected such as: a. Wandering (moving with no rational purpose, seemingly oblivious to needs or safety). b. Verbally abusive (screaming at, cursing at, or threatening others). c. Socially inappropriate/disruptive behavior (makes disrupting sounds, noisy, screams, self-negative acts, inappropriate sexual behavior, disrobing in public, smearing/throwing food/feces, hoarding, rummaging through others' belongings). d. Resisting care (taking medications/injections and or resisting ADL assistance). e. Hallucinations/delusions. f. Poor self-care. g. Unsociable behavior. h. Periods of restlessness (fidgeting or picking at skin, clothing, napkins, etc.; frequent position changes; repetitive physical movements or calling out). i. Uncooperativeness. j. Agitated behaviors that may or may not represent a danger to the resident or others. Sudden onset or worsening of changes in cognition such as: 1. Impaired memory. 2. Disordered thinking that may be manifested by rambling, irrelevant, or incoherent speech. Sudden onset or worsening of mood and behavior patterns such as: 1. Anxiety; 2. Depression; 3. [MEDICAL CONDITION]; 4. Sense of initiative and involvement; 5. Loss of interest and/or isolation; or 6. Indifference to surrounding; or 7. Verbal expressions of distress (increased or decreased numbers, frequency, or intensity of expressions of signs of distress). 8. Sudden onset or worsening of lethargy (sluggishness, staring into space; difficult to arouse; little body movement). *Any situation which requires a change in medication or treatment regime, i.e., need for restraints, exacerbation of known condition, onset of new condition, abnormal lab values, behavior, weight loss, appointments, elopement and skin breakdown. *When the resident leaves against medical advice. *Any resident-to-resident altercation. *When the decision to transfer or discharge the resident from the facility has been made or in the event of resident death. *The charge nurse on the unit is responsible with assistance from RN Supervisor. 4.There will be a 100% audit of medication carts to ensure all ordered meds are available. The emergency drug boxes automated medication dispenser will be monitored for availability of drugs as listed. This audit will be conducted by licensed nursing staff with oversight from DON, ADON, and Pharmacy Nurse with completion date of [DATE]. The medication carts and automated medication dispenser will be monitored daily with oversite from DON, ADON, and Pharmacy Nurse beginning [DATE] and ongoing. The night shift nurses will check medication carts nightly to ensure all prescribed medications are ordered timely beginning [DATE] and ongoing. 5.The Director of Nursing and Clinical Nurse Consultant will monitor to ensure the changes in condition, as outlined above in Criteria 2 #2 and #3, are documented and physician notified timely remain in continued compliance. This will be monitored daily X 3 weeks, weekly X 4 weeks and monthly X 3 months beginning [DATE]. Ongoing, after daily review of nurse's 24-hour report, nurse management team will follow up on any concerns identified. These concerns will be logged and presented during QAPI meeting. Change in condition identification and physician notification will become part of the monthly facility QAPI process. During each meeting, QAPI team consisting of Administrator, Medical Director, DON, ADON's Infection Preventionist as well as other pertinent members of IDT, will review current process and make recommendations to be implemented. This will be an ongoing process to ensure continued compliance. Criteria #3: 1. Licensed staff will be re-educated on change in condition and physician notification. 2. Licensed nurses will be re-educated on obtaining after hour medications to include contacting the off-hour pharmacy delivery. If the medication will not be available timely the nurses are to contact the MD to notify him/her that the medication is not available and obtain alternate order. If no timely response from the Dr. that was called the nurses are instructed to notify the house supervisor and DON. The supervisor and DON will be responsible for contacting the medical director and/or other physician on call to obtain any orders to include transfer to the ER if indicated. 3. RN Supervisors and nursing leadership to be re-educated regarding follow-up on residents with medical concerns. This includes identification of change in condition and physician notification. RN Supervisors will receive report from off going RN Supervisor both written and oral. RN Supervisor will also read 24-hour report in PCC, as well as risk management. Supervisor will then make rounds of all residents identified with concerns and monitor for appropriate documentation and nurses' response. During rounds supervisor will check with charge nurse of any other concerns they may have and will assess those residents as well. 4. Licensed staff to be re-educated on reviewing of 24-hour reports, presenting verbal reports, and adequate documentation. Reports to include the following guideline of condition of each resident. List and report any elevated temperatures or abnormal vital signs and the last time checked. Report the last dose of any PRN medication administered and effectiveness. Report and condition change or follow-up on any condition change of any resident. Report incidents, status of residents, orders to be followed. Report equipment failure or supplies needed. Report status on CALLS TO PHYSICIANS Why call was placed Name of the resident Wh

Based on interview and record review, the facility failed to ensure the resident's right to be free from neglect for 1 of 10 residents (Resident #1) reviewed for neglect. The facility failed to assess and respond timely to a change in condition and to consult with the attending physician on [DATE] when Licensed Vocational Nurse (LVN) K on the 2:00 PM to 10:00 PM shift noted pin point spots of blood on Resident #1's brief. On [DATE] the Licensed Staff failed to administer [MEDICATION NAME] (antibiotic) as ordered for hematuria (blood in the urine). The facility failed to assess, respond timely and consult with the attending physician when Resident #1 displayed signs of a change in condition. On [DATE] Resident #1's condition worsened, including a significant decline in physical functioning and decreased level of consciousness, the facility failed to assess, respond timely and consult with Resident #1's physician. On [DATE], Resident #1 was sent to the emergency room (ER) where he died . This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE]. While the IJ was lowered on [DATE] at 2:00 PM the non-compliance continued at a level of actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate and monitor the effectiveness of their corrective action system. This failure has the potential to affect 21 residents that reside on the Special Care Unit (where Resident #1 resided) by placing them at risk of potential medical complications, hospitalization , or even death related to changes in condition. Findings included: RESIDENT #1 Review of Resident #1's Electronic Medical Record (EMR) undated Face Sheet documented Resident #1 was a [AGE] year-old male readmitted to the facility on [DATE]. Review of Resident #1's most recent History and Physical dated [DATE] documented in part; Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] documented, in part: Hearing adequate Speech clear Made himself understood Understood others Brief Interview for Mental Status (BIMS) score 13 which indicated he was cognitively intact Independent for eating Required one staff and extensive assistance for transfer and toilet use. Used a wheelchair for mobility Review of Nurse's Notes documented, in part: [DATE] at 11:28 PM the nurse going off duty documented: This nurse observed several pin point size spots of blood on the brief when the resident was being changed. Brief wet at this time with urine. Reported to oncoming nurse to monitor for any further changes. Signed by LVN K. [DATE] at 10:15 PM the nurse going off duty documented: Resident noted to have hematuria X 2. Observed blood tinged urine on his brief during the last two changes. Call placed to physician and orders received to get urinalysis for culture and sensitivity, Complete blood count (CBC) and give a one-time dose of [MEDICATION NAME] 1-gram IM. Signed by LVN K. (No documentation of Resident #1 receiving [MEDICATION NAME].) [DATE] at 5:20 AM resident noted with abdominal distention, no urine output throughout shift, last void was yesterday at 8:00PM. Resident complained of discomfort to lower abdomen. This nurse offered pain medication, resident denied. Call placed to physician. Vital Signs (VS) ,[DATE] (blood pressure), 86 (pulse), 18 (respirations), 94% oxygen saturation on 2 L/M (liters per minute), 98.9 temporal temperature. Will pass on report, continue to monitor. Signed by LVN J. [DATE] at 5:47 AM physician called back and ordered in and out catheter. Urine output 850ml (milliters). Pending call back from physician to report urine output, will pass on in report. Signed by LVN J. [DATE] at 7:01 AM per ,[DATE] nurse pending call back from physician to report urine output, will continue to monitor. Signed by LVN A [DATE] at 9:52 AM resident noted to be very weak and physical appearance out of the norms. VS ,[DATE] (blood pressure), 86 (pulse), 19 (respirations), 97.6 (temperature), oxygen saturation 85 on room air, blood sugar 62. Nurse administered as needed oxygen via nasal cannula and oxygen saturation increased to 95%. Nurse also gave orange juice and blood sugar up to 110. Resident refused to take his [MEDICATION NAME]due to low blood sugar, will continue to monitor. Signed by LVN A [DATE] at 1:51 PM resident assessed with [REDACTED]. Resident stated, I peed today . Bladder scan performed and found 29mls of urine, will continue to monitor. Signed by LVN A. [DATE] at 7:49 PM This nurse placed call (to physician) to report in and out of the morning. Pending call back. Signed by LVN A. [DATE] at 5:00 AM at this time resident noted with labored breathing, VS ,[DATE], 112, 30, 101.8 and oxygen saturation 92% with oxygen on, blood sugar 122. Resident unable to answer any questions, unable to swallow water. Signed by LVN L. [DATE] at 5:15 AM On call MD returned call back with new order to send resident out to hospital, 911 call placed by this nurse. Signed by LVN L. [DATE] at 5:35 AM resident leaving facility via ambulance. Signed by LVN L. During an interview on [DATE] at 1:58 PM CNA C said Resident #1 would always stand and pivot when transferring. On [DATE], (Sunday morning) when she went in to get him ready for breakfast, he was not himself. She said Resident #1 could not help her get him up and she had to physically slide him into his wheelchair to transfer him; she then took him to the dining room. CNA C said Resident #1 was very weak and couldn't eat anything, she went and told LVN A and LVN A came and took his blood sugar. CNA C said LVN A told her the blood sugar was low, so she gave him apple juice with sugar in it. LVN A checked again, and his blood sugar had come up, but he remained very weak and could hardly sit up. CNA C said she took him back to bed and he was so bad she could not get him back by herself. She said she had to get another CNA (CNA G) to help her put him in bed. He stayed in bed the remainder of the weekend. CNA C said she told LVN A how bad he was, and that he needed to go to the hospital and she should call 911. LVN A said she had to call the doctor first because that was protocol. CNA C said the resident did not urinate or have a bowel movement for the entire weekend. She was very worried about him because he was always up and ate everything, and this was a big change. She said all total that day Resident #1 was up for maybe 10 minutes. During an interview on [DATE] at 3:11 PM RN Supervisor D said the last few days before Resident #1 went out to the hospital the CNA's had reported he was weaker. In an interview on [DATE] at 2:18 PM CNA F said she worked on Friday ([DATE]), Saturday ([DATE]) and Sunday ([DATE]). She said one of the last days Resident #1 was in dining room, probably Friday, she noticed he didn't eat very much; he had just picked at his food. CNA F said she reported it to the LVN because Resident #1 usually ate everything. In an interview on [DATE] at 9:25 AM CNA G said on Friday, [DATE], Resident #1 seemed fine. She said on Saturday, [DATE], he was a little quiet but, he went to the dining room and ate everything for breakfast and a little lunch. CNA G said she changed his brief and he had urine and it was not bloody. She said Resident #1 called his wife as he did every day. CNA G said on Sunday [DATE] Resident #1 had a big, big change and he couldn't even stand up. CNA G said at the dining room CNA C told LVN A to check Resident #1 because he could not stand up, he did not eat, and he was very weak. CNA G said LVN A said his sugar was low. CNA G said she helped CNA C get Resident #1 back in bed after breakfast. She said CNA C told LVN A that Resident #1 was not feeling good, did not eat anything, did not have any urine all day and he was not talking. CNA G said she was with CNA C when CNA C reported Resident #1's bad condition to the RN Supervisor B, they were together. In an interview on [DATE] at 4:22 PM LVN A said she worked weekends from 6:00 AM until 10:00 PM on the Special Care Unit, and Resident #1 was her resident. She said she remembered on Saturday morning ([DATE]) the night nurse told her the [MEDICATION NAME] was pending delivery from the pharmacy. LVN A said the medication was never delivered and she did not call the pharmacy to check on it. LVN A said on Sunday ([DATE]) Resident #1's appearance was off; he got up but looked fatigued. She said his oxygen saturation and blood sugar were low, she gave him PRN oxygen and held his morning and afternoon insulin. LVN A said she thinks she told RN Supervisor B, but she did not notify the physician. LVN A said the night nurse had done an in and out catheter because the resident had not voided all night. LVN A said when Resident #1 had not voided by around noon on Sunday ([DATE]) she was going to do another in and out catheter, but RN Supervisor B told her not to. He said he would come and do a bladder scan. She said Resident #1 stayed in bed all day. LVN A said she remembered CNA C reporting to her Resident #1's drastic change and CNA C wanted her to call 911. LVN A said she told the CNA that it was just because of his blood sugar. In a telephone interview on [DATE] at 2:58 PM RN Supervisor B said at about 3:00 PM on Sunday ([DATE]) LVN A told him Resident #1 had not had any urine output and she was going to do an in and out catheter. He said he told LVN A he would go and do a bladder scan, which he did. RN Supervisor B said when he did the scan Resident #1 only had about 30ml of urine in his bladder. He said the resident told him he had peed . The resident told him he had peed, and he thought the resident should know better than the CNA's. RN Supervisor B said he did not go back later to check on the resident. RN Supervisor B said Resident #1 was usually up in his wheelchair propelling himself throughout the facility but on [DATE] Resident #1 was in bed. RN Supervisor B said he did not think it was strange that he was in bed and not up because sometimes old people do that. RN Supervisor B said he was not aware of an order for [REDACTED].>In a telephone interview on [DATE] at 2:55 PM the Pharmacy Manager said they received an order for [REDACTED]. The Pharmacy Manager said the pharmacy did not call to notify the facility because all nurses are supposed to know what medications were in the automated medication dispenser. In an interview on [DATE] at 3:05 PM the Director of Nursing (DON) said she did not see that anything was done wrong concerning Resident #1's care from [DATE] until [DATE]. The DON said because she did not find anything wrong, no in-services were done. There was not an incident report for that time period. In an interview on [DATE] at 1:10 PM the Director of Nursing (DON) said the resident's physician informed her Resident #1's cause of death was due [MEDICAL CONDITION], pneumonia and acute [MEDICAL CONDITION]. The DON said she wasn't there and it wasn't her making the decisions about calling the physician for Resident #1. The DON said the Licensed Vocational Nurse (LVN) used her clinical judgement; and if she didn't call the physician it was because she didn't think she should call. The DON said the physician did not need to be called when Resident #1's blood sugar and oxygen saturation were low, even though it had not been that low before, because the nurse had PRN orders to use. The DON said the physician did not need to be notified when there was only 29ml of urine in Resident #1's bladder after not voiding for eight hours, because it would depend on the resident's intake. The DON said the low level of urine would not necessarily make her think [MEDICAL CONDITION] because nurses can't diagnose. The DON said she wasn't there and could not say what should have been done because the nurses used their clinical judgement. The DON said the [MEDICATION NAME] was never administered, the nurses did not check the automated medication dispenser or call the pharmacy. In an interview on [DATE] at 2:00 PM the attending physician for Resident #1, Medical Doctor (MD) I, said there was a Physician on call each weekday from 5:00 PM until 7:00 AM and 24 hours a day on weekends. MD I said she should have been notified if an oxygen saturation was low and it was necessary to give PRN oxygen. MD I said when Resident #1's bladder scan revealed 29ml of urine and the staff reported no urine for the past eight hours the staff should have notified the on-call physician. MD I said at that time Resident #1 should have been sent to the emergency room to be evaluated by a physician in person. MD I said all of the factors and facility failures could have contributed to Resident #1's condition getting worse and resulted in his death. Review of the Fire Department Emergency Medical Services (EMS) Prehospital Care Report, dated [DATE], documented they arrived at the patient at 5:30 AM. They documented on assessment Resident #1 was unresponsive, had hot skin, his pulse was elevated at 108 - 116, respirations were labored and elevated at 31 - 42, he had no eye movement, no motor response, and no verbal or vocal response. The report documented EMS arrived on scene to find the resident laying in bed with labored belly breathing. The report documented the staff reported he had altered mental status for 30 minutes, he had a urinary tract infection, and they were waiting for medication from the pharmacy. EMS documented they were unable to obtain IV access in the facility, and the resident was transported to the closest hospital. Review of hospital emergency room notes, dated [DATE], documented Resident #1 arrived in severe distress and ill appearing with an obviously altered mental status and sonorous (an abnormal snoring sound) respirations at a rate of 30 - 40 and hypotensive (low blood pressure). Resident #1 had [MEDICAL CONDITION] (fast heartbeat) which was treated and resolved. The physician discussed the poor prognosis with the wife and given he was breathing 30 - 40 times a minute she was told that he likely was not going to survive much longer. He did not survive to make it to a hospital bed and died while in the emergency department. Resident #1's death was pronounced at 9:33 AM. Review of Resident #1's death certificate documented the cause of death was urinary tract infection, pneumonia,[MEDICAL CONDITION] and acute [MEDICAL CONDITION] due to infection. Review of Policy and Procedure, Change in Resident Condition or Status dated (MONTH) 2012 documented in part: Purpose: to establish guidelines for determining changes in resident status (condition) Change in Resident Condition or Status 1. Changes in usual bladder elimination patterns 2. No urine output for eight (8) hours/one (1) shift 3. Change in limb movement 4. Changes in: transfer and ambulation, dressing, bathing and/or grooming, eating, chewing and/or swallowing, toileting 5. Changes in range of motion 6. Sudden onset or worsening of lethargy (sluggishness, difficult to arouse and little body movement) Review of Policy and Procedure, Change of Status Notification dated (MONTH) 2012 documented in part: Purpose: To notify the resident's attending physician of change in the resident's condition or status. Procedure: In the following situations the resident's attending physician or designee will be notified 1. A sudden or unexpected change or deterioration in resident's physical, mental or emotional status 2. Any situation which requires a change in medication or treatment such as onset of a new condition On [DATE] at 10:00 AM the Administrator, DON and Assistant Director of Nursing (ADON) were informed an Immediate Jeopardy had been identified. The facility's 3rd Plan of Removal was accepted on [DATE]. Review of the facility's Plan of Removal, accepted [DATE], documented: Criteria #1: 1. Resident X was discharged (MONTH) 21, (YEAR). Criteria #2: 1. DON will generate the 24-hour reports from (MONTH) 26, (YEAR) to present in order to identify any residents that have experienced change in condition beginning (MONTH) 26, (YEAR) and completed [DATE]. 2. For any residents identified with change in condition, the change in condition/notification policy will be followed in its entirety. This will be overseen by the DON/designee on a daily basis beginning [DATE]. This includes: There is an incident or accident involving the resident. A sudden or unexpected change or deterioration in resident's physical, mental or emotional status (psychosocial) Appetite/Fluid Consumption: 1. Frequent deviation from therapeutic diet. Hydration: 1. Unexpected signs/symptoms of dehydration such as dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, fever, abnormal laboratory values such as elevated hemoglobin and hematocrit, potassium, chloride, sodium, [MEDICATION NAME], blood urea nitrogen (BUN) or urine specific gravity Nutrition: 1. Unexpected signs/symptoms of malnutrition such as pale skin, dull eyes, swollen lips, swollen gums, swollen and/or dry tongue with scarlet or magenta hue, poor skin turgor, cachexia, bilateral [MEDICAL CONDITION] and muscle wasting. Weight: 1. Significant unexpected weight change of: a. 5% in 30 days b. 7.5% in 90 days c. 10% in 180 days Elimination Habits Habits/Patterns (Bowel and Bladder): Bowel: 1. Changes in usual bowel elimination pattern. 2. Changes in color, consistency, odor, and/or frequency of bowel movements. 3. Two (2) or more loose stools in an eight (8) hour period. 4. Absence of bowel movements for three (3) or more consecutive days. Bladder: 1. Changes in usual bladder elimination patterns. 2. Changes in color, clarity, odor, pain/burning, urgency and/or frequency in urinary output. 3. No urine output for eight (8) hours/one (1) shift. Neurological: 1. Change in orientation (person, time, place). 2. Sudden onset or worsening of: a. Disorientation b. Stupor or coma c. Level of arousal, including painful stimuli. 3. Loss of consciousness. 4. Pupillary response 5. Limb movement Cardiovascular: 1. New onset of chest pain. 2. New onset of dependent, [MEDICAL CONDITION]. 3. Capillary refill time of three (3) seconds. 4. New onset of pallor or cyanosis. Vital Signs: 1. Change in resting pulse rate that is = or < 60 or = > 100. 2. Change in blood pressure. 3. Oral temperature <96 or >100. 4. Axillary temperature <95 or >99. 5. Resting respiratory rate <10 or >24 Digestive System: 1. Sudden onset, worsening, or reports of: a. Indigestion/heartburn or flatulence. b. Nausea/vomiting c. Bloating/abdominal distention or constipation. d. Appearance of blood in stools or vomitus. e. Glucose testing - follow physician's protocol or orders. Respiratory Status: 1. Change in rhythm (regularity). 2. New onset of chest pain. 3. Changes in breath sounds including wheezing, crackles, rales, and/or rhonchi. 4. New onset of cough. 5. Complaints or reports of dyspnea or shortness of breath. 6. Pulse oximetry reading of 92% or less. Pain: 1. Sudden onset of pain and/or expression of pain (verbal or nonverbal). 2. Change in duration, location, intensity, character, quality of pain. Physical Functioning: 1. Changes in: a. Transfer and ambulation b. Dressing, bathing and/or grooming. c. Eating, chewing and/or swallowing. d. Toileting. e. Use of speech, language, or other functional communication system. f. Vision and hearing 2. Range of motion: a. Limitations b. Changes and/or alterations. Skin Integrity: 1. New onset of Stage I or greater nosocomial pressure ulcers. 2. New onset of rashes, blisters or denuded skin. Behavior (certain behaviors may be indicative of an altered mental status): 1. Sudden onset or worsening of inappropriate behaviors that cannot be easily redirected such as: a. Wandering (moving with no rational purpose, seemingly oblivious to needs or safety). b. Verbally abusive (screaming at, cursing at, or threatening others). c. Socially inappropriate/disruptive behavior (makes disrupting sounds, noisy, screams, self-negative acts, inappropriate sexual behavior, disrobing in public, smearing/throwing food/feces, hoarding, rummaging through others' belongings). d. Resisting care (taking medications/injections and or resisting ADL assistance). e. Hallucinations/delusions. f. Poor self-care. g. Unsociable behavior. h. Periods of restlessness (fidgeting or picking at skin, clothing, napkins, etc.; frequent position changes; repetitive physical movements or calling out). i. Uncooperativeness. j. Agitated behaviors that may or may not represent a danger to the resident or others. Sudden onset or worsening of changes in cognition such as: 1. Impaired memory. 2. Disordered thinking that may be manifested by rambling, irrelevant, or incoherent speech. Sudden onset or worsening of mood and behavior patterns such as: 1. Anxiety; 2. Depression; 3. [MEDICAL CONDITION]; 4. Sense of initiative and involvement; 5. Loss of interest and/or isolation; or 6. Indifference to surrounding; or 7. Verbal expressions of distress (increased or decreased numbers, frequency, or intensity of expressions of signs of distress). 8. Sudden onset or worsening of lethargy (sluggishness, staring into space; difficult to arouse; little body movement). *Any situation which requires a change in medication or treatment regime, i.e., need for restraints, exacerbation of known condition, onset of new condition, abnormal lab values, behavior, weight loss, appointments, elopement and skin breakdown. *When the resident leaves against medical advice. *Any resident-to-resident altercation. *When the decision to transfer or discharge the resident from the facility has been made or in the event of resident death. *The charge nurse on the unit is responsible with assistance from RN Supervisor. 3. 24-hour reports will be reviewed daily by DON, ADON, and RN Supervisors beginning (MONTH) 26,2018 in order to identify change in condition and to ensure policies are followed. This over-site to be provided by the Regional Clinical Nurse Consultant beginning (MONTH) 27, (YEAR). These policies include: There is an incident or accident involving the resident. A sudden or unexpected change or deterioration in resident's physical, mental or emotional status (psychosocial). Appetite/Fluid Consumption: 1. Frequent deviation from therapeutic diet. Hydration: 1. Unexpected signs/symptoms of malnutrition such as pale skin, dull eyes, swollen lips, swollen gums, swollen and/or dry tongue with scarlet or magenta hue, poor skin turgor, cachexia, bilateral [MEDICAL CONDITION], muscle wasting. Nutrition: 1. Unexpected signs/symptoms of malnutrition such as pale skin, dull eyes, swollen lips, swollen gums, swollen and/or dry tongue with scarlet or magenta hue, poor skin turgor, cachexia, bilateral [MEDICAL CONDITION] and muscle wasting. Weight: 1. Significant unexpected weight change of: a. 5% in 30 days b. 7.5% in 90 days c. 10% in 180 days Elimination Habits Habits/Patterns (Bowel and Bladder): Bowel: 1. Changes in usual bowel elimination pattern. 2. Changes in color, consistency, odor, and/or frequency of bowel movements. 3. Two (2) or more loose stools in an eight (8) hour period. 4. Absence of bowel movements for three (3) or more consecutive days. Bladder: 1. Changes in usual bladder elimination patterns. 2. Changes in color, clarity, odor, pain/burning, urgency and/or frequency in urinary output. 3. No urine output for eight (8) hours/one (1) shift. Neurological: 1. Change in orientation (person, time, place). 2. Sudden onset or worsening of: a. Disorientation b. Stupor or coma c. Level of arousal, including painful stimuli. 3. Loss of consciousness. 4. Pupillary response 5. Limb movement Cardiovascular: 1. New onset of chest pain. 2. New onset of dependent, [MEDICAL CONDITION]. 3. Capillary refill time of three (3) seconds. 4. New onset of pallor or cyanosis. Vital Signs: 1. Change in resting pulse rate that is = or < 60 or = > 100. 2. Change in blood pressure. 3. Oral temperature <96 or >100. 4. Axillary temperature <95 or >99. 5. Resting respiratory rate <10 or >24 Digestive System: 1. Sudden onset, worsening, or reports of: a. Indigestion/heartburn or flatulence. b. Nausea/vomiting c. Bloating/abdominal distention or constipation. d. Appearance of blood in stools or vomitus. e. Glucose testing - follow physician's protocol or orders. Respiratory Status: 1. Change in rhythm (regularity). 2. New onset of chest pain. 3. Changes in breath sounds including wheezing, crackles, rales, and/or rhonchi. 4. New onset of cough. 5. Complaints or reports of dyspnea or shortness of breath. 6. Pulse oximetry reading of 92% or less. Pain: 1. Sudden onset of pain and/or expression of pain (verbal or nonverbal). 2. Change in duration, location, intensity, character, quality of pain. Physical Functioning: 1. Changes in: a. Transfer and ambulation b. Dressing, bathing and/or grooming. c. Eating, chewing and/or swallowing. d. Toileting. e. Use of speech, language, or other functional communication system. f. Vision and hearing 2 Range of motion: a. Limitations b. Changes and/or alterations. Skin Integrity: 1. New onset of Stage I or greater nosocomial pressure ulcers. 2. New onset of rashes, blisters or denuded skin. Behavior (certain behaviors may be indicative of an altered mental status): 1. Sudden onset or worsening of inappropriate behaviors that cannot be easily redirected such as: a. Wandering (moving with no rational purpose, seemingly oblivious to needs or safety). b. Verbally abusive (screaming at, cursing at, or threatening others). c. Socially inappropriate/disruptive behavior (makes disrupting sounds, noisy, screams, self-negative acts, inappropriate sexual behavior, disrobing in public, smearing/throwing food/feces, hoarding, rummaging through others' belongings). d. Resisting care (taking medications/injections and or resisting ADL assistance). e. Hallucinations/delusions. f. Poor self-care. g. Unsociable behavior. h. Periods of restlessness (fidgeting or picking at skin, clothing, napkins, etc.; frequent position changes; repetitive physical movements or calling out). i. Uncooperativeness. j. Agitated behaviors that may or may not represent a danger to the resident or others. Sudden onset or worsening of changes in cognition such as: 1. Impaired memory. 2. Disordered thinking that may be manifested by rambling, irrelevant, or incoherent speech. Sudden onset or worsening of mood and behavior patterns such as: 1. Anxiety; 2. Depression; 3. [MEDICAL CONDITION]; 4. Sense of initiative and involvement; 5. Loss of interest and/or isolation; or 6. Indifference to surrounding; or 7. Verbal expressions of distress (increased or decreased numbers, frequency, or intensity of expressions of signs of distress). 8. Sudden onset or worsening of lethargy (sluggishness, staring into space; difficult to arouse; little body movement). *Any situation which requires a change in medication or treatment regime, i.e., need for restraints, exacerbation of known condition, onset of new condition, abnormal lab values, behavior, weight loss, appointments, elopement and skin breakdown. *When the resident leaves against medical advice. *Any resident-to-resident altercation. *When the decision to transfer or discharge the resident from the facility has been made or in the event of resident death. *The charge nurse on the unit is responsible with assistance from RN Supervisor. 4.There will be a 100% audit of medication carts to ensure all ordered meds are available. The emergency drug boxes automated medication dispenser will be monitored for availability of drugs as listed. This audit will be conducted by licensed nursing staff with oversight from DON, ADON, and Pharmacy Nurse with completion date of [DATE]. The medication carts and automated medication dispenser will be monitored daily with oversite from DON, ADON, and Pharmacy Nurse beginning [DATE] and ongoing. The night shift nurses will check medication carts nightly to ensure all prescribed medications are ordered timely beginning [DATE] and ongoing. 5.The Director of Nursing and Clinical Nurse Consultant will monitor to ensure the changes in condition, as outlined above in Criteria 2 #2 and #3, are documented and physician notified timely remain in continued compliance. This will be monitored daily X 3 weeks, weekly X 4 weeks and monthly X 3 months beginning [DATE]. Ongoing, after daily review of nurse's 24-hour report, nurse management team will follow up on any concerns identified. These concerns will be logged and presented during QAPI meeting. Change in condition identification and physician notification will become part of the monthly facility QAPI process. During each meeting, QAPI team consisting of Administrator, Medical Director, DON, ADON's Infection Preventionist as well as other pertinent members of IDT, will review current process and make recommendations to be implemented. This will be an ongoing process to ensure continued compliance. Criteria #3: 1. Licensed staff will be re-educated on change in condition and physician notification. 2. Licensed nurses will be re-educated on obtaining after hour medications to include contacting the off-hour pharmacy delivery. If the medication will not be available timely the nurses are to contact the MD to notify him/her that the medication is not available and obtain alternate order. If no timely response from the Dr. that was called the nurses are instructed to notify the house supervisor and DON. The supervisor and DON will be responsible for contacting the medical director and/or other physician on call to obtain any orders to include transfer to the ER if indicated. 3. RN Supervisors and nursing leadership to be re-educated regarding follow-up on residents with medical concerns. This includes identification of change in condition and physician notification. RN Supervisors will receive report from off going RN Supervisor both written and oral. RN Supervisor will also read 24-hour report in PCC, as well as risk management. Supervisor will then make rounds of all residents identified with concerns and monitor for appropriate documentation and nurses' response. During rounds supervisor will check with charge nurse of any other concerns they may have and will assess those residents as well. 4. Licensed staff to be re-educated on reviewing of 24-hour reports, presenting verbal reports, and adequate documentation. Reports to include the following guideline of condition of each resident. List and report any elevated temperatures or abnormal vital signs and the last time checked. Report the last dose of any PRN medication administered and effectiveness. Report and condition change or follow-up on any condition change of any resident. Report incidents, status of residents, orders to be followed. Report equipment failure or supplies needed. Report status on CALLS TO PHYSICIANS Why call was placed Name of the resident When last call was placed Report on medications not administered as ordered and reasons Report on residents out on pass Report on residents with low output that must be checked. Report

Based on interview and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 10 residents (Resident #1) reviewed for quality of care. The facility failed to respond timely and to consult with the attending physician on [DATE] when Licensed Vocational Nurse (LVN) K on the 2:00 PM to 10:00 PM shift noted pin point spots of blood on Resident #1's brief. On [DATE] failed to administer [MEDICATION NAME] (antibiotic) as ordered for hematuria (blood in urine). Failed to respond timely and to consult with the attending physician when Resident #1 displayed signs of a change in condition. On [DATE] Resident #1's condition worsened, including a significant decline in physical functioning and decreased level of consciousness, the facility failed to respond and consult with Resident #1's physician. On [DATE], Resident #1 was sent to the emergency room (ER) where he died . This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE]. While the IJ was lowered on [DATE] at 2:00 PM the non-compliance continued at a level of actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate and monitor the effectiveness of their corrective action system. This failure has the potential to affect 21 residents that reside on the Special Care Unit (where Resident #1 resided) by placing them at risk of potential medical complications, hospitalization , or even death related to changes in condition. Findings included: RESIDENT #1 Review of Resident #1's Electronic Medical Record (EMR) undated Face Sheet documented Resident #1 was a [AGE] year-old male readmitted to the facility on [DATE]. Review of Resident #1's most recent History and Physical dated [DATE] documented in part; Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] documented, in part: Hearing adequate Speech clear Made himself understood Understood others Brief Interview for Mental Status (BIMS) score 13 which indicated he was cognitively intact Independent for eating Required one staff and extensive assistance for transfer and toilet use. Used a wheelchair for mobility Review of Resident #1's Care Plan dated [DATE] documented in part: Monitor/document/report to MD as needed signs or symptoms of [DIAGNOSES REDACTED] (low blood sugar) Observe for signs or symptoms of decreased or no urine output. Report to MD Notify MD of any signs or symptoms of immobility. Review of Nurse's Notes documented, in part: [DATE] at 11:28 PM the nurse going off duty documented: This nurse observed several pin point size spots of blood on the brief when the resident was being changed. Brief wet at this time with urine. Reported to oncoming nurse to monitor for any further changes. Signed by LVN K. [DATE] at 10:15 PM the nurse going off duty documented: Resident noted to have hematuria X 2. Observed blood tinged urine on his brief during the last two changes. Call placed to physician and orders received to get urinalysis for culture and sensitivity, Complete blood count (CBC) and give a one-time dose of [MEDICATION NAME] 1-gram IM. Signed by LVN K. (No documentation of Resident #1 receiving [MEDICATION NAME].) [DATE] at 5:20 AM resident noted with abdominal distention, no urine output throughout shift, last void was yesterday at 8:00PM. Resident complained of discomfort to lower abdomen. This nurse offered pain medication, resident denied. Call placed to physician. Vital Signs (VS) ,[DATE] (blood pressure), 86 (pulse), 18 (respirations), 94% oxygen saturation on 2 L/M (liters per minute), 98.9 temporal temperature. Will pass on report, continue to monitor. Signed by LVN J. [DATE] at 5:47 AM physician called back and ordered in and out catheter. Urine output 850ml (milliters). Pending call back from physician to report urine output, will pass on in report. Signed by LVN J. [DATE] at 7:01 AM per ,[DATE] nurse pending call back from physician to report urine output, will continue to monitor. Signed by LVN A [DATE] at 9:52 AM resident noted to be very weak and physical appearance out of the norms. VS ,[DATE] (blood pressure), 86 (pulse), 19 (respirations), 97.6 (temperature), oxygen saturation 85 on room air, blood sugar 62. Nurse administered as needed oxygen via nasal cannula and oxygen saturation increased to 95%. Nurse also gave orange juice and blood sugar up to 110. Resident refused to take his [MEDICATION NAME]due to low blood sugar, will continue to monitor. Signed by LVN A [DATE] at 1:51 PM resident assessed with [REDACTED]. Resident stated, I peed today . Bladder scan performed and found 29mls of urine, will continue to monitor. Signed by LVN A. [DATE] at 7:49 PM This nurse placed call (to physician) to report in and out of the morning. Pending call back. Signed by LVN A. [DATE] at 5:00 AM at this time resident noted with labored breathing, VS ,[DATE], 112, 30, 101.8 and oxygen saturation 92% with oxygen on, blood sugar 122. Resident unable to answer any questions, unable to swallow water. RN Supervisor aware. Signed by LVN L. [DATE] at 5:15 AM On call MD returned call back with new order to send resident out to hospital, 911 call placed by this nurse. Signed by LVN L. [DATE] at 5:35 AM resident leaving facility via ambulance. Signed by LVN L. During an interview on [DATE] at 1:58 PM CNA C said Resident #1 would always stand and pivot when transferring. On [DATE], (Sunday morning) when she went in to get him ready for breakfast, he was not himself. She said Resident #1 could not help her get him up and she had to physically slide him into his wheelchair to transfer him; she then took him to the dining room. CNA C said Resident #1 was very weak and couldn't eat anything, she went and told LVN A and LVN A came and took his blood sugar. CNA C said LVN A told her the blood sugar was low, so she gave him apple juice with sugar in it. LVN A checked again, and his blood sugar had come up, but he remained very weak and could hardly sit up. CNA C said she took him back to bed and he was so bad she could not get him back by herself. She said she had to get another CNA (CNA G) to help her put him in bed. He stayed in bed the remainder of the weekend. CNA C said she told LVN A how bad he was, and that he needed to go to the hospital and she should call 911. LVN A said she had to call the doctor first because that was protocol. CNA C said the resident did not urinate or have a bowel movement for the entire weekend. She was very worried about him because he was always up and ate everything, and this was a big change. She said all total that day Resident #1 was up for maybe 10 minutes. During an interview on [DATE] at 3:11 PM RN Supervisor D said the last few days before Resident #1 went out to the hospital the CNA's had reported he was weaker. In an interview on [DATE] at 2:18 PM CNA F said she worked on Friday ([DATE]), Saturday ([DATE]) and Sunday ([DATE]). She said one of the last days Resident #1 was in dining room, probably Friday, she noticed he didn't eat very much; he had just picked at his food. CNA F said she reported it to the LVN because Resident #1 usually ate everything. In an interview on [DATE] at 9:25 AM CNA G said on Friday, [DATE], Resident #1 seemed fine. She said on Saturday, [DATE], he was a little quiet but, he went to the dining room and ate everything for breakfast and a little lunch. CNA G said she changed his brief and he had urine and it was not bloody. She said Resident #1 called his wife as he did every day. CNA G said on Sunday [DATE] Resident #1 had a big, big change and he couldn't even stand up. CNA G said at the dining room CNA C told LVN A to check Resident #1 because he could not stand up, he did not eat, and he was very weak. CNA G said LVN A said his sugar was low. CNA G said she helped CNA C get Resident #1 back in bed after breakfast. She said CNA C told LVN A that Resident #1 was not feeling good, did not eat anything, did not have any urine all day and he was not talking. CNA G said she was with CNA C when CNA C reported Resident #1's bad condition to the RN Supervisor B, they were together. In an interview on [DATE] at 4:22 PM LVN A said she worked weekends from 6:00 AM until 10:00 PM on the Special Care Unit, and Resident #1 was her resident. She said she remembered on Saturday morning ([DATE]) the night nurse told her the [MEDICATION NAME] was pending delivery from the pharmacy. LVN A said the medication was never delivered and she did not call the pharmacy to check on it. LVN A said on Sunday ([DATE]) Resident #1's appearance was off; he got up but looked fatigued. She said his oxygen saturation and blood sugar were low, she gave him PRN oxygen and held his morning and afternoon insulin. LVN A said she thinks she told RN Supervisor B, but she did not notify the physician. LVN A said the night nurse had done an in and out catheter because the resident had not voided all night. LVN A said when Resident #1 had not voided by around noon on Sunday ([DATE]) she was going to do another in and out catheter, but RN Supervisor B told her not to. He said he would come and do a bladder scan. She said Resident #1 stayed in bed all day. LVN A said she remembered CNA C reporting to her Resident #1's drastic change and CNA C wanted her to call 911. LVN A said she told the CNA that it was just because of his blood sugar. In a telephone interview on [DATE] at 2:58 PM RN Supervisor B said at about 3:00 PM on Sunday ([DATE]) LVN A told him Resident #1 had not had any urine output and she was going to do an in and out catheter. He said he told LVN A he would go and do a bladder scan, which he did. RN Supervisor B said when he did the scan Resident #1 only had about 30ml of urine in his bladder. He said the resident told him he had peed . The resident told him he had peed, and he thought the resident should know better than the CNA's. RN Supervisor B said he did not go back later to check on the resident. RN Supervisor B said Resident #1 was usually up in his wheelchair propelling himself throughout the facility but on [DATE] Resident #1 was in bed. RN Supervisor B said he did not think it was strange that he was in bed and not up because sometimes old people do that. RN Supervisor B said he was not aware of an order for [REDACTED].>In a telephone interview on [DATE] at 2:55 PM the Pharmacy Manager said they received an order for [REDACTED]. The Pharmacy Manager said the pharmacy did not call to notify the facility because all nurses are supposed to know what medications were in the automated medication dispenser. In an interview on [DATE] at 3:05 PM the Director of Nursing (DON) said she did not see that anything was done wrong concerning Resident #1's care from [DATE] until [DATE]. The DON said because she did not find anything wrong, no in-services were done. There was not an incident report for that time period. In an interview on [DATE] at 1:10 PM the Director of Nursing (DON) said the resident's physician informed her Resident #1's cause of death was due [MEDICAL CONDITION], pneumonia and acute [MEDICAL CONDITION]. The DON said she wasn't there and it wasn't her making the decisions about calling the physician for Resident #1. The DON said the Licensed Vocational Nurse (LVN) used her clinical judgement; and if she didn't call the physician it was because she didn't think she should call. The DON said the physician did not need to be called when Resident #1's blood sugar and oxygen saturation were low, even though it had not been that low before, because the nurse had PRN orders to use. The DON said the physician did not need to be notified when there was only 29ml of urine in Resident #1's bladder after not voiding for eight hours, because it would depend on the resident's intake. The DON said the low level of urine would not necessarily make her think [MEDICAL CONDITION] because nurses can't diagnose. The DON said she wasn't there and could not say what should have been done because the nurses used their clinical judgement. The DON said the [MEDICATION NAME] was never administered, the nurses did not check the automated medication dispenser or call the pharmacy. In an interview on [DATE] at 2:00 PM the attending physician for Resident #1, Medical Doctor (MD) I, said there was a Physician on call each weekday from 5:00 PM until 7:00 AM and 24 hours a day on weekends. MD I said she should have been notified if an oxygen saturation was low and it was necessary to give PRN oxygen. MD I said when Resident #1's bladder scan revealed 29ml of urine and the staff reported no urine for the past eight hours the staff should have notified the on-call physician. MD I said at that time Resident #1 should have been sent to the emergency room to be evaluated by a physician in person. MD I said all of the factors and facility failures could have contributed to Resident #1's condition getting worse and resulted in his death. Review of the Fire Department Emergency Medical Services (EMS) Prehospital Care Report, dated [DATE], documented they arrived at the patient at 5:30 AM. They documented on assessment Resident #1 was unresponsive, had hot skin, his pulse was elevated at 108 - 116, respirations were labored and elevated at 31 - 42, he had no eye movement, no motor response, and no verbal or vocal response. The report documented EMS arrived on scene to find the resident laying in bed with labored belly breathing. The report documented the staff reported he had altered mental status for 30 minutes, he had a urinary tract infection, and they were waiting for medication from the pharmacy. EMS documented they were unable to obtain IV access in the facility, and the resident was transported to the closest hospital. Review of hospital emergency room notes, dated [DATE], documented Resident #1 arrived in severe distress and ill appearing with an obviously altered mental status and sonorous (an abnormal snoring sound) respirations at a rate of 30 - 40 and hypotensive (low blood pressure). Resident #1 had [MEDICAL CONDITION] (fast heartbeat) which was treated and resolved. The physician discussed the poor prognosis with the wife and given he was breathing 30 - 40 times a minute she was told that he likely was not going to survive much longer. He did not survive to make it to a hospital bed and died while in the emergency department. Resident #1's death was pronounced at 9:33 AM. Review of Resident #1's death certificate documented the cause of death was urinary tract infection, pneumonia,[MEDICAL CONDITION] and acute [MEDICAL CONDITION] due to infection. Review of Policy and Procedure, Change in Resident Condition or Status dated (MONTH) 2012 documented in part: Purpose: to establish guidelines for determining changes in resident status (condition) Change in Resident Condition or Status 1. Changes in usual bladder elimination patterns 2. No urine output for eight (8) hours/one (1) shift 3. Change in limb movement 4. Changes in: transfer and ambulation, dressing, bathing and/or grooming, eating, chewing and/or swallowing, toileting 5. Changes in range of motion 6. Sudden onset or worsening of lethargy (sluggishness, difficult to arouse and little body movement) Review of Policy and Procedure, Change of Status Notification dated (MONTH) 2012 documented in part: Purpose: To notify the resident's attending physician of change in the resident's condition or status. Procedure: In the following situations the resident's attending physician or designee will be notified 1. A sudden or unexpected change or deterioration in resident's physical, mental or emotional status 2. Any situation which requires a change in medication or treatment such as onset of a new condition On [DATE] at 10:00 AM the Administrator, DON and Assistant Director of Nursing (ADON) were informed an Immediate Jeopardy had been identified. The facility's 3rd Plan of Removal was accepted on [DATE]. Review of the facility's Plan of Removal, accepted [DATE], documented: Criteria #1: 1. Resident X was discharged (MONTH) 21, (YEAR). Criteria #2: 1. DON will generate the 24-hour reports from (MONTH) 26, (YEAR) to present in order to identify any residents that have experienced change in condition beginning (MONTH) 26, (YEAR) and completed [DATE]. 2. For any residents identified with change in condition, the change in condition/notification policy will be followed in its entirety. This will be overseen by the DON/designee on a daily basis beginning [DATE]. This includes: There is an incident or accident involving the resident. A sudden or unexpected change or deterioration in resident's physical, mental or emotional status (psychosocial) Appetite/Fluid Consumption: 1. Frequent deviation from therapeutic diet. Hydration: 1. Unexpected signs/symptoms of dehydration such as dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, fever, abnormal laboratory values such as elevated hemoglobin and hematocrit, potassium, chloride, sodium, [MEDICATION NAME], blood urea nitrogen (BUN) or urine specific gravity Nutrition: 1. Unexpected signs/symptoms of malnutrition such as pale skin, dull eyes, swollen lips, swollen gums, swollen and/or dry tongue with scarlet or magenta hue, poor skin turgor, cachexia, bilateral [MEDICAL CONDITION] and muscle wasting. Weight: 1. Significant unexpected weight change of: a. 5% in 30 days b. 7.5% in 90 days c. 10% in 180 days Elimination Habits Habits/Patterns (Bowel and Bladder): Bowel: 1. Changes in usual bowel elimination pattern. 2. Changes in color, consistency, odor, and/or frequency of bowel movements. 3. Two (2) or more loose stools in an eight (8) hour period. 4. Absence of bowel movements for three (3) or more consecutive days. Bladder: 1. Changes in usual bladder elimination patterns. 2. Changes in color, clarity, odor, pain/burning, urgency and/or frequency in urinary output. 3. No urine output for eight (8) hours/one (1) shift. Neurological: 1. Change in orientation (person, time, place). 2. Sudden onset or worsening of: a. Disorientation b. Stupor or coma c. Level of arousal, including painful stimuli. 3. Loss of consciousness. 4. Pupillary response 5. Limb movement Cardiovascular: 1. New onset of chest pain. 2. New onset of dependent, [MEDICAL CONDITION]. 3. Capillary refill time of three (3) seconds. 4. New onset of pallor or cyanosis. Vital Signs: 1. Change in resting pulse rate that is = or < 60 or = > 100. 2. Change in blood pressure. 3. Oral temperature <96 or >100. 4. Axillary temperature <95 or >99. 5. Resting respiratory rate <10 or >24 Digestive System: 1. Sudden onset, worsening, or reports of: a. Indigestion/heartburn or flatulence. b. Nausea/vomiting c. Bloating/abdominal distention or constipation. d. Appearance of blood in stools or vomitus. e. Glucose testing - follow physician's protocol or orders. Respiratory Status: 1. Change in rhythm (regularity). 2. New onset of chest pain. 3. Changes in breath sounds including wheezing, crackles, rales, and/or rhonchi. 4. New onset of cough. 5. Complaints or reports of dyspnea or shortness of breath. 6. Pulse oximetry reading of 92% or less. Pain: 1. Sudden onset of pain and/or expression of pain (verbal or nonverbal). 2. Change in duration, location, intensity, character, quality of pain. Physical Functioning: 1. Changes in: a. Transfer and ambulation b. Dressing, bathing and/or grooming. c. Eating, chewing and/or swallowing. d. Toileting. e. Use of speech, language, or other functional communication system. f. Vision and hearing 2. Range of motion: a. Limitations b. Changes and/or alterations. Skin Integrity: 1. New onset of Stage I or greater nosocomial pressure ulcers. 2. New onset of rashes, blisters or denuded skin. Behavior (certain behaviors may be indicative of an altered mental status): 1. Sudden onset or worsening of inappropriate behaviors that cannot be easily redirected such as: a. Wandering (moving with no rational purpose, seemingly oblivious to needs or safety). b. Verbally abusive (screaming at, cursing at, or threatening others). c. Socially inappropriate/disruptive behavior (makes disrupting sounds, noisy, screams, self-negative acts, inappropriate sexual behavior, disrobing in public, smearing/throwing food/feces, hoarding, rummaging through others' belongings). d. Resisting care (taking medications/injections and or resisting ADL assistance). e. Hallucinations/delusions. f. Poor self-care. g. Unsociable behavior. h. Periods of restlessness (fidgeting or picking at skin, clothing, napkins, etc.; frequent position changes; repetitive physical movements or calling out). i. Uncooperativeness. j. Agitated behaviors that may or may not represent a danger to the resident or others. Sudden onset or worsening of changes in cognition such as: 1. Impaired memory. 2. Disordered thinking that may be manifested by rambling, irrelevant, or incoherent speech. Sudden onset or worsening of mood and behavior patterns such as: 1. Anxiety; 2. Depression; 3. [MEDICAL CONDITION]; 4. Sense of initiative and involvement; 5. Loss of interest and/or isolation; or 6. Indifference to surrounding; or 7. Verbal expressions of distress (increased or decreased numbers, frequency, or intensity of expressions of signs of distress). 8. Sudden onset or worsening of lethargy (sluggishness, staring into space; difficult to arouse; little body movement). *Any situation which requires a change in medication or treatment regime, i.e., need for restraints, exacerbation of known condition, onset of new condition, abnormal lab values, behavior, weight loss, appointments, elopement and skin breakdown. *When the resident leaves against medical advice. *Any resident-to-resident altercation. *When the decision to transfer or discharge the resident from the facility has been made or in the event of resident death. *The charge nurse on the unit is responsible with assistance from RN Supervisor. 3. 24-hour reports will be reviewed daily by DON, ADON, and RN Supervisors beginning (MONTH) 26,2018 in order to identify change in condition and to ensure policies are followed. This over-site to be provided by the Regional Clinical Nurse Consultant beginning (MONTH) 27, (YEAR). These policies include: There is an incident or accident involving the resident. A sudden or unexpected change or deterioration in resident's physical, mental or emotional status (psychosocial). Appetite/Fluid Consumption: 1. Frequent deviation from therapeutic diet. Hydration: 1. Unexpected signs/symptoms of malnutrition such as pale skin, dull eyes, swollen lips, swollen gums, swollen and/or dry tongue with scarlet or magenta hue, poor skin turgor, cachexia, bilateral [MEDICAL CONDITION], muscle wasting. Nutrition: 1. Unexpected signs/symptoms of malnutrition such as pale skin, dull eyes, swollen lips, swollen gums, swollen and/or dry tongue with scarlet or magenta hue, poor skin turgor, cachexia, bilateral [MEDICAL CONDITION] and muscle wasting. Weight: 1. Significant unexpected weight change of: a. 5% in 30 days b. 7.5% in 90 days c. 10% in 180 days Elimination Habits Habits/Patterns (Bowel and Bladder): Bowel: 1. Changes in usual bowel elimination pattern. 2. Changes in color, consistency, odor, and/or frequency of bowel movements. 3. Two (2) or more loose stools in an eight (8) hour period. 4. Absence of bowel movements for three (3) or more consecutive days. Bladder: 1. Changes in usual bladder elimination patterns. 2. Changes in color, clarity, odor, pain/burning, urgency and/or frequency in urinary output. 3. No urine output for eight (8) hours/one (1) shift. Neurological: 1. Change in orientation (person, time, place). 2. Sudden onset or worsening of: a. Disorientation b. Stupor or coma c. Level of arousal, including painful stimuli. 3. Loss of consciousness. 4. Pupillary response 5. Limb movement Cardiovascular: 1. New onset of chest pain. 2. New onset of dependent, [MEDICAL CONDITION]. 3. Capillary refill time of three (3) seconds. 4. New onset of pallor or cyanosis. Vital Signs: 1. Change in resting pulse rate that is = or < 60 or = > 100. 2. Change in blood pressure. 3. Oral temperature <96 or >100. 4. Axillary temperature <95 or >99. 5. Resting respiratory rate <10 or >24 Digestive System: 1. Sudden onset, worsening, or reports of: a. Indigestion/heartburn or flatulence. b. Nausea/vomiting c. Bloating/abdominal distention or constipation. d. Appearance of blood in stools or vomitus. e. Glucose testing - follow physician's protocol or orders. Respiratory Status: 1. Change in rhythm (regularity). 2. New onset of chest pain. 3. Changes in breath sounds including wheezing, crackles, rales, and/or rhonchi. 4. New onset of cough. 5. Complaints or reports of dyspnea or shortness of breath. 6. Pulse oximetry reading of 92% or less. Pain: 1. Sudden onset of pain and/or expression of pain (verbal or nonverbal). 2. Change in duration, location, intensity, character, quality of pain. Physical Functioning: 1. Changes in: a. Transfer and ambulation b. Dressing, bathing and/or grooming. c. Eating, chewing and/or swallowing. d. Toileting. e. Use of speech, language, or other functional communication system. f. Vision and hearing 2 Range of motion: a. Limitations b. Changes and/or alterations. Skin Integrity: 1. New onset of Stage I or greater nosocomial pressure ulcers. 2. New onset of rashes, blisters or denuded skin. Behavior (certain behaviors may be indicative of an altered mental status): 1. Sudden onset or worsening of inappropriate behaviors that cannot be easily redirected such as: a. Wandering (moving with no rational purpose, seemingly oblivious to needs or safety). b. Verbally abusive (screaming at, cursing at, or threatening others). c. Socially inappropriate/disruptive behavior (makes disrupting sounds, noisy, screams, self-negative acts, inappropriate sexual behavior, disrobing in public, smearing/throwing food/feces, hoarding, rummaging through others' belongings). d. Resisting care (taking medications/injections and or resisting ADL assistance). e. Hallucinations/delusions. f. Poor self-care. g. Unsociable behavior. h. Periods of restlessness (fidgeting or picking at skin, clothing, napkins, etc.; frequent position changes; repetitive physical movements or calling out). i. Uncooperativeness. j. Agitated behaviors that may or may not represent a danger to the resident or others. Sudden onset or worsening of changes in cognition such as: 1. Impaired memory. 2. Disordered thinking that may be manifested by rambling, irrelevant, or incoherent speech. Sudden onset or worsening of mood and behavior patterns such as: 1. Anxiety; 2. Depression; 3. [MEDICAL CONDITION]; 4. Sense of initiative and involvement; 5. Loss of interest and/or isolation; or 6. Indifference to surrounding; or 7. Verbal expressions of distress (increased or decreased numbers, frequency, or intensity of expressions of signs of distress). 8. Sudden onset or worsening of lethargy (sluggishness, staring into space; difficult to arouse; little body movement). *Any situation which requires a change in medication or treatment regime, i.e., need for restraints, exacerbation of known condition, onset of new condition, abnormal lab values, behavior, weight loss, appointments, elopement and skin breakdown. *When the resident leaves against medical advice. *Any resident-to-resident altercation. *When the decision to transfer or discharge the resident from the facility has been made or in the event of resident death. *The charge nurse on the unit is responsible with assistance from RN Supervisor. 4.There will be a 100% audit of medication carts to ensure all ordered meds are available. The emergency drug boxes automated medication dispenser will be monitored for availability of drugs as listed. This audit will be conducted by licensed nursing staff with oversight from DON, ADON, and Pharmacy Nurse with completion date of [DATE]. The medication carts and automated medication dispenser will be monitored daily with oversite from DON, ADON, and Pharmacy Nurse beginning [DATE] and ongoing. The night shift nurses will check medication carts nightly to ensure all prescribed medications are ordered timely beginning [DATE] and ongoing. 5.The Director of Nursing and Clinical Nurse Consultant will monitor to ensure the changes in condition, as outlined above in Criteria 2 #2 and #3, are documented and physician notified timely remain in continued compliance. This will be monitored daily X 3 weeks, weekly X 4 weeks and monthly X 3 months beginning [DATE]. Ongoing, after daily review of nurse's 24-hour report, nurse management team will follow up on any concerns identified. These concerns will be logged and presented during QAPI meeting. Change in condition identification and physician notification will become part of the monthly facility QAPI process. During each meeting, QAPI team consisting of Administrator, Medical Director, DON, ADON's Infection Preventionist as well as other pertinent members of IDT, will review current process and make recommendations to be implemented. This will be an ongoing process to ensure continued compliance. Criteria #3: 1. Licensed staff will be re-educated on change in condition and physician notification. 2. Licensed nurses will be re-educated on obtaining after hour medications to include contacting the off-hour pharmacy delivery. If the medication will not be available timely the nurses are to contact the MD to notify him/her that the medication is not available and obtain alternate order. If no timely response from the Dr. that was called the nurses are instructed to notify the house supervisor and DON. The supervisor and DON will be responsible for contacting the medical director and/or other physician on call to obtain any orders to include transfer to the ER if indicated. 3. RN Supervisors and nursing leadership to be re-educated regarding follow-up on residents with medical concerns. This includes identification of change in condition and physician notification. RN Supervisors will receive report from off going RN Supervisor both written and oral. RN Supervisor will also read 24-hour report in PCC, as well as risk management. Supervisor will then make rounds of all residents identified with concerns and monitor for appropriate documentation and nurses' response. During rounds supervisor will check with charge nurse of any other concerns they may have and will assess those residents as well. 4. Licensed staff to be re-educated on reviewing of 24-hour reports, presenting verbal reports, and adequate documentation. Reports to include the following guideline of condition of each resident. List and report any elevated temperatures or abnormal vital signs and the last time checked. Report the last dose of any PRN medication administered and effectiveness. Report and condition change or follow-up on any condition change of any resident. Report incidents, status of residents, orders to be followed. Report equ

Based on interview and record review, the facility failed to ensure 1 (Resident #1) of 9 residents reviewed for insulin administration was free of significant medication errors. Licensed Vocational Nurse (LVN) A administered 100 units of Humolog insulin to Resident #1 instead of the 3 units of Humolog insulin as prescribed by his physician (more than 33 times the ordered dose). Resident #1 was admitted to the ICU (Intensive Care Unit) on 11/14/15 as a result of this error. An Immediate Jeopardy (IJ) was identified on 1/4/16. While the IJ was removed on 1/6/16, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy, isolated, because the facility had not monitored their plan for effectiveness. These facility failure resulted in harm for Resident #1 and could affect the 23 other residents who receive insulin and place them at risk for low blood sugar, coma and death. Findings included: Review of Resident #1 ' s face sheet dated 11/15/15 revealed he was [AGE] year old male admitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set- dated 10/30/15 revealed his BIMs (Brief Interview for Mental Status) score was 14 (cognitively intact). Review of Physicians Orders dated November 2015 documented Humalog Solution 100 Unit/ML Inject 3 Units subcutaneously before meals related to Type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]. Review of Resident #1 ' s Medication Administration Records (MARs) dated 11/01/15-11/30/15 revealed Resident #1 had been prescribed Humalog Solution 100 UNIT/ ML Inject 3 unit subcutaneously before meals related to Type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]. Review of the Humalog Prescribing Information Packet (dated October 2011 <http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/ 3s117lbl.pdf>), revealed: Humalog is a rapid acting human insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus. Humalog is fast-acting insulin and should be given within 15 minutes before a meal or immediately after a meal. Review of Resident #1 ' s Nurses Notes dated 11/14/15 time 10:55 PM revealed This nurse administered incorrect dose of Humalog. Dosage was 100 units. When error realized (4:55 PM) BS (blood sugar) was retaken and OJ (orange juice) was given. BS at that time was 133. Registered Nurse (RN) notified at 5:00 PM. RN instructed this nurse to continue to monitor resident and recheck BS every 10-15 mins. Res (Resident) alert, speak WNL (within normal limits), denies dizziness or blurred vision. RN received telephone order from PCM( primary care physician) for [MEDICATION NAME]. [MEDICATION NAME] administered at 5:18 PM. Physician gave order via telephone to transfer to ER (emergency room ) at 5:20 PM. Res (Resident) remain alert with BS (blood sugar) 144, 153. Res left facility at 5:35 PM via ambulance. RN made notifications to family and DON (Director of Nursing). At 10:50 PM this nurse called hospital for report, resident is stable, blood sugar within normal limits, on IV drip of continuous D5. Resident to stay overnight for observation. Review of Resident #1 ' s Nurses Notes dated 11/14/15 time 18:31 revealed physician called back at 5:20 PM and gave order to transport resident to the emergency room . Resident remained alert and responsive. Glucose at time of transport 155. Review of Incident Report dated 11/15/15, revealed LVN A gave incorrect dosage of Humalog insulin to Resident at 1655. She took the medication into the resident ' s room, was chatting with him and got side tracked by the conversation. She drew up the incorrect dose and administered it. Once out of the room she was aware that she had given an over dose & immediately notified her supervisor RN B and DON. Blood sugars were obtained every 10 minutes prior to him being sent to the hospital. Upon departure blood sugar was 154. Review of Resident #1's Hospital emergency room History and Physical dated 11/14/15 revealed the following: Date 11/14/15 Time: 18:25 Glucose 79 Date 11/14/15 Time: 19:47 Glucose 100 Date 11/14/15 Time: 23:12 Glucose 66 Date 11/15/15 Time: 00:15 Glucose 98 Date 11/15/15 time 04:20 Glucose 104 Review of Hospital Provider Progress Note dated 11/15/15 at 11:27 AM revealed Patient admitted to Intensive Care Unit (ICU) 7 hours after accidental overdose of rapid acting insulin. No other pathologies found during admission that require continued care. Has not required Intensive Care Unit intervention or monitoring since admission and may restart all home medications along with transfer back to nursing home. Review of Resident#1 ' s Nurses Notes dated 11/15/15 dated 9:42 PM revealed Resident returned to facility from hospital .blood sugar 120 . In an interview on 12/16/15 at 9:30 AM, Resident #1 stated a nurse made a mistake with one of my medications and I don ' t remember what exactly happened. I was sent to the hospital. I don't remember the exact time it was around a month ago. They fixed it in the hospital and I came back here after that. In an interview on 12/16/15 at 12:05 PM, LVN A stated I had just come off training. I was inside the room talking to Resident #1, I had the box of insulin in my hand and the vial, I read on the box 100 units, I got distracted talking to him (Resident #1) and I drew 100 units of insulin and administered it. I realized it after a few minutes I was out of the room. I should have drawn it at the med cart. I parked it (medication cart) several doors down and maybe if I would have drawn it at the cart I would just have been concentrating on drawing the right dose of the medication. Now we have to have two nurses check the insulin before we give it. It was an accident, I was talking to him I got distracted it caused me to make an error. I realized it and told my supervisor. I assured his safety, I followed the procedure gave him orange juice, and called the doctor, he gave me orders for [MEDICATION NAME]. LVN A stated I got counseled and retrained and I had to demonstrate to ADON B that I was able to read the medication label documenting the physician instructions. LVN A stated , Resident #1 was alert and talking to me when I explained what I had done. He understood what was happening; at no point did he ever lose consciousness. In an interview on 12/16/15 at 10:00 AM, Assistant Director of Nurses (ADON) B stated: the nurse got distracted by talking to him (Resident #1) at his bedside and had the syringe and box of insulin with her at the bedside. Licensed Vocational Nurse (LVN) A told me that she read the box of insulin, 100 units was printed on the box. She (LVN A) said that she drew the 100 units and administered it to Resident #1. She (LVN A) said that she realized she had made an error when she stepped out of the room. In an interview on 12/17/15 at 8:45 AM, ADON B stated LVN A came to work with us PRN (as needed basis) and did not deal with insulin frequently before. ADON B stated that medication administration is something she must have known as part of her nursing skills, insulin administration is something she absolutely should have known. In an interview on 12/16/15 at 9:45 AM, the Director of Nurses (DON) stated LVN A gave 100 units of Humalog, she was talking to him (Resident #1) and got distracted, it was an error she did not do it maliciously. She reported it to the supervisor right away. She (LVN A) said that soon as she stepped out of the room, within 5 minutes after she gave him the insulin she realized that she had made a mistake. She gave him orange juice and the called physician and gave him the [MEDICATION NAME]. The doctor gave orders to send him to the hospital. DON stated Resident #1 had no negative effects from the incorrect insulin administration. The DON stated LVN A had completed the orientation process, and had shadowed a nurse at the facility. The DON stated LVN A completed the orientation process without any problems. DON stated due to this incident the facility had implemented a new protocol to have two nurses check the insulin dosage before administering it. In an interview on 12/17/15 at 9:00 AM, the DON stated Resident #1 ' s blood sugar could have dropped very low. She stated that due to the incident with Resident #1 and the insulin administration the facility had implemented a protocol, we have two nurses check the dosage of the insulin before it is administered. The nurse draws the insulin, and with the needle still on the vial they will seek a second nurse to verify that the drawn insulin is the amount documented in the doctor order, then the insulin gets administered. The DON stated The nurse that is orienting the new nurse tells us if the new nurse has any issues. We don't go over and teach the new hires how to read medication labels and administer medication, medication administration is part of the skills we expect nurses to come in with as part of their training. We have implemented this because before the nurses were not required to have two nurses check insulin. We don't have the staff for it. Even if it's hard for the staff we are going to implement this protocol now to ensure the safety of the residents. In an interview on 12/17/15 at 10:55 AM, LVN C stated we have to do a 2 person check now for insulin before we give it. We started this new, about a month ago. In an interview on 12/17/15 at 11:00 AM, LVN D stated we do a 2 person check, if I draw insulin I go with another nurse, and have her verify the dosage and the resident. It's working out pretty well there is someone around you can check with all the time. In an interview on 12/17/15 at 11:30 AM, LVN D stated, We check with another nurse before we administer insulin. I show them the medication, Medication Administration Record [REDACTED]. In an interview on 12/17/15 at 9:45 AM, the Nursing Home Administrator (NHA) stated that Resident #1 went out to the hospital because LVN A administered too much insulin. NHA stated Resident #1 had not had any additional medical issues as a result of the insulin administration incident. The NHA stated the DON retrained the nurse and verified she was able to complete her nursing duties. We implemented a new protocol of having 2 persons check the insulin before they administered it. The NHA stated that since the date of Resident #1 ' s hospitalization there had not been any other residents hospitalized due to incorrect insulin administration. Review of the Diabetic Management Policy dated (4/2011) revealed Anti-diabetic agents (insulin or oral anti-diabetic agents) shall be administered per physician order. All insulin needs to be verified by a second licensed nurse prior to administering and documented appropriately. In an interview on 12/17/15 at 9:00 AM the DON stated the facility did not have a specific policy on insulin administration. In an interview on 1/4/16 at 3:20 PM the DON said nurses were told to have another nurse verify the insulin prior to administration and make a notation of the nurse verifying. The DON said no monitoring of insulin verification was being done; a monitoring plan had not been set up. Record review of Resident #1's Medication Administration Records (MAR) dated 11/16/15 7:30 AM through 1/4/16 11:30 AM documented Humalog insulin administered 146 times since the overdose. The MAR's documented out of the 146 occasions a second nurse verification of correct amount was documented only 14 times. An IJ was identified on 1/4/16 at 3:27 PM and the NFA was informed. In an interview on 1/4/16 at 4:05 PM, Resident #1 said he was given a shot with too much insulin and he was rushed to the hospital. Resident #1 said he felt a little woozie after the shot, but the nurse was very brave she told him she had given him too much insulin and she gave him orange juice. Record review of Order Listing Report dated 11/1/15 - 1/31/16 provided by the DON on 1/4/16 recorded 9 residents received insulin. Record review of Order Listing Report dated 7/1/15 - 1/31/16 provided by the DON on 1/5/16 recorded 22 residents received insulin. Record review of Order Listing Report undated provided by the DON on 1/5/16 recorded 23 residents received insulin. In an interview on 1/5/16 at 10:40 AM the DON said she does not know how many insulin dependent diabetics (IDDM) are in the facility. The DON said she goes to the medication cart and looks at the insulin vials to see who is on insulin. The DON said she can't pull a report or doesn't know how to pull a report of current diabetics on insulin. During the interview the Nursing Home Administrator (NHA) asked, Is it a regulation that the DON know the diabetics? In an interview on 1/5/16 at 5:00 PM the DON said her Assistant Directors of Nursing (ADON) were working with the facility's computer software company to devise a system to require a set of initials of the nurse verifying before the insulin administration would close. In an interview on 1/6/16 at 8:44 AM the DON said the software company (PCC) devised a system to require a set of initials from the nurse verifying the insulin amount be put into the computer before the insulin would close as administered. The DON said nurses were in-serviced on the new process and the in-servicing would continue. The Plan of Removal was accepted on 1/6/16 at 2:27 PM and it included the following: Facility Wide In-service on the 5 rights of medication administration and to document the name of the nurse that verified the insulin 11/15/15. PCC was updated, 2nd nurse will have to initial in MAR for verification of insulin, in-service all nurses started 1/5/16 with full completion expected 1/10/16. Nurse management will review 30% of insulin recipients MAR for second nurse signature. Weekly pull a report from the software system of all residents that have orders for insulin and compare that report to the insulin vials in the medication carts and the MAR's On 1/6/16 the surveyor confirmed by interviews with nursing and administrative staff and by record review that nursing staff were in-serviced on the above and were knowledgeable about changes in procedures. On 1/6/16 at 2:27 PM the NFA was informed the IJ was removed. The facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy, isolated, because the facility had not in-serviced all staff and had not monitored their plan for effectiveness. Record review of the document Order Listing Report undated provided by the DON on 1/5/16 recorded 23 residents received insulin medication.

Based on interview and record review the facility failed to ensure that 1 (Resident #1) of 5 residents reviewed for accidents and supervision received adequate supervision to prevent accidents. On [DATE] at 10:30 AM, Certified Occupational Therapy Aide (COTA) A placed a heating pack, without a physician order, on Resident #1's back. COTA A forgot about the hot pack. Two and ,[DATE] hours later 2 Certified Nurse Aides (CNAs D and E) saw dried blood on the blankets on the resident's back. Licensed Vocational Nurse (LVN B) assessed Resident #1 and found a heating pack on the resident. On Resident #1's back was a 20 cm by 30 cm (the size of the heating pack) reddened area with an 11.3 cm by 3.9 cm peeled area in the center of the redness. This failure led to 1st and 2nd degree burns on Resident #1 and could place 23 residents receiving occupational therapy at risk for injury. The findings included: Record review of the face sheet dated [DATE] documented Resident #1 was an [AGE] year old man with [DIAGNOSES REDACTED]. Resident #1 was admitted on [DATE], was on palliative care and died on [DATE]. Record review of the admission Minimum Data Set ((MDS) dated [DATE] documented Resident #1 had a BIMS (Basic Interview for Mental Status) score of 6 out of 15 (severely impaired cognition for daily decision making), had no behaviors, required 1 person extensive assistance for mobility, had constant pain that interfered with daily activities and had a pressure ulcer. Record review of the Provider Investigation Report dated [DATE] documented on [DATE] a hot pack was placed on Resident #1's back at approximately 10:30 AM and left on until 1:00 PM. The description of the injury was a redness and blistering where the hot pack was applied. The Description of Assessment stated Assessment of the resident's lower back revealed blanching redness 20 cm X 30 cm with an open skin area 11.3 cm X 3.9 cm, and several layers of redness with blisters forming. The Investigation Summary stated After investigation it was determined that COTA A placed a hot pack on Resident #1's lower back and covered it with a towel around 10:30 AM on [DATE]; she then turned Resident #1 over to SLP (Speech Language Pathologist) and failed to inform her that she had placed a hot pack on Resident #1; COTA A failed to remember the hot pack on Resident #1 and it was not discovered until he was brought back to his room for ADL (activities of daily living) care around 1:00 PM. Record review of COTA A's written statement included I put the hot pack on Resident #1 about 1030 more or less. I did not set a timer and began with another patient. I did not take Resident #1 back to the MCU (Memory Care Unit). SLP E asked if I was done with him so she could begin therapy. I said yes he was finished with me for therapy. The hot pack was on the lower back and the patient was covered with blanket, hot pack was not visible. Record review of Physician order [REDACTED]. Record review of Physician Telephone Orders dated [DATE] documented orders for an ice pack for 30 minutes and to then clean the wound to Resident #1's lower back and apply Silvadene and cover with a dressing. Record review of the contract rehabilitation company's in-service dated [DATE] documented the in-service included the hot pack safety policy. The handout titled Thermomodalities, Hot Pack/Moist Heat Utilization Compliance Tool; Clinical/Documentation stated all hot packs will be applied in the therapy gym and with supervision - a patient will never be left alone with a hot pack; Provide a bell or immediate means to call for help; Visually inspect the skin under the hot pack after 5 minutes maximum for excessive redness, blistering, or other signs of burning; After 20 minutes remove hot pack - no treatment should be greater than 20 minutes. It is normal for the area to appear red and feel warm to touch. The handout titled Thermomodalities; Hot Pack/Moist Heat Utilization stated a physician order [REDACTED]. COTA A signed the In-Service Acknowledgement. Interview on [DATE] at 9:49 AM, CNA E said after lunch, about 12:30 or 1:00 PM, on [DATE], he took Resident #1 to his room to lay him down and noticed what looked like dried blood on the resident's chair. CNA E said he lifted the resident's shirt and saw a reddened area with dried blood along his spine. There were also small blisters. CNA D said Resident #1 did not complain of pain until they started looking at the wound. Interview on [DATE] at 2:48 PM, Physical Therapy Aide (PTA) D said a hydrocollator (a piece of equipment used to heat and store hot packs) contained hot packs at a temperature of 165 - 170 degrees Fahrenheit. The hot packs are a superficial heater that conducts heat about a 1 cm depth on the body. The hot pack is placed on the body and insulated with blankets depending on the resident's size and skin condition. Use of the hot pack requires a physician order [REDACTED]. PTA D's experience with the hot packs is they retain heat for about 40 minutes. Residents, especially those with a decreased cognitive ability, were checked frequently - every ,[DATE] minutes. PTA D said the rehabilitation company policy for the hydrocollator was posted above the hydrocollator prior to it being removed from the building. Interview on [DATE] at 10:22 AM, LVN B said on [DATE] the CNAs had taken Resident #1 to his room after lunch so he could perform would care on the resident. The CNAs called him into the room and he saw a large, rectangular-shaped burn on Resident #1's lower back. The large area appeared as a first degree burn, while there was an area in the center that appeared to have been a ruptured blister. LVN B said Resident #1 usually slid down in his bed, but when he saw him, Resident #1 was moving up and down in his chair rubbing his back against the back of the chair. LVN B called the doctor and received orders to use Silvadene (burn ointment) on the area. Telephone interview on [DATE] at 12:12 PM, LVN C said Resident #1 came back from therapy on [DATE] around 11:30 AM for lunch in the Memory Care Unit. He appeared uncomfortable and was squirming in his Geri-chair. He did not say he was in pain and after lunch the CNAs took him to his room to put in bed. LVN C was called into the room and saw a towel with a small amount of blood on it, and an area that appeared like a friction rub along his spine. When she saw the heating blanket she realized it was a burn from the heating pad. There was an area that was the length of an index finger and as wide of skin that had pulled off. Telephone interview on [DATE] at 12:50 PM, COTA A said Resident #1 came into the therapy room shivering cold on [DATE]. She said she had seen hot packs on Resident #1 in the past and so she placed a hot pack with 6 layers of blankets on his mid back in an attempt to warm him. COTA A said she got busy, did not remove the hot pack and sent the resident to his other therapy disciplines. COTA A said the hot pack should not be on for more than 15 minutes. COTA A said she apparently was in trouble because there was no doctor's order for the hot pack. She said she had never seen an order for [REDACTED]. COTA A said she did attend an in-service in December concerning use of the hydrocollator and use of hot packs. She said the policy was posted above the hydrocollator but did not remember needing a doctor ' s order. As she read out loud the bulleted points on her copy of the policy she read a physician order [REDACTED]. Review of the website <http://hbtinstitute.com/files/Hydrocollator_Icepack_Heat_Retention2.pdf> posted a study titled Rate of Heat Transfer in Hydrocollator Pads and Gel Ice Pack. The findings were the pads from the Hydrocollator retained heat sufficient to burn human skin for at least fifty minutes even with appropriate towels for insulation. The interface temperature between heat pack and body part is exactly the same at fifty minutes as the temperature of the actual Hydrocollator pack even with a manufacturer's terry cloth pad and twelve layers of additional terry cloth towel between heat pack and patient. The list of 23 residents receiving Occupational Therapy was obtained from the Nursing Facility Administrator in a telephone interview on [DATE].

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for 1 (Certified Medication Aide (CMA) A) of 4 CMAs whose certification to administer medications was reviewed. CMA A was hired on [DATE] as a medication aide and the facility failed to check her credentials prior to or upon hire. CMA A administered medications to residents on the Memory Support Unit for 2 months when it was discovered during personnel file review she did not have a certification to administer medications. CMA A committed a medication error during the medication pass on [DATE] by attempting to give Resident #36 a medication that was not ordered by his physician. This deficient practice resulted in an immediate jeopardy identified on [DATE]. While the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at widespread as the implemented systems needed to be monitored and evaluated for effectiveness. This failure placed 56 residents on the Memory Support Unit at risk of injury from not receiving medications according to physician order. It also could have placed a total of 151 residents of the facility at risk of not receiving medications according to physician order from the facility not ensuring staff were certified/licensed to administer medications. The findings included: Review of the facility policy Resident Abuse/Neglect/Exploitation/Misappropriation of Resident Property/Involuntary Seclusion/Corporal Punishment dated [DATE] stated, in part, the following: POLICY: New hires will be screened per Reference Checks, Criminal History, Employee Misconduct Registry, Licensing and Certification Boards. All offers of employment are contingent, pending receipt of the information. Review of the facility policy Licensure and Certification dated [DATE] stated in part the following: BACKGROUND: The State requirements require all personnel and consultants must be licensed, registered or certified as required by State and Local Law. POLICY: To ensure that all licensed facilities under the provider are in compliance with applicable standards as it relates to Licensed, Registered, or Certified Personnel, all facilities shall maintain records of such personnel by indicating: a. Name b. Position c. License Number or Certification Number d. Renewal Date for License if applicable PROCEDURE: The Administrator will appoint the Human Resource (HR) Coordinator and/or the Administrative Secretary to be responsible for maintaining up-to-date records on licensure and certification of employees. Review of the facility's Certified Medication Aide job description dated [DATE] stated in part the following: Essential Functions: 1. Preparation, administration and charting of medications including regularly prescribed, PRN (as needed) medications and oxygen. 2. Taking and recording vital signs 3. Observe resident for changes 4. Help feed and render direct patient care as necessary 7. Attend in-service training and education session as assigned Education Requirements: Graduate of approved medication course One year of experience as a Certified Medication Aide preferred. CMA A signed on [DATE] a written acknowledgment located on page 5 of the job description that she understood the position description and had the opportunity to ask her supervisor about any points she did not understand. "I hereby state that I can perform the essential functions of this position with or without reasonable accommodation." Record review of personnel records with the HR Director on [DATE] at 10:11 AM, revealed CMA A was hired as a Certified Medication Aide on [DATE]. There was a copy of a National Certified Medical Assistant card that had expired [DATE]. There was no evidence she had a certification to administer medications. The Employability Status Check Search dated [DATE] was blank under Medication Aide Registry Status. The Employability Status Check Search dated [DATE] was also blank. If CMA A had been certified as a medication aide, under Medication Aide Registry Status would have appeared "active", lapsed" or "revoked". Record review of the Employee Disciplinary Action Form dated [DATE] documented CMA A did not have a CMA certification. The Nursing Facility Administrator (NFA) wrote, "CMA A knowingly impersonated a Certified Medication Aide..., and administered medications to residents unlawfully." Observation during the medication pass on [DATE] at 11:32 AM, revealed CMA A attempted to administer the following medications to Resident #36 by mouth: a. [MEDICATION NAME] (for depression and anorexia) 30 mg 1 tablet daily by mouth. b. Allergy [MEDICATION NAME] 10 mg 1 tablet c. [MEDICATION NAME] 0.05% Nasal Spray One spray to each nostril daily for allergies [REDACTED]. Observation during the medication pass on [DATE] at 11:32 AM, CMA A checked the computer screen and paper MARS (Medication Administration Record [REDACTED]. CMA A pulled an over the counter white bottle with a label "Allergy" in large letters smaller letters stated [MEDICATION NAME] 10 mg. CMA A placed both pills ([MEDICATION NAME] 30 mg and [MEDICATION NAME] 10 mg) into a medication cup. CMA A also took a white bottle from medication cart labeled "[MEDICATION NAME] 0.05%". CMA A proceeded to Resident #36's room, explained to the resident what she was about to administer; however prior to CMA A administering medications the surveyor asked CMA A to step into the hallway. In an interview on [DATE] at 11:40 AM, CMA A was asked about the Doctor's order for [MEDICATION NAME] 10 mg po (by mouth). CMA A pointed to an order (on the computer screen) for [MEDICATION NAME] (laxative) 5 mg tablet and stated "He can't have that one, because he already had a bowel movement" CMA A was asked again for the order to administer [MEDICATION NAME] 10 mg. CMA A said, "I don't know" and took the [MEDICATION NAME] pill out of medicine cup using a tongue blade and placed it in the trash. Record review on [DATE] at 1:30 PM of Physician's Order sheet and Medication Administration sheet revealed there was no order for [MEDICATION NAME] 10 mg 1 tab po daily for Resident #36. In an interview on [DATE] at 10:11 AM, Assistant Director of Nurses (ADON) C and the HR Director said there was no evidence in CMA A's personnel file of a current Medication Aide certification. The HR Director brought up the Employability Status Check Search web site for CMA A and the Medication Aide Registry Status was blank. In an interview on [DATE] at 10:23 AM, ADON C said she would contact CMA A and have her bring in her documentation of certification to administer medications. In an interview on [DATE] at 12:15 PM, the HR Director said she thought the medication aide certification was OK. She said she misread the Employability Search for CMA A and thought she had a CMA certification. The HR Director said she spoke with CMA A and she does not have a current medication aide certification. Attempts by the surveyor to contact CMA A on [DATE] were unsuccessful. An immediate jeopardy was identified and the Nursing Facility Administrator was informed at 5:30 PM on [DATE]. The following Plan of Removal was accepted at 5:20 PM on [DATE]. 1. On [DATE], employee file was observed to not have needed/required documentation for proof of CMA license. 2. Once this was brought to the attention of the Administrator the employee was suspended immediately pending investigation. 3. (The facility) CMA staff listing was audited to determine the exact number of CMA's on staff currently at the facility. (The facility) are as follows: a. CMA B b. CMA A c. CMA G d. CMA S 4. Administrator verbally spoke with CMA A and requested actual proof of licensure. 5. Upon review of actual license, it was determined that CMA A was a certified medical assistant and not a certified medication aide. 6. Employee has bee terminated for impersonating a Certified Medication Aide as of [DATE]. 7. Upon further review of CMA licensure web site it was determined that CMA B's license expired on [DATE]. CMA B was suspended immediately pending proof of non-expired certification. Upon further review it was determined this employee has submitted the required renewal documents to the State Agency Medication Aide Program prior to expiration date of license. However, the packet she submitted was returned to her due to a personal check as opposed to the required money order form of payment. At that time, CMA B immediately "over-nighted" the required cashier's check. Her permit renewal was stamped with a received date of [DATE]. At this time the medication aide web site has not been updated top reflect licensure renewal for this employee. 8. A 100% audit has been performed of all licensed staff to include nurse assistants, Certified Medication Aides, Registered Nurses and LVN's (Licensed Vocational Nurse). Other than the two employees noted above there are no current expired licenses for any licensed staff. 9. All licenses have been checked against the licensure renewal boards for all licensed staff. These verifications have been printed and verified by administrator and director of Human Resources. 10. The director of Human Resources has been in-serviced by administrator personally as to the proper way to verify license on all licensed staff. 11. The ADON's (Assistant Director of Nurses) who hire licensed staff and interview licensed staff have also been in-serviced by administrator to ensure 100% compliance with required hiring policies. 12. All licensed verifications will be reviewed and signed off by the following department: a. Nursing b. Human Resources c. Administrator 13. This will provide a three person approval process for all licensed staff upon hire and upon license renewal time frame. 14. Every 30 days a "licensed staff" report will be generated and reviewed by the three above departments to ensure compliance. Any discrepancies and or concerns will be immediately brought to the attention of the administrator/designee. Through observations, interviews, and record reviews the surveyors determined that the interventions documented in the facility's action plan were implemented and the immediate jeopardy was removed effective [DATE] at 5:20 PM and the Nursing Facility Administrator was notified. The facility remained out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy at widespread as the implemented systems needed to be monitored and evaluated for effectiveness. The census of 151 was obtained from the CMS 672 dated [DATE].

Based on observation, interview and record review the facility failed to ensure that 1 (Resident #7) of 3 residents reviewed for medications was free of significant medication errors. Facility Licensed Vocational Nurse (LVN) "M" failed to follow the physician's orders [REDACTED]. Each time Resident #7 was given 800MG for a total of 1600MG. Resident #7 ' s usual dose is 400MG three times a day(TID). Later the same day (06/25/14) Resident #7 was found on the bathroom floor extremely anxious, alert and awake but confused, with a skin tear to shin area. He was transported to the hospital for evaluation. An Immediate Jeopardy (IJ) was identified on 10/24/2014 and Nursing Facility Administrator (NFA) was informed at 3:40 PM. While the IJ was removed on 10/27/2014, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy at patterned because the facility had not monitored their plan for effectiveness. These failures could affect 26 residents residing on 300 Hallway by placing them at risk for not receiving medications as ordered by physician. Findings include: Record review of Resident #7 ' s Face Sheet dated June 06, 2014 reflected he was an [AGE] year old male admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of physician's order [REDACTED]. Article review: http://emedicine.medscape.com/article/ 4-clinical#a0218 d<http://emedicine.medscape.com/article/ 4-clinical> [MEDICATION NAME] ([MEDICATION NAME]) is an anticonvulsant. It works by decreasing nerve impulses that cause [MEDICAL CONDITION] and pain. [MEDICATION NAME] is used to treat [MEDICAL CONDITION] and nerve pain such as [DIAGNOSES REDACTED] and diabetic [MEDICAL CONDITION]. Therapeutic levels are 4-12 mg/L, but individual variation exists. Ataxia and [DIAGNOSES REDACTED] may occur at levels greater than 10 mg/L Cardiovascular effects are usually seen at levels greater than 12 mg/L. The drug interferes with action potentials in Purkinje fibers and the His bundle, which may lead to [MEDICAL CONDITION] ventricular blocks and arrhythmias. Record review of Medication Administration Record [REDACTED]. Review of incident reports dated 6/25/14 reflected at: -8:00 AM an incident report reported by LVN M and entered into system by DON. The report was described as a medication error type of report. According to the DON " the day shift nurse did not notice the blister pack was sent with 2 tabs and administering a total of 4 pills at 8 am and 12 pm " -9:20 AM an incident report describing Resident #7 being found in the bathroom after sustaining a fall it also shows resident #7 being anxious and therefore medicated with anti-anxiety medication. Report was reported and entered by LVN M. Review of medication cart on 10/21/14 at 11:05 AM with LVN N of Medication Bubble Pack Card with name of Resident # 7 revealed [MEDICATION NAME] 200MG Give 2 (400MG) three times per day printed on the front of blister pack. Record review of Nurse ' s note dated 6/25/14 reflected: 9:45 AM " Resident found on the floor, sitting, trying to get up by himself, not in his room. ROM (range of motion) performed, denies pain or discomfort at this time. POA and family notified. Neurochecks initiated as facility protocol. RT sustains a ST to L shin 2.0 X 0.1cm clean with NS pad dry & TO applied. Will continue to monitor. [MEDICATION NAME] 2mg given, with good effect. Signed by LVN " Record review of Nurse ' s note dated 6/25/10 reflected: 9:45 PM " VS Bp 106/63, P 67, T 98.9 R 22. Resident noted lethargic S/P fall with injuries noted to left lower leg and Lt arm. Resident was sent to ER for lethargy as per Doctor ' s orders and to have medication levels checked. Resident ' s status checked at 2030 with hospital RN. Call placed at 2045 placed to facility Doctor to give report on Resident ' s condition. Spoke to son at 2135. Resident left via stretcher ambulance. " Record review of Hospital records dated 6/25/14 reflected at: 10:10 PM Resident arrived at Hospital via ambulance he was taken to the Emergency department where he was evaluated. According to the record Resident #7 ' s chief complaint was " Decreased Mental Status ". While in the emergency department Resident #7 had a complete blood count, Renal hepatic, Ammonia level, PT, INR, urine specimen, special toxicology screen test troponin test, blood sugar, CT scan of the head, portable chest x-ray. No [MEDICATION NAME] level was done while in the emergency department. No orders were found for a [MEDICATION NAME] level to be done from the transferring doctor nor Emergency Department doctor. A [MEDICATION NAME] level was not order by LVN " M " on Resident #7 ' s transfer form. The reason for transfer stated " Possible med error " on the same resident transfer form. A [MEDICATION NAME] level was ordered stat on 6/26/14 and it was collected on that same day as per the Doctor ' s orders. Record review of Nurse ' s note dated 6/26/14 reflected at 12:55 AM " Spoke with RN from Hospital; he gave me report that Resident #7 is coming back to facility. States negative/normal findings or behavior and CT scan that was done on patient, states patient is somewhat confused, reported that the patient would be leaving Hospital as soon as they have transportation for patient. " Record review of Nurse ' s note dated 6/26/14 reflected at 2:00 AM " 97.8, 54-28- 126/64, Spo2- 95% Resident arrived from Hospital via stretcher escorted by EMT ' s. Patient alert to self, disoriented to time and place. Denies pain, at this time. Pt. HOH (hard of Hearing) yells out " Hello " constantly. Pt is in NAD (no acute distress). Has dressing to LLE (left lower extremity) that C/D/I (clean dry, intact). Call light within reach. Will continue to monitor. Record review of Nurse ' s note dated 6/26/14 at 9:15 PM showed " STAT ordered for [MEDICATION NAME] level pending results " Record review of Lab work dated 6/26/14 Revealed a [MEDICATION NAME] level which was collected on 06/26/14 at 8:03 PM, 36 hours after resident was administered twice the ordered amount at 8:00 am and 12:00 noon of the same day. Resident #7 ' s level was 14.9 (Therapeutic level is 4-12). Record Review of Nurses notes dated 05/19/13 Revealed Resident # 7 had been previously over medicated with the same medicine, [MEDICATION NAME] (on 5/19/13). At that time he was given six, 200mg pills to equal 1200mg once in the morning and again six, 200 mg pills to equal 1200mg again during the noon med pass. Resident #7 was also sent to hospital via ambulance during this medication error on 5/19/13. Resident #7 was admitted to the hospital, intubated and placed on a ventilator. Record review of Resident Transfer Form dated 5/19/2013 reflected the reason for transfer to hospital : Altered Mental Status, Possible [MEDICATION NAME] over Dose (OD). [DIAGNOSES REDACTED]. [MEDICATION NAME] was also given at 2:00 PM to Resident #7 on 5/19/13. In an interview on 10/27/14 at 11:30 with ADON D, stated she was not working as a ADON D when incident involving resident #7 being given double the dose of [MEDICATION NAME], occurred the second time, but was aware of incidents. As per ADON D, LVN M who worked with resident #7 on the day of the incident (6/25/14) was terminated and no longer had access to speak to them. Surveyor questioned ADON D in regards to having any records of a [MEDICATION NAME] level being done at the facility, prior to Resident #7 being sent to the emergency department. The ADON D stated they didn ' t. Surveyor asked ADON D when were [MEDICATION NAME] levels drawn or ordered and the ADON D stated facility didn ' t have a set time or a set schedule for levels, but instead it was all up to the Doctor ' s discretion. ADON D also stated since the medication was not being used for [MEDICAL CONDITION] but rather for pain in Resident ' s # 7 case, that could be the reason why his levels were not checked on a regular basis. In an interview on 10/25/2014 at 12:00 with DON she stated when the first incident occurred on 05/19/2013, Resident #7 was sent to the hospital, the family was informed and training were done to cover every nurse in the facility. A copy of the training was obtained and reviewed. The Training ' s title was " [MEDICATION NAME] Toxicity Clinical Presentation. " The training was started as a result of first overdose incident last year (5/19/13). As per the DON Resident #7 was alert and awake unlike the first time when he was transferred to the hospital. The second error (6/25/14) was found by surveyors while reviewing the facility's incident reports. When the DON was questioned she stated the incident was discovered by the 2nd shift nurse. According to the DON when the 2nd shift LVN went to give the 8:00PM dose, that ' s when she discovered the extra doses, had been given. The DON explained how the mistake was made. She stated the error was mainly due to the packaging of the pharmacy, who instead of putting one pill in each blister space had put two pills in each blister pack that was separated by a thin paper. When the nurse popped a blister to obtain one pill, two pills came out of the blister pack giving him a total of 4 pill every time instead of 2 pills. According to DON, LVN M was terminated due to other reasons but said the medication error contributed to the decision of terminating her, but it wasn ' t the sole cause. The DON stated the LVN should ' ve read instructions and milligrams on the medication pack. An IJ was identified on 10/24/14 at 3:40 and NFA was informed. The Plan of Removal was accepted on 10/27/14 at 3:24 PM and it included the following: Facility Wide In-Service on [MEDICATION NAME], Adverse Effect, and signs and symptoms of overdose was initiated on 10/24/2014. Facility Wide In-service on Med-Pass, the 5 Rights of administering medication. Beginning 10/26/14 [MEDICATION NAME] levels will be checked when ordered and a note will be entered stating the physician was notified. On 10/27/14, the surveyors confirmed by interviews with nursing and administrative staffs and by record reviews that all nursing staff were in-serviced on the above and were knowledgeable about changes in procedures. The surveyors confirmed the new policies and procedures were developed and in place. The surveyor also confirmed by interviews that nursing staff were knowledgeable about the new policies and procedures. On 10/27/14 at 3:24 p.m. the NFA was informed the IJ was removed. The facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy at patterned because the facility had not monitored their plan for effectiveness. The facility census, dated 10/16/2013 documented 26 residents residing on 300 Hallway.

Based on observation, interview, and record review the facility failed to implement policies and procedures to prohibit neglect for 2 of 30 (Resident #2 and 13) residents reviewed for sexual abuse. The facility failed to protect Resident #13 from a sexual assault by Resident #2. Resident #2 had a history of [REDACTED]. On 10/25/13 at 8:30 PM Certified Nurse Aide (CNA) I found Resident #2 sitting on Resident #13 ' s bed with his hands on her thighs and his head between her legs and his face on her exposed genitals. An Immediate Jeopardy (IJ) was identified on 10/31/13 and Administrator H was informed at 4:05 PM. While the IJ was removed on 11/05/13, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy at isolated because the facility had not monitored their plan for effectiveness. These failures could affect all 11 female residents in the Traditional unit by placing them at risk of being neglected. The findings include: Resident #2's Face Sheet dated 03/23/2012 indicated Resident #2 was an [AGE] year-old male admitted to the nursing facility on 03/23/2012 with [DIAGNOSES REDACTED]. 04/18/2012- Resident #2 was transferred from the Memory Unit to the Traditional Unit on 03/27/2013 following a sexual encounter in the Memory Unit. To date no sexual inappropriate behavior noted in Traditional Unit. Plan: Continue to Monitor. Review of Minimum Data Set (MDS) Quarterly Review assessment dated [DATE] identified Resident #2 as: Makes self understood, ability to understand others; Scored 11 out of 15 on Brief Interview for Mental Status (BIMS) (a score of 8 to 12 indicates moderately impaired decision-making ability); Physical behavior symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) --- behavior of this type occurred 1 to 3 days; Required limited assistance of one person physical assist for bed mobility, transfers and dressing; Locomotion On unit and Off unit -- independent with setup help only; mobility devices -- wheelchair. Review of Resident #2's Care Plan dated 04/04/13 and revised on 10/04/13 revealed: - Problem: Altered social interactions and adjustment. Resident has short term and long term memory problems and difficulty in new situations, has [DIAGNOSES REDACTED]. - Problem: Impaired mobility with potential for functional decline related to [MEDICAL CONDITION]. - Resident displays sexual inappropriate behavior as evidenced by inappropriate statements or actions toward caregivers, history of pushing a Certified Nurse Aide ' s (CNA) hand into his crotch during shower; Statements that female CNAs are flirting and touching him inappropriately; History of touching female resident inappropriately. Approach: Monitor and document behavior; Staff to inform social services of continued inappropriate behavior; Redirect resident as needed; Speak with resident and educate regarding socially unacceptable behavior. Resident #2 was observed during initial rounds on 10/28/13 at 10:49 AM to be up in his wheelchair in the activity room, alert and oriented to person and place. A Certified Nurse Aide (CNA) was providing 1:1. Resident #13 ' s Minimum Data Set Admission assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the nursing facility on 10/10/13 with [DIAGNOSES REDACTED]. of one person physical assist for bed mobility, transfers; Locomotion On unit and Off unit -- Limited assistance of one person physical assist; Required Extensive assistance of one person physical assist for dressing and eating; Required total dependence of one person physical assist for toilet use, personal hygiene and bathing. Review of Resident #13's Care Plan dated 10/28/13 revealed: Impaired ability to communicate related to cognitive loss secondary to dementia. Resident has memory problems related to Dementia. Resident has impaired daily decision making related to Dementia. Resident #13 was observed during initial rounds on 10/28/13 at 10:30 AM to be up in her wheelchair attending therapy, very confused, singing " la, la, la " as she banged the right wheelchair armrest with her right hand. Review of Provider Investigation Report dated 11/04/13 revealed that on 10/25/13 at 8:45 PM staff member was in resident #13's room assisting another resident with pericare when she heard the roommate moaning from behind the privacy curtain. She pulled the curtain back and saw Resident #2 (male) sitting on Resident #13's (female) bed with his hands on her thigh and head between her legs near her groin area. The diaper was opened. The staff member asked Resident #2 what he was doing and he verbalized that she needed some help and he was giving her some air. Resident #2 was removed from Resident #13's room. Registered Nurse (RN) Supervisor assessed Resident #13 ' s genital area and noted no redness, swelling, bleeding or scratching to area. Pericare was done and resident remained calm during the assessment with no signs of acute distress. Law enforcement was notified and 24 hour visual one to one (1:1) monitoring on Resident #2 was initiated. In an interview on 10/30/13 at 9:29 AM Resident #2 reported that on the day of the incident he heard a woman screaming down the hall. He reported that he was lying down in bed, got up and transferred himself to his wheelchair. He said that he pedaled on his wheelchair to the room where he heard the woman screaming out for help. There was no one in the hallway and he did not see anyone coming to her assistance. He said he went to the room and to her bed and tried to give her some comfort. He was unable to state how he was going to give her some comfort. He reported that the female was saying something to him in Spanish and he could not understand. He tried to comfort her but would not specify how. When asked if he was sexually aroused during this time, he stated he may have been. He reported that the female was wearing a long t-shirt and her undergarment (brief). He reported that he never removed her brief. When asked how her underwear was found opened by the staff, he reported that it was windy that evening and that perhaps the wind may have removed her blanket as well as her brief. When asked to provide specific details of what he did that evening in the room with the female resident, he reported that he did not remember. When asked if he was questioned that evening by police officers he reported that he had been questions in reference to a car crash he had been in. In an interview on 10/29/13 at 2:48 PM CNA I reported that on 10/25/13 approximately at 8:30 PM she was providing care to Resident #13's roommate in bed " A " . CNA I heard moaning behind the privacy curtain in bed " B " and thought Resident #13 ' s husband was with her so continued providing care to her roommate. When she was done, CNA I peeked around the side of the privacy curtain, pulled it back and saw Resident #2 sitting on Resident #13's bed near the head rest. Resident #13 was uncovered, the brief was opened exposing her genitals and Resident #2 ' s hands were on Resident #13's thighs, his head was between her thighs and his face on her genitals. CNA I asked Resident #2 what he was doing and with a surprised look on his face he responded, "Giving her air". CNA I left the room without removing Resident #2 from the room to inform Licensed Vocational Nurse (LVN) K about the incident. As CNA I was leaving, she saw CNA J walking towards her so she told her that Resident #2 was in Resident #13's room. CNA I reported the incident to RN Supervisor X and Licensed Vocational Nurse (LVN) K. All three returned to Resident #13's room within one minute, Resident #2 was outside the room sitting on his wheelchair. As we entered the room, CNA J was already changing Resident #13's brief. At around 11:45 PM 3 police officers were with Resident #2 in the TV lobby area talking to Resident #2 and reading him his rights. In an interview on 10/31/13 at 2:17 PM CNA J said that 10/25/13 approximately at 8:30 PM CNA I was coming out of Resident #13's room with a surprised look on her face. She told me that Resident #2 was in Resident #13 ' s room. CNA J told her to go tell LVN K and immediately went inside the room. When CNA J entered the room Resident #2 was sitting on Resident #13's bed near the head rest. Resident #13 ' s brief was opened exposing her genitals. Resident #2 had his right hand on her stomach. Resident #13 was very agitated, looked scared and was shaking her hands as she kept asking " what's going on, tell me what's going on " . CNA J asked Resident #2 what he was doing and he responded " she needs to breathe and I ' m helping her to get some air ". CNA J put him back on his wheelchair and wheeled him out on the hall in front of his room. CNA J checked Resident #13 ' s private area, stomach area and her buttocks area to make sure she didn ' t have any scratch marks, redness or any blood and proceeded to clean resident with perineal wash spray, cleaned her front, cleaned her back and then applied a clean brief. She stated that she was aware the nurses are responsible for assessing residents but she just wanted to make sure Resident #13 was fine. LVN K and RN Supervisor X arrived approximately within 7 to 10 minutes. CNA J showed both LVN K and RN Supervisor X the wet brief and told them everything was okay. The two nurses proceeded to check Resident #13 again. CNA J further stated that Resident #2 always tries to grab her from her buttocks during care and transfers. She has reported the incidents to the nurses. In an interview on 10/29/13 at 3:27 PM and 10/31/13 at 5:00 PM LVN K reported she has been working at the nursing facility since June 2013. On 10/25/13 after 8:00 PM CNA I who appeared to be in shock, approached LVN K and RN Supervisor X saying " come, come I need to show you something " Approximately 3 minutes later LVN K and RN Supervisor X followed her to Resident #13 ' s room. When they arrived to resident #13's room, the resident had her brief and clothes on and showed no distress. CNA J informed LVN K and RN Supervisor X that Resident #2 was on Resident #13's bed looking at her genitals. While RN Supervisor X went to the telephone to make a call to the Director of Nursing (DON) C and ADON D, LVN K assessed Resident #13 physically and psychologically and showed no signs or symptoms of physical abuse on her genitals. Later on that evening, CNA I had told her that Resident #2 had his head between Resident #13 ' s thighs. After the incident, Resident #2 was placed on 1:1 supervision until they decided what to do with him. After the incident, 2 police officers had spoken with Resident #2. Further interview with LVN K reported that on another occasion not too long ago, LVN K was giving medication to Resident #2's roommate in his room and Resident #2 brushed his hand on my behind. His roommate told Resident #2 " son of a [***] , don't touch her " . CNAs are not allowed to go by themselves to Resident #2's room because he tends to touch staff. Approximately 10 days ago LVN K was giving Resident #2 his medications and she asked him to open his mouth to make sure he had swallowed the medications. He stuck his tongue in an obscene manner and LVN K told him to stop and reminded him that he needed to be more respectful. LVN K did not document the incident in the nurses' notes. Resident #2 was alert and oriented to person and place and pretends not to remember bad events. In an interview on 10/28/13 at 10:49 AM with Resident #2's roommate, he reported that 2 police officers showed up 2 evenings ago to talk to his roommate. He reported that approximately 2 weeks ago, he was getting his medications from LVN K when Resident #2 grabbed LVN K's buttocks. LVN K was mad and told Resident #2 "don't do that". In a telephone interview on 11/05/13 at 5:30 AM Registered Nurse (RN) Supervisor V stated that she works from 12:00 AM to 8:00 AM and had arrived to the nursing facility on 10/26/13 at 12:00 AM. RN Supervisor W gave report and informed her that Certified Nurse Aide (CNA) I had observed Resident #2 sitting on Resident #13's bed leaning towards perineal area "giving air". In an interview on 11/01/13 at 7:45 AM CNA LL reported that approximately half a year ago she was showering another resident in the shower room while a female student military CNA was showering Resident #2. She heard Resident #2 telling the student "touch my penis". CNA student just kept quiet. She reported the incident to the charge nurse. In an interview on 11/01/13 at 8:54 AM CNA L reported that in the later part of October 2013 during the breakfast meal, Resident #2 was sitting next to Resident #13 as he reached for the coffee cup he was observed brushing his hand and arm across Resident #13 ' s breast. She informed a nurse who no longer is employed with the nursing facility and Resident #13 was moved to another table. In an interview on 10/31/2013 at 2:08pm with Social Worker A, she reported that she had been the social worker for the traditional unit at this facility since November 2012. She reported that she was not sure why or when Resident #2 was moved from the Memory Support Unit to the Traditional unit. Prior to the incident on 10/25/2013, she had heard about one sexual inappropriate behavior since she had been employed with the facility. Review of Resident #2's Social Services Notes revealed the following summary on the notes: 09/14/2012- Meeting was held with Social worker and Resident #2 ' s girlfriend. Social worker informed girlfriend that Resident #2 ' s memory was getting worse. Recommendation for guardianship noted. Girlfriend noted that his daughters did not want to take guardianship of him and that she was too old to care for him. Social worker notified girlfriend about referral for psychological services and girlfriend responded that Resident #2 could not afford the co-payment for psychological services. Plan: Continue to monitor. 05/09/2013- Physician requested referral to psychological services. Psychological services were contacted from assessment. Plan: Continue to monitor. In an interview on 10/31/13 at 10:46 AM Administrator stated he had been informed on 10/25/13 at 11:00 PM by Registered Nurse (RN) Supervisor X on duty of the incident on resident to resident sexual abuse involving Resident #2 and Resident #13. He requested for RN Supervisor X to make plans to call ADON D and "make plans to report". He requested for the ADON D to come into the facility and make a more detailed assessment. On 10/26/13 at 2:00 AM ADON D called him back and stated "perpetrator (Resident #2) had not pulled diaper off or anything. Resident #13 was fine. The diaper was on. He was informed that no actual touching had been made and he trusted ADON D had already spoken to the person that saw the incident. I embraced the fact my resident had not been harmed. I trusted information from ADON D on the date of the incident and told her this needs to be reported. He stated that he was not aware of the September 2012 referral for psychological services for Resident #2 and it was not brought to his attention. He stated that if it was a matter of finance that Resident #2 did not receive counseling, it would have been brought to me for my awareness and possible intervention. 10/24/2013 - Social Worker A spoke with resident, he stated he is doing okay. There have been no recent reports of inappropriate behavior on resident ' s part nor has he made any recent allegations of inappropriate behaviors from staff towards him. Continue to monitor. 10/31/2013 - Resident was assessed by the owner of an unlicensed facility at 10:30 AM and was accepted. Later that day at 1:30 PM resident was discharged to this same foster home. Interview on 10/31/13 at 2:03 PM CNA BB reported that she received a telephone call from Registered Nurse (RN) V on 10/26/13 at 12:30 AM to come to the nursing facility to help care for Resident #2, to be with him all the time and to document every hour what he was doing. She stated that Resident #2 slept all night and she watched him until 8:00 AM. She reported that she had watched him today also from 11:00 AM until almost 2:00 PM before he had been discharged from the nursing facility. Record review of the "One Hour Observation" sheets revealed that from 10/26/13 at 1:00 AM through 10/31/13 at 2:00 PM Resident #2 was being monitored every hour. Observation of Resident #2 on 10/28/13 at 10:49 AM and 4:30 PM; 10/29/13 at 8:20 AM, 10:00 AM, 12:09 PM; 10/30/13 at 9:29 AM, 3:00 PM; and 10/31/13 at 8:15 AM revealed resident to have a CNA on a 1:1. Review of facility's policy entitled Resident Abuse/Neglect/Exploitation/Misappropriation of Resident Property/Involuntary Seclusion/Corporal Punishment, dated January 2011 revealed, in part: "The resident has the right to be free of abuse, neglect..." The staff will be trained on how to prevent abuse such as being more observant in secluding areas, monitoring appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. Any employee having knowledge or suspicions of an alleged violation involving resident abuse, neglect...is required to report immediately to the Campus Administrator, to the Risk Manager or to the Department Manager without fear of reprisal. All incidents...Potential abuse, neglect, exploitation...will be prevented during investigation. Results of investigation will be reported immediately to the Campus Administrator or designee and other officials in accordance with Texas law. A written report, if appropriate, will be sent to the Texas Department of Aging and Disability Services (TDADS) within five (5) days following the verbal report, in accordance with applicable laws. Refer to the most recent TDADS provider letter, "Guidelines for Reporting Incidents." "Sexual abuse" includes but is not limited to, sexual harassment, sexual coercion or sexual assault. "Neglect" means failure to provide goods and services to avoid physical harm, mental anguish, or mental illness. An IJ was identified on 10/31/13 at 4:05 PM and Administrator H was informed. The Plan of Removal was accepted on 11/04/13 at 3:24 PM and it included the following: As of 11/01/13 each department head has interviewed their staff to affirm if anyone of them encountered or witnessed any inappropriate sexual behaviors from residents. If any sexual or inappropriate behaviors are identified, we will conduct appropriate assessment, notify appropriate family, physician, care plan and follow up as appropriate. Residents Record Review/Audit to identify any other residents having demonstrated any inappropriate sexual behaviors initiated today by MDS coordinators and has been completed by 11/04/13. In-service staff on reporting behaviors and documentation of those behaviors. In-services have been initiated by unit managers 11/01/13 and completed as of 11/04/13. In-service staff beginning on 11/01/13 on protecting a resident from abusive situations. In-servicing has been completed on 11/04/13. Educate all departments on abuse, including inappropriate sexual behaviors, as well as behavior monitoring has been completed by department managers on 11/03/13 and will continue with the new hires and at least quarterly with all staff thereafter. Any residents noted to have behaviors identified as being inappropriate, will be reviewed weekly during the Risk Meeting and also reviewed quarterly and PRN during the Interdisciplinary Care Plan Meetings starting 11/01/13 and will continue as appropriate. Unit Managers/Charge Nurses will document noted inappropriate behaviors every shift, utilizing the Behavior Monitoring Sheets which will be followed up by the DON daily for the next 60 days and quarterly after. Social Workers will intervene to make appropriate referrals to Psychiatrist, Psychologist, or outpatient counseling and will follow up to assure resident participation. Social Worker to follow up with above agents or agencies to ensure resident's participation and track resident's progress and the social worker will follow-up with the unit managers. Social Worker to make appropriate referrals (as necessary) for alternate placement of resident, if the Interdisciplinary Team determines that the facility can no longer meet the resident's needs. Any inappropriate sexual behaviors, whether toward another resident, staff member, and or visitor, will be recorded on the daily 24 hour report and discussed at the morning Stand up Meeting and daily Clinical Meeting starting 11/01/13. On 11/05/13, the surveyors confirmed by interviews with nursing and administrative staffs, and by record reviews that all nursing staff were in-serviced on the above and were knowledgeable about changes in procedures. The surveyors confirmed the new policies and procedures were developed and in place. The surveyor also confirmed by interviews that nursing staff were knowledgeable about the new policies and procedures. The IJ was removed on 11/05/13 and Interim Administrator HH was informed at 3:15 PM. The surveyors determined that the Plan of Removal had been implemented through staff interviews, review of inservice training on Abuse, Neglect, Important facts on Investigations and Resident Safety. While the IJ was removed, the facility remained out of compliance at a scope and severity of actual harm at isolated because the facility needed to complete inservice training and had to monitor their plan for effectiveness. The list of 11 female residents was obtained from the Census dated 10/28/13.

Based on observation, interview, and record review the facility failed to immediately protect and immediately report an incident of resident to resident sexually inappropriate behavior for 2 of 30 (Resident #2, #13) residents reviewed for sexual abuse. Resident #2 had a history of [REDACTED]. On 10/25/13 at 8:30 PM Certified Nurse Aide (CNA) I found Resident #2 sitting on Resident #13 ' s bed with his hands on her thighs and his head between her legs and his face on her exposed genitals. CNA I left the room to inform the nurse without removing Resident #2 from the room. The facility did not report the incident to the state until 10/28/13 at 1:45 p.m., 65 hours after the incident. An Immediate Jeopardy (IJ) was identified on 10/31/13 and Administrator H was informed at 4:05 PM. While the IJ was removed on 11/05/13, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy at isolated because the facility had not monitored their plan for effectiveness. These failures could affect all 11 female residents in the Traditional unit by placing them at risk of being neglected. The findings include: Resident #2's Face Sheet dated 03/23/2012 indicated Resident #2 was an [AGE] year-old male admitted to the nursing facility on 03/23/2012 with [DIAGNOSES REDACTED]. 04/18/2012- Resident #2 was transferred from the Memory Unit to the Traditional Unit on 03/27/2013 following a sexual encounter in the Memory Unit. To date no sexual inappropriate behavior noted in Traditional Unit. Plan: Continue to Monitor. Review of Minimum Data Set (MDS) Quarterly Review assessment dated [DATE] identified Resident #2 as: Makes self understood, ability to understand others; Scored 11 out of 15 on Brief Interview for Mental Status (BIMS) (a score of 8 to 12 indicates moderately impaired decision-making ability); Physical behavior symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) --- behavior of this type occurred 1 to 3 days; Required limited assistance of one person physical assist for bed mobility, transfers and dressing; Locomotion On unit and Off unit -- independent with setup help only; mobility devices -- wheelchair. Review of Resident #2's Care Plan dated 04/04/13 and revised on 10/04/13 revealed: - Problem: Altered social interactions and adjustment. Resident has short term and long term memory problems and difficulty in new situations, has [DIAGNOSES REDACTED]. - Problem: Impaired mobility with potential for functional decline related to [MEDICAL CONDITION]. - Resident displays sexual inappropriate behavior as evidenced by inappropriate statements or actions toward caregivers, history of pushing a Certified Nurse Aide ' s (CNA) hand into his crotch during shower; Statements that female CNAs are flirting and touching him inappropriately; History of touching female resident inappropriately. Approach: Monitor and document behavior; Staff to inform social services of continued inappropriate behavior; Redirect resident as needed; Speak with resident and educate regarding socially unacceptable behavior. Resident #2 was observed during initial rounds on 10/28/13 at 10:49 AM to be up in his wheelchair in the activity room, alert and oriented to person and place. A Certified Nurse Aide (CNA) was providing 1:1. Resident #13 ' s Minimum Data Set Admission assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the nursing facility on 10/10/13 with [DIAGNOSES REDACTED]. of one person physical assist for bed mobility, transfers; Locomotion On unit and Off unit -- Limited assistance of one person physical assist; Required Extensive assistance of one person physical assist for dressing and eating; Required total dependence of one person physical assist for toilet use, personal hygiene and bathing. Review of Resident #13's Care Plan dated 10/28/13 revealed: Impaired ability to communicate related to cognitive loss secondary to dementia. Resident has memory problems related to Dementia. Resident has impaired daily decision making related to Dementia. Resident #13 was observed during initial rounds on 10/28/13 at 10:30 AM to be up in her wheelchair attending therapy, very confused, singing " la, la, la " as she banged the right wheelchair armrest with her right hand. In an interview on 10/28/13 at 8:07 AM during the entrance conference Administrator H was asked by surveyor if there were any incidents that were reported to the State, he responded that he might have a self-reportable resident to resident sexual abuse, male (ID#2) to female (ID#13). Review of Provider Investigation Report dated 11/04/13 revealed that on 10/25/13 at 8:45 PM staff member was in resident #13's room assisting another resident with pericare when she heard the roommate moaning from behind the privacy curtain. She pulled the curtain back and saw Resident #2 (male) sitting on Resident #13's (female) bed with his hands on her thigh and head between her legs near her groin area. The diaper was opened. The staff member asked Resident #2 what he was doing and he verbalized that she needed some help and he was giving her some air. Resident #2 was removed from Resident #13's room. Registered Nurse (RN) Supervisor assessed Resident #13 ' s genital area and noted no redness, swelling, bleeding or scratching to area. Pericare was done and resident remained calm during the assessment with no signs of acute distress. Law enforcement was notified and 24 hour visual one to one (1:1) monitoring on Resident #2 was initiated. In an interview on 10/30/13 at 9:29 AM Resident #2 reported that on the day of the incident he heard a woman screaming down the hall. He reported that he was lying down in bed, got up and transferred himself to his wheelchair. He said that he pedaled on his wheelchair to the room where he heard the woman screaming out for help. There was no one in the hallway and he did not see anyone coming to her assistance. He said he went to the room and to her bed and tried to give her some comfort. He was unable to state how he was going to give her some comfort. He reported that the female was saying something to him in Spanish and he could not understand. He tried to comfort her but would not specify how. When asked if he was sexually aroused during this time, he stated he may have been. He reported that the female was wearing a long t-shirt and her undergarment (brief). He reported that he never removed her brief. When asked how her underwear was found opened by the staff, he reported that it was windy that evening and that perhaps the wind may have removed her blanket as well as her brief. When asked to provide specific details of what he did that evening in the room with the female resident, he reported that he did not remember. When asked if he was questioned that evening by police officers he reported that he had been questions in reference to a car crash he had been in. In an interview on 10/29/13 at 2:48 PM CNA I reported that on 10/25/13 approximately at 8:30 PM she was providing care to Resident #13's roommate in bed " A " . CNA I heard moaning behind the privacy curtain in bed " B " and thought Resident #13 ' s husband was with her so continued providing care to her roommate. When she was done, CNA I peeked around the side of the privacy curtain, pulled it back and saw Resident #2 sitting on Resident #13's bed near the head rest. Resident #13 was uncovered, the brief was opened exposing her genitals and Resident #2 ' s hands were on Resident #13's thighs, his head was between her thighs and his face on her genitals. CNA I asked Resident #2 what he was doing and with a surprised look on his face he responded, "Giving her air". CNA I left the room without removing Resident #2 from the room to inform Licensed Vocational Nurse (LVN) K about the incident. As CNA I was leaving, she saw CNA J walking towards her so she told her that Resident #2 was in Resident #13's room. CNA I reported the incident to RN Supervisor X and Licensed Vocational Nurse (LVN) K. All three returned to Resident #13's room within one minute, Resident #2 was outside the room sitting on his wheelchair. As we entered the room, CNA J was already changing Resident #13's brief. At around 11:45 PM 3 police officers were with Resident #2 in the TV lobby area talking to Resident #2 and reading him his rights. In an interview on 10/31/13 at 2:17 PM CNA J said that 10/25/13 approximately at 8:30 PM CNA I was coming out of Resident #13's room with a surprised look on her face. She told me that Resident #2 was in Resident #13 ' s room. CNA J told her to go tell LVN K and immediately went inside the room. When CNA J entered the room Resident #2 was sitting on Resident #13's bed near the head rest. Resident #13 ' s brief was opened exposing her genitals. Resident #2 had his right hand on her stomach. Resident #13 was very agitated, looked scared and was shaking her hands as she kept asking " what's going on, tell me what's going on " . CNA J asked Resident #2 what he was doing and he responded " she needs to breathe and I ' m helping her to get some air ". CNA J put him back on his wheelchair and wheeled him out on the hall in front of his room. CNA J checked Resident #13 ' s genitals, stomach area and her buttocks area to make sure she didn ' t have any scratch marks, redness or any blood and proceeded to clean resident with perineal wash spray, cleaned her front, cleaned her back and then applied a clean brief. She stated that she was aware the nurses are responsible for assessing residents but she just wanted to make sure Resident #13 was fine. LVN K and RN Supervisor X arrived approximately within 7 to 10 minutes. CNA J showed both LVN K and RN Supervisor X the wet brief and told them everything was okay. The two nurses proceeded to check Resident #13 again. CNA J further stated that Resident #2 always tries to grab her from her buttocks during care and transfers. She has reported the incidents to the nurses. In an interview on 10/29/13 at 3:27 PM and 10/31/13 at 5:00 PM LVN K reported she has been working at the nursing facility since June 2013. On 10/25/13 after 8:00 PM CNA I who appeared to be in shock, approached LVN K and RN Supervisor X saying " come, come I need to show you something " LVN K asked her if someone had fallen and she stated no, that she needed to come because she needed to show me something. Approximately 3 minutes later LVN K and RN Supervisor X followed her to Resident #13 ' s room. When they arrived to resident #13's room, the resident had her brief and clothes on and showed no distress. CNA J informed LVN K and RN Supervisor X that Resident #2 was on Resident #13's bed looking at her genitals. While RN Supervisor X went to the telephone to make a call to the Director of Nursing (DON) C and ADON D, LVN K assessed Resident #13 physically and psychologically and showed no signs or symptoms of physical abuse on her genitals. Later on that evening, CNA I had told her that Resident #2 had his head between Resident #13 ' s thighs. After the incident, Resident #2 was placed on 1:1 supervision until they decided what to do with him. After the incident, 2 police officers had spoken with Resident #2. Further interview with LVN K reported that on another occasion not too long ago, LVN K was giving medication to Resident #2's roommate in his room and Resident #2 brushed his hand on my behind. His roommate told Resident #2 " son of a [***] , don't touch her " . CNAs are not allowed to go by themselves to Resident #2's room because he tends to touch staff. Approximately 10 days ago LVN K was giving Resident #2 his medications and I asked him to open his mouth to make sure he had swallowed the medications. He stuck his tongue in an obscene manner and LVN K told him to stop and reminded him that he needed to be more respectful. LVN K did not document the incident in the nurses' notes. Resident #2 was alert and oriented to person and place and pretends not to remember bad events. In an interview on 10/28/13 at 10:49 AM with Resident #2's roommate, he reported that 2 police officers showed up 2 evenings ago to talk to his roommate. He reported that approximately 2 weeks ago, he was getting his medications from LVN K when Resident #2 grabbed LVN K's buttocks. LVN K was mad and told Resident #2 "don't do that". In a telephone interview on 11/05/13 at 5:30 AM Registered Nurse (RN) Supervisor V stated that she works from 12:00 AM to 8:00 AM and had arrived to the nursing facility on 10/26/13 at 12:00 AM. RN Supervisor W gave report and informed her that Certified Nurse Aide (CNA) I had observed Resident #2 sitting on Resident #13's bed leaning towards perineal area "giving air". In an interview on 11/01/13 at 7:45 AM CNA LL reported that approximately half a year ago she was showering another resident in the shower room while a female student military CNA was showering Resident #2. She heard Resident #2 telling the student "touch my penis". CNA student just kept quiet. She reported the incident to the charge nurse. In an interview on 11/01/13 at 8:54 AM CNA L reported that in the later part of October 2013 during the breakfast meal, Resident #2 was sitting next to Resident #13 as he reached for the coffee cup he was observed brushing his hand and arm across Resident #13 ' s breast. She informed a nurse who no longer is employed with the nursing facility and Resident #13 was moved to another table. In an interview on 10/31/2013 at 2:08pm with Social Worker A, she reported that she had been the social worker for the traditional unit at this facility since November 2012. She reported that she was not sure why or when Resident #2 was moved from the Memory Support Unit to the Traditional unit. Prior to the incident on 10/25/2013, she had heard about one sexual inappropriate behavior since she had been employed with the facility. Review of Resident #2's Social Services Notes revealed the following summary on the notes: 09/14/2012- Meeting was held with Social worker and Resident #2 ' s girlfriend. Social worker informed girlfriend that Resident #2 ' s memory was getting worse. Recommendation for guardianship noted. Girlfriend noted that his daughters did not want to take guardianship of him and that she was too old to care for him. Social worker notified girlfriend about referral for psychological services and girlfriend responded that Resident #2 could not afford the co-payment for psychological services. Plan: Continue to monitor. 05/09/2013- Physician requested referral to psychological services. Psychological services were contacted from assessment. Plan: Continue to monitor. In an interview on 10/31/13 at 10:46 AM Administrator stated he had been informed on 10/25/13 at 11:00 PM by Registered Nurse (RN) Supervisor X on duty of the incident on resident to resident sexual abuse involving Resident #2 and Resident #13. He requested for RN Supervisor X to make plans to call ADON D and "make plans to report". He requested for the ADON D to come into the facility and make a more detailed assessment. On 10/26/13 at 2:00 AM ADON D called him back and stated "perpetrator (Resident #2) had not pulled diaper off or anything. Resident #13 was fine. The diaper was on. He was informed that no actual touching had been made and he trusted ADON D had already spoken to the person that saw the incident. I embraced the fact my resident had not been harmed. I trusted information from ADON D on the date of the incident and told her this needs to be reported. He stated that he was not aware of the September 2012 referral for psychological services for Resident #2 and it was not brought to his attention. He stated that if it was a matter of finance that Resident #2 did not receive counseling, it would have been brought to me for my awareness and possible intervention. 10/24/2013 - Social Worker A spoke with resident, he stated he is doing okay. There have been no recent reports of inappropriate behavior on resident ' s part nor has he made any recent allegations of inappropriate behaviors from staff towards him. Continue to monitor. 10/31/2013 - Resident was assessed by the owner of an unlicensed facility at 10:30 AM and was accepted. Later that day at 1:30 PM resident was discharged to this same foster home. Interview on 10/31/13 at 2:03 PM CNA BB reported that she received a telephone call from Registered Nurse (RN) V on 10/26/13 at 12:30 AM to come to the nursing facility to help care for Resident #2, to be with him all the time and to document every hour what he was doing. She stated that Resident #2 slept all night and she watched him until 8:00 AM. She reported that she had watched him today also from 11:00 AM until almost 2:00 PM before he had been discharged from the nursing facility. Record review of the "One Hour Observation" sheets revealed that from 10/26/13 at 1:00 AM through 10/31/13 at 2:00 PM Resident #2 was being monitored every hour. Observation of Resident #2 on 10/28/13 at 10:49 AM and 4:30 PM; 10/29/13 at 8:20 AM, 10:00 AM, 12:09 PM; 10/30/13 at 9:29 AM, 3:00 PM; and 10/31/13 at 8:15 AM revealed resident to have a CNA on a 1:1. Review of facility's policy entitled Resident Abuse/Neglect/Exploitation/Misappropriation of Resident Property/Involuntary Seclusion/Corporal Punishment, dated January 2011 revealed, in part: "The resident has the right to be free of abuse, neglect..." The staff will be trained on how to prevent abuse such as being more observant in secluding areas, monitoring appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. Any employee having knowledge or suspicions of an alleged violation involving resident abuse, neglect...is required to report immediately to the Campus Administrator, to the Risk Manager or to the Department Manager without fear of reprisal. All incidents...Potential abuse, neglect, exploitation...will be prevented during investigation. Results of investigation will be reported immediately to the Campus Administrator or designee and other officials in accordance with Texas law. A written report, if appropriate, will be sent to the Texas Department of Aging and Disability Services (TDADS) within five (5) days following the verbal report, in accordance with applicable laws. Refer to the most recent TDADS provider letter, "Guidelines for Reporting Incidents." "Sexual abuse" includes but is not limited to, sexual harassment, sexual coercion or sexual assault. "Neglect" means failure to provide goods and services to avoid physical harm, mental anguish, or mental illness. An IJ was identified on 10/31/13 at 4:05 PM and Administrator H was informed. The Plan of Removal was accepted on 11/04/13 at 3:24 PM and it included the following: As of 11/01/13 each department head has interviewed their staff to affirm if anyone of them encountered or witnessed any inappropriate sexual behaviors from residents. If any sexual or inappropriate behaviors are identified, we will conduct appropriate assessment, notify appropriate family, physician, care plan and follow up as appropriate. Residents Record Review/Audit to identify any other residents having demonstrated any inappropriate sexual behaviors initiated today by MDS coordinators and has been completed by 11/04/13. In-service staff on reporting behaviors and documentation of those behaviors. In-services have been initiated by unit managers 11/01/13 and completed as of 11/04/13. In-service staff beginning on 11/01/13 on protecting a resident from abusive situations. In-servicing has been completed on 11/04/13. Educate all departments on abuse, including inappropriate sexual behaviors, as well as behavior monitoring has been completed by department managers on 11/03/13 and will continue with the new hires and at least quarterly with all staff thereafter. Any residents noted to have behaviors identified as being inappropriate, will be reviewed weekly during the Risk Meeting and also reviewed quarterly and PRN during the Interdisciplinary Care Plan Meetings starting 11/01/13 and will continue as appropriate. Unit Managers/Charge Nurses will document noted inappropriate behaviors every shift, utilizing the Behavior Monitoring Sheets which will be followed up by the DON daily for the next 60 days and quarterly after. Social Workers will intervene to make appropriate referrals to Psychiatrist, Psychologist, or outpatient counseling and will follow up to assure resident participation. Social Worker to follow up with above agents or agencies to ensure resident's participation and track resident's progress and the social worker will follow-up with the unit managers. Social Worker to make appropriate referrals (as necessary) for alternate placement of resident, if the Interdisciplinary Team determines that the facility can no longer meet the resident's needs. Any inappropriate sexual behaviors, whether toward another resident, staff member, and or visitor, will be recorded on the daily 24 hour report and discussed at the morning Stand up Meeting and daily Clinical Meeting starting 11/01/13. On 11/05/13, the surveyors confirmed by interviews with nursing and administrative staffs, and by record reviews that all nursing staff were in-serviced on the above and were knowledgeable about changes in procedures. The surveyors confirmed the new policies and procedures were developed and in place. The surveyor also confirmed by interviews that nursing staff were knowledgeable about the new policies and procedures. The IJ was removed on 11/05/13 and Interim Administrator HH was informed at 3:15 PM. The surveyors determined that the Plan of Removal had been implemented through staff interviews, review of inservice training on Abuse, Neglect, Important facts on Investigations and Resident Safety. While the IJ was removed, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy at isolated because the facility needed to complete inservice training and had to monitor their plan for effectiveness. The list of 11 female residents was obtained from the Census dated 10/28/13.

Based on observation, interview, and record review the facility failed to implement written policies and procedures to prohibit, identify, report, investigate, and prevent further potential neglect for 2 of 30 (Resident #2 and 13) residents reviewed for sexual abuse. The facility failed to protect Resident #13 from a sexual assault by Resident #2. Resident #2 had a history of [REDACTED]. On 10/25/13 at 8:30 PM Certified Nurse Aide (CNA) I found Resident #2 sitting on Resident #13 ' s bed with his hands on her thighs and his head between her legs and his face on her exposed genitals. CNA I left the room to inform the nurse without removing Resident #2 from the room. The facility did not report the incident to the state until 10/28/13 at 1:45 p.m., 65 hours after the incident. An Immediate Jeopardy (IJ) was identified on 10/31/13 and Administrator H was informed at 4:05 PM. While the IJ was removed on 11/05/13, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy at isolated because the facility had not monitored their plan for effectiveness. These failures could affect all 11 female residents in the Traditional unit by placing them at risk of being neglected. The findings include: Review of facility's policy entitled Resident Abuse/Neglect/Exploitation/Misappropriation of Resident Property/Involuntary Seclusion/Corporal Punishment, dated January 2011 revealed, in part: "The resident has the right to be free of abuse, neglect..." The staff will be trained on how to prevent abuse such as being more observant in secluding areas, monitoring appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. Any employee having knowledge or suspicions of an alleged violation involving resident abuse, neglect...is required to report immediately to the Campus Administrator, to the Risk Manager or to the Department Manager without fear of reprisal. All incidents...Potential abuse, neglect, exploitation...will be prevented during investigation. Results of investigation will be reported immediately to the Campus Administrator or designee and other officials in accordance with Texas law. A written report, if appropriate, will be sent to the Texas Department of Aging and Disability Services (TDADS) within five (5) days following the verbal report, in accordance with applicable laws. Refer to the most recent TDADS provider letter, "Guidelines for Reporting Incidents." "Sexual abuse" includes but is not limited to, sexual harassment, sexual coercion or sexual assault. "Neglect" means failure to provide goods and services to avoid physical harm, mental anguish, or mental illness. Resident #2's Face Sheet dated 03/23/2012 indicated Resident #2 was an [AGE] year-old male admitted to the nursing facility on 03/23/2012 with [DIAGNOSES REDACTED]. 04/18/2012- Resident #2 was transferred from the Memory Unit to the Traditional Unit on 03/27/2013 following a sexual encounter in the Memory Unit. To date no sexual inappropriate behavior noted in Traditional Unit. Plan: Continue to Monitor. Review of Minimum Data Set (MDS) Quarterly Review assessment dated [DATE] identified Resident #2 as: Makes self understood, ability to understand others; Scored 11 out of 15 on Brief Interview for Mental Status (BIMS) (a score of 8 to 12 indicates moderately impaired decision-making ability); Physical behavior symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) --- behavior of this type occurred 1 to 3 days; Required limited assistance of one person physical assist for bed mobility, transfers and dressing; Locomotion On unit and Off unit -- independent with setup help only; mobility devices -- wheelchair. Review of Resident #2's Care Plan dated 04/04/13 and revised on 10/04/13 revealed: - Problem: Altered social interactions and adjustment. Resident has short term and long term memory problems and difficulty in new situations, has [DIAGNOSES REDACTED]. - Problem: Impaired mobility with potential for functional decline related to [MEDICAL CONDITION]. - Resident displays sexual inappropriate behavior as evidenced by inappropriate statements or actions toward caregivers, history of pushing a Certified Nurse Aide ' s (CNA) hand into his crotch during shower; Statements that female CNAs are flirting and touching him inappropriately; History of touching female resident inappropriately. Approach: Monitor and document behavior; Staff to inform social services of continued inappropriate behavior; Redirect resident as needed; Speak with resident and educate regarding socially unacceptable behavior. Resident #2 was observed during initial rounds on 10/28/13 at 10:49 AM to be up in his wheelchair in the activity room, alert and oriented to person and place. A Certified Nurse Aide (CNA) was providing 1:1. Resident #13 ' s Minimum Data Set Admission assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the nursing facility on 10/10/13 with [DIAGNOSES REDACTED]. of one person physical assist for bed mobility, transfers; Locomotion On unit and Off unit -- Limited assistance of one person physical assist; Required Extensive assistance of one person physical assist for dressing and eating; Required total dependence of one person physical assist for toilet use, personal hygiene and bathing. Review of Resident #13's Care Plan dated 10/28/13 revealed: Impaired ability to communicate related to cognitive loss secondary to dementia. Resident has memory problems related to Dementia. Resident has impaired daily decision making related to Dementia. Resident #13 was observed during initial rounds on 10/28/13 at 10:30 AM to be up in her wheelchair attending therapy, very confused, singing " la, la, la " as she banged the right wheelchair armrest with her right hand. In an interview on 10/28/13 at 8:07 AM during the entrance conference Administrator H was asked by surveyor if there were any incidents that were reported to the State, he responded that he might have a self-reportable resident to resident sexual abuse, male (ID#2) to female (ID#13). Review of Provider Investigation Report dated 11/04/13 revealed that on 10/25/13 at 8:45 PM staff member was in resident #13's room assisting another resident with pericare when she heard the roommate moaning from behind the privacy curtain. She pulled the curtain back and saw Resident #2 (male) sitting on Resident #13's (female) bed with his hands on her thigh and head between her legs near her groin area. The diaper was opened. The staff member asked Resident #2 what he was doing and he verbalized that she needed some help and he was giving her some air. Resident #2 was removed from Resident #13's room. Registered Nurse (RN) Supervisor assessed Resident #13 ' s genital area and noted no redness, swelling, bleeding or scratching to area. Pericare was done and resident remained calm during the assessment with no signs of acute distress. Law enforcement was notified and 24 hour visual one to one (1:1) monitoring on Resident #2 was initiated. In an interview on 10/30/13 at 9:29 AM Resident #2 reported that on the day of the incident he heard a woman screaming down the hall. He reported that he was lying down in bed, got up and transferred himself to his wheelchair. He said that he pedaled on his wheelchair to the room where he heard the woman screaming out for help. There was no one in the hallway and he did not see anyone coming to her assistance. He said he went to the room and to her bed and tried to give her some comfort. He was unable to state how he was going to give her some comfort. He reported that the female was saying something to him in Spanish and he could not understand. He tried to comfort her but would not specify how. When asked if he was sexually aroused during this time, he stated he may have been. He reported that the female was wearing a long t-shirt and her undergarment (brief). He reported that he never removed her brief. When asked how her underwear was found opened by the staff, he reported that it was windy that evening and that perhaps the wind may have removed her blanket as well as her brief. When asked to provide specific details of what he did that evening in the room with the female resident, he reported that he did not remember. When asked if he was questioned that evening by police officers he reported that he had been questions in reference to a car crash he had been in. In an interview on 10/29/13 at 2:48 PM Certified Nurse Aide (CNA) I reported that on 10/25/13 approximately at 8:30 PM she was providing care to Resident #13's roommate in bed " A " . CNA I heard moaning behind the privacy curtain in bed " B " and thought Resident #13 ' s husband was with her so continued providing care to her roommate. When she was done, CNA I peeked around the side of the privacy curtain, pulled it back and saw Resident #2 sitting on Resident #13's bed near the head rest. Resident #13 was uncovered, the brief was opened exposing her genitals and Resident #2 ' s hands were on Resident #13's thighs, his head was between her thighs and his face on her genitals. CNA I asked Resident #2 what he was doing and with a surprised look on his face he responded, "Giving her air". CNA I left the room without removing Resident #2 from the room to inform Licensed Vocational Nurse (LVN) K about the incident. As CNA I was leaving, she saw CNA J walking towards her so she told her that Resident #2 was in Resident #13's room. CNA I reported the incident to RN Supervisor X and Licensed Vocational Nurse (LVN) K. All three returned to Resident #13's room within one minute, Resident #2 was outside the room sitting on his wheelchair. As we entered the room, CNA J was already changing Resident #13's brief. At around 11:45 PM 3 police officers were with Resident #2 in the TV lobby area talking to Resident #2 and reading him his rights. In an interview on 10/31/13 at 2:17 PM CNA J said that 10/25/13 approximately at 8:30 PM CNA I was coming out of Resident #13's room with a surprised look on her face. She told me that Resident #2 was in Resident #13 ' s room. CNA J told her to go tell LVN K and immediately went inside the room. When CNA J entered the room Resident #2 was sitting on Resident #13's bed near the head rest. Resident #13 ' s brief was opened exposing her genitals. Resident #2 had his right hand on her stomach. Resident #13 was very agitated, looked scared and was shaking her hands as she kept asking " what's going on, tell me what's going on " . CNA J asked Resident #2 what he was doing and he responded " she needs to breathe and I ' m helping her to get some air ". CNA J put him back on his wheelchair and wheeled him out on the hall in front of his room. CNA J checked Resident #13 ' s genitals, stomach area and her buttocks area to make sure she didn ' t have any scratch marks, redness or any blood and proceeded to clean resident with perineal wash spray, cleaned her front, cleaned her back and then applied a clean brief. She stated that she was aware the nurses are responsible for assessing residents but she just wanted to make sure Resident #13 was fine. LVN K and RN Supervisor X arrived approximately within 7 to 10 minutes. CNA J showed both LVN K and RN Supervisor X the wet brief and told them everything was okay. The two nurses proceeded to check Resident #13 again. CNA J further stated that Resident #2 always tries to grab her from her buttocks during care and transfers. She has reported the incidents to the nurses. In an interview on 10/29/13 at 3:27 PM and 10/31/13 at 5:00 PM LVN K reported she has been working at the nursing facility since June 2013. On 10/25/13 after 8:00 PM CNA I who appeared to be in shock, approached LVN K and RN Supervisor X saying " come, come I need to show you something " Approximately 3 minutes later LVN K and RN Supervisor X followed her to Resident #13 ' s room. When they arrived to resident #13's room, the resident had her brief and clothes on and showed no distress. CNA J informed LVN K and RN Supervisor X that Resident #2 was on Resident #13's bed looking at her genitals. While RN Supervisor X went to the telephone to make a call to the Director of Nursing (DON) C and ADON D, LVN K assessed Resident #13 physically and psychologically and showed no signs or symptoms of physical abuse on her genitals. Later on that evening, CNA I had told her that Resident #2 had his head between Resident #13 ' s thighs. After the incident, Resident #2 was placed on 1:1 supervision until they decided what to do with him. After the incident, 2 police officers had spoken with Resident #2. Further interview with LVN K reported that on another occasion not too long ago, LVN K was giving medication to Resident #2's roommate in his room and Resident #2 brushed his hand on my behind. His roommate told Resident #2 " son of a [***] , don't touch her " . CNAs are not allowed to go by themselves to Resident #2's room because he tends to touch staff. Approximately 10 days ago LVN K was giving Resident #2 his medications and I asked him to open his mouth to make sure he had swallowed the medications. He stuck his tongue in an obscene manner and LVN K told him to stop and reminded him that he needed to be more respectful. LVN K did not document the incident in the nurses' notes. Resident #2 was alert and oriented to person and place and pretends not to remember bad events. In an interview on 10/28/13 at 10:49 AM with Resident #2's roommate, he reported that 2 police officers showed up 2 evenings ago to talk to his roommate. He reported that approximately 2 weeks ago, he was getting his medications from LVN K when Resident #2 grabbed LVN K's buttocks. LVN K was mad and told Resident #2 "don't do that". In a telephone interview on 11/05/13 at 5:30 AM Registered Nurse (RN) Supervisor V stated that she works from 12:00 AM to 8:00 AM and had arrived to the nursing facility on 10/26/13 at 12:00 AM. RN Supervisor W gave report and informed her that Certified Nurse Aide (CNA) I had observed Resident #2 sitting on Resident #13's bed leaning towards perineal area "giving air". In an interview on 11/01/13 at 7:45 AM CNA LL reported that approximately half a year ago she was showering another resident in the shower room while a female student military CNA was showering Resident #2. She heard Resident #2 telling the student "touch my penis". CNA student just kept quiet. She reported the incident to the charge nurse. In an interview on 11/01/13 at 8:54 AM CNA L reported that in the later part of October 2013 during the breakfast meal, Resident #2 was sitting next to Resident #13 as he reached for the coffee cup he was observed brushing his hand and arm across Resident #13 ' s breast. She informed a nurse who no longer is employed with the nursing facility and Resident #13 was moved to another table. In an interview on 10/31/2013 at 2:08pm with Social Worker A, she reported that she had been the social worker for the traditional unit at this facility since November 2012. She reported that she was not sure why or when Resident #2 was moved from the Memory Support Unit to the Traditional unit. Prior to the incident on 10/25/2013, she had heard about one sexual inappropriate behavior since she had been employed with the facility. Review of Resident #2's Social Services Notes revealed the following summary on the notes: 09/14/2012- Meeting was held with Social worker and Resident #2 ' s girlfriend. Social worker informed girlfriend that Resident #2 ' s memory was getting worse. Recommendation for guardianship noted. Girlfriend noted that his daughters did not want to take guardianship of him and that she was too old to care for him. Social worker notified girlfriend about referral for psychological services and girlfriend responded that Resident #2 could not afford the co-payment for psychological services. Plan: Continue to monitor. 05/09/2013- Physician requested referral to psychological services. Psychological services were contacted from assessment. Plan: Continue to monitor. In an interview on 10/31/13 at 10:46 AM Administrator stated he had been informed on 10/25/13 at 11:00 PM by Registered Nurse (RN) Supervisor X on duty of the incident on resident to resident sexual abuse involving Resident #2 and Resident #13. He requested for RN Supervisor X to make plans to call ADON D and "make plans to report". He requested for the ADON D to come into the facility and make a more detailed assessment. On 10/26/13 at 2:00 AM ADON D called him back and stated "perpetrator (Resident #2) had not pulled diaper off or anything. Resident #13 was fine. The diaper was on. He was informed that no actual touching had been made and he trusted ADON D had already spoken to the person that saw the incident. I embraced the fact my resident had not been harmed. I trusted information from ADON D on the date of the incident and told her this needs to be reported. He stated that he was not aware of the September 2012 referral for psychological services for Resident #2 and it was not brought to his attention. He stated that if it was a matter of finance that Resident #2 did not receive counseling, it would have been brought to me for my awareness and possible intervention. 10/24/2013 - Social Worker A spoke with resident, he stated he is doing okay. There have been no recent reports of inappropriate behavior on resident ' s part nor has he made any recent allegations of inappropriate behaviors from staff towards him. Continue to monitor. 10/31/2013 - Resident was assessed by the owner of an unlicensed facility at 10:30 AM and was accepted. Later that day at 1:30 PM resident was discharged to this same foster home. Interview on 10/31/13 at 2:03 PM CNA BB reported that she received a telephone call from Registered Nurse (RN) V on 10/26/13 at 12:30 AM to come to the nursing facility to help care for Resident #2, to be with him all the time and to document every hour what he was doing. She stated that Resident #2 slept all night and she watched him until 8:00 AM. She reported that she had watched him today also from 11:00 AM until almost 2:00 PM before he had been discharged from the nursing facility. Record review of the "One Hour Observation" sheets revealed that from 10/26/13 at 1:00 AM through 10/31/13 at 2:00 PM Resident #2 was being monitored every hour. Observation of Resident #2 on 10/28/13 at 10:49 AM and 4:30 PM; 10/29/13 at 8:20 AM, 10:00 AM, 12:09 PM; 10/30/13 at 9:29 AM, 3:00 PM; and 10/31/13 at 8:15 AM revealed resident to have a CNA on a 1:1. An IJ was identified on 10/31/13 at 4:05 PM and Administrator H was informed. The Plan of Removal was accepted on 11/04/13 at 3:24 PM and it included the following: As of 11/01/13 each department head has interviewed their staff to affirm if anyone of them encountered or witnessed any inappropriate sexual behaviors from residents. If any sexual or inappropriate behaviors are identified, we will conduct appropriate assessment, notify appropriate family, physician, care plan and follow up as appropriate. Residents Record Review/Audit to identify any other residents having demonstrated any inappropriate sexual behaviors initiated today by MDS coordinators and has been completed by 11/04/13. In-service staff on reporting behaviors and documentation of those behaviors. In-services have been initiated by unit managers 11/01/13 and completed as of 11/04/13. In-service staff beginning on 11/01/13 on protecting a resident from abusive situations. In-servicing has been completed on 11/04/13. Educate all departments on abuse, including inappropriate sexual behaviors, as well as behavior monitoring has been completed by department managers on 11/03/13 and will continue with the new hires and at least quarterly with all staff thereafter. Any residents noted to have behaviors identified as being inappropriate, will be reviewed weekly during the Risk Meeting and also reviewed quarterly and PRN during the Interdisciplinary Care Plan Meetings starting 11/01/13 and will continue as appropriate. Unit Managers/Charge Nurses will document noted inappropriate behaviors every shift, utilizing the Behavior Monitoring Sheets which will be followed up by the DON daily for the next 60 days and quarterly after. Social Workers will intervene to make appropriate referrals to Psychiatrist, Psychologist, or outpatient counseling and will follow up to assure resident participation. Social Worker to follow up with above agents or agencies to ensure resident's participation and track resident's progress and the social worker will follow-up with the unit managers. Social Worker to make appropriate referrals (as necessary) for alternate placement of resident, if the Interdisciplinary Team determines that the facility can no longer meet the resident's needs. Any inappropriate sexual behaviors, whether toward another resident, staff member, and or visitor, will be recorded on the daily 24 hour report and discussed at the morning Stand up Meeting and daily Clinical Meeting starting 11/01/13. On 11/05/13, the surveyors confirmed by interviews with nursing and administrative staffs, and by record reviews that all nursing staff were in-serviced on the above and were knowledgeable about changes in procedures. The surveyors confirmed the new policies and procedures were developed and in place. The surveyor also confirmed by interviews that nursing staff were knowledgeable about the new policies and procedures. The IJ was removed on 11/05/13 and Interim Administrator HH was informed at 3:15 PM. The surveyors determined that the Plan of Removal had been implemented through staff interviews, review of inservice training on Abuse, Neglect, Important facts on Investigations and Resident Safety. While the IJ was removed, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy at isolated because the facility needed to complete inservice training and had to monitor their plan for effectiveness. The list of 11 female residents was obtained from the Census dated 10/28/13.

Based on observation, interview and record review the facility failed to ensure that 1 of 4 residents reviewed for [MEDICATION NAME] Therapy (Resident #1) was free from unnecessary drugs (drugs prescribed without adequate monitoring). Resident #1 was on long term [MEDICATION NAME] therapy (a blood thinner used to inhibit blood clot formation). On 7/11/13, Resident #1's physician ordered a PT/INR lab test be drawn on 7/17/13 due to having a critically high PT of 59.9 and INR of 5.09 7/11/13. ([MEDICATION NAME] Time and International Normalized Ratio are used to make sure the [MEDICATION NAME] is in an appropriate dosage and not too high where excessive bleeding may occur.) Resident #1's [MEDICATION NAME] was held on 7/12/13 and 7/14/13 per physician order [REDACTED]. The blood specimen was drawn on 7/17/13; however, the facility failed to obtain the results of the repeat PT/INR for Resident #1. Resident #1 continued receiving [MEDICATION NAME] for the next 14 days without knowing what the resident's repeat lab tests showed. The resident was also taking [MEDICATION NAME] (another medication used to prevent blood clots) 75 mg every day which also increases the side effects of bleeding. On 8/01/13 Resident #1 began passing blood and blood clots from his rectum. The physician ordered Resident #1 to be sent to the hospital where a blood test for PT/INR resulted in a PT of 90 seconds (normal levels are 11.6 - 14.6 sec.) and an INR of 11.6 (therapeutic levels are 1.5 - 3.5). Resident #1 was admitted to the intensive care unit with profuse GI (gastrointestinal) bleeding, coagulopathy (disease affecting the blood's ability to clot), [MEDICAL CONDITION] and [MEDICATION NAME] toxicity on 8/01/13. In the emergency room Resident #1 was transfused with 2 units of Fresh Frozen Plasma (the liquid part of blood that contains clotting properties) and 1 unit of Leukocyte-Poor Red Blood Cells (the solid part of the blood). This failure resulted in an immediate jeopardy (IJ) that was identified on 8/29/13. While the IJ was lifted on 08/30/13, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy at isolated because the facility had not monitored their plan for effectiveness. This failure could have placed 14 residents receiving [MEDICATION NAME] at risk for undetected health issues, overdosing, bleeding, delayed treatment, and death. The findings are: Record review of clinical records revealed resident #1 was a [AGE] year old man admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a BIMS (Basic Interview of Mental Status) score of 15 out of 15 (cognitively intact), had no behaviors and received 5 days of anticoagulants since admission. Record review of Resident Care Plan, last reviewed on 8/01/13 documented Resident #1 had a potential for bleeding/bruising related to anticoagulant ([MEDICATION NAME]) use related to history of [MEDICAL CONDITION] ([MEDICAL CONDITION] - blood clot), [MEDICAL CONDITION] and prosthetic heart valves. He takes [MEDICATION NAME] daily and [MEDICATION NAME] daily (dose varies according to lab values). The Care Plan documented on 7/11/13 Resident #1 had a "PT/INR of 59.9/5.9" and to hold [MEDICATION NAME] for 2 days and resume at 2 mg every day and obtain PT/INR on 7/17/13. The approaches stated to monitor labs as ordered and notify physicians with abnormal labs and follow orders. Record review of Resident #1's Physician Telephone Orders dated 7/11/13 documented the following: a. Hold [MEDICATION NAME] for 2 days then resume [MEDICATION NAME] at 2 mg daily for all days, D/C (discontinue) all previous [MEDICATION NAME] orders. b. PT/INR on 7/17/13 Record review of Resident #1's electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Starting on 7/14/13, Resident #1 was administered [MEDICATION NAME] 2 mg at 6 PM every day. Record review of laboratory results dated [DATE] documented Resident #1's PT was 59.9H (high, reference range 9.6 - 12.8) and INR 5.09CH (critically high, reference range 2.0 - 3.0). "Comment: INR should be used only with reference to patients on oral anticoagulant therapy (OAT). The therapeutic range shown is indicated for the following: deep vein [MEDICAL CONDITIONS] embolism, acute [MEDICAL CONDITION] infarction, [MEDICAL CONDITION]. The INR therapeutic range for moderate intensity anticoagulation (prevention of embolism in patients with mechanical heart valves, treatment of [REDACTED]." Record review of the Lab Book documented on the Lab Specimen Collection Log for 7/17/13 the PT/INR was drawn for Resident #1. There was no yellow receipt of the Lab Requisition for this draw in the Lab Book. In record review of 24 Hour Report/Change of Condition Report for 7/11/13 and 7/17/13, there was no documentation of a PT/INR draw or pending lab results for Resident #1. Record review of Medicare Skilled Nurses Notes dated 8/01/13, 10:30 AM, documented a large amount of blood noted to diaper as CNA (Certified Nurse Aide) was changing diaper this morning at 9:20 AM. Large blood clots noted as well. The doctor was notified at 9:30 AM and the resident was transferred to the hospital at 10:15 AM. Record review of Resident #1 ' s Physician Telephone Orders dated 8/01/13 documented to send to ER for evaluation, Dx (diagnosis) rectal bleeding, clotting. Record review of Provider Investigation Report documented a "systemic failure in providing patient care" occurred on 8/01/13 at 9:20 AM. "On 7/11/13 the assigned charge nurse affirmed that this resident ' s [MEDICATION NAME] INR was in the critical range of 5.09." An order was received to hold Resident #1's dosage of [MEDICATION NAME] for 2 days, then resume the [MEDICATION NAME] at 2 mg daily and repeat the PT/INR on 7/17/13. On 7/17/13 the lab specimen was drawn but as of 8/01/13 the lab had not notified the facility of the results and no one from the facility followed-up with the lab. On 8/01/13 the nurse noted Resident #1 had a bloody "diaper" and was bleeding from the anus. The resident was transferred to the hospital where he was diagnosed with [REDACTED]. The Investigation Summary stated the lab failed to leave the yellow copy (receipt) of the lab requisition, failed to send a copy to the Burbank (Ca.) lab and failed to process the PT/INR specimen. The physician and the nursing staff failed to follow-up with the lab for results and the resident continued to receive the [MEDICATION NAME] until he was sent to the hospital for a GI bleed and [MEDICATION NAME] toxicity. Record review of the Emergency Provider Report dated 8/01/13 documented Resident #1 had a lower gastrointestinal hemorrhage, [MEDICAL CONDITION] and [MEDICATION NAME] toxicity. Resident #1's blood pressure was 88/56 (low) and he was given fluid and blood and placed in the intensive care unit. Record review of hospital lab results dated 8/01/13 documented Resident #1's PT/INR as 90H/11.6H (3 times the moderate intensity therapeutic range). Record review of hospital Laboratory Services documented on 8/01/13 2 units of Fresh Frozen Plasma (given for its clotting factors) and 1 unit of Leukocyte-Poor Red Blood Cells (to replace the blood loss) were transfused into Resident #1. Record review of the policy Medical Management - [MEDICATION NAME] Therapy effective date 3/14/06 stated in part the following: Purpose: To chronologically record PT/INR results, [MEDICATION NAME] doses and next date of PT/INR; to provide the Resident's physician a reference for PT/INR history and therapeutic responses to [MEDICATION NAME] therapy. Procedure: Upon receipt of PT/INR results the licensed nurse or supervisor will record the following on the [MEDICATION NAME] Flow Sheet : Record date lab done Record last [MEDICATION NAME] dose Record current PT/INR result The physician's response will include the [MEDICATION NAME] dose to be administered and date of the next PT/INR. Record these on the flow sheet. Note: Evening licensed nurses or the supervisor should reference the next date the PT/INR is due to ensure that the current [MEDICATION NAME] dose is correct. The licensed nurse or supervisor will complete proper lab form to order next PT/INR. In an interview on 8/28/13 at 12:38 PM, Licensed Vocational Nurse (LVN) C said before the incident when Resident #1 was sent to the hospital on [DATE], there was no system for [MEDICATION NAME] monitoring. When a lab was ordered a Lab requisition was filled out and put into the lab book on the date the blood was to be drawn. If there was an order for [REDACTED]. If the results were critical, the lab would call. If lab results were not back by the end of the shift, she would check the fax machine. If the results were not there, she would report to the oncoming nurse to call the lab and ask about the result. In an interview on 8/28/13 at 3:56 PM, LVN E said labs are put into the computer and will pop-up on the screen for night shift on the morning it is to be drawn as a reminder for the night nurse. On day and evening shifts a message will pop-up on the e-MAR screen to remind the nurse to check for results. The pending lab results were also written on the 24 hour report as a reminder until the results were received. LVN E said the [MEDICATION NAME] Flow Sheet was implemented 2 weeks ago. Prior to the use of the flow sheet it was up to the evening nurse to get the pending lab results. LVN E, although she took the order for the repeat PT/INR on 7/11/13, said she did not know results were pending on 7/17/13. There was no report there was pending lab results for Resident #1. In an interview on 8/28/13 at 4:06 PM, Director of Nurses (DON) A and Corporate Quality Assurance (QA) Nurse B said the current policy for [MEDICATION NAME] monitoring, even though dated March 2006 and included in in-services dated 8/05/13, was not implemented until last week (8/19/13). The corporation had recently hired a management company and had not implemented their policies and procedures yet - only as problems occur have they looked at the management company ' s policies. DON A said [MEDICATION NAME] monitoring was not tracked prior to the incident with Resident #1. DON A said they depended on the lab to call results. "If there was no fax or phone call from the lab with results then there were no results (obtained)." The nurses did not call the lab for Resident #1's PT/INR results even though the resident had been running critical high INRs. DON A said there were never any results from the lab draw for Resident #1 on 7/17/13 as the lab did not follow its policies and the PT/INR were never run. QA Nurse B said she would provide the corporate policies that were in effect for labs and drug monitoring at the time of the incident. In an interview on 8/28/13 at 4:37 PM, QA Nurse B said there was no corporate policy for therapeutic drug monitoring in effect at the time of the incident with Resident #1. In an interview on 8/29/13 at 12:27 PM, LVN D said there was a miscommunication about Resident #1's PT/INR lab draw. She said no one passed on in report that there were labs pending on Resident #1. LVN D said the pop-up reminder system was not yet in effect. On the morning of 8/01/13, Resident #1 began bleeding. After he was sent to the hospital the staff began looking back at his labs and discovered the results of the PT/INR drawn on 7/17/13 were never received. LVN D said now when a lab order is received the family is notified, it is entered into the e-MAR, a lab requisition is filled out and put into the lab book, written on the 24 hour report and entered on to the [MEDICATION NAME] Flow Sheet. The results are written on the [MEDICATION NAME] Flow Sheet and if a follow-up PT/INR is ordered it also written on the flow sheet. In a telephone interview on 8/29/13 at 12:38 PM, Laboratory Provider Clerk said there was no record of a lab draw/results for a PT/INR for Resident #1 on 7/17/13, but she would check with someone else and call back. The clerk called back at 1:49 PM and said because of HIPAA (patient privacy act) no information could be given and any information would have to come from the facility. Record review of Resident #1' s Physician Telephone Orders dated 8/27/13, after he was readmitted to the facility, documented a PT/INR draw for Tuesday 9/03/13. In record review of the [MEDICATION NAME] Flow Sheet on 8/28/13 for Resident #1, there was no documentation that a PT/INR was scheduled to be drawn on 9/03/13. In an interview on 8/29/13 at 12:27 PM, LVN D , LVN D confirmed that the ordered PT/INR for Resident #1 for 9/03/13 was not entered on to the [MEDICATION NAME] Flow Sheet. Observation on 8/28/13 at 8:17 AM, revealed Resident #1 was seated in his bed at the facility. He was receiving oxygen at 2 L/M (liters per minute) by nasal cannula. He had bruises to both forearms and had a dressing on his left forearm with bloody drainage seen beneath the surface of the dressing. An immediate jeopardy that was identified on 8/29/13 and the administrator was informed at 1:16 PM. The following Action Plan submitted by the facility was accepted on 8/30/13 at 3:50 PM to remove the Immediacy: 1. Each area charge nurse will enter lab orders into the eMar. 2. Each area charge nurse that receives the order for the lab will fill out the Lab Requisition Slip and place it in the Lab Book 3. The DON, RN Supervisor or designee will review lab orders and check lab log (see attached) daily to ensure labs are drawn when ordered. 4. The Unit manager, RN Supervisor or designee will check electronic lab results daily. 5. The Unit manager, RN Supervisor or designee will initial Phlebotomist log to affirm lab results are received daily. 6. The area charge nurse will notify the attending physician of abnormal lab results and document in the nurses notes. 7. Each area charge nurse will log in the current treatment, PT/INR results, new [MEDICATION NAME] orders (if applicable), and date of next lab draw on to the [MEDICATION NAME] flow sheet (see attached). 8. Any new orders or changes in treatment will be documented into the resident's medical record. 9. The Unit manager, RN Supervisor or designee will check [MEDICATION NAME] log daily to ensure compliance with current treatment. 10. The Unit manager, RN Supervisor or designee will crosscheck the [MEDICATION NAME] log with the Physicians orders weekly. All logs will be maintained at the nurse's stations. On 8/30/13, the surveyor confirmed by interviews with nursing and administrative staffs, and by record reviews that all nursing staff were in-serviced on the above and were knowledgeable about changes in procedures. The surveyor confirmed the new policies and procedures were developed and in place. The surveyor also confirmed by interviews that nursing staff were knowledgeable about the new policies and procedures. The surveyor confirmed that the facility conducted an audit of laboratory procedures to ascertain all pending labs had been ordered and/or had been obtained. The administrator was informed the immediate jeopardy was removed on 8/30/13 at 4:28 PM prior to exit, but the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy at isolated because the facility had not monitored their plan for effectiveness A list obtained from DON A on 8/28/13 documented 14 residents received [MEDICATION NAME].

Based on observation, interview and record review the facility failed to ensure that 1 (Resident #1) of 3 residents reviewed for medications was free of significant medication errors. Facility Licensed Vocational Nurse (LVN) "A" failed to follow the physician's orders [REDACTED]. Each time Resident #1 was given 1200MG for a total of 2400MG Resident #1 ' s usual dose is 400MG three times a day(TID). Resident #1 was found in his room two hours later extremely anxious, unable to respond verbally, diaphoretic, and in respiratory distress. This failure resulted in Resident #1 being rushed to the hospital where his [MEDICATION NAME] level was Critical High at 24 (therapeutic level is 4-12). Resident #1 was intubated and admitted to ICU with the primary [DIAGNOSES REDACTED]. These failures could affect 26 residents residing on 300 Hallway by placing them at risk for not receiving medications as ordered by physician. Findings include: Record review of Resident #1 ' s Face Sheet dated [DATE] reflected he was an [AGE] year old male. Record review of physician's order [REDACTED]. Article review: http://emedicine.medscape.com/article/ 4-clinical#a0218 <http://emedicine.medscape.com/article/ 4-clinical> [MEDICATION NAME] ([MEDICATION NAME]) is an anticonvulsant. It works by decreasing nerve impulses that cause [MEDICAL CONDITION] and pain. [MEDICATION NAME] is used to treat [MEDICAL CONDITION] and nerve pain such as [DIAGNOSES REDACTED] and diabetic [MEDICAL CONDITION]. Therapeutic levels are 4-12 mg/L, but individual variation exists. Ataxia and [DIAGNOSES REDACTED] may occur at levels greater than 10 mg/L Cardiovascular effects are usually seen at levels greater than 12 mg/L. The drug interferes with action potentials in Purkinje fibers and the His bundle, which may lead to atrioventricular blocks and arrhythmias. Record review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of Nurse ' s Note dated 5/19/13 reflected at 2:00 PM " During medication pass, observed resident extremely anxious and attempting to sit up in bed, observed wife at bedside. Resident not verbally responsive, diaphoretic, labored breathing observed. Residents wife stated this was not normal behavior. Resident continued with diaphoresis and observed respiratory distress. Observed resident gagging and attempting to vomit with no emesis produced. Resident placed in a sidelying position. Patient not able to verbalize pain or distress. " 4:23 PM " Resident transferred via EMS to WBAMC for altered mental status and continued labored breathing, verbal unresponsiveness, and labored breathing. Observed son and Resident ' s wife at the bedside during emergency transfer " 4:35 PM " Spouse at bedside voiced concern on medications provided at noon only stating " he took (6) six pills " " Review of medication cart on 6/4/13 at 1:20 PM with LVN B of Medication Bubble Pack Card with name of Resident # 1 revealed Tregratol 200MG Give 2 (400MG) q(every) 8 hours. In an interview on 6/6/13 at 3:00 PM LVN A stated, " I worked the 300 hall on 5/19/13 from 6:00AM to 2:00 PM. I had trouble logging onto the computer in the morning so the nursing supervisor (NS) logged me on. I misunderstood the order, the " in a day " part. I administered Carbanazepine 1200 MG to Resident #1 at 8:00 AM and 12:00 NOON, I thought it said to equal 1200 MG and I did not see the " in a day " . In an interview on 6/6/13 at 4:00 PM NS E stated, " I was called to the bedside of resident #1 by the 2-10 nurse. The family was explaining what happened, we held (did not administer) the 4:00 PM dose of Carbanazepine, the physician was called and the patient was sent to the emergency room (ER). " Record review of Resident Transfer Form dated 5/19/2013 reflected reason for transfer to hospital Altered Mental Status, Possible Tregratol Over Dose (OD). [DIAGNOSES REDACTED]. Additional Pertinent Information [MEDICATION NAME] given at 2:00 PM. In an interview on 6/4/13 at 9:00AM Resident #1 stated, " They gave me too much of a drug, I don ' t remember much about it. I was out of it but my son could tell you a lot more. The drug was [MEDICATION NAME] I take it for pain from [DIAGNOSES REDACTED] In an interview on 6/4/13 at 9:30 AM the son of Resident #1 stated, " My father was given 2400MG of [MEDICATION NAME] in a 4-5 hour period he is supposed to get 400MG three times a day. I am really upset because my mother was in the room and told the nurse that was too many pills and he was not supposed to get 6 pills at one time. The nurse told my mother; No, that ' s the order and the nurse gave the pills anyway and he started going downhill. After my father was unresponsive the nurse also tried to give [MEDICATION NAME]. My father ' s heart rate was 37 and I told the nurse to send my father to the hospital. When my father got to the hospital they intubated him, put a tube down his throat into his lungs and he was on a ventilator. Since he returned from the hospital he could not eat yesterday or today and he has increased confusion that was not there before. He calls me at 7:30 PM at night and thinks it ' s morning he never did that before." In an interview on 6/6/13 at 8:30 AM Son of Resident #1 stated, " My father had a sleepless night, and he is still having the confusion that was not there before the overdose, but otherwise he is doing well. " In an Interview on 6/4/13 at 1:20PM LVN B revealed a change order sticker on the Medication /Bubble Pack Card. LVN B stated the change sticker means the physician has been called and the time changed from q8 hours to Three Times a Day (TID) In an interview on 6/4/13 at 11:35 AM Director of Nursing (DON) C stated, " LVN A had been a full time employee until recently when she started school and changed to as needed (PRN) status. When nurses are hired they get orientation on the floor with a preceptor for about a week. The preceptor supervises to make sure the new employee knows the proper procedure. LVN A had orientation when she was first hired but not when she changed status. After a medication error the nurse has a Medication Administration Observation done. " DON C provided Medication Administration Observation for LVN A dated as completed on 5/24/13. DON C was unable to provide a Medication Administration Observation dated prior to 5/19/13. In an interview on 6/6/13 at 1:55 PM DON C revealed, Nurse competency is checked by doing Medication Administration Observations. A Registered Nurse (RN) observes the nurse when she is administering medications and fills out a form entitled Medication Administration Observation. Random monthly Medication Administration Observations are done on 6 nurses every month by the Assistant Director of Nursing (ADON) ' s and supervisors. A copy of the Medication Administration Observation is placed into the nurse record in Human Resources (HR). Pharmacy also does Medication Administration Observation and that also goes into the nurse record. When asked, " How do you track who is observed? How do you know the same 6 nurses aren ' t the ones observed over and over? " DON C stated, " Every year each employee gets an annual evaluation. When it is time for a nurse ' s annual evaluation, if a Medication Administration Observation has not been done, it is done at that time and copies are kept in their HR file. " When asked, " How is the competency measured from the tool and what is done about it? " DON C revealed, it would affect the annual evaluation. In an interview on 6/6/13 at 2:30 PM ADON D stated, " We make sure nurses have Medication Administration Observations annually with their evaluation. A list of who needs Medication Administration Observations is left for the nurse supervisor to complete. The ADON keeps a copy and 1 copy is given to HR to put in the nurses file. The same procedure is used for every nurse. " In an interview on 6/6/13 at 4:00 PM Nursing Supervisor (NS) E stated, " When I am required to complete a Medication Administration Observation after it is completed I put it under DON C ' s door. In an interview on 6/6/13 at 3:50 PM Director of Human Resources (DHR) F stated, " Medication Administration Observation ' s are not in Human Resources, it is not in the employee files, no one has ever given me a Medication Administration Observation form. " In an interview on 6/6/13 at 4:32 PM ADON D stated, " After a Medication Administration Observation is done I keep one copy and I give one copy to HR to put in the employees file. I have employee files in my office where I keep things like verbal counseling ' s and other small things that don ' t need to go into the employee file in HR. " ADON D was unable to produce any Medication Administration Observations from the employee files in her office. " The facility census, dated 6/04/2013 documented 26 residents residing on 300 Hallway.

Based on observation, interviews, and record review the facility failed to ensure that 11 (ID#1) of 12 sampled residents identified as smokers received the adequate supervision and assistance to prevent accidents as evidenced by: A. The facility failed to identify and evaluate the risk of accidents when resident #1 was admitted to the facility on [DATE] with a fractured right humerus and fractured right distal radius. Resident's dominant hand was in a sling and had very limited movement to the right hand. Resident's T-shirt caught fire and sustained first, second, and third degree burns to 20 percent of her body. The resident was flown to the burn center on 5/28/11. B. The facility failed to follow their smoking policy by allowing 11 (ID#1, ID#2, ID #4, ID# 5, ID#6, ID#7, ID# 8, ID# 9, ID #10. ID# 11, ID# 12) of 12 sampled residents identified as smokers to keep cigarettes, pipe, and lighters in their rooms. C. The facility failed to ensure that facility staff were inform of the facility's Smoking Policy and the process on when to complete Smoking Assessments. Interviews with several staff members revealed that they were not aware if the facility had a Smoking Policy or when Smoking Assessments were to be completed on those residents who had been identified as smokers. Failure to supervise residents while smoking and failure to secure smoking material could place 11 residents identified as smokers at risk for injuries. Findings include: RESIDENT #1: Closed record review on 5/30/11 revealed Admission Record documented resident #1 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. The History & Physical dated 5/26/11 documented resident was an [AGE] years old female with [DIAGNOSES REDACTED]. Alert x 2/3 (oriented to person and place). The Right arm is in a sling. Record review on 5/30/11 revealed that the facility did not have any Minimum Data Set forms or Care Plans in the resident ' s chart at time of initial review on 5/30/11. Record review of the Fire Department report dated 5/28/11 documented ambulance was dispatched at 9:58 AM and arrived at facility at 10:04 AM. Chief Complaint: My clothes caught fire and I got burned. Resident oriented and obeys commands. Narrative: Upon arrival found [AGE] year old female patient in the lobby of the nursing home with 1st and 2nd degree burns to her chest, back, left arm and face (20 percent to her body). Staff at nursing home stated that the patient was taken outside by another staff member to smoke like she always does. Staff then went back inside for unknown reasons and when they looked outside within minutes of taking patient outside they noticed that the patient was on fire. Staff members then went outside to put out the fire on the victim with their own clothes. Patient was oriented to time, person, and place and stated that she had no other injuries other than the burns. She did have a previous injury on her right wrist that was wrapped. The resident was transported to the hospital at 10:19 AM. HOSPITAL emergency room REPORTS: Record review of the Hospital emergency room Documentation documented resident #1 arrived to the ER at 10:33 AM by ambulance. The patient presented with first and second degree burns -20% burn to neck, chest and abdomen. The character of symptoms is pain. Drug test dated 5/28/11 at 10:59 AM documented Benzo-positive and Opiates. History of present illness: The patient presents with burn and thermal burn. The onset was just prior to arrival. Agent-flame: Cigarette. Location: Trunk abdomen, face, neck. The degree of symptoms is severe. Risk factors consist of smoking age. Patient smoking outside nursing home and caught on fire. Transferred to the Burn Center 5/28/11 at 11:29:00. Record review of the Hospital History & Physical dated 5/28/11 documented resident was smoking outside. She was found by nursing home staff outside covered with smoldering clothes on her chest. The patient was alert and oriented. The patient has burns to the neck area, approximately first and second degree burns. She had second and third degree burns to the chest originating mid sternum to the right shoulder and upper arm mid humerus area. Abdomen had some burns in the middle area, approximately second and third degree burns. The patient will be intubated in the emergency department for airway protection and she is going to be flown to the Burn Center. During placement of the Foley, there was a very cloudy urine. Will treat her with antibiotics x 1 dose for suspected UTI (urinary tract infection). Hospital Microbiology Report dated 5/28/11 at 11:30 AM documented Urine Culture 5/29/11 Greater than 100,000 colonies/ml gram-negative rods. Indicating the the resident had a urinary tract infection. REHABILITATION HOSPITAL RECORDS: Record review of the Rehabilitation Hospital Progress Note dated 5/09/11 for resident #1 documented in part: The patient up in a wheelchair, mildly confused. Record review of the Rehabilitation Hospital Psychological Evaluation dated 5/10/11 for resident #1 documented in part: Resident #1 is an [AGE] year-old female of German descent who presented to Military Medical Center after falling 4/27/11. A workup revealed right humeral neck fracture and right distal radius fracture. Resident #1 was not felt to be a surgical candidate and was monitored conservatively. By 5/02/11, she was deemed medically stable and able to participate in a more aggressive rehabilitation care plan and was transferred to Rehabilitation hospital for further care. Psychiatric History: Daughter reported resident #1 has had a long history of depression. Substance Use: Resident #1 stated that she smoked for [AGE] years. She smokes three cigarettes a day. Orientation: Resident #1 is oriented to person, place, and time. Thinking: Judgment: Fair to Poor. Psychological: Affect: Blunted. Eye Contact: Normal. Speech: Fluent. Pain: Resident #1 reported that she only experiences pain when her shoulder is moved. Major Psychological Symptoms: Major Depressive Disorder, recurrent moderate. Adjustment disorder with anxiety. FACILITY'S RECORDS: Record review of Provider 's Investigation report provided to the surveyor by Assistant Director of Nurses (ADON) #A on 5/30/11 documented in part: Incident Date: 5/28/11 at 10:00 AM, Location: patio. Resident #1's Functional Ability: Extensive. No special supervision required, Interviewable and capable of making informed decisions. Description of Injury: Burns on left side of scalp, left chin, entire left upper extremity, chest area and abdomen, and redness to the left cheek. Investigation Summary: documented in part, Resident #1 was on front patio smoking a cigarette at about 10:00 AM. Resident was assessed to be alert and oriented x 3 and capable to making her own decisions and assessed to not have any cognitive impairments prior to being allowed to smoke by herself on the patio, in the designated smoking area. A few minutes later, resident was seen by Charge Nurse to have flames on her left shoulder area. Flames were extinguished by staff. Resident was assessed to have burns. Resident was alert and able to verbalize needs. No change in mental status noted. Resident was concerned about keeping track of her cigarettes and fanny pack. Resident was transported via EMS (Emergency Medical Services) to ER (emergency room ) for further evaluation. Resident was further transferred to the Burn Center (per daughter). Record review of a written statement attached to the facility's investigation report dated 5/28/11 written by LVN #C documented in part, "at approximately 9:45 AM-10:15 AM, I was walking through lobby area to go check on a resident who was outside the facility with an escort. When I turned my head toward the patio area, I noticed that resident #1 was sitting in her wheelchair facing towards the driveway. Back to me up in flames. Ran outside to help resident. Approached resident and started to extinguished flames with the use of my T-shirt and a facility staff Certified Nurse Aide ran outside as well to help me. Resident with no verbal complain of pain, no screaming, or crying. Resident with second and third degree burns to stomach area upper body, bilateral upper arms, left ear and neck. No blisters noted. Brought back inside facility. T-shirt and right arm brace removed with no discomfort. " Record review of written statement by Certified Nurse Aide (CNA) #B provided by DON (Director of Nurses) on 6/01/11 revealed employee's statement that was undated or signed. The statement documented, "It was about 9:15 AM, when I got resident #1 dressed. She asked me if I can take her out for a smoke. I am PRN (as needed) and my second time I am working this shift here in the Special Care. I did not know nor do I know what is done in this case, so I asked my co-worker CNA #G who I was working under. CNA #G told me that I can take resident #1 to smoke but after I did the beds on my list. I then did the beds and hoped that this lady, resident #1 had forgotten about taking her out to smoke. Just before 10 O 'clock, she asked me again, so I told my coworker under whom I was working CNA #G and she said that I can take her out. I also asked if I am to wait for her and CNA #G said for me to leave her there and return after a few minutes. I did just that. It was about 10 O 'clock that I then took her out through a side door at the lobby and told her that I would return after about 5 minutes. She then said 15 minutes. I then said OK. I left her and went into the restroom by the lobby and it did not take me too long when I smelled smoke. I opened the door and saw some people running to the lobby. I followed and saw the commotion outside, so I went outside and saw that resident #1's clothes was burnt. She had burns on her chest and left hand. The supervisor instructed me to go get some towels. When I returned back with the towels, the resident was already inside in the lobby area. I put the towels over her and heard them call 911. I then left and returned to the special care unit. " In a telephone interview on 06/01/11 at 12:09 PM CNA #B reported that he had been employed at the facility since February 2011 and worked PRN. CNA #B stated, "on that day, I got resident #1 dressed and took her to therapy upon her request. When we got to the therapy room the therapy department was closed on that day. I did not know what to do, when the resident asked me to take her out to smoke. I went to ask CNA #G what to do. CNA #G told me to wheel resident #1 out to the front of the facility and to leave the resident outside by herself for approximately 10 minutes and than to go and get the resident. I did not light the cigarette for the resident. That was the first time that I was assigned to resident #1. Resident #1 was alert and oriented. I do not know if the residents keep cigarettes or lighters in their rooms. I also remember that on that day initially someone else was assigned to resident #1. I was informed by CNA #G that I would be taking over the care for resident #1 on that day. I did not provide any personal care to resident #1 on that day. I do not know if resident #1 had difficulty using her hands. Resident #1 had a sling to the right arm. I left the resident sitting outside so I went to use the bathroom. When I came out I noted a lot of people going out through the side exit. That is when I saw that resident #1 was burning. " In an interview on 5/30/11 at 11:17 AM, resident #12 reported that he always saw resident #1 smoking outside unsupervised." Resident #12 stated, "It's too bad, about that poor old lady that got burned. The staff would take her out to smoke and would tell her that they would be right back. Right back was about 20 minutes or more. I, knew that something bad was going to happen. I was always afraid that she would doze off and burn herself. In an interview on 5/31/11 at 2:15 PM Licensed Vocational Nurse (LVN) #C reported that he had worked on Saturday 5/28/11 when the incident happened with resident #1. LVN #C stated, " On that day, I was just making rounds and was going outside to check up on one of my residents. When I was walking towards the main entrance of the facility, I noted flames and smoke coming from the side entrance where resident #1 was sitting outside. The flames and smoke were coming from the front of the resident. The resident's back was facing us. When I opened the door, I heard the resident screaming for help. Another employee and I went outside to check on the resident. The flames were mainly on her chest. The T-shirt was on fire. The resident had a sling to the right arm. We tried to put out the fire out with our hands but the fire was too hot. I then took of my shirt and wrapped it around her. That is how we put out the fire. The resident was calm and quiet. She was more concerned about her cigarettes. I do not know if the facility has a smoking policy. They should have one. I have seen Smoking Assessments in the resident's charts. I guess that that these Smoking Assessments are done upon admission. I don't know. " In an interview on 5/30/11 at 3:04 PM, CNA #D reported that he was sitting in the main lobby when he saw one of the nurses run toward the side exit door. CNA #D stated, "I immediately went to see what was going on. We saw smoke and flames coming from the front of resident #1. Resident #1 was sitting close to the side exit door with her back to the door. We attempted to put out the fire with our hands but the fire was too hot. It was also very windy on that day. The nurse pulled off his shirt and wrapped it around the resident to put out the fire. The resident was not screaming. She was just sitting in the wheelchair and stared at us. I remember that the resident had a sling on one of the arms, so it made it very difficult to remove her T-shirt. On that day I also remember that the curtains in the lobby were still closed because it was on the week end. I do not know if the facility has a policy & procedure on smoking. I usually see residents smoking in the front of the building or in the back patio unsupervised. " In an interview on 5/31/11 at 2:45 PM, Week End Receptionist #E reported that she had worked on Saturday 5/28/11 when the incident happened with resident #1. The Receptionist stated, " The incident happened at approximately 10-10:30 AM. Resident #1 was sitting outside in her wheelchair with her back towards me. LVN #C was walking towards the main entrance of the facility and looked to the side were the exit door is, and that's when I noted the smoke and the flames coming from the front of resident #1. You cannot hear the people outside when the doors are closed. I did not hear if resident #1 was calling for help. The resident was just staring at the staff when they brought her inside to the main lobby. LVN #C and CNA #D attempted to put the fire out with their hands, but because it was very windy the fire kept spreading. Then LVN #C pulled off his scrub top and was attempting to put out the fire with his hands. LVN #C and CNA #D eventually were able to pull off the resident 's T-shirt. The resident 's hair and ears were still burning. I always see the residents smoking outside unsupervised." The Receptionist reported that she was not aware if the facility had a policy & procedure on smoking. In an interview on 5/31/11 at 3:35 PM, resident #1's daughter and son reported that no one at the facility had asked her father or them if their mother could safely smoke unsupervised. The daughter stated, "My mother's dominant hand and arm were fractured. My mother had her right arm wrapped in an Ace wrap and had a cloth arm sling. My mother also had a tremor to the right hand. In addition to that, my mother was taking a lot of pain medications. I know that my mother had been medicated for pain on that day, how could she be safe to smoke unsupervised. My mother needed to be wheeled by the staff. My mother usually was taken out to smoke two times a day for 10 minutes. The resident's son stated, "We believe that these residents because of their age, should not be allowed to smoke unsupervised " In an interview on 5/31/11 at 10:50 AM with the facility's Administrator and DON, reported that they were not aware if the facility had any smoking policy in the facility's Admission Packet. The Administrator stated, "I don't know if the Admission Coordinator inquires upon admission, if the residents are safe to smoke unsupervised. I know that we do ask upon admission if the resident smokes." The DON reported that the facility 's Licensed Staff are responsible for completing a Smoking Assessment for those residents that smoke upon admission to the facility and on a quarterly basis. The DON stated, "We do not have a written policy & procedure for the Smoking Assessments but I know that the Smoking Assessments are done on admission and should be done every 90 days." In an interview on 5/31/11 at 2:13 PM, the Administrator reported that he was not sure if the Admission Coordinator asked on admission if the resident was a smoker. The Administrator stated, " I really don't know if the Admission Coordinator asks any questions related to smoking. I do know that smoking if briefly mentioned in the Handbook that is provided to the residents on Admission." In an interview on 6/01/11 at 10:00 AM, Admission Coordinator reported that he had admitted resident #1. The Admission Coordinator stated, "I remember that the resident's husband signed all of the admission paperwork. I only ask upon admission if the resident smokes or drinks alcohol. I informed them that they are not allowed to keep alcohol in their rooms. The only information I provide on smoking is the resident's Handbook that is given to the family member or the resident upon admission. That is the extent of what I tell them on admission. I do remember that resident #1 was not smoking upon admission to the facility. I noted that she did not look as alert as other times when she has been a resident here on previous occasions. You know how the hospitals drug you up and then they come here to us to dry out." Record review of the Resident's Handbook provided by the Administrator documented in part: Smoking Policy-No smoking by employees, residents, or visitors except in designated areas. Visitors must check in with the Charge Nurse before leaving smoking material for residents. Visitors may smoke only in designated areas. No smoking in resident's rooms. In an interview on 5/31/11 at 12:51 PM, LVN #F reported that resident #1 was alert and oriented to person, place and time. The resident required total assistance with Activities of Daily Living. The resident was incontinent of bowel/bladder and used disposable briefs. The resident had a fractured right humerus and right radius. The resident had an Ace wrap on her right arm and kept it on a cloth sling. LVN #F stated, "I think that her dominant hand was the right. The resident kept her cigarettes and lighter in her fanny pack that she kept around her waist. The resident sat in a wheelchair and was wheeled by staff. The resident was able to light her cigarette by using her lighter. The resident would bring her head down to the middle of the chest to light the cigarette because she had her right arm in a sling and had very limited movement to the right arm. The resident complained of pain to the right arm and was medicated as needed. I have never seen a smoking apron or cigarette holder in the facility. I'm not sure of the facility's policy and procedure on completing the Smoking Assessments. I 'm not sure how often the Smoking Assessments are updated. I am not aware if the facility has a Smoking Policy. The residents that are smokers, smoke outside unsupervised. I also know that the residents keep their cigarettes and lighters in their rooms." In an interview on 6/02/11 at 9:28 AM, the Occupational Therapist reported that she had only seen resident #1 once for the initial evaluation on 5/16/11. The therapist reported that resident #1 was not a surgical candidate and was being treated conservatively which meant the resident's fractures would heal without surgery. The Therapist stated, "On 5/16/11 resident #1 could not do active range of motion to the right upper arm. The resident did not have a tremor to the right hand. She did have limited range of motion to the right hand because she had a fracture above the wrist and this caused decrease movement to the right hand. The resident was having pain which was more than moderate. The resident's right arm was in a cloth sling at 90 degrees. The resident was cognitive and oriented to person and place." In an interview on 6/02/11 at 9:37 AM, COTA (Certified Occupational Therapist Assistant) reported resident #1 had very limited shoulder flexion to the right shoulder. The elbow flexion to the right elbow was within functional limits. Resident had pain to right wrist with passive range of motion, pain to fingers and had weak grasp to the right hand. The resident had an Ace wrap from the wrist to the triceps (forearm and arm) and had a sling to the right arm that was removed in therapy for passive range of motion. The resident's right forearm was swollen. The COTA stated, "resident was alert, able to answer questions, was able to verbalize needs but she looked like if she was out of it. The resident was unmotivated." In an interview on 6/02/11 at 12:00 Noon, Social Worker #H reported resident #1 was alert and oriented. Resident was able to readily respond to questions. Resident complained of pain to the right wrist with movement. Record review of Prior Level of Function Assessment for New Admissions dated 5/13/11 for resident #1 documented resident was hospitalized for [REDACTED]. Resident was living at home with spouse. History of falls with generalized weakness. Pre-Admission & Admission Acuity documented Pre-Admission Acuity-Basic Hygiene/Bathing/ Skin Care: Complete Assist, Nutrition/Feeding: Partial Assist, Elimination: Partial Assist, Mobility: Self, Behavior/Orientation: Alert/Oriented/Responsive. Admission Acuity documented-Basic Hygiene/Bathing/Skin Care: Complete Assist, Nutrition/Feeding: Complete Assist, Elimination: Incontinent/Foley, Mobility: Two Person Assist, Behavior/Orientation: Alert/Oriented/Responsive. Record review on 5/31/11 at 4:56 PM DON confirmed that the History & Physical dated 5/26/11 for resident #1 documented [DIAGNOSES REDACTED].#1 was never confused. The resident's attending physician says that we all have some Dementia." The DON reported that the MDS dated [DATE] did not show resident #1 used Tobacco because she did not start smoking until 5/16/11. Record review Admission physician's orders [REDACTED]. Record review on 5/31/11 at 4:46 PM DON confirmed that Pain Evaluation completed by ADON #A for resident #1 was undated. Fractured humerus and radius. Resident verbalizes pain. Onset of pain 4/27/11. Pain is increased with movement to the RUE (right upper extremity). Type of pain: Internal/Acute to right lower and upper arm. The Pain Evaluation documented resident was not moving her right upper extremity. Pain medication-Vicodin. Inability to perform ADLs (activities of daily living). Record review of the Individual Patient ' s Narcotic Record for resident #1 documented resident was medicated for pain with Hydrocodone-Acetaminophen 5-325 one tablet by mouth at 5:58 AM on 5/28/11. Record review of the Medication Administration Record dated May 2011 for resident #1 documented on 5/28/11 at 5:58 AM resident #1 was medicated for pain with Vicodin 5/325 mg one tablet by mouth every four hours as needed for pain. Followed Up: at 6:24 AM. Effectiveness: with good effect. Record review of the Admission Nursing assessment dated [DATE] for resident #1 documented in part: resident oriented, comprehension: Quick, Personal Habits: Smokes No. Record review with DON on 5/31/11 at 5:00 PM, revealed Smoking assessment dated [DATE] for resident #1 documented resident was not a smoker upon admit. Record review with DON on 5/31/11 at 5:00 PM revealed a Smoking assessment dated [DATE] for resident #1 completed by LVN #F. The DON confirmed that the smoking assessment was incomplete and did not document if the resident needed a smoking apron or a cigarette holder. Record review on 5/31/11 at 5:00 PM with the DON confirmed there was a Care Plan dated 5/13/11 for resident #1 that documented Potential for injury, resident is a smoker. The DON confirmed that the approaches listed on the care plan were undated. Record review on 5/31/11 with MDS Nurse #P revealed that the admission MDS dated [DATE] for resident #1 documented in part: Assessment Reference Date 5/20/11. Resident understood, able to express ideas and wants. Clear comprehension. Activities of Daily Living (ADLs): Requires extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. One person assistance required for ADLs. Total assistance for locomotion on and off unit. Limited assistance with eating. Current Tobacco use-No. In an interview on 6/01/11 at 9:10 AM Director of Nurses confirmed that the MDS dated [DATE] for resident #1 documented no Tobacco use. The DON stated, "The Assessment Reference date on the MDS was 5/20/11. Maybe when they talked to the resident at that time, the resident was not smoking yet." Nurses Notes written Registered Nurse (RN) #I documented in part: 5/28/11 at 9:59 AM "This nurse was paged overhead to lobby area immediately was made aware by front desk receptionist that resident #1 was on fire. Once in lobby was directed to the side patio where resident #1 was sitting up in a wheelchair near the side door entrance with her back to the door. 400 hall Charge Nurse LVN #C was standing in front of her at which point he reported that the resident #1 in flames to her upper body and that he ran outside to put them out. On initial observation resident #1 was noted to be draped with a burned blue T-shirt both upper extremities exposed, arm sling and ace bandage noted to right arm, immediate skin assessment revealed her hair was burned to the lift side of head, redness to left side of face and chin, yellowish skin to chest and abdomen, reddened pealing skin noted to entire left upper extremity, there was also a large circular burn noted to the front of her incontinent brief which was exposed near her lower abdomen. No injury noted to pubic area or both lower extremities. Resident was awake with steady eye contact, upper dentures coming halfway out of her mouth, calm. Resident alert and oriented x 3. but when asked how flames started she stated, "I don't know." Record review of the Nurses Notes dated 5/28/11 at 11:15 AM, written by LVN #J documented, " Notified by CNA #D from traditional (Traditional Unit) that resident #1 was smoking outside and her shirt caught fire. Rushed to resident already inside in front lobby, supervisor RN #I onsite calling EMS, fire had been put out by CNA #D and LVN #C. Resident alert and oriented x 3, answering questions and asking for her cigarettes. Resident had redness and burns to left side of face, arm, burns to her chest area, redness to left side of face. EMS arrived at 11:15 and transported resident to county hospital. " Record review of the Nurses Notes dated 5/28/11 documented, "12:00 Late Entry: resident #1 was assisted by CNA #B to front patio area to smoke prior to event. CNA #B reported that he left the resident in the front patio and told her he would return to get her. CNA #B went to lobby bathroom and returned outside when he came out of the bathroom seeing multiple staff members running outside. Resident permitted to smoke alone prior to event secondary to being alert and oriented status." Observation on 5/30/11 at 10:46 AM revealed there was an ash tray outside in the front of the facility by the side exit door in the main lobby area. It was observed that the ash tray was not visible from the reception area in the main entrance of the facility. There were two metal ashtray towers in the shaded area in front of the facility. Observation on 5/30/11 at 10:54 AM in the patio area by exit #6 revealed there were several cigarette butts on the ground. There were two steel trash cans with ashtray tops. The ashtrays did not have sand in them. It was observed that the trash cans were full of trash. There was approximately 1/2 of an inch between the ashtray and the trash in the trash cans. Observation on 5/31/11 at 11:10 AM in the patio area by exit #6 revealed there was a paper towel, an empty cigarette pack and several cigarette butts in one of the trash cans with an ashtray top. RESIDENT #2: Record review revealed Admission Record documented resident #2 was admitted to the facility on [DATE]. History & Physical dated 12/03/09 documented resident #2 was an [AGE] year old male with [DIAGNOSES REDACTED]. Resident alert and oriented x 3. In an interview on 5/30/11 at 3:11 PM, resident #2 revealed resident was alert and oriented to person, place and time. It was observed, that there was an open packet of cigarettes and 2 lighters in a small plastic opened container on top of the residents dresser. Record review on 5/30/11 revealed a Smoking Assessment was completed on resident #2 on 5/28/11. There were no other Smoking Assessments in the resident's clinical record. Record review on 5/30/11 revealed that the Smoking Care Plan for resident #2 was dated 3/16/11. Record review on 6/01/11 at 4:19 PM, with Medical Record Clerk revealed that the facility did not have any Smoking Assessments in the thinned record for resident #2. No other information was brought forth during the investigation process. RESIDENT #4: Record review revealed Admission Record documented resident #4 was admitted to the facility on [DATE]. History & Physical dated 5/10/11 documented resident was an [AGE] year old male with [DIAGNOSES REDACTED]. Record review on 5/30/11 at 12:31 PM revealed Smoking Assessment for resident #4 dated 5/28/11. Record review on 5/30/11 revealed that the Smoking Care Plan was dated 5/14/11. In an interview on 5/30/11 LVN #M reported that resident #4 smoked every now and then. LVN #M stated, "This is the Alzheimer's Unit and the residents are confused. The staff will take the residents out to smoke and will always stay with the residents while the residents are smoking. We keep the cigarettes and lighter at the nurses station on this unit." Record review with Medical Records Clerk on 6/01/11 at 5:07 PM revealed that the facility did not have any Smoking Assessments in the thinned record for resident #4. No other information was brought forth during the investigation process. In an interview on 6/01/11 at 5:09 PM, revealed resident #4 was alert and oriented to person. Resident #4 reported that he occasionally went out to smoke in the patio if the weather permitted. Evidence continued under F9999