Every finding on record at Ashford Gardens

Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (CR #1) reviewed for pain management.The facility failed to address CR #1's pain to her left side on 7/31/26 in a timely manner.This failure could place residents at risk of untreated pain, decreased quality of life, and hospitalization.Findings included: Record review of CR #1's admission record dated 8/4/26 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included unspecified fracture of right acetabulum (pelvis), unsteadiness on feet, other abnormalities of gait and mobility other lack of coordination, weakness, and pain. She was discharged to an acute care hospital on 8/1/26.Record review of CR #1's 5-day MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADLs. In the last 5 days she received prn pain medication or was offered and declined it. She had pain or was hurting occasionally. The pain rarely or did not at all make it hard for her to sleep at night or limited her participation in rehabilitation therapy sessions. Her pain intensity was 2 out of 10. Record review of CR #1's care plan revised on 8/4/26 revealed she had an actual fall and remained at risk for falls related to generalized weakness and a history of falls prior to admission. 7/30/26 unwitnessed fall with no injuries noted, 7/31/26 delayed injury noted - fx left femur (bone in the upper leg). Her care plan had a focus of Pain management (Gabapentin). Interventions were to assess for pain at frequent routine intervals and before/after specific activities. If unable to self-report pain, discuss pain management history with family/caregiver, observe for behaviors that may indicate pain, review clinical condition for contributory factors, and review any psychological factors that may play a role in pain management. She was admitted with a fracture noted to the right hip related to unconfirmed/unwitnessed fall at home, date initiated 7/30/26. Interventions were to monitor/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain. She had an alteration in musculoskeletal status as evidenced by a fracture to the left femur, dated 7/31/26. Interventions were to give analgesics (pain reliever) as ordered by the MD. Monitor and document for side effects and effectiveness.Record review of CR #1's nursing note dated 7/30/26 at 9:51 p.m. written by LVN E revealed, .Writer was alerted by staff that resident was on the floor. Upon entering the room resident was sitting on the floor on the left side of the bed. Writer assessed the resident for any injuries. Resident was able to verbalize that she was without any pain. Writer performed ROM assisted resident off the floor along with staff. Writer then started neuro checks (series of observations and tests used to evaluate how well the nervous system is functioning), informed the DON, on call MD and RP.Record review of CR #1's Post Fall Observation dated 7/30/26 revealed, .Assessment date: 7/30/26 2p -10p shift.Pain level: 0.Does the resident or caregiver report a change in pain level? No.3. Is the resident satisfied with current pain control regimen? Yes.Record review of CR #1's Post Fall Observation dated 7/30/26 revealed, .Assessment date: 7/30/26 10p - 6a shift. Pain level: 0.Does the resident or caregiver report a change in pain level? No.3. Is the resident satisfied with current pain control regimen? Yes.Record review of CR #1's nursing note dated 7/31/26 at 8:16 a.m. by Treatment Nurse revealed, .Upon admission, resident seen by wound care for initial skin assessment. Upon assessment, resident noted with stage 2 pressure injury to sacrum (the part of the spinal column that is directly connected with or forms a part of the pelvis and in humans consists of five fused vertebrae) .resident denies pain to area but reports L hip and stomach pain, charge nurse aware.Record review of CR #1's OT Evaluation and Plan of Treatment dated 7/31/26 revealed, .Pain assessment, patient verbalized pain level. Pain at rest = 2/10; frequency = constant, location: RLE; pain description/type: aching. Pain with movement = 3/10; frequency = constant; Location = RLE; pain description/type: aching.Record review of CR #1's PT Evaluation and Plan of Treatment dated 7/31/26 at 2:10 p.m. EDT revealed, .pain assessment.pain level determined based upon behaviors exhibited by patient.pt reports pain in both R hip and also L knee and somewhat in L hip as well, LLE pain is related to fall last night, reports pain in L knee is the worst, nurse notified of all findings regarding LLE and family concerns related to fall and possible injury to this leg.Record review of CR #1's Post Fall Observation dated 7/30/26 revealed, .Assessment date 7/31/26 6a - 2p shift. Pain level: 0.Does the resident or caregiver report a change in pain level? No.3. Is the resident satisfied with current pain control regimen? No. Signed by LVN A on 8/4/26.Record review of CR #1's MD orders revealed an order for Acetaminophen 325 mg give 2 tablets by mouth every 8 hours as needed for general discomfort related to pain, order date 7/31/26 at 2:54 p.m. There were no orders for pain prior to this date and time. There was an order for Gabapentin 300 mg give 1 capsule three times a day for polyneuropathy (nerve disease caused by damage to many nerves), order date 7/30/26. Record review of CR #1's MAR revealed Acetaminophen was documented as administered on 7/31/26 at 6:00 p.m. by LVN E.Record review of CR #1's nursing note dated 7/31/26 at 7:00 p.m. by LVN E revealed, .writer was alerted by family member that resident continue to half (sic) pain on her left side. Writer asked family member where the pain was located. Resident first stated to family member that the pain was in her knee. Family member asked was the resident going to have an x-ray. Writer informs the family that she will contact the doctor to get an x-ray and give pain medication to help with the pain. Writer administered acetaminophen 325mg 2 tab and received an order to stat X-rays. DON and RP were notified.Record review of CR #1's nursing note dated 7/31/26 at 7:33 p.m. revealed, .The Change In Condition/s reported on this CIC Evaluation are/were: New or Worsening Pain. Recommendations: MD order x-ray stat.Record review of CR #1's nursing note dated 7/31/26 at 10:30 p.m. by RN C revealed , .STAT x-Rays results received for Left femur. Conclusion: Fracture of the proximal (situate close to) left femur. Results reported to On call services for (MD) . Received new order to transfer resident to ER Hospital for evaluation and treatment .Record review of CR #1's nursing note dated 7/31/26 at 11:30 p.m. by RN C revealed, .Resident left the facility awake and alert, no c/o pain at this time.Record review of CR #1's Post Fall Observation dated 7/30/26 revealed, .Assessment date 7/31/26 2 p - 10p shift. Pain level: 5.Does the resident or caregiver report a change in pain level? No.3. Is the resident satisfied with current pain control regimen? No. Signed by LVN E on 8/1/26.In an interview on 8/4/26 at 12:42 p.m. Treatment Nurse said she conducted CR #1's initial skin assessment on 7/31/26 around 8:16 a.m. She said the resident had stomach pain and when she turned the resident to check her back the resident said, ehh my (left) hip and grimaced. Treatment Nurse asked the resident where the pain was, and the resident pointed to the area (left hip). Treatment Nurse said she tried to obtain a number on the pain scale but was unable to get a straight answer from the resident. She said she repositioned the resident and asked her multiple times if she was comfortable, which she was. She said she probably reported everything including the left hip pain to the resident's charge nurse LVN A. She could not recall what LVN A responded to her with. She said at the time of the skin assessment she was not aware the resident had fallen at the facility. In an interview on 8/4/26 at 1:07 p.m. LVN A said CR #1 had a fall on the shift prior to hers. LVN A said she completed neuro checks and vitals that morning (7/31/26) and the resident was not in pain at that time. She said the treatment nurse reported to her between 9:00 a.m. and 10:00 a.m. that CR #1 was in pain but did not say where. LVN A assessed the resident approximately 20-30 minutes later and the resident said there was no pain. The therapist informed her the resident started therapy with no pain but now had pain in her left hip. She said after CR #1's afternoon therapy session, the family notified her of pain in the left knee (pain level of 4 or 5 out of 10) and she contacted the MD around 2 p.m. - 2:30 p.m. for pain medication. She said post fall monitoring included monitoring for pain. She said she reported to the next nurse that pain medication was given to the resident (when the order was received at 2:54 p.m.) and to follow up with her pain.In an interview on 8/4/26 at 2:10 p.m. CNA G said she worked with CR #1 on the evening she fell (7/30/26). She said the resident complained of hip pain (unsure of the side) prior to the fall. After the fall she did not complain of any additional pain, but the same pain that she had before.In an interview on 8/4/26 at 2:35 p.m. Director of Rehabilitation said he conducted occupational therapy with CR #1 on 7/31/26 around 10 a.m. He said she needed maximum assistance with getting out of bed and into the wheelchair. She complained of pain and was in pain at the beginning of the session, but he did not force her to get up. He could not remember where the pain was located. He said the resident did not grimace or express excruciating pain. He said he spoke to the nurse to inform her of what was going on and believed the nurse gave the resident something for pain right before lunch. In an interview on 8/4/26 at 2:53 p.m. DON said an in-service was conducted with staff on pain management (on 8/1/26) because the nurses should notify the MD if pain was not managed or if there was breakthrough pain. In an interview on 8/4/26 at 3:02 p.m. PT said she conducted a physical therapy evaluation on CR #1 (on 7/31/26). She reviewed her chart prior to the evaluation, and determined it was ok to proceed with the session. During the evaluation the resident complained of pain on the left and right side. Throughout the session the resident reported pain in the left knee and thigh area and did not want to extend her knee. She said the resident verbalized the pain by saying dolor (which meant pain in Spanish) and pointed to the area. She said sometimes the resident reports were not very accurate due to her dementia, but PT was concerned because the resident required more assistance and experienced more pain. PT said the resident did not resist getting up but the ROM provoked the pain. PT assisted the resident to the commode and noticed the transfer was harder than indicated in the hospital therapy documentation and she required maximum assistance. She said that was her first clue that something was not right. She reported to the nurse LVN A, that she was really concerned about the resident's pain and weight bearing status and did not recommend continuing therapy until imaging was available. She said LVN A was responsive and would notify the MD. In an interview on 8/4/26 at 3:15 p.m. LVN E said CR #1 did not have pain on admission and she did not have to administer any pain medication on the day of admission. She said CR #1 fell at the facility around 8:45 p.m. (on 7/30/26). LVN E conducted range of motion assessment of both arms and legs and the resident was not in pain. She assisted the resident to bed, started neuro checks, and notified the on-call MD, DON, and RP. She said she returned to the facility on 7/31/26 for her 2 p.m. - 10 p.m. shift and the resident was resting at the start of her shift, and she was not alerted of any pain from the previous nurse. She said around 5:30 p.m. CR #1's family reported the resident was in pain on the left side. She administered Tylenol and obtained a stat order for x-rays. She said when she left her shift the resident was comfortable and the Tylenol was effective. In an observation and interview on 8/4/26 at 5:00 p.m. of CR #1 in the local hospital bed. She said she was hurting a lot right now and pointed to her left side. She said she fell out the bed at the facility. She said after the fall staff told her she did not have any problems and did not give her medicine. CR #1 was unable to answer questions in detail due to her being confused. In an interview on 8/4/26 at 5:07 p.m. CR #1's Family Member A said the resident broke her bone on the left side at the facility. She said the resident arrived at the hospital on Friday night (7/31/26) and had surgery to put screws in Saturday morning (8/1/26). In an interview on 8/4/26 at 5:25 p.m. CR #1's Family Member B said she arrived at the facility on 7/31/26 around 9:00 a.m. - 9:30 a.m. and CR #1 was sleepy and lying down. Around 10:00 - 10:30 a.m. she notified a staff member (unknown) that the resident was in a lot of pain, did not want to eat and requested pain medication. She said when PT arrived, she tried to sit the resident on the chair but CR #1 was concerned about pain. CR #1 also did not place a lot of weight/help on her feet and peed on the floor due to pain. She could help with steps before, but when she saw PT CR #1 needed help with sitting so she knew something was wrong. CR #1's Family Member B asked for medicine one more time and staff administered her Gabapentin around 12:30 p.m. which did not help.In an interview on 8/4/26 at 5:46 p.m. CR #1's Family Member C said she arrived at the facility on 7/31/26 between 9:00 a.m. - 9:30 a.m. and CR #1 was asleep. Family woke her up and the resident said she fell last night and was in pain. She said she asked a nurse (unknown) for pain medication around 10:00 a.m. and said that the resident was in pain, her stomach was unsteady and she had not eaten. During physical therapy CR #1 did not help with standing and could not do much which concerned CR #1's Family Member C. She said staff gave the resident Gabapentin for pain a little after therapy around 12:30 p.m. Later in the afternoon, she reported that CR #1 still had a lot of pain, and the staff responded that they would notify the MD.In an interview on 8/5/26 at 10:48 a.m. MA F said on 7/31/26 she administered CR #1's morning medication, and the resident did not say she was in pain and did not display any facial signs of pain. She said between 11:45 a.m. - 12:30 p.m. CR #1's family member approached her and was looking for the nurse because the resident was in pain but did not say where. She said that was the first time the resident expressed pain. MA F said she looked at the resident's MAR and saw she had Gabapentin and administered it. She said Gabapentin was used for nerve pain, but she was unsure what kind of pain the resident had. She said the normal process was to report the pain to the nurse because medication aides could not assess for pain. She said the nurse would have given prn pain medication and assessed for effectiveness. She said this situation was different because CR #1 was new and she just checked the MAR to see if any medication needed to be given.In an interview on 8/5/26 at 11:05 a.m. CNA L said she worked with CR #1 on the morning of 7/31/26 but the resident did not complain about hip pain to her. In an interview on 8/5/26 at 11:18 a.m. LVN A said on 7/31/26 CR #1's family did not mention pain to her throughout the day. Treatment Nurse informed her that CR #1's left side was hurting more than her right and mentioned that the resident had stomach pain but did not say the resident had hip pain. LVN A said after she was informed by Treatment Nurse she asked the resident if she wanted something for her stomach but did not ask her if she was hurting anywhere else. She said Director of Rehabilitation did not report CR #1's pain to her. The morning medication aide (MA F) did not report CR #1's concerns of pain to her. PT alerted her about CR #1's pain toward the end of her shift around 2 p.m. and she notified the MD and she watched MA G administer Tylenol to the resident (when the medication was ordered around 2:54 p.m.). She said if the staff reported the pain earlier, she would have notified the MD and conducted a pain assessment at that time.In an interview on 8/5/26 at 11:44 a.m. PT said she conducted the physical therapy evaluation with CR #1 between 12:30 p.m. - 12:45 p.m. on Friday 7/31/26 and the session lasted about 45 minutes - 1 hr. She notified LVN A about the pain around 1:30 p.m. - 2 p.m.In an interview on 8/5/26 at 12:35 p.m. DON said if staff were notified about pain, they should immediately report it to the charge nurse so the nurse could immediately assess the patient and initiate interventions to reduce the level of pain. She said if the pain was not reported, the patient would have pain. She said CR #1 did not complain of pain on the day of the fall.In an interview on 8/5/26 at 2:17 p.m. Administrator said she expected nursing staff to follow the policy and procedure on pain management. She said staff should notify the nurse if a patient complained of pain. If medication was not available, staff should immediately call the MD for pain. In an interview on 8/5/26 at 3:40 p.m. Social Services said she conducted a social services assessment with CR #1 on 7/31/26 but did not recall the resident, and did not recall any resident being in pain. She said if someone complained of pain she would report it to the nurse. Record review of the facility's Pain Management policy dated 12/1/25 revealed in part, .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain). c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: a. Change in gait (e.g. limping), skin color, vital signs (e.g. increased heart rate, respirations, and/or blood pressure), perspiration. b. Loss of function or inability to perform activities of daily living (ADLs) (e.g. rubbing a specific location of the body, or guarding a limb or other body parts). f. Difficulty eating or loss of appetite.

Based on 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 1 of 5 residents (CR #1) reviewed for pharmacy services.LVN A failed to document administration of CR #1's Acetaminophen on 7/31/26.The facility failed to ensure CR #1 received Acetaminophen at the frequency indicated by the MD on 7/31/26. CR #1 received two doses of Acetaminophen in a 3-hour time span, instead of every 8 hours as indicated by the MD order. This failure could place residents at risk of overdose and hospitalization.Findings included: Record review of CR #1's admission record dated 8/4/26 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included unspecified fracture of right acetabulum (pelvis), unsteadiness on feet, other abnormalities of gait and mobility other lack of coordination, weakness, and pain. She was discharged to an acute care hospital on 8/1/26.Record review of CR #1's 5-day MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADLs. In the last 5 days she received prn pain medication or was offered and declined it. She had pain or was hurting occasionally. The pain rarely or did not at all make it hard for her to sleep at night or limited her participation in rehabilitation therapy sessions. Her pain intensity was 2 out of 10. Record review of CR #1's care plan revised on 8/4/26 revealed she had an alteration in musculoskeletal status as evidenced by a fracture to the left femur ((bone in the upper leg), dated 7/31/26. Interventions were to give analgesics (pain reliever) as ordered by the MD. Monitor and document for side effects and effectiveness.Record review of CR #1's MD orders revealed an order for Acetaminophen 325 mg give 2 tablets by mouth every 8 hours as needed for general discomfort related to pain, order date 7/31/26 at 2:54 p.m. Record review of CR #1's MAR revealed prn Acetaminophen was documented as administered on 7/31/26 at 6:00 p.m. by LVN E. There were no other entries to indicate Acetaminophen was administered at any other time.Record review of CR #1's nursing note dated 7/31/26 at 7:00 p.m. by LVN E revealed, .writer was alerted by family member that resident continue to half (sic) pain on her left side. Writer asked family member where the pain was located. Resident first stated to family member that the pain was in her knee. Family member asked was the resident going to have an x-ray. Writer informs the family that she will contact the doctor to get an x-ray and give pain medication to help with the pain. Writer administered acetaminophen 325mg 2 tab and received an order to stat X-rays. DON and RP were notified.In an interview on 8/4/26 at 3:15 p.m. LVN E said she arrived to the facility on 7/31/26 for her 2 p.m. - 10 p.m. shift and the resident was resting at the start of her shift, and she was not alerted of any pain from the previous nurse. She said around 5:30 p.m. CR #1's family reported the resident was in pain on the left side. She administered Tylenol and obtained a stat order for x-rays. She said when she left her shift the resident was comfortable and the Tylenol was effective. In an interview on 8/5/26 at 11:18 a.m. LVN A said on 7/31/26 she notified CR #1's MD about her pain near the end of her shift around 2 p.m. The MD responded with an order for Tylenol 325 mg 2 tablets. She said the medication aide from 2 p.m. - 10 p.m. shift administered the Tylenol to CR #1 (when the mediation was ordered around 2:54 p.m.), and she watched her administer it. In an interview on 8/5/26 at 12:35 p.m. DON said prn medication was administered by the nurses which was the protocol at the facility. The administration should be documented electronically on the MAR which is the medical record or in the progress note. She said it should be documented in the MAR to ensure the administration reflects when something was given. She said if someone else gave an earlier dose to CR #1 it could be a medication error which could result in an adverse reaction. She said that was the incorrect process if that occurred. She said all prn medications were given by the nurses so the follow up could be completed. She said the 2-10 p.m. nurse should have received the report and followed up on the prn medication.In an interview on 8/5/26 at 1:08 p.m. LVN E said she did not see any documentation that Tylenol was administered to CR #1 7/31/26. She said the documentation would have been indicated on the MAR. She said LVN A did not tell her she administered Tylenol to CR #1.In an interview on 8/5/26 at 1:30 p.m. MA G said she arrived to the facility on the 2nd day of CR #1's admission [DATE]). When she arrived at 2 p.m. CR #1's family said the resident was complaining of pain. She said LVN A called the MD to get an order because she did not have anything for the resident. She said about 30 minutes later the MD approved an order for prn Tylenol and LVN A asked the medication aide to administer the Tylenol to CR #1. She said LVN A was present with her at the time of administration. MA G said she could not document the administration and the nurse normally administered prn medication. She said LVN A informed her that she would document the administration.In an interview on 8/5/26 at 2:05 p.m. LVN A said after the Tylenol was given to CR #1 she did her shift report with the oncoming nurse and left. She said the Tylenol was prn, which the nurse should give. She said she was supposed to document the administration but did not because it was missed. She said in her head she thought she documented it and then realized she did not. She said the purpose of documenting medication administration was to ensure it was done and to let others know the time the medication was given. She said the risk of not documenting was double dosing the patient. In an interview on 8/5/26 at 2:21 p.m. Administrator said staff should document medication administration as soon as the resident received the medication so that other nurses who come in know the medication has been given.Record review of the facility's Medication Administration policy revised on 12/1/25 revealed, .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. 19. Sign MAR after administered.

Based on interview and record review, the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (Resident #2, Resident #3, and Resident #4) of 5 residents reviewed for quality of care.- The facility failed to establish wound care services for Resident #2 as ordered for 7/4/26, 07/06/26, 06/29/26, and 05/21/26.- The facility failed to establish wound care services for Resident #3's as ordered for 07/11/26, 06/07/26, 06/14/26, 06/15/26, 06/23/26, 05/21/26, 05/23/26, and 05/31/26.- The facility failed to establish wound care services for Resident #4's as ordered for 6/07/26, 05/21/26, and 05/27/26.This failure could place residents at of not receiving adequate care in a timely manner, deterioration of skin, and decreased quality of life.The findings included:Resident #2Record review of Resident #2's admission Record, dated 07/15/26, revealed a [AGE] year-old female who was originally admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis (hemiplegia is paralysis of one side of the body, while hemiparesis is weakness on one side) following cerebral infarction (ischemic stroke and requiring targeted rehabilitation for recovery) affecting right dominant side, muscle weakness and other abnormalities of gait (walking pattern) and mobility.Record review of Resident #2's Modified Comprehensive MDS Assessment, dated 06/30/26, revealed a BIMS score of 6, indicating severely impaired cognitive skills. Further review revealed resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity.) on completing toileting hygiene shower/bathing, and personal hygiene. Resident #2 also was dependent on rolling left and right and chair/bed-to-chair transfer. Resident was coded 0 for unhealed pressure ulcers/injuries.Record review of Resident #2's Care Plan, undated, revealed resident was incontinent of bowel, may not have been able to complete sentences related to impaired cognitive function/impaired thought processes, had an unstageable pressure ulcer to the sacrum, and had potential/actual impairment to skin integrity of the sacrum r/t fragile skin and excess moisture related to obesity. Interventions for Resident #2's pressure ulcer included administering treatments as ordered and monitoring for effectiveness, teaching resident/family the importance of changing positions for prevention of pressure ulcers and encouraging small frequent position changes, treatment to pressure ulcer per physician's order, and to turn/reposition Q2hrs.Record review of Resident #2's physician orders revealed:-Wound Treatment - Dry Dressing every day shift, cleanse wound to sacrum with normal saline or skin cleanser, pat dry, apply TAO Santyl and calcium alginate, pack with gauze, cover with dry dressing, ordered date 05/13/26, and start date 05/14/26.-Wound Treatment - Dry Dressing every day shift, cleanse skin tear to L arm with normal saline or skin cleanser, pat dry, apply collagen, cover with dry dressing, ordered date 07/07/26 and start date 07/08/26.Record review of Resident's 2's Wound Care Treatment Administration Record, dated 05/01/26-05/31/26 revealed wound care treatment to sacrum on 05/21/26, had a chart code of 9 (other/see progress notes) documented by Nurse A.Record review of Resident's 2's Wound Care Treatment Administration Record, dated 06/01/26-06/30/26, revealed wound care treatment to sacrum on 06/29/26, had a chart code of 6 (out on pass) documented by Treatment Nurse A.Record review of Resident's 2's Wound Care Treatment Administration Record, dated 07/01/26-07/31/26, revealed wound care treatment to sacrum and R arm on 07/04/26 and 07/06/26 had a chart code of 6 (out on pass) documented; 07/04/26 was documented by Nurse B and 07/06/26 was documented by Treatment Nurse A.Record review on 07/14/26 of Resident 2's progress notes revealed no documentation that wound care treatment was or was not provided on 05/21/26 or when resident returned to the facility from pass on 06/29/26, 07/04/26, or 07/06/26.Observation and an attempted interview on 07/15/26 at 8:45 a.m., revealed Resident #2 was at the hospital. Resident was lying in bed, awake. Resident said yes when asked if she was Resident #3 but did not respond to any questions about the reason for her hospitalization or about the wound care she was receiving at the facility. Resident #3Record review of Resident #3's admission Record, dated 07/15/26, revealed a [AGE] year-old male who was originally admitted to the facility on [DATE]. His diagnoses included osteomyelitis (infection of the vertebrae typically caused by bacteria or fungi) of vertebra (bones that form the spine or backbone), sacral (triangular bone at the base of the spine), and sacrococcygeal region (tailbone area located at the very bottom of the spine), other acute osteomyelitis, left ankle and foot, pressure ulcer of sacral region, unspecified stage, muscle weakness, other abnormalities of gait and mobility, and paraplegia (form of paralysis that primarily affects the lower half of the body, unspecified.Record review of Resident #3's 5-day MDS Assessment, dated 06/13/26, revealed a BIMS score of 12, indicating intact cognitive skills. Further review revealed resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity.) on completing toileting hygiene and shower/bathing. Resident #3 was also dependent on rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer and toilet transfer. Resident was coded yes for unhealed pressure ulcers/injuries.Record review of Resident 3's Care Plan, undated, revealed resident had bowel incontinence r/t paraplegic, was resistive to care AEB continued refusal of medications, required pressure ulcer prevention, and had stage 4 pressure ulcers on sacrum, L ischium, coccyx, and an unstageable L heel that was reclassified to an arterial ulcer. Interventions for Resident #3's ulcers included administering treatments as ordered and monitoring for effectiveness, educating the resident/family/caregivers as to causes of skin breakdown, and treatment to pressure ulcer per physician's order; interventions were initiated on 09/04/25.Record review of Resident #3's physician orders revealed:-Wound Treatment - Dry Dressing, every day shift, cleanse wound to L heel with normal saline or skin cleanser, pat dry, apply collagen and calcium alginate w/silver and TAO, cover with dry dressing, ordered date 04/30/26 and start date 05/01/26.-Wound Treatment - Dry Dressing, every day shift, cleanse wound to sacrococcyx with normal saline or skin cleanser, pat dry, apply calcium alginate with silver, collagen and TAO, cover with dry dressing, ordered date 07/08/26 and start date 07/09/26.-Wound Treatment - Dry Dressing, every day shift, cleanse scrotum with normal saline or skin cleanser, pat dry, apply barrier cream, cover with dry dressing, ordered date 07/08/26, and start date 07/09/26.-Wound Treatment - Dry Dressing, every day shift, cleanse wound to R ischium with normal saline or skin cleanser, pat dry, apply TAO, collagen and calcium alginate w/ silver, cover with dry dressing, ordered date 04/30/26, and start date 05/01/26.-Wound Treatment - Dry Dressing, every day shift, cleanse wound to sacrum with NS/wound cleanser, pat dry, apply TAO, collagen and calcium alginate w/ silver, cover with protective dressing, ordered date 03/13/26, and start date 03/14/26.-Wound Treatment - Dry Dressing, every day shift, cleanse wound L ischium with NS/wound cleanser, pat dry, apply collagen and calcium alginate w/ silver, cover with protective dressing, ordered date 03/13/26, start date 03/14/26, and end date 04/30/26.-Wound Treatment - Dry Dressing, every day shift, cleanse wounds with normal saline or skin cleanser, pat dry, cover with dry dressing as needed AND as needed clean wound with ns, pat dry, cover with dry dressing, start date 07/15/26 and revised date 07/16/26.-Wound Treatment - Dry Dressing, as needed Clean wounds with ns, pat dry, cover with dry dressing as needed, ordered date 01/09/26 and start date 01/09/26.Record review of Resident's 3's Wound Care Treatment Administration Record, dated 05/01/26-05/31/26, revealed wound care treatment to L ischium, L heel, R ischium, and sacrum, on 05/21/26 and 05/31/26, had a chart code of 6 (out on pass) documented by Nurse A. On 5/23/26, Nurse C documented code 6 for wound care treatment to resident's L ischium and sacrum.Record review of Resident's 3's Wound Care Treatment Administration Record, dated 06/01/26-06/30/26, revealed wound care treatment to L ischium, L heel, R ischium, and sacrum on 06/07/26 and 06/14/26, had a chart code of 9 (other/see progress notes) documented by Nurse A; 06/15/26 had a chart code of 9 documented by Nurse D; and 06/23/26 had a chart code of 9 documented by Treatment Nurse A.Record review of Resident's 3's Wound Care Treatment Administration Record, dated 07/01/26-07/31/26, revealed wound care treatment to L ischium, scrotum, L heel, R ischium, sacrococcyx, and sacrum had a chart code of 6 (out on pass) documented on 07/11/26 by Nurse B.Record review on 07/16/26 of Resident 3's progress notes revealed no documentation that wound care treatment was or was not provided on 05/21/26, 05/23/26, 05/31/26, and 07/11/26 when resident returned from pass or on 06/07/26, 06/14/26, 06/15/26, and 06/23/26.Record review of Resident #3's wound care visit notes, dated 05/20/26 and 07/15/2026, revealed no deterioration of wounds.Observation and interview on 07/15/26 at 4:33 p.m. revealed resident was in his room sitting in his wheelchair. He said he has wounds that he receives wound care treatment from the facility's treatment nurse and said the wound care doctor sees him once a week. He said his wounds were getting better and did not have any concerns about his treatment. Resident #4Record review of resident #4's admission Record, dated 07/15/26, revealed a [AGE] year-old female who was originally admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis (hemiplegia is paralysis of one side of the body, while hemiparesis is weakness on one side) following cerebral infarction (ischemic stroke and requiring targeted rehabilitation for recovery) affecting right dominant side, muscle weakness, and type 2 diabetes mellitus without complications (condition where the body is resistant to insulin, leading to elevated blood sugar levels, but no serious health problems have developed yet), other abnormalities of gait and mobility.Record review of Resident #4's Quarterly MDS Assessment, dated 05/23/26, revealed a BIMS was not conducted and coded 0 as resident was rarely/never understood. Further review revealed resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity.) on completing toileting hygiene, shower/bathing, and personal hygiene. Resident #4 was also dependent on rolling left and right, and chair/bed-to-chair transfer. Resident was coded yes for unhealed pressure ulcers/injuries and unstageable - deep tissue injury.Record review of Resident #4's Care Plan, undated, revealed resident was incontinent of bladder and bowel, had a stage 4 pressure ulcer to sacrum, and potential/actual impairment to skin r/t fragile skin, and a non- pressure wound to R heel. Interventions for Resident #4's pressure ulcer included administering treatments as ordered and monitoring for effectiveness, teaching resident/family the importance of changing positions for prevention of pressure ulcers and encouraging small frequent position changes, and treatment to pressure ulcer per physician's order.Record review of Resident #4's physician orders revealed:-Wound Treatment - Dry Dressing, every day shift, cleanse wound to sacrum with normal saline or skin cleanser, pat dry, apply barrier cream to peri wound, apply collagen and calcium alginate, cover with dry dressing, ordered date 03/31/26 and start date 04/01/26.-Wound Treatment - Dry Dressing, as needed for clean wound with ns, pat dry, cover with dry dressing as needed, ordered date 07/15/26, and start date 07/15/26.- Wound Treatment - Dry Dressing, every day shift, cleanse wound to R heel with normal saline or skin cleanser, pat dry, apply betadine Santyl and calcium alginate, cover with dry dressing, ordered date 05/07/26, and start date 05/08/26.Record review of Resident's 4's Wound Care Treatment Administration Record, dated 05/01/26-05/31/26 revealed wound care treatment to sacrum and R heel had a chart code of 9 (other/see progress notes) documented on 05/21/26 by Nurse A and code 6 (out on pass) documented on 05/27/26 by Treatment Nurse A.Record review of Resident's 4's Wound Care Treatment Administration Record, dated 06/01/26-06/30/26, revealed wound care treatment to sacrum and R heel had a chart code of 9 (other/see progress notes) documented on 06/07/26 by Nurse A.Record review of Resident 4's Progress Notes on 07/16/26, dated 05/27/26 at 8:54 a.m. by Nurse E, revealed resident was out to doctor's appointment. No documentation found of wound care treatment being administered after resident returned from appointment on 05/27/26. No documentation found that resident received treatment on 05/21/26 or 06/07/26.Record review of Resident #4's wound care visit notes, dated 07/01/26 and 07/15/2026, revealed no deterioration of wounds.Observation and an attempted interview on 07/15/26 at 4:38 p.m. revealed Resident #4 was lying in bed with her eyes closed, appeared to be asleep, and did not open eyes when greeted.During an interview on 07/15/26 at 12:26 p.m., Treatment Nurse A said she did not complete wound care for Resident #2 on 06/29/26 and 07/06/26 and coded Wound Care Treatment Administration Record code 6 because resident went to dialysis and she was gone when the resident returned to the facility.During an interview on 07/15/26 at 2:20 p.m., Nurse F said she was not told on 07/06/26 that Resident #2 needed wound care treatment completed when she returned from dialysis. She said she provided wound care treatment to the resident on 07/06/26 after she returned because she was in need of a brief change and was notified by a CNA. She said she should have documented that wound care was completed but she was not aware wound care needed to be completed. She said if it is not documented, it was not done. She said if wound care was not completed, it could hurt the healing process, resident's comfort level, and the amount of pain the resident could be in.During a telephone interview on 07/15/26 at 3:14 p.m., Nurse B said if she coded a 6 on a resident's Wound Care Treatment Administration Record then the resident was out of the facility. She said if she could not complete wound care she would communicate it to the charge nurse on duty and believes they would document it on 24-hour report but would have to ask DON. She said on 07/04/26, she went to Resident 2's room, the bed was not made, and the charge nurse told her the resident was out of the facility. She said if wound care was not completed the wound could deteriorate.During an interview on 07/15/26 at 3:49 p.m., Nurse G said she does not recall providing wound care to Resident #2 on 6/29/26. She said usually the wound care would let the nurse know that the resident needs to have wound care. She said she was not aware the resident was missed during wound care rounds and was not informed that resident needed to have wound care completed. She said she was not notified by any CNAs that Resident #2's dressing needed to be changed on 06/29/26. She said if wound care was not completed, a resident could develop an infection, and/or the wound could worsen in size. During an interview on 07/15/26 at 4:51 p.m., the DON said the outgoing nurse (whoever is designated to do treatment for the day) was to notify the nurse who was present that the resident needs their wound care to be completed, if that nurse was not able to complete wound care by the end of their shift. She said the nurse would document in the PRN order or enter a progress note to show it was completed. She said if it was not documented, it could have very well not been completed. She said if wound care was not completed, there could be a deterioration of the wound.During a telephone interview on 07/16/26 at 11:03 a.m., Nurse A said she was a PRN Treatment Nurse and has been working at the facility for about 5 years. She said she incorrectly documented a code 9 on the Wound Care Treatment Administration Records, used a code 9 because the system would check all of a resident's wound care orders off as being completed as group instead of having to click each order off individually. She said it was just a faster way to do it and said she provided wound care.During a telephone interview on 07/16/26 at 11:23 a.m., Nurse C said if she coded Resident 3's Wound Care Treatment Administration Record a 6 on 05/23/26 then he was out on pass. She said she tries to complete wound care treatment when resident returns. She said if she was not able to complete resident's wound care by the end of her shift, she would report it to oncoming nurse. She said she thinks she notified the oncoming nurse on 05/23/26 that Resident 3's wound care needed to be done. She said if wound care was not completed, a resident's wound could deteriorate, get bigger, and/or get infected.Record review of the facility's policy, Provision of Quality Care, Date Implemented: 10/2025, revealed .Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices.Record review of the facility's policy, Documentation of Wound Treatments, Date Reviewed/Revised: 12/01/2025, revealed .The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment.Policy Explanation and Compliance Guidelines.3. Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact).

Based on interview and record review the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 5 residents (CR #1) reviewed for discharge.-The facility failed to provide CR #1 with a written discharge notice before discharging her on 7/3/26.This failure could place residents at risk of not knowing their discharge rights. Findings included: Record review of CR #1's face sheet dated 7/4/26 revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included atherosclerosis of native arteries of left leg with ulceration of calf (the buildup of fats, cholesterol and other substances in and on artery walls), neuralgia (severe, shooting pain along a nerve) and neuritis (inflammation of a nerve that can cause pain, numbness, or weakness), peripheral vascular disease (narrowed arteries that reduce blood flow to the limbs), acquired absence of other left toe, and infection of amputation stump, right lower extremity. The admission record revealed she discharged to an acute care hospital on 7/3/26.Record review of CR #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. She required assistance from staff with ADL care. Active discharge planning was not already occurring for the resident to return to the community. She did not want to talk to someone about the possibility of leaving the facility or returning to live and receive services in the community. Record review of CR #1's order summary report revealed an order for: may discharge with skilled nursing, home health services, OT/PT to evaluate and treat. DME: wheelchair. Wound care if wounds present upon discharge, order date 6/19/26.Record review of CR #1's social services note dated 7/2/26 written by the Director of Social Services read in part, .SW, Discharge Planner and Admin had a d/c meeting with Resident. SW explained that her days had been extended through the VA and the BOM explained last week, that her d/c date was 7/3. Resident stated that she didn't want to go home. SW asked if she was able to go home and resident stated yes, but she is refusing. SW asked about the PCH homes that were presented a couple of weeks ago. Resident stated that she didn't want to pay. Resident was asked about resident's ability to pay her co-pay. Resident stated that her [family member's] insurance should pay it. SW and Discharge planner asked about a d/c address so that follow up care can visit. Resident stated that she doesn't have an address. Resident asked what time was she supposed to d/c. SW explained that she doesn't have a specific time however, the Nursing team would like to be prepared. Resident stated that she will decide tomorrow.Record review of CR #1's nursing note dated 7/3/26 at 11:08 a.m. read in part, .Patient D/C via transportation from facility, paperwork and patient education on medication reconciliation effective with understanding, patient AOX4 no complaints of pain or any needs. LEFT @ 11:08.Record review of CR #1's discharge instruction form dated 7/3/26 revealed she was being discharged home with family member/caregiver. She was referred and accepted to a home health company. She was to follow up with a PCP within 7-10 days for continuation of care. She was discharged from the facility on 7/3/26 at 11:04 a.m.In an interview on 7/4/26 at 11:08 a.m. the Director of Social Services said discharge planning started upon admission. She said when CR #1 admitted to the facility she and her family member were unsure if she would be long term or discharge home. She said CR #1 wanted to stay in the facility and was unsure if she wanted to go home because she liked that the facility was taking care of her. She said the resident was discharged because there was no skillable need (a medical or therapeutic requirement that necessitates the expertise of a licensed nurse or therapist to ensure proper care, recovery, and patient safety), and the resident did not provide financial information to apply for Medicaid. She said CR #1 was able to do a lot for herself and would leave the facility at times. She said CR #1 was given other options such as a personal care home in case she did not want to go home. In an interview on 7/4/26 at 11:20 a.m. the Discharge planner said CR #1 was discharged from the facility because she stayed over her 100 days and there was no skillable need and services could be done at home per the MDS nurse and BOM. She said CR #1 knew for a while that she was discharging but there was no set date. She said the BOM would be the staff to provide the discharge notice. The Discharge planner said she ordered a wheelchair, set up home health and wound services for CR #1 and informed her of the agency names that would provide care.In an interview on 7/4/26 at 11:42 a.m. the BOM said CR #1's discharge was a facility-initiated discharge because on 6/30/26 some members of the IDT team had a meeting and made the decision that she no longer had a skilled need. She said if there was no longer a skilled need, the facility could discharge the resident to the prior level of care. She said CR #1's insurance plan covered her stay based on skilled needs and did not require that a notice of non-coverage be provided to the resident. She said she spoke with resident on 6/30/26 and gave a 48-hour notice of discharge. She said a written 30-day discharge letter was not needed if the resident had insurance and the insurance was the entity that said she had to go. She said the resident did not meet the criteria to stay in the nursing home. The BOM was responsible to issue a notice if the resident did not have a payor service. She said a 30-day discharge letter would be provided for residents with behaviors or non-payment and was unsure if the facility should have issued one to CR #1. She said she was unsure what information the discharge notice had on it. She said there was no opportunity given to CR #1 to appeal the discharge due to no written notice given to her. She said if a notice was required, the appeal option would be given. She said she had no documentation regarding the discharge of the resident.In an interview on 7/4/26 at 12:06 p.m. the Regional Director of Clinical Services said the Administrator and Social Worker would issue a 30-day written discharge notice to residents who were non-compliant. In an interview on 7/4/26 at 12:19 p.m. the DON said CR #1's insurance did not issue notice of non-coverages and there was no appeal option with her insurance. She said they provided a 48-hour notice to CR #1 and her insurance no longer covered her stay.In an interview on 7/4/26 at 1:27 p.m. the Regional Director of Clinical Services said the written discharge form was only provided when the facility initiated the discharge of the resident. He said CR #1's insurance initiated the discharge, not the facility. In an interview on 7/4/26 at 1:41 p.m. CR#1 said the facility did not provide her with a written discharge letter but gave her a paper that said she was discharged and listed her medications. She said she was discharged from the facility too soon and was not told why. She said the facility told her on Thursday (7/2/26) that her time was up and provided two places she could discharge to. She said the BOM and Social Worker informed her that her insurance stopped paying for her services, would not cover her stay, and the insurance was $52,000 in the hole. She tried to make a verbal appeal with the Social Worker and Case Worker but it was denied and the staff did not hear her situation. She said she could not find a place with such short notice and facility staff told her to just go back home and stay in her room. She said she was not informed that she was well enough to go home. She was supposed to discharge from the facility last Saturday (6/27/26) but did not due to surgery that extended her stay. She still had concerns about her foot and spoke with her MD about it. She said she still needed help with showers, toileting, and training due to her foot and prosthetic leg. She said she was safe at home with her family member.In an interview on 7/4/26 at 2:07 p.m. the Regional Director of Clinical Services said there was no definitive date on when CR #1 was to discharge. Discharge depended on her insurance and her approved days was 100. In an interview on 7/4/26 at 2:22 p.m. the BOM said she did not see a need to provide CR #1 with a written discharge notice. She said she had received training on issuing discharge letters and had worked in that position for 22 years. She said she also informed CR #1 that her insurance had not yet paid the facility and the insurance owed $52,000. She said the decision to discharge the resident had nothing to do with the outstanding amount and her discharge was due to not having a skill-able need. In an interview on 7/4/26 at 3:04 p.m. CR #1's attending MD said she spoke with the facility's Discharge Planner and based on the authorization, CR #1's discharge date was yesterday. She said CR #1 had questions about where she would discharge because she did not get along with her family member. The facility provided other options for the resident and was waiting for her to make a decision. She said she would need to review CR #1's therapy notes to see if she met her goals. She said the wound care nurse felt CR #1's wound care could be provided at home. She said once the insurance no longer covered the stay for skilled patients the facility would issue a NOMNC and the resident would have to pay privately if they did not discharge.Record review of the facility's blank Nursing Home Transfer and Discharge Notice form read in part, .This form is required for those transfers and discharges initiated by the nursing home facility, and not by the resident or by the resident's physician or legal guardian or representative . The notice included a space for the date the notice was given, effective date of transfer, location to which resident is discharged (required), name of Ombudsman notified. The notice included a section for the reason for discharge which required the form to be signed by the resident's physician if the resident's health improved sufficiently so that they no longer needed the services provided by the facility. The form also included the right to appeal the discharge and numbers to the local ombudsman.Record review of the facility's Transfer and Discharge (including AMA) policy revised 12/1/2025 read in part, .It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source.2. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions:. b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility.3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge.b. The effective date of transfer or discharge.c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .d. An explanation of the right to appeal the transfer or discharge to the State.e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests.f. Information on how to obtain an appeal form.g Information on obtaining assistance in completing and submitting the appeal hearing request.h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman.i. For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations.4. Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is effected because: b. The resident's health improves sufficiently to allow a more immediate transfer or discharge. 7. The facility will not discharge a resident based solely on resident's payment source or change in the resident's payment source. In situations where a resident's Medicare coverage may be ending, and the resident continues to need long-term care services, the facility will offer the resident the ability to remain, which may include:a. Offering the resident an option to remain in the facility by paying privately for a bed.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 1 (Resident #1) of 5 residents reviewed for quality of life.-The facility failed to ensure Resident #1's brief was changed before becoming full of urine and wetting his bed sheet.This failure could place residents at risk of skin breakdown.The findings included:Record review of Resident #1's admission Record, dated 05/27/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included acute cystitis without hematuria (bladder infection without blood in the urine), deficiency of other vitamins, pain, and quadriplegia, C5-C7 incomplete (spinal cord injury resulting in partial loss of motor function and sensation in all four limbs).Record review of Resident #1's MDS Assessment, dated 05/22/26, revealed a BIMS score of 15, indicating cognition was intact. Further review revealed resident's speech was clear, and he required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene and chair/bed-to-chair transfer. In addition, resident was frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding).Record Review of Resident #1's Care Plan, undated, revealed he had an ADL self-care performance deficit r/t limited mobility. Resident required assistance x2 with transferring and was totally dependent upon staff for personal hygiene. Interventions included encouraging discussing his feelings about self-care deficit and using bell to call for assistance. Resident #1 was also at risk for alteration in skin related to incontinence of bowel and bladder.Record review of Resident #1's Progress Notes, effective date: 05/27/26 at 9:14 a.m., revealed a CIC was entered for a change in skin color or condition and PCP recommended barrier cream.Record review of Resident #1's Progress Notes, effective date: 05/27/26 at 10:02 a.m., read in part .resident [#1] complained of burning and redness to testicles. Upon assessment resident was noted to have redness to scrotum area. Resident complained that the burning feeling possibly came from not being changed during the night. Barrier cream applied to area. Notified NP.NP to visit with resident tomorrow. Will continue to monitor.Observation and interview on 05/27/26 at 8:00 a.m. revealed, Resident #1 was lying in bed awake with his call light within reach. He said he was doing okay. He said his brief had not been changed today, 05/27/26, and said staff had not changed his brief since yesterday, 05/26/26. He said he had not used his call light to ask for a brief change.Observation and interview on 05/27/26 at 8:10 a.m., CNA A said she was working 6:00 a.m.-2:00 p.m. today but was late and arrived to work at approximately 7:31 a.m. She said she did not know who was covering her assigned rooms before she arrived. She said she had not yet changed Resident #1's brief. CNA A went to Resident #1's room, checked his brief, and said it was full of urine. She performed a brief change and said resident had a little redness on the cheeks of his butt and got the barrier cream to apply. CNA A said some urine had soaked through resident's brief and onto the bed sheet that was placed under him and said the wet area was about the size of a tennis ball. Observation revealed the brief was full of urine and that his bed sheet had an irregular round shape, about the size of a tennis ball, with a light brownish/yellowish outer edge, and wet center. During a follow-up interview on 05/27/26 at 9:24 a.m., CNA A said she went by Resident #1's room at approximately 7:38 a.m. and he was asleep. She said she went back by his room at approximately 7:50 a.m. to give him some coffee. She said when she gave Resident #1 coffee, he never asked for a brief change, and she said she never asked him if he needed one. She said leaving a resident in a wet brief for too long could lead to skin damage.During an interview on 05/27/26 at 10:34 a.m., the Staffing Coordinator/Lead CNA said CNA A called her this morning at approximately around 5:40 a.m.-5:50 a.m. to let her know she was going to be late due to car problems. She said she notified Nurse A, CNA B, and CNA C. She said she told the 2 CNAs to watch the call lights and when breakfast was ready to pass out the trays. She said residents should be checked and changed every two hours or when they are hitting their call light.Record review of the facility's policy, Perineal Care, date reviewed/revised: 12/01/2025, revealed .Perineal Care.Policy: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to provide pharmaceutical services which included procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 of 8 medication carts (Hall 2300/2400 Nurse cart and Hall 2100/2200 Med Aide cart) reviewed for pharmacy services.1. The facility failed to ensure expired medications were not stored with current medications on the 2300/2400 Hall Nurse cart.2. The facility failed to ensure expired medications were not stored with current medications on the 2100/2200 Med Aide cart.These failures could place residents at risk for not receiving therapeutic benefits of the medication and/or worsening health concerns.Findings include: In an observation on 5/1/26 at 9:47 AM of Hall 2300/2400 Nurse cart the following expired medications were found:-Insulin Lispro 100/ml Opened 3/26/26-Insulin Lantus 100/ml Opened 3/17/26-Insulin Lantus 100/ml Opened 3/31/26-Artificial Tears Opened 3/4/26-Pro-Stat (liquid protein) Expired 4/30/26In an interview on 5/1/26 at 9:47 AM, LVN B said the insulin was only good for 28 days after it was opened and the eye drops were good for 30 days after they were opened. She said if expired medications were given to the resident it could be harmful or not be as effective. The nurse said she tried to check her cart every day but there was not an actual policy/procedure for checking the carts for expired medications that she knew of.In an observation on 5/1/26 at 10:10 AM of Hall 2100/2200 Med Aide cart the following expired medications were found:-Brimonidine (lower eye pressure) Solution 0.2% eye drops Opened 3/30/26-Bimatoprost (lower eye pressure) Solution 0.03% eye drops Opened 3/30/26-Latanoprost (lower eye pressure) Solution 0.005% eye drops Opened 3/23/26-Latanoprost Solution (lower eye pressure) 0.005% eye drops Opened 3/28/26-Simbrinza Suspension (lower eye pressure) 1-0.2% eye drops Opened 4/1/26In an interview on 5/1/26 at 10:10 AM, MA C said the eye drops expired 30 days after being opened. She said if the expired medications were given to a resident they would not be as effective. MA C said she checked her cart every morning for expired eye drops.In an interview on 5/1/26 at 2:50 PM, the DON said eye drops were only good for 30 days and insulin was only good for 28 days after they were opened. She said if a resident received expired medications they could have adverse reactions. She said staff were expected to date the bottle as soon as it was opened and then check their cart every morning for expired medications before starting their shift.Record review of the facility's policy and procedures on Medication Storage (implemented 12/1/25) read in part: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.Record review of the facility's policy and procedures on Medication Administration (revised 12/30/25) read in part: .Keep medication cart clean, organized, and stocked with adequate supplies.Identify expiration date. If expired, notify nurse manager.

Number of residents sampled: Number of residents cited: Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 2 of 4 hallways, (Halls 2400 and Hall 1200), the conference room and Resident #44's room. The facility had live flies, roaches and bed bugs in areas of the facility including Halls 2400, 1200, the conference room and Resident #44's room. This failure could place residents at risk for decreased health, safety and quality of life. Findings included: Record review of Resident #44's Electronic Health Record revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosesis including idiopathic (a chronic condition characterized by a sudden drop in blood pressure upon standing), Hyperkalemia (excessively high potassium levels in the blood), Cellulitis of right toe and right lower limb, muscle weakness, elevated white blood cell count, Pseudomonas aeruginosa (Gram-negative rod-shaped bacteria known for causing infections). Record review of the Resident #44's Quarterly MDS dated revealed a BIMS score of 09, which indicated moderately impaired. Section GG of the MDS revealed the resident did not use a mobility device and she was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting hygiene, shower/bathe self, putting on/taking off footwear, and roll left and right. Resident #44 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for upper body dressing and lower body dressing. Resident #44 required setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, oral hygiene, and personal hygiene. Record review of Resident #44's progress notes documented by LVN B revealed on 03/27/26, the resident was observed with red raised bumps on bilateral arms, and it was noted that the resident had been scratching red raised bumps and had several scabbed areas on left arm. The resident received an order to start Hydroxyzine 10mg 1 tab PO daily x 7 days. Record review of Resident #44's order summary revealed an order dated 03/28/26 for Hydroxyzine HCI Oral Tablet 10 MG Give 1 tablet by mouth one time a day for itching for 7 days In an observation on 04/28/26 at 09:43am, approximately 2 flies were observed on Hall 1200. In an observation on 04/28/26 at 11:11am, approximately 4 flies were observed on Hall 2400. In an observation on 04/28/26 at 01:58pm, approximately 4 flies were observed in the conference room of the facility. In an observation on 05/01/26 at 09:40am, a cockroach was observed crawling on the floor in the conference room of the facility. In an interview/observation on 05/01/26 at 09:34am with Resident #44, the resident was observed in her room lying in bed. She stated she was moved out of her room earlier this week and it was deep cleaned and sprayed by maintenance. She stated she kept getting bitten by something and stated the staff was giving her medication., sShe stated this occurred about a month ago. When asked what she was being bitten by, she reported she was being bitten by ants. When asked if it could have been bedbugs, she stated it was not bed bugs, it was ants. The resident reported having ants in her room and being bitten made her feel uncomfortable. The resident reported she was bitten on her shoulder and her leg but reported she no longer had any marks and stated everything had healed. Surveyor observed the resident's shoulder and there appeared to be no open bite marks, there was what appeared to small faded circular scars. that could have possibly been from bit marks. There were no ants or bed bugs observed in the room while surveyor was in the resident's room. In an interview on 05/01/26 at 9:42am with Administrator, he stated the pest could be eliminated in the facility if you could convince the families to do the laundry in house instead of doing laundry at their homes. He stated he had not had any complaints regarding bed bugs. He stated pest control comes out 2 times per month and if there wereare any sightings at the facility, they will come out. He did not provide the risk of having pest in the facility. In an interview on 05/01/26 at 9:50am with the Maintenance Director, he stated he treated Resident #44's room this week. He stated he had the staff bring the resident out so he could check the room. He stated he found some sugar ants and the resident had a lot of things (like snacks) in the dresser, he stated he sprayed the room and the house keepers cleaned the room. He stated since he worked at the facility, he has never seen any bed bugs in the facility. He stated pest control was going to the facility today (05/01/26) to check the resident's room. Record review of the facility's invoice/service ticket number dated 05/01/26 revealed pest control serviced the facility at 11:00am and found 8 bedbugs on back of the mattress. In an interview on 05/01/26 at 2:36pm with the Administrator, he reported that pest control came out to the facility and found active bed bugs in Resident #44's room on back of her mattress. He stated the resident was moved to another room and her room was serviced. Record review of the facility's pest control policy dated 11/01/25 reflected, Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations. Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 2 of 4 hallways, (Halls 2400 and Hall 1200), the conference room, and 1 of 129 resident rooms (Resident #44). The facility had live flies, roaches and bed bugs in areas of the facility including Halls 2400, 1200, the conference room and Resident #44's room. This failure could place residents at risk for decreased health, safety and quality of life. Findings included: Record review of Resident #44's Electronic Health Record revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosesis including idiopathic (a chronic condition characterized by a sudden drop in blood pressure upon standing), Hyperkalemia (excessively high potassium levels in the blood), Cellulitis of right toe and right lower limb, muscle weakness, elevated white blood cell count, Pseudomonas aeruginosa (Gram-negative rod-shaped bacteria known for causing infections). Record review of the Resident #44's Quarterly MDS dated revealed a BIMS score of 09, which indicated moderately impaired. Section GG of the MDS revealed the resident did not use a mobility device and she was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting hygiene, shower/bathe self, putting on/taking off footwear, and roll left and right. Resident #44 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for upper body dressing and lower body dressing. Resident #44 required setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, oral hygiene, and personal hygiene. Record review of Resident #44's progress notes documented by LVN B revealed on 03/27/26, the resident was observed with red raised bumps on bilateral arms, and it was noted that the resident had been scratching red raised bumps and had several scabbed areas on left arm. The resident received an order to start Hydroxyzine 10mg 1 tab PO daily x 7 days. Record review of Resident #44's order summary revealed an order dated 03/28/26 for Hydroxyzine HCI Oral Tablet 10 MG Give 1 tablet by mouth one time a day for itching for 7 days In an observation on 04/28/26 at 09:43am, approximately 2 flies were observed on Hall 1200. In an observation on 04/28/26 at 11:11am, approximately 4 flies were observed on Hall 2400. In an observation on 04/28/26 at 01:58pm, approximately 4 flies were observed in the conference room of the facility. In an observation on 05/01/26 at 09:40am, a cockroach was observed crawling on the floor in the conference room of the facility. In an interview/observation on 05/01/26 at 09:34am with Resident #44, the resident was observed in her room lying in bed. She stated she was moved out of her room earlier this week and it was deep cleaned and sprayed by maintenance. She stated she kept getting bitten by something and stated the staff was giving her medication., She stated this occurred about a month ago. When asked what she was being bitten by, she reported she was being bitten by ants. When asked if it could have been bedbugs, she stated it was not bed bugs, it was ants. The resident reported having ants in her room and being bitten made her feel uncomfortable. The resident reported she was bitten on her shoulder and her leg but reported she no longer had any marks and stated everything had healed. Surveyor observed the resident's shoulder and there appeared to be no open bite marks, there was what appeared to small faded circular scars. that could have possibly been from bit marks. There were no ants or bed bugs observed in the room while surveyor was in the resident's room. In an interview on 05/01/26 at 9:42am with Administrator, he stated the pest could be eliminated in the facility if you could convince the families to do the laundry in house instead of doing laundry at their homes. He stated he had not had any complaints regarding bed bugs. He stated pest control comes out 2 times per month and if there were are any sightings at the facility, they will come out. He did not provide the risk of having pest in the facility. In an interview on 05/01/26 at 9:50am with the Maintenance Director, he stated he treated Resident #44's room this week. He stated he had the staff bring the resident out so he could check the room. He stated he found some sugar ants and the resident had a lot of things (like snacks) in the dresser, he stated he sprayed the room and the house keepers cleaned the room. He stated since he worked at the facility, he has never seen any bed bugs in the facility. He stated pest control was going to the facility today (05/01/26) to check the resident's room. Record review of the facility's invoice/service ticket number dated 05/01/26 revealed pest control serviced the facility at 11:00am and found 8 bedbugs on back of the mattress. In an interview on 05/01/26 at 2:36pm with the Administrator, he reported that pest control came out to the facility and found active bed bugs in Resident #44's room on back of her mattress. He stated the resident was moved to another room and her room was serviced. Record review of the facility's pest control policy dated 11/01/25 reflected, Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.

Number of residents sampled: Number of residents cited: Based on interviews and record review, the facility failed to provide residents access to visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident for 1 of 1 facility's.- The facility failed to allow any visitors in the building after 8pm when the doors locked.This failure could place residents at risk for decreased quality of life, sadness, and depression.Findings include: In an interview on 4/30/26 at 9:45am, LVN I said visitation hours were from 8am to 8pm and they did not allow any family members in the facility after 8pm. She said the doors locked at 8pm and the only people that were allowed to come in after that were EMS personnel or family to a resident who was passing away. She said EMS personnel had to ring the doorbell or call the facility on the phone.In an interview on 4/30/26 at 9:49am, the Receptionist said she worked Tuesdays, Thursdays, and Fridays from 8am to 8pm. She said there was another receptionist who worked the other days from 8am to 8pm. The Receptionist said visitation hours were from 8am to 8pm and after that the doors remained locked. She said the only family that were allowed to visit after hours were family that were care planned for a particular reason or if the resident was actively dying.In an interview on 4/30/26 at 1:40pm the Receptionist said family members were not allowed to come after 8pm and they told family they were not allowed to come.In an interview on 5/1/26 at 2:45pm, the Assist ED said the doors locked at 8pm for security reasons but family members were still allowed in. He said family would ring the doorbell and the nurse would go see who it was and let them in. He said if residents were not allowed to see their family members they could get depressed. The Assist ED said his staff were misinformed and family members were allowed to come whenever they wanted to, and he was not sure where they got that information from.Record review of the facility's policy and procedure on Resident Right to Access and Visitation (implemented 10/1/25) read in part: It is the policy of this facility to support and facilitate the resident's right to receive visitors of their choosing, at the time of their choosing. Visitation will be person-centered, consider the residents' physical, mental, and psychosocial well-being, and support their quality of life .The facility will provide immediate access to any resident by.The resident representative. The facility will provide immediate access to a resident by immediate family and other relatives of the resident.Resident's family members are not subject to visiting hour limitations or other restrictions not imposed by the resident.If familial visits infringe upon the rights of other residents (e.g. family visits late at night when the resident's roommate is already asleep), staff will find a location other than the resident's room for visits. The facility will provide immediate access to a resident by others who are visiting with the consent of the resident.The facility will inform each resident and/or resident representative of his or her visitation rights and related facility policies and procedures, including any clinical or safety restriction or limitation of such rights, in a manner he or she understands.The facility will ensure all visitors enjoy full and equal visitation privileges consistent with resident preferences.Keeping the facility locked at night with a system in place for allowing visitors approved by the resident.Record review of the facility's policy and procedures on Resident Rights (revised 12/1/25) read in part: .The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner, that does not impose on the rights of another resident.

Number of residents sampled: Number of residents cited: Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 out of 28 resident rooms (Resident #42 and Resident #97) reviewed for infection control. - LVN AB failed to wear appropriate PPE while giving G-tube (tube into stomach for nutrition) medications to Resident #42, when she was on Enhanced Barrier Precautions.- LVN A failed to wear appropriate PPE while giving G-tube medications to Resident #97, when he was on Enhanced Barrier Precautions.These failures could place residents and staff at risk for cross contamination and infection.The findings included:Record review of Resident #42's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses of acute kidney failure (kidneys are not filtering), aphasia (trouble speaking), diabetes mellitus (body does not produce insulin or resists it), pressure ulcer of sacrum (tailbone), dysphagia (trouble swallowing), and gastrostomy (tube into stomach for nutrition).Record review of Resident #42's Annual MDS assessment dated [DATE] revealed a BIMS score of 00 which indicated severely impaired cognition. The resident had impairment on both sides of her upper and lower extremities. Resident #42 was dependent (helper does all of the effort and resident does none of the effort) for all ADLs. The assessment revealed the resident had a feeding tube, received 51% or more calories through it, and received 501cc/day or more of fluid intake through it.Record review of Resident #42, Care Plan dated 12/9/24 revealed a Focus: Resident #42 was at risk for infection related to gastrostomy status *Enhanced Barrier Precautions* (Initiated: 1/8/25). The interventions included initiating appropriate isolation precautions and staff to follow standard precautions including proper hand washing. Focus: Enhanced Barrier Precautions implemented r/t G-tube feeding, pressure ulcer (Initiated: 12/9/25). Interventions included implementing enhanced barrier precautions.Record review of Resident #42's Physician Orders as of 5/1/26 revealed the following orders from the Medical Director:- Enhanced Barrier Precautions every shift Follow Facility Policy - **USE for patients with any of the following (when Contact Precautions do not otherwise apply}: Wounds or indwelling medical devices, regardless of MDRO (antibiotic resistant bacteria) colonization status Infection or colonization with an MDRO**. Ordered 1/7/25.- Wound care consult. Ordered 7/7/25.- Wound Treatment - Hydrocolloid Dressing [type of wound care] as needed, apply to sacrum (tailbone) as needed. Ordered 7/17/25.- Enteral Feed Order, every shift Jevity 1.2 at 55 ml/hr via feeding tube. To run continuously until total volume of 1210ml administered x 22 hours. May remove 2 hours for care and services. Ordered 2/27/26.- Wound consult with Skilled Wound care [company] until wounds resolve. Ordered 3/17/26.In an observation on 4/28/26 at 10:25am, Resident #42 had an EBP sign on her door. The resident was lying in bed with Jevity 1.2 (type of g-tube feed) running at 55ml/hr via PEG tube. The resident was non-verbal.In an observation on 4/29/26 at 9:12am, LVN AB performed a medication pass on Resident #42. Resident #42 was on EBP with a sign on her door. LVN AB did not wear a gown during the medication administration.In an interview on 4/29/26 at 9:49am, LVN AB said EBP was to protect the resident from any infection from staff and to protect herself from infection from the resident. She said EBP was used for any indwelling lines and wounds and she should have had a gown on when giving G-tube meds but she forgot.In an interview on 4/30/26 at 10:32am, the DON said there was EBP signs outside the resident's doors and over their beds. She said EBP was to protect residents and staff from outside infections and were for any devices/wounds the residents were not born with. She said examples were a foley catheter (tube into bladder to drain urine), g-tubes, wounds, trachs (hole in throat for breathing), etc. The DON said PPE would be worn when staff provided close care to the resident, where they were touching the resident. She said giving g-tube meds would require the PPE to be worn. Record review of Resident #97's undated face sheet revealed he was a [AGE] year old male who admitted to the facility 4/13/26 with diagnoses of sepsis (infection throughout body), type 2 diabetes (body does not produce insulin or resists it), cerebral infarction (stroke), metabolic encephalopathy (change in brain due to underlying condition), and pressure ulcer of unspecified site and stage.Record review of Resident #97's admission MDS assessment dated [DATE] revealed a BIMS score of 00 out of 15, which indicated severely impaired cognition. The resident was substantial/max assist (helper does more than half the effort) for all ADLs. The assessment revealed the resident had a feeding tube, received 51% or more calories through it, and received 501cc/day or more of fluid intake through it. Resident #97 also had one stage 3 (full thickness tissue loss with subcutaneous fat visible) unhealed pressure ulcer and one unstageable (unknown due to dead tissue covering the wound) pressure ulcer.Record review of Resident #97's Care Plan dated 4/13/26 revealed a Focus: Resident #97 required tube feeding due to dysphagia (trouble swallowing). Interventions included monitoring for s/sx of infection at tube site and providing care to the g-tube site. Focus: Enhanced Barrier Precautions implemented r/t feeding tubes, wounds. Interventions included implementing enhanced barrier precautions and monitoring for s/sx of infection. Focus: Resident #97 had pressure ulcers: Stg 3 sacrum (tailbone), Stg 3 R ischium (hip)-resolved. Interventions included treatment to pressure ulcer per doctor's orders, turning/repositioning, and weekly head to toe assessment.Record review of Resident #97's Physician Orders as of 5/1/26 revealed the following orders from the Medical Director:- Enhanced Barrier Precautions DX: Wounds/G - tube every shift Follow Facility Policy - **USE for patients with any of the following (when Contact Precautions do not otherwise apply): Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO**. Ordered 4/13/26.- Wound Treatment - Dry Dressing every day shift Cleanse wound to _Sacrum ____ with Normal Saline or Skin Cleanser. Pat Dry apply Medi honey and calcium alginate (type of wound care) Cover with Dry Dressing. Ordered 4/14/26.- Wound Supplement one time a day related to PRESSURE ULCER OF UNSPECIFIED SITE, UNSPECIFIED STAGE (L89.90) 30 ml via G-Tube. Ordered 4/16/26.- Enteral Feed Order every shift Diabetasource @ 75cc/hr via feeding tube to run continuously x 22 hrs. May remove for care and services. Ordered 4/21/26. In an observation and interview on 4/30/26 at 9:35am, LVN A performed a medication pass on Resident #97. Resident #97 was on EBP and there was a sign over his bed indicating it. LVN A did not wear a gown during the medication administration. LVN A said EBP was for g-tubes, wounds, and any indwelling devices. He said he was supposed to wear a gown during g-tube care and giving medications because it protected the resident and himself from infection. He said he forgot to put a gown on.Record review of the facility's policy and procedures on Enhanced Barrier Precautions Policy (revised 12/30/25) read in part: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions.An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers [wounds due to poor circulation] and/or indwelling medical devices (e.g., central lines [tube inserted into large vein ending near the heart], urinary catheters, feeding tubes, tracheostomy/ventilator tubes [breathing machine], hemodialysis catheters [tube into large vein for dialysis], PICC lines [tube inserted into large vein ending near the heart], midline catheters [tube inserted into vein longer than regular IV]) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors [monitors blood sugar], insulin pumps, or ostomies [opening to outside where stool collects] without an associated indwelling medical device are not an indication for EBP.).PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room.High-contact resident care activities include.Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters.Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.Record review of the facility's policy and procedures on Infection Prevention and Control Program (revised 12/1/25) read in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.All staff are responsible for following all policies and procedures related to the program.All staff shall use personal protective equipment (PPE) according to the established facility policy governing the use of PPE.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure residents were free from any significant medication errors for 1 of 3 (Resident #97) residents reviewed for pharmacy services.1. LVN A failed to give Resident #97 the correct dose of Valproic Acid (seizure medication) and gave the resident a double dose during his morning medication administration on 4/30/26. 2. LVN A failed to give Resident #97 the correct form of Valproic Acid and gave it in capsule form instead of liquid form during his morning medication administration on 4/30/26.3. LVN A failed to give Resident #97 his Insulin Glargine during his morning medication administration on 4/30/26.These failures could place residents at risk of side effects due to an increase in dosage, toxicity, and overdose.Findings include:Record review of Resident #97's, undated, face sheet revealed a [AGE] year old male who was admitted to the facility 4/13/26. Resident #97 had diagnoses which included sepsis (infection throughout body), type 2 diabetes (body does not produce insulin or resists it), cerebral infarction (stroke), metabolic encephalopathy (change in brain due to underlying condition), epilepsy (seizures), and pressure ulcer of unspecified site and stage.Record review of Resident #97's admission MDS assessment, dated 4/20/26, revealed a BIMS score of 00 out of 15, which indicated severely impaired cognition. The resident was substantial/max assist (helper does more than half the effort) for all ADLs. Resident #97 was marked for having a seizure disorder. The assessment revealed the resident had a feeding tube, received 51% or more calories through it, and received 501cc/day or more of fluid intake through it. Resident #97 was taking hypoglycemics and anticonvulsants.Record review of Resident #97's Care Plan, dated 4/13/26, revealed a Focus: Resident #97 required tube feeding due to dysphagia. Interventions included monitoring for s/sx of infection at tube site and providing care to the g-tube site. Focus: Resident #97 had diabetes mellitus w/ current treatment Insulin Glargine SQ 100u/ml, Insulin Lispro SQ 100u/ml. Interventions included diabetes medication as ordered by the doctor. Focus: Resident #97 was on anticonvulsant therapy Valproic Acid Oral Solution 250mg/5ml, Divalproex Sodium Oral Tablet Delayed Release 500mg. Interventions included giving medications per order, monitoring labs, and monitoring for signs of seizure.Record review of Resident #97's MRR revealed on 4/15/26 the Consultant Pharmacist recommended discontinuing Divalproex DR Tablet 500mg BID via g-tube because there was already an order for Valproic Acid Oral Solution 250mg/5ml 4xday via g-tube. NP A agreed with the recommendation, however the blister pack was not removed from the medication cart.In an observation on 4/30/26 at 8:48 AM, LVN A was observed crushing and giving the following medication to Resident #97. -Valproic Acid 250mg 2 capsules via g-tubeIn an interview on 4/30/26 at 8:48 AM, LVN A said there was not any liquid Valproic Acid and that was why he was crushing the capsules trying to get the liquid out. He said the pharmacy did not have any liquid Valproic Acid. LVN A did not attempt to look in the medication cart or ask anyone about it. LVN A was not observed giving Insulin Glargine 10u, and the Valproic Acid was ordered to be given in liquid form 250mg/5ml. LVN A also gave a double dose of Valproic Acid.In a phone interview on 4/30/26 at 11:00 AM, an unknown Pharmacist at [pharmacy] said a 280ml bottle of Valproic Acid for Resident #97 had been sent to the facility on 4/14/26.In an interview on 4/30/26 at 11:29 AM, LVN A said he did not see the order for Insulin Glargine 5u and it did not flag on his MAR. LVN A said he did not have the liquid Valproic Acid without looking for it. LVN A was informed a bottle of liquid Valproic Acid for Resident #97 was sent to the facility. LVN A and the State Surveyor looked in the two medication storage rooms and did not find it. LVN A looked in the nurse cart for the 2400 hall, because the resident had moved from that hall, and the medication was not there. The State Surveyor asked LVN A if he looked in his own medication cart and he said he had and it was not there. The State Surveyor looked in LVN A's medication cart and the Valproic Acid liquid for Resident #97 was found at the bottom of his cart, where all the other liquid medications were stored. LVN A said he gave the wrong dosage of Valproic Acid because he gave the capsules but looked at the dosage for the liquid order. He said Resident #97 could have side effects due to getting a double dose of Valproic Acid. The nurse said the medication should always be given in the ordered form so medication errors did not happen.In an interview on 4/30/26 at 12:02 PM, the DON said the Valproic Acid should have been given in liquid form because the wrong dose could be given. She stated the Insulin Glargine 10u should have been given as well.In an interview on 4/30/26 at 12:10 PM, NP A said a onetime extra dose of Valproic Acid would not affect Resident #97. She said if the resident was over dosed she would look for a decrease in alertness and a change in vital signs.In an interview on 4/30/26 at 12:40 PM, the DON said she had a one on one in-service with LVN A and relieved him of his duties for that day. She said they were also performing STAT labs on Resident #97 and monitoring his vital signs. She said they had already notified the provider and his RP, and the wrong dosage of Valproic Acid had already been removed from the medication cart.Record review of Resident #97's chart revealed a Change in Condition, dated 4/30/26 at 2:11 PM. The Change in Condition was for a medication error. According to the report, there had not been any changes in the resident's status. A complete assessment of Resident #97 was completed which included a head to toe assessment and vital signs. The resident was going to be monitored over 72hr for any adverse effects and a STAT Valproic Acid was drawn.Record review of Resident #97's Physician Orders as of 5/1/26 revealed the following orders from the Medical Director:- Enteral Feed Order every shift Diabetasource @ 75cc/hr via feeding tube to run continuously x 22 hrs. May remove for care and services. Ordered 4/21/26.- Valproic Acid (Depakene) SENT Uncollected 5/1/2026 7:37 AM one time only related to EPILEPSY, UNSPECIFIED. Ordered 5/1/26.- Insulin Glargine Subcutaneous Solution 100 UNIT/ML (insulin Glargine) Inject 10 unit SQ QD related to TYPE 2 DIABETES MELLITUS. Hold for BS less than 100. Ordered 4/13/26.- Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 5 ml via G-Tube 4xday related to EPILEPSY, UNSPECIFIED. Dose must equal 250mg total. Ordered 4/13/26.- Divalproex Sodium Oral Tablet Delayed Release 500mg, Give 1 tablet via G-tube BID related to EPILEPSY, UNSPECIFIED. Ordered on 4/14/26 and discontinued on 4/20/26.Record review of the facility's policy and procedures on Medication Errors (implemented 10/2025) read in part: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services. Medication error rate is determined by calculating the percentage of errors observed during a medication administration observation. The numerator is the total number of errors that is observed, both significant and non-significant. The denominator consists of the total number of observations or opportunities of error and includes all the doses observed being administered plus the doses ordered but not administered. The equation for calculating a medication error is as follows: Medication Error Rate = Number of Errors Observed divided by the Opportunities for Errors (doses given + doses ordered but not given) x 100. The facility shall ensure medications will be administered as follows: According to physician's orders.The facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events.The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: Incorrect dose, route of administration, dosage form, time of administration; Medication omission.To prevent medication errors and ensure safe medication administration, nurses should verify the following information: Right medication, dose, route, and time of administration.If a medication error occurs, the following procedure will be initiated: The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. Document actions taken in the medical record. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report.Record review of the facility's policy and procedures on Medication Administration (revised 12/30/25) read in part: 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.Right dosage, Right route. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Do Not Crush Medications: Slow release Enteric coated.Record review of the facility's policy and procedures on Medication Administration via Enteral Tube (implemented 11/1/25) read in part: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines.Pharmacy will be notified that an order to give medications through enteral tube has been received and suspensions for medications will be supplied when possible.Prior to crushing tablets, nurses will consult the Medications Not to Be Crushed list (from pharmacy) or the manufacturer's labeling/package insert.Sublingual, enteric coated, or modified release medications will not be administered through the enteral tube. Pharmacy will be notified for more appropriate dosage form.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 18%, based on 5 errors out of 27 opportunities, which involved 2 of 3 residents (Resident #70 and Resident #97) and 2 of 3 staff (MA K and LVN A) observed during medication administration reviewed for medication errors.- MA K failed to give Resident #70 his Supplement Pass (provides protein) 90ml during his morning medication administration on 4/29/26.- MA K failed to give Resident #70 his Aspirin 81mg during his morning medication administration on 4/29/26. - LVN A failed to give Resident #97 his Vitamin C 500mg/5ml in the right dose and right form during his morning medication administration on 4/30/26.- LVN A failed to give Resident #97 his Valproic Acid (seizure medication) 250mg/5ml in the right dose and right form during his morning medication administration on 4/30/26.- LVN A failed to give Resident #97 his Insulin Glargine [controls blood sugar] 100u/ml during his morning medication administration on 4/30/26.These failures could place residents at risk for not receiving the therapeutic effects of their prescribed medications and possible adverse reactions.Finding include: 1. Record review of Resident #70's, undated, face sheet revealed a [AGE] year old male who was admitted to the facility on [DATE]. Resident #70 had diagnoses which included multiple myeloma (cancer of cells in the bone marrow), protein-calorie malnutrition, high blood pressure, acute atopic conjunctivitis of right eye (eye infection), heart burn, high cholesterol, weakness, and depression.Record review of Resident #70's Quarterly MDS assessment, dated 1/30/26, revealed a BIMS score of 15 out of 15, which indicated normal cognition. The resident was partial/moderate assistance (helper does less than half the effort) for all ADLs and used a rollator (walker with wheels) for mobility. Resident #70 was occasionally incontinent of urine and never incontinent of bowel. The resident required a mechanically altered diet (change in texture of food or liquids) while a resident.Record review of Resident #70's Care Plan, dated 1/18/25, revealed a Focus: Resident #70 was at risk for nutritional decline related to swallowing difficulty. Interventions included assisting with meals, consulting with a dietician, and consulting with speech therapy.In an observation on 4/29/26 at 9:12 AM, revealed MA K gave the morning medications to Resident #70. She gave the following medications to Resident #70:1. Gabapentin 300mg 1 PO2. Protein Liquid 30ml PO3. Lidocaine Patch 1 topically4. Bumetanide 0.5mg 1 PO5. Famciclovir 500mg 1 PO6. Miralax 17g PO7. Mupro 128 eye ointment 1 gtt R eye8. Senna 8.6mg/50mg 1 PO9. Sulfamethoxazole-Trimethoprim Tablet 800-160 mg 1 PO10. Norco 325mg/5mg 1 PO11. Iron 325mg 1 PO12. Fluticasone Nasal Spray 1 spray each nostril13. Multivitamin Gummies 2 POIn an interview on 4/29/26 at 9:12 am, MA K stated there were nine pills in her medicine cup before she gave the cup of medicine to Resident #70. She did not have the Supplement Pass 90ml and said she would have to go look in the medication storage room for a bottle of it. MA K was not observed giving Aspirin 81mg to Resident #70. MA K said she would get the State Surveyor once she went and found a bottle of Supplement Pass. In an interview and observation on 4/29/26 at 11:30 AM, MA K gave the Supplement Pass 90ml to Resident #70. She said it would be counted as the lunch dosage since he was supposed to get it TID, and the morning administration was counted as not given. MA K said she did not realize she did not give the Aspirin and said she must have checked it off and not realized it. She said she normally popped out the pill first and then checked off the medication, so she was unsure of what happened. MA K said if the resident did not get the medication, they would not get the benefit of the medication.Record review of Resident #70's Physician Orders as of 5/1/26 revealed the following orders from the Medical Director:- Aspirin Oral Capsule 81 MG (Aspirin), 1 PO QD for Anticoagulant. Ordered 4/7/25.- Supplement Pass TID related to Mild Protein-Calorie Malnutrition, Give 90ml. Ordered 12/4/25.- Bumetanide Oral Tablet 0.5mg, 1 PO BID for Edema (swelling) BLE. Ordered 8/4/25.- Famciclovir Oral (antiviral) Tablet 500 MG (Famciclovir), 1 PO QD for therapy. Ordered 9/24/25.- Ferrous Sulfate Oral Tablet 325 (65 Fe) MG (Ferrous Sulfate), 1 PO BID for Anemia. Ordered 7/10/25.- Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) 1 spray in both nostrils QD for Allergic Rhinitis (runny nose). Ordered 9/15/25.- Gabapentin Oral Capsule 300 MG (Gabapentin), 1 PO Q8hr for NEUROPATHY (burning in extremities). Ordered 3/17/26.- HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) 1 PO Q6hr related to LOW BACK PAIN. Ordered 1/21/26.- Lidocaine External Patch 4 % (pain relief) (Lidocaine) Apply to back topically QD for pain and remove per schedule. Ordered 9/15/25.- Miralax Powder 17 GM/SCOOP (Polyethylene Glycol Phone 3350) Give 17 gram PO QD for constipation Mix 1 cap full with 6-8 ml liquid. Ordered 4/29/26.- Muro 128 Ophthalmic Solution 5 % (antibiotic) (Sodium Chloride Hypertonic) Instill 1 gtt R eye 4xday for Eye Surgery related to CONJUNCTIVITIS, RIGHT EYE for 14 Days. Ordered 4/13/26.- Senna S Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 1 PO QD day for constipation. Ordered 1/21/26.- Sulfamethoxazole-Trimethoprim (antibiotic) Tablet 800-160 MG, Give 1 PO QD every Mon, Wed, Fri for Multiple Myeloma. Ordered 8/5/26.- Multivitamin Gummies 200 mcg chewable tablet, take 2 PO QD for supplement. Ordered 10/8/25. 2. Record review of Resident #97's, undated, face sheet revealed a [AGE] year old male who was admitted to the facility on [DATE]. Resident 97 had diagnoses which included sepsis (infection throughout body), type 2 diabetes (body does not produce insulin or resists it), cerebral infarction (stroke), metabolic encephalopathy (change in brain due to underlying condition), and pressure ulcer of unspecified site and stage.Record review of Resident #97's admission MDS assessment, dated 4/20/26, revealed a BIMS score of 00 out of 15, which indicated severely impaired cognition. The resident was substantial/max assist (helper does more than half the effort) for all ADLs. The assessment revealed the resident had a feeding tube, received 51% or more calories through it, and received 501cc/day or more of fluid intake through it. Resident #97 was taking hypoglycemics and anticonvulsants.Record review of Resident #97's Care Plan, dated 4/13/26, revealed a Focus: Resident #97 required tube feeding due to dysphagia (trouble swallowing). Interventions included monitoring for s/sx of infection at tube site and providing care to the g-tube site. Focus: Resident #97 had Diabetes Mellitus w/ current treatment Insulin Glargine SQ Solution 100u/ml and Insulin Lispro Injection Solution 100u/ml. Interventions included giving diabetes medication as ordered by the doctor. Focus: Resident #97 was on anticonvulsant therapy Valproic Acid Oral Solution 250mg/5ml and Divalproex Sodium Oral Tablet Delayed Release 500mg. Interventions including giving the medications per order.Record review of Resident #97's MRR revealed on 4/15/26 the Consultant Pharmacist recommended discontinuing Divalproex DR (seizure medication) Tablet 500mg BID via g-tube because there was an order for Valproic Acid Oral Solution 250mg/5ml 4xday via g-tube. NP A agreed with the recommendation, however the blister pack was not removed from the medication cart.In an observation and interview on 4/30/26 at 8:48 AM, revealed LVN A gave the morning medications to Resident #97. He gave the following medications to Resident #70:1. Vitamin C 500mg 1 Tablet crushed via g-tube2. Aspirin 81mg 1 crushed via g-tube3. Multi-Vite 5ml via g-tube4. Modafanil (for sleepiness) 200mg 1 crushed via g-tube5. Insulin Lispro 4u SQ6. Valproic Acid 250mg 2 capsules via g-tube7. Lisinopril (blood pressure) 20mg 1 crushed via g-tubeIn an interview on 4/30/26 at 8:48 AM, LVN A stated he had 6 pills in his medicine cups before he crushed the medications for Resident #97. LVN A said there was not any liquid Valproic Acid and that was why he was crushing the capsules trying to get the liquid out. He said the pharmacy did not have any liquid Valproic Acid. He did not attempt to look in the medication cart or ask anyone about it. LVN A was not observed giving Insulin Glargine 10u, the Vitamin C was ordered to be given in liquid form 500mg/5ml, and the Valproic Acid was ordered to be given in liquid form 250mg/5ml. LVN A also gave a double dose of Vitamin C and Valproic Acid.In a phone interview on 4/30/26 at 11:00 AM, an unknown Pharmacist at [pharmacy] said a 280ml bottle of Valproic Acid for Resident #97 had been sent to the facility on 4/14/26.In an interview on 4/30/26 at 11:29 AM, LVN A said he did not see the order for Insulin Glargine 10u and it did not flag on his MAR. LVN A said he did not have the liquid Valproic Acid or the liquid Ascorbic Acid, without looking anywhere. LVN A was told a bottle of liquid Valproic Acid for Resident #97 was sent to the facility so he started looking for it. He and the State Surveyor looked in the two medication storage rooms and did not find it. We looked in the nurse cart for the 2400 hall, because the resident had moved from that hall, and the medication was not there. The State Surveyor asked LVN A if he looked in his medication cart and he said he had and it was not there. The State Surveyor looked in his medication cart and the Valproic Acid liquid was found at the bottom of his cart, where all the other liquid medications were stored. LVN A said he gave the wrong dosage of Valproic Acid because he looked at the dosage for the liquid order. He said Resident #97 could have side effects due to getting a double dose of Valproic Acid. He said the medication should always be given in the ordered form so medication errors did not happen.In an interview on 4/30/26 at 12:02 PM, the DON said the Valproic Acid should have been given in liquid form because the wrong dose could be given. She stated the Insulin Glargine 10u should have been given as well.In an interview on 4/30/26 at 12:10 PM, NP A said a one-time extra dose of Valproic Acid would not affect Resident #97. She said if the resident was over dosed she would look for a decrease in alertness and a change in vital signs.In an interview on 4/30/26 at 12:40 PM, the DON said she had a one-on-one in-service with LVN A and relieved him of his duties for that day. She said they were also performing STAT labs on Resident #97 and monitoring his vital signs. She said they had already notified the provider and his RP, and the wrong dosage of Valproic Acid had already been removed from the medication cart.Record review of Resident #97's chart revealed a Change in Condition, dated 4/30/26 at 2:11 PM. The Change in Condition was for a medication error. According to the report, there had not been any changes in the resident's status. A complete assessment of Resident #97 was completed which included a head to toe assessment and vital signs. The resident was going to be monitored over 72hr for any adverse effects and a STAT Valproic Acid was drawn.Record review of Resident #97's Physician Orders as of 5/1/26 revealed the following orders from the Medical Director:- Enteral Feed Order every shift Diabetasource @ 75cc/hr via feeding tube to run continuously x 22 hrs. May remove for care and services. Ordered 4/21/26.- Valproic Acid (Depakene) SENT Uncollected 5/1/2026 7:37 AM one time only related to EPILEPSY, UNSPECIFIED. Ordered 5/1/26.- Ascorbic Acid Liquid 500 MG/5ML Give 2.5 ml via G-Tube BID related to PRESSURE ULCER OF UNSPECIFIED SITE. Ordered 4/21/26.- Aspirin Tablet Chewable 81 MG Give 1 tablet via G-Tube QD for Prophylaxis related to CEREBRAL INFARCTION. Ordered 4/13/26.- Insulin Glargine Subcutaneous Solution 100 UNIT/ML (insulin Glargine) Inject 10 unit SQ QD related to TYPE 2 DIABETES MELLITUS. Hold for BS less than 100. Ordered 4/13/26.- Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 4 unit SQ Q6hr related to TYPE 2 DIABETES MELLITUS. Hold for BS less than 100. Ordered 4/13/26.- Lisinopril Tablet 20 MG Give 1 tablet via G-Tube QD related to HYPERTENSION Hold for BP less than 110/60 or Pulse less than 60bpm. Ordered 4/13/26.- Modafinil Oral Tablet 200 MG (Modafinil) Give 1 tablet by mouth QD related to EPILEPSY, UNSPECIFIED. Ordered 4/25/26.- Multivitamin Liquid (Multiple Vitamins-Minerals) Give 5 ml via G-Tube QD related to PRESSURE ULCER OF UNSPECIFIED SITE. Ordered 4/14/26.- Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 5 ml via G-Tube 4xday related to EPILEPSY, UNSPECIFIED. Dose must equal 250mg total. Ordered 4/13/26.- Divalproex Sodium Oral Tablet Delayed Release 500mg, Give 1 tablet via G-tube BID related to EPILEPSY, UNSPECIFIED. Ordered on 4/14/26 and discontinued on 4/20/26.Record review of the facility's policy and procedures on Medication Errors (implemented 10/2025) read in part: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services. Medication error rate is determined by calculating the percentage of errors observed during a medication administration observation. The numerator is the total number of errors that is observed, both significant and non-significant. The denominator consists of the total number of observations or opportunities of error and includes all the doses observed being administered plus the doses ordered but not administered. The equation for calculating a medication error is as follows: Medication Error Rate = Number of Errors Observed divided by the Opportunities for Errors (doses given + doses ordered but not given) x 100. The facility shall ensure medications will be administered as follows: According to physician's orders.The facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events.The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: Incorrect dose, route of administration, dosage form, time of administration; Medication omission.To prevent medication errors and ensure safe medication administration, nurses should verify the following information: Right medication, dose, route, and time of administration.If a medication error occurs, the following procedure will be initiated: The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. Document actions taken in the medical record. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report.Record review of the facility's policy and procedures on Medication Administration (revised 12/30/25) read in part: 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.Right dosage, Right route. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Do Not Crush Medications: Slow release Enteric coated.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 (Resident #97) residents reviewed for tube feeding. LVN A failed to check for placement of the G-tube before giving Resident #97 his morning medications on 4/30/26.This failure could place residents at risk for the medications going into the abdominal cavity, pain, infection, and hospitalization.Findings include:Record review of Resident #97's, undated, face sheet revealed a [AGE] year old male who was admitted to the facility on [DATE]. Resident #97 had diagnoses which included sepsis (infection throughout body), type 2 diabetes (body does not produce insulin or resists it), cerebral infarction (stroke), metabolic encephalopathy (change in brain due to underlying condition), epilepsy (seizures), and pressure ulcer of unspecified site and stage.Record review of Resident #97's admission MDS assessment, dated 4/20/26, revealed a BIMS score of 00 out of 15, which indicated severely impaired cognition. The resident was substantial/max assist (helper does more than half the effort) for all ADLs. The assessment revealed the resident had a feeding tube, received 51% or more calories through it, and received 501cc/day or more of fluid intake through it. Record review of Resident #97's Care Plan, dated 4/13/26, revealed a Focus: Resident #97 required tube feeding due to dysphagia. Interventions included checking for tube placement per facility protocol and record, hold feed if greater than 60cc when aspirated. In an observation on 4/30/26 at 8:48 AM, LVN A was observed giving the morning medications to Resident #97. He gave the following medications to Resident #70 without checking for placement of the g-tube first:-Vitamin C 500mg 1 Tablet crushed via g-tube-Aspirin 81mg 1 crushed via g-tube-Multi-Vite 5ml via g-tube-Modafanil 200mg 1 crushed via g-tube-Valproic Acid 250mg 2 capsules via g-tube-Lisinopril 20mg 1 crushed via g-tubeIn an interview on 4/30/26 at 9:35 AM, LVN A said to check for placement with g-tubes he checked for residual (pulling back on the syringe to get the feeding in the syringe). He said he did not check for placement because it was hard to check residual with the type of g-tube Resident #97 had. LVN A said it was easier to give an air bolus (syringe full of air) to check for placement with Resident #97. He said he did not check for placement by residual or air bolus because he was used to Resident #97, so he felt like it was safe to go ahead and give him his medications without checking for placement. LVN A said if the g-tube was not checked for placement it could be in the wrong place, and it could be fatal.In an interview on 4/30/26 at 10:13 AM, NP A said g-tube placement should be checked prior to giving medications through it and the nurse's should follow the facility's policy. She said the risk to the resident would be low if the g-tube was older than 6 mths. NP A said there was a higher risk of the g-tube migrating out of place if it was less than 6mths old.In an interview on 4/30/26 at 10:32 AM, the DON said the facility policy for checking g-tube placement was checking the residual. She said if the residual was not checked and medications were given; they could potentially go to the wrong place.Record review of Resident #97's Physician Orders as of 5/1/26 revealed the following orders from the Medical Director:-Enteral Feed Order every shift Diabetasource @ 75cc/hr via feeding tube to run continuously x 22 hrs. May remove for care and services. Ordered 4/21/26.-G Tube - Check Tube Placement every shift Check tube for proper placement by auscultation (listen with stethoscope) of injected air or visual inspection of aspirated stomach contents prior to instilling medication, and/or initiating a feeding. Ordered 4/13/26.Record review of the facility's policy and procedures on Medication Administration via Enteral Tube (Implemented 11/1/25) read in part: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines.Enteral tube placement must be verified prior to administering any fluids or medication.

Based on interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Residents #101 and #146) reviewed for comprehensive care plans. -The facility failed to provide Residents #101 and #146 with a comprehensive person-centered care plan to address their diet orders. This failure could place residents at risk of not having personalized plans developed to address their specific care needs. Findings included: Record review of Resident #101's face sheet dated 05/01/2026 revealed a [AGE] year old female with an admission date 05/20/2022 with a primary diagnosis of hypertension (condition where the force of blood against the artery walls is consistently too high). Resident #101 had a secondary diagnosis to include dysphagia (when it's hard to get food or drink from your mouth down to your stomach.) Record review of Resident #101's Quarterly MDS dated [DATE] revealed BIMS score of 15, indicating intact cognition status in section C. In section K revealed that Resident #101 was triggered for a mechanically altered diet (require change in texture of food or liquids e.g., pureed food, thickened liquids). Record review of Resident #101's undated care plan did not reveal a focus, goal, or interventions to address Resident #101's diet. Record review of Resident#101's physician order dated 04/23/2025 with an order summary, Regular Diet: Ground texture, regular/thin consistency, may have baked whole fish. Record review of Resident #146's face sheet dated 04/30/2026 revealed an [AGE] year-old male with an admission date 01/22/2026 with a primary diagnosis of encephalopathy (condition where the brain isn't working properly, causing confusion, memory problems, or changes in behavior). Resident #146 had a secondary diagnosis to include heart failure (condition when the heart does not pump blood as well as it should, so the body does not get enough oxygen and nutrients) and presence of cardiac pacemaker (a device that helps the heart beat in a regular rhythm.) Record review of Resident #146's Quarterly MDS dated [DATE] revealed BIMS score of 07, indicating moderate cognition status in section C. In section K revealed that Resident #146 was triggered for a therapeutic diet (e.g., low salt, diabetic, low cholesterol). Record review of Resident #146's undated care plan did not reveal a focus, goal, or interventions to address Resident #146's diet. Record review of Resident#146's physician order dated 01/22/2026 with an order summary, Liberal Cardiac Diet: regular texture, regular/thin consistency, divided plate with all meals. In an interview on 04/28/206 at 10:27 am Resident#101 said that she did not have concerns overall with her care. She said that the food was often served warm when it should be hot. In an interview on 04/28/206 at 11:28 am Resident#146 said that he did not have concerns overall with his care. He said that the food was not good and was often served cold. In an interview on 05/01/2026 at 12:00pm RN F said that all residents should have a comprehensive person centered care plan. She said that the care plan should have a focus, goal, and interventions for a residents diet. She said that without a comprehensive person centered care plan to address the diet, a residents diet interventions could be missed. She said that Resident#101 had a ground texture diet, and her care plan was not updated to reflect her diet order. She said that Resident#146 had a cardiac diet, and his care plan was not updated to reflect his diet order. She said that she did not know who should update the care plan to address residents diet. She said that any nurse that viewed the care plan should be able to see if there were no diet interventions and have it corrected. In an interview on 05/01/2026 at 12:05pm the Unit Manager said that all residents should have a diet order, the diet should be triggered on the MDS assessment, and there should be diet focus, with goals, and interventions on the care plan. She said that diet interventions could be missed if it were not on the care plan. She said that the MDS Coordinator was responsible for updating the care plans. She said that any nurse that viewed a care plan could have it correct if the diet were missing. She said that Resident#101 had a ground texture diet, and her care plan was not updated to reflect her diet order. She said that Resident#146 had a cardiac diet, and his care plan was not updated to reflect his diet order. In an interview on 05/01/2026 at 2:11pm the MDS Coordinator said that he managed the care plans and it was his responsibility to ensure that care plans were updated with a focus, goal, and interventions based on the MDS assessment. He said that without a comprehensive person centered care plan a resident may not get the care that was needed. He said that all residents should have a diet order, the diet should be triggered on the MDS assessment, and there should be a diet focus, with goals, and interventions on the care plan. He said that a resident did not have a diet focus on their care plan it was an oversight. He said that any clinical staff that viewed the care plan could have had the error corrected. In an interview on 05/01/2026 at 2:21pm with the DON while the ASSIST ED was present, DON said that care plans should be comprehensive person centered, and without focus for care areas care could be missed. She said that the MDS Coordinator was ultimately responsible of updating the care plans. She said care plans should be updated with a focus, goal, and interventions based on the MDS assessment. She said that care plans should have a focus for a diet. She said that if a resident did not have a focus for a diet it would have been an oversight by the MDS Coordinator. She said that she was not aware of Resident#101 or #146 to not have a focus for their diet. She said that any clinical staff could that viewed the care plan could have caught and corrected the error. Record review of the facility policy titled, Comprehensive Care plans, dated 10/01/2025 read in part, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interviews, and record reviews, the facility failed to ensure Resident #1 received treatment and care in accordance with professional stands of practice for one (Resident #1).The facility failed to follow Resident #1's physician order to ensure his legs were wrapped on 3/31/2026.This failure could place residents at risk of neglect and not having their care needs met, a decline in physical and psychosocial health, and worsening of the residents' condition. Findings include: Record Review of Resident #1's face sheet dated 03/31/2026 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cardiac arrhythmia, unspecified symptoms and signs involving the musculoskeletal system, osteitis deformans of multiple sites, disorder of the eye and adnexa (the structures surrounding the eye, which include the eyelids, conjunctiva, lacrimal (tear) glands, and extraocular muscles), lymphedema (cancer that affects the lymphatic system), major depressive disorder, disorder of prostate, other chronic pain, hypokalemia (low blood potassium levels), chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), muscle weakness, lack of coordination, localization-related symptomatic epilepsy and epileptic syndromes with complex partial seizures, unsteadiness on feet, and other abnormalities of giant and mobility, and weakness.Record Review of Resident #1's Quarterly MDS dated [DATE] revealed a cognitive BIMS score of 15, indicating his cognition was intact. Resident #1's functional abilities and goals revealed the Resident was dependent assistance toileting hygiene, shower/bathe self, and personal hygiene. Record review of Resident #1's March MAR revealed:Ace wrap to the Bilateral LE every AM, started on 12/01/2024Remove ace wrap to Bilateral LE, every evening shift, started on 12/1/2024Tylenol oral tablet 325 mg, one tablet orally every four hours as needed for milk pain (1-3) Start Date-12/18/2024 Simethicone oral tablet 125 mg, one tablet given every 6 hours as needed for bloating -Start Date-12/01/2024 GABAPENTIN CAP 100mg, give 1 capsule orally every 12 hours for neuropathy- Start Date- 01/06/2026 Bumetanide Tablet 2 mg, give 1 tablet by mouth two times a day for fluid retention -Start Date-11/22/2025Check and Record Edema every shift every shift Check and Document Edema-Start Date-11/06/2025 Cyclobenzaprine HCl Oral Tablet ,10 mg (Cyclobenzaprine HCl) Give 1 tablet orally three times a day for MUSCLE PAIN-Start Date-11/24/2025 Record Review of Resident #1's March 2026 MAR revealed Charge Nurse A revealed Resident #1 am leg wrap treatment was completed but when the surveyor reviewed it at 11:50 am on 3/31/2026, it was not completed, as documented.In an interview and observation on 3/31/2026 at 11:21 a.m. with Resident #1, he was observed sitting in his wheelchair with his legs not wrapped. He stated he had been in the facility since 2018. He stated the care at the facility could be better. He stated he has lymphedema which is severe swelling to the legs. Resident #1 stated his legs are required to be wrapped daily; the last time they were wrapped was a week ago. Resident #1 was asked if he used his call light to request his leg treatment. He stated it depends on who answers his call light, but the facility staff might come back, or they might not. Resident #1 stated the facility actions makes him feel bad when they do not come back to address his treatment. In an interview on 3/31/2026 at 12:32 p.m. with Charge Nurse A, he stated Resident #1 would tell him when he needed a pain pill. He stated it is not normal nurse practice to document Resident treatment before it is completed. He stated he just wanted to put the Resident into his wheelchair for now. He stated he was waiting for Resident #1 to get a shower. He stated most of the time Resident #1 is in bed. He stated Resident #1 normally gets his treatment after his shower, but that morning Resident #1 had not had his shower yet. He stated it is the nurse's responsibility to ensure Resident #1 receives his leg treatment. He stated he does understand the risk to Resident #1 if his treatment was not done. He stated the risk to the Resident if the treatments was not done is his condition could get worse or their ability to do things can decrease.In an interview on 3/31/2026 at 1:06 p.m. with CNA A, she stated she has been working at the facility for almost 2 months. She stated she worked with Resident #1. She stated Resident #1 is calm and nice to talk to. She stated she does know that Resident #1 had lymphedema and it is hard for him to turn his legs. She stated the wraps are always on him when she gets his bed bath. She stated she did not bathe him on 3/31/2026. In an interview on 3/31/2026 at 1:11 p.m. with CNA B, she stated she has been working at the facility since October 2024. She stated she works with Resident #1 all the time. She stated Resident #1 is nice and is totally dependent, but is able to feed himself. She stated sometimes Resident #1 has his legs wrapped, but sometimes the wrapping is too tight and she has to get a nurse to loosen them. She stated that day Resident #1 legs were not wrapped. She stated Resident #1's legs were wrapped yesterday. She stated she gave Resident #1 a bed bath that morning. She stated the night shift usually takes the wraps off. She stated she thinks Resident #1's legs were not wrapped that day because he got up into his chair. She stated Resident #1 is normally in bed. In an interview on 3/31/2026 at 1:16 p.m. with CNA C, she stated she had been working at the facility for 3 1/2 years. She stated she is familiar with Resident #1. She stated Resident #1 is alert, very nice, and friendly. She stated Resident #1 hits the call light when he wants to get changed and lets staff know the days he wishes to get up. She stated Resident #1's legs are swollen a lot. She stated the nurse wraps his legs. She stated the nurse will wrap Resident #1's legs after his baths. She stated Resident#1 does get bed baths, shaves and hair washes. She stated there was no time when his legs was unwrapped. She states she has never had to take the wrap off.In an attempted interview on 3/31/2026 at 1:21 p.m. with Primary Physician, the clinic representative stated she was unable to provide his direct number.In an interview on 3/31/2026 at 1:23 p.m. with the Nurse Practitioner, he stated the importance of the wrap was to enhance the circulation because of the lymphedema. He stated he does not know the stage of Resident #1's lymphedema, maybe it was a 4 (is when cancer has spread to at least one body organ outside the lymphatic system), almost max, but Resident #1 received potassium. He stated Resident #1 receives Bumetanide, 2 tablets twice a day for fluid retention. He stated Resident #1 barely complained of any pain. In an interview on 3/31/2026 at 1:53 p.m. with the Director of Nurses, she stated Resident #1 was alert and oriented. She stated Resident #1 does have lymphedema. She stated Resident #1 is being treated with bi lateral leg wraps in the am and bilateral leg wraps off in the pm. She stated her expectation of staff documenting treatment is it should be done as directed, and will sign it was complete or the Resident declined, after the fact. She stated she was advised, around at 12 pm, that the Resident #1 's legs were not wrapped. She stated Charge Nurse A informed her that Resident #1's legs were not wrapped because the Resident was waiting on a bed bath. She stated it is the charge nurse's responsibility to ensure the Resident's legs are wrapped. She states the risk to the resident if he did not receive his leg wrap treatment was he can get further swelling. She stated she educated the staff and did a one-on-one education with then about documenting treatment. In an interview on 3/31/2026 at 2:05 p.m. with the Administrator, she stated Resident #1 is nice and moves around in his scooter. She stated she is not familiar with the issues with his legs. She stated they are wrapped, but she does not know why. She stated her expectation of staff document treatment is to look at the orders, perform the treatment, and then document. She states she does not know why Resident #1's treatment was documented, but was not done. She stated the DON informed her that he had a shower but they did not wrap his legs. She stated the charge nurses or DON is responsible for ensuring Resident #1's legs are wrapped. She states she understands the risk to the residents was it may cause an infection if his legs are not wrapped.Record review of the facility's policy titled, Documentation In Medical Records, dated 11/1/2025 revealed, Documentation shall be completed at the time of service but no later than the shift in which the assessment, observation, or care service occurred. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. False information shall not be documented.

Based on observation, interview, and record review the facility failed to establish and maintain an infection control prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards. 1. The facility failed to ensure CNA Q followed standard precautions by leaving soiled gloves and gowns in a clear plastic bag and leaving soiled linens on top of the chest of drawers and on the floor in Resident # 6 on enhanced barrier precautions. 2. The facility failed to ensure CNA R followed enhanced barrier precautions when providing assistance with toileting for Resident # 6. These failures could place residents at risk for developing infection from cross contamination.Findings included: Record review of Resident # 6 face sheet, dated 10/21/2025, reflected a [AGE] year-old female who was admitted on [DATE] with a diagnoses which included dependence on renal dialysis ( a situation where a person's life depends on the ongoing use of treatment to survive because their kidneys have failed), chronic kidney disease ( a condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), and encephalopathy ( any disease or damage that affects the brain's function, resulting in a decline in mental ability and brain function), and other cirrhosis of liver ( a chronic condition in which the liver becomes permanently damaged and scarred). Record review of Resident # 6's admission MDS dated [DATE] was in process. Record review of Resident # 6 Baseline Care Plan, dated 10/17/2025, reflected Resident # 6 had an intravenous access device dialysis catheter for the purposes of receiving hemodialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so). Interventions: were to administer Resident #6's intravenous fluids as prescribed. Change Resident # 6's tubing and site dressing every 72 hours. Check Resident # 6's IV site every two hours. Observe for signs of infection (redness, swelling, pain at site), and infiltration (swelling, blanching at site). Resident #6 was on enhanced barrier precautions (an infection control intervention) due to hemodialysis catheter, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Observation on 10/20/2025 at 8:51 a.m. in Resident #6's room there were not any staff in the room. Resident # 6 was lying in bed. There was a clear plastic bag with soiled gloves, garbage, and soiled gown in the bag beside the bedside table. There were dirty sheets lying on the floor near Resident 's foot of her bed. There was a soiled bedspread and blanket lying on the chest of drawers. CNA Q entered Resident 's room without washing her hands and without wearing a gown. CNA Q picked up the soiled linens and placed them in a clear plastic bag. CNA Q gathered a clear plastic bag and exited Resident # 6's room. CNA Q walked down the hall and entered room [ROOM NUMBER]'s and placed both clear plastic bags on the floor in room [ROOM NUMBER]. CNA Q was in room [ROOM NUMBER] approximately 7 minutes and exited room [ROOM NUMBER] and carried the clear plastic bags with dirty gloves, gowns and garbage in the garbage can located in soiled room and carried the dirty linens to the laundry (the part of laundry where dirty soil was stored). Interview on 10/20/2025 at 9:10 AM CNA Q stated she did change Resident # 6 clothes and gave ADL care to Resident # 6. CNA Q was asked what type of ADL care she provided for Resident # 6. CNA Q did not respond to the question. She stated she was in a hurry to get all her work finished and forgot to pick up the dirty linens and the garbage. She stated she did leave it in the room, and she knew she was to take the dirty linens and the garbage out of Resident # 6 room when she finished giving care. CNA Q stated it was infection control issue leaving dirty linens on floor and on the chest of drawers. She stated there was a possibility Resident # 6's roommate may contract some type of infection from Resident #6. CNA Q stated there was dirty gloves, dirty gown, and garbage in the clear plastic bag on the floor. She stated that was her gown and gloves she was wearing when she was giving care to Resident # 6. She stated she was not to take garbage bags full of soiled linens, dirty gowns, gloves, and garbage into another resident's room. She stated she was in a hurry and forgot to take the garbage in the appropriate garbage area and the soiled linen to the laundry area where soiled linen is kept until the laundry staff can place them in the washer. She stated she was expected to place gown on and gloves on when in Resident #6 room when she entered the room to pick up the soiled linen and place the linen in the clear garbage bag. CNA Q stated she had been in-service on Enhanced Barrier Precautions and Infection control. She stated she did not remember the date of the in-service. Interview on 10/20/2025 at 9:25 AM Infection Control Nurse stated CNA Q did not follow the facilities infection control protocol. She stated that anyone on Enhanced Barrier Precautions whose soiled linens was expected to be placed immediately in a clear plastic bag and the staff was expected to wear a gown and gloves when handling soiled linen from a Resident on Enhanced Barrier Precautions. She stated CNA Q was not to leave any type of garbage in clear garbage bag on the floor in any resident's room. The Infection Control Nurse stated CNA Q was not to carry the dirty linen and garbage into another resident room. She stated there was a possibility infection could be spread from one room to another room. She also stated with soiled linens placed on furniture and in floor there was a potential Resident # 6 roommate may develop some type of infection. She stated the staff has been in service on infection control and Enhanced Barrier Precautions. She stated she did not recall the date of the last in-service. Infection Control Nurse stated anytime staff gave care to a Resident on enhanced barrier precautions all staff was to sanitize or wash their hands prior to donning gloves and gown. She stated anytime a staff member touched something that was considered contaminated they were to change gloves and wash their hands prior to donning new gloves. Observation on 10/20/2025 at 1:05 PM CNA R entered Resident # 6 room to assist with transferring and cleaning Resident # 6 to the toilet. When CAN R entered Resident # 6 room she did not sanitize or wash her hands. She donned her gown and touched the front right side of her scrub top. CNA R reached for gloves in the glove box and touched the outside of fourchettes (the separate sheaths for the fingers on a glove) and the inside of the glove with her soiled hands. CNA R entered the bathroom where Resident # 6 was located, and surveyor was unable to observe the care. Resident #6 was not completely dressed. Interview on 10/20/2025 at 1:10 PM CNA R stated she was assisting giving hygiene care to Resident # 6 when she was in the bathroom. She stated she did not wash her hands prior to placing gown and gloves on her body and hands. She stated she may have touched her scrub top. She stated everything was happening so fast she did not notice if she did touch her top. CNA R stated she was expected to wash or sanitize her hands prior to touching the gloves and placing gloves on her hands. She stated she did touch outside of the gloves and there was a possibility of cross contamination. CNA R stated when she was giving care to Resident # 6 there was a possibility of transferring bacteria onto Resident # 6. She stated she knew Resident # 6 was on enhanced barrier precautions. She was asked what specific type of care she gave to Resident # 6, and she did not respond to the question. She stated she had been in-service on infection control and enhanced barrier precautions CNA R stated she did not recall the date. Interview on 10/24/2025 at 8:45 AM the Director of Nurses stated all staff providing care to any resident on enhanced barrier precautions was expected to wash or sanitize their hands prior to donning gloves and gown. She stated if the staff touched their clothes prior to donning gloves, the staff was expected to wash or sanitize their hands after they had touched their clothes. She stated clothes was considered contaminated. The Director of Nurses stated all soiled linen was expected to be placed in a bag immediately and not left on chest of drawers or on floor in a resident's room. She stated there was a potential of spread of infection. The Director of Nurses stated staff was immediately to place the garbage in appropriate trash container and place the soiled linen in the portion of the laundry room where soiled clothes and linen were stored until laundry staff washed them. She stated it was not the proper protocol to take dirty linens in a bag and garbage to another resident's room and place it on the floor. The Director of Nurses stated there was a potential to transfer infection from one resident to another resident. She stated the staff had been in serviced on infection control and enhanced barrier precautions. The Director of Nurses stated she did not recall the date of the in-service. Record review of the Facility Policy on Enhanced Barrier Precautions, dated August 2022, reflected. Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing. b. bathing/showering. c. transferring. d. providing hygiene. e. changing linens. f. changing briefs or assisting with toileting. g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. (and similar things); and h. wound care (any skin opening requiring a dressing).

Based on observation, interview, and record review, the facility failed make sure that drugs are stored properly and only authorized persons have access for 5 of 5 medication carts (MC #1, MC #2, MC #3, OFMC #4, and MC #5) reviewed for drug storage and labeling.The facility failed to ensure MC #1, MC #2, MC #3, MC #4, MC #5, and OFMC #6 were locked, and medications were secured, and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings included:During an observation on 10/21/2025 at 8:56 a.m., of MC #5, revealed the MC was near the nurse's station on the second floor between 2300 hall and 2400 hall. MC #5's bottom drawer was not closed completely and was unlocked. The bottom drawer consisted of pain relief lidocaine patches, MiraLAX and other medications. MC #5 also had the reconciliation binder with information about residents and their medications. During an observation on 10/22/2025 at 4:10 p.m., MC #1 on 1300 hall was near the front of the right side of the hallway. MC #1 appeared to be locked but when surveyor pushed the lock downward on the MC. The MC was not locked, and the surveyor was able to open all the drawers on the MC. MC #1 had over the counter medications belonging to residents.During an observation on 10/22/2025 at 4:26 PM, MC #2 was toward the end of 1100 hall. The Surveyor touched the locking device on MC #2, when the surveyor touched the device the medication cart unlocked. During an observation on 10/23/2025 at 7:40 AM while entering the facility, MC #3, and OFMC #4 were unlocked. MC #3 was displaying the red on the MC that was visible when the MC was unlocked. MC #3 had residents' prescription drugs, and over the counter medications. The surveyor opened OFMC #3 and there was a resident's medication in the cart for nausea, vomiting, and needles for insulin, medical supplies, and enema. During an interview with CMA S on 10/21/25 at 9:15AM, it was revealed that CMA S did lock MC #5, but she did not notice the bottom drawer was not all the way closed before she locked MC #5. She said the medication carts were supposed to always be locked when not in use. She said if a medication cart was left unattended and unlocked residents and visitors could potentially get into them and take some medication that was stored in the medication cart. She said the medication aide and the nurses were responsible for ensuring the medication carts were locked. She said she overlooked the bottom drawer and thought the cart was locked. During an interview on 10/21/25 at 10:15 AM, the DON revealed all medication carts were to be always locked when not in use. She also said some medication carts needed to be repaired, and the issue was reported to the MS. She said the medication carts had a battery on the back of the cart and when the CMA's or nurses hit the medication cart against the wall sometimes, it would affect the battery, and the medication cart will not lock properly. She said she was not aware MC #1 and MC #2 were not locked properly. She said if a resident had taken medications there was a possibility a resident may have an allergic reaction to the medications or potentially harm the resident. She also said she could not know exactly what could happen to the resident because she would not know what medication the resident ingested. During an interview on 10/22/2025 at 4:05 PM, the MS revealed he had fixed some of the medication carts before. He said he also had replaced the batteries on the back of the medication carts. He said there were times the staff would bang the medication carts against the walls, and the batteries would get loose. He said because of the batteries coming loose, the code for opening and locking the medication carts did not work. He said the DON was responsible for training nursing staff on how to lock and unlock the medication/nursing carts. The MS said he was responsible for repairing the medication carts. He said in this case the medication carts' batteries just needed to be adjusted on the back of the medication carts. He said staff were trained on how to replace the batteries and how to check them. He said the nursing staff should have known how to check the batteries. During an interview on 10/22/2025 at 4:14 PM, CMA BB revealed the medication carts were to always be locked unless the nurse or CMA was dispensing medications. She said MC #1 was not locking. She said there was a code staff needed to enter to unlock MC #1. She also said only the nurses knew the code for MC #1. She said she did not remember if she had reported to anyone the medication cart was not locking. She said she was responsibility to ensure the medication cart was locked and secured. She said if a resident had accessed the medication cart the resident could have overdosed, taken the wrong medication, had an allergic reaction, and possibly could have been admitted to the hospital. She said MC #1 contained residents' prescription medication. Interview on 10/22/2025 at 4:29 PM, CMA CC revealed MC #2 did not lock. She said MC #2 looked like it was locked but it would not lock. She said she did not recall who she told about the medication cart not remaining locked. She said all medication carts were to be locked except when a nurse or CMA was dispensing medications from the cart to give to a resident. She said anytime a nurse or CMA walked away from the medication cart they were to ensure it was locked. She said if a resident opened the medication cart and took some medications there was a possibility of an allergic reaction to someone else's medication. She said a resident could become severely sick such as decrease in blood pressure if the resident ingested another resident's blood pressure medication. She said there was a possibility a resident could die from taking medications not prescribed by their physician. CMA CC said there were all types of medications in the medication cart. She stated the narcotics were locked and the nurses were the only staff with access to the narcotics. During an attempted interview on 10/23/2025 at 7:43 AM, LVN F revealed she did not know why MC #3 and OFMC #4 was unlocked. She said OFMC #4 was not in use. She would not answer any questions and walked away from surveyor. During an interview on 10/24/2025 at 9:30 AM, the DON revealed the OFMC #4 that was found unlocked on 10/23/2025 was an extra cart the facility used when there was an increase of census. She said at this time that medication cart should not have been in use. She said the medication in the cart belonged to a resident who was no longer at the facility. She said the OFMC #4 was expected to be locked. She also said she was investigating why it was unlocked and had medication in the cart. She said in-services were given prior to all nursing staff on locking medication carts. She said she in serviced all CMA and nurses this week on locking medication carts and reporting when medication cart would not lock. Record review of Medication Labeling and Storage Policy, dated 02/2023, revealed, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after being hospitalized for 1 resident (Resident #1) of 5 residents reviewed for transfer/discharge. The facility failed to ensure Resident #1, was given his medication when he went out on pass. Resident #1 had behavior and mental illness issue that required medication. This failure could place residents at risk for serious injury, harm, and/or death due to lack of appropriate supervision.The findings included:Record review of Resident #1's, face sheet, dated 10/22/2025, revealed a [AGE] year-old male, admitted [DATE]. Resident #1's diagnosis included metabolic encephalopathy (reversable brain dysfunction caused by metabolic imbalances such as liver failure, kidney failure or severe electrolyte disturbances), psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), schizophrenia (a chronic mental health condition characterized by a combination of symptoms that affect a person's thoughts, perceptions, emotions, and behavior), and schizoaffective disorder, bipolar type (mental health condition that causes extreme mood swings). Record review of Resident #1's entry MDS, dated [DATE], revealed a BIMS of 14 which indicated intact cognitive functions. The MDS revealed Resident #1 was a smoker.Record review of Resident #1 care plan, dated 08/18/2025, revealed Resident #1 was a smoker and at risk of injury with the following interventions, assisted to smoking area on request, check for burns (clothing, fingers, skin); report to the nurse. Keep matches/lighters at the Nurses Station. Perform smoking assessment according to facility policy. Post smoking schedule for residents to refer to facility smoking times.Record review on 10/22/25 of Resident #1's electronic medical record for smoking assessment and policy acknowledgement revealed Resident #1 did not have a smoking assessment uploaded to his medical records.During an interview with Resident #1's PCP on 10/24/2025 at 12:46 p.m., it revealed if Resident #1 left the facility without medications he was at risk for increased psychotic episodes and may have increased hallucinations. She stated he would not be safe in making any type of judgements for himself. PCP stated he was not safe to be on the streets or anywhere without his medications being administered. She stated he did not have any homicidal or suicidal issues in the past, however, there was a possibility he may become homicidal or suicidal without the proper medication to treat his mental issues. During an interview with RN O on 10/24/2025 at 12:50 p.m., it was revealed that she had been trained on signing out on pass. She said the policy was the residents had to sign out when they were leaving the facility. She said when a resident leaves the facility overnight the nurse was supposed to give the resident their medication if the resident was cognitive. She said if the resident was going out on pass overnight with family the nurse was to give the medication and instructions to the family. She said if a resident does not have their medications when they are out on pass the resident could have become unstable from not having their medications. She said the nurse was responsible for ensuring the resident signed out on pass and give the resident his medication. She said she did not think Resident #1 was cognitive enough to follow the directions to take the medication. She said the nurses had to educate him on his medication for him to take them. She said the resident had been sent to the hospital in the past for his behavior. She said she did not think it was a good idea Resident #1 was out in the community without his medication. She said she believed Resident #1 might hurt himself or someone else. She said she did not know why Resident #1's medication was not sent with him. During an interview with the DON on 10/24/2025 at 1:12 p.m. it was revealed the policy was the residents were allowed to leave but they had to sign out before leaving. She also said that the residents were to sign back in when they returned to the facility. She said that when the residents were going to sign out the resident was to notify the nurse. She also said the residents would have their medication sent with them. She said several things could happen. She also said the residents could have issues if they did not have their medication. She said the nurse was responsible for ensuring the resident signed out and the resident had their medication when they left. She said she did not know who monitored to ensure the signing out policy was being followed. She said she thought that Resident #1 left before the nurse was notified. She said she thought he was safe and functional. She also said she felt that Resident #1 needed his medication. Record review of Resident #1's progress notes from the SW dated 10/22/2025 revealed Resident #1 walked up to SW while I was standing at the Nursing station and asked why he was being held prisoner. SW explained that he is not being held prisoner. Resident #1 asked why he could not leave. SW explained that Resident #1 has the right to leave but SW would like to assist him with finding a safe location. Resident #1stated that he did not need the SW help and that he could return to his last place. Resident #1 then stated that he has money in the bank and did not need my help. Resident #1 then went to the BOM's office and said that he was leaving. The BOM tried to convince Resident #1 to stay and get some help finding a place and Resident #1 started yelling that he did not need any help and we did not have a reason to keep him here. Resident #1 then left out the front door. SW, Nurse Manager, Psychologist & BOM tried to convince resident to return the facility, but he refused. Although Resident #1has a right to leave with a BIMS of 14, SW will contact the non-emergency line to [NAME] (be on the lookout), for resident in case he needs assistance. Resident #1 has not done anything wrong, just wanted to ensure resident's safety.Record review of Signing Residents Out policy dated 8/2006 revealed that Each resident leaving the premises (excluding transfers/discharges) must be signed out. A sign-out register is located at each nurses' station. Registers must indicate the resident's expected time of return. Unless otherwise prohibited by law, medications that must be administered while the resident is out will be given to the resident/person signing the resident out. Written and/or oral instructions on when and how to administer the medication will be provided to the resident or to the person signing the resident out. Only medications that must be administered while the resident is out will be issued.

Based on observation, interview, and record review, the facility failed to ensure residents were free from any physical restraints imposed for purposes of convenience and not required to treat the resident's medical symptoms for 1 (Residents #5) of 9 residents reviewed for restraints. The facility failed to ensure that bedrails were not used on the side of Resident #5's bed. This failure could place residents at risk of having physical restraints used that limited their movement without being evaluated for the medical need.Findings included: Record review of Resident #5's face sheet, dated 10/21/2025, reflected a [AGE] year-old female, admitted [DATE], with diagnoses including type 2 diabetes mellitus without complications (high blood sugar), hypertension (high blood pressure), disease of stomach and duodenum (a disease in two important organs in the digestive system), pain, constipation, hyperlipidemia (high cholesterol), and atrial fibrillation (abnormal heart rhythm). Record review of Resident #5's quarterly MDS Assessment, dated 10/03/2025, reflected a BIMS score of 10 indicating moderate impairment. The MDS also indicated Resident #5 was dependent on staff for bed mobility, and repositioning and transfers. Record Review of Resident #5's physician orders revealed, dated 10/21/2025, there were no orders for the half bed rails. Record Review of Resident #5's care plan, dated 07/12/2025, revealed Resident #5 did not have any information about bed rails in her care plan. Resident #5 also did not care about planned as being a fall risk. The care plan stated, Resident #5 was at risk for self-care deficit related to limited physical mobility. Observation of Resident #5 on 10/21/2025 at 09:13 a.m., revealed that Resident #5's bed had 1/2 bed rails that were positioned from the top of her bed to the middle of her bed. The 1/2 bed rails were up on both sides of Resident #5's bed. Observation of Resident #5 on 10/21/2025 at 11:15 a.m., revealed that Resident #5's bed had 1/2 bed rails that were positioned from the top of her bed to the middle of her bed. The 1/2 bed rails were up on both sides of Resident #5's bed. During an interview on 10/21/2025 at 11:36 a.m., Resident #5 revealed staff had been using the bed rails on her bed for about six months. She said she did not ask the staff to use the bed rails. She said she was told the bed rails were used to keep her in the bed. She said staff had also told her not to get up. She said the bed rails did prevent her from getting up. She said that she had not been hurt on the bed rails. She had not had any falls and had not attempted to get out of bed herself. She said she did not use the bed rails to reposition herself. She said she did not care if staff used the bed rails or not. During an interview on 10/21/2025 at 11:58 a.m., CNA E revealed she was trained on restraints. She said the policy was absolutely no restraints. She said the policy on bed rails depended on the resident. She said the bed rails were used to keep the resident in bed. She said if a resident was a fall risk staff would use three of the four bed rails that were on the bed. She also said she would put a wedge under the resident to keep the resident from falling. She said a risk of using bed rails were the resident could get stuck in the bed rail and hurt themselves. She said the bed rails were used depending on the resident's care. She said that the resident had to have a doctor's order for the bed rails before using the rails. She said Resident #5 did not have an order for bed rails. She said the facility started using two bed rails on Resident #5's bed about a month ago. She said the rails were used on Resident #5 to keep her in the bed. She said the bed rails were not a restraint because the facility did not use all four rails. She said Resident #5 did not have a decline due to the bed rails being used. She said Resident #5 could advocate for herself. During an interview on 10/24/2025 at 1:03 p.m., RN O revealed she was trained on restraints. She said the facility had a procedure for the bed rails. She said the procedure was staff could use the rails for four hours at a time. She said the facility had to have a doctor's order to use the bed rails. She said the risk of using the bed rails was that the resident could get hurt. She said the benefits were that the resident could not get out of bed and fall. She said she was not sure who monitored to ensure the resident's had a doctor's order for the bed rails. She said she did not know when the staff started using the bed rails for Resident #5. She said she did not know why the bed rails were being used for Resident #5 without a doctor's order. During an interview with the DON on 10/25/2025 at 12:45 p.m., she said she and staff were trained on resident rights. She said the policy for bed rails was staff were to do an assessment on the resident, and if the facility was going to use bed rails staff needed to get a doctor's order. She said the facility did not utilize full bed rails. She said the facility used assist rails, and staff needed to get consent from the resident and the RP. She said she was not sure when staff started using the bed rails on Resident #5. She said for the half bed rails the facility needed a doctor's order. She said the nurse was responsible for monitoring to ensure the facility had orders for the half bed rails. She said a resident could get hurt if staff misused the bed rails. She said if the bed rails were used for the intended purpose, the resident could not get hurt. She said the bed rails assisted the resident and the staff. She said that Resident #5 required extensive assistance with her functional ability. She also said she dd not know how long the bed rails stayed up on Resident #5. She said she did not know why staff were using the bed rails on Resident #5. She said she thought the bed rails were used on Resident #5's bed so that Resident #5 could assist staff when rolling. Record Review of Restraint Free Environment Policy, dated 8/1/2025, revealed, It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints. Physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner unless the resident has previously made a valid refusal of the treatment in question. Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility and 2 of 16 residents (Resident #217 and Resident #218) reviewed for infection control. 1. The facility failed to establish and provide documentation for a water management program as part of the infection control program. 2. The facility failed to ensure Housekeeper L wore the appropriate PPE for contact precautions when she was cleaning the room for Resident #217. 3. The facility failed to ensure LVN S wore appropriate PPE when administering IV medication to Resident #218 on 1/8/25 who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes). This failure could place residents at risk of exposure to Legionnaires' disease (a serious type of lung infection caused by Legionella bacteria which can live in standing water within facility water systems), and other infectious diseases due to improper infection control practices. Findings include: 1. In an interview on 1/9/25 at 2:15 p.m., Maintenance V said he had worked at the facility for 18yrs. He said he did not have a policy or protocol for checking for water-borne pathogens. He said he checked the backflow from the city water, with the Fire Marshall once a year. He said he also checked the water heater temperatures once a day, but he did not know anything about a Water Management Program or about Legionella. In an interview on 1/9/25 at 2:17 p.m., the ADON, who was the Infection Preventionist, said they had never had any residents who had Legionnaire's Disease. In an interview on 1/9/25 at 2:18 p.m., the Clinical Resource Nurse, said there was a policy on water-borne illness, and she would call Maintenance V's boss and ask him about it. In an interview on 1/10/25 at 12:24 p.m., the ADON/Infection Preventionist said she had been with the facility since August 2024. She said she did not know anything about a policy/procedure on water-borne illness or water management. She said that would be maintenance's department. In an interview on 1/10/25 at 12:54 p.m., the DON said that she had heard of legionella bacteria, but she did not know anything about a policy or procedure on Water Management. She said she would check with the Administrator. In an interview on 1/10/25 at 4:14 p.m., the Administrator, said she did not know there was supposed to be a Water Management System. She said she thought she had heard about it a few years ago but was not for sure. She said she would get it fixed right away. 2. Record review Resident #217's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of urinary tract infection, respiratory failure (not enough oxygen in the blood), severe sepsis with shock (severe infection throughout the body that is starting to shut down organs), type 2 diabetes (body does not produce insulin or resists it), aphasia (trouble speaking), dysphagia (trouble swallowing), COPD (chronic lung disease that reduces airflow and makes breathing difficult), tracheostomy (opening in the neck to provide an airway to the lungs), gastrostomy (opening into the stomach from the abdominal wall), and pressure ulcer of the sacrum (tailbone). Record review of Resident #217's Admission MDS assessment dated [DATE] revealed a BIMS could not be conducted due to medical conditions. The MDS revealed she was dependent (the helper does all of the effort or the assistance of 2 or more helpers is required) with all ADLs. The MDS indicated the resident had an indwelling catheter (tube into the bladder to drain urine) and was always incontinent of bowel. Resident #217 was on a feeding tube (nutrition through a tube into the stomach) and had an unstageable (not stageable due to coverage of wound bed by dead skin or infection) pressure ulcer. Record review of Resident #217's care plan dated 12/10/24 revealed a Focus: Resident is at risk for infection related to Candida Auris (resistant fungal infection), tracheostomy, and g tube and she needed to be on Enhanced Barrier Precautions (Initiated: 12/11/24, Revised: 12/11/24). Interventions: Educate resident/RP on infection control practices. Focus: Resident requires tube feeding (Initiated: 12/10/24, Revised: 12/10/24). Interventions: Provide local care to G-tube site as ordered. Focus: Resident has Stage 4 pressure ulcer to sacrum (Initiated: 12/26/24, Revised: 12/26/24). Interventions: Administer treatments as ordered. Focus: Resident has a tracheostomy (Initiated: 12/10/24, Revised: 10/10/24). Interventions: Oxygen via trach collar at 5L continuously. Record review of Resident #217's Physician Orders revealed the following order from MD P: - Contact Isolation, every shift. Follow facility policy-Use contact precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Ordered on 1/7/25. In an observation of Resident #217 on 1/7/25 at 10:44 a.m., there was a contact isolation sign on her door with PPE outside the room. The resident was lying on her left side with her eyes closed. She had a tracheostomy with 10L of oxygen, a foley catheter, and a gastrostomy tube. In an observation of Resident #217 on 1/8/25 at 9:39 a.m., her door was open, and Housekeeper L was in her room cleaning without any PPE on. There was still a contact isolation sign on Resident #217's door. In an interview with the Housekeeping Supervisor on 1/8/25 at 9:41am, she said when there was a contact isolation sign on the door, everyone including housekeeping had to wear a gown and gloves into the room. She said Housekeeper L was new and had just started the day before and did not know. In an interview using Spanish translator services with Housekeeper L on 1/8/25 at 9:45am, she said she thought she only wore a gown if she was going to touch the resident. She said she started at the facility in November 2024 and her trainer did not wear a gown into any of the rooms. She said she could not read the isolation sign because it was in English, and she could not read English. She said she did not know any of the signs said she had to wear a gown. Once the surveyor explained cross contamination Housekeeper L voiced understanding and the importance of wearing a gown. 3. Record review of Resident #218's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of infection and inflammatory reaction due to internal left knee prosthesis, enterococcus (a large group of lactic acid bacteria), type 2 diabetes (body does not make insulin or resists it), anemia (not enough iron), and pressure ulcer of unspecified site. Record review of Resident #218's Admission MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated normal cognition. The MDS revealed she had recent knee replacement surgery. She had an unstageable pressure injury presenting as a deep tissue injury, surgical wound, and was receiving IV medication. Record review of Resident #218's care plan dated 1/3/25, did not have the IV antibiotics, the surgical wound, or the isolation precautions on it. Record review of Resident #218's hospital records from 1/1/25 revealed she had a revision of her left total knee replacement and now had a surgical site infection with Enterococcus Faecalis (type of bacteria), which would require several weeks of IV antibiotics. Record review of Resident #218's chart revealed a nursing note from 1/2/25 that revealed the resident admitted with a diagnosis of infected left knee due to arthroplasty, she had a left knee incision and a PICC (flexible tube that's inserted into a vein in the arm and threaded into a large vein near the heart) to her RUE line for IV antibiotics. Record review of Resident #218's Physician Orders revealed the following orders from MD P: - Ampicillin Sodium Injection Solution 2 GM (type of antibiotic), 2 grams intravenously every 8 hours related to direct infection of left knee in infectious and parasitic diseases. Ordered on 1/3/25. - Ceftriaxone Sodium Injection Solution 2 GM (type of antibiotic), 2 grams intravenously every 12 hours related to direct infection of left knee in infectious and parasitic diseases. Ordered on 1/3/25. - IV-Flush SASH Method, every shift related to infection and inflammatory reaction due to internal left knee prosthesis. Ordered on 1/4/25. - Wound Treatment-Dry Dressing, every day shift, every Mon, Wed, Fri. Cleanse SDTI to Lt heel with Normal Saline or Skin Cleanser, Pat dry, apply skin prep and cover with dry dressing. Ordered on 1/6/25. - Wound Treatment-Dry Dressing, every day shift, every Mon, Wed, Fri. Monitor surgical dressing to LLE. DO not remove dressing wrap with kerlex and ace wrap, notify MD of any changes. Ordered on 1/6/25. In an interview and observation of Resident #218 on 1/7/24 at 10:35 a.m., the resident was sitting in a recliner in her room with a brace on her left leg. There was not an isolation sign on her door. A PICC line was seen on her RUA. She said she was there for an infection of her left knee and was on IV antibiotics. In an observation and interview on 1/8/25 at 9:06 a.m., LVN S administered Resident #218's Ampicillin IV via her PICC line. She wore gloves but did not wear a gown. She said enhanced barrier precautions was used for residents with an artificial opening such as a PEG tube and PICC line. She said she wore gloves but did not wear a gown. She said she had training on EBP but there was no PPE cart present in the resident's room. In an interview and observation of Resident #218 on 1/8/25 at 9:35 a.m., staff were putting an Enhanced Barrier Precaution sign on her door and PPE outside of her room. The resident said the facility had just added the sign to the door and they had not been wearing any PPE before. In an interview with the ADON/Infection Preventionist on 1/10/25 at 12:24 p.m., she said Enhanced Barrier Precautions was for any resident with artificial openings, PICC lines, catheters, or g-tubes. She said staff were expected to wear gloves and gowns with ADL care, transfers, when giving g-tube meds or IV meds, and whenever providing up close and personal care, including therapists. She said when a resident was on contact isolation, everyone needed to wear gloves, gowns, and a face shield if coming in contact with something that might splash. She said that included family, doctors, housekeeping, everyone. The Infection Preventionist said contact isolation was for residents that had MDROs like ESBL of the urine or any kind of bugs in wounds. She said if a staff member did not wear PPE into a contact isolation room, the staff member could get an infection and could transfer it to another resident. She said if staff did not wear PPE in an EBP room they could spread infections to other residents. She said she provided training on infection control and had an in-service this week and in December. In an interview with the DON on 1/10/25 at 12:54 p.m., she said she expected staff to stop and look at the isolation signs before going in and touching the patient, so they knew how to suit up. She said if someone did not wear PPE and went into a EBP room they could spread infection to and from the resident. She said if someone went into a contact isolation room without PPE, they could get an infection. The DON said for contact isolation everyone had to wear PPE, including housekeeping. Record review of the facility's policy and procedure on Infection Control (revised November 2017) read in part: The facility must establish an infection prevention and control program (IPCP) that must include: A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases .An individual Infection Control Surveillance Report designed to identify possible communicable diseases or infections before they can spread to other persons in the facility must be completed by the nurse manager or designee upon the occurrence of any infection and reported to the Director of Nursing Services . Record review of the facility's policy and procedure on Legionella Surveillance and Detection (Revised September 2022) read in part: Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Legionnaire's disease is included as part of our infection surveillance activities. Legionella can grow in parts of building water systems that are continually wet .and certain devices can spread contaminated water droplets via aerosolization. Legionellosis outbreaks are generally linked to locations where water is held or accumulates and pathogens can reproduce .As part of the infection prevention and control program, all cases of pneumonia that are diagnosed in residents> 48 hours after admission are investigated for possible Legionnaire's diseases .If pneumonia or Legionnaire's disease is suspected, the nurse will notify the physician or practitioner immediately. Residents who have signs and symptoms of pneumonia may be placed on transmission-based (droplet) precautions .Diagnosis of Legionnaire's disease is based on a culture of lower respiratory secretions and urinary antigen testing .If Legionella is detected in one or more residents, the infection preventionist will: initiate active surveillance for Legionnaire's disease, notify the water management team, notify the local health department, and notify the administrator and the director of nursing services.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessments for 2 of 8 residents (Resident #72 and #105) reviewed for care plans. The facility failed to care plan Resident #105's gastrostomy status nor tube feeding. The facility failed to care plan Resident #72s allegation that a car ran over his foot while out of the facility. This failure could place residents at risk of not receiving individualized care and services. Findings include: 1. Record review of Resident #105's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with diagnosis of gastrostomy status (opening into the stomach from the abdominal wall. Record review of Resident #105's Admission MDS assessment dated [DATE] revealed a BIMS score could not be conducted due to medical conditions. According to the MDS, the resident had diagnoses of dysphagia (trouble swallowing) and gastrostomy. The MDS revealed Resident #105 was on a feeding tube (nutrition through a tube) while a resident. Record review of Resident #105's Care Plan from 10/8/24, did not mention the gastrostomy or tube feeding. Record review of Resident #105's chart revealed the following orders from MD P: - NPO diet, NPO texture, NPO consistency. Ordered on 11/26/24. - Enteral (through the intestine)-Check Tube Placement, every shift. Check tube for proper placement by auscultation (listening) of injected air or visual inspection of aspirated (sucked out) stomach contents prior to instilling medication, and/or initiating a feeding. Ordered on 11/26/24. - G Tube Site Care, every day shift. Check GT site daily for s/s of infection. Cleanse with Normal Saline or soap and water as appropriate. Apply dry dressing if drainage noted. Ordered on 11/26/24. - Enteral Feed Order, every shift. Isosource 1.5 at 60 ml/hr via feeding tube for 22 hours, to run continuously until total volume of 1320 ml administered. May remove for care and services. 2 hour bowel rest every 24hr. Ordered on 12/23/24. Record review of Resident #105's chart revealed an H&P dated 12/12/24 from NP M, which revealed the resident received a gastrostomy tube and started on tube feedings before he was admitted to the facility on [DATE]. Record review of Resident #105's nurse's note dated 12/13/24 by LVN C, revealed the resident was on g-tube feedings and tolerated them. In an observation on 1/7/25 at 9:38 a.m., Resident #105 was lying on his back in bed, with his g-tube running Isosource 1.5 at 60ml/hr. In an interview with MDS K on 1/10/25 at 9:15 a.m., he said he was responsible for comprehensive care plans triggered by the MDS. He said the acute care plans were done by the unit managers, and there were 2-3 of them. He said the unit manager would put the care plan in and then he would check to make sure the care plan made sense and had goals and interventions entered correctly. In an interview with the Clinical Resource Nurse on 1/10/25 at 12:52 p.m., she said the Unit Managers were responsible for the acute care plans. In an interview with the DON on 1/10/25 at 12:54 p.m., she said the Infection Preventionist updated the care plan regarding anything to do with infection control or antibiotics. She said there was not anyone specific who updated the care plans and that everyone was doing it since they were merging over to the new EMR system. She said there were care plans in the old system and care plans in the new system. She said as the resident's quarterly review came up they were merging the care plans over to the new system and they had a year to use the old system. The DON said all of the leadership team was updating the care plans and there was not one specific person. 2. Record review of Resident #72's face sheet revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnosis included multiple sclerosis and seizures. Record review of Resident #72's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #72's care plan dated 3/3/23 - Current revealed the resident was at risk for injury related to falls and was resistant to care. He also rejected or resisted care (taking medications/injections ADL assistance or eating), refused air mattress, and wound treatments. Interventions were to talk to resident about reasons for refusal of care and potential risks and identify times/approaches/staff that result in least resistance. When care is refused, remind resident of potential risk. Coax but do not force compliance. Record review of Resident #72's care plan initiated 12/9/24 revealed no documentation of his allegation that a car ran over his foot or any other behaviors. Record review of Resident #72's nursing note dated 12/6/24 written by LVN O revealed the resident complained of right foot pain due to a car running over his foot 2 days ago. No swelling noted, no warmth to touch, no bruising on right foot. Resident medicated for pain, NP notified, and new order received for right foot x ray stat. Record review of Resident #72's Radiology report dated 12/6/24 revealed no fractures to right ankle, foot, or tibia and fibula. In an interview on 1/8/25 at 4:30 p.m., LVN A said Resident #72 returned to the facility from the store late at night and told him someone hit him. He said the resident informed him the ambulance brought him back to the facility and nothing was wrong with him. LVN A said he assessed the resident, and he was normal with no pain. He said he did not report the incident to anyone and did not document because nothing was wrong. He said if something was wrong, he would have notified the MD. LVN A said he left to go home and was off work for the next few days. In an observation and interview on 1/9/25 at 11:52 a.m., of Resident #72, he shrugged his shoulder when asked if he had an incident where a car ran over his foot. He said he had normal pains. In an interview on 1/9/25 at 12:28 p.m., the Social Worker said she was unaware of the alleged incident with Resident #72. She said she would have care planned it, determined what happened, reviewed medications, and tried to prevent it from happening again. In an observation on 1/9/25 at 12:49 p.m., the Social Worker conducted a BIMS assessment on Resident #72 with a result of 14 of 15 which indicated no cognitive impairment. In an interview on 1/9/25 at 1:35 p.m., the Administrator said she was not aware Resident #72 said his foot was run over by a car until the Surveyors started investigating. She said the incident should have been care planned, staff in-serviced, and education provided to the resident. She said Resident #72 did go in and out the facility and she warned him before to be careful. She said he was not deemed incompetent and had the right to make the decision to go out. In an interview on 1/9/25 at 2:29 p.m., the DON said she was not aware that Resident #72 said someone ran over him and did not see the nurses note until the Surveyor showed her. She said the facility recently switched electronic systems and the note was not originally there, once the resident readmitted on [DATE] it showed up. She said the incident should have been care planned so facility staff know what accusations were made when he was out of the building. She said even though he said he was run over; he was alert and oriented and the facility could not force him to stay but could continue to monitor for pain and talk to him about being careful. In an interview on 1/10/25 at 8:50 a.m., LVN O said (on 12/6/24) Resident #72 asked her for pain medicine. She said he reported his foot was hurting. She assessed his foot and saw no swelling, redness, warmth, and no apparent injury. She said the NP reported to her approximately 10-15 minutes later that Resident #72 said a car ran over him. LVN O said she was not previously aware of that allegation. She said she reported it to the next nurse but did not report it to the DON or Administrator because she thought they knew since it happened a couple of days ago. In an interview on 1/10/25 at 9:06 a.m., NP A said Resident #72, who was not her patient, reported to her (on 12/6/24) that his ankle was hurting, and he got hit by a car approximately 2 days ago. She said there was no apparent injury. She said she notified the MD, and ordered an x-ray on his ankle, foot, and tibia/fibula. In an interview on 1/10/25 at 9:15 a.m., MDS K said he was unaware of the incident where Resident #72 alleged his foot was ran over by a car. He said one of the Unit Managers would have updated the care plan. He said the incident was not discussed in morning meeting. He said if aware, he would have made sure psych services were implemented to ensure his mind was right and reviewed his medications. In an interview on 1/10/25 at 9:30 a.m., Unit Manager T said the MDS K and MDS R primarily updated care plans, but she was able to do them if asked. She said LVN W did staffing and oversaw falls and incidents on the care plans. She said if facility staff asked her to do a care plan she would because she was a nurse, but she did not really have anything to do with them. She said she was just notified of the incident with Resident #72 today and no one said anything to her about his foot being ran over. She said she did not recall discussing the incident in morning meeting. She said she would have put something in place, monitored him for pain, determine what happened, and educate him on safety. In an interview on 1/10/25 at 12:20 p.m., the Administrator said MDS K and MDS R updated the care plans. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated March 2022 read in part, .a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation . 1.The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment and no more than 21 days after admission . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

Based on observation, interview and record review, the facility failed to identify and ensure that residents received the necessary treatment and services, to promote healing and prevent infection for 2 of 9 residents (CR#1 and Resident #2) reviewed for pressure ulcer in that: -The facility failed to identify and treat pressure sore on CR#1's penis, left foot 5th toe, Right Toe Digit 1, great -The facility failed to provide CR#1 with an air mattress for 20 days with multiple diagnoses of Stage 4 pressure ulcers. -The facility failed to initiate precautions for pressure sores when an order was not obtained for air mattress. -The facility failed to prevent progression of the CR#1's Stage 4 Sacral Pressure Ulcer that was not getting better and enlarged from 6x6.2x0.4 cm on 2/27/24 to 10.7x8.9x0.4 cm on 4/15/24, had odor and exhibited signs of infection. -Resident #2's Pressure wounds dressing was not changed as per physician's orders. An Immediate Jeopardy (IJ) was identified on 5/2/24 at 3:46 p.m. While the IJ was lowered on 5/5/244 at 4:27 p.m., to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy at a scope of pattern while the facility continued to monitor the implementation of effectiveness of their plan of removal. These failures placed residents with multiple Stage 4 pressure ulcers and those who are at risk of developing wounds at risk of hospitalization , surgeries, sepsis infection, a decline in health, and pain. Findings included: CR #1 Record review of Resident#1's face sheet dated 4/24/24 revealed he was a [AGE] year-old male admitted to the facility initially on 2/2/24 and readmitted on [DATE] with a diagnosis of pain, type 2 diabetes, elevated white blood cell count, pressure ulcer of right lower back unspecified stage, and pressure ulcer of sacral region, unstageable. Record review of CR#1's comprehensive MDS dated [DATE] revealed a BIMS score of 8 indicating moderately impaired cognition. CR#1 required substantial maximal assistance for eating, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear and personal hygiene. CR #1 was dependent on staff for rolling left and right, sitting to lying, lying to sitting on side of bed, and sitting to standing and chair/bed-to-chair was not attempted due to medical condition or safety concerns. CR#1 could not attempt toilet/transfer, tub shower transfer, car transfer and walk 10 feet due to CR#1's current illness. CR#1 had diagnosis of local infection of the skin and subcutaneous tissue, pressure ulcer of unspecified site, Pressure ulcer of sacral region, unstageable, hypertension (high blood pressure), neuralgia and neuritis, and diabetes insipidus. Record review of CR#1's Care plan dated 4/24/24 revealed, CR#1 had an indwelling foley catheter related to impaired skin integrity. He was at risk for skin impairment related to acute skin impairment, impaired mobility, muscle weakness and incontinence with interventions as administer medications as ordered, follow facility policies/protocols for the prevention/treatment of skin breakdown, and monitor nutritional status. CR#1 was identified for a pressure area: Stage: unstageable, Right heel with the goal to have skin remain clean and dry and area will heal over the next 90 days. The interventions included: Encourage by mouth and fluid intake within dietary limits, keep family/responsible party and MD informed of CR#1's progress, assist with turn/repositioning every two hours and prn, Use padding between pressure areas and positioning devices for proper body alignment. Provide pressure relieving device for bed and wheelchair. Monitor labs and report and report to MD, and Dietary consult for proper nutrition resolve pressure area. CR#1 had a stage 4 pressure ulcer Sacrum with interventions such as Drawsheet to be used when positioning patient, Notify physician of abnormal labs, Obtain lab work as ordered, Use of suspension devices, pillows, and /or wedges to reduce pressure on heels and pressure points, and Provide Wound Care as directed by physician order. CR#1 also had stage 3 pressure ulcer (12,16) right ischium with interventions such as: Patients who rely on nursing staff for positioning will be turned and repositioned every 2 hours and as needed, Perform nutritional screening, Adjust diet/supplements as indicated to reduce the risk of skin breakdown, Pressure redistribution support cushion in chair/wheelchair, Pressure redistribution support surface mattress on the bed, Provide Wound Care as directed by physician Order, Use of suspension devices, pillows, and /or wedges to reduce pressure on heels and pressure points, Obtain lab work as ordered, Notify physician of abnormal labs, and Drawsheet to be used when positioning patient. Record review of CR#1's Physician Orders dated 4/30/24 revealed the following orders: *2/20/24 Nectar thickened liquids, puree *2/21/24 Weekly head to toe 1 time weekly *Wound Supplement (30ml) Oral one time daily dated 2/22/24 *Supplement pass (120 cc) Oral one time daily dated 3/1/24 and discontinued 4/8/24 *3/7/24 Wound Treatment- Santyl 3 times daily *3/12/24 Wound Treatment-Collagen 1 Time Daily *3/12/24 Wound Treatment- Santyl 3 times weekly *3/13/24 Wound Treatment- Collagen 1 Time daily discontinued 3/27/24 *3/13/24 Wound Treatment- Collagen 1 Time daily *3/13/24 Wound Treatment- Santyl 3 times weekly *3/15/24 Pre-Wound Treatment- Pain intensity Score-Can verbalize 1 time daily *3/15/24 Post Wound Treatment- Pain intensity Score- Can verbalize 1 Time daily * *3/27/24 Wound Treatment- Santyl 1 Time Daily *3/27/24 Podus Boot (S) 1 time daily *4/11/24 Initiate IV Access 1 Time Daily *4/11/24 IV Dressing Change Every 1 Week Further review of CR#1's orders did not reveal orders for an air mattress. Record review of CR#1's February 2024 TAR dated 2/20/24- 2/29/24 revealed: Wound Treatment-Dry Dressing by Shift Starting 2/20/24 Discontinued 2/21/24 Cleanse Wound to Sacrum with normal saline or skin. Cleanser. Pat Dry. Cover with Dry Dressing. Wound Treatment- Apply Betadine Three Times Weekly Starting 2/21/24 Order date 2/21/24 Discontinued 3/6/24. Clean wound to right heel with normal saline pat dry, apply betadine and cover with dry dressing. RP Aware Wound Treatment-Collagen Three Times Weekly Staring 2/21/24 Order [NAME] 2/21/24 Discontinued 3/6/24. Notes: Clean wound o sacrum with normal saline pa dry apply collagen and cover with dry dressing. RP aware. Wound Treatment-Collagen Three Times Weekly Staring 2/21/24 Order [NAME] 2/21/24 Discontinued 3/12/24. Notes: Clean wound o sacrum with normal saline pat dry apply collagen and cover with dry dressing. RP aware. Wound Treatment- Apply Betadine Three Times Weekly Starting 2/21/24 Order Date 2/21/24. Discontinued 3/6/24. Notes: clean wound to right heel with normal saline pat dry apply betadine and cover with dry dressing. RP aware. Wound Treatment- Collagen Three Times Weekly Starting 2/21/24 Order Date: 2/21/24 Discontinued: 3/6/24 Notes: Clean wound to sacrum with normal saline pat dry apply collagen and cover with dry dressing. RP aware. Wound Treatment- Collagen Three Times Weekly Starting 2/21/24 Order Date: 2/21/24 Discontinued: 3/12/24 Notes: Clean wound to right Ischium with normal saline pat dry apply collagen and cover with dry dressing. RP aware. Wound Treatment- Collagen Three Times Weekly Starting 3/6/24 Order Date: 2/21/24 Discontinued: 3/12/24 Notes: Clean wound to sacrum with normal saline pat dry apply collagen and calcium alginate cover with dry dressing. RP aware. Wound Treatment- Santyl Three times weekly Starting 3/7/24 Order date 3/6/24. Discontinued 3/12/24. Notes: clean wound to right heel with normal saline pat dry apply Santyl and cover with dry dressing. RP aware Wound Treatment Collagen One time daily starting 3/13/24 Order date 3/12/24 Discontinued 3/27/24. Notes: Clean wound to sacrum with normal saline pat dry apply collagen and calcium alginate cover with dry dressing. RP aware Wound Treatment- Collagen One time daily Starting 3/13/24 order date: 3/12/24 discontinued 3/27/24 Notes: Clean wound to sacrum with normal saline pat dry apply collagen and calcium alginate cover with dry dressing. RP aware. Wound Treatment-Collagen One time daily starting 3/13/24 order date: 3/12/24 Completed. Notes: clean wound to right ischium with normal saline pat dry apply collagen and cover with dry dressing. RP aware. Wound Treatment-Santyl Three times Weekly Starting 3/13/24 Order date: 3/12/24 Completed. Notes: clean wound to right heel with normal saline pat dry apply iodosorb and cover with dry dressing every other day. RP aware. Podus Boot(s) One time daily Starting 3/27/24 Order Date: 3/27/24 Completed Notes: Apply heel protector boots daily RP aware. Wound Treatment-Santyl One time daily Starting 3/28/24 Order Date: 3/27/24 Completed Notes: Clean wound to sacrum with normal saline pat dry apply Santyl and calcium alginate cover with dry dressing. RP aware Record review of CR#1's Wound Evaluation & Management Summary dated 2/27/24 revealed the following 1.Site 1-Stage 4 Pressure Wound Sacrum Full thickness: *Wound size 6x6.2x0.4cm, *Surface Area: 37.20 cm, *Exudate: Light serosanguinous, *granulation tissue: 100%, *Wound progress: not at goal .Dressing treatment plan .Alginate calcium apply once daily for 20 days. Collagen sheet apply once daily for 30 days, Secondary Dressings: Gauze island with bdr apply once daily for 9 days, *Plan of Care Reviewed and Addressed: .Float heel in bed; off-load wound; Cleanse with wound cleanser at time of dressing change; Group 2 Mattress; Pressure Off-loading boot; multi vitamin once daily by mouth; Vitamin C 500mg Twice daily by mouth. 2.Site 2-Stage 4 Pressure Wound of the Left heel full thickness: Wound Size 5x6x0.2 cm. This visit's measurements are noted by the clinician to be exactly the same as the previous visit. *Surface Area: 30.00 cm, *Exudate: Light Serous, Thick adherent devitalized necrotic tissue: 80%, granulation tissue: 20%, *Wound progress: not at goal .Dressing Treatment Plan: Primary dressing(s) Santyl apply every two days for 20 days, Secondary dressing(s): gauze island with bdr apply every two days for 9 days. *Plan of Care reviewed and addressed: Float heel in bed; off-load wound; Cleanse with wound cleanser at time of dressing change; Group 2 Mattress; Pressure off-loading boot; Multi vitamin once daily by mouth; Vitamin C 500mg twice daily by mouth. Site 2: Surgical Excisional debridement procedure: Remove necrotic tissue and establish the margins of viable tissue. *Consent for procedure: Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 02/17/2024 to the patient who indicated agreement to proceed with the procedure(s). *Procedure note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise 3.0cm^2 of devitalized tissue and necrotic muscle level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 80 percent to 70 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. 3.Stage 3 Pressure wound of the right ischium . Record review of CR#1's Wound Evaluation & Management Summary dated 4/9/24 revealed: Stage 4 Pressure Wound Sacrum full thickness: *Wound size 8.9x6.8x0.4 cm, *Surface Area: 60.52 cm, *Peri wound radius: Surrounding DTI (Purple/Maroon), *Exudate: Moderate Serous, thick adherent devitalized necrotic tissue: 10%, *Slough: 10%, *Granulation tissue: 80%, *Wound progress: Exacerbated due to generalized decline of patient. Dressing treatment plan: primary dressing(s) Alginate calcium apply once daily for 30 days; Santyl apply once daily for 9 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 23 days. Plan of care reviewed and addressed: Float Heels in Bed; Off-Load Wound; Cleanse with wound cleanser at time of dressing change; Group-2 Mattress; Pressure Off-Loading Boot; Multivitamin Once Daily PO; Vitamin C 500mg Twice daily PO. SITE 1: surgical excisional debridement procedure: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise 9.08cm^2 of devitalized tissue and necrotic muscle level tissues along with slough and biofilm were removed at a depth of 0.4 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 20 percent to 5 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. Record review of CR#1's Local hospital labs dated 4/15/24 revealed WBC 26.7, Hemoglobin 8.1, Sedimentation rate 58, Platelet count 504, Procalcitonin 2.53 and lactic acid was 2.3. Record review of CR#1's WOUND EVALUATION & MANAGEMENT SUMMARY dated 4/15/24 revealed: Appetite-Fair .Bed- Group 1 .Stage 4 Pressure Wound Sacrum full thickness- *Wound size 10.7 x 8.9 x 0.4 cm, *Surface area: 95.23 cm, *Exudate: Light serous, Thick adherent devitalized necrotic tissue: *100%, Wound progress: Exacerbated due to generalized decline of patient. Expanded evaluation performed: The progress of this wound and the context surrounding the progress were considered in greater depth today. Impaired nutritional status discussed with patient, family, nursing staff, and/or dietitian. *Dressing treatment plan: Primary Dressing(s) Sodium hypochlorite solution (Dakin's) apply once daily for 30 days: 0.25% soaked gauze. Secondary Dressing(s) Gauze Island w/ bdr apply once daily for 17 days. Plan of care reviewed and addressed- *Recommendations: Float Heels in Bed; Off-Load Wound; Cleanse with wound cleanser at time of dressing change; Group-2 Mattress ; Pressure Off-Loading Boot ; Multivitamin Once Daily PO ; Vitamin C 500mg Twice daily PO. SITE 1: Surgical excisional debridement procedure indication for procedure Remove Necrotic Tissue and Establish the Margins of Viable Tissue, Remove Thick Adherent Eschar and Devitalized Tissue. Consent for procedure: Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 02/06/2024 to the patient who indicated agreement to proceed with the procedure(s). Procedure note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 19.05cm^2 of devitalized tissue and necrotic muscle level tissues were removed at a depth of 0.5 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 100 percent to 80 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. Record review of CR#1's Local Hospitalist History & Physical dated 4/16/24 at 7:26 am by Physician revealed, . previous admissions for infected decubitus ulcers who was discharged last from our facility 2/2nd after debridement of decubitus ulcer and was continued on IV antibiotics for 2 weeks who presents this time from SNF [facility] with leukocytosis. Reportedly patient was placed again IV antibiotics through mid-line in facility. He was found to have significantly elevated WBCs so he was sent to the ER. In our ER he was found to have WBCs 26.7, Anemia with Hgb of 8.1, Lactic acid of 2.3 so he was referred for admission for further evaluation. Spoke with CR#1's family member who reported that patient has been declining recently in facility. She noted to have worsening wounds and worsening mental status. She reported very poor po intake for over the last 2 months. She reported being angry at the facility for not doing enough for him. Assessment and Plan revealed, 1. Sepsis: Secondary to pneumonia and suspected infected sacral decubitus ulcer. Continue IV fluid and IV antibiotics. Admit to tele. Close monitor to VS and wbc's 2. Gram negative pneumonia: Left lower lobe. empiric broad spectrum antibiotics Will add and suction. Pulmonary hygiene, 3. Multiple decubitus ulcers presented on admission: Possible infected sacral decubitus, Continue antibiotics. surgical eval for possible need for debridement, 4. Significant leukocytosis: Secondary to sepsis. Monitor. 5. Lactic acidosis: Secondary to above. Monitor. 6. Chronic Anemia: Likely anemia of chronic disease. Monitor. 7. Possible UTI associated with indwelling foley catheter POA: Exchange foley. Empiric antibiotics. Follow cx 8. History of dysphagia: Speech eval. He was placed on pureed last hospitalization . 9. Acute Metabolic encephalopathy: Likely secondary to pneumonia and sepsis. Record review of CR#1's Hospital assessment dated [DATE] at 2:08 pm revealed: #1 Sacrum: Pt with extensive stage IV pressure ulcer with ~100% black necrotic tissue / bone exposed / foul odor / + undermining / + stringy slough. This site would benefit from surgical consult. #2 (R) Ischium: Unstageable. Site with 100% soft brownish yellow slough coverage / foul odor. This site would benefit from surgical consult. #3 (L) Ischium: Superficial skin breakdown / 100% red/pink tissue. #4 (R) heel: 100% stringy yellow slough coverage / max foul odor / max drainage amount. This site would benefit from surgical consult. Support surface/specialty bed recommendation: Low air loss replacement with bed frame. Recommended consults: General surgeon, RN and Attending MD notified of recommendation. Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/24 at 8:20 pm revealed: Assessment and Documentation: *Head to Toe skin assessment completed. Yes, *Skin integrity intact. No, Wound 01/27/24 Diabetic Ulcer Right Heel (Active) First Assessment Date/First Assessment Time: 01/27/24 1651, Primary Wound Type: Diabetic Ulcer Orientation: Right Location: Heel. Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM revealed, Current Dressing Status Clean, dry, and intact, Wound 01/27/24 Pressure Injury Midline Sacrum (Active). First Assessment Date/First Assessment Time: 01/27/24 1651, Primary Wound Type: Pressure Injury Orientation: Midline, Location: Sacrum Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM revealed: Current Dressing Status Clean, dry, and intact, Wound 01/27/24 Pressure Injury Left Ischium (Active), First Assessment Date/First Assessment Time: 01/27/24 1651, Primary Wound Type: Pressure Injury Orientation: Left Location: Ischium Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM, Current Dressing Status Clean, dry, and intact, Wound 01/27/24 Pressure Injury Right Ischium (Active), First Assessment Date/First Assessment Time: 01/27/24 1651, Primary Wound Type: Pressure Injury Orientation: Right Location: Ischium Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM, Current Dressing Status Clean, dry, and intact, wound 04/16/24 Other (comment) Penis (Active), First Assessment Date/First Assessment Time: 04/16/24 0830, Present on Original Admission: Yes, Primary Wound Type: Other (comment) Location: Penis. Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM, Wound Base Appearance Red, Peri-wound Assessment Induration; Red, Urethral Catheter Other (Comment) 16 Fr. (Active) Placement Date/Time: 04/16/24 1800 Present on Admission: NO Reason for Insertion: (c) Healing of open sacral or perineal wounds in incontinent patients Inserted/Placed by: (c) Catheter Type: (c) Other (Comment) Tube Size : Catheter . Assessments 4/16/2024 8:20 PM Already in place, Site Assessment Edema, Collection Container Standard drainage bag to dependent drainage, Securement Method Securing device, Daily Review of Reason for Continuing Urinary Catheterization Healing of open sacral or perineal wounds in incontinent patients. Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/24 at 8:20 pm revealed: Dorsal (foot); Left Description (Comments): left foot 5th toe, Assessments Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM, Primary Dressing Open to air, Wound 04/16/24 Other (comment) Dorsal (foot); Right Toe D1, great (Active) Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/24 at 8:10 pm revealed: First Assessment Date/First Assessment Time: 04/16/24 0810 pm, Present on Original Admission: Yes, Primary Wound Type: Other (comment) Orientation: Dorsal (foot); Right Location: Toe D1, great Record review of CR#1's Local Hospital 2 RN Skin Assessment Note dated 4/16/2024 8:20 PM revealed, Wound Base Appearance Slough, Primary Dressing Open to air First assessment dated [DATE] at 8:30 pm revealed, Present on Original Admission: Yes Primary Wound Type: Other comment) Location: Penis Assessments 4/16/2024 8:20 PM Wound Base Appearance Red, Peri-wound Assessment Induration; Red Urethral Catheter Other (Comment) (Active) Record review of CR#1's Local Hospital PT Wound Care Evaluation dated 4/16/24 at 9:50 am revealed Principal Problem: . *Skin Integrity: Diabetic Ulcer Right Heel: Wound appearance: necrotic; slough; pink; tan, exposed structures: Bone necrosis, Wound 6.5x5.5x2 cm, Surface area 35.75 cm^2, Wound volume 71.5 cm^3, drainage amount: large, drainage odor: maximum, drainage description: yellow . *Pressure Injury Midline Sacrum (Active), Stage 4, Wound appearance: Necrotic; Black; Brown; Slough, Exposed structures: Bone; Bone necrosis, Shape: irregular, Peri-wound assessment: pink, Wound 9.5x 7x 3.5 cm, Wound surface area 66.5 cm^2, Wound volume 232.75 cm ^3, drainage amount: moderate, drainage odor: Maximum, drainage description: Brown; Black . Pressure Injury Left Ischium (Active):Wound appearance: Red; Pink; Slough, Peri-wound assessment: pink; Maceration, Wound 5x 3.5 cm, Wound surface area 17.5 cm^2, drainage amount: scant, drainage description: serosanguineous; serous. Pressure Injury Right Ischium (Active): Wound appearance: slough; tan; pink, Peri-wound assessment: Pink, Wound 3.8 x 3.5 x0.2 cm, Wound Surface area 13.3 cm ^2, Wound volume 2.66 cm^3, drainage amount: small, drainage odor: minimal. Incision Buttocks (Active), Wound 4/16/24 Penis (Active): wound appearance: red, Peri-wound assessment: Induration, 4/16/24 Dorsal foot-Left (Active): Peri-wound assessment: clean; intact, drainage amount: none, drainage odor: none. 4/16/24 Dorsal Left foot (Active): Peri-wound assessment: clean; intact. 4/16/24 Dorsal right toe D1, great (Active): Current dressing status: Absent, Wound appearance: slough. Wound 4/16/24 Abrasion Upper Back (active): Peri-wound assessment: clean, dry and intact. In an observation and attempted interview on 4/30/24 at 9:15 am with CR#1 at the Local Hospital observation revealed CR #1 was seen lying in the bed with a fall mat at bedside. CR#1 appeared to have difficulty responding due to speech difficulty. In an interview on 4/30/24 at 9:25 a.m. at Local Hospital with RN she stated CR#1 had a lot of pressure sores and he had been in the hospital for 14 days. She stated a lot of the pressure sores were unstageable on hips, right heel, and his sacrum. She stated the sore on the sacrum is unstageable and the hospital did debridement on the sacrum and the right heel. In a record review and interview on 4/30/24 at 9:46 am with RN, Quality & Patient Safety Dept. of CR#1's hospital records she stated CR#1 admitted to the local hospital on 2/2/24 and had been admitted to the hospital the first time on 1/26/24 and discharged on [DATE] to the Nursing facility. She stated CR#1 had multiple decubitus ulcer present on admission on 1/26/24 on the heel, sacrum and buttocks and readmitted to the hospital on 4/15/24. She stated CR#1 was admitted for pneumonia of left lung, and sepsis secondary to pneumonia, Wbc 26.7, additional pressure ulcers on his scrotum, dorsal left foot, dorsal right foot, right toe, penis, abrasion to upper back and sacrum. She stated record review of pressure ulcer and observation of the pictures revealed large pressure sore, much worse from when he was discharged from the hospital. In a record review and interview on 4/30/24 at 11:02 am of CR#1's local hospital records with BSN, Wound Ostomy Nurse he stated CR#1's ulcer of the right heel could be from the eschar coming off and it was still unstageable. He stated they keep the eschar stable because they did not know the underlying condition of the patient. He stated he did not know the underlying condition of the patient, but it was usually due to sepsis, and/or high blood pressure. He stated CR#1 had sacral debridement on 1/31/24, 4/24/24 surgery on right foot, incision and partial calcinatory with skin biologic. CR#1 was found to have severe protein malnutrition and was diabetic. He stated the dietician met with him on 4/19/24 and CR#1 was tolerating the pureed food. He stated they are discussing whether CR#1 would get an ostomy and PEG tube for optimum healing, but he was receiving nutrition supplements. The Wound Ostomy Nurse stated the type of dressing was important to see how CR#1's wound was being cared for. He stated CR#1's right heel opened up because the Nursing home added Santyl. He stated if CR#1 had poor circulation then you do not want to debride the wound. He stated sepsis was infection to the bloodstream that can lead to multiple organ failure. He did have elevated lactic acid, but it went down. He stated the Nutrition pays a big part of his wound and if he was not getting any nutrition supplements that was huge, no peg, no ostomy and off-loading was the key. He stated if CR#1 was not turning or repositioning that can get bad fast. He stated CR#1 required strict turning and support surface. In a record review and interview on 4/30/24 at 11:46 am at Local Hospital Physician she stated the wounds getting better depends on a lot of things like nutrition, and wound care. She stated CR#1 did not have a feeding tube, and she did not know how much nutrition he was getting. She stated Albumen was 1.7 and pre albumen. She stated CR#1's albumen had increased to 1.4 and CR#1 needed air fluidized. She stated CR#1 was on a specialty bed and was being turned. CR#1 was having contamination of stool and they could not account for what happened to him for the 2 months. He was in the nursing facility. In an interview on 4/30/24 at 7:50 pm with CR#1's family member she stated on 4/15/24, she popped into the Nursing facility unannounced to see CR#1 and on this day, she walked into CR#1's room and his room door was left almost closed. She stated she walked in the room and noticed that CR#1 was laying on his side and he was bare bottom, no diaper on, no depend on, not covered, and she freaked out. She stated there was a fly in the room and her eyes noticed on CR#1's bottom and she saw bone. She stated she went into the hallway asking where the nurse was and there was no one in the hallway. She stated the caregiver said she was changing CR#1 and she had to go get the diaper. CR#1's family member asked the CNA shouldn't she already have the diaper if she was changing him. CR#1's family member stated the CNA said she went to go get the wound nurse. She stated she told the CNA that there was a fly in the room and flies carry disease. She stated she noticed an IV in CR#1's arm and no one told her anything. She stated she holds his Medical Power of Attorney and she spoke with the DON. CR#1's family member stated the in-house Doctor came twice a month and the Doctor mentioned CR#1's wbc was high. She said there were antibiotics is in CR#1's arm and she said she would rather CR#1 go to the hospital to find out what type of infection he is fighting or what he has. CR#1's family member stated she told the nursing facility this at around 11 am or 11:30 am on 4/15/24. CR#1's family member stated the DON did not want to call 911 and said they gave CR#1 antibiotics. CR#1's family member stated before she gave CR#1 a needle they were supposed to call her. She said the DON went to her computer and there was no note. She stated the DON apologized and said someone was supposed to call her. She said she did not give any kind of consent to go to the hospital by 911. CR#1's family member stated the DON did not want to call the ambulance and said the only time they call if it's a dire situation, but she said CR#1 has an infection and they don't know what it is. She stated it was 7 pm and she was waiting, and she was crying and could not even look at CR#1. CR#1 stated she went to her car and called another family member, and it was overwhelming, and they just did not care. CR#1's family member stated the nursing facility wanted to call local transportation company and when CR#1 was checked into the hospital, they took pictures of the wounds. She stated CR#1's bed sore on his bottom, and his foot was a Stage 4 where the bone was exposed. She stated when CR#1 got to the hospital he had pneumonia, he was severely dehydrated and malnutrition. CR#1's family member stated the facility just said that CR#1 was not eating, but it was their job to find another way to get him to eat. She stated they should have called her to ask if she wanted them to do a feeding tube, but no one called her. She stated when CR#1 got to the hospital they said he was 144 lbs and he had to have 2 bags of blood, 2 surgeries this week on both bed sores because they were infected with sepsis. She stated CR#1 was in the hospital for 2 weeks and CR#1 also had a pressure sore on his penis and scrotum that they found on 4/15/24 and she has the pictures the hospital took. She stated when CR#1 got to the facility before he was eating, and he just dropped a lot of weight. She stated CR#1 was found turned over with nothing on his bottom, the curtain was not pulled back, the door was almost closed, and the IV was in his arm. She said the facility did not come to her with the 2nd care plan until she went to talk with them on 4/15/24 and they said maybe you can put him on hospice or maybe put him on a feeding tube on that day. She stated the DON did not ask her about a feeding tube until 4/15/24. In an interview on 4/30/24 at 2:33 pm with the Wound care Nurse she stated CR#1 admitted , left and went home and came back the next day long-term. She stated CR#1 was bed bound, admitted with wounds, and was a total assist resident. She stated CR#1 admitted with a wound to the sacrum, heels, and ischium. She stated the Wound Care Doctor saw CR#1 every week. She stated the sacrum wound was not improving any, but the ischium was. She stated the wound was beefy red until a week or so before his last stay. She stated the day of CR#1 being transferred to the hospital the Wound Care Doctor just gave orders to try to turn the wound around. The Wound Care Nurse stated CR#1 had 2 family members, but they were aware of what was going on. She stated the other Doctor made rounds that day on 4/15/24 and she does not put a clean dressing on a soiled body, so she put the button (call light) on and waited for the CNA and she came and started gathering materials to do incontinent care. She stated she was rounding with the Doctor and the CNA called her and she went downstairs, and the CNA had finished cleaning him up. She stated when the CNA initially called her, she was in with the [TRUNCATED]

Based on interview and record review, the facility failed to ensure that personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -The facility failed to initiate and conduct CPR immediately after finding CR#1 unresponsive. -The facility failed to immediately contact 911 for EMS services; EMS was not contacted until approximately 31 minutes after the resident was found unresponsive. -The facility to perform CPR appropriately as LVN B instructed a CNA to clean CR#1 of a bowel movement. -The facility failed to follow CPR protocol resulting in delayed treatment, improper documentation, and delayed notification to the family and physician. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:52 p.m. While the IJ was removed on [DATE] at 2:07 p.m., the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could affect Full Code Residents who could need CPR by placing them at risk of death. Findings Included: CR#1 Record review of CR#1's face sheet revealed CR#1 was a [AGE] year-old female resident admitted to the facility on [DATE]. CR#1 was discharged at the time of death on [DATE] at 8:06 am. CR#1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#1 Comprehensive MDS assessment dated [DATE] revealed CR#1 had a BIMS score of 11 indicating moderately impaired cognition. CR# required extensive assistance by one-person physical assist for all ADLs. CR#1 was incontinent to bowel and bladder. CR#1 had a g-tube. Record review of CR#1s Care plan dated ,d+[DATE] through present revealed CR#1 was full code status. Record review of Progress Note dated [DATE] revealed LVN B entered note on [DATE] at 8:55 a.m. that read, went in to speak to patient during rounds, although patient is nonverbal. Left out of room when informed by another CNA another patient (roommate) needed my assistance in the dining room. Note effective date and time of the occurrence was [DATE] at 6:30 a.m. Record review of Progress Notes dated [DATE] revealed LVN B entered note on [DATE] at 9:07 a.m. that read, When going to do blood sugar and give meds, I spoke to patient and told her I need to do her blood sugar, as normal sometimes she will respond, I took her hand to do the blood sugar and after I stuck her and got the blood, the reading was 59 and a BP of ,d+[DATE] with a pulse of 101, I noticed she did not respond as usual. I then shook patient and called out her name again with no response. Then 911 was immediately called. I then pulled back the covers and still got response, I then check for a pulse and got no pulse, then CPR was started. The med aide was called from the hallway for help, I instructed her to get the other nurse while continuing CPR. Upon the other nurse coming in, he went to get the crash cart, when he returned, the patient was placed on the floor on a backboard and CPR was continued until EMS arrived, case was then transferred to EMS. Effective date and time of occurrence was [DATE] at 8:55 a.m. Record review of SBAR Communication Form completed by LVN B on [DATE] at 9:22 a.m. revealed CR#1's symptoms of low vitals began on [DATE]. Things that make the symptom better are CPR. Vitals were documented as: Pulse- 101; blood sugar- 59; BP- ,d+[DATE]. CR#1 had decreased level of consciousness, decreased mobility, no changes in respiratory evaluation, and resting pulse greater than 100. Observation and evaluation were summarized as patient not a normal baseline, vital signs taken (BP ,d+[DATE], P-101, BS-59), patient not responding, CPR started. Physician and family notified at 9:00 am on [DATE]. In an interview on [DATE] at 11:25 a.m., LVN B said she recalled CR#1. She said on that morning on the 7th ([DATE]), Monday morning, she came in and completed her rounds as normal and spoke to all of her residents. CR#1 was nonverbal, as she came back around the second time, she completed meds and blood sugar. She would ask CR#1 for her hand and say good morning. Sometimes CR#1 grunted or smiled, or sometimes didn't move. She said she held her hand and received her blood and her blood sugar was 56. She said this was alarming for her because it had not been that low for CR#1. She checked CR#1 and she didn't blink, and she removed the covers, and CR#1 didn't move. She called CMA D and instructed her to get the other nurse (LVN C). She wasn't loud because other residents were sleeping, and she didn't want to startle others. She started CPR on CR#1. Then the other nurse came in, LVN C, and they moved CR#1 to the floor and continued CPR and obtained crash cart and called 911. She said LVN C called 911 and got the crash cart. When she checked her blood sugar CR#1 was laying on her side, with her knees up like a semi fetal position. That was how she laid every day. Her bed was in the low position and she had the covers on her, and her head was elevated. She was full code. She said during CPR, she had a blood pressure cuff on her, and the vital readings were not good. She said she completed notes, incident report, and transfer document to take her out of the system. CR#1 didn't go to the hospital. EMS showed up and EMS pronounced her deceased at 8:06 a.m. She said EMS showed up at 7:51 a.m. She said between 7:25 a.m. and 7:30 a.m., somewhere in there, was when she saw CR#1 unresponsive. EMS didn't say or do much of anything. She said she was doing CPR when EMS showed up. The AED was on CR#1 and it kept saying continue CPR. EMS did not do CPR. She said that the palm and the soles of CR#1's feet were pale but not blue. Her hand was in between normal body temp and cool. She said when she started rounds CR#1 looked at her. CR#1 didn't move at that time, but that was normal. In a follow up interview on [DATE] at 1:00 p.m. with LVN B she said that when she went to check CR#1's glucose, she had not checked other parts of CR#1's vitals, like blood pressure and pulse. She said she would have checked vitals at the time of giving CR#1's medications. She said she checked sugar first. She said CR#1's sugar were 56, and CR#1 didn't move, so she checked her pulse, and didn't get a pulse. That's why she initiated CPR. She said when LVNC came to room they both did CPR and LVN C then left to get AED and call 911. She said she took the residents blood pressure, and it was ,d+[DATE] or something close to that. The blood pressure was checked during CPR, she put a cuff on CR#1 while doing CPR and hit the button and kept doing CPR. In an interview on [DATE] at 1:08 p.m., CMA D said she didn't know what time, but it was around 7 something. She went to go get the other nurse, LVN C. She said the nurse, LVN B, asked her too. She said LVN B and her went to get LVN C. She said they all three met up together at the nurse's station. She then walked back to the med cart and the nurses went to do what they had to do together. She said she didn't know if EMS ever shower up. She said she never went back to check on the resident or ask about her. In an interview on [DATE] at 2:03 p.m., LVN C said he was on duty when CR#1 coded. He said he was working on the other side, CR#1 was not his patient. He said LVN B was the nurse for the other side, for CR#1. He said he was walking out from his hall and LVN B walked out of her hall and informed him at the nursing station she had a code blue. He said they walked down there and the resident was unresponsive and had no pulse. CR#1 was full code and they started CPR. He said he called 911 and brought the crash cart. CPR continued until 911 arrived. AED was applied. LVN B checked vital signs, while he called 911. He wasn't sure what her vitals were, he just knew she had no pulse because he checked her pulse on her neck and wrist. He said her skin was cold when he checked her skin. He said her skin where he checked pulse (pointed to neck and wrist) were fine, but her extremities were cold, her feet were cold. He said he checked CR#1's neck and wrist for a pulse and didn't feel one and then checked on her ankle and didn't feel one, but she felt cold. He said at this time, he worked with the nurse and the male CNA. EMS showed up immediately. He said when EMS took over, he went to an emergency on his hall. He said he was coming from his hall, he saw LVN B rush down the hall, and they met at the nurse station, and then they rushed to the room. CR#1 was in her bed. The resident was under covers when he got into the room. He said he saw the need for CPR based on his assessment of no pulse. He said the only person who told him about the code was LVN B. He said that LVN B reported that CR#1 was unresponsive, she didn't say anything about bs, or other vitals. In an interview on [DATE] at 2:40 p.m., the DON said that the nurse, LVN B, called and said that they were finishing up the code for CR#1. LVN B explained that LVN B went into CR#1's room to check blood sugar. She said she checked the sugar, they were low, and when she grabbed her hand to check sugar, the resident would normally grab her hand back but didn't. The LVN B knew something was immediately wrong, and she went ahead called for a code. The paramedics came and when the paramedics were leaving, they told her (DON) that CR#1 already passed prior to arrival. The paramedics didn't say much of anything, and she thought they were coming back in the building because they didn't say anything. She said the paramedics should not have just left her. The LVN B said that whole situation was awkward. She said she called the police and had the police come because she needed the EMT's to come back. They did not come back; the police would not call the EMT's back because they pronounced CR#1 deceased . She said she was called around 5 minutes to 8 by LVN B about finishing up the code. LVN B did not go into details about the situation. She said that she asked her standard questions about the rounds and reporting off to each other at shift change. LVN B reported to the DON, when she checked CR#1's blood sugar she realized she was not breathing. LVN B said her blood sugar were around 58 or 59; something around there. LVN B said she then checked for a pulse and she did not get a pulse at all. She said LVN B did not mention CR#1's blood pressure at all. The nurse that LVN B was working with was LVN C. She said that LVN B said she told CMA D to call LVN C. The nurse should not leave the room, they know to not leave the room. She said at the time of documentation, she (DON) didn't have all the story, but she felt uneasy about what EMS did, so she wanted to make sure it was all documented. She said it was very important for nurses to document everything because in these situations it could be difficult to remember. She said the expectation was that a nurse should stay with resident until EMT's arrive and take over. She said that she read the notes that day ([DATE]) but had not reviewed them since. She said she talked to CMA D, but CMA D didn't have a lot to say. CMA D didn't tell her that they (LVN B and CMA D) walked together to get the other nurse. LVN C reported that she came to get him. She said she doesn't know if it was the nurse or the med aide, she did not ask him who. LVN C reported to her they moved her from bed to floor and placed her on backboard and started CPR. The nurses didn't go in details about who did what and when. She did not ask. In a follow up in interview on [DATE] at 10:35 a.m., LVN B said when she needed LVN C, she could not remember if she ran to get LVN C or if CMA D got LVN C. She said CR#1 was in the bed when she started CPR, because she couldn't move her to the floor. The bed was already low, so it was easy to do CPR in the bed. She said she didn't know if LVN C checked for the pulse. LVN C got the AED and put the pads on, and CPR was done according to the AED. She said when she started CPR CR#1 was not breathing that's one of the reason she started CPR. The other reason was her low glucose. She said the facility policy was to check the resident, check for pulse, start CPR and call for help. CPR should be initiated when there was no pulse. She said she did not look at the blood pressure cuff for the pulse reading or blood pressure because she checked her carotid for pulse. In a follow up interview on [DATE] at 11:12 a.m., LVN C said the facility policy for initiating CPR was the nurses have to alert other nurses by any means necessary. When a patient was unresponsive, and no pulse start CPR. If a patient was unresponsive with a pulse, do not do CPR. CPR was is not done on a patient that was DNR. LVN C said that he called 911 from the nurse's station phone, but he did not announce a code blue status over the intercom to alert anyone else in the building. He said LVN B said that she called a code, but he didn't hear it. He said when LVN B told him CR#1 was unresponsive he called 911 from the nurse station immediately and pushed the crash cart to the room. He said once he entered the room he did not leave the room. He said there was also a male CNA (surveyor identified as CNA A) in CR#1's room as well who was cleaning CR#1 up because she pooped. LVN B came out of the resident's room and said CR#1 was unresponsive, when he got to the room. He repeated, he took the crash cart, joined LVN B in CR#1's room, assisted getting CR#1 down to the floor, and started CPR. CNA A came in room to clean CR#1 during CPR. When AED started everyone had to step back, and then CPR would continue. Surveyor asked LVN C if incontinent care or cleaning of bowel movement should be done on a patient while CPR was in progress? LVN C did not respond. He then said the CNA only moved the blanket because it had poop on it. On [DATE] at 12:45 p.m. and 5:14 p.m. messages were left for CNA A. In an interview on [DATE] at 1:41 p.m. with the DON and Administrator, the surveyor notified them that it had been reported LVN B and LVN C were doing CPR while a CNA was providing incontinent care. and The DON and Administrator said that CPR and incontinent care should not be occurring simultaneously under any circumstances. On [DATE] at 2:08 p.m. the DON and the Administrator returned to the surveyor with LVN C and the Administrator said she wanted LVN C to clarify his initial statement and make sure surveyor understood. LVN C said that CR#1 was in the bed and there was poop all over the sheet. Himself, and LVN B brought CR#1 down to the floor and started CPR. They called CNA A from the hallway and requested him to clean the poop away to make room for CPR. The plan was not incontinent care but for comfortable CPR. In an interview on [DATE] at 12:00 p.m., CNA E said she started her shift on [DATE] around 6:30 am. She said she never heard a code being called by any nurse. In an interview on [DATE] at 10:27 a.m., CMA D said she didn't hear a code being called, for CR#1, but that doesn't mean it wasn't called. She said she could've been in a resident's room. She said that codes should be called loudly. She said when LVN B informed her about CR#1 being unresponsive, they both left the room to get LVN C. She said she was not delegated a task so she went back to passing medications. She said her responsibility was a med aide and to pass medications. In a phone interview on [DATE] at 12:12 p.m. CR#1's Family Member said on [DATE] a lady at the nursing home (phone number was DON's according to the employee phone list) called her at 9:01 a.m. and she missed the call. She returned her call at 9:07 a.m. on [DATE] and she (DON) told her the nurses tried to resuscitate CR#1 until paramedics came and took over. She (DON) said the paramedics took over and couldn't resuscitate CR#1 and she passed. She was under the impression that paramedics did CPR. Record review of Record of Death for CR#1 revealed the date and time of death was [DATE] at 8:06 a.m. DON completed record on [DATE]. Record review of EMS Report revealed 911 was called on [DATE] at 7:56 a.m. EMS arrived on scene at 8:03 a.m. EMS arrived at CR#1 at 8:04 a.m. EMS left scene at 8:34 a.m. CR#1 was found lying in the care of healthcare professionals. CR#1 was DOA (dead on arrival). AED was used prior to EMS arrival without defibrillation (without shock). CR#1 was unresponsive with no reactive eye and absent heart beat. In an interview on [DATE] at 11:32 a.m. the DON said she didn't know if LVN B ever told her a time she found CR#1 unresponsive. She just knew she went in to check the residents sugar level. She didn't ask her what time she found her unresponsive. She said she is was trying to get better as far asking questions and learning the role as the DON. She said she passed EMS around 8am when she entered work. She said LVN B reported to her that EMS did not do CPR. CPR should be initiated immediately after a resident was found unresponsive without a pulse. CPR will would not be done if the resident had a pulse. She said she didn't believe that any documentation was falsified, she believed that LVN B documented poorly, and left out details that she should have said, for example the times the events took place. She said she would expect detailed documentation. She said she believed in painting a better timeline and entering exact times. She said she didn't document the note, so she cannot say why a pulse was documented in the same note as the CPR being initiated and 911 being called. She said she believed in sitting down and documenting exactly when it happened. She said she does not know what time EMS was called. She said she believed LVN C called 911. She said 911/EMS should be called immediately when the incident occurs and the nurse is calling for help. When a code is called, the proper procedures are when resident was found unresponsive the nurse or staff should pull the call light, holler for help, send someone to call a code over the intercom for other staff to assist, and whoever is nearest should respond immediately. The responsibility was the person who found the resident unresponsive to delegate the tasks and not leave the resident. The nurse delegating tasks will know someone made the code call because they will hear it over the intercom. A code call should always be done over the intercom. She said she can honestly not say if it was called over the intercom because she was not in the building. She said she began in servicing the staff because there were some things that occurred that should not have occurred, like the nurse leaving the room. The DON said it was her (DON) responsibility to look into the incident to ensure things were done according to policy and also the administrator, if necessary. She said she was continuing to look into the incident, the process started that day and it is still ongoing. She said she didn't ask LVN B Monday ([DATE]) after she read the progress note about CR#1 having a pulse of 101 and then not having a pulse and CPR and 911 being called. She said the lack of information and lack of story is what got her attention and she addressed it with her the next day, on Tuesday, and then yesterday as well. She said she didn't know there was 30 minute delay in calling 911. She said anyone can call 911; a CNA, CMA or other nurse, any staff in the building can call 911 and doesn't have to be delegated by the nurse. She said she has reviewed all of the documents surrounding this incident. She said that there was nothing standing out to her that she didn't already address. She said the family should be notified as soon as being able to, or immediately after the emergency was over. She said this emergency ended when EMS left the building. The nurse should have notified the family when EMS left the building. She said she didn't wait an hour to notify the family. She was in the process of asking LVN B if family and doctor were notified. She said that as soon as she became aware that they were not notified she notified the family. In an interview on [DATE] at 12:06 p.m. the Administrator said she got the call on Monday, [DATE] from the DON about 8:30am and she said that CR#1 coded. The Administrator said that she was just getting in the building and she was upstairs. She said that once she got upstairs, she asked what happened. The DON said that CR#1 coded and EMS didn't take the body. She said that she (administrator) called the police because usually police show up, but EMS already had left the scene. The police called the ME and the body was released. She said that she did talk to LVN B and she reported that she saw CR#1 around 6:20 a.m. making rounds. LVN B said she went back around 7:30 a.m. and when she did the finger stick on CR#1 she didn't pull her finger back as she normally did. LVN B reported that she called her name and received a glucose reading of 59 or so. The Administrator said that LVN B had the blood pressure cuff on her arm. She said that there was no pulse and CR#1 was unresponsive. LVN B started CPR and called over her shoulder to the med aid to call for help. LVN C then came with crash cart and they continued CPR until EMS arrived, but EMS did not take over and EMS pronounced CR#! deceased . She said that she read over the documentation after the incident, she read over everything, well just the nurses notes. She said when she read the note, the Administrator believed that she had a pulse and then didn't have a pulse so CPR was started. She said she talked to the DON about it when they called the police officer. She said she didn't talk to LVN C, CNA A, or CMA D. She said that LVN B was the lead and she was the nurse for CR#1 so she only spoke to LVN B. The expectation is if anyone found a patient unresponsive and without a pulse, they are to call out and hit the call light, begin CPR and the other nurses will come in and assist. She said the staff will go through the steps of the AED and then transfer care to EMS when they arrive. The resident should not be left by herself. She said that they usually holler out or hit the call light and if access to overhead someone on the team can make the overhead call. The CNA's and CMA's held a responsibility to the residents as well, and can notify the nurse and even begin CPR if they were certified. The Administrator said anyone can call out for help. She said 911 should be called as soon as possible, once anyone realized a patient was unresponsive and CPR began. She said everything should happen simultaneously and while CPR was in progress. She said calling 911 30 minutes later is too late. She said that once a resident is found unresponsive without a pulse and code status is checked, CPR should be initiated immediately. The family should be notified once EMS is done at the latest, but the expectation is that someone should be calling 911, calling family, and doctor simultaneously while CPR is in progress. An hour after EMS left the building is considered too late to notify the family. She said she didn't know what time CPR was initiated, because she didn't ask, but the time should be documented. She said that she would assume CPR started shortly right after 7:30 a.m. when LVN B checked sugar. She said LVN B was suspended because of the documentation and the discrepancy of what she reported about the incident. Although, the Administrator said she didn't see anything wrong with what LVN B reported and documented. She said that she didn't feel she need to suspend LVN C because surveyor didn't lead her to believe there was a major concern or discrepancy of the CPR process. The Administrator said she made the decision not suspend to CMA D because she was the one who got the other nurse, LVN C, and then she was not involved anymore. The Administrator said that CMA D could have called 911. She said that she didn't speak with CMA D about the incident. She then said that CMA D said she was in the hall passing medications and didn't see anything. The Administrator said the responsibility is the DON's to ensure compliance with CPR policy and coding. She said that LVN B reported to her that EMS didn't do CPR because she already passed away. The Administrator said she would say it was a shared responsibility with the DON to know what happened to ensure CPR compliance. Surveyor requested that the Administrator notify CNA A of surveyor's calls and request a call back. In a phone interview on [DATE] at 9:43 a.m. CNA A said that he worked the overnight (10pm to 6am) shift from Sunday ([DATE]th) to Monday ([DATE]th). He said CR#1 was one of his residents. He said he was doing his last round around 5 or 5:30 am, and the nurses, he didn't know their name put a call light on in CR#1's room. He said he put his head in the room and they asked him to come in and said she CR#1 had coded. He said she coded, then they turned on the calllight and they were doing CPR and they asked him to come in the room. Surveyor asked what happened next. CNAA said he didn't touch CR#1, but there was poop on the floor and he didn't touch her. He said he cleaned the area so they can do CPR on her. He said they didn't stop performing CPR. He said when he put his head in the room he was asked to clean the area and pull the sheet off of the bed and the sheet is was what he used to clean the area. He said this was around 5 to 530 am. He said he knows for sure because he was in the midst of doing his last round and he can say that without a doubt. He said he didn't hear anyone call for a code. He just saw the light on and that's what got his attention. He said after he cleaned the BM the nurses didn't instruct him to do anything else, so he just left the room. He said that if he hears a code, and he was in the general area he is was to go to the room and ask what he needs to do. He said he was CPR certified so he could take over if needed. He said the nurses were doing their thing (CPR). He said he never heard a code called. He said he did eventually see EMS come in the building because he physically saw them coming in the building. He said he was unsure if EMS came around the same time as the CPR being performed. In an interview on [DATE] at 3:51 p.m., Resident #2 said she was CR#1's roommate. She said she remembered her. She said that she leaves the facility around 8 something to go to [CONDITION(S)] on Mondays. She said she remembered the morning her roommate (CR#1) passed away. She said that the nurse that was for her side (LVN B) came in and then said she had to go get the other nurse (LVN C). This was around 7 something. She then she came back with the other nurse and they brought the cart to do CPR. She said the nurse (LVN B) came in around 7 something and this was the first time she came in the room that morning. She said she went to the dining around 7 am, then went back to her room and then that's when LVN B came to the room or the first time. Resident #2 said before she went to the dining room that morning LVN B didn't enter her room. Surveyor asked Resident #2 if she asked a CNA for assistance that morning. She said for what? She said she didn't need any assistance from any nurse; she dresses herself, makes her bed and does everything for herself. She said she didn't see the med aide that morning. She said CR#1 was in the bed when LVN C came to the room with the crash cart. She said that before LVN B left to go get LVN C, she did not do CPR on CR#1. She said she was asked to leave the room when LVN C came with the cart. She said then a male CNA went into the room with an adult brief brief. In an interview on [DATE] at 12:35 p.m. LVN B said CR#1 pooped and it came out of the adult brief brief and was on the draw sheet when she was placed on the floor. LVN C requested an aide come clean her up. The CNA entered, took off the adult brief brief and wiped her during CPR and then placed a new adult brief brief on her. There was not poop all around the floor, it was only on the draw sheet. She continued CPR throughout the whole time. Record review of facility's Cardiopulmonary Resuscitation Policy dated [DATE] revealed the responsibility of CPR belonged to a licensed nurse and any person in the facility with CPR expertise. The purpose is to ventilate and establish circulation on a patient with absence of respirations and pulse. Procedure is to determine unresponsiveness, call out for help and press call light, delegate specific individual to check patient medical record/care plan for CPR or no CPR order and report back immediately, have individual call paramedics, attending physician, and administrative personnel per facility policy and report back to you as soon as possible, do not start CPR if patient is breathing and has a pulse, position patient by turning on back supporting head and neck, open airway, determine respiratory status, determine pulselessness, delegate a specific individual to check on status of paramedics, and continue CPR until relieved by another qualified person; i.e paramedic or a physician pronounces the patient dead and gives orders to discontinue CPR. CPR documentation should include date and exact time condition changed was observed, vital signs or absence of vitals signs, exact time CPR was started, exact time paramedics were notified, exact time paramedics arrived, exact time attending physician was called and exact time reached, notification of patient's family or responsible party .and complete documentation with the signature and title of licensed nurse. Record review of Facility's Resident Advanced Directives dated [DATE] revealed the facility had 83 residents as a full code status. This was determined to be an Immediate Jeopardy (IJ) situation on [DATE] at 2:52 p.m. The Corporate Nurse, Administrator and DON were notified and a plan of removal was requested. The Administrator was provided an Immediate Jeopardy template on [DATE] at 2:52 p.m. The following Plan of Removal was submitted and accepted on [DATE] at 1:25 a.m.: Immediate Jeopardy Plan of Removal [DATE] Immediate action: Medical Director was notified on [DATE] at 3:00pm Emergent QAPI meeting was conducted on [DATE] Root-cause identified that re-education of the CPR process was needed. Systematic Approach: 1. The facility suspended LVN A on [DATE] pending completion of a thorough investigation. If suspended staff are able to return post investigation prior to returning to the floor will be in-serviced on CPR process. 2. The facility Social Worker conducted an audit on [DATE] verifying residents' charts contained the correct code status. Facility has 83 Full-Code status 3. The facility HR conducted an audit on [DATE] verifying licensed nursing staff files contain current CPR certification. Facility has set-up CPR Training Courses for [DATE] and [DATE] for all Clinical staff and available for all employees. RN/LVN are required to be CPR certified 4. Nurse Management will conduct Mock codes from [DATE] to [DATE] ensuring lifesaving procedures are understood and followed. DON will continue to schedule on monthly basis. RNs, LVN's, CMA's and CNA's participated in the mock codes. Proper execution of CPR steps and utilization of AED machine will be reviewed in the mock code. Any deficient practice will be corrected and reported to the ED immediately and all findings will be discussed in the monthly/and as necessary. 5. Beginning [DATE] to [DATE] and will continue until 100% of nursing staff has been in-serviced by DON. Unit Manager and Designee on the following topics: Clinical staff will not be allowed to work after [DATE] prior to completing below in-serv [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents reviewed for Administration (CR#1). The Administrator failed to provide guidance to the DON based on best practice to ensure that nursing staff were following physician's orders [REDACTED]. The DON and Administrator failed to: Ensure there was an effective process in place to determine if the facility could meet CR #1's needs before she was admitted to the facility. provide CR #1 with a critical antibiotic medication, when they were aware that CR #1 was admitted to the facility with an order for [REDACTED].>Utilize resources available from the corporate office, including reaching out to regional staff and consultants, to ensure medications were administered as ordered. On 1/15/2018, an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on 1/17/2018, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 1 former resident requiring hospitalization and caused a decline in health and quality of life. Findings included: Intake # 4 In an interview on 1/16/19 at 2:01pm, the DON said she thought the issue with CR #1 occurred because they did not order the [MEDICATION NAME]. She said she did not think it was intentional. She said they should always follow the physician orders. When asked about the resources available to the facility, she said they had consultants, regional staff and additional clinical nurses. In an interview on 1/16/19 at 2:45pm, The Administrator said they had daily stand up meetings and discuss all issues and followup on everything the next day to ensure resident's needs are being met. She said they had a meeting within 48 hours with the IDT to ensure they are following admission orders [REDACTED]. She said the issue with CR #1 occurred because she thought the physician or the manufacturer would get back to them sooner. She said she had not dealt with cost issues before. She said if the medication was not available or they could not get it, they would not admit a resident. She said they had learned a lesson. When asked about the resources available to the facility, she said they had policies, and systems, consultants, regional staff additional clinical nurses. CR #1 Record review of CR #1's face sheet revealed she was admitted to the facility on [DATE] for a long term acute care hospital with [DIAGNOSES REDACTED]. She was [AGE] years of age. Her attending physician was MD A. She discharged to the hospital on [DATE]. Record review of an Infectious Disease Medicine Follow-up Note dated 12/15/18 from the hospital, provided by the facility, revealed CR #1 had recurrent urinary tract infection due to [MEDICATION NAME]-resistant [MEDICATION NAME] faescium (VRE) . The VRE was only susceptible to linezolid and [MEDICATION NAME] in urine culture on 12/09/18. The physician documented CR #1 needed to complete at least 2 or 3 weeks of [MEDICATION NAME] IV. Record review of CR #1's LTAC discharge medications dated 12/18/18 revealed she was prescribed [MEDICATION NAME] 500mg IV injection for 3 weeks, give at 5pm on Mondays, Wednesdays and Fridays after [MEDICAL TREATMENT]. The last dose given in the hospital was 12/17/18 at 5:40pm. Record review of CR #1's physician's orders [REDACTED]. Record review of an Authorization and Clarification Form from the pharmacy dated 12/19/18 at 4:05pm revealed they received an order to fill [MEDICATION NAME] 500mg/100mL for CR #1. The letter read in part, Authorization is required due to the cost of the medication. The cost of this medication is 911.14 (dollars) for a 2 days' supply. Please provide the pharmacy with written authorization to dispense the medication .Please email or scan the requested .authorization as soon as possible to prevent medication delays. Record review of CR #1's MAR indicated [REDACTED]. The medication was scheduled to be administered at 8:00am daily on the MAR. Record review of a nurses note dated 12/21/18 at 10:58am written by the DON read in part, 10:04am- DON informed that (MD A) needed to speak to the director of nursing in regards to [MEDICATION NAME]. (MD A) did give a new order to d/c the [MEDICATION NAME] and to start the patient on [MEDICATION NAME] 3 grams iv every 12 hours x 3 weeks. DON did request to change this medication to (sic) on the 19th and (MD A) declined to change the medication. Facility continued to look for other means to obtain this medication .10:30am- DON wen to assess the patient and speak to the family .Patient is awake, alert, talking (mumbled) and you could hear gurgling. Charge nurse to suction the patient . DON stated (to MD A) the patient is unstable and needs to be evaluated in the ER . (MD A) said he will be here to see the patient and do not send her out .10:50am- (MD A) arrived per (Unit Manager) with orders to send the patient to St. Joseph. In an observation on 1/10/19 at 3:45pm, CR #1 was in the ICU at a local hospital. Her family member was at her bedside. She was not alert or oriented and her eyes were closed. She had a nasogastric-feeding tube, a catheter and was receiving IV antibiotics ([MEDICATION NAME] 100mg). She was gurgling while breathing and her legs were swollen. In an interview on 1/14/19 at 2:00pm, the Community Relations Coordinator said the facility had a third-party company that reviewed prospective patient's clinical information to determine if they were appropriate for admission to the facility. She said the third-party company would highlight care areas or medications that the facility should be aware of and send the information in an email. She said she could not remember what the third party highlighted for CR #1. She looked in her e-mail and could not find anything for CR #1. She said the DON, ADON and Business Office Manager usually reviewed the patient's clinical information to determine if they were appropriate. She said if a patient was on an expensive medication or treatment, the Administrator and Regional Staff had to approve the admission. In an interview on 1/14/19 at 12:45pm, the Administrator said patient referrals went to a third party company, then they reviewed the patient information to determine if they were appropriate for admission to the facility. She said if the patient had complex needs, then someone would have to do an on-site visit in the hospital. She said the DON, LSW and Administrator would decide if the were appropriate for the facility. She said they usually look at things like behaviors or complex needs when determining if a resident is not appropriate. She said she could not remember what was discussed before CR #1 was admitted to the facility. In an interview on 1/10/19 at 12:30pm, the DON said CR #1's antibiotic medication was expensive. She said the pharmacy had it in stock. She said because the resident was on Medicare, the facility would have been responsible for the cost. She said she asked MD A on 12/19/18 if he would change the medication to something else, and he refused. She said this physician was difficult to work with. She said they asked the Medical Director if he could change the medication, and he did not want to get involved because he knew MD A. She then asked the social worker to reach out to the manufacturer to get the medication at a lower cost. She said the family was involved and notified of the issues. She said because she had a nephrectomy (surgical removal of a kidney) so they had to be careful with the type of medication you give her. She said [MEDICATION NAME], the medication she requested MD A change her order to, was more careful on the system. She said usually, when a medication was too expensive, the physician would change the order. When asked what the risk was if she did not receive the antibiotic as ordered, she said the infection could come back. In an interview on 1/10/19 at 1:00pm, the LSW said when she found out the antibiotic prescribed to CR #1 was too expensive, she reached out to the manufacturer to get the medication for a cheaper price. She said she e-mailed them and they sent an acknowledgement. She said a few days later, she received the confirmation that they could work with them on the price. She said because CR #1 was on Medicare and was using skilled days, the facility would be responsible for the cost of the medication. In an interview on 1/10/19 at 1:30pm, the Unit Manager said CR #1 was admitted to the facility with an order for [REDACTED]. She said MD A would not change the antibiotic. She said they notified the family member and the family member kept calling the physician to get the medication changed. She said she was not sure why the physician would not change the order. She said the resident was at risk of the infection coming back. In an interview on 1/10/19 at 2:50pm, The Administrator said CR #1's antibiotic medication would have cost about $3,000 for the facility, but would have done if needed. She said the social worker was trying to get the medication for a lower price. She said if the resident was still at the facility, she would have received the medication, but she discharged to the hospital. In a telephone interview on 1/11/19 at 1:28pm, MD A said he had worked with CR #1 since (MONTH) (YEAR) during her stay at the hospital and the LTAC facility. He said she [MEDICAL CONDITION] 4 or 5 times during her stay. He said the infectious disease physician recommended the antibiotic medication because she did not respond to other [MEDICATION NAME] agents. He said the nursing facility agreed to order the antibiotics. He said the facility was supposed to call him to verify the admission orders [REDACTED]. He said he visited the facility on 12/19/18 and talked to the DON and Unit Manager about the resident's antibiotic medication. He said they told him they had to get it from the pharmacy. He said he told them CR #1 needed them now because she had been on them since (MONTH) (YEAR). He said the next day the facility did not get the antibiotics and he was not notified. He said the next day, 12/21/18, he got a call from the nurse who stated the resident did not look good and they were transferring her to the hospital. He said he went to the facility to see her and said she looked severely septic, shaking, chills, shortness of breath. He said when she arrived to the ER, she was intubated and given antibiotics. He said the infection got worse and attributed her condition to the missed doses of the antibiotic. He said, It's disheartening .totally negligent. In an interview on 1/14/19 at 1:15pm, the ADON said when a resident is first admitted , the nurse on duty would call the physician to let them know they are at the facility and verify orders. She said she was responsible for auditing the charts of new admissions. When asked about CR #1, said she did not know if the nurse on duty verified CR #1's orders when she was admitted . She said the day after she was admitted , on 12/19/18, MD A visited the facility and they reviewed CR #1's medications together and agreed on a medication list. She said after they reviewed the medications, they got the authorization from the pharmacy regarding the [MEDICATION NAME] medication. She said when MD A did not change the medication, she went to the Medical Director's office and asked if he could change the medication. She said the Medical Director refused to get involved because MD A was one of those doctors that would refer him to the board. In an interview on 1/14/19 at 1:45pm, the DON said the facility should have known about CR #1's [MEDICATION NAME] medication before she was admitted so they could have made sure they had it on hand. She said they try to have everything residents need before admission. She said if they had known about the [MEDICATION NAME], it would have affected her admission. She said when the Medical Director did not change the antibiotic, then the LSW got involved to try to get the medication cheaper. When asked what the facility should have done, she said MD A should have changed the medication and worked with them to get her a different antibiotic. In an interview on 1/15/19 at 12:45pm, the Administrator said the facility tried to get the [MEDICATION NAME] antibiotic, then the resident was sent to the hospital for respiratory distress. She said it was the DON and the Administrator's decision that the medication was too expensive to pay for and regional staff were not involved. In an interview on 1/15/19 at 1:10pm, the DON said the Administrator and the DON made the decision to not order the medication for CR #1. She said they tried to get it. She said she had learned some lessons and they had a lot of work to do. She said her first day working at the facility was 12/17/18. In an interview on 1/15/19 at 2:14pm, the DON said CR #1 did not receive the antibiotic on the 19th and the 20th. She said she did not think it was neglect, but said it was not best practice. She said they were trying to get the medication. She said she wanted to hold off to see if they could get something else or get it cheaper. She said she thought CR #1 went to the hospital for chronic heart failure and fluid overload and not for the missed antibiotic. She said they should not accept residents with high cost medications or make sure they had a medication on hand before someone was admitted . In an interview on 1/15/19 at 4:02pm, Regional Staff A said what happened to CR #1 should have never happened. She said the Administrator and the DON should have ordered the medication, and she did not understand why they did not. The facility Administrator and the DON were notified on 1/15/19 at 2:15pm that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 1/15/19. After several revisions, the final Plan of Removal was accepted on 1/16/19 at 3:43pm. The plan of removal included the following: Ashford Gardens Immediate Jeopardy Plan of Removal 01/15/2019 Systematic Approach 1. Administration of Antibiotics a. Licensed nursing staff and Medication Aides were in-serviced 01/15/2019 at (4:30pm) by ((Regional Director of Clinical Services) and (PharmD)) in regards to Antibiotic Administration, the need to follow antibiotic orders as received completing the full course of antibiotics as ordered, Medication Administration, verifying orders, utilization of e-kit/E-kit policy until medications arrive from pharmacy and ensuring the availability of medications. Licensed nurses, including PRN nurses who are unavailable for the in service will not be allowed to work until such in-services have been given. In-services starting 01/15/19 and ending 01/16/2019. b. Patients newly admitted and existing patients with new orders for medications will be reviewed daily to ensure that all medications are available and orders are being followed as written/ directed (01/15/19). No changes to these orders will be made without a physician directive/ order. c. CR #1, identified as one of the patients affected is currently in the hospital and cannot be assessed. Resident #2, the 2nd patient affected has been assessed with [REDACTED]. d. The facility conducted an audit on 01/15/19 on all patients that had antibiotic orders from 12/18/18 to present to ensure that there were no other errors. In addition to the antibiotic orders audit all medication orders were reviewed to ensure availability and accuracy in administration e. Monitoring of antibiotic use and administration shall be completed during an Antibiotic Stewardship Meeting to be held each morning after Stand-Up. Medication Administration records shall be reviewed to ensure antibiotics/medications are given as ordered. Antibiotic medication reviews will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing and/or Designee. The facility will also generate tracking reports from the Electronic Medical Record to monitor that Antibiotics/medications were administered by staff appropriately and without omissions. If antibiotics/medications are held for any reason, notification to the Physician and Patient Representative will be completed. Staff nurses will alert the Unit Managers or Director of Nursing when an antibiotic/medication is not given. This was started (01/15/19) and will continue indefinitely. f. As a systematic change, new Medication orders will be monitored daily by the unit manager and the Director of Nursing during the Stand-Up Meeting. A QAPI meeting regarding Medication Administration/Medication availability will be held monthly to ensure use and administration are occurring as ordered each morning. This will be started (01/15/19) and continued indefinitely. Immediate education of the Administrator and Director of Nursing to fill medications regardless of the cost was conducted per Regional Director of Operations on 01/15/19. In addition to the above change, ED and DON will ensure that medications are accessible through the DON's review of the clinical record prior to accepting the Patient. If medications are not available, the admission will be delayed until available. The surveyors confirmed the Plan to lower the Immediately Jeopardy had been implemented sufficiently by: Record Review of the In-Service dated 1/15/19 revealed nursing staff were educated on medication administration, antibiotic use, medication availability, abuse and neglect and new admissions/readmissions. Observations and record reviews between 1/15/19-1/17/19 of 6 sampled residents revealed they were receiving their medications, including antibiotics, as ordered. In an interview on 1/17/19 at 8:30am, the DON said here were no new admissions in the last few days. Interviews conducted from 1/16/19 to 1/17/19 with 7 nurses and medication aides on various shifts revealed staff could verbalize the information from the recent in-services. The Administrator was notified that the IJ was lowered on 1/17/19 at 11:28am. However, the facility remained out of compliance at a severity of level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility needing more time to monitor the plan of correction effectiveness.

Based on interview, record review, and observation, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 12 residents (CR #1 and Resident #2) reviewed for pharmacy services, in that: The facility failed to ensure CR #1 antibiotic medication was ordered from the pharmacy, regardless of the price of the medication. CR #1 went without a critical antibiotic medication for 4 days, had a change of condition, and was admitted to the hospital intensive care unit with a [DIAGNOSES REDACTED]. The facility failed to ensure Resident #2 recieved her antibiotic medication as ordered. On 1/15/2018, an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on 1/17/2018, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 1 former resident requiring hospitalization and caused a decline in health and quality of life, and not receiving the intended therapeutic benefit of her medication, and placed 1 current resident at risk of not receiving the intended therapeutic benefit of her medication. Findings included: Intake # 4 CR #1 Record review of CR #1's face sheet revealed she was admitted to the facility on [DATE] for a long term acute care hospital with [DIAGNOSES REDACTED]. She was [AGE] years of age. Her attending physician was MD A. She discharged to the hospital on [DATE]. Record review of an Infectious Disease Medicine Follow-up Note dated 12/15/18 from the hospital, provided by the facility, revealed CR #1 had recurrent urinary tract infection due to [MEDICATION NAME]-resistant [MEDICATION NAME] faescium (VRE) . The VRE was only susceptible to linezolid and [MEDICATION NAME] in urine culture on 12/09/18. The physician documented CR #1 needed to complete at least 2 or 3 weeks of [MEDICATION NAME] IV. Record review of CR #1's LTAC discharge medications dated 12/18/18 revealed she was prescribed [MEDICATION NAME] 500mg IV injection for 3 weeks, give at 5pm on Mondays, Wednesdays and Fridays after [MEDICAL TREATMENT]. The last dose given in the hospital was 12/17/18 at 5:40pm. Record review of CR #1's Clinical Notes Report revealed the following: - 12/18/18 at 10:00pm written by LVN A : .resident arrived at facility via EMS .in stable condition upon arrival is alert and able to understand .noted 3 lumen PICC line to right upper arm. Record review of CR #1's physician's orders dated 12/18/2018 revealed an order for [REDACTED]. Record review of the Medline Plus online reference at https://medlineplus.gov/druginfo/meds dated 8/15/2017 revealed [MEDICATION NAME] injection is an antibiotic that is used to treat certain blood infections in adults caused by bacteria. If you stop using [MEDICATION NAME] injection too soon or skip doses, your infection may not be completely treated and the bacteria may become resistant to antibiotics. In an interview on 1/14/19 at 2:00pm, the Community Relations Coordinator said the facility had a third-party company that reviewed prospective patient's clinical information to determine if they were appropriate for admission to the facility. She said the third-party company would highlight care areas or medications that the facility should be aware of and send the information in an email. She said she could not remember what the third party highlighted for CR #1. She looked in her e-mail and could not find anything for CR #1. She said the DON, ADON and Business Office Manager usually reviewed the patient's clinical information to determine if they were appropriate. She said if a patient was on an expensive medication or treatment, the Administrator and Regional Staff had to approve the admission. In an interview on 1/14/19 at 2:12pm, LVN A said when CR #1 was admitted , she did an assessment, notified MD A and put CR #1's medications in the computer. She said she did not verify CR #1's medications with MD A because MD A said he would review the medications when he visited the facility. She said she used the MAR from the hospital. In an interview on 1/14/19 at 12:45pm, the Administrator said patient referrals went to a third-party company, then they reviewed the patient information to determine if they were appropriate for admission to the facility. She said if the patient had complex needs, then someone would have to do an on-site visit in the hospital. She said the DON, LSW and Administrator would decide if they were appropriate for the facility. She said they usually look at things like behaviors or complex needs when determining if a resident is not appropriate. She said she could not remember what was discussed before CR #1 was admitted to the facility. Record review of CR #1's baseline care plan dated 12/19/18 revealed she was on [MEDICAL TREATMENT] Tuesday, Thursday and Saturdays. She required standard infection control precautions and had disorders of the cardiac/circulatory system and nervous system. Record review of CR #1's admission MDS assessment dated [DATE] revealed her payor source was Medicare. She could understand others and was understood. She had a BIMS score of 13, indicating no cognitive impairment. The facility marked that she required IV medications while a resident. Record review of an Authorization and Clarification Form from the pharmacy dated 12/19/18 at 4:05pm revealed they received an order to fill [MEDICATION NAME] 500mg/100mL for CR #1. The letter read in part, Authorization is required due to the cost of the medication. The cost of this medication is 911.14 (dollars) for a 2 days' supply. Please provide the pharmacy with written authorization to dispense the medication .Please email or scan the requested .authorization as soon as possible to prevent medication delays. Record review of CR #1's MAR dated (MONTH) (YEAR) revealed the [MEDICATION NAME] 500mg IV solution was not administered to the resident during her stay at the facility between 12/18/18-12/21/18. The medication was scheduled to be administered at 8:00am daily on the MAR. Record review of CR #1's Clinical Notes Report revealed the following: - 12/20/18 at 10:49pm written by LSW: .Resident has some confusion and memory loss. Resident went to the hospital (before admission to the facility) with pneumonia and acquired a kidney infection while there according to her (family members). (Family member) stated that resident had a kidney removed and will return in 60 days to have the other kidney removed .not aware if there will be a kidney transplant . - There were no nursing notes for CR #1 on 12/20/18. - 12/21/18 at 9:49am written by LSW: (Social Worker) reached out to Biotain Pharma Co for assistant (sic) with medication for resident. (Social Worker) will continue to follow up with Biotain. - 12/21/18 at 10:58am written by the DON: 10:04am- DON informed that (MD A) needed to speak to the director of nursing in regards to [MEDICATION NAME]. (MD A) did give a new order to d/c the [MEDICATION NAME] and to start the patient on [MEDICATION NAME] 3 grams iv every 12 hours x 3 weeks. DON did request to change this medication to (sic) on the 19th and (MD A) declined to change the medication. Facility continued to look for other means to obtain this medication .10:30am- DON wen to assess the patient and speak to the family .Patient is awake, alert, talking (mumbled) and you could hear gurgling. Charge nurse to suction the patient . DON stated (to MD A) the patient is unstable and needs to be evaluated in the ER . (MD A) said he will be here to see the patient and do not send her out .10:50am- (MD A) arrived per (Unit Manager) with orders to send the patient to St. Joseph. - 12/21/18 at 3:03pm written by LVN B: 6a-2p shift. Client exhibited respiratory distress, accompanied with AMS (altered mental status). Pulse: [MEDICAL CONDITION] (rapid heart rate) . left facility at around 11:30am. In a telephone interview on 1/10/19 at 12:05pm, CR #1's family member said she felt like the facility refused to give the antibiotic medication. The family member stated whenever she asked about the medication, they always told her they had not received it yet. Family member said CR #1 was talking and moving around when she was admitted to the facility but on Thursday, 12/20/18, she started feeling sick, sleepy and coughing a lot. Family member said CR #1 had been in the ICU since she was discharged . In an interview on 1/10/19 at 12:30pm, the DON said CR #1's antibiotic medication was expensive. She said the pharmacy had it in stock. She said because the resident was on Medicare, the facility would have been responsible for the cost. She said she asked MD A on 12/19/18 if he would change the medication to something else, and he refused. She said this physician was difficult to work with. She said they asked the Medical Director if he could change the medication, and he did not want to get involved because he knew MD A. She then asked the social worker to reach out to the manufacturer to get the medication at a lower cost. She said the family was involved and notified of the issues. She said because she had a nephrectomy (surgical removal of a kidney) so they had to be careful with the type of medication you give her. She said [MEDICATION NAME], the medication she requested MD A change her order to, was more careful on the system. She said usually, when a medication was too expensive, the physician would change the order. When asked what the risk was if she did not receive the antibiotic as ordered, she said the infection could come back. In an interview on 1/10/19 at 1:00pm, the LSW said when she found out the antibiotic prescribed to CR #1 was too expensive, she reached out to the manufacturer to get the medication for a cheaper price. She said she e-mailed them and they sent an acknowledgement. She said a few days later, she received the confirmation that they could work with them. She said because CR #1 was on Medicare and was using skilled days, the facility would be responsible for the cost of the medication. In an interview on 1/10/19 at 1:20pm, LVN B said he worked with CR #1 the day she was admitted to the hospital, 12/21/18. He said CR #1 was coughing and they had to suction her. He said she was not stable, so they called MD A to have her transferred to the hospital. He said MD A insisted he see her before she was sent out. He said MD A visited the facility shortly after the phone call and she was sent to the hospital. In an interview on 1/10/19 at 1:30pm, the Unit Manager said CR #1 was admitted to the facility with an order for [REDACTED]. She said usually the physician would change the medication if it was too expensive. She said MD A would not change the antibiotic. She said they notified the family member and the family member kept calling the physician to get the medication changed. She said she was not sure why the physician would not change the order. She said the resident was at risk of the infection coming back. In an interview on 1/10/19 at 2:50pm, The Administrator said CR #1's antibiotic medication would have cost about $3,000 for the facility, but would have done if needed. She said the social worker was trying to get the medication for a lower price. She said if the resident was still at the facility, she would have received the medication, but she discharged to the hospital. In a telephone interview on 1/11/19 at 1:28pm, MD A said he had worked with CR #1 since (MONTH) (YEAR) during her stay at the hospital and the LTAC facility. He said she [MEDICAL CONDITION] 4 or 5 times during her stay. He said the infectious disease physician recommended the antibiotic medication because she did not respond to other [MEDICATION NAME] agents. He said the nursing facility agreed to order the antibiotics. He said the facility was supposed to call him to verify the admission orders [REDACTED]. He said he visited the facility on 12/19/18 and talked to the DON and Unit Manager about the resident's antibiotic medication. He said they told him they had to get it from the pharmacy. He said he told them CR #1 needed them now because she had been on them since (MONTH) (YEAR). He said the next day the facility did not get the antibiotics and he was not notified. He said the next day, 12/21/18, he got a call from the nurse who stated the resident did not look good and they were transferring her to the hospital. He said he went to the facility to see her and said she looked severely septic, shaking, chills, shortness of breath. He said when she arrived to the ER, she was intubated and given antibiotics. He said the infection got worse and attributed her condition to the missed doses of the antibiotic. He said, It's disheartening .totally negligent. In an observation on 1/10/19 at 3:45pm, CR #1 was in the ICU at a local hospital. Her family member was at her bedside. She was not alert or oriented and her eyes were closed. She had a nasogastric-feeding tube, a catheter and was receiving IV antibiotics ([MEDICATION NAME] 100mg). She was gurgling while breathing and her legs were swollen. In an interview on 1/14/19 at 1:15pm, the ADON said when a resident is first admitted , the nurse on duty would call the physician to let them know they are at the facility and verify orders. She said she was responsible for auditing the charts of new admissions. When asked about CR #1, said she did not know if the nurse on duty verified CR #1's orders when she was admitted . She said the day after she was admitted , on 12/19/18, MD A visited the facility and they reviewed CR #1's medications together and agreed on a medication list. She said after they reviewed the medications, they got the authorization from the pharmacy regarding the [MEDICATION NAME] medication. She said when MD A did not change the medication, she went to the Medical Director's office and asked if he could change the medication. She said the Medical Director refused to get involved because MD A was one of those doctors that would refer him to the board. In an interview on 1/14/19 at 1:45pm, the DON said the facility should have known about CR #1's [MEDICATION NAME] medication before she was admitted so they could have made sure they had it on hand. She said they try to have everything residents need before admission. She said if they had known about the [MEDICATION NAME], it would have affected her admission. She said when the Medical Director did not change the antibiotic, then the LSW got involved to try to get the medication cheaper. When asked what the facility should have done, she said MD A should have changed the medication and worked with them to get her a different antibiotic. In an interview on 1/15/19 at 12:45pm, the Administrator said the facility tried to get the [MEDICATION NAME] antibiotic, then the resident was sent to the hospital for respiratory distress. She said it was the DON and the Administrator's decision that the medication was too expensive to pay for and regional staff were not involved. In an interview on 1/15/19 at 1:10pm, the DON said the Administrator and the DON made the decision to not order the medication for CR #1. She said they tried to get it. She said she had learned some lessons and they had a lot of work to do. She said her first day working at the facility was 12/17/18. In an interview on 1/15/19 at 2:14pm, the DON said CR #1 did not receive the antibiotic on the 19th and the 20th. She said she did not think it was neglect, but said it was not best practice. She said they were trying to get the medication. She said she wanted to hold off to see if they could get something else or get it cheaper. She said she thought CR #1 went to the hospital for chronic heart failure and fluid overload and not for the missed antibiotic. She said they should not accept residents with high cost medications or make sure they had a medication on hand before someone was admitted . In an interview on 1/15/19 at 4:02pm, Regional Staff A said what happened to CR #1 should have never happened. She said the Administrator and the DON should have ordered the medication, and she did not understand why they did not. Resident #2 Record review of Resident #2's Face Sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #2's care plan (undated) revealed she was at risk of infection related to indwelling catheter. Interventions included reported any sign of infection and clean around catheter with soap and water. Further review of Resident #2's care plan revealed she had a history of [REDACTED]. Interventions included obtain urine samples as ordered. Record review of Resident #2's Urinalysis Results dated 12/26/18 revealed many bacteria were seen in the urine. Record review of Resident #2's nurse's notes revealed she had signs of a urinary tract infection on 12/21/18. The physician ordered [MEDICATION NAME] and Bactrim on 12/24/18. Record review of Resident #2's MAR dated (MONTH) (YEAR) revealed she received [MEDICATION NAME] 875-125mg once every 12 hours and Bactrim DS 800mg-160mg every 12 hours between 12/24/18 and 12/31/18. Record review of Resident #2's nurse note dated 12/31/18 revealed she was lethargic with low blood pressure and was sent to the hospital. Record review of Resident #2's nurse note dated 1/8/19 revealed she was readmitted to the facility with a history of recurrent urinary tract infection. Record review of Resident #2's physician's order dated 1/8/19 revealed an order for [REDACTED]. Record review of Resident #2's MAR dated (MONTH) 2019 printed on 1/10/19 revealed an order for [REDACTED]. The medication was administered on 1/8/19 at 8:00am and 1/8/19 at 4:00pm. There were '=' signs in the MAR for 1/9/19 at 8:00am and 4:00pm and 1/10/19 at 8:00am. On the key, the '=' sign indicated the medication was Previously Scheduled. Record review of Resident #2's MAR dated (MONTH) 2019 printed on 1/14/19 revealed the [MEDICATION NAME] 300mg was signed as administered on 1/8/19 at 8:00am, 1/8/19 at 4:00pm, 1/10/19 at 8:00am, 1/10/19 at 4:00pm, 1/11/19 at 8:00am, 1/11/19 at 4:00pm and 1/12/19 at 4:00pm. There were '=' signs in the MAR for 1/9/19 at 8:00am, 1/9/19 at 4:00pm, 1/12/19 at 8:00am, 1/13/19 at 8:00am, 1/13/19 at 4:00pm and 1/14/19 at 8:00am. On the key, the '=' sign indicated the medication was Previously Scheduled. In an observation on 1/10/19 at 9:30am, Resident #2 was lying in bed watching television. She said she had been at the facility for a few days. Observation on 1/14/19 at 4:00pm of Resident #2's blister pack on the medication cart for [MEDICATION NAME] Capsule 300mg revealed there were 5 capsules left. The medication was filled on 1/9/19. In an interview on 1/14/19 at 3:35pm, the DON said she would check with the Medication Aide who administered the [MEDICATION NAME] medication to Resident #2 to see if she received them. In an interview on 1/15/19 at 2:14pm, the DON said she believed Resident #2 received the [MEDICATION NAME] medication on the days it was not documented on the MAR. She said the medication aide who was assigned to give the medications did not tell the nurse that she needed two signatures. She said she thought some of the [MEDICATION NAME] capsules were taken out of the e-kit but they could not find the charge slip. Record review of a notice in the medication room (undated) on 1/15/19 read in part, Attention: Nurses. All medication must be pulled and signed out by a license nurse. Medication pull from the E-kit must have a charge slip filled out completely, must have a physicians order, both the charge slip and order must be faxed to pharmacy and placed in ekit. Per Pharmacy guidelines and policy . Record review of the facility policy for Pharmacy Services: Medication Order and Administration (undated) read in part, Medications must be given according to Physician order only, and if any variation from order occurs MD must be notified . From admission to our facility we have 4 hours to receive for dosing antibiotics and routine pain medications .If you find that a medication is not going to be available to dose contact MD immediately for action on the order . The facility Administrator and the DON were notified on 1/15/19 at 2:15pm that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 1/15/19. After several revisions, the final Plan of Removal was accepted on 1/16/19 at 3:43pm. The plan of removal included the following: Ashford Gardens Immediate Jeopardy Plan of Removal 01/15/2019 Systematic Approach 1. Administration of Antibiotics a. Licensed nursing staff and Medication Aides were in-serviced 01/15/2019 at (4:30pm) by ((Regional Director of Clinical Services) and (PharmD)) in regards to Antibiotic Administration, the need to follow antibiotic orders as received completing the full course of antibiotics as ordered, Medication Administration, verifying orders, utilization of e-kit/E-kit policy until medications arrive from pharmacy and ensuring the availability of medications. Licensed nurses, including PRN nurses who are unavailable for the in service will not be allowed to work until such in-services have been given. In-services starting 01/15/19 and ending 01/16/2019. b. Patients newly admitted and existing patients with new orders for medications will be reviewed daily to ensure that all medications are available and orders are being followed as written/ directed (01/15/19). No changes to these orders will be made without a physician directive/ order. c. (CR #1) identified as one of the patients affected is currently in the hospital and cannot be assessed. (Resident #2), the 2nd patient affected has been assessed with [REDACTED]. d. The facility conducted an audit on 01/15/19 on all patients that had antibiotic orders from 12/18/18 to present to ensure that there were no other errors. In addition to the antibiotic orders audit all medication orders were reviewed to ensure availability and accuracy in administration e. Monitoring of antibiotic use and administration shall be completed during an Antibiotic Stewardship Meeting to be held each morning after Stand-Up. Medication Administration records shall be reviewed to ensure antibiotics/medications are given as ordered. Antibiotic medication reviews will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing and/or Designee. The facility will also generate tracking reports from the Electronic Medical Record to monitor that Antibiotics/medications were administered by staff appropriately and without omissions. If antibiotics/medications are held for any reason, notification to the Physician and Patient Representative will be completed. Staff nurses will alert the Unit Managers or Director of Nursing when an antibiotic/medication is not given. This was started (01/15/19) and will continue indefinitely. f. As a systematic change, new Medication orders will be monitored daily by the unit manager and the Director of Nursing during the Stand-Up Meeting. A QAPI meeting regarding Medication Administration/Medication availability will be held monthly to ensure use and administration are occurring as ordered each morning. This will be started (01/15/19) and continued indefinitely. Immediate education of the Administrator and Director of Nursing to fill medications regardless of the cost was conducted per Regional Director of Operations on 01/15/19. In addition to the above change, ED and DON will ensure that medications are accessible through the DON's review of the clinical record prior to accepting the Patient. If medications are not available, the admission will be delayed until available. The surveyors confirmed the Plan to lower the Immediately Jeopardy had been implemented sufficiently by: Record Review of the In-Service dated 1/15/19 revealed nursing staff were educated on medication administration, antibiotic use, medication availability, abuse and neglect and new admissions/readmissions. Observations and record reviews between 1/15/19-1/17/19 of 6 sampled residents revealed they were receiving their medications, including antibiotics, as ordered. In an interview on 1/17/19 at 8:30am, the DON said here were no new admissions in the last few days. Interviews conducted from 1/16/19 to 1/17/19 with 7 nurses and medication aides on various shifts revealed staff could verbalize the information from the recent in-services. The Administrator was notified that the IJ was lowered on 1/17/19 at 11:28am. However, the facility remained out of compliance at a severity of level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility needing more time to monitor the plan of correction effectiveness.

Based on observation, interview, and record review, the facility failed to ensure residents have the right to be free from neglect for 1 of 12 residents (CR #1) reviewed for neglect. The facility failed to ensure they could meet resident's needs before being admitted to the facility. The facility failed to have a system in place to ensure newly admitted residents received their medications as ordered. The facility failed to ensure CR #1 antibiotic medication was ordered from the pharmacy, regardless of the price of the medication. CR #1 went without a critical antibiotic medication for 4 days, had a change of condition, and was admitted to the hospital intensive care unit with a [DIAGNOSES REDACTED]. On 1/15/2018, an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on 1/17/2018, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 1 former resident requiring hospitalization and caused a decline in health and quality of life. Findings included: Intake # 4 CR #1 Record review of CR #1's face sheet revealed she was admitted to the facility on [DATE] for a long term acute care hospital with [DIAGNOSES REDACTED]. She was [AGE] years of age. Her attending physician was MD A. She discharged to the hospital on [DATE]. Record review of an Infectious Disease Medicine Follow-up Note dated 12/15/18 from the hospital, provided by the facility, revealed CR #1 had recurrent urinary tract infection due to [MEDICATION NAME]-resistant [MEDICATION NAME] faescium (VRE) . The VRE was only susceptible to linezolid and [MEDICATION NAME] in urine culture on 12/09/18. The physician documented CR #1 needed to complete at least 2 or 3 weeks of [MEDICATION NAME] IV. Record review of CR #1's LTAC discharge medications dated 12/18/18 revealed she was prescribed [MEDICATION NAME] 500mg IV injection for 3 weeks, give at 5pm on Mondays, Wednesdays and Fridays after [MEDICAL TREATMENT]. The last dose given in the hospital was 12/17/18 at 5:40pm. Record review of CR #1's Clinical Notes Report revealed the following: - 12/18/18 at 10:00pm written by LVN A : .resident arrived at facility via EMS .in stable condition upon arrival is alert and able to understand .noted 3 lumen PICC line to right upper arm. Record review of CR #1's physician's orders [REDACTED]. Record review of the Medline Plus online reference at https://medlineplus.gov/druginfo/meds dated 8/15/2017 revealed [MEDICATION NAME] injection is an antibiotic that is used to treat certain blood infections in adults caused by bacteria. If you stop using [MEDICATION NAME] injection too soon or skip doses, your infection may not be completely treated and the bateria may become resistant to antibiotics. In an interview on 1/14/19 at 2:00pm, the Community Relations Coordinator said the facility had a third-party company that reviewed prospective patient's clinical information to determine if they were appropriate for admission to the facility. She said the third-party company would highlight care areas or medications that the facility should be aware of and send the information in an email. She said she could not remember what the third party highlighted for CR #1. She looked in her e-mail and could not find anything for CR #1. She said the DON, ADON and Business Office Manager usually reviewed the patient's clinical information to determine if they were appropriate. She said if a patient was on an expensive medication or treatment, the Administrator and Regional Staff had to approve the admission. In an interview on 1/14/19 at 2:12pm, LVN A said when CR #1 was admitted , she did an assessment, notified MD A and put CR #1's medications in the computer. She said she did not verify CR #1's medications with MD A because MD A said he would review the medications when he visited the facility. She said she used the MAR from the hospital. In an interview on 1/14/19 at 12:45pm, the Administrator said patient referrals went to a third party company, then they reviewed the patient information to determine if they were appropriate for admission to the facility. She said if the patient had complex needs, then someone would have to do an on-site visit in the hospital. She said the DON, LSW and Administrator would decide if the were appropriate for the facility. She said they usually look at things like behaviors or complex needs when determining if a resident is not appropriate. She said she could not remember what was discussed before CR #1 was admitted to the facility. Record review of CR #1's baseline care plan dated 12/19/18 revealed she was on [MEDICAL TREATMENT] Tuesday, Thursday and Saturdays. She required standard infection control precautions and had disorders of the cardiac/circulatory system and nervous system. Record review of CR #1's admission MDS assessment dated [DATE] revealed her payor source was Medicare. She could understand others and was understood. She had a BIMS score of 13, indicating no cognitive impairment. The facility marked that she required IV medications while a resident. Record review of an Authorization and Clarification Form from the pharmacy dated 12/19/18 at 4:05pm revealed they received an order to fill [MEDICATION NAME] 500mg/100mL for CR #1. The letter read in part, Authorization is required due to the cost of the medication. The cost of this medication is 911.14 (dollars) for a 2 days' supply. Please provide the pharmacy with written authorization to dispense the medication .Please email or scan the requested .authorization as soon as possible to prevent medication delays. Record review of CR #1's MAR indicated [REDACTED]. The medication was scheduled to be administered at 8:00am daily on the MAR. Record review of CR #1's Clinical Notes Report revealed the following: - 12/20/18 at 10:49pm written by LSW: .Resident has some confusion and memory loss. Resident went to the hospital (before admission to the facility) with pneumonia and acquired a kidney infection while there according to her (family members). (Family member) stated that resident had a kidney removed and will return in 60 days to have the other kidney removed .not aware if there will be a kidney transplant . - There were no nursing notes for CR #1 on 12/20/18. - 12/21/18 at 9:49am written by LSW: (Social Worker) reached out to Biotain Pharma Co for assistant (sic) with medication for resident. (Social Worker) will continue to follow up with Biotain. - 12/21/18 at 10:58am written by the DON: 10:04am- DON informed that (MD A) needed to speak to the director of nursing in regards to [MEDICATION NAME]. (MD A) did give a new order to d/c the [MEDICATION NAME] and to start the patient on [MEDICATION NAME] 3 grams iv every 12 hours x 3 weeks. DON did request to change this medication to (sic) on the 19th and (MD A) declined to change the medication. Facility continued to look for other means to obtain this medication .10:30am- DON wen to assess the patient and speak to the family .Patient is awake, alert, talking (mumbled) and you could hear gurgling. Charge nurse to suction the patient . DON stated (to MD A) the patient is unstable and needs to be evaluated in the ER . (MD A) said he will be here to see the patient and do not send her out .10:50am- (MD A) arrived per (Unit Manager) with orders to send the patient to St. Joseph. - 12/21/18 at 3:03pm written by LVN B: 6a-2p shift. Client exhibited respiratory distress, accompanied with AMS (altered mental status). Pulse: [MEDICAL CONDITION] (rapid heart rate) . left facility at around 11:30am. In a telephone interview on 1/10/19 at 12:05pm, CR #1's family member said she felt like the facility refused to give the antibiotic medication. The family member stated whenever she asked about the medication, they always told her they had not received it yet. Family member said CR #1 was talking and moving around when she was admitted to the facility but on Thursday, 12/20/18, she started feeling sick, sleepy and coughing a lot. Family member said CR #1 had been in the ICU since she was discharged . In an interview on 1/10/19 at 12:30pm, the DON said CR #1's antibiotic medication was expensive. She said the pharmacy had it in stock. She said because the resident was on Medicare, the facility would have been responsible for the cost. She said she asked MD A on 12/19/18 if he would change the medication to something else, and he refused. She said this physician was difficult to work with. She said they asked the Medical Director if he could change the medication, and he did not want to get involved because he knew MD A. She then asked the social worker to reach out to the manufacturer to get the medication at a lower cost. She said the family was involved and notified of the issues. She said because she had a nephrectomy (surgical removal of a kidney) so they had to be careful with the type of medication you give her. She said [MEDICATION NAME], the medication she requested MD A change her order to, was more careful on the system. She said usually, when a medication was too expensive, the physician would change the order. When asked what the risk was if she did not receive the antibiotic as ordered, she said the infection could come back. In an interview on 1/10/19 at 1:00pm, the LSW said when she found out the antibiotic prescribed to CR #1 was too expensive, she reached out to the manufacturer to get the medication for a cheaper price. She said she e-mailed them and they sent an acknowledgement. She said a few days later, she received the confirmation that they could work with them. She said because CR #1 was on Medicare and was using skilled days, the facility would be responsible for the cost of the medication. In an interview on 1/10/19 at 1:20pm, LVN B said he worked with CR #1 the day she was admitted to the hospital, 12/21/18. He said CR #1 was coughing and they had to suction her. He said she was not stable, so they called MD A to have her transferred to the hospital. He said MD A insisted he see her before she was sent out. He said MD A visited the facility shortly after the phone call and she was sent to the hospital. In an interview on 1/10/19 at 1:30pm, the Unit Manager said CR #1 was admitted to the facility with an order for [REDACTED]. She said MD A would not change the antibiotic. She said they notified the family member and the family member kept calling the physician to get the medication changed. She said she was not sure why the physician would not change the order. She said the resident was at risk of the infection coming back. In an interview on 1/10/19 at 2:50pm, The Administrator said CR #1's antibiotic medication would have cost about $3,000 for the facility, but would have done if needed. She said the social worker was trying to get the medication for a lower price. She said if the resident was still at the facility, she would have received the medication, but she discharged to the hospital. In a telephone interview on 1/11/19 at 1:28pm, MD A said he had worked with CR #1 since (MONTH) (YEAR) during her stay at the hospital and the LTAC facility. He said she [MEDICAL CONDITION] 4 or 5 times during her stay. He said the infectious disease physician recommended the antibiotic medication because she did not respond to other [MEDICATION NAME] agents. He said the nursing facility agreed to order the antibiotics. He said the facility was supposed to call him to verify the admission orders [REDACTED]. He said he visited the facility on 12/19/18 and talked to the DON and Unit Manager about the resident's antibiotic medication. He said they told him they had to get it from the pharmacy. He said he told them CR #1 needed them now because she had been on them since (MONTH) (YEAR). He said the next day the facility did not get the antibiotics and he was not notified. He said the next day, 12/21/18, he got a call from the nurse who stated the resident did not look good and they were transferring her to the hospital. He said he went to the facility to see her and said she looked severely septic, shaking, chills, shortness of breath. He said when she arrived to the ER, she was intubated and given antibiotics. He said the infection got worse and attributed her condition to the missed doses of the antibiotic. He said, It's disheartening .totally negligent. In an observation on 1/10/19 at 3:45pm, CR #1 was in the ICU at a local hospital. Her family member was at her bedside. She was not alert or oriented and her eyes were closed. She had a nasogastric-feeding tube, a catheter and was receiving IV antibiotics ([MEDICATION NAME] 100mg). She was gurgling while breathing and her legs were swollen. In an interview on 1/14/19 at 1:15pm, the ADON said when a resident is first admitted , the nurse on duty would call the physician to let them know they are at the facility and verify orders. She said she was responsible for auditing the charts of new admissions. When asked about CR #1, said she did not know if the nurse on duty verified CR #1's orders when she was admitted . She said the day after she was admitted , on 12/19/18, MD A visited the facility and they reviewed CR #1's medications together and agreed on a medication list. She said after they reviewed the medications, they got the authorization from the pharmacy regarding the [MEDICATION NAME] medication. She said when MD A did not change the medication, she went to the Medical Director's office and asked if he could change the medication. She said the Medical Director refused to get involved because MD A was one of those doctors that would refer him to the board. In an interview on 1/14/19 at 1:45pm, the DON said the facility should have known about CR #1's [MEDICATION NAME] medication before she was admitted so they could have made sure they had it on hand. She said they try to have everything residents need before admission. She said if they had known about the [MEDICATION NAME], it would have affected her admission. She said when the Medical Director did not change the antibiotic, then the LSW got involved to try to get the medication cheaper. When asked what the facility should have done, she said MD A should have changed the medication and worked with them to get her a different antibiotic. In an interview on 1/15/19 at 12:45pm, the Administrator said neglect was the willful intention to withhold treatment and not provide care and services per the resident's plan of care. She said what happened to CR #1 was not neglect. She said the facility tried to get the [MEDICATION NAME] antibiotic, then the resident was sent to the hospital for respiratory distress. She said it was the DON and the Administrator's decision that the medication was too expensive to pay for and regional staff were not involved. In an interview on 1/15/19 at 1:10pm, the DON said the Administrator and the DON made the decision to not order the medication for CR #1. She said they tried to get it. She said she had learned some lessons and they had a lot of work to do. She said her first day working at the facility was 12/17/18. In an interview on 1/15/19 at 2:14pm, the DON said CR #1 did not receive the antibiotic on the 19th and the 20th. She said she did not think it was neglect, but said it was not best practice. She said they were trying to get the medication. She said she wanted to hold off to see if they could get something else or get it cheaper. She said she thought CR #1 went to the hospital for chronic heart failure and fluid overload and not for the missed antibiotic. She said they should not accept residents with high cost medications or make sure they had a medication on hand before someone was admitted . In an interview on 1/15/19 at 1:32pm, the Unit Manager said what happened to CR #1 was not neglect, but was more of a documentation error. She said they tried to get MD A to change the medication and he should have changed it. She said neglect was residents not being cleaned, not receiving the proper care and not receiving proper medications. In an interview on 1/15/19 at 4:02pm, Regional Staff A said what happened to CR #1 should have never happened. She said the Administrator and the DON should have ordered the medication, and she did not understand why they did not. Record review of the facility Abuse Protocol dated (MONTH) (YEAR) read in part, The patient/resident has the right to be free from Abuse, neglect and mistreatment of [REDACTED].Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a patient/resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . The facility Administrator and the DON were notified on 1/15/19 at 2:15pm that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 1/15/19. After several revisions, the final Plan of Removal was accepted on 1/16/19 at 3:43pm. The plan of removal included the following: Ashford Gardens Immediate Jeopardy Plan of Removal 01/15/2019 Systematic Approach 1. Administration of Antibiotics a. Licensed nursing staff and Medication Aides were in-serviced 01/15/2019 at (4:30pm) by ((Regional Director of Clinical Services) and (PharmD)) in regards to Antibiotic Administration, the need to follow antibiotic orders as received completing the full course of antibiotics as ordered, Medication Administration, verifying orders, utilization of e-kit/E-kit policy until medications arrive from pharmacy and ensuring the availability of medications. Licensed nurses, including PRN nurses who are unavailable for the in service will not be allowed to work until such in-services have been given. In-services starting 01/15/19 and ending 01/16/2019. b. Patients newly admitted and existing patients with new orders for medications will be reviewed daily to ensure that all medications are available and orders are being followed as written/ directed (01/15/19). No changes to these orders will be made without a physician directive/ order. c. (CR #1) identified as one of the patients affected is currently in the hospital and cannot be assessed. (Resident #2), the 2nd patient affected has been assessed with [REDACTED]. d. The facility conducted an audit on 01/15/19 on all patients that had antibiotic orders from 12/18/18 to present to ensure that there were no other errors. In addition to the antibiotic orders audit all medication orders were reviewed to ensure availability and accuracy in administration e. Monitoring of antibiotic use and administration shall be completed during an Antibiotic Stewardship Meeting to be held each morning after Stand-Up. Medication Administration records shall be reviewed to ensure antibiotics/medications are given as ordered. Antibiotic medication reviews will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing and/or Designee. The facility will also generate tracking reports from the Electronic Medical Record to monitor that Antibiotics/medications were administered by staff appropriately and without omissions. If antibiotics/medications are held for any reason, notification to the Physician and Patient Representative will be completed. Staff nurses will alert the Unit Managers or Director of Nursing when an antibiotic/medication is not given. This was started (01/15/19) and will continue indefinitely. f. As a systematic change, new Medication orders will be monitored daily by the unit manager and the Director of Nursing during the Stand-Up Meeting. A QAPI meeting regarding Medication Administration/Medication availability will be held monthly to ensure use and administration are occurring as ordered each morning. This will be started (01/15/19) and continued indefinitely. Immediate education of the Administrator and Director of Nursing to fill medications regardless of the cost was conducted per Regional Director of Operations on 01/15/19. In addition to the above change, ED and DON will ensure that medications are accessible through the DON's review of the clinical record prior to accepting the Patient. If medications are not available, the admission will be delayed until available. The surveyors confirmed the Plan to lower the Immediately Jeopardy had been implemented sufficiently by: Record Review of the In-Service dated 1/15/19 revealed nursing staff were educated on medication administration, antibiotic use, medication availability, abuse and neglect and new admissions/readmissions. Observations and record reviews between 1/15/19-1/17/19 of 6 sampled residents revealed they were receiving their medications, including antibiotics, as ordered. In an interview on 1/17/19 at 8:30am, the DON said here were no new admissions in the last few days. Interviews conducted from 1/16/19 to 1/17/19 with 7 nurses and medication aides on various shifts revealed staff could verbalize the information from the recent in-services. The Administrator was notified that the IJ was lowered on 1/17/19 at 11:28am. However, the facility remained out of compliance at a severity of level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility needing more time to monitor the plan of correction effectiveness.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (CR#1) of 12 residents reviewed for quality of care. The facility failed to ensure CR #1 antibiotic medication was ordered from the pharmacy, regardless of the price of the medication. CR #1 went without a critical antibiotic medication for 4 days, had a change of condition, and was admitted to the hospital intensive care unit with a [DIAGNOSES REDACTED]. On 1/15/2018, an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on 1/17/2018, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 1 former resident requiring hospitalization and caused a decline in health and quality of life. Findings included: Intake # 4 CR #1 Record review of CR #1's face sheet revealed she was admitted to the facility on [DATE] for a long term acute care hospital with [DIAGNOSES REDACTED]. She was [AGE] years of age. Her attending physician was MD A. She discharged to the hospital on [DATE]. Record review of an Infectious Disease Medicine Follow-up Note dated 12/15/18 from the hospital, provided by the facility, revealed CR #1 had recurrent urinary tract infection due to [MEDICATION NAME]-resistant [MEDICATION NAME] faescium (VRE) . The VRE was only susceptible to linezolid and [MEDICATION NAME] in urine culture on 12/09/18. The physician documented CR #1 needed to complete at least 2 or 3 weeks of [MEDICATION NAME] IV. Record review of CR #1's LTAC discharge medications dated 12/18/18 revealed she was prescribed [MEDICATION NAME] 500mg IV injection for 3 weeks, give at 5pm on Mondays, Wednesdays and Fridays after [MEDICAL TREATMENT]. The last dose given in the hospital was 12/17/18 at 5:40pm. Record review of CR #1's Clinical Notes Report revealed the following: - 12/18/18 at 10:00pm written by LVN A : .resident arrived at facility via EMS .in stable condition upon arrival is alert and able to understand .noted 3 lumen PICC line to right upper arm. Record review of CR #1's physician's orders dated 12/18/2018 revealed an order for [REDACTED]. Record review of the Medline Plus online reference at https://medlineplus.gov/druginfo/meds dated 8/15/2017 revealed [MEDICATION NAME] injection is an antibiotic that is used to treat certain blood infections in adults caused by bacteria. If you stop using [MEDICATION NAME] injection too soon or skip doses, your infection may not be completely treated and the bacteria may become resistant to antibiotics. In an interview on 1/14/19 at 2:00pm, the Community Relations Coordinator said the facility had a third-party company that reviewed prospective patient's clinical information to determine if they were appropriate for admission to the facility. She said the third-party company would highlight care areas or medications that the facility should be aware of and send the information in an email. She said she could not remember what the third party highlighted for CR #1. She looked in her e-mail and could not find anything for CR #1. She said the DON, ADON and Business Office Manager usually reviewed the patient's clinical information to determine if they were appropriate. She said if a patient was on an expensive medication or treatment, the Administrator and Regional Staff had to approve the admission. In an interview on 1/14/19 at 2:12pm, LVN A said when CR #1 was admitted , she did an assessment, notified MD A and put CR #1's medications in the computer. She said she did not verify CR #1's medications with MD A because MD A said he would review the medications when he visited the facility. She said she used the MAR from the hospital. In an interview on 1/14/19 at 12:45pm, the Administrator said patient referrals went to a third-party company, then they reviewed the patient information to determine if they were appropriate for admission to the facility. She said if the patient had complex needs, then someone would have to do an on-site visit in the hospital. She said the DON, LSW and Administrator would decide if they were appropriate for the facility. She said they usually look at things like behaviors or complex needs when determining if a resident is not appropriate. She said she could not remember what was discussed before CR #1 was admitted to the facility. Record review of CR #1's baseline care plan dated 12/19/18 revealed she was on [MEDICAL TREATMENT] Tuesday, Thursday and Saturdays. She required standard infection control precautions and had disorders of the cardiac/circulatory system and nervous system. Record review of CR #1's admission MDS assessment dated [DATE] revealed her payor source was Medicare. She could understand others and was understood. She had a BIMS score of 13, indicating no cognitive impairment. The facility marked that she required IV medications while a resident. Record review of an Authorization and Clarification Form from the pharmacy dated 12/19/18 at 4:05pm revealed they received an order to fill [MEDICATION NAME] 500mg/100mL for CR #1. The letter read in part, Authorization is required due to the cost of the medication. The cost of this medication is 911.14 (dollars) for a 2 days' supply. Please provide the pharmacy with written authorization to dispense the medication .Please email or scan the requested .authorization as soon as possible to prevent medication delays. Record review of CR #1's MAR indicated [REDACTED]. The medication was scheduled to be administered at 8:00am daily on the MAR. Record review of CR #1's Clinical Notes Report revealed the following: - 12/20/18 at 10:49pm written by LSW: .Resident has some confusion and memory loss. Resident went to the hospital (before admission to the facility) with pneumonia and acquired a kidney infection while there according to her (family members). (Family member) stated that resident had a kidney removed and will return in 60 days to have the other kidney removed .not aware if there will be a kidney transplant . - There were no nursing notes for CR #1 on 12/20/18. - 12/21/18 at 9:49am written by LSW: (Social Worker) reached out to Biotain Pharma Co for assistant (sic) with medication for resident. (Social Worker) will continue to follow up with Biotain. - 12/21/18 at 10:58am written by the DON: 10:04am- DON informed that (MD A) needed to speak to the director of nursing in regards to [MEDICATION NAME]. (MD A) did give a new order to d/c the [MEDICATION NAME] and to start the patient on [MEDICATION NAME] 3 grams iv every 12 hours x 3 weeks. DON did request to change this medication to (sic) on the 19th and (MD A) declined to change the medication. Facility continued to look for other means to obtain this medication .10:30am- DON wen to assess the patient and speak to the family .Patient is awake, alert, talking (mumbled) and you could hear gurgling. Charge nurse to suction the patient . DON stated (to MD A) the patient is unstable and needs to be evaluated in the ER . (MD A) said he will be here to see the patient and do not send her out .10:50am- (MD A) arrived per (Unit Manager) with orders to send the patient to St. Joseph. - 12/21/18 at 3:03pm written by LVN B: 6a-2p shift. Client exhibited respiratory distress, accompanied with AMS (altered mental status). Pulse: [MEDICAL CONDITION] (rapid heart rate) . left facility at around 11:30am. In a telephone interview on 1/10/19 at 12:05pm, CR #1's family member said she felt like the facility refused to give the antibiotic medication. The family member stated whenever she asked about the medication, they always told her they had not received it yet. Family member said CR #1 was talking and moving around when she was admitted to the facility but on Thursday, 12/20/18, she started feeling sick, sleepy and coughing a lot. Family member said CR #1 had been in the ICU since she was discharged . In an interview on 1/10/19 at 12:30pm, the DON said CR #1's antibiotic medication was expensive. She said the pharmacy had it in stock. She said because the resident was on Medicare, the facility would have been responsible for the cost. She said she asked MD A on 12/19/18 if he would change the medication to something else, and he refused. She said this physician was difficult to work with. She said they asked the Medical Director if he could change the medication, and he did not want to get involved because he knew MD A. She then asked the social worker to reach out to the manufacturer to get the medication at a lower cost. She said the family was involved and notified of the issues. She said because she had a nephrectomy (surgical removal of a kidney) so they had to be careful with the type of medication you give her. She said [MEDICATION NAME], the medication she requested MD A change her order to, was more careful on the system. She said usually, when a medication was too expensive, the physician would change the order. When asked what the risk was if she did not receive the antibiotic as ordered, she said the infection could come back. In an interview on 1/10/19 at 1:00pm, the LSW said when she found out the antibiotic prescribed to CR #1 was too expensive, she reached out to the manufacturer to get the medication for a cheaper price. She said she e-mailed them and they sent an acknowledgement. She said a few days later, she received the confirmation that they could work with them. She said because CR #1 was on Medicare and was using skilled days, the facility would be responsible for the cost of the medication. In an interview on 1/10/19 at 1:20pm, LVN B said he worked with CR #1 the day she was admitted to the hospital, 12/21/18. He said CR #1 was coughing and they had to suction her. He said she was not stable, so they called MD A to have her transferred to the hospital. He said MD A insisted he see her before she was sent out. He said MD A visited the facility shortly after the phone call and she was sent to the hospital. In an interview on 1/10/19 at 1:30pm, the Unit Manager said CR #1 was admitted to the facility with an order for [REDACTED]. She said MD A would not change the antibiotic. She said they notified the family member and the family member kept calling the physician to get the medication changed. She said she was not sure why the physician would not change the order. She said the resident was at risk of the infection coming back. In an interview on 1/10/19 at 2:50pm, The Administrator said CR #1's antibiotic medication would have cost about $3,000 for the facility, but would have done if needed. She said the social worker was trying to get the medication for a lower price. She said if the resident was still at the facility, she would have received the medication, but she discharged to the hospital. In a telephone interview on 1/11/19 at 1:28pm, MD A said he had worked with CR #1 since (MONTH) (YEAR) during her stay at the hospital and the LTAC facility. He said she [MEDICAL CONDITION] 4 or 5 times during her stay. He said the infectious disease physician recommended the antibiotic medication because she did not respond to other [MEDICATION NAME] agents. He said the nursing facility agreed to order the antibiotics. He said the facility was supposed to call him to verify the admission orders [REDACTED]. He said he visited the facility on 12/19/18 and talked to the DON and Unit Manager about the resident's antibiotic medication. He said they told him they had to get it from the pharmacy. He said he told them CR #1 needed them now because she had been on them since (MONTH) (YEAR). He said the next day the facility did not get the antibiotics and he was not notified. He said the next day, 12/21/18, he got a call from the nurse who stated the resident did not look good and they were transferring her to the hospital. He said he went to the facility to see her and said she looked severely septic, shaking, chills, shortness of breath. He said when she arrived to the ER, she was intubated and given antibiotics. He said the infection got worse and attributed her condition to the missed doses of the antibiotic. He said, It's disheartening .totally negligent. In an observation on 1/10/19 at 3:45pm, CR #1 was in the ICU at a local hospital. Her family member was at her bedside. She was not alert or oriented and her eyes were closed. She had a nasogastric-feeding tube, a catheter and was receiving IV antibiotics ([MEDICATION NAME] 100mg). She was gurgling while breathing and her legs were swollen. In an interview on 1/14/19 at 1:15pm, the ADON said when a resident is first admitted , the nurse on duty would call the physician to let them know they are at the facility and verify orders. She said she was responsible for auditing the charts of new admissions. When asked about CR #1, said she did not know if the nurse on duty verified CR #1's orders when she was admitted . She said the day after she was admitted , on 12/19/18, MD A visited the facility and they reviewed CR #1's medications together and agreed on a medication list. She said after they reviewed the medications, they got the authorization from the pharmacy regarding the [MEDICATION NAME] medication. She said when MD A did not change the medication, she went to the Medical Director's office and asked if he could change the medication. She said the Medical Director refused to get involved because MD A was one of those doctors that would refer him to the board. In an interview on 1/14/19 at 1:45pm, the DON said the facility should have known about CR #1's [MEDICATION NAME] medication before she was admitted so they could have made sure they had it on hand. She said they try to have everything residents need before admission. She said if they had known about the [MEDICATION NAME], it would have affected her admission. She said when the Medical Director did not change the antibiotic, then the LSW got involved to try to get the medication cheaper. When asked what the facility should have done, she said MD A should have changed the medication and worked with them to get her a different antibiotic. In an interview on 1/15/19 at 12:45pm, the Administrator said said the facility tried to get the [MEDICATION NAME] antibiotic for CR #1,, then the resident was sent to the hospital for respiratory distress. She said it was the DON and the Administrator's decision that the medication was too expensive to pay for and regional staff were not involved. In an interview on 1/15/19 at 1:10pm, the DON said the Administrator and the DON made the decision to not order the medication for CR #1. She said they tried to get it. She said she had learned some lessons and they had a lot of work to do. She said her first day working at the facility was 12/17/18. In an interview on 1/15/19 at 2:14pm, the DON said CR #1 did not receive the antibiotic on the 19th and the 20th. She said she did not think it was neglect, but said it was not best practice. She said they were trying to get the medication. She said she wanted to hold off to see if they could get something else or get it cheaper. She said she thought CR #1 went to the hospital for chronic heart failure and fluid overload and not for the missed antibiotic. She said they should not accept residents with high cost medications or make sure they had a medication on hand before someone was admitted . In an interview on 1/15/19 at 4:02pm, Regional Staff A said what happened to CR #1 should have never happened. She said the Administrator and the DON should have ordered the medication, and she did not understand why they did not. Record review of the facility policy for Pharmacy Services: Medication Order and Administration (undated) read in part, Medications must be given according to Physician order only, and if any variation from order occurs MD must be notified . From admission to our facility we have 4 hours to receive for dosing antibiotics and routine pain medications .If you find that a medication is not going to be available to dose contact MD immediately for action on the order . The facility Administrator and the DON were notified on 1/15/19 at 2:15pm that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 1/15/19. After several revisions, the final Plan of Removal was accepted on 1/16/19 at 3:43pm. The plan of removal included the following: Ashford Gardens Immediate Jeopardy Plan of Removal 01/15/2019 Systematic Approach 1. Administration of Antibiotics a. Licensed nursing staff and Medication Aides were in-serviced 01/15/2019 at (4:30pm) by ((Regional Director of Clinical Services) and (PharmD)) in regards to Antibiotic Administration, the need to follow antibiotic orders as received completing the full course of antibiotics as ordered, Medication Administration, verifying orders, utilization of e-kit/E-kit policy until medications arrive from pharmacy and ensuring the availability of medications. Licensed nurses, including PRN nurses who are unavailable for the in service will not be allowed to work until such in-services have been given. In-services starting 01/15/19 and ending 01/16/2019. b. Patients newly admitted and existing patients with new orders for medications will be reviewed daily to ensure that all medications are available and orders are being followed as written/ directed (01/15/19). No changes to these orders will be made without a physician directive/ order. c. (CR #1) identified as one of the patients affected is currently in the hospital and cannot be assessed. (Resident #2), the 2nd patient affected has been assessed with [REDACTED]. d. The facility conducted an audit on 01/15/19 on all patients that had antibiotic orders from 12/18/18 to present to ensure that there were no other errors. In addition to the antibiotic orders audit all medication orders were reviewed to ensure availability and accuracy in administration e. Monitoring of antibiotic use and administration shall be completed during an Antibiotic Stewardship Meeting to be held each morning after Stand-Up. Medication Administration records shall be reviewed to ensure antibiotics/medications are given as ordered. Antibiotic medication reviews will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing and/or Designee. The facility will also generate tracking reports from the Electronic Medical Record to monitor that Antibiotics/medications were administered by staff appropriately and without omissions. If antibiotics/medications are held for any reason, notification to the Physician and Patient Representative will be completed. Staff nurses will alert the Unit Managers or Director of Nursing when an antibiotic/medication is not given. This was started (01/15/19) and will continue indefinitely. f. As a systematic change, new Medication orders will be monitored daily by the unit manager and the Director of Nursing during the Stand-Up Meeting. A QAPI meeting regarding Medication Administration/Medication availability will be held monthly to ensure use and administration are occurring as ordered each morning. This will be started (01/15/19) and continued indefinitely. Immediate education of the Administrator and Director of Nursing to fill medications regardless of the cost was conducted per Regional Director of Operations on 01/15/19. In addition to the above change, ED and DON will ensure that medications are accessible through the DON's review of the clinical record prior to accepting the Patient. If medications are not available, the admission will be delayed until available. The surveyors confirmed the Plan to lower the Immediately Jeopardy had been implemented sufficiently by: Record Review of the In-Service dated 1/15/19 revealed nursing staff were educated on medication administration, antibiotic use, medication availability, abuse and neglect and new admissions/readmissions. Observations and record reviews between 1/15/19-1/17/19 of 6 sampled residents revealed they were receiving their medications, including antibiotics, as ordered. In an interview on 1/17/19 at 8:30am, the DON said here were no new admissions in the last few days. Interviews conducted from 1/16/19 to 1/17/19 with 7 nurses and medication aides on various shifts revealed staff could verbalize the information from the recent in-services. The Administrator was notified that the IJ was lowered on 1/17/19 at 11:28am. However, the facility remained out of compliance at a severity of level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility needing more time to monitor the plan of correction effectiveness.

Based on observation, record review, and interview the facility failed to implement their policies and procedures that prohibit neglect for one of 10 residents (Residents #1) who were reviewed for neglect. The facility failed to have an RN conduct Resident #1's initial assessment. The resident was administered [MEDICATION NAME] three times when it was only ordered to be given once daily and his blood sugar dropped to 20. Resident #1 was not transported to the emergency room for treatment for 35 minutes. The facility failed to coordinate his [MEDICAL TREATMENT] treatment. Resident #1 went five days without [MEDICAL TREATMENT] treatment. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 6/28/16. While the IJ was removed on 6/30/16, the facility remained out of compliance at actual harm that was not Immediate Jeopardy with a scope identified as pattern. The facility continued to monitor and evaluate the effectiveness of their plan. These failures affected one resident and placed an additional 21 residents with a [DIAGNOSES REDACTED]. Complaint # 3 Findings include: Resident #1 Record review of Resident #1's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with [REDACTED]. Resident #1 was discharged from the facility when he experienced a severe hypoglycemic episode on 6/21/16 and was hospitalized . Record review of Resident #1's hospital medication discharge orders dated 6/16/16 revealed: [MEDICATION NAME] 5 mg oral tablet, 1 tablet by mouth daily with breakfast. Record review of Resident #1's Medication Administration Record revealed that [MEDICATION NAME] 5 mg (1 Tab) tablet orally one time daily was entered three times. Further review revealed the medication was administered twice by the ADON on 6/20/16 at 8:00 AM and then a third time by MA A on 6/20/16 at 9:00 AM. Record Review of the Physician order [REDACTED]. LVN A entered the first order on 6/18/16 at 12:50 AM ADON entered the second order on 6/20/16 at 1:54 PM ADON entered the third order on 6/20/16 at 1:55 PM Record Review of the Clinical notes dated 6/21/16 at 10:29 a.m. revealed LVN B was completing 6:30 a.m. rounds and Resident #1 was alert and his blood sugar was 44. LVN B gave the resident raw sugar under his tongue and added sugar to his orange juice. Resident #1 only took sips of the orange juice and held it in his mouth before swallowing. LVN B documented she received an order to transfer Resident #1 to the hospital. LVN B took Resident #1's blood sugar again and documented the blood sugar was 27. She then called their transportation service, to transport Resident #1 to a local hospital. In an interview on 6/29/16 at 11:39 a.m. LVN B stated Resident #1 was admitted to the facility on the weekend and she did complete a full assessment of the resident on that Monday 6/20/16. LVN B stated Resident #1 told her he did not check his blood sugar and that he just took pills. Resident #1 missed his [MEDICAL TREATMENT] appointment at 5:30 a.m., so she called to make another appointment and the [MEDICAL TREATMENT] center gave her a 3:30 p.m. appointment. LVN B stated she called for transportation and she said they did not have an ambulance available at that time, but if the facility van took the resident then the ambulance would pick him up. LVN B stated that somehow the appointment she made got canceled and she did not know what happened. The interview continued with LVN B stating on Tuesday morning 6/21/16, LVN B stated Resident #1 called out to her at 6:30 a.m. as if he was saying hello. LVN B stated she said hello at the door and said she would be back. MA A came to her and said the family of Resident #1 said the resident was not acting right. LVN B stated she went to the room and the resident was sweating. She took his blood sugar and it read 47. LVN B stated she gave Resident #1 sugar and orange juice and the resident was not cooperating too well and kept holding the orange juice in his mouth and not swallowing. At this time, LVN B began asking all staff if they had [MEDICATION NAME] to help to increase Resident #1's blood sugar level and she called the transportation company and they said they would be there in 20 minutes. LVN B stated she waited a few minutes and checked the blood sugar again and it was 33 and by this time the ADON and LVN E got to the facility. LVN E went upstairs to get the [MEDICATION NAME]. Resident #1 was given the [MEDICATION NAME] and she checked Resident #1's blood sugar again and it was 23. In 10 more minutes, LVN B stated she called the physician and got orders to call the hospital informing them of the emergency transfer. The transportation arrived in 30 to 35 minutes. LVN B continued by stating the orders she saw later that day, she had not seen before. LVN B stated on Tuesday there was an order to check blood sugars, but it was not there before. LVN B stated she was not oriented to the Admission process when she was hired. LVN B stated she would think the ADON should overlook all of the admission assessments. There was nothing in the computer to alert her for transportation for [MEDICAL TREATMENT]. The night nurse should have set up [MEDICAL TREATMENT] and she could have said something at Report when they communicate Nurse to Nurse. Nothing was set up on the weekend. LVN B stated she should have called 9-1-1 instead of the regular transportation and maybe they would have come 5 minutes faster. Resident #1 was sweating and she did not know his baseline. In an interview with LVN C on 6/28/16 at 11:43 a.m. she stated Resident #1 was administered the [MEDICATION NAME] medication twice based on the Administration history form on 6/20/16 at 8 a.m. and 9 a.m. One was administered by the ADON and one by the Medication Aide. She stated double administration of diabetes medication could cause the blood sugar to drop. In an interview on 6/29/16 at 2:30 p.m., MA A revealed that she did administer Resident #1's [MEDICATION NAME] medication on 6/20/16 at 9 a.m. because she was the medication aide on duty. The MA A revealed that she came in from 6 a.m. to 2 p.m. and she was passing medication on that day, but whoever the nurse was that morning administered medication. MA A stated that based on Resident #1's Administration history form for 6/20/16, Resident #1 received [MEDICATION NAME] three times. MA A stated that the medication order shows that the ADON administered [MEDICATION NAME] twice on 6/20/16 at 8 a.m. The Medication Aide stated that if a medicine is only supposed to be administered once daily, then MA A should not have given it because it had to be given that morning. In an interview with the Regional Nurse on 6/29/16 at 2:45 p.m. she stated that according to Medication Administration Record for Resident #1 he received [MEDICATION NAME] 5 mg oral tablet, where the orders were 1 tablet by mouth 3 times on 6/20/16 at 9 a.m., 8 a.m. and again at 8 a.m. Record review of facility form Managed Care Authorization Request dated 6/16/16 revealed that Resident #1's equipment needs were [MEDICAL TREATMENT] on Monday, Wednesday and Friday at local [MEDICAL TREATMENT] center at 6:15 a.m. Record review revealed a Minimum Data Set (MDS) comprehensive assessment was not completed for Resident #1 prior to his discharge. Record Review of Resident #1's Clinical Notes Report dated 6/18/16 at 4:04 a.m. with the effective date of 6/17/16 at 10:30 p.m. written by LVN A revealed Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident #1's pain was documented an 8 out of 10. Resident #1 was to have [MEDICAL TREATMENT] on Monday, Wednesday and Friday at 6:15 a.m. with an outside contractor [MEDICAL TREATMENT] provider (specific provider was named). Record Review of Resident #1's Clinical Notes on 6/18/16 at 4:47 am revealed Resident #1 had an episode of vomiting. Resident was cleaned up and repositioned. Resident #1 was feeling better and was encouraged to have fluids. Record review of Resident #1's facility Care Plan dated 6/20/16 revealed he received [MEDICAL TREATMENT] three times a week and was at risk for increased shortness of breath, chest pains, blood pressure, itchy skin, nausea/vomiting, and infected access site. The interventions stated that Resident #1 will be monitored for increased complications from [MEDICAL TREATMENT] and that they would report abnormalities to the Medical Doctor (MD). Resident #1 would be served his diet per order, labs would be monitored and abnormalities would be reported to the MD. Resident #1 would be encouraged to be out of bed daily and activity attendance as tolerated, the access site would be monitored for infection, do not take blood pressure in ext. of access site and to allow Resident #1 to verbalize feelings of disease process. Resident #1 was also to be assisted with ADL's and comfort measures as needed and he would be weighed weekly and as ordered. The same care plan revealed Resident #1 was at risk of hyper or hypoglycemic episodes secondary to his [DIAGNOSES REDACTED]. The facility interventions stated that Resident #1's medication would be given as ordered, the labs would be as ordered and abnormalities would be reported to MD. Resident #1 would be monitored for thirst, excessive appetite or voiding, change in level of consciousness or mood, perspiring and report to MD promptly, skin would be monitored for redness or circulatory problems. Other interventions stated were Resident #1 would be monitored and assured positioning problems, encouraged to exercise and activity attendance and his diet would be as ordered and his intake would be monitored. Record Review of Resident #1's hospital records with a date of admission of 6/21/16 and printed on 6/23/16 revealed the attending physician documented, according to Resident #1, he was not getting adequate care. Resident #1 was not dialyzed yesterday, which was supposed to be the patient's [MEDICAL TREATMENT] day. The patient was brought to the emergency room and was found to have a blood sugar of 20. Resident #1 also had chest pain. Tests showed Resident #1 had abnormal findings. The hospital assessment revealed severe [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high potassium level). Observation and Interview on 6/23/16 at 4:15 p.m. at the local hospital, Resident #1 revealed when he got to the facility on Friday he noticed when he pressed the call light button, it took a long time for staff to come and when the staff came they acted as if he was bothering them. Resident #1 stated that by 3 p.m. he needed to go to the restroom. He pressed his call light and it took them an hour to two hours to come so he tried to get up and he twisted his body and fell . Resident #1 stated the last time he had [MEDICAL TREATMENT] was on 6/15/16 at the hospital. Resident #1 stated he was not dialyzed on Friday when he was admitted to the facility because he left the hospital mid-day. On Monday, Resident #1 stated he called [MEDICAL TREATMENT] himself and they told him there was no chair set up for him on Monday. Resident #1 stated that he got [MEDICAL TREATMENT] scheduled for 6:30 a.m. on Wednesday. Resident #1 stated on Tuesday, he felt like he was not going to make it, and he kept pressing the call light because he could not breathe. Resident #1 stated the local hospital checked his blood sugar when he arrived and it was 20. Resident #1 stated the staff nurse (LVN B) had told him she was not aware the resident was a diabetic. In an interview on 6/23/16 at 4:42 p.m. at the local hospital, Resident #1's family member revealed Resident #1 was going into a diabetic coma on 6/21/16 at 8 a.m. because he was sweating, his eyes were really big and LVN B came to the room at 8 a.m. The family member stated no one at the facility checked Resident #1's blood sugar all weekend and LVN B told her she did not know that Resident #1 had a [DIAGNOSES REDACTED].#1 vomited, she was the one that had to clean it up because the staff at the facility threw a towel on it and left it there. Resident #1 stated that LVN B told him also she did not know that Resident #1 was diabetic. In an interview with the Local Hospital Case Manager on 6/23/16 at 5 p.m. she stated Resident #1's history at the local hospital revealed he was admitted on [DATE] and discharged on Friday, 6/17/16 to the nursing facility. Resident #1 received [MEDICAL TREATMENT] on Wednesday, 6/15/16. No [MEDICAL TREATMENT] was given at the local hospital on Friday, 6/17/16. All of his records were sent to the Nursing home with a [DIAGNOSES REDACTED]. Resident #1 was admitted back to the local hospital on [DATE]. In an interview on 6/24/16 at 12:45 p.m., the Administrator revealed on Monday 6/20/16, she received a message about Resident #1 having pain so she met with the resident. Resident #1 stated he missed [MEDICAL TREATMENT] on that day and the [MEDICAL TREATMENT] center called him while she was in the room. The Administrator stated she spoke with the [MEDICAL TREATMENT] center personnel and they stated it was not necessary for the resident to get to [MEDICAL TREATMENT] and that he could receive [MEDICAL TREATMENT] on either Tuesday 6/21/16 or Wednesday 6/22/16. During the facility's end of day meeting on 6/17/16 at 4:34 PM, Resident #1 was listed as a planned admission. The Clinical Team was responsible for getting the [MEDICAL TREATMENT] set up along with LVN A. LVN A and the ADON were responsible for making sure the Admission process went as it should. In the same interview with the Administrator, she stated Resident #1's Admission Assessment was completed by LVN A and it was documented the resident had [MEDICAL TREATMENT] on Monday, Wednesday and Friday at 6:15 a.m., but transportation was not set up. The Administrator stated she did not believe Resident #1 came with orders to have blood sugars done, but the [DIAGNOSES REDACTED]. The Administrator revealed Resident #1 had one blood sugar check in the system on 6/21/16. The Administrator stated she did find where it was documented that Resident #1 was taking diabetes medication. The Administrator stated the Nurse conducting the Admission Assessment (LVN A) should have questioned why there was no order for blood sugar checks. On the morning of 6/21/16, the facility got orders to check Resident #1's blood sugar. The Administrator stated the Clinical team was composed of the Director of Nursing, Assistant Director of Nursing and MDS Coordinator. In the same interview the Administrator stated LVN A was supposed to contact the facility's provider transportation company to schedule appointments. The ADON was supposed to review all new admissions and make sure all parameters were in place. Record review of Resident #1's admission assessment completed by LVN A dated 6/17/16 at 11:52 PM, revealed no documentation of Resident #1's diagnoses. In an interview on 6/24/16 at 2:45 p.m. LVN A stated she completed the Admission Assessment for Resident #1 and he came into the facility at 10:30 p.m. on 6/17/16. LVN A stated it was too late to set up appointments for the resident. LVN A stated she had never had to set up transportation for residents, so she did not know what time they opened. LVN A stated when she did Resident #1's medication he did not have insulin, and she did not know that he was diabetic. LVN A stated she was not told Resident #1 had a [DIAGNOSES REDACTED]. LVN A stated she wrote in Report that Resident #1 had [MEDICAL TREATMENT] at the local [MEDICAL TREATMENT] clinic on Monday, Wednesday and Friday. LVN A stated transportation was usually set up before the resident came to the facility. LVN A said she set up Resident #1's medication that night and the resident got medication from their E-kit for pain and other medications would be delivered to the facility by 9 a.m. LVN A stated she did not inform anyone before she left that Resident #1 was not set up for [MEDICAL TREATMENT] and she never checked his blood sugar. LVN A stated she did get the resident's vital signs and body assessment and the resident never objected to care. LVN A stated when Resident #1 vomited she could not clean up all the vomit, so she left a clean towel on the floor so nobody would step in it. In the same interview on 6/24/2016 LVN A stated in hind sight, she would have put in an order to check Resident #1's blood sugar. LVN A stated there was nothing to point her in that direction and she did verify the resident's medications with the doctor. LVN A stated she went over Resident #1's orders with the resident's new doctor, but she did not tell the doctor the resident was a diabetic. LVN A stated the DON would look at her assessments, but she does not know if she saw it because it was done on the weekend. LVN A did state she did enter Resident #1's [MEDICATION NAME] into the facility's system, but she did not know that medication was for diabetes. In a telephone interview on 6/24/16 at 1:52 p.m. the ADON stated that Resident #1 was admitted to the facility on Friday evening, 6/17/16 and he was taking the medication [MEDICATION NAME] for his diabetes. The ADON stated there was nothing documented on the Medication Administration Record where staff were checking the Resident's blood sugars. LVN B checked the resident's blood sugar, gave Resident #1 the [MEDICATION NAME], but he refused the orange juice and the sugar. The ADON stated she was not sure why Resident #1 [MEDICAL TREATMENT] appointment was not set up. The ADON stated she did not work on weekends and the staff informed her of Resident #1 admission. The ADON said normally the hospital informed them the last time the resident had [MEDICAL TREATMENT] and how much they took off. The nurse taking report should have asked when the last time the Resident was dialyzed and about checking the resident's blood sugar. The nurse taking report should have also set up transportation for Resident #1's [MEDICAL TREATMENT]. The ADON stated if the resident had an episode of emesis that would should have cued the nurse that something was going on with the resident because with [DIAGNOSES REDACTED] they can have episodes of nausea and vomiting. A telephone interview was attempted on 6/24/16 with the previous DON at 2:15 p.m. A message was left. In an interview on 6/28/16 at 3:45 p.m. with the Administrator she stated that whenever an appointment was scheduled, the staff should have set up transportation. In an interview on 6/29/16 at 10:40 a.m. the Administrator stated the DON and ADON both knew what was going on in the facility and they resigned during this investigation. The Administrator stated it was unusual for LVN A to have completed an Admission Assessment because of the shift she works which was from 10 p.m. to 6 a.m. and resident were usually not admitted on that shift, but she should still know how to do it. The weekend supervisor should have checked the new admission, made sure medication was in the house and the DON should have followed up on Monday. Record review of the facility [MEDICAL TREATMENT] Protocols policy dated February 2010 revealed the following: The Charge Nurse should initiate a telephone order for [MEDICAL TREATMENT], listing the name of the [MEDICAL TREATMENT] facility, the scheduled days and the phone number. The Charge Nurse will establish transportation to and from [MEDICAL TREATMENT] facility for the Patient. Record review of the Facility Patient Care Management System 12 policy dated December 2014 revealed: 1. A Nursing Assessment must be completed within 24 hours of admission (including readmission) of a Patient. The completed Assessment is filed in the Patient's medical record under the Assessments tab. 2. Upon admission (including readmission) the medication orders, to include allergies [REDACTED]. An Admission/Administration Record must be completed upon admission (including readmission). Record review of facility Abuse Protocol dated March 2012 revealed Our facility will not condone Patient abuse, neglect, mistreatment or misappropriation of Patient property by anyone, including staff members, other Patients, consultants, volunteers, staff of other agencies serving the Patient, family members, legal guardians Record review of the facility Reportable Incident Protocol dated March 2012 revealed the following: Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Internal Reportable Incident: If the Facility staff believes that an accident/incident does not meet the criteria for being reportable to DADS, the accident/incident must still be immediately reported to the Regional Director of Operations and the Regional Director of Clinical Services if the accident/incident is one of the following: .Serious medication errors . The facility Administrator was notified on 6/28/16 at 10:30 a.m. that an Immediate Jeopardy (IJ) situation had been identified due to the above failures. The facility submitted an Immediate Jeopardy Plan of Removal and it was accepted on 6/29/2016. Immediate Jeopardy Plan of Removal 1. Accurate Assessment of Patients a. Licensed nursing staff was in-serviced 6/25/16 and 6/27/16 on the admission assessment process to include: head to toe assessment with documentation of findings in the clinical record, medication review and verification with the admitting practitioner, appropriate [DIAGNOSES REDACTED]. This in-service emphasized assessment of Diabetic patients including indications of monitoring parameters, necessary lab work, medication monitoring and blood sugar check monitoring and signs and symptoms of hyper/hypo glycemia. b. Licensed nursing staff was in-serviced 6/25/16 and 6/27/16 on medication administration and associated knowledge of medication use as well as parameters of monitoring for the medication. c. The facility conducted an audit 6/25/16 of patient records to ensure that appropriate parameters were in place for diabetic patients including blood sugar monitoring. d. Monitoring of appropriate assessment of patients will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing or Designee. The facility will also retrieve tracking reports from the EMR to evidence blood sugars were completed by staff and that there are no duplication of medication orders. e. As a systematic change, monitoring of admission assessments and clinical needs will be conducted by a Registered Nurse no later 24 hours after admission. During this review, the medication regimen will be reviewed to ensure that there is no supplication in medication orders. f. Licensed nursing staff who are PRN or unavailable for the in-service will not be allowed to work until such a time as the in-service is completed. 2. [MEDICAL TREATMENT] Patient Management a. Licensed nursing staff was in-serviced 6/25/16 and 6/27/16 regarding the admission process when admitting [MEDICAL TREATMENT] patients. The in-services included: Verifying report with the transferring facility, [MEDICAL TREATMENT] facility location, address, phone number, chair time, method of transportation required, scheduling of the transportation with appropriate identified method, notification of dietary of meals and snacks that need to be sent with the patient to [MEDICAL TREATMENT]. b. Licensed nursing staff were also in-serviced on the appropriate documentation of [MEDICAL TREATMENT] information in the EMR as well as the creation of the communication binder. This in-service included the [MEDICAL TREATMENT] Communication Record , c. The facility conducted audits on 6/25/16 of residents who were receiving [MEDICAL TREATMENT] and to ensure that aspects of the [MEDICAL TREATMENT] requirement above were completed. d. Monitoring of the [MEDICAL TREATMENT] information, including the transportation will be conducted by the Unit Manager and Director of Nursing through daily report as well as by record review in the EMR. Any resident who misses [MEDICAL TREATMENT] for refusal, illness, etc. shall have this refusal documented in the clinical record along with the notification of the physician of said refusal. e. As a systematic change, monitoring of admission assessments and clinical needs, including [MEDICAL TREATMENT] care will be conducted by a Registered Nurse no later 24 hours after admission. f. Licensed nursing staff who are PRN or unavailable for the in-service will not be allowed to work until such a time as the in-service is completed. 3. Physician Notification a. Licensed nursing staff was in-serviced 6/28/16 on physician notification of change of status when there is a need to alter care. b. Monitoring of physician notification will be completed through unit mangers and the Director of Nursing or designee during the Daily Morning Meeting. c. Licensed nursing staff who are PRN or unavailable for in-service will not be allowed to work until such a time as the in-service is completed. Monitoring of plan: Record review of the facility Admission Process in-service dated 6/25/16 and 6/27/16 revealed that 24 staff had been in-serviced that it was the nurses responsibility to complete a head to toe assessment and document the findings in patients charts. All medications must be reviewed and verified with accepting physician and/or nurse practitioner. The in-service also revealed that the nurse should get the appropriate [DIAGNOSES REDACTED]. Record review of the facility Admission Process When Admitting Diabetic Patients dated 6/25/16 and 6/27/16 revealed that 23 staff had been in-serviced to ensure that staff add the [DIAGNOSES REDACTED]. Record review of the facility Medication Administration in-service dated 6/25/16 and 6/27/16 revealed that 23 staff were in-serviced that is was the staff's responsibility to know why a patient is receiving a medication. The in-service also revealed that blood pressure must be checked prior to administering medication and blood sugar must be checked prior to administering anti-diabetic medication. Record review of facility in-service dated 6/28/16 revealed 12 staff were in-serviced on notification on patients change in condition to physician/nurse practitioner and responsible party. In an interview on 6/28/16 at 11:39 a.m. with LVN C she stated that staff were in-serviced on what to do when a resident returns from the hospital or is admitted from the hospital that they should call the doctor to get orders for accucheck's if they are not already in the orders for diabetes and [MEDICAL TREATMENT]. The LVN also stated that the Nurses have to set up transportation for [MEDICAL TREATMENT] if it not already set up. Record review on 6/29/16 revealed that ten staff were in-serviced on following physician orders [REDACTED]. Record review dated 6/29/16 revealed that ten Nurses and Medication aides had been in-serviced on Duplication orders. The in-service stated that staff should review orders for their assigned patients upon receiving new orders and upon receiving new admissions to prevent duplication of orders. Observations on 6/28/16 through 6/30/16 revealed that residents' blood sugars and blood pressures were being checked and medication was being given according to physician orders. Interviews with all staff on 6/28/16 through 6/30/16 revealed that all Nursing and Medication aides were knowledgeable regarding change in condition, setting up transportation, following physician orders, accuchecks, and Residents with a [DIAGNOSES REDACTED]. On 6/30/2016 at 12:37 p.m. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy with a scope identified as pattern. The facility was continuing to monitor the plan of removal to ensure all residents were being monitored with physician's orders [REDACTED]. The facility reported 21 residents had [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to ensure one of 10 residents (Resident #1) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care in that: The facility failed to have an RN conduct Resident #1's initial assessment. The resident was administered [MEDICATION NAME] three times when it was only ordered to be given once daily and his blood sugar dropped to 20. Resident #1 was not transported to the emergency room for treatment for 35 minutes. The facility failed to coordinate his [MEDICAL TREATMENT] treatment. Resident #1 went five days without [MEDICAL TREATMENT] treatment. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 6/28/16. While the IJ was removed on 6/30/16, the facility remained out of compliance at actual harm that was not Immediate Jeopardy with a scope identified as pattern. The facility continued to monitor and evaluate the effectiveness of their plan. These failures affected one resident and placed an additional 21 residents with a [DIAGNOSES REDACTED]. Complaint # 3 Findings include: Resident #1 Record review of Resident #1's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with [REDACTED]. Resident #1 was discharged from the facility when he experienced a severe hypoglycemic episode on 6/21/16 and was hospitalized . Record review of Resident #1's hospital medication discharge orders dated 6/16/16 revealed: [MEDICATION NAME] 5 mg oral tablet, 1 tablet by mouth daily with breakfast. Record review of Resident #1's Medication Administration Record revealed that [MEDICATION NAME] 5 mg (1 Tab) tablet orally one time daily was entered three times. Further review revealed the medication was administered twice by the ADON on 6/20/16 at 8:00 AM and then a third time by MA A on 6/20/16 at 9:00 AM. Record Review of the Physician order [REDACTED]. LVN A entered the first order on 6/18/16 at 12:50 AM ADON entered the second order on 6/20/16 at 1:54 PM ADON entered the third order on 6/20/16 at 1:55 PM Record Review of the Clinical notes dated 6/21/16 at 10:29 a.m. revealed LVN B was completing 6:30 a.m. rounds and Resident #1 was alert and his blood sugar was 44. LVN B gave the resident raw sugar under his tongue and added sugar to his orange juice. Resident #1 only took sips of the orange juice and held it in his mouth before swallowing. LVN B documented she received an order to transfer Resident #1 to the hospital. LVN B took Resident #1's blood sugar again and documented the blood sugar was 27. She then called their transportation service, to transport Resident #1 to a local hospital. In an interview on 6/29/16 at 11:39 a.m. LVN B stated Resident #1 was admitted to the facility on the weekend and she did complete a full assessment of the resident on that Monday 6/20/16. LVN B stated Resident #1 told her he did not check his blood sugar and that he just took pills. Resident #1 missed his [MEDICAL TREATMENT] appointment at 5:30 a.m., so she called to make another appointment and the [MEDICAL TREATMENT] center gave her a 3:30 p.m. appointment. LVN B stated she called for transportation and she said they did not have an ambulance available at that time, but if the facility van took the resident then the ambulance would pick him up. LVN B stated that somehow the appointment she made got canceled and she did not know what happened. The interview continued with LVN B stating on Tuesday morning 6/21/16, LVN B stated Resident #1 called out to her at 6:30 a.m. as if he was saying hello. LVN B stated she said hello at the door and said she would be back. MA A came to her and said the family of Resident #1 said the resident was not acting right. LVN B stated she went to the room and the resident was sweating. She took his blood sugar and it read 47. LVN B stated she gave Resident #1 sugar and orange juice and the resident was not cooperating too well and kept holding the orange juice in his mouth and not swallowing. At this time, LVN B began asking all staff if they had [MEDICATION NAME] to help to increase Resident #1's blood sugar level and she called the transportation company and they said they would be there in 20 minutes. LVN B stated she waited a few minutes and checked the blood sugar again and it was 33 and by this time the ADON and LVN E got to the facility. LVN E went upstairs to get the [MEDICATION NAME]. Resident #1 was given the [MEDICATION NAME] and she checked Resident #1's blood sugar again and it was 23. In 10 more minutes, LVN B stated she called the physician and got orders to call the hospital informing them of the emergency transfer. The transportation arrived in 30 to 35 minutes. LVN B continued by stating the orders she saw later that day, she had not seen before. LVN B stated on Tuesday there was an order to check blood sugars, but it was not there before. LVN B stated she was not oriented to the Admission process when she was hired. LVN B stated she would think the ADON should overlook all of the admission assessments. There was nothing in the computer to alert her for transportation for [MEDICAL TREATMENT]. The night nurse should have set up [MEDICAL TREATMENT] and she could have said something at Report when they communicate Nurse to Nurse. Nothing was set up on the weekend. LVN B stated she should have called 9-1-1 instead of the regular transportation and maybe they would have come 5 minutes faster. Resident #1 was sweating and she did not know his baseline. In an interview with LVN C on 6/28/16 at 11:43 a.m. she stated Resident #1 was administered the [MEDICATION NAME] medication twice based on the Administration history form on 6/20/16 at 8 a.m. and 9 a.m. One was administered by the ADON and one by the Medication Aide. She stated double administration of diabetes medication could cause the blood sugar to drop. In an interview on 6/29/16 at 2:30 p.m., MA A revealed that she did administer Resident #1's [MEDICATION NAME] medication on 6/20/16 at 9 a.m. because she was the medication aide on duty. The MA A revealed that she came in from 6 a.m. to 2 p.m. and she was passing medication on that day, but whoever the nurse was that morning administered medication. MA A stated that based on Resident #1's Administration history form for 6/20/16, Resident #1 received [MEDICATION NAME] three times. MA A stated that the medication order shows that the ADON administered [MEDICATION NAME] twice on 6/20/16 at 8 a.m. The Medication Aide stated that if a medicine is only supposed to be administered once daily, then MA A should not have given it because it had to be given that morning. In an interview with the Regional Nurse on 6/29/16 at 2:45 p.m. she stated that according to Medication Administration Record for Resident #1 he received [MEDICATION NAME] 5 mg oral tablet, where the orders were 1 tablet by mouth 3 times on 6/20/16 at 9 a.m., 8 a.m. and again at 8 a.m. Record review of facility form Managed Care Authorization Request dated 6/16/16 revealed that Resident #1's equipment needs were [MEDICAL TREATMENT] on Monday, Wednesday and Friday at local [MEDICAL TREATMENT] center at 6:15 a.m. Record review revealed a Minimum Data Set (MDS) comprehensive assessment was not completed for Resident #1 prior to his discharge. Record Review of Resident #1's Clinical Notes Report dated 6/18/16 at 4:04 a.m. with the effective date of 6/17/16 at 10:30 p.m. written by LVN A revealed Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident #1's pain was documented an 8 out of 10. Resident #1 was to have [MEDICAL TREATMENT] on Monday, Wednesday and Friday at 6:15 a.m. with an outside contractor [MEDICAL TREATMENT] provider (specific provider was named). Record Review of Resident #1's Clinical Notes on 6/18/16 at 4:47 am revealed Resident #1 had an episode of vomiting. Resident was cleaned up and repositioned. Resident #1 was feeling better and was encouraged to have fluids. Record review of Resident #1's facility Care Plan dated 6/20/16 revealed he received [MEDICAL TREATMENT] three times a week and was at risk for increased shortness of breath, chest pains, blood pressure, itchy skin, nausea/vomiting, and infected access site. The interventions stated that Resident #1 will be monitored for increased complications from [MEDICAL TREATMENT] and that they would report abnormalities to the Medical Doctor (MD). Resident #1 would be served his diet per order, labs would be monitored and abnormalities would be reported to the MD. Resident #1 would be encouraged to be out of bed daily and activity attendance as tolerated, the access site would be monitored for infection, do not take blood pressure in ext. of access site and to allow Resident #1 to verbalize feelings of disease process. Resident #1 was also to be assisted with ADL's and comfort measures as needed and he would be weighed weekly and as ordered. The same care plan revealed Resident #1 was at risk of hyper or hypoglycemic episodes secondary to his [DIAGNOSES REDACTED]. The facility interventions stated that Resident #1's medication would be given as ordered, the labs would be as ordered and abnormalities would be reported to MD. Resident #1 would be monitored for thirst, excessive appetite or voiding, change in level of consciousness or mood, perspiring and report to MD promptly, skin would be monitored for redness or circulatory problems. Other interventions stated were Resident #1 would be monitored and assured positioning problems, encouraged to exercise and activity attendance and his diet would be as ordered and his intake would be monitored. Record Review of Resident #1's hospital records with a date of admission of 6/21/16 and printed on 6/23/16 revealed the attending physician documented, according to Resident #1, he was not getting adequate care. Resident #1 was not dialyzed yesterday, which was supposed to be the patient's [MEDICAL TREATMENT] day. The patient was brought to the emergency room and was found to have a blood sugar of 20. Resident #1 also had chest pain. Tests showed Resident #1 had abnormal findings. The hospital assessment revealed severe [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high potassium level). Observation and Interview on 6/23/16 at 4:15 p.m. at the local hospital, Resident #1 revealed when he got to the facility on Friday he noticed when he pressed the call light button, it took a long time for staff to come and when the staff came they acted as if he was bothering them. Resident #1 stated that by 3 p.m. he needed to go to the restroom. He pressed his call light and it took them an hour to two hours to come so he tried to get up and he twisted his body and fell . Resident #1 stated the last time he had [MEDICAL TREATMENT] was on 6/15/16 at the hospital. Resident #1 stated he was not dialyzed on Friday when he was admitted to the facility because he left the hospital mid-day. On Monday, Resident #1 stated he called [MEDICAL TREATMENT] himself and they told him there was no chair set up for him on Monday. Resident #1 stated that he got [MEDICAL TREATMENT] scheduled for 6:30 a.m. on Wednesday. Resident #1 stated on Tuesday, he felt like he was not going to make it, and he kept pressing the call light because he could not breathe. Resident #1 stated the local hospital checked his blood sugar when he arrived and it was 20. Resident #1 stated the staff nurse (LVN B) had told him she was not aware the resident was a diabetic. In an interview on 6/23/16 at 4:42 p.m. at the local hospital, Resident #1's family member revealed Resident #1 was going into a diabetic coma on 6/21/16 at 8 a.m. because he was sweating, his eyes were really big and LVN B came to the room at 8 a.m. The family member stated no one at the facility checked Resident #1's blood sugar all weekend and LVN B told her she did not know that Resident #1 had a [DIAGNOSES REDACTED].#1 vomited, she was the one that had to clean it up because the staff at the facility threw a towel on it and left it there. Resident #1 stated that LVN B told him also she did not know that Resident #1 was diabetic. In an interview with the Local Hospital Case Manager on 6/23/16 at 5 p.m. she stated Resident #1's history at the local hospital revealed he was admitted on [DATE] and discharged on Friday, 6/17/16 to the nursing facility. Resident #1 received [MEDICAL TREATMENT] on Wednesday, 6/15/16. No [MEDICAL TREATMENT] was given at the local hospital on Friday, 6/17/16. All of his records were sent to the Nursing home with a [DIAGNOSES REDACTED]. Resident #1 was admitted back to the local hospital on [DATE]. In an interview on 6/24/16 at 12:45 p.m., the Administrator revealed on Monday 6/20/16, she received a message about Resident #1 having pain so she met with the resident. Resident #1 stated he missed [MEDICAL TREATMENT] on that day and the [MEDICAL TREATMENT] center called him while she was in the room. The Administrator stated she spoke with the [MEDICAL TREATMENT] center personnel and they stated it was not necessary for the resident to get to [MEDICAL TREATMENT] and that he could receive [MEDICAL TREATMENT] on either Tuesday 6/21/16 or Wednesday 6/22/16. During the facility's end of day meeting on 6/17/16 at 4:34 PM, Resident #1 was listed as a planned admission. The Clinical Team was responsible for getting the [MEDICAL TREATMENT] set up along with LVN A. LVN A and the ADON were responsible for making sure the Admission process went as it should. In the same interview with the Administrator, she stated Resident #1's Admission Assessment was completed by LVN A and it was documented the resident had [MEDICAL TREATMENT] on Monday, Wednesday and Friday at 6:15 a.m., but transportation was not set up. The Administrator stated she did not believe Resident #1 came with orders to have blood sugars done, but the [DIAGNOSES REDACTED]. The Administrator revealed Resident #1 had one blood sugar check in the system on 6/21/16. The Administrator stated she did find where it was documented that Resident #1 was taking diabetes medication. The Administrator stated the Nurse conducting the Admission Assessment (LVN A) should have questioned why there was no order for blood sugar checks. On the morning of 6/21/16, the facility got orders to check Resident #1's blood sugar. The Administrator stated the Clinical team was composed of the Director of Nursing, Assistant Director of Nursing and MDS Coordinator. In the same interview the Administrator stated LVN A was supposed to contact the facility's provider transportation company to schedule appointments. The ADON was supposed to review all new admissions and make sure all parameters were in place. Record review of Resident #1's admission assessment completed by LVN A dated 6/17/16 at 11:52 PM, revealed no documentation of Resident #1's diagnoses. In an interview on 6/24/16 at 2:45 p.m. LVN A stated she completed the Admission Assessment for Resident #1 and he came into the facility at 10:30 p.m. on 6/17/16. LVN A stated it was too late to set up appointments for the resident. LVN A stated she had never had to set up transportation for residents, so she did not know what time they opened. LVN A stated when she did Resident #1's medication he did not have insulin, and she did not know that he was diabetic. LVN A stated she was not told Resident #1 had a [DIAGNOSES REDACTED]. LVN A stated she wrote in Report that Resident #1 had [MEDICAL TREATMENT] at the local [MEDICAL TREATMENT] clinic on Monday, Wednesday and Friday. LVN A stated transportation was usually set up before the resident came to the facility. LVN A said she set up Resident #1's medication that night and the resident got medication from their E-kit for pain and other medications would be delivered to the facility by 9 a.m. LVN A stated she did not inform anyone before she left that Resident #1 was not set up for [MEDICAL TREATMENT] and she never checked his blood sugar. LVN A stated she did get the resident's vital signs and body assessment and the resident never objected to care. LVN A stated when Resident #1 vomited she could not clean up all the vomit, so she left a clean towel on the floor so nobody would step in it. In the same interview on 6/24/2016 LVN A stated in hind sight, she would have put in an order to check Resident #1's blood sugar. LVN A stated there was nothing to point her in that direction and she did verify the resident's medications with the doctor. LVN A stated she went over Resident #1's orders with the resident's new doctor, but she did not tell the doctor the resident was a diabetic. LVN A stated the DON would look at her assessments, but she does not know if she saw it because it was done on the weekend. LVN A did state she did enter Resident #1's [MEDICATION NAME] into the facility's system, but she did not know that medication was for diabetes. In a telephone interview on 6/24/16 at 1:52 p.m. the ADON stated that Resident #1 was admitted to the facility on Friday evening, 6/17/16 and he was taking the medication [MEDICATION NAME] for his diabetes. The ADON stated there was nothing documented on the Medication Administration Record where staff were checking the Resident's blood sugars. LVN B checked the resident's blood sugar, gave Resident #1 the [MEDICATION NAME], but he refused the orange juice and the sugar. The ADON stated she was not sure why Resident #1 [MEDICAL TREATMENT] appointment was not set up. The ADON stated she did not work on weekends and the staff informed her of Resident #1 admission. The ADON said normally the hospital informed them the last time the resident had [MEDICAL TREATMENT] and how much they took off. The nurse taking report should have asked when the last time the Resident was dialyzed and about checking the resident's blood sugar. The nurse taking report should have also set up transportation for Resident #1's [MEDICAL TREATMENT]. The ADON stated if the resident had an episode of emesis that would should have cued the nurse that something was going on with the resident because with [DIAGNOSES REDACTED] they can have episodes of nausea and vomiting. A telephone interview was attempted on 6/24/16 with the previous DON at 2:15 p.m. A message was left. In an interview on 6/28/16 at 3:45 p.m. with the Administrator she stated that whenever an appointment was scheduled, the staff should have set up transportation. In an interview on 6/29/16 at 10:40 a.m. the Administrator stated the DON and ADON both knew what was going on in the facility and they resigned during this investigation. The Administrator stated it was unusual for LVN A to have completed an Admission Assessment because of the shift she works which was from 10 p.m. to 6 a.m. and resident were usually not admitted on that shift, but she should still know how to do it. The weekend supervisor should have checked the new admission, made sure medication was in the house and the DON should have followed up on Monday. Record review of the facility [MEDICAL TREATMENT] Protocols policy dated February 2010 revealed the following: The Charge Nurse should initiate a telephone order for [MEDICAL TREATMENT], listing the name of the [MEDICAL TREATMENT] facility, the scheduled days and the phone number. The Charge Nurse will establish transportation to and from [MEDICAL TREATMENT] facility for the Patient. Record review of the Facility Patient Care Management System 12 policy dated December 2014 revealed: 1. A Nursing Assessment must be completed within 24 hours of admission (including readmission) of a Patient. The completed Assessment is filed in the Patient's medical record under the Assessments tab. 2. Upon admission (including readmission) the medication orders, to include allergies [REDACTED]. An Admission/Administration Record must be completed upon admission (including readmission). The facility Administrator was notified on 6/28/16 at 10:30 a.m. that an Immediate Jeopardy (IJ) situation had been identified due to the above failures. The facility submitted an Immediate Jeopardy Plan of Removal and it was accepted on 6/29/2016. Immediate Jeopardy Plan of Removal 1. Accurate Assessment of Patients a. Licensed nursing staff was in-serviced 6/25/16 and 6/27/16 on the admission assessment process to include: head to toe assessment with documentation of findings in the clinical record, medication review and verification with the admitting practitioner, appropriate [DIAGNOSES REDACTED]. This in-service emphasized assessment of Diabetic patients including indications of monitoring parameters, necessary lab work, medication monitoring and blood sugar check monitoring and signs and symptoms of hyper/hypo glycemia. b. Licensed nursing staff was in-serviced 6/25/16 and 6/27/16 on medication administration and associated knowledge of medication use as well as parameters of monitoring for the medication. c. The facility conducted an audit 6/25/16 of patient records to ensure that appropriate parameters were in place for diabetic patients including blood sugar monitoring. d. Monitoring of appropriate assessment of patients will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing or Designee. The facility will also retrieve tracking reports from the EMR to evidence blood sugars were completed by staff and that there are no duplication of medication orders. e. As a systematic change, monitoring of admission assessments and clinical needs will be conducted by a Registered Nurse no later 24 hours after admission. During this review, the medication regimen will be reviewed to ensure that there is no supplication in medication orders. f. Licensed nursing staff who are PRN or unavailable for the in-service will not be allowed to work until such a time as the in-service is completed. 2. [MEDICAL TREATMENT] Patient Management a. Licensed nursing staff was in-serviced 6/25/16 and 6/27/16 regarding the admission process when admitting [MEDICAL TREATMENT] patients. The in-services included: Verifying report with the transferring facility, [MEDICAL TREATMENT] facility location, address, phone number, chair time, method of transportation required, scheduling of the transportation with appropriate identified method, notification of dietary of meals and snacks that need to be sent with the patient to [MEDICAL TREATMENT]. b. Licensed nursing staff were also in-serviced on the appropriate documentation of [MEDICAL TREATMENT] information in the EMR as well as the creation of the communication binder. This in-service included the [MEDICAL TREATMENT] Communication Record , c. The facility conducted audits on 6/25/16 of residents who were receiving [MEDICAL TREATMENT] and to ensure that aspects of the [MEDICAL TREATMENT] requirement above were completed. d. Monitoring of the [MEDICAL TREATMENT] information, including the transportation will be conducted by the Unit Manager and Director of Nursing through daily report as well as by record review in the EMR. Any resident who misses [MEDICAL TREATMENT] for refusal, illness, etc. shall have this refusal documented in the clinical record along with the notification of the physician of said refusal. e. As a systematic change, monitoring of admission assessments and clinical needs, including [MEDICAL TREATMENT] care will be conducted by a Registered Nurse no later 24 hours after admission. f. Licensed nursing staff who are PRN or unavailable for the in-service will not be allowed to work until such a time as the in-service is completed. 3. Physician Notification a. Licensed nursing staff was in-serviced 6/28/16 on physician notification of change of status when there is a need to alter care. b. Monitoring of physician notification will be completed through unit mangers and the Director of Nursing or designee during the Daily Morning Meeting. c. Licensed nursing staff who are PRN or unavailable for in-service will not be allowed to work until such a time as the in-service is completed. Monitoring of plan: Record review of the facility Admission Process in-service dated 6/25/16 and 6/27/16 revealed that 24 staff had been in-serviced that it was the nurses responsibility to complete a head to toe assessment and document the findings in patients charts. All medications must be reviewed and verified with accepting physician and/or nurse practitioner. The in-service also revealed that the nurse should get the appropriate [DIAGNOSES REDACTED]. Record review of the facility Admission Process When Admitting Diabetic Patients dated 6/25/16 and 6/27/16 revealed that 23 staff had been in-serviced to ensure that staff add the [DIAGNOSES REDACTED]. Record review of the facility Medication Administration in-service dated 6/25/16 and 6/27/16 revealed that 23 staff were in-serviced that is was the staff's responsibility to know why a patient is receiving a medication. The in-service also revealed that blood pressure must be checked prior to administering medication and blood sugar must be checked prior to administering anti-diabetic medication. Record review of facility in-service dated 6/28/16 revealed 12 staff were in-serviced on notification on patients change in condition to physician/nurse practitioner and responsible party. In an interview on 6/28/16 at 11:39 a.m. with LVN C she stated that staff were in-serviced on what to do when a resident returns from the hospital or is admitted from the hospital that they should call the doctor to get orders for accucheck's if they are not already in the orders for diabetes and [MEDICAL TREATMENT]. The LVN also stated that the Nurses have to set up transportation for [MEDICAL TREATMENT] if it not already set up. Record review on 6/29/16 revealed that ten staff were in-serviced on following physician orders [REDACTED]. Record review dated 6/29/16 revealed that ten Nurses and Medication aides had been in-serviced on Duplication orders. The in-service stated that staff should review orders for their assigned patients upon receiving new orders and upon receiving new admissions to prevent duplication of orders. Observations on 6/28/16 through 6/30/16 revealed that residents' blood sugars and blood pressures were being checked and medication was being given according to physician orders. Interviews with all staff on 6/28/16 through 6/30/16 revealed that all Nursing and Medication aides were knowledgeable regarding change in condition, setting up transportation, following physician orders, accuchecks, and Residents with a [DIAGNOSES REDACTED]. On 6/30/2016 at 12:37 p.m. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy with a scope identified as pattern. The facility was continuing to monitor the plan of removal to ensure all residents were being monitored with physician's orders [REDACTED]. The facility reported 21 residents had [DIAGNOSES REDACTED].

Based on interview and record review, the Administration failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for one of 12 residents (Resident #1) who were reviewed for maintaining their highest physical well-being. The Administrator failed to implement the facility's Abuse Prevention Program Policies and Procedures to prevent neglect. The Administrator failed to supervise the DON in the training and monitoring of the nursing staff with systems including the Admission and Assessment Process, monitoring residents with diabetes, Coordinating resident's transportation to outside services, and medication administration per doctors' orders. The DON failed to supervise and train the nursing staff on the admission and assessment process, assessing and monitoring residents with diabetes and high blood pressure, arranging services for residents with outside providers, administering medications per doctor's orders, and assessing residents for appropriate types of transfers. An Immediate Jeopardy (IJ) was identified on 6/28/16. While the IJ was removed on 6/30/16 at 12:37 p.m., the facility remained out of compliance at actual harm that was not Immediate Jeopardy with a scope identified as pattern. The facility needed additional time to evaluate the effectiveness of their plan. These failures affected one resident who was not assessed and provided physician ordered medications and services and placed 21 residents who had a [DIAGNOSES REDACTED]. Complaint # 3 Findings include: Resident #1 Record review revealed that Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with [REDACTED]. Resident #1 experienced severe hypoglycemic episode on 6/21/16 and was hospitalized . Record review of Resident #1's medical record revealed he was admitted to the facility on Friday 6/17/2016 late in the evening. The physician's orders [REDACTED]. The resident also had scheduled [MEDICAL TREATMENT] for Mondays, Wednesdays, and Fridays. The admission nurse, LVN A, during the assessment and verifying orders with the resident's newly assigned physician at the facility, was not aware the resident had diabetes so did not inform the physician nor did she receive an order to monitor the resident's blood sugars. LVN A, did note the resident was to have [MEDICAL TREATMENT] three times a week but did not set up transportation or communicate it to the next shift concerning the need for the transportation and [MEDICAL TREATMENT] to be coordinated. Further review of the same medical record revealed on Monday 6/20/2016, Resident #1 did not receive any [MEDICAL TREATMENT] treatment. Resident #1, due to a nurse transcription error of the physician's orders [REDACTED]. On Thursday, 6/21/2016 the resident experienced a change in condition and upon testing it was discovered the resident's blood sugar had dropped to 44 (normal range 70-130). LVN B tried to elevate Resident #1's blood sugar by administrating sugar and orange juice but it continued to decline until LVN B contacted the physician and received an order to transfer the resident to the hospital. Resident #1's blood sugar continued to drop with it now being 27. LVN B contacted the regular transport company to transfer Resident #1 to the hospital instead of calling 9-1-1. The transport did not arrive for thirty to thirty five minutes and when Resident #1 arrived at the hospital the physician documented the resident's blood sugar was 20 and he was experiencing chest pains. The hospital assessment dated [DATE] revealed Resident #1 had severe [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high potassium). In an interview with Resident #1 on 6/23/16 at 4:15 p.m. at local hospital he stated that when he got to the facility on Friday he noticed that when he pressed the call light button, it took a long time for staff to come and when the staff came they acted as if he was bothering them. Resident #1 stated that by 3 p.m. he needed to go to the restroom, he pressed his call light and it took them an hour to two hours to come so he tried to get up and he twisted his body and fell . Resident #1 stated that on Tuesday, he felt like he was not going to make it, and he kept pressing the call light because he could not breathe. Resident #1 stated that the local hospital checked his blood sugar when he arrived and it was 20. In an interview on 6/24/16 at 12:45 p.m. the Administrator stated the Clinical Team was responsible for getting [MEDICAL TREATMENT] sat up along with the Admission Nurse. LVN A and the ADON were responsible for making sure that the Admission process went as it should. The Administrator stated that the Clinical team was composed of the Director of Nursing, Assistant Director of Nursing, Unit Manager and MDS Coordinator makes up the Clinical Team. The Administrator stated on 6/24/16 at 12:45 p.m. that LVN A was supposed to contact their provider transportation company, FMR to schedule their appointments. The Unit Manager was supposed to review all new admissions and make sure all perimeters were in place. In a telephone interview on 6/24/16 at 1:52 p.m. the ADON stated she was not sure why Resident #1 missed his [MEDICAL TREATMENT] appointment and they were not set up. The ADON stated that she did not work on weekends and the staff informed her of admissions. The ADON stated that normally the hospital informed them the last time the resident had [MEDICAL TREATMENT] and how much they took off. The nurse taking report should have asked when the last time the resident was dialyzed and about checking blood sugars. The nurse taking report should have also set up transportation. The ADON stated if the resident had an episode of emesis that would have cued the nurse that something was going on with the Resident because with [DIAGNOSES REDACTED] they can have episodes of nausea and vomiting. A telephone interview was attempted on 6/24/16 with former DON at 2:15 p.m. A message was left but no return call was recieved during the investigation. In an interview on 6/29/16 at 10:40 a.m. the Administrator stated the DON and ADON both knew what was going on in the facility and they resigned during the investigation of this admission. The Administrator stated it was unusual for LVN A to have completed an Admission Assessment because of the shift she works which was from 10 p.m. to 6 a.m. and resident were usually not admitted on that shift, but she should still know how to do it. The weekend supervisor should have checked the new admission, made sure medication was in the house and the DON should have followed up on Monday. In an interview on 6/28/16 at 3:45 p.m. with the Administrator stated that whenever an appointment is scheduled, the staff should have set up transportation. The Administrator in the same interview on 6/28/16 at 3:45 p.m. stated she had been having problems with the DON not doing her job and the Administrator reported this to the corporate office. The Administrator stated the corporate office had sent a Regional Nurse to assist the facility, but the DON did not want her help, so the Regional Nurse left the facility. The DON was in the process of being transferred to another facility at the time of this investigation. The DON was supposed to return to the facility on [DATE], but when she heard that State was in the building she stated she was not coming back. The Administrator stated she was not aware of the exact details of what happened to cause immediate jeopardy, but when she became aware, she began in-servicing staff and re-educating the team members. The Administrator stated on 6/29/2016 at 10:40 am in order to ensure the nursing needs of residents are being met they start in their morning meeting. The Administrative team goes through the 24 hour reports with the morning nurses. The facility has a system review and they cover things like skin, weight issues and the QA process. The Administrator stated she normally has all of her Department heads in the meeting and they always invite the Medical Director. The Administrator stated she realized that a part of the problem was the DON asked questions, but she never hit the floor to make sure everything was being done by the Nurses. The DON needed to engage the Clinical team and follow through the process. The Administrator stated they use the interviewing process and classroom orientation and floor orientation to ensure the staff was competent. The DON should look at the weekend report through Monday to ensure everything was done. The Administrator continued to state the facility had resources available to them such as two medical directors, they consult with a pulmonologist, Nursing Administration Team, Sister facilities and they have someone from Regional for every one of their support areas. In an interview on 6/30/16 at 9:52 a.m. with the Acting DON she stated the facility had policies and procedures, a Regional Nurse, Sister facilities, a dietary consultant, social service, Medical Director, the Administrator and Corporate staff were all resources that were available to her and the staff to assist them. The Acting DON stated the incident occurred due to inconsistency, there was no one in place and the facility has to inspect what they expect. The Acting DON stated when the facility has a new admission the chart needs to be checked within 24 hours. The Admission Nurse needs to ask the Doctor if the Nurse has diabetic medication for an order to check blood sugar. The facility has to have a DON, ADON, and Unit Manager's who care and were consistent. Record review of the facility [MEDICAL TREATMENT] Protocols policy dated February 2010 revealed The Charge Nurse should initiate a telephone order for [MEDICAL TREATMENT], listing the name of the [MEDICAL TREATMENT] facility, the scheduled days and the phone number. The Charge Nurse will establish transportation to and from [MEDICAL TREATMENT] facility for the Patient. Review of the facility Patient Care Management System 12 policy dated December 2014 revealed: 1. A Nursing Assessment must be completed within 24 hours of admission (including readmission) of a Patient. The completed Assessment is filed in the Patient's medical record under the Assessments tab. 2. Upon admission (including readmission) the medication orders, to include allergies [REDACTED]. An Admission/Administration Record must be completed upon admission (including readmission). Review of the facility Physician order [REDACTED]. Obtain order from physician authorized/designee. Read order back to physician/designee to verify and/or clarify. Fill out telephone order form completely. Review of the facility Abuse Protocol dated March 2012 revealed the following: Our facility will not condone Patient abuse, neglect, mistreatment or misappropriation of Patient property by anyone, including staff members, other Patients, consultants, volunteers, staff of other agencies serving the Patient, family members, legal guardians . Review of the Reportable Incident Protocol dated March 2012 revealed: Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Internal Reportable Incident: If the Facility staff believes that an accident/incident does not meet the criteria for being reportable to DADS, the accident/incident must still be immediately reported to the Regional Director of Operations and the Regional Director of Clinical Services if the accident/incident is one of the following: .Serious medication errors . The facility Administrator was notified on 6/28/16 at 10:30 a.m. that an Immediate Jeopardy (IJ) situation had been identified due to the above failures. Immediate Jeopardy Plan of Removal was submitted and accepted by the regional office on 6/29/16 at 12:15 p.m. The plan included: Immediate Jeopardy Plan of Removal 1. Accurate Assessment of Patients a. Licensed nursing staff was in-serviced 6/25/16 and 6/27/16 on the admission assessment process to include: head to toe assessment with documentation of findings in the clinical record, medication review and verification with the admitting practitioner, appropriate [DIAGNOSES REDACTED]. This in-service emphasized assessment of Diabetic patients including indications of monitoring parameters, necessary lab work, medication monitoring and blood sugar check monitoring and signs and symptoms of hyper/hypo glycemia. b. Licensed nursing staff was in-serviced 6/25/16 and 6/27/16 on medication administration and associated knowledge of medication use as well as parameters of monitoring for the medication. c. The facility conducted an audit 6/25/16 of patient records to ensure that appropriate parameters were in place for diabetic patients including blood sugar monitoring. d. Monitoring of appropriate assessment of patients will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing or Designee. The facility will also retrieve tracking reports from the EMR to evidence blood sugars were completed by staff and that there are no duplication of medication orders. e. As a systematic change, monitoring of admission assessments and clinical needs will be conducted by a Registered Nurse no later 24 hours after admission. During this review, the medication regimen will be reviewed to ensure that there is no supplication in medication orders. f. Licensed nursing staff who are PRN or unavailable for the in-service will not be allowed to work until such a time as the in-service is completed. 2. [MEDICAL TREATMENT] Patient Management a. Licensed nursing staff was in-serviced 6/25/16 and 6/27/16 regarding the admission process when admitting [MEDICAL TREATMENT] patients. The in-services included: Verifying report with the transferring facility, [MEDICAL TREATMENT] facility location, address, phone number, chair time, method of transportation required, scheduling of the transportation with appropriate identified method, notification of dietary of meals and snacks that need to be sent with the patient to [MEDICAL TREATMENT]. b. Licensed nursing staff were also in-serviced on the appropriate documentation of [MEDICAL TREATMENT] information in the EMR as well as the creation of the communication binder. This in-service included the [MEDICAL TREATMENT] Communication Record , c. The facility conducted audits on 6/25/16 of residents who were receiving [MEDICAL TREATMENT] and to ensure that aspects of the [MEDICAL TREATMENT] requirement above were completed. d. Monitoring of the [MEDICAL TREATMENT] information, including the transportation will be conducted by the Unit Manager and Director of Nursing through daily report as well as by record review in the EMR. Any resident who misses [MEDICAL TREATMENT] for refusal, illness, etc. shall have this refusal documented in the clinical record along with the notification of the physician of said refusal. e. As a systematic change, monitoring of admission assessments and clinical needs, including [MEDICAL TREATMENT] care will be conducted by a Registered Nurse no later 24 hours after admission. f. Licensed nursing staff who are PRN or unavailable for the in-service will not be allowed to work until such a time as the in-service is completed. 3. Physician Notification a. Licensed nursing staff was in-serviced 6/28/16 on physician notification of change of status when there is a need to alter care. b. Monitoring of physician notification will be completed through unit mangers and the Director of Nursing or designee during the Daily Morning Meeting. c. Licensed nursing staff who are PRN or unavailable for in-service will not be allowed to work until such a time as the in-service is completed. Monitoring of plan: Record review of in-services dated 6/25/16 and 6/27/16 revealed that 24 staff had been in-serviced on the Admission process. The in-service emphasized and trained the nurses of their responsibility to complete a head to toe assessment and document the findings in patient's charts. All medications must be reviewed and verified with accepting physician and/or nurse practitioner. The in-service also trained the nurse that they should get the appropriate [DIAGNOSES REDACTED]. Record review of in-services dated 6/25/16 and 6/27/16 revealed that 23 staff had been in-serviced on the admission process. Emphasizing when admitting diabetic patients to ensure staff add the [DIAGNOSES REDACTED]. Record review of in-services on 6/25/16 and 6/27/16 revealed that 23 staff were in-serviced on Medication Administration stating the staff's responsibility to know why a patient was receiving a medication. The in-service also stated patient's blood pressure must be checked prior to administering blood pressure medication and blood sugars must be checked prior to administering anti-diabetic medication. Record review of in-services on 6/28/16 revealed 12 staff were in-serviced on notification on patients change in condition to physician/nurse practitioner and responsible party. In an interview on 6/28/16 at 11:39 a.m. with LVN C she stated that staff were in-serviced on what to do when a resident returns from the hospital or was admitted from the hospital. She stated staff would call the doctor to get orders for accucheck's if not already in the orders for residents who had diabetes. The LVN also stated the Nurses were trained to set up transportation for [MEDICAL TREATMENT] if it had not already been set up. Record review of in-service on 6/29/16 revealed that ten staff were in-serviced on following physician orders [REDACTED]. Record review of in-service dated 6/29/16 revealed that ten Nurses and Medication aides had been in-serviced on duplication of orders. The in-service revealed staff should review orders for their assigned patients upon receiving new orders and upon receiving new admissions to prevent duplication of orders. Observations on 6/28/16 through 6/30/16 revealed for the sampled Residents blood sugars and blood pressures were being checked and medications were being given according to the physician orders. Interviews with various staff on 6/28/16 through 6/30/16 revealed that all Nurses and medication aides were knowledgeable regarding change in condition, setting up transportation, following physician orders, accucheck's, and Residents with a [DIAGNOSES REDACTED]. On 6/30/2016 at 12:37 p.m. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy with a scope identified as pattern. The facility was continuing to monitor the plan of removal to ensure all residents were being monitored with physician's orders [REDACTED]. The facility reported 21 residents had [DIAGNOSES REDACTED].

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for two of six residents (Resident #1 and CR#5) reviewed for neglect. --The facility neglected to promptly address Resident #1's swelling and fracture in his right femur (thigh bone) by failing to effectively communicate Resident #1's change in condition from shift to shift between nursing staff and failing to promptly communicate with Resident #1's physician related to his change in condition. -- The facility neglected to provide timely assessments, closely monitor and provide adequate treatment and interventions for CR #5's right foot which had necrotic areas to his toes. Twelve days following admission, CR #5 was found with his right foot tip of all toes black, his right foot purple in color and a deep tissue injury to his right heel. CR#5 was admitted into intensive care unit with [DIAGNOSES REDACTED]. This failure affected one resident (Resident #1) residing at the facility and one former resident (CR#5) who had delayed treatments and required hospitalization and placed 109 residents residing at the facility at risk of not having their medical needs addressed timely which could cause extended durations of pain and a delay in medical treatments. Findings included: Intake # 7 and # 4 Resident #1 Record review of the facility face sheet revealed Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] revealed Resident #1 was unable to complete the Brief Interview for Mental Status. He sometimes made self understood and sometimes understood others. He required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #1 was always incontinent of bowel and bladder. Record review of the facility's Investigation Report dated 2/23/2016 and signed by the DON revealed in part: .Resident #1 arrived to the facility on [DATE] around 11:00 a.m. Head to toe assessment was completed and he was noted with 1+ [MEDICAL CONDITION] to his right femur area that has a history of being contracted. The nurse went verifying orders then informed the MD and he said to monitor the site. During the night shift the area was noted to be increased in swelling to 4+ non-pitting, however, Resident #1 did not appear to be in any pain from the swelling. The MD was called and he gave an order for [REDACTED].#1 was sent out to the hospital on [DATE] and returned on 2/20/2016. The [DIAGNOSES REDACTED]. Record review of Resident #1's hand written physician's orders [REDACTED]. -Monitor right leg for swelling dated 2/15/2016. -Transfer to hospital dated 2/17/2016 Record review of Resident #1's electronic physician's orders [REDACTED]. -[MEDICATION NAME] 50 mg via gastrostomy tube three times daily at 8:00 a.m., 12:00 p.m. and 4:00 p.m. for generalized pain dated 8/20/2015. -Venous Doppler (noninvasive test that is used to check the circulation in the large veins) of right thigh, up to the knee, due to 4+ [MEDICAL CONDITION] dated 2/16/2016 at 6:35 a.m. -STAT (immediately) X-ray dated 2/16/2016. Record review of Resident #1's ultrasound report for date of service 2/16/2016 revealed in part: Venous Doppler right extremity limb: Pain in unspecified limb. Findings: No [MEDICAL CONDITION] seen. Record review of Resident #1's radiology report for date of service 2/16/2016 revealed in part: Right femur. Results: There is a [MEDICAL CONDITION] right femur. There is a large medial angulation and superior displacement of the distal fragment. There is no apparent callus formation. Record review of Resident #1's Accident/Incident report dated 2/17/2016 and signed by LVN A revealed in part: .Person in charge - Account of occurrence: Resident #1 noted with swelling on admission. X-ray results showed fracture of unknown origin. Discovered/Reported by: RN B. Shift: 2 to 10 p.m . Further record review revealed DON and Administrator had not signed the incident report. Record review of Resident #1's electronic Clinical Notes revealed in part: -2/15/2016 at 1:24 p.m. signed by LVN C Post hospital return, clean no breaks noted head to toe . -2/15/2016 at 11:54 p.m. signed by RN B Resident #1 is a readmission from the hospital status [REDACTED].Plan of care will be updated based on identified needs -2/16/2016 at 6:54 a.m. signed by LVN D .4+ non [MEDICAL CONDITION] to right thigh, no signs of discomfort noted. MD notified. New orders for venous Doppler -Addendum note dated 2/16/2016 at 7:21 a.m. and signed by LVN A Resident #1 arrived via ambulance. Slight swelling to right leg noticed. Call placed to MD awaiting call back. Oncoming nurse notified of Resident #1's return and orders. Will continued to monitor. Upon arrival this a.m. as to followed up swelling , Resident #1 has new order to complete Doppler. -2/16/2016 at 8:38 a.m. signed by LVN A .Call placed to MD for slight swelling to right leg with new order for STAT X-ray. -2/16/2016 at 10:11 p.m. signed by RN B .Placed a call to Mobilex ([MEDICAL CONDITION] company) venous Doppler done but test results not available until 24 to 48 hours .Right thigh area larger than left thigh, slightly warmer than left but not hot, not able to palpate pulses . -2/17/2016 at 3:49 a.m. signed by LVN E .Right thigh area [MEDICAL CONDITION] 6 c.m. noted. No fever noted. No facial grimacing noted when lightly palpating the leg. Will continue to monitor -2/17/2016 at 7:15 p.m. signed by RN F .MD was notified of results and X-ray results positive for fracture of right femur. MD with orders to send Resident #1 to hospital. Resident #1 was transferred to the hospital at 7:40 p.m . In an interview on 02/19/2016 at 11:20 a.m. with LVN C, she stated that Resident #1 arrived from the hospital on [DATE] at around 11:00 a.m. LVN C said that she performed head to toe assessment to Resident #1 before lunch time and that he did not have any swelling anywhere in his body and that he did not have any pain during the assessment. She continued saying that Resident #1 would not speak but he was able to say yes or no when a question was asked and that he denied having pain at the time of the assessment. In an interview on 02/19/2016 at 11:39 a.m., LVN A stated that she assessed Resident #1 on 02/15/2016 after lunch time and that she noticed that Resident #1's right upper leg area was slightly swollen and that Resident #1 denied having pain by shaking his head to the sides and saying No. LVN A continued saying that she then called the MD and that he ordered to monitor the swelling area. LVN A further said It was a busy day, I don't remember if I documented that information but I do remember reporting the information to the next shift nurse who was RN B. I believe the facility uses the SBAR for changes in condition but I am new and I don't know all the systems in the computer. When asked if she completed an SBAR for Resident #1's swelling area to his right upper leg, LVN A said I did not do an SBAR for the swelling on his leg. You would do it for a big change in condition, not for a swelling. During training, they did not give me specifics for what to use an SBAR, they just said to use SBAR for changes in condition. The swelling to Resident #1's leg was not a big change in condition, it was only slightly swollen. It was not as big change to require an SBAR. Further interview at that time, LVN A said that on 02/16/2016 when she arrived at work, there was already an order for [REDACTED].#1's right leg and that Resident #1 had the X-ray sometime during the same day but did not remember the time and did not get the results either. LVN A then said that she reported the information to RN B during shift change. LVN A said that change of shift report were given orally and that there were no written 24 hour reports for shift changes that she was aware of. She further said I know that there is a 24 hour report that is in the computer system but I don't know what other nurses know. I just give verbal reports. I will go to my computer training next week. In an interview on 2/19/2016 at 12:47 PM with a staff member from the x-ray company used by the facility said that anytime they find an x-ray comes back positive for a fracture, they will call the facility and let them know as well as send a fax. The x-ray staff member said when Resident #1's x-ray results came back as positive on 2/16/2015, they called the facility at 4:13 PM and said the facility staff member who was notified was RN B. They also said the results were faxed to the facility at that time. In an interview on 02/19/2016 at 1:03 p.m. with the DON, she said that she was new in the facility and that she had just returned on 02/18/2016 from an out of town training that lasted 3 days and that she was still investigating what happened to Resident #1's leg fracture. She further said I was supposed to start making phone calls to the x-ray company and the ambulance company today but then State shows. When asked if she knew why was the delay of sending Resident #1 to the hospital if the X-ray was done on 2/16/2016 showing fracture and he did not get to go to the hospital until 2/17/2016, the DON responded We were supposed to call the X-ray manager today, from what I know was that the nurses were waiting for the Doppler results. I had been trying to talk to RN B but I haven't talked to her yet. In an interview on 02/19/2016 at 2:24 p.m. with RN B, she stated that she did not received any report on 02/15/2016 about Resident #1's right upper leg's swelling. RN B said that it was around 6:00 p.m. on that day that she noticed that Resident #1's right upper leg was slightly swollen but was not hot to touch and Resident #1 denied any pain. RN B further said that it was around 10:30 p.m. that one C.N.A. (did not remember who) called her to Resident #1's room and reported that Resident #1's right leg was big. RN B then said that C.N.A. was acting like Resident #1's leg was so huge, so I went there to see him together with the oncoming nurse for the night shift. When I saw him, his right upper leg was bigger than what I saw earlier on that day and he grimaced his face with movement, so I called the MD and he said to monitor Resident #1 . When asked if she wrote down on Resident #1's electronic charting about MD notification, RN B said Yes, I did. When asked to review the records with surveyor about MD notifications, RN B looked at Resident #1's electronic notes and said Well, on 2/15/2016 there was nothing to call the MD because the leg was not really expanded or swollen, not like to say Oh My God, something is wrong. When asked about the increased in swelling to Resident #1's leg that she noticed on 02/15/2016 at 10:30 p.m., RN B said that was not a case to call the MD, it was swollen but not that huge, so it was not a change in condition and he was already on pain medication [MEDICATION NAME] three times a day, he had [DIAGNOSES REDACTED]. Continued interview with RN B at that time, she stated that on 02/16/2016, LVN A did not report to her during shift change that Resident #1 had an X-ray done during the day shift so she did not follow up with the results because she did not know Resident #1 had an X-ray done. She further said, I saw his leg on 2/16/2016 and his leg was pretty big. I guess the mix up was that I was waiting for the Doppler results and only called to find out about the Doppler results and not about the X-ray results because I did not know that Resident #1 had any X-rays during the day shift and I did not call the MD to report the increased swelling because I was waiting for the Doppler results. RN B continued saying that she was not made aware of the X-ray results until 2/17/2016 during her 2 to 10 p.m. shift and that was when she called the MD to give the results that there was a fracture to Resident #1's upper leg and that she had another nurse to help her transfer Resident #1 to the hospital. In a phone interview on 2/22/2016 at 9:04 a.m. with Resident #1's MD, he stated that he believed he was informed by the facility about the swelling to Resident #1's upper leg the next day after he was admitted to the facility. The MD further said whenever I ordered the Doppler, that's when I was first informed of the swelling. I wanted to make sure there was no blood clots. After they gave me the results that the Doppler was negative for blood clots, I gave orders for STAT X-ray and I gave orders to send Resident #1 to hospital when the facility called me with the results of the X-ray. In a phone interview on 2/22/2016 at 11:28 a.m. with C.N.A. H, she stated that on 2/15/2016 at around 10:25 p.m. she was going to start her rounds for the night shift with Resident #1 and that she saw Resident #1's right upper leg very swollen and that she immediately went and reported to RN B (from the 2 - 10 p.m. shift) and LVN D (from the 10 - 6 a.m. shift). C.N.A. H further said RN B said that she did not know about Resident #1's leg and that nobody had reported anything to her. Resident #1 grimaced his face while nurses where looking at him. Observation on 2/23/2016 at 11:10 AM revealed Resident #1 in lying in bed. Resident #1 did not respond to questions, only made eye contact. In a phone interview on 2/23/2016 at 1:31 p.m. with LVN D, she stated that on 2/15/2016 when she arrived for the night shift, she was made aware that Resident #1's right upper leg was swollen and when she saw Resident #1's leg, it was swollen. LVN D further said that she did not call the doctor at that time to update him on Resident #1's condition because RN B told her that she had already called the doctor and had obtained orders to just monitor the leg. LVN D continued saying that Resident #1 was aphasic (difficulty expressing self) but was able to answer yes or no questions and that he had said he was not in pain. LVN D further said that she called the MD until the morning on 2/16/2016 at around 6:30 a.m. and obtained orders for Venous Doppler. In an interview on 2/23/2016 at 3:30 p.m. with the Acting Administrator, she stated that nurses were supposed to review the clinical notes from the residents to find out what happened to the residents on the previous shift just in case the nurse who is supposed to give report gets busy or forgets. In an interview on 2/23/2016 at 3:46 p.m. with the Acting Administrator and the DON, the DON stated that her understanding was that when nurses noticed the swelling to Resident #1's right upper leg, they notified the MD right away and when the nurses noticed that Resident #1's right upper leg was increasing in size, they got the order for the Doppler. CR #5 Record review of the facility face sheet revealed CR #5 was a [AGE] year old male admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #5 was re-admitted to the facility on [DATE] and he was admitted to a local hospital on [DATE] with [DIAGNOSES REDACTED]. Record review of CR #5's care plan with effective date of 9/30/2015 to present revealed in part: -Problems: Arterial wound to right great toe. Goals: CR#5 will suffer no further skin breakdown during the next 90 days. Goal date: 4/13/2016. Further record review revealed that CR#5 was identified at risk of pressure ulcer with goals to remain free of skin breakdown over the next 90 days. Care plan did not have interventions to prevent skin breakdown. Continued record review revealed no care plan that identified CR #5's [DIAGNOSES REDACTED]. Care plan did not included interventions to treat and/or monitor CR #5's right foot necrotic areas to toes #2, #3, and #4 and no interventions were put in place to prevent the deep tissue injury to his right foot. Record review of the quarterly MDS dated [DATE] revealed CR #5 had severe cognitive impairment. He required supervision and one person physical assist for bed mobility, transfer, walk in room, walk in corridor, locomotion on unit and off unit, dressing, toilet use and extensive assistance for personal hygiene and total dependent on staff for bathing. CR #5 was frequent incontinent of bladder and occasionally incontinent of bowel. He was identified at risk of developing pressure ulcers and did not have pressure ulcers or venous or arterial ulcers. CR #5 was not on a turning or repositioning program. Record review of CR #5's wound assessments revealed in part: - Assessments dated on 01/12/2016, 1/20/2016 and 1/26/2016 for right great toe. Arterial. Size 0.5 x 1 c.m. wound black/brown (eschar). -02/05/2016 weekly head to toe notes, non pressure left arm, left jugular and right clavicle. -02/11/2016 comments: CR#5 had post surgical wounds. Right clavicle, left jugular and left arm areas show no signs of infection. Clean and dry. Dry skin noted to bilateral lower extremities. Dry hardened dark area (0.2 x 0.1) noted to right great toe. No other skin problems identified. Record review of CR#5's electronic clinical notes revealed in part: -01/11/2016 CR #5's noted with black necrotic areas to left foot great toes, second toe and moist drainage between third and fourth toes. Left foot great toe red. MD with orders for Arterial Doppler to bilateral extremities. Record review of CR #5's bilateral lower extremity Arterial Doppler dated 01/19/2016 revealed in part: Scattered plaques are seen in the lower extremity bilaterally. Impression: On the right side the posterior tibial artery shows no flow and is occluded. Significant low velocities on the right side is likely due to severe external iliac artery disease . Record review of CR #5's electronic clinical notes revealed in part: -01/26/2016 CR #5 seen by wound care MD for arterial wound to right great toe and right second toe. -01/28/2016 MD called with new order to send CR #5 to a local hospital in am for [MEDICAL TREATMENT] and procedure on right foot. -01/29/2016 CR #5 transported to a local hospital. -02/05/2016 at 6:13 p.m. CR#5 readmitted with necrotic areas to right foot on toes #1, #2, #3, and #4 appeared to be old arterial ulcers. Note signed by LVN J Further record review revealed note on 02/05/2016 at 7:17 p.m. .Received CR #5 via stretcher. status [REDACTED]. New [MEDICAL TREATMENT] port a cath noted at left [MEDICATION NAME]/chest area .Skin assessment performed by wound care nurse . -02/15/2016 CR#5 continue with eschar to right great toes. -02/17/2016 at 11:43 a.m. Upon assessment CR #5's foot noted dark purple-reddish in color and he is unable to wiggle toes and denies feeling to extremity. MD made aware and stated that he was going to visit CR#5 to see if he still need procedure to right foot. Further record review of notes at 2:40 p.m. read in part MD here with orders to schedule CR #5 in am for direct admit to hospital for possible surgery to right foot Continued record review of notes at 3:30 p.m. read in part CR #5 noted with change in level of consciousness. Oxygen saturation 85% MD notified and informed about CR #5's significant change of condition and lethargy with new orders to send CR #5 to the emergency room In an interview on 02/23/2016 at 10:50 a.m. with the DON, she stated that she was new in the facility and did not know much about CR#5. In an interview on 02/23/2016 at 11:30 a.m. with RN K, she stated that she saw CR #5 right before he went to the hospital on [DATE] and that he had a deep tissue injury to his right heel and necrotic areas on two of his toes. She further stated that she was filling in for the treatment nurse who had resigned from the facility on around February the 8 or the 10th. She further said that she did not measure the deep tissue injury to CR #5's right heel. She continued saying that she did weekly assessments on CR#5 on 2/11/2016 and that she did not see any problems with his toes except for the dry hardened dark area (0.2 x 0.1) to right great toe. RN K continued saying that CR #5 did not have any wound care orders for his feet. When asked if she had received any notification from the staff regarding any skin concerns regarding CR #5's right foot prior to finding the deep tissue injury to his right heel, she said nobody said a word about his foot until 02/17/2016. Observation on 02/23/2016 at 12:25 p.m. revealed that CR #5 was in the Intensive Care Unit of a local hospital. CR#5 was non-verbal to surveyor. In an interview at that time with a hospital RN, she stated that CR #5 was admitted to the hospital with [REDACTED]. Interview on 02/23/2016 at 2:14 p.m. with C.N.A. L, she stated that she was the nursing assistant of CR #5 the day he was sent to the hospital. She continued saying that she saw CR#5's heel that was completely black and purple in color and the tip of all toes were black. She further said that CR#5's entire right foot was purple in color and that she called the nurse and the wound care nurse to see his foot. When asked if anyone from the previous shift had reported anything about CR#5's right foot, C.N.A. L responded nobody reported anything to me. C.N.A. L further said that nursing assistants float on different hallways and that there was no assigned staff for the residents. In a phone interview on 02/23/2016 at 2:47 p.m. with LVN J, she stated that she was not working at the facility anymore and the she remembered doing the admission assessment to CR#5 when he returned from the hospital on [DATE] and that when she wrote necrotic areas to right foot toes #1, #2, #3 and #4 was because the areas were black. In an interview on 02/23/2016 at 4:00 p.m. with the DON and the Acting Administrator, the DON said that she was told that CR#5 was sent out to the hospital because of shortness of breath and his oxygen saturation had dropped. She further said that changes in skin condition were reported to the nurses. When asked if CR #5 skin condition to his right foot was care planned with interventions to monitor skin changes and interventions. The Acting Administrator stated the treatment nurse keeps her own care plans, she is in charge of the care plans for skin condition. Wound care nurse have a folder with the care plans in her room and further asked the DON to go and get the care plan folder. Further interview and observation, the DON, RN K and LVN G (electronic medical record specialist) were at the computer looking at the care plan for CR#5. When asked if there was a care plan that reflected the condition of CR #5's right foot toes #2, #3 and #4 and interventions for CR#5 to prevent pressure sores as his care plan indicated he was at risk to develop pressure sores. LVN G stated as he looked at the care plan at the computer this was a care plan done by the admitting nurse, there are no interventions. Further interview at that time, the DON asked RN K to go upstairs and look for the binder of care plans kept by the wound care nurse. Continued observation and interview, RN K went into a room and said was the wound care nurse room and started opening cabinets, looking at the binders and flipping books and said to surveyor there is nothing here. Record review of the facility's policy and procedure with title Abuse Protocol revealed in part: .Our facility will not condone Patient neglect by anyone.3. The Executive Director, and in his/her absence, the Director of Nursing, will perform the duties of the Abuse Prevention Coordinator.Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The definition of neglect was not included in this document. Record review of the facility's policy and procedure for Significant change in patient status dated February 2010 revealed in part: .A significant change in Patient status is defined as deterioration or marked improvement in the health, mental or psychosocial status in either life-threatening conditions As a significant change in Patient condition occurs, the Charge Nurse will notify the physician of the significant change immediately . Record review of the facility's policy and procedure with title Skin dated January 2015 revealed in part: Any new skin issues identified must be addressed by the charge nurse to include assessments and documentation of the skin site and initiating appropriate clinical interventions. The Director of Nursing or designee must monitor the care plan, the appropriateness of interventions . CMS form 672 revealed a census of 110.

Based on interview and record review, the facility failed to implement policies and procedures that prohibit neglect for two of six residents reviewed for abuse and neglect (Resident #1 and CR#5). --The facility neglected to promptly address Resident #1's swelling and fracture in his right femur (thigh bone) by failing to effectively communicate Resident #1's change in condition from shift to shift between nursing staff and failing to promptly communicate with Resident #1's physician related to his change in condition. -- The facility neglected to provide timely assessments, closely monitor and provide adequate treatment and interventions for CR #5's right foot which had necrotic areas to his toes. Twelve days following admission, CR #5 was found with his right foot tip of all toes black, his right foot purple in color and a deep tissue injury to his right heel. CR#5 was admitted into intensive care unit with [DIAGNOSES REDACTED]. These failures affected one resident (Resident #1) and one former resident (CR#5) and could place the 109 residents residing at the facility at risk of not receiving adequate assessments, medical care, pain and decline in their health condition well-being. Findings included: Intake # 7 and # 4 Record review of the facility's policy and procedure with title Abuse Protocol revealed in part: .Our facility will not condone Patient neglect by anyone.3. The Executive Director, and in his/her absence, the Director of Nursing, will perform the duties of the Abuse Prevention Coordinator.Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The definition of neglect was not included in this document. Resident #1 Record review of the facility face sheet revealed Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] revealed Resident #1 was unable to complete the Brief Interview for Mental Status. He sometimes made self understood and sometimes understood others. He required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #1 was always incontinent of bowel and bladder. Record review of the facility's Investigation Report dated 2/23/2016 and signed by the DON revealed in part: .Resident #1 arrived to the facility on [DATE] around 11:00 a.m. Head to toe assessment was completed and he was noted with 1+ [MEDICAL CONDITION] to his right femur area that has a history of being contracted. The nurse went verifying orders then informed the MD and he said to monitor the site. During the night shift the area was noted to be increased in swelling to 4+ non-pitting, however, Resident #1 did not appear to be in any pain from the swelling. The MD was called and he gave an order for [REDACTED].#1 was sent out to the hospital on [DATE] and returned on 2/20/2016. The [DIAGNOSES REDACTED]. Record review of Resident #1's hand written Physician orders [REDACTED]. -Monitor right leg for swelling dated 2/15/2016. -Transfer to hospital dated 2/17/2016 Record review of Resident #1's electronic physician orders [REDACTED]. -[MEDICATION NAME] 50 mg via gastrostomy tube three times daily at 8:00 a.m., 12:00 p.m. and 4:00 p.m. for generalized pain dated 8/20/2015. -Venous Doppler (noninvasive test that is used to check the circulation in the large veins) of right thigh, up to the knee, due to 4+ [MEDICAL CONDITION] dated 2/16/2016 at 6:35 a.m. -STAT (immediately) X-ray dated 2/16/2016. Record review of Resident #1's ultrasound report for date of service 2/16/2016 revealed in part: Venous Doppler right extremity limb: Pain in unspecified limb. Findings: No [MEDICAL CONDITION] seen. Record review of Resident #1's radiology report for date of service 2/16/2016 revealed in part: Right femur. Results: There is a [MEDICAL CONDITION] right femur. There is a large medial angulation and superior displacement of the distal fragment. There is no apparent callus formation. Record review of Resident #1's Accident/Incident report dated 2/17/2016 and signed by LVN A revealed in part: .Person in charge - Account of occurrence: Resident #1 noted with swelling on admission. X-ray results showed fracture of unknown origin. Discovered/Reported by: RN B. Shift: 2 to 10 p.m . Further record review revealed DON and Administrator had not signed the incident report. Record review of Resident #1's electronic Clinical Notes revealed in part: -2/15/2016 at 1:24 p.m. signed by LVN C Post hospital return, clean no breaks noted head to toe . -2/15/2016 at 11:54 p.m. signed by RN B Resident #1 is a readmission from the hospital status [REDACTED].Plan of care will be updated based on identified needs -2/16/2016 at 6:54 a.m. signed by LVN D .4+ non [MEDICAL CONDITION] to right thigh, no signs of discomfort noted. MD notified. New orders for venous Doppler -Addendum note dated 2/16/2016 at 7:21 a.m. and signed by LVN A Resident #1 arrived via ambulance. Slight swelling to right leg noticed. Call placed to MD awaiting call back. Oncoming nurse notified of Resident #1's return and orders. Will continued to monitor. Upon arrival this a.m. as to followed up swelling , Resident #1 has new order to complete Doppler. -2/16/2016 at 8:38 a.m. signed by LVN A .Call placed to MD for slight swelling to right leg with new order for STAT X-ray. -2/16/2016 at 10:11 p.m. signed by RN B .Placed a call to Mobilex ([MEDICAL CONDITION] company) venous Doppler done but test results not available until 24 to 48 hours .Right thigh area larger than left thigh, slightly warmer than left but not hot, not able to palpate pulses . -2/17/2016 at 3:49 a.m. signed by LVN E .Right thigh area [MEDICAL CONDITION] 6 c.m. noted. No fever noted. No facial grimacing noted when lightly palpating the leg. Will continue to monitor -2/17/2016 at 7:15 p.m. signed by RN F .MD was notified of results and X-ray results positive for fracture of right femur. MD with orders to send Resident #1 to hospital. Resident #1 was transferred to the hospital at 7:40 p.m . In an interview on 02/19/2016 at 11:20 a.m. with LVN C, she stated that Resident #1 arrived from the hospital on [DATE] at around 11:00 a.m. LVN C said that she performed head to toe assessment to Resident #1 before lunch time and that he did not have any swelling anywhere in his body and that he did not have any pain during the assessment. She continued saying that Resident #1 would not speak but he was able to say yes or no when a question was asked and that he denied having pain at the time of the assessment. In an interview on 02/19/2016 at 11:39 a.m., LVN A stated that she assessed Resident #1 on 02/15/2016 after lunch time and that she noticed that Resident #1's right upper leg area was slightly swollen and that Resident #1 denied having pain by shaking his head to the sides and saying No. LVN A continued saying that she then called the MD and that he ordered to monitor the swelling area. LVN A further said It was a busy day, I don't remember if I documented that information but I do remember reporting the information to the next shift nurse who was RN B. I believe the facility uses the SBAR assessment for changes in condition but I am new and I don't know all the systems in the computer. When asked if she completed an SBAR assessment for Resident #1's swelling area to his right upper leg, LVN A said I did not do an SBAR assessment for the swelling on his leg. You would do it for a big change in condition, not for a swelling. During training, they did not give me specifics for what to use an SBAR assessment, they just said to use SBAR assessment for changes in condition. The swelling to Resident #1's leg was not a big change in condition, it was only slightly swollen. It was not as big change to require an SBAR assessment. Further interview at that time, LVN A said that on 02/16/2016 when she arrived at work, there was already an order for [REDACTED].#1's right leg and that Resident #1 had the X-ray sometime during the same day but did not remember the time and did not get the results either. LVN A then said that she reported the information to RN B during shift change. LVN A said that change of shift report were given orally and that there were no written 24 hour reports for shift changes that she was aware of. She further said I know that there is a 24 hour report that is in the computer system but I don't know what other nurses know. I just give verbal reports. I will go to my computer training next week. In an interview on 2/19/2016 at 12:47 PM with a staff member from the x-ray company used by the facility said that anytime they find an x-ray comes back positive for a fracture, they will call the facility and let them know as well as send a fax. The x-ray staff member said when Resident #1's x-ray results came back as positive on 2/16/2015, they called the facility at 4:13 PM and said the facility staff member who was notified was RN B. They also said they results were faxed to the facility at that time. In an interview on 02/19/2016 at 1:03 p.m. with the DON, she said that she was new in the facility and that she had just returned on 02/18/2016 from an out of town training that lasted 3 days and that she was still investigating what happened to Resident #1's leg fracture. She further said I was supposed to start making phone calls to the x-ray company and the ambulance company today but then State shows. When asked if she knew why was the delay of sending Resident #1 to the hospital if the X-ray was done on 2/16/2016 showing fracture and he did not get to go to the hospital until 2/17/2016, the DON responded We were supposed to call the X-ray manager today, from what I know was that the nurses were waiting for the Doppler results. I had been trying to talk to RN B but I haven't talked to her yet. In an interview on 02/19/2016 at 2:24 p.m. with RN B, she stated that she did not receive any report on 02/15/2016 about Resident #1's right upper leg's swelling. RN B said that it was around 6:00 p.m. on that day that she noticed that Resident #1's right upper leg was slightly swollen but was not hot to touch and Resident #1 denied any pain. RN B further said that it was around 10:30 p.m. that one C.N.A. (did not remember who) called her to Resident #1's room and reported that Resident #1's right leg was big. RN B then said that C.N.A. was acting like Resident #1's leg was so huge, so I went there to see him together with the oncoming nurse for the night shift. When I saw him, his right upper leg was bigger from what I saw earlier on that day and he grimaced his face with movement, so I called the MD and he said to monitor Resident #1 . When asked if she wrote down on Resident #1's electronic charting about MD notification, RN B said Yes, I did. When asked to review the records with surveyor about MD notifications, RN B looked at Resident #1's electronic notes and said Well, on 2/15/2016 there was nothing to call the MD because the leg was not really expanded or swollen, not like to say Oh My God, something is wrong. When asked about the increased in swelling to Resident #1's leg that she noticed on 02/15/2016 at 10:30 p.m., RN B said that was not a case to call the MD, it was swollen but not that huge, so it was not a change in condition and he was already on pain medication [MEDICATION NAME] three times a day, he had [DIAGNOSES REDACTED]. Continued interview with RN B at that time, she stated that on 02/16/2016, LVN A did not report to her during shift change that Resident #1 had an X-ray done during the day shift so she did not follow up with the results because she did not know Resident #1 had an X-ray done. She further said I saw his leg on 2/16/2016 and his leg was pretty big. I guess the mix up was that I was waiting for the Doppler results and only called to find out about the Doppler results and not about the X-ray results because I did not know that Resident #1 had any X-rays during the day shift and I did not call the MD to report the increased in swelling because I was waiting for the Doppler results. RN B continued saying that she was made aware of the X-ray results until 2/17/2016 during her 2 to 10 p.m. shift and that was the time she called the MD to give the results that was a fracture to Resident #1's upper leg and that she had another nurse to help her transfer Resident #1 to the hospital. In a phone interview on 2/22/2016 at 9:04 a.m. with Resident #1's MD, he stated that he believed he was informed by the facility about the swelling to Resident #1's upper leg the next day after he was admitted to the facility. The MD further said whenever I ordered the Doppler, that's when I was first informed of the swelling. I wanted to make sure there was no blood clots. After they gave me the results that the Doppler was negative for blood clots, I gave orders for STAT X-ray and I gave orders to send Resident #1 to hospital when the facility called me with the results of the X-ray. In a phone interview on 2/22/2016 at 11:28 a.m. with C.N.A. H, she stated that on 2/15/2016 at around 10:25 p.m. she was going to start her rounds for the night shift with Resident #1 and that she saw Resident #1's right upper leg very swollen and that she immediately went and reported to RN B (from the 2 - 10 p.m. shift) and LVN D (from the 10 - 6 a.m. shift). C.N.A. H further said RN B said that she did not know about Resident #1's leg and that nobody had reported anything to her. Resident #1 grimaced his face while nurses where looking at him. Observation on 2/23/2016 at 11:10 AM revealed Resident #1 in lying in bed. Resident #1 did not respond to questions, only made eye contact. In a phone interview on 2/23/2016 at 1:31 p.m. with LVN D, she stated that on 2/15/2016 when she arrived for the night shift, she was made aware that Resident #1's right upper leg was swollen and went she saw Resident #1's leg, it was swollen. LVN D further said that she did not call the doctor at that time to update him on Resident #1's condition because RN B told her that she had already called the doctor and had obtained orders to just monitor the leg. LVN D continued saying that Resident #1 was aphasic (difficulty expressing self) but was able to answer yes or no questions and that he had said he was not in pain. LVN D further said that she called the MD until the morning on 2/16/2016 at around 6:30 a.m. and obtained orders for Venous Doppler. In an interview on 2/23/2016 at 3:30 p.m. with the Acting Administrator, she stated that nurses were supposed to review the clinical notes from the residents to find out what happened to the residents on the previous shift just in case the nurse who is supposed to give report gets busy or forgets. In an interview on 2/23/2016 at 3:46 p.m. with the Acting Administrator and the DON, the DON stated that her understanding was that when nurses noticed the swelling to Resident #1's right upper leg, they notified the MD right away and when the nurses noticed that Resident #1's right upper leg was increasing in size, they got the order for the Doppler. CR #5 Record review of the facility face sheet revealed CR #5 was a [AGE] year old male admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #5 was re-admitted to the facility on [DATE] and he was admitted to a local hospital on [DATE] with [DIAGNOSES REDACTED]. Record review of CR #5's care plan with effective date of 9/30/2015 to present revealed in part: -Problems: Arterial wound to right great toe. Goals: CR#5 will suffer no further skin breakdown during the next 90 days. Goal date: 4/13/2016. Further record review revealed that CR#5 was identified at risk of pressure ulcer with goals to remain free of skin breakdown over the next 90 days. Care plan did not have interventions to prevent skin breakdown. Continued record review revealed no care plan that identified CR #5's [DIAGNOSES REDACTED]. Care plan did not included interventions to treat and/or monitor CR #5's right foot necrotic areas to toes #2, #3, and #4 and no interventions were put in place to prevent the deep tissue injury to his right foot. Record review of the quarterly MDS dated [DATE] revealed CR #5 had severe cognitive impairment. He required supervision and one person physical assist for bed mobility, transfer, walk in room, walk in corridor, locomotion on unit and off unit, dressing, toilet use and extensive assistance for personal hygiene and total dependent on staff for bathing. CR #5 was frequent incontinent of bladder and occasionally incontinent of bowel. He was identified at risk of developing pressure ulcers and did not have pressure ulcers or venous or arterial ulcers. CR #5 was not on a turning or repositioning program. Record review of CR #5's wound assessments revealed in part: - Assessments dated on 01/12/2016, 1/20/2016 and 1/26/2016 for right great toe. Arterial. Size 0.5 x 1 c.m. wound blach/brown (eschar). -02/05/2016 weekly head to toe notes, non pressure left arm, left jugular and right clavicle. -02/11/2016 comments: CR#5 had post surgical wounds. Right clavicle, left jugular and left arm areas show no signs of infection. Clean and dry. Dry skin noted to bilateral lower extremities. Dry hardened dark area (0.2 x 0.1) noted to right great toe. No other skin problems identified. Record review of CR#5's electronic clinical notes revealed in part: -01/11/2016 CR #5's noted with black necrotic areas to left foot great toes, second toe and moist drainage between third and fourth toes. Left foot grea toe red. MD with orders for Arterial Doppler to bilateral extremities. Record review of CR #5's bilateral lower extremity Arterial Doppler dated 01/19/2016 revealed in part: Scattered plaques are seen in the lower extremity bilaterally. Impression: On the right side the posterior tibial artery shows no flow and is occluded. Significant low velocities on the right side is likely due to severe external iliac artery disease . Record review of CR #5's electronic clinical notes revealed in part: -01/26/2016 CR #5 seen by wound care MD for arterial wound to right great toe and right second toe. -01/28/2016 MD called with new order to send CR #5 to a local hospital in am for [MEDICAL TREATMENT] and procedure on right foot. -01/29/2016 CR #5 transported to a local hospital. -02/05/2016 at 6:13 p.m. CR#5 readmitted with necrotic areas to right foot on toes #1, #2, #3, and #4 appeared to be old arterial ulcers. Note signed by LVN J Further record review revealed note on 02/05/2016 at 7:17 p.m. .Received CR #5 via stretcher. status [REDACTED]. New [MEDICAL TREATMENT] port a cath noted at left [MEDICATION NAME]/chest area .Skin assessment performed by wound care nurse . -02/15/2016 CR#5 continue with eschar to right great toes. -02/17/2016 at 11:43 a.m. Upon assessment CR #5's foot noted dark purple-reddish in color and he is unable to wiggle toes and denies feeling to extremity. MD made aware and stated that he was going to visit CR#5 to see if he still need procedure to right foot. Further record review of notes at 2:40 p.m. read in part MD here with orders to schedule CR #5 in am for direct admit to hospital for possible surgery to right foot Continued record review of notes at 3:30 p.m. read in part CR #5 noted with change in level of consciousness. Oxygen saturation 85% MD notified and informed about CR #5's significant change of condition and lethargy with new orders to send CR #5 to the emergency room In an interview on 02/23/2016 at 10:50 a.m. with the DON, she stated that she was new in the facility and did not know much about CR#5. In an interview on 02/23/2016 at 11:30 a.m. with RN K, she stated that she saw CR #5 right before he went to the hospital on [DATE] and that he had a deep tissue injury to his right heel and necrotic areas on two of his toes. She further stated that she was filling in for the treatment nurse who had resigned from the facility on around February the 8 or the 10th. She further said that she did not measure the deep tissue injury to CR #5's right heel. She continued saying that she did weekly assessments on CR#5 on 2/11/2016 and that she did not see any problems with his toes except for the dry hardened dark area (0.2 x 0.1) to right great toe. RN K continued saying that CR #5 did not have any wound care orders for his feet. When asked if she had received any notification from the staff regarding any skin concerns regarding CR #5's right foot prior to finding the deep tissue injury to his right heel, she said nobody said a word about his foot until 02/17/2016. Observation on 02/23/2016 at 12:25 p.m. revealed that CR #5 was in the Intensive Care Unit of a local hospital. CR#5 was non-verbal to surveyor. In an interview at that time with a hospital RN, she stated that CR #5 was admitted to the hospital with [REDACTED]. Interview on 02/23/2016 at 2:14 p.m. with C.N.A. L, she stated that she was the nursing assistant of CR #5 the day he was sent to the hospital. She continued saying that she saw CR#5's heel that was completely black and purple in color and the tip of all toes were black. She further said that CR#5's entire right foot was purple in color and that she called the nurse and the wound care nurse to see his foot. When asked if anyone from the previous shift had reported anything about CR#5's right foot, C.N.A. L responded nobody reported anything to me. C.N.A. L further said that nursing assistants float on different hallways and that there was no assigned staff for the residents. In a phone interview on 02/23/2016 at 2:47 p.m. with LVN J, she stated that she was not working at the facility anymore and the she remembered doing the admission assessment to CR#5 when he returned from the hospital on [DATE] and that when she wrote necrotic areas to right foot toes #1, #2, #3 and #4 was because the areas were black. In an interview on 02/23/2016 at 4:00 p.m. with the DON and the Acting Administrator, the DON said that she was told that CR#5 was sent out to the hospital because of shortness of breath and his oxygen saturation had dropped. She further said that changes in skin condition were reported to the nurses. When asked if CR #5 skin condition to his right foot was care planned with interventions to monitor skin changes and interventions. The Acting Administrator stated the treatment nurse keeps her own care plans, she is in charge of the care plans for skin condition. Wound care nurse have a folder with the care plans in her room and further asked the DON to go and get the care plan folder. Further interview and observation, the DON, RN K and LVN G (electronic medical record specialist) were at the computer looking at the care plan for CR#5. When asked if there was a care plan that reflected the condition of CR #5's right foot toes #2, #3 and #4 and interventions for CR#5 to prevent pressure sores as his care plan indicated he was at risk to develop pressure sores. LVN G stated as he looked at the care plan at the computer this was a care plan done by the admitting nurse, there are no interventions. Further interview at that time, the DON asked RN K to go upstairs and look for the binder of care plans kept by the wound care nurse. Continued observation and interview, RN K went into a room and said was the wound care nurse room and started opening cabinets, looking at the binders and flipping books and said to surveyor there is nothing here. Record review of the facility's policy and procedure for Significant change in patient status dated February 2010 revealed in part: .A significant change in Patient status is defined as deterioration or marked improvement in the health, mental or psychosocial status in either life-threatening conditions As a significant change in Patient condition occurs, the Charge Nurse will notify the physician of the significant change immediately . Record review of the facility's policy and procedure with title Skin dated January 2015 revealed in part: Any new skin issues identified must be addressed by the charge nurse to include assessments and documentation of the skin site and initiating appropriate clinical interventions. The Director of Nursing or designee must monitor the care plan, the appropriateness of interventions . CMS form 672 revealed a census of 110.

Based on observation, interview and record review the facility failed to ensure that two of six residents (Resident #1 and CR#5) reviewed for care provided, were provided care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care, as evidenced by: --The facility failed to promptly address Resident #1's swelling and fracture in his right femur (thigh bone) by failing to effectively communicate Resident #1's change in condition from shift to shift between nursing staff and failing to promptly communicate with Resident #1's physician related to his change in condition. -- The facility failed to provide timely assessments, closely monitor and provide adequate treatment and interventions for CR #5's right foot which had necrotic areas to his toes. Twelve days following admission, CR #5 was found with his right foot tip of all toes black, his right foot purple in color and a deep tissue injury to his right heel. CR#5 was admitted into intensive care unit with [DIAGNOSES REDACTED]. --The facility failed to Care plan interventions to treat and/or monitor CR #5's right foot necrotic areas. CR #5 was assessed at risk to develop pressure sores and no interventions were put in place to prevent the deep tissue injury to his right heel. These failures affected one resident (Resident #1) and one former resident (CR#5) who had delayed medical treatment and could place the 95 residents who required assistance for transferring at the facility at risk of not receiving adequate assessments, medical care, pain and decline in their physical, mental and psychosocial health and self esteem. Findings included: Intake # 7 and # 4 Resident #1 Record review of the facility face sheet revealed Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] revealed Resident #1 was unable to complete the Brief Interview for Mental Status. He sometimes made self understood and sometimes understood others. He required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #1 was always incontinent of bowel and bladder. Record review of Resident #1's Care Plan read in part, At Risk for Falls R/T inability to move self, ambulate etc., cognitive impairment, medications that may increase the risk for falls.Turning/positioning in bed (bed mobility) - (Resident #1) requires extensive assistance x 1-2.Transfers - x 2 assist with use of a hoyer lift. this document was dated 9/22/2015. Record review of the facility's Investigation Report dated 2/23/2016 and signed by the DON revealed in part: .Resident #1 arrived to the facility on [DATE] around 11:00 a.m. Head to toe assessment was completed and he was noted with 1+ [MEDICAL CONDITION] to his right femur area that has a history of being contracted. The nurse went verifying orders then informed the MD and he said to monitor the site. During the night shift the area was noted to be increased in swelling to 4+ non-pitting, however, Resident #1 did not appear to be in any pain from the swelling. The MD was called and he gave an order for [REDACTED].#1 was sent out to the hospital on [DATE] and returned on 2/20/2016. The [DIAGNOSES REDACTED]. Record review of Resident #1's hand written Physician orders [REDACTED]. -Monitor right leg for swelling dated 2/15/2016. -Transfer to hospital dated 2/17/2016 Record review of Resident #1's electronic physician orders [REDACTED]. -[MEDICATION NAME] 50 mg via gastrostomy tube three times daily at 8:00 a.m., 12:00 p.m. and 4:00 p.m. for generalized pain dated 8/20/2015. -Venous Doppler (noninvasive test that is used to check the circulation in the large veins) of right thigh, up to the knee, due to 4+ [MEDICAL CONDITION] dated 2/16/2016 at 6:35 a.m. -STAT (immediately) X-ray dated 2/16/2016. Record review of Resident #1's ultrasound report for date of service 2/16/2016 revealed in part: Venous Doppler right extremity limb: Pain in unspecified limb. Findings: No [MEDICAL CONDITION] seen. Record review of Resident #1's radiology report for date of service 2/16/2016 revealed in part: Right femur. Results: There is a [MEDICAL CONDITION] right femur. There is a large medial angulation and superior displacement of the distal fragment. There is no apparent callus formation. Record review of Resident #1's Accident/Incident report dated 2/17/2016 and signed by LVN A revealed in part: .Person in charge - Account of occurrence: Resident #1 noted with swelling on admission. X-ray results showed fracture of unknown origin. Discovered/Reported by: RN B. Shift: 2 to 10 p.m . Further record review revealed DON and Administrator had not signed the incident report. Record review of Resident #1's electronic Clinical Notes revealed in part: -2/15/2016 at 1:24 p.m. signed by LVN C Post hospital return, clean no breaks noted head to toe . -2/15/2016 at 11:54 p.m. signed by RN B Resident #1 is a readmission from the hospital status [REDACTED].Plan of care will be updated based on identified needs -2/16/2016 at 6:54 a.m. signed by LVN D .4+ non [MEDICAL CONDITION] to right thigh, no signs of discomfort noted. MD notified. New orders for venous Doppler -Addendum note dated 2/16/2016 at 7:21 a.m. and signed by LVN A Resident #1 arrived via ambulance. Slight swelling to right leg noticed. Call placed to MD awaiting call back. Oncoming nurse notified of Resident #1's return and orders. Will continued to monitor. Upon arrival this a.m. as to followed up swelling , Resident #1 has new order to complete Doppler. -2/16/2016 at 8:38 a.m. signed by LVN A .Call placed to MD for slight swelling to right leg with new order for STAT X-ray. -2/16/2016 at 10:11 p.m. signed by RN B .Placed a call to Mobilex ([MEDICAL CONDITION] company) venous Doppler done but test results not available until 24 to 48 hours .Right thigh area larger than left thigh, slightly warmer than left but not hot, not able to palpate pulses . -2/17/2016 at 3:49 a.m. signed by LVN E .Right thigh area [MEDICAL CONDITION] 6 c.m. noted. No fever noted. No facial grimacing noted when lightly palpating the leg. Will continue to monitor -2/17/2016 at 7:15 p.m. signed by RN F .MD was notified of results and X-ray results positive for fracture of right femur. MD with orders to send Resident #1 to hospital. Resident #1 was transferred to the hospital at 7:40 p.m . In an interview on 02/19/2016 at 11:20 a.m. with LVN C, she stated that Resident #1 arrived from the hospital on [DATE] at around 11:00 a.m. LVN C said that she performed head to toe assessment to Resident #1 before lunch time and that he did not have any swelling anywhere in his body and that he did not have any pain during the assessment. She continued saying that Resident #1 would not speak but he was able to say yes or no when a question was asked and that he denied having pain at the time of the assessment. In an interview on 02/19/2016 at 11:39 a.m., LVN A stated that she assessed Resident #1 on 02/15/2016 after lunch time and that she noticed that Resident #1's right upper leg area was slightly swollen and that Resident #1 denied having pain by shaking his head to the sides and saying No. LVN A continued saying that she then called the MD and that he ordered to monitor the swelling area. LVN A further said It was a busy day, I don't remember if I documented that information but I do remember reporting the information to the next shift nurse who was RN B. I believe the facility uses the SBAR assessments for changes in condition but I am new and I don't know all the systems in the computer. When asked if she completed an SBAR assessment for Resident #1's swelling area to his right upper leg, LVN A said I did not do an SBAR assessment for the swelling on his leg. You would do it for a big change in condition, not for a swelling. During training, they did not give me specifics for what to use an SBAR assessment, they just said to use SBAR assessment for changes in condition. The swelling to Resident #1's leg was not a big change in condition, it was only slightly swollen. It was not as big change to require an SBAR assessment. Further interview at that time, LVN A said that on 02/16/2016 when she arrived at work, there was already an order for [REDACTED].#1's right leg and that Resident #1 had the X-ray sometime during the same day but did not remember the time and did not get the results either. LVN A then said that she reported the information to RN B during shift change. LVN A said that change of shift report were given orally and that there were no written 24 hour reports for shift changes that she was aware of. She further said I know that there is a 24 hour report that is in the computer system but I don't know what other nurses know. I just give verbal reports. I will go to my computer training next week. In an interview on 2/19/2016 at 12:47 PM with a staff member from the x-ray company used by the facility said that anytime they find an x-ray comes back positive for a fracture, they will call the facility and let them know as well as send a fax. The x-ray staff member said when Resident #1's x-ray results came back as positive on 2/16/2015, they called the facility at 4:13 PM and said the facility staff member who was notified was RN B. They also said they results were faxed to the facility at that time. In an interview on 02/19/2016 at 1:03 p.m. with the DON, she said that she was new in the facility and that she had just returned on 02/18/2016 from an out of town training that lasted 3 days and that she was still investigating what happened to Resident #1's leg fracture. She further said I was supposed to start making phone calls to the x-ray company and the ambulance company today but then State shows. When asked if she knew why was the delay of sending Resident #1 to the hospital if the X-ray was done on 2/16/2016 showing fracture and he did not get to go to the hospital until 2/17/2016, the DON responded We were supposed to call the X-ray manager today, from what I know was that the nurses were waiting for the Doppler results. I had been trying to talk to RN B but I haven't talked to her yet. In an interview on 02/19/2016 at 2:24 p.m. with RN B, she stated that she did not receive any report on 02/15/2016 about Resident #1's right upper leg's swelling. RN B said that it was around 6:00 p.m. on that day that she noticed that Resident #1's right upper leg was slightly swollen but was not hot to touch and Resident #1 denied any pain. RN B further said that it was around 10:30 p.m. that one C.N.A. (did not remember who) called her to Resident #1's room and reported that Resident #1's right leg was big. RN B then said that C.N.A. was acting like Resident #1's leg was so huge, so I went there to see him together with the oncoming nurse for the night shift. When I saw him, his right upper leg was bigger from what I saw earlier on that day and he grimaced his face with movement, so I called the MD and he said to monitor Resident #1 . When asked if she wrote down on Resident #1's electronic charting about MD notification, RN B said Yes, I did. When asked to review the records with surveyor about MD notifications, RN B looked at Resident #1's electronic notes and said Well, on 2/15/2016 there was nothing to call the MD because the leg was not really expanded or swollen, not like to say Oh My God, something is wrong. When asked about the increase in swelling to Resident #1's leg that she noticed on 02/15/2016 at 10:30 p.m., RN B said that was not a case to call the MD, it was swollen but not that huge, so it was not a change in condition and he was already on pain medication [MEDICATION NAME] three times a day, he had [DIAGNOSES REDACTED]. Continued interview with RN B at that time, she stated that on 02/16/2016, LVN A did not report to her during shift change that Resident #1 had an X-ray done during the day shift so she did not follow up with the results because she did not know Resident #1 had an X-ray done. She further said I saw his leg on 2/16/2016 and his leg was pretty big. I guess the mix up was that I was waiting for the Doppler results and only called to find out about the Doppler results and not about the X-ray results because I did not know that Resident #1 had any X-rays during the day shift and I did not call the MD to report the increased in swelling because I was waiting for the Doppler results. RN B continued saying that she was not made aware of the X-ray results until 2/17/2016 during her 2 to 10 p.m. shift. She said that was the time she called the MD to give the results that was a fracture to Resident #1's upper leg and that she had another nurse to help her transfer Resident #1 to the hospital. In a phone interview on 2/22/2016 at 9:04 a.m. with Resident #1's MD, he stated that he believed he was informed by the facility about the swelling to Resident #1's upper leg the next day after he was admitted to the facility. The MD further said whenever I ordered the Doppler, that's when I was first informed of the swelling. I wanted to make sure there was no blood clots. After they gave me the results that the Doppler was negative for blood clots, I gave orders for STAT X-ray and I gave orders to send Resident #1 to hospital when the facility called me with the results of the X-ray. In a phone interview on 2/22/2016 at 11:28 a.m. with C.N.A. H, she stated that on 2/15/2016 at around 10:25 p.m. she was going to start her rounds for the night shift with Resident #1 and that she saw Resident #1's right upper leg was very swollen and that she immediately went and reported to RN B (from the 2 - 10 p.m. shift) and LVN D (from the 10 - 6 a.m. shift). C.N.A. H further said RN B said that she did not know about Resident #1's leg and that nobody had reported anything to her. Resident #1 grimaced his face while nurses where looking at him. Observation on 2/23/2016 at 11:10 AM revealed Resident #1 in lying in bed. Resident #1 did not respond to questions, only made eye contact. In a phone interview on 2/23/2016 at 1:31 p.m. with LVN D, she stated that on 2/15/2016 when she arrived for the night shift, she was made aware that Resident #1's right upper leg was swollen and went she saw Resident #1's leg, it was swollen. LVN D further said that she did not call the doctor at that time to update him on Resident #1's condition because RN B told her that she had already called the doctor and had obtained orders to just monitor the leg. LVN D continued saying that Resident #1 was aphasic (difficulty expressing self) but was able to answer yes or no questions and that he had said he was not in pain. LVN D further said that she called the MD until the morning on 2/16/2016 at around 6:30 a.m. and obtained orders for Venous Doppler. In an interview on 2/23/2016 at 3:30 p.m. with the Acting Administrator, she stated that nurses were supposed to review the clinical notes from the residents to find out what happened to the residents on the previous shift just in case the nurse who is supposed to give report gets busy or forgets. In an interview on 2/23/2016 at 3:46 p.m. with the Acting Administrator and the DON, the DON stated that her understanding was that when nurses noticed the swelling to Resident #1's right upper leg, they notified the MD right away and when the nurses noticed that Resident #1's right upper leg was increasing in size, they got the order for the Doppler. CR #5 Record review of the facility face sheet revealed CR #5 was a [AGE] year old male admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #5 was re-admitted to the facility on [DATE] and he was admitted to a local hospital on [DATE] with [DIAGNOSES REDACTED]. Record review of CR #5's care plan with effective date of 9/30/2015 to present revealed in part: -Problems: Arterial wound to right great toe. Goals: CR#5 will suffer no further skin breakdown during the next 90 days. Goal date: 4/13/2016. Further record review revealed that CR#5 was identified at risk of pressure ulcer with goals to remain free of skin breakdown over the next 90 days. Care plan did not have interventions to prevent skin breakdown. Continued record review revealed no care plan that identified CR #5's [DIAGNOSES REDACTED]. Care plan did not include interventions to treat and/or monitor CR #5's right foot necrotic areas to toes #2, #3, and #4 and no interventions were put in place to prevent the deep tissue injury to his right foot. Record review of the quarterly MDS dated [DATE] revealed CR #5 had severe cognitive impairment. He required supervision and one person physical assist for bed mobility, transfer, walk in room, walk in corridor, locomotion on unit and off unit, dressing, toilet use and extensive assistance for personal hygiene and total dependent on staff for bathing. CR #5 was frequent incontinent of bladder and occasionally incontinent of bowel. He was identified at risk of developing pressure ulcers and did not have pressure ulcers or venous or arterial ulcers. CR #5 was not on a turning or repositioning program. Record review of CR #5's wound assessments revealed in part: - Assessments dated on 01/12/2016, 1/20/2016 and 1/26/2016 for right great toe. Arterial. Size 0.5 x 1 c.m. wound black/brown (eschar). -02/05/2016 weekly head to toe notes, non pressure left arm, left jugular and right clavicle. -02/11/2016 comments: CR#5 had post surgical wounds. Right clavicle, left jugular and left arm areas show no signs of infection. Clean and dry. Dry skin noted to bilateral lower extremities. Dry hardened dark area (0.2 x 0.1) noted to right great toe. No other skin problems identified. Record review of CR#5's electronic clinical notes revealed in part: -01/11/2016 CR #5's noted with black necrotic areas to left foot great toes, second toe and moist drainage between third and fourth toes. Left foot great toe red. MD with orders for Arterial Doppler to bilateral extremities. Record review of CR #5's bilateral lower extremity Arterial Doppler dated 01/19/2016 revealed in part: Scattered plaques are seen in the lower extremity bilaterally. Impression: On the right side the posterior tibial artery shows no flow and is occluded. Significant low velocities on the right side is likely due to severe external iliac artery disease . Record review of CR #5's electronic clinical notes revealed in part: -01/26/2016 CR #5 seen by wound care MD for arterial wound to right great toe and right second toe. -01/28/2016 MD called with new order to send CR #5 to a local hospital in am for [MEDICAL TREATMENT] and procedure on right foot. -01/29/2016 CR #5 transported to a local hospital. -02/05/2016 at 6:13 p.m. CR#5 readmitted with necrotic areas to right foot on toes #1, #2, #3, and #4 appeared to be old arterial ulcers. Note signed by LVN J Further record review revealed note on 02/05/2016 at 7:17 p.m. .Received CR #5 via stretcher. status [REDACTED]. New [MEDICAL TREATMENT] port a cath noted at left [MEDICATION NAME]/chest area .Skin assessment performed by wound care nurse . -02/15/2016 CR#5 continue with eschar to right great toes. -02/17/2016 at 11:43 a.m. Upon assessment CR #5's foot noted dark purple-reddish in color and he is unable to wiggle toes and denies feeling to extremity. MD made aware and stated that he was going to visit CR#5 to see if he still need procedure to right foot. Further record review of notes at 2:40 p.m. read in part MD here with orders to schedule CR #5 in am for direct admit to hospital for possible surgery to right foot Continued record review of notes at 3:30 p.m. read in part CR #5 noted with change in level of consciousness. Oxygen saturation 85% MD notified and informed about CR #5's significant change of condition and lethargy with new orders to send CR #5 to the emergency room In an interview on 02/23/2016 at 10:50 a.m. with the DON, she stated that she was new in the facility and did not know much about CR#5. In an interview on 02/23/2016 at 11:30 a.m. with RN K, she stated that she saw CR #5 right before he went to the hospital on [DATE] and that he had a deep tissue injury to his right heel and necrotic areas on two of his toes. She further stated that she was filling in for the treatment nurse who had resigned from the facility on around February the 8 or the 10th. She further said that she did not measure the deep tissue injury to CR #5's right heel. She continued saying that she did weekly assessments on CR#5 on 2/11/2016 and that she did not see any problems with his toes except for the dry hardened dark area (0.2 x 0.1) to right great toe. RN K continued saying that CR #5 did not have any wound care orders for his feet. When asked if she had received any notification from the staff regarding any skin concerns regarding CR #5's right foot prior to finding the deep tissue injury to his right heel, she said nobody said a word about his foot until 02/17/2016. Observation on 02/23/2016 at 12:25 p.m. revealed that CR #5 was in the Intensive Care Unit of a local hospital. CR#5 was non-verbal to surveyor. In an interview at that time with a hospital RN, she stated that CR #5 was admitted to the hospital with [REDACTED]. Interview on 02/23/2016 at 2:14 p.m. with C.N.A. L, she stated that she was the nursing assistant of CR #5 the day he was sent to the hospital. She continued saying that she saw CR#5's heel that was completely black and purple in color and the tip of all toes were black. She further said that CR#5's entire right foot was purple in color and that she called the nurse and the wound care nurse to see his foot. When asked if anyone from the previous shift had reported anything about CR#5's right foot, C.N.A. L responded nobody reported anything to me. C.N.A. L further said that nursing assistants float on different hallways and that there was no assigned staff for the residents. In a phone interview on 02/23/2016 at 2:47 p.m. with LVN J, she stated that she was not working at the facility anymore and the she remembered doing the admission assessment to CR#5 when he returned from the hospital on [DATE] and that when she wrote necrotic areas to right foot toes #1, #2, #3 and #4 was because the areas were black. In an interview on 02/23/2016 at 4:00 p.m. with the DON and the Acting Administrator, the DON said that she was told that CR#5 was sent out to the hospital because of shortness of breath and his oxygen saturation had dropped. She further said that changes in skin condition were reported to the nurses. When asked if CR #5 skin condition to his right foot was care planned with interventions to monitor skin changes and interventions. The Acting Administrator stated the treatment nurse keeps her own care plans, she is in charge of the care plans for skin condition. She said the wound care nurse had a folder with the care plans in her room and further asked the DON to go and get the care plan folder. Further interview and observation, the DON, RN K and LVN G (electronic medical record specialist) were at the computer looking at the care plan for CR#5. When asked if there was a care plan that reflected the condition of CR #5's right foot toes #2, #3 and #4 and interventions for CR#5 to prevent pressure sores as his care plan indicated he was at risk to develop pressure sores. LVN G stated as he looked at the care plan at the computer this was a care plan done by the admitting nurse, there are no interventions. Further interview at that time, the DON asked RN K to go upstairs and look for the binder of care plans kept by the wound care nurse. Continued observation and interview, RN K went into a room and said was the wound care nurse room and started opening cabinets, looking at the binders and flipping books and said to surveyor there is nothing here. Record review of the facility's policy and procedure for Significant change in patient status dated February 2010 revealed in part: .A significant change in Patient status is defined as deterioration or marked improvement in the health, mental or psychosocial status in either life-threatening conditions As a significant change in Patient condition occurs, the Charge Nurse will notify the physician of the significant change immediately . Record review of the facility's policy and procedure with title Skin dated January 2015 revealed in part: Any new skin issues identified must be addressed by the charge nurse to include assessments and documentation of the skin site and initiating appropriate clinical interventions. The Director of Nursing or designee must monitor the care plan, the appropriateness of interventions . CMS form 672 revealed 96 residents who required assist of one or two staff for transferring.

Based on interview and record review, the facility failed to promptly consult with the physician when one of six residents (Resident #1) reviewed for a change in condition had increased in swelling to his right upper leg in that: --The facility failed to promptly consult with the physician related to the change in condition for Resident #1 when there was swelling and fracture to the resident's right femur (thigh bone). These failures affected one resident (Resident #1) and placed 113 residents residing at the facility at risk of not having their physicians aware of a change in their medical condition which could cause extended durations of pain and a delay in medical treatment. Findings included: Intake # 7 Record review of the facility face sheet revealed Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] revealed Resident #1 was unable to complete the Brief Interview for Mental Status. He sometimes made self understood and sometimes understood others. He required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #1 was always incontinent of bowel and bladder. Record review of the facility's Investigation Report dated 2/23/2016 and signed by the DON revealed in part: .Resident #1 arrived to the facility on [DATE] around 11:00 a.m. Head to toe assessment was completed and he was noted with 1+ [MEDICAL CONDITION] to his right femur area that has a history of being contracted. The nurse went verifying orders then informed the MD and he said to monitor the site. During the night shift the area was noted to be increased in swelling to 4+ non-pitting, however, Resident #1 did not appear to be in any pain from the swelling. The MD was called and he gave an order for [REDACTED].#1 was sent out to the hospital on [DATE] and returned on 2/20/2016. The [DIAGNOSES REDACTED]. Record review of Resident #1's hand written Physician orders [REDACTED]. -Monitor right leg for swelling dated 2/15/2016. -Transfer to hospital dated 2/17/2016 Record review of Resident #1's electronic physician orders [REDACTED]. -[MEDICATION NAME] 50 mg via gastrostomy tube three times daily at 8:00 a.m., 12:00 p.m. and 4:00 p.m. for generalized pain dated 8/20/2015. -Venous Doppler (noninvasive test that is used to check the circulation in the large veins) of right thigh, up to the knee, due to 4+ [MEDICAL CONDITION] dated 2/16/2016 at 6:35 a.m. -STAT (immediately) X-ray dated 2/16/2016. Record review of Resident #1's ultrasound report for date of service 2/16/2016 revealed in part: Venous Doppler right extremity limb: Pain in unspecified limb. Findings: No [MEDICAL CONDITION] seen. Record review of Resident #1's radiology report for date of service 2/16/2016 revealed in part: Right femur. Results: There is a [MEDICAL CONDITION] right femur. There is a large medial angulation and superior displacement of the distal fragment. There is no apparent callus formation. Record review of Resident #1's Accident/Incident report dated 2/17/2016 and signed by LVN A revealed in part: .Person in charge - Account of occurrence: Resident #1 noted with swelling on admission. X-ray results showed fracture of unknown origin. Discovered/Reported by: RN B. Shift: 2 to 10 p.m . Further record review revealed DON and Administrator had not signed the incident report. Record review of Resident #1's electronic Clinical Notes revealed in part: -2/15/2016 at 1:24 p.m. signed by LVN C Post hospital return, clean no breaks noted head to toe . -2/15/2016 at 11:54 p.m. signed by RN B Resident #1 is a readmission from the hospital status [REDACTED].Plan of care will be updated based on identified needs -2/16/2016 at 6:54 a.m. signed by LVN D .4+ non [MEDICAL CONDITION] to right thigh, no signs of discomfort noted. MD notified. New orders for venous Doppler -Addendum note dated 2/16/2016 at 7:21 a.m. and signed by LVN A Resident #1 arrived via ambulance. Slight swelling to right leg noticed. Call placed to MD awaiting call back. Oncoming nurse notified of Resident #1's return and orders. Will continued to monitor. Upon arrival this a.m. as to followed up swelling , Resident #1 has new order to complete Doppler. -2/16/2016 at 8:38 a.m. signed by LVN A .Call placed to MD for slight swelling to right leg with new order for STAT X-ray. -2/16/2016 at 10:11 p.m. signed by RN B .Placed a call to Mobilex ([MEDICAL CONDITION] company) venous Doppler done but test results not available until 24 to 48 hours .Right thigh area larger than left thigh, slightly warmer than left but not hot, not able to palpate pulses . -2/17/2016 at 3:49 a.m. signed by LVN E .Right thigh area [MEDICAL CONDITION] 6 c.m. noted. No fever noted. No facial grimacing noted when lightly palpating the leg. Will continue to monitor -2/17/2016 at 7:15 p.m. signed by RN F .MD was notified of results and X-ray results positive for fracture of right femur. MD with orders to send Resident #1 to hospital. Resident #1 was transferred to the hospital at 7:40 p.m . In an interview on 02/19/2016 at 11:20 a.m. with LVN C, she stated that Resident #1 arrived from the hospital on [DATE] at around 11:00 a.m. LVN C said that she performed head to toe assessment to Resident #1 before lunch time and that he did not have any swelling anywhere in his body and that he did not have any pain during the assessment. She continued saying that Resident #1 would not speak but he was able to say yes or no when a question was asked and that he denied having pain at the time of the assessment. In an interview on 02/19/2016 at 11:39 a.m., LVN A stated that she assessed Resident #1 on 02/15/2016 after lunch time and that she noticed that Resident #1's right upper leg area was slightly swollen and that Resident #1 denied having pain by shaking his head to the sides and saying No. LVN A continued saying that she then called the MD and that he ordered to monitor the swelling area. LVN A further said It was a busy day, I don't remember if I documented that information but I do remember reporting the information to the next shift nurse who was RN B. I believe the facility uses the SBAR assessment for changes in condition but I am new and I don't know all the systems in the computer. When asked if she completed an SBAR assessment for Resident #1's swelling area to his right upper leg, LVN A said I did not do an SBAR assessment for the swelling on his leg. You would do it for a big change in condition, not for a swelling. During training, they did not give me specifics for what to use an SBAR assessment, they just said to use SBAR assessment for changes in condition. The swelling to Resident #1's leg was not a big change in condition, it was only slightly swollen. It was not as big change to require an SBAR assessment. Further interview at that time, LVN A said that on 02/16/2016 when she arrived at work, there was already an order for [REDACTED].#1's right leg and that Resident #1 had the X-ray sometime during the same day but did not remember the time and did not get the results either. LVN A then said that she reported the information to RN B during shift change. LVN A said that change of shift report were given orally and that there were no written 24 hour reports for shift changes that she was aware of. She further said I know that there is a 24 hour report that is in the computer system but I don't know what other nurses know. I just give verbal reports. I will go to my computer training next week. In an interview on 2/19/2016 at 12:47 PM with a staff member from the x-ray company used by the facility said that anytime they find an x-ray comes back positive for a fracture, they will call the facility and let them know as well as send a fax. The x-ray staff member said when Resident #1's x-ray results came back as positive on 2/16/2015, they called the facility at 4:13 PM and said the facility staff member who was notified was RN B. They also said the results were faxed to the facility at that time. In an interview on 02/19/2016 at 1:03 p.m. with the DON, she said that she was new in the facility and that she had just returned on 02/18/2016 from an out of town training that lasted 3 days and that she was still investigating what happened to Resident #1's leg fracture. She further said I was supposed to start making phone calls to the x-ray company and the ambulance company today but then State shows. When asked if she knew why was the delay of sending Resident #1 to the hospital if the X-ray was done on 2/16/2016 showing fracture and he did not get to go to the hospital until 2/17/2016, the DON responded We were supposed to call the X-ray manager today, from what I know was that the nurses were waiting for the Doppler results. I had been trying to talk to RN B but I haven't talked to her yet. In an interview on 02/19/2016 at 2:24 p.m. with RN B, she stated that she did not receive any report on 02/15/2016 about Resident #1's right upper leg's swelling. RN B said that it was around 6:00 p.m. on that day that she noticed that Resident #1's right upper leg was slightly swollen but was not hot to touch and Resident #1 denied any pain. RN B further said that it was around 10:30 p.m. that one C.N.A. (did not remember who) called her to Resident #1's room and reported that Resident #1's right leg was big. RN B then said that C.N.A. was acting like Resident #1's leg was so huge, so I went there to see him together with the oncoming nurse for the night shift. When I saw him, his right upper leg was bigger from what I saw earlier on that day and he grimaced his face with movement, so I called the MD and he said to monitor Resident #1 . When asked if she wrote down on Resident #1's electronic charting about MD notification, RN B said Yes, I did. When asked to review the records with surveyor about MD notifications, RN B looked at Resident #1's electronic notes and said Well, on 2/15/2016 there was nothing to call the MD because the leg was not really expanded or swollen, not like to say Oh My God, something is wrong. When asked about the increased in swelling to Resident #1's leg that she noticed on 02/15/2016 at 10:30 p.m., RN B said that was not a case to call the MD, it was swollen but not that huge, so it was not a change in condition and he was already on pain medication [MEDICATION NAME] three times a day, he had [DIAGNOSES REDACTED]. Continued interview with RN B at that time, she stated that on 02/16/2016, LVN A did not report to her during shift change that Resident #1 had an X-ray done during the day shift so she did not follow up with the results because she did not know Resident #1 had an X-ray done. She further said I saw his leg on 2/16/2016 and his leg was pretty big. I guess the mix up was that I was waiting for the Doppler results and only called to find out about the Doppler results and not about the X-ray results because I did not know that Resident #1 had any X-rays during the day shift and I did not call the MD to report the increased in swelling because I was waiting for the Doppler results. RN B continued saying that she was not made aware of the X-ray results until 2/17/2016 during her 2 to 10 p.m. shift and that was the time she called the MD to give the results that was a fracture to Resident #1's upper leg and that she had another nurse to help her transfer Resident #1 to the hospital. In a phone interview on 2/22/2016 at 9:04 a.m. with Resident #1's MD, he stated that he believed he was informed by the facility about the swelling to Resident #1's upper leg the next day after he was admitted to the facility. The MD further said whenever I ordered the Doppler, that's when I was first informed of the swelling. I wanted to make sure there was no blood clots. After they gave me the results that the Doppler was negative for blood clots, I gave orders for STAT X-ray and I gave orders to send Resident #1 to hospital when the facility called me with the results of the X-ray. In a phone interview on 2/22/2016 at 11:28 a.m. with C.N.A. H, she stated that on 2/15/2016 at around 10:25 p.m. she was going to start her rounds for the night shift with Resident #1 and that she saw Resident #1's right upper leg very swollen and that she immediately went and reported to RN B (from the 2 - 10 p.m. shift) and LVN D (from the 10 - 6 a.m. shift). C.N.A. H further said RN B said that she did not know about Resident #1's leg and that nobody had reported anything to her. Resident #1 grimaced his face while nurses where looking at him. Observation on 2/23/2016 at 11:10 AM revealed Resident #1 in lying in bed. Resident #1 did not respond to questions, only made eye contact. In a phone interview on 2/23/2016 at 1:31 p.m. with LVN D, she stated that on 2/15/2016 when she arrived for the night shift, she was made aware that Resident #1's right upper leg was swollen and went she saw Resident #1's leg, it was swollen. LVN D further said that she did not call the doctor at that time to update him on Resident #1's condition because RN B told her that she had already called the doctor and had obtained orders to just monitor the leg. LVN D continued saying that Resident #1 was aphasic (difficulty expressing self) but was able to answer yes or no questions and that he had said he was not in pain. LVN D further said that she called the MD until the morning on 2/16/2016 at around 6:30 a.m. and obtained orders for Venous Doppler. In an interview on 2/23/2016 at 3:30 p.m. with the Acting Administrator, she stated that nurses were supposed to review the clinical notes from the residents to find out what happened to the residents on the previous shift just in case the nurse who is supposed to give report gets busy or forgets. In an interview on 2/23/2016 at 3:46 p.m. with the Acting Administrator and the DON, the DON stated that her understanding was that when nurses noticed the swelling to Resident #1's right upper leg, they notified the MD right away and when the nurses noticed that Resident #1's right upper leg was increasing in size, they got the order for the Doppler. Record review of the facility's policy and procedure for Significant change in patient status dated February 2010 revealed in part: .A significant change in Patient status is defined as deterioration or marked improvement in the health, mental or psychosocial status in either life-threatening conditions As a significant change in Patient condition occurs, the Charge Nurse will notify the physician of the significant change immediately . CMS form 672 revealed a census of 110.

Based on observation, interview, and record review the facility failed to ensure 1 of 6 residents (Resident #1) reviewed for accidents received adequate supervision and ensured the environment remained as free of accident hazards as possible in that: The facility failed to conduct proper assessments and provide the necessary care and services after Resident #1 reported that she fell in the facility van on 12/8/2015. The resident was found to have a fracture on 12/9/15 resulting in hospitalization . This failure affected 1 resident and placed 5 residents at risk for falls with major injury at risk for a delay in treatment, complications, and hospitalization . Findings Include: Intake # 3 Resident #1 Record review of Resident #1's medical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was [AGE] years of age. Further review of Resident #1's medical record revealed she was transferred to the hospital on [DATE] related to a leg fracture, and had not returned to the facility. This document also revealed she went to a [MEDICAL TREATMENT] center on Tuesdays, Thursdays, and Saturdays. Record review of Resident #1's admission MDS assessment dated [DATE] revealed she had a BIMS score of 11, indicating mild to moderate cognitive impairment, and had no signs of [MEDICAL CONDITIONS] or behaviors. It further revealed she required extensive assistance of two people for transfers and locomotion on and off unit. She had a weight of 166 pounds. Record review of Resident #1's Care Plan dated 11/5/2015 revealed that she was at risk for falls and had a goal to .ambulate/transfer without fall related injuries . Interventions included .keep areas free of obstructions to reduce the risk of falls or injury . Provide reminders to use ambulation and transfer assist devices. It further revealed she had chronic pain. Interventions included .Assess (Resident #1) to determine if experiencing pain. If pain is present, conduct and document pain assessment particularly location, nature, intensity, and duration of pain. Record review of the Provider Investigation Report dated 12/15/2015 revealed that Resident #1 alleges that she fell on the van and complained of leg pain when she returned from [MEDICAL TREATMENT]. Resident was medicated and went to bed. Resident slept threw (sic) the night. Resident was getting ready for therapy and complained of leg pain . Res. was assessed, medicated, MD was notified of findings . It is undetermined if resident slid or fell . Record review of Resident #1's medical record revealed there were no progress notes or assessments concerning a fall or pain on 12/8/2015. Record review of the facility schedule revealed that CNA A and CNA B worked from 2pm to 10pm on 12/8/2015. Record review of an undated written statement signed by CNA B read in part . At the time, (CNA A) and I, (CNA B), were getting ready to assist (Resident #1) get into bed, she, (Resident #1), said to us that she was in pain, and that in the ambulance, she fell , with her seatbelt, and everything, and the driver just picked her up. She also said that she was telling the driver to pull over, and the driver responded, that there was no where to pull over. Record review of a witness statement dated 12/10/2015 signed by RN B read in part . On the night of 12/09/2015, (Resident #1), was noted to have uneventful hours. Resident slept quietly throughout the night. Resident verbalized no complaints of pain or discomfort . (COTA), physical therapist came up to the cart (shortly after 6:00am) and said, 'Excuse me . (Resident #1) said she fell yesterday at [MEDICAL TREATMENT] and hurt her leg. She wants something for pain. ' . That is when the incident was brought to my attention. Record review of an Accident/Incident Report dated and signed by LVN A on 12/10/2015 revealed that on 12/9/2015 at 6:00am, Resident #1 complained of right leg pain. .RESIDENT STATED THAT SHE WAS STRAPPED IN HER WHEELCHAIR IN THE AMBULANCE THAT TOOK HER TO [MEDICAL TREATMENT] AND SHE fell I ASKED RESIDENT HOW DID SHE GET UP RESIDENT STATED THAT THE DRIVER OF THE AMBULANCE GOT HER UP. It further stated that LVN A called the physician, received an order for [REDACTED].#1) for pain. Record review of an Incident Statement dated 12/10/2015 written by LVN B read in part . 12/9/15 @ 10:00am went in to (Resident #1)'s room to perform wound care treatment to bilateral heels. Resident yelling 'I am hurting, right leg is hurting. I fell in the ambulance last night. Record review of a Physician's Telephone Order dated 12/9/2015 at 10:36am received by LVN A revealed that an order was received by Resident #1's physician for an x-ray of the right pelvis, femur, knee, tibia, fibula, ankle, and foot. Record review of a Skilled Daily Nurses Note signed by LVN A and dated 12/9/2015 at 2:03pm revealed that Resident #1 had a pain level of 6 on a scale of 1 to 10 in her right leg. Record review of Resident #1's MAR dated December 2015 revealed the medication Tylenol 325mg, take two tablets by mouth every 6 hours as needed for chronic pain, was not documented as administered on any day in December. She received [MEDICATION NAME] 100mg (a medication to treat diabetic nerve pain), take two tablets by mouth daily. The medication was documented as given twice daily from December 1, 2015 to December 9, 2015. There were no other medications prescribed for pain. Record review of an x-ray report dated 12/9/2015 revealed that Resident #1 had a supracondylar [MEDICAL CONDITION] femur, and a suspected nondisplaced right calcaneum (a bone of the heel) fracture. The results were communicated to the facility on [DATE] at 5:17pm. Record review of the Nursing Home to Hospital Transfer Form signed by RN A and dated 12/9/2015 revealed that Resident #1 was transferred to the hospital at 6:15pm. The reason for transfer was documented as .fall related injury: major injury . other changes in condition not specified elsewhere: uncontrolled pain. In an interview on 12/22/2015 at 10:55am, LVN A said she cared for Resident #1 on the morning after the alleged incident. She said Resident #1 was assisted out of bed by two therapy assistants. She said the therapy assistants brought the resident to the nurse's station and told her that she was complaining of pain. She said she gave her Tylenol, assisted her back to bed, and called the physician. She said he ordered a stat x-ray of her hips and legs. She said she checked on her during lunch and she did not show signs of pain, but asked her to move the table because it was touching her leg. She said she seemed fine. In an interview on 12/22/2015 at 1:00pm, when asked about the Incident/Accident Report and the fall, LVN A said she was reporting what Resident #1 had told her. She said she was not sure what happened, but addressed the issues once she found out about it. She said Resident #1 was transported to and from [MEDICAL TREATMENT] using the facility van. In an interview on 12/22/2015 at 1:20pm, Unit Manager A said Resident #1 first complained of pain when she returned from [MEDICAL TREATMENT]. She said two aides were putting her to bed when she told them she fell or slid in the van. She said RN A was the nurse on the evening shift, and she was not sure what he did. She said the next morning, she complained of pain again, so they ordered the x-ray. She said Resident #1 was a large woman and it would be difficult for the driver to pick her up. She said she was not sure how the fracture occurred. In an interview on 12/22/2015 at 1:45pm, Unit Manager B said she heard Resident #1 complain of pain to her leg on the morning after the alleged incident, and advised LVN A to call the physician. She said she did not work the evening before and was not sure what staff did to address the issue. She said she did not assess Resident #1's leg. She said she was not sure how Resident #1 injured her leg. In an interview on 12/22/2015 at 1:55pm, LVN A said when she assessed Resident #1's leg the morning she complained of pain, her knee appeared to be a little swollen. She said she did not notice other signs of injury. In a continued interview on 12/22/2015 at 2:00pm, LVN A said she gave Resident #1 two Tylenol 325mg tablets around 7:30am. She said she monitored her through breakfast and was initially showing signs of pain, but gradually got better. When asked why the medication was not documented as given on the MAR, she said she was not sure why it was not there. She said the facility was using a new computer system and it was difficult to document. In an interview on 12/22/2015 at 3:10pm, RN A said Resident #1 had arthritis and frequently complained of pain. He said on the day the alleged incident, she returned to the facility around 6:00pm. He said around 7:00pm, she complained of leg pain so he administered 2 Tylenol 325mg tablets. He said her pain was about a 3 or 4 on a scale of 1-10. He said he assessed her leg and did not see any swelling, and said she did not tell him that she fell . He said Resident #1 was sometimes confused and had some memory loss. He said if he had known that she fell , he would have called the physician and requested an x-ray. He said CNA A thought she reported it to him, but said he could not remember. I'm not saying she didn't .but maybe I didn't hear. When asked why the Tylenol 325mg tablet was not documented on the MAR, he said the computer system is new and it takes a long time. In a telephone interview on 12/22/2015 at 3:40pm, CNA A said on the day of the alleged incident, CNA B asked if she could help put Resident #1 to bed around 8:30-9:00pm. She said when they were putting her in bed, she complained of pain to her leg and said she fell in the van. She said Resident #1 explained that she was in her wheelchair and had her seatbelt on, but fell anyway and asked the driver to pull over and she refused. She said she reported the fall and pain to RN A, who was sitting at the nurse ' s station, and he said okay. She said she worked the next morning and saw Resident #1 near the nurse ' s station screaming and hollering . saying she fell and was in a lot of pain. She said she reported it to the nurses on duty, and they said they were working on it. In an interview on 12/22/2015 at 4:10pm, CNA C, the facility van driver, said the day of the alleged incident she picked up Resident #1 from the [MEDICAL TREATMENT] center. She said she was already in her wheelchair, and she put her on the ramp and into the van. She said she tied two straps to the back of her wheelchair and two straps to the front of her wheelchair, and then put a seatbelt around her. She said before we hit the freeway, she was asleep. She said she could not pick up Resident #1 without assistance because she is a two person transfer. When asked if the resident fell or slid from her chair, she said no. They might bounce a little bit, but that's it. In an interview on 12/22/2015 at 4:30pm, Unit Manager B said she did not witness Resident #1 call out in pain. When asked if Tylenol was sufficient for her level of pain, she said she did not see the resident at all that day, and does not know her pain tolerance, so she couldn ' t say. She said if RN A knew about the fall the night before, she would expect him to call her and the physician, get an order for [REDACTED]. The surveyor attempted to contact CNA B by telephone on 12/22/2015 and was unsuccessful. Record review of In-Service Training Reports dated 12/10/2015 revealed nursing staff were educated regarding assessments, transfers and lifting, incident/accident reporting, and pain management with proper assessments and follow-ups. Record review of a Pain Management policy dated March 2013 read in part . A Pain Assessment must be completed for a Patient upon admission, including re-admission, the onset or an increase in pain and any significant change in the Patient's condition . If a Patient's pain intensity score is > 1 or has been assessed with [REDACTED]. When asked about a policy regarding a change of condition, the Administrator brought an SBAR Communication Form and Progress Note that explains that staff should assess the situation, gather background information, assess the resident, and request orders or treatments. According to the CMS Form 802, there were 5 residents who were at risk for falls.

Based on observation, interview, and record review the facility failed to ensure 1 of 6 residents (Resident #1) reviewed for accidents received adequate supervision and ensured the environment remained as free of accident hazards as possible in that: The facility failed to conduct proper assessments and provide the necessary care and services after Resident #1 reported that she fell in the facility van on 12/8/2015. The resident was found to have a fracture on 12/9/15 resulting in hospitalization . This failure affected 1 resident and placed 5 residents at risk for falls with major injury at risk for a delay in treatment, complications, and hospitalization . Findings Include: Intake # 3 Resident #1 Record review of Resident #1's medical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was [AGE] years of age. Further review of Resident #1's medical record revealed she was transferred to the hospital on [DATE] related to a leg fracture, and had not returned to the facility. This document also revealed she went to a hemodialysis center on Tuesdays, Thursdays, and Saturdays. Record review of Resident #1's admission MDS assessment dated [DATE] revealed she had a BIMS score of 11, indicating mild to moderate cognitive impairment, and had no signs of delirium, psychosis or behaviors. It further revealed she required extensive assistance of two people for transfers and locomotion on and off unit. She had a weight of 166 pounds. Record review of Resident #1's Care Plan dated 11/5/2015 revealed that she was at risk for falls and had a goal to .ambulate/transfer without fall related injuries . Interventions included .keep areas free of obstructions to reduce the risk of falls or injury . Provide reminders to use ambulation and transfer assist devices. It further revealed she had chronic pain. Interventions included .Assess (Resident #1) to determine if experiencing pain. If pain is present, conduct and document pain assessment particularly location, nature, intensity, and duration of pain. Record review of the Provider Investigation Report dated 12/15/2015 revealed that Resident #1 alleges that she fell on the van and complained of leg pain when she returned from dialysis. Resident was medicated and went to bed. Resident slept threw (sic) the night. Resident was getting ready for therapy and complained of leg pain . Res. was assessed, medicated, MD was notified of findings . It is undetermined if resident slid or fell . Record review of Resident #1's medical record revealed there were no progress notes or assessments concerning a fall or pain on 12/8/2015. Record review of the facility schedule revealed that CNA A and CNA B worked from 2pm to 10pm on 12/8/2015. Record review of an undated written statement signed by CNA B read in part . At the time, (CNA A) and I, (CNA B), were getting ready to assist (Resident #1) get into bed, she, (Resident #1), said to us that she was in pain, and that in the ambulance, she fell , with her seatbelt, and everything, and the driver just picked her up. She also said that she was telling the driver to pull over, and the driver responded, that there was no where to pull over. Record review of a witness statement dated 12/10/2015 signed by RN B read in part . On the night of 12/09/2015, (Resident #1), was noted to have uneventful hours. Resident slept quietly throughout the night. Resident verbalized no complaints of pain or discomfort . (COTA), physical therapist came up to the cart (shortly after 6:00am) and said, 'Excuse me . (Resident #1) said she fell yesterday at dialysis and hurt her leg. She wants something for pain. ' . That is when the incident was brought to my attention. Record review of an Accident/Incident Report dated and signed by LVN A on 12/10/2015 revealed that on 12/9/2015 at 6:00am, Resident #1 complained of right leg pain. .RESIDENT STATED THAT SHE WAS STRAPPED IN HER WHEELCHAIR IN THE AMBULANCE THAT TOOK HER TO DIALYSIS AND SHE fell I ASKED RESIDENT HOW DID SHE GET UP RESIDENT STATED THAT THE DRIVER OF THE AMBULANCE GOT HER UP. It further stated that LVN A called the physician, received an order for [REDACTED].#1) for pain. Record review of an Incident Statement dated 12/10/2015 written by LVN B read in part . 12/9/15 @ 10:00am went in to (Resident #1)'s room to perform wound care treatment to bilateral heels. Resident yelling 'I am hurting, right leg is hurting. I fell in the ambulance last night. Record review of a Physician's Telephone Order dated 12/9/2015 at 10:36am received by LVN A revealed that an order was received by Resident #1's physician for an x-ray of the right pelvis, femur, knee, tibia, fibula, ankle, and foot. Record review of a Skilled Daily Nurses Note signed by LVN A and dated 12/9/2015 at 2:03pm revealed that Resident #1 had a pain level of 6 on a scale of 1 to 10 in her right leg. Record review of Resident #1's MAR dated December 2015 revealed the medication Tylenol 325mg, take two tablets by mouth every 6 hours as needed for chronic pain, was not documented as administered on any day in December. She received Lyrica 100mg (a medication to treat diabetic nerve pain), take two tablets by mouth daily. The medication was documented as given twice daily from December 1, 2015 to December 9, 2015. There were no other medications prescribed for pain. Record review of an x-ray report dated 12/9/2015 revealed that Resident #1 had a supracondylar fracture of the right femur, and a suspected nondisplaced right calcaneum (a bone of the heel) fracture. The results were communicated to the facility on [DATE] at 5:17pm. Record review of the Nursing Home to Hospital Transfer Form signed by RN A and dated 12/9/2015 revealed that Resident #1 was transferred to the hospital at 6:15pm. The reason for transfer was documented as .fall related injury: major injury . other changes in condition not specified elsewhere: uncontrolled pain. In an interview on 12/22/2015 at 10:55am, LVN A said she cared for Resident #1 on the morning after the alleged incident. She said Resident #1 was assisted out of bed by two therapy assistants. She said the therapy assistants brought the resident to the nurse's station and told her that she was complaining of pain. She said she gave her Tylenol, assisted her back to bed, and called the physician. She said he ordered a stat x-ray of her hips and legs. She said she checked on her during lunch and she did not show signs of pain, but asked her to move the table because it was touching her leg. She said she seemed fine. In an interview on 12/22/2015 at 1:00pm, when asked about the Incident/Accident Report and the fall, LVN A said she was reporting what Resident #1 had told her. She said she was not sure what happened, but addressed the issues once she found out about it. She said Resident #1 was transported to and from dialysis using the facility van. In an interview on 12/22/2015 at 1:20pm, Unit Manager A said Resident #1 first complained of pain when she returned from dialysis. She said two aides were putting her to bed when she told them she fell or slid in the van. She said RN A was the nurse on the evening shift, and she was not sure what he did. She said the next morning, she complained of pain again, so they ordered the x-ray. She said Resident #1 was a large woman and it would be difficult for the driver to pick her up. She said she was not sure how the fracture occurred. In an interview on 12/22/2015 at 1:45pm, Unit Manager B said she heard Resident #1 complain of pain to her leg on the morning after the alleged incident, and advised LVN A to call the physician. She said she did not work the evening before and was not sure what staff did to address the issue. She said she did not assess Resident #1's leg. She said she was not sure how Resident #1 injured her leg. In an interview on 12/22/2015 at 1:55pm, LVN A said when she assessed Resident #1's leg the morning she complained of pain, her knee appeared to be a little swollen. She said she did not notice other signs of injury. In a continued interview on 12/22/2015 at 2:00pm, LVN A said she gave Resident #1 two Tylenol 325mg tablets around 7:30am. She said she monitored her through breakfast and was initially showing signs of pain, but gradually got better. When asked why the medication was not documented as given on the MAR, she said she was not sure why it was not there. She said the facility was using a new computer system and it was difficult to document. In an interview on 12/22/2015 at 3:10pm, RN A said Resident #1 had arthritis and frequently complained of pain. He said on the day the alleged incident, she returned to the facility around 6:00pm. He said around 7:00pm, she complained of leg pain so he administered 2 Tylenol 325mg tablets. He said her pain was about a 3 or 4 on a scale of 1-10. He said he assessed her leg and did not see any swelling, and said she did not tell him that she fell . He said Resident #1 was sometimes confused and had some memory loss. He said if he had known that she fell , he would have called the physician and requested an x-ray. He said CNA A thought she reported it to him, but said he could not remember. I'm not saying she didn't .but maybe I didn't hear. When asked why the Tylenol 325mg tablet was not documented on the MAR, he said the computer system is new and it takes a long time. In a telephone interview on 12/22/2015 at 3:40pm, CNA A said on the day of the alleged incident, CNA B asked if she could help put Resident #1 to bed around 8:30-9:00pm. She said when they were putting her in bed, she complained of pain to her leg and said she fell in the van. She said Resident #1 explained that she was in her wheelchair and had her seatbelt on, but fell anyway and asked the driver to pull over and she refused. She said she reported the fall and pain to RN A, who was sitting at the nurse ' s station, and he said okay. She said she worked the next morning and saw Resident #1 near the nurse ' s station screaming and hollering . saying she fell and was in a lot of pain. She said she reported it to the nurses on duty, and they said they were working on it. In an interview on 12/22/2015 at 4:10pm, CNA C, the facility van driver, said the day of the alleged incident she picked up Resident #1 from the dialysis center. She said she was already in her wheelchair, and she put her on the ramp and into the van. She said she tied two straps to the back of her wheelchair and two straps to the front of her wheelchair, and then put a seatbelt around her. She said before we hit the freeway, she was asleep. She said she could not pick up Resident #1 without assistance because she is a two person transfer. When asked if the resident fell or slid from her chair, she said no. They might bounce a little bit, but that's it. In an interview on 12/22/2015 at 4:30pm, Unit Manager B said she did not witness Resident #1 call out in pain. When asked if Tylenol was sufficient for her level of pain, she said she did not see the resident at all that day, and does not know her pain tolerance, so she couldn ' t say. She said if RN A knew about the fall the night before, she would expect him to call her and the physician, get an order for [REDACTED]. The surveyor attempted to contact CNA B by telephone on 12/22/2015 and was unsuccessful. Record review of In-Service Training Reports dated 12/10/2015 revealed nursing staff were educated regarding assessments, transfers and lifting, incident/accident reporting, and pain management with proper assessments and follow-ups. Record review of a Pain Management policy dated March 2013 read in part . A Pain Assessment must be completed for a Patient upon admission, including re-admission, the onset or an increase in pain and any significant change in the Patient's condition . If a Patient's pain intensity score is > 1 or has been assessed with [REDACTED]. When asked about a policy regarding a change of condition, the Administrator brought an SBAR Communication Form and Progress Note that explains that staff should assess the situation, gather background information, assess the resident, and request orders or treatments. According to the CMS Form 802, there were 5 residents who were at risk for falls.