Every finding on record at Avir at Arden Wood

Based on interview and record review, the facility failed to ensure that resident environment remains as free of accident hazards as is possible for 1 of 9 (Resident #8) resident reviewed for quality of care. The facility failed to safely secure the locking mechanisms on Resident #8's bed wheels on a bed in high position, resulting in resident's fall with injury fracture on 04/09/2026. This failure could place residents at risk of injury or anxiety due to unstable environmental hazard. Findings included:Record review of Resident #8's face sheet reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnosis included right knee pain, spinal stenosis (pressure on the spinal cord and nerves), chronic obstructive pulmonary disease (progressive irreversible lung disease that restricts airflow and makes breathing difficult), pressure ulcer (injury to skin and underlying tissues) of sacral region (a large, triangular bone at the base of the spine, positioned just below the lumbar region (lower back) and above the coccyx (tailbone) state 4 (a severe, full-thickness tissue injury where the damage extends deep into muscles, tendons, or bones) and right buttock unstageable (severe injury - full-thickness tissue loss, but the true depth is hidden by dead tissue: slough or eschar), obesity (chronic disease of excessive body fat), along term use of anticoagulants (medication to prevent blood clots, strokes, and heart attacks), acute embolism and thrombosis (clotting of blood that blocks blood flow) of unspecified deep veins of lower extremity (major blood vessels beneath the deep fascia (3-dimensional web of tissue surrounding, protecting, and supporting muscles, bone, and blood vessels) in the legs), and hemiplegia (near-complete paralysis (loss of muscle function) and hemiparesis (partial weakness or loss of strength) following cerebral infarction affecting (blood flow to an area of the brain is interrupted) unspecified side. Record review of Resident #8's Quarterly MDS assessment dated [DATE], reflected that the resident had a BIMS score of 12 reflecting the resident had moderate impaired cognition. The resident required 2 or more helpers repositioning and turning in bed, and personal care assistance. Record review of Resident #8's care plan reflected, resident required 2-person assist with mobile transfers by use of mechanical aid sling revised on 11/22/2022, resident required 2-person assist with repositioning and turning in bed date initiated on 11/22/2022 and revised on 05/19/2026. Resident was at risk for falls; staff were to anticipate and meet the resident's needs and keep furniture in locked position 11/10/2022 and revised on 02/15/2023. Goal: the resident would not sustain serious injury through the review date of 08/17/2026. The resident had a mildly comminuted nondisplaced fracture of right distal femur without dislocation and sent to the hospital date initiated on 04/10/2026 and revised on 04/27/2026. Goal: The resident will remain free of complications related to right knee fracture, such as contracture formation, embolism and immobility through review date initiated on 04/10/2026 and revised on 05/04/2026. The resident was on anticoagulant therapy. Resident was of paraplegia status date initiated on 11/10/2022 and revised on 02/15/2023. Goal: Resident to remain free of complications or discomfort related to paraplegia through review date. The resident had ADL self-care performance deficit date initiated on 11/10/2022 and revised on 11/10/2022. The resident uses a wheelchair date initiated on 11/10/2022. Staff were to encourage turning and repositioning resident frequently while in bed date initiated on 06/04/2025. Resident had a low loss air mattress to bed date initiated on 03/26/2025. Resident was on anticoagulant therapy 11/10/2022 and revised on 06/09/2025. Resident was on pain medication therapy dated 04/04/2024. Record review of Resident #8's Change of Condition Communication dated 04/09/2026 at 09:00 a.m. and created by LVN K, reflected, WCN who witnessed fall, walked in the room and observed the resident positioned on left side in bed. The resident was alert, and the bed was noted to be in high position with resident's right hand on quarter rail. The resident spoke to WCN as treatment supplies were put down on the right side of the bed. As the resident spoke, she slightly turned her head towards WCN and began to slide off the left side of the bed near the wall onto the floor. The bed moved as the resident fell. Pain noted to resident's right elbow, right hand, and right knee. No neurological changes observed. Resident on anticoagulants. No laboratory tests/diagnostic procedures to report. Record review of Resident #8's skin and wound dated 04/09/2026 at 09:13 a.m., created by NP B reflected, resident was unable to be evaluated by the skin and wound team that day. Resident declined care after experiencing a fall just prior to wound care team arriving. Record review of Resident #8's progress note dated 04/09/2026 at 09:13 a.m., and created by NP B reflected, upon walking in the room, NP B observed the resident positioned on left side in bed. The resident was alert. The bed was noted to be in high position with resident's right hand on quarter rail. The resident spoke as treatment supplies were placed down on the right side of the bed. As the resident spoke, she slightly turned her head towards NP B and began sliding off the left side of the bed near the wall onto the floor. The bed moved as the resident fell. NP B attempted to reach resident to prevent fall, but the attempt was unsuccessful. Immediate assistance was provided to the resident and NP B observed vital signs being taken and the resident was assisted from the floor back to the bed x 5. LVN K notified MD, DON, and ADON A receiving new orders. Record review of Resident #8's pain interview dated 04/09/2026 at 09:18 p.m., reflected resident received Tylenol 500mg 2 tablets by mouth every 4 hours as needed for pain. Record review of Resident #8's progress note dated 04/09/2026 at 09:38 a.m. and created by LVN K reflected, upon walking into resident's room, WCN observed the resident positioned on left side in bed. The bed was noted to be in high position, and resident was alert with her right hand on quarter rail. The resident spoke to WCN while WCN put treatment supplies down on the right side of the bed. As the resident spoke, she slightly turned her head towards WCN and began to slide off the left side of the bed near the wall onto the floor. The bed moved as the resident was falling. WCN attempted to reach the resident to prevent the fall, but the attempt was unsuccessful. LVN K immediately assisted providing vital signs. Resident was assisted from the floor back to the bed x 5. LVN K notified MD, DON, and ADON A and new orders received and noted. Record review of Resident #8's progress note dated 04/09/2026 at 09:40 a.m. reflected MD ordered to administer Tylenol Oral Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain. Record review of Resident #8's progress note dated 04/09/2026 at 01:09 p.m. created by MD reflected, MD examinate resident with new order. Record review of Resident #8's Radiology Results Report in the dated 04/09/26 revealed,- Procedure: Hand Right. Examination Date: 04/09/26 at 01:09 PM, Reported date: 04/09/26 at 02:50 PM, Observation Value: Right Hand, History: Pain, Findings: There is no evidence of obvious acute fracture or dislocation- Procedure: Knee Right. Examination Date: 04/09/26 at 01:10 PM, Reported date: 04/09/26 at 02:55 PM, Observation Value: Right Knee, History: Pain. Findings: mildly-comminuted (bone is broken and splintered into more than two pieces, though they are tiny) nondisplaced fracture (broken bone pieces that have not shifted out of their normal alignment) seen across distal femoral along the lateral femoral condyle( at the very end of the thighbone, specifically on the outer bump that forms the knee joint) with overlying periarticular soft tissue swelling and effusion noted (inflammation, and excess fluid built up inside the knee joint in response to a fracture). a small, crack in the thighbone at the knee joint, accompanied by welling.- Procedure: Hand Right. Examination Date: 04/09/26 at 01:15 PM, Reported date: 04/09/26 at 03:25 PM, Observation Value: Right Elbow, History: Pain, Findings: There is no evidence of obvious acute fracture or dislocation Record review of Resident #8's progress note dated 04/10/2026 at 06:16 a.m., created by LVN L reflected s/p fall day 1/3 no injury and no complins of pain or discomfort. Neuro check continues and vital signs stable. Record review of Resident #8's progress note dated 04/10/2026 at 09:33 a.m., created by LVN K reflected, LVN K spoke to MD regarding right knee x-ray results - impression, mildly, comminuted nondisplaced fracture, no evidence of dislocation. New order to transport resident to the ER. Record review of Resident #8's progress note dated 04/10/2026 at 10:46 a.m., created by LVN Q reflected, MD notified of resident's x-ray report of fracture to right femur, new order for resident to be3 sent out to hospital for further evaluation. Resident was medicated with Tylenol for pain to right leg. Vitals: blood pressure 95/63, temperature 97.2, respirator 18, heartrate 98, oxygen saturation at 97%.Record review of Resident #8's progress note dated 04/10/2026 at 10:48 a.m., reflected ER informed resident in route with right knee fracture. Record review of Resident #8's progress note dated 04/10/2026 at 11:16 a.m., created by LVN Q reflected, resident left facility to ER via stretcher with EMS. Record review of Resident #8's Discharge summary dated [DATE] at 11:19 a.m., reflected, resident received new order to send to hospital ER for right knee fracture s/p fall from bed for evaluation. Record review of Resident #8's progress note dated 04/10/2026 at 07:50 p.m., reflected, resident returned to facility with new order Norco 5/323 mg 1 tab every 6 hours as needed for pain (7-10) x 3 days. Resident had splint to her right leg. Resident lying in bed with 4/10 pain. Resident requested only Tylenol. Record review of Resident #8's late entry IDT progress note dated 04/24/2026 at 09:05 a.m. created by DON, reflected on 04/09/2026 at 08:49 a.m., resident rolled from bed to floor in witnessed fall. WCN entered room to provide wound care. Resident was lying on side in preparation for care. Resident inadvertently shifted weight and rolled over side of bed falling between bed and wall. Head to toe assessment completing. A knee injury sustained. Resident complained of pain to left knee. X-rays ordered of leg, hand and foot. Fracture of leg near knee confirmed. Resident sent to ER per resident's request for further evaluation and treatment. Resident returned with mild comminuted, nondisplaced fracture diagnosed. RP notified, therapy consults requested, and care plan reviewed. Record review of Resident #8's PT notes certification period: 4/11/2026 - 5/8/2026. Start of resident's care: Reduce risk of injury by target date of 05/08/2026. Resident to remain in right knee extension 24-hrs. a day. Goal: Resident to position and reposition self in bed with substantial/maximal assistance without use of positioning devices in order to facilitate intact skin integrity, in order to achieve proper joint alignment, in order to enhance comfort, in order to reduce the risk for falls, in order to increase functional use of extremity, in order to increase level of ADLs, in order to promote adequate hygiene, in order to maintain joint integrity, in order to reduce tone, promote mobility, in order to facilitate joint mobility and in order to facilitate participation in activities of interest by target date of 04/24/2026. During an interview on 05/19/2026 at 10:30 a.m., Resident #8 stated she had suffered 2-strokes and 2-heart attacks that left her lower extremities paraplegic. She stated she could not move her left side of her body, and the right side was extremely weak. She stated on 04/09/2026 at 8:15 a.m., she fell from the bed in preparation for wound care after the wheels on her bed were not locked in place. She stated she sustained a hairline fracture to her right leg as a result of the fall. She stated on that date; CNA A had changed her brief and positioned her on her left side with her back to the door and face forward towards the wall in preparation for wound care to her sacrum area. She stated she required 2-persons assistance during incontinent and wound care, and she was not to be left without hands on her until after wound care was completed and she was repositioned to her back in the bed. She stated that she was left alone in the room for 5 to 10 minutes with no staff in the room before WCN and NP B entered the room and began setting up their supplies on a bedside table. She stated as she spoke to the wound care team, she began to see that the bed was moving away from the wall and quickly realized she was falling forward. She stated she looked over her right shoulder and saw the WCN and NP B with their backs to her when she spoke out I'm falling and she fell to the floor between the bed and the wall. She stated she landed on her right knee, right elbow, and right hand being careful while falling to keep her head up to prevent head injury. During an interview on 05/19/2026 at 01:05 p.m., the WCN stated on 04/09/2026 at 08:15 a.m., CNA A informed her that Resident #8 was ready for wound care. She stated that her and NP B entered the resident's room and observed the resident positioned on her left side, back to the door, and facing the wall. She stated the bed was in a high position and she had not stabilized the air flow in the resident's air mattress and was unaware if it was in stagnant mode. She stated no other staff were in the room when they entered. She stated while her and NP B were getting items together for care, she saw the resident looking over the resident's right shoulder to speak when the resident vocalized, she was falling and fell to the floor. She stated her and NP B ran over to the floor having to move the bed away from the resident to reach her. She stated there was 2.5 feet of space between the bed and wall to allow standing room for the person assisting with wound care. She stated it had been her expectation and policy that a resident who required 2-person assist such as Resident #8, would have 2-staff in the room at all times during wound care prep, during wound care, and until wound care was completed. She stated 1-staff was to have hands on the resident at all times until the resident was positioned back on their backside. She stated the importance of keeping hands on a resident was to ensure a resident's balance was not lost. She stated residents should not be expected to hold themselves while on their side as it could be too difficult to hold their own weight depending on their strength. She stated that Resident #8 had no strength on her left side and extreme weakness on her right and was not capable of holding her own weight. She stated the risk of leaving a resident without hands on then while on their side could result in them leaning forward and rolling out the bed. She stated a fall could place a resident at risk for injury or death. She stated a CNA should have been waiting with Resident #8 until she entered the resident's room. During an interview on 05/19/2026 at 1:47 p.m., CNA A stated on 04/09/2026 at 08:00 a.m., her and. CNA B changed Resident #8's r brief in preparation for WCN and NP B to perform wound care. She stated they position the resident onto her left side with the resident facing the window. She stated they had to move the bed away from the wall when performing care so each of them could be on either side of the bed. She stated normally the CNAs would stay and wait for the WNC to enter the room and complete care before leaving the resident, but the breakfast meal trays had come out, and she and CNA B had to leave the resident to pass the meal trays. She stated she usually pulled the resident towards the left side of the bed to allow the resident to hold the mobility bar. She stated the resident was holding onto the mobility bar with her right hand, which was the resident's stronger side when she left the room. She stated she could not remember had she positioned the resident too far over to the end of the bed, but remembered pushing the bed back against the wall, and believed she had relocked the bed wheels before exiting the resident's room. She stated while passing the meal trays, she heard the resident hollering out in pain. She thought it odd as the resident's room door was closed. She stated she went to the resident's room and was shocked to see the resident on the floor near the window and wall after falling out of bed. She stated LVN K was assessing the resident and the resident complained of pain to her knee and arm. She stated she helped several staff (who all she could not name) including LVN K roll the resident onto a sheet, and they put the resident to bed. She stated that the resident complained of some pain as they moved her into the bed. She stated it was normal to leave the resident unattended on her side waiting for the WCN because the WCN was never more than 5-minutes behind her to complete care. She stated that the resident was a 2-person assist and required two people for transfer, incontinence care, and wound care. She stated the 2-person assist required a staff on each side of the bed and required the bed to be moved from the wall. She stated she did not know how the resident fell when the bed was up against the wall with wheels locked. She stated that the resident's bed had not moved before when the wheels were locked as the bed was pretty solid. She stated she would never leave a resident on their side with the bed pulled away from the wall to prevent the resident from falling out of bed. During an interview on 05/19/2026 at 2:40 p.m., Resident #8 stated that staff were not to leave her alone at any time on her side while waiting for the WCN. She stated the bed was against the wall, but the bed wheels could not have been locked because the bed began to slowly move away from the wall. She stated she had a mobility bar, but she was not strong enough to hold it. She stated when she fell, she landed on her right side and cried, cussed, screamed out from pain, and demanded staff get her off the floor. She stated no one assessed or asked her about her pain while she was on the floor. She stated staff stuffed a blanket near her hip and rolled her back to her left side onto her back, away from wall. She stated when she fell, the WCN ran out of the room and got help and several other staff ran in. She stated the staff rolled her onto the blanket and used the blanket to lift her off the floor into the bed; she seen the bed had been moved out of the way. She stated once in the bed LVN K asked about her pain, and Resident #8 rated her pain at a 10 with 10 being the worst pain, and she learned she would receive an x-ray. She stated she asked LVN K if they would send her to the ER for the x-ray, but LVN K told her the facility would send in their own imaging company to perform the x-rays. She stated she cried for 30 minutes due to pain, received PRN Tylenol, and waited a few hours for x-ray to arrive. She stated no physician came to assess her and no new orders were received for pain. She stated the next day, the x-ray results came in showing she had a hairline fracture to her right leg, and the facility sent her to the ER. She stated since the fall, staff have not left her unattended on her side with at least one person in preparation for wound care and made sure the bed wheels were locked. She stated the bed wheels not being locked was partially her fault, as she should have made sure the staff locked the bed. She stated her pain in her leg was at a 5 on the day of the interview. She stated that she would have declined a stronger pain medication than Tylenol had one been offered to reduce any side effects of constipation, drowsiness, and dizziness to stay awake and maintain awareness during the day. She stated that had narcotic medication been offered for pain management, she would have accepted the medication at bedtime only. During an interview on 05/19/2026 at 03:28 p.m., LVN K stated on 04/09/2026, she was called to Resident #8's room and observed the resident on the floor laying on her left side between the bed and the window. She stated the WCN, NP B, and CNAs were in the room. She stated the resident insisted staff immediately pick her up off the floor. She stated she began vital signs and checked and slightly moved the resident's hands and lower extremities checking for injuries. She stated the resident told her she had fallen on her knee and she was able to move with no pain. She stated the resident was not crying or hollering and she found the resident to have no bruising, bleeding, swelling, or pain. She stated after assessing the resident, the staff in the room took a sheet and tucked it under the resident, rolled the resident onto the sheet and while 5 staff members left the resident, LVA A used both her arms as a splint to stabilize the resident's leg with pain. She stated once the resident was in bed she rechecked the resident's vitals, oxygen, and pulse finding them all within range. She stated the resident stated her arm and knee hit the floor and her knee was hurting. She stated she gave the resident PRN Tylenol right away. She stated she notified NP A of the fall, and an x-ray was ordered for the resident's hand, knee, and elbow. She stated that the DON and ADON A were on shift when the resident fell and were aware of the resident's fall. She stated CNA A told her when the WCN and NP B walked into the room; the resident had turned in the bed and fell to the floor. She stated it took between 1-3 hrs. for x-ray. She stated a few hours later, the resident complained of pain again, and she administered the resident's PRN Tylenol. She stated the x-ray results came back just before she ended shift at 10:00 p.m. She stated she took a picture of the printed results, sent them via text message to the NP and she left shift. She stated NP A responded, Nothing there. and she assumed NP A was saying that there were no injuries found from the x-ray. She stated had NP A not responded she would have called. She stated she had read the x-ray and saw that there was a fracture to the resident's right leg and had not questioned NP A's response because she followed the direction of the physicians and the resident's condition had not worsened. She stated had there been bad swelling she would have called the NP A and shared those changes in condition. She stated she left shift, was on vacation a few days, and had not spoken to the NP A. She stated she had not called the on-call physician, received no new orders, and had not updated the resident on the x-ray results, nor informing the on-coming nurse about the resident's fall or x-rays that day. She stated she could not recall which night nurse relieved her from shift. She stated that the resident's fall was listed on the 24-hr. report and she laid the resident's x-ray results on top of the report for the oncoming nurse to review. She stated she should have called on-call after 9:00 p.m. with emergencies and sent NP A the x-ray results because she was most familiar with the resident. She stated because NP A stated, Nothing there, she thought there was no need to report anything to the on-call physicians. She stated the risks of a fracture going untreated could cause the condition to worsen, bad swelling, and pain. She stated that she medicated the resident and the resident had no pain and the resident stated the Tylenol was effective. She stated when she returned from vacation, she learned the resident in fact had a fracture that was communicated to the MD and the resident was prescribed a narcotic medication for pain and a splint to stabilize the resident's leg. She stated she was not aware if the resident had been to the hospital, because the resident had a history of refusing to go to the hospital, she thought the resident had not gone. She stated when she returned to shift, she received several in-service trainings on falls, locking bed wheels, repositioning residents, performing neurological checks every 2-hours, falls for residents on anticoagulants, and pain management. She stated that the resident was a total assist, could move her hands, could barely move her legs, was in constant pain, and wounds that were healing. During an interview on 05/20/2026 at 08:22 a.m., MD stated that on 04/09/2026 while making rounds she learned of Resident #8's fall. She stated she could not recall any other details on the resident's fall event or of identified pain. She stated it had been routine for the NP to be notified of a resident's fall, and the NP would decide on new orders and translate those events to the MD. She stated a fall or x-rays resulted after 6:00 p.m., were to be directed to the on-call team. She stated it had not been her expectation nurses send pictures of x-ray results via text after hours to a MD or NP. She stated the official physician notification required nurses to place a call to the resident's medical team and if result came in after business hours, the nurse would call the on-call team to receive orders on the next level of care the resident needed. She stated not following the official form of contact could result in a resident having unmedicated pain, delays in x-ray imaging, and delays in the resident being sent out for higher level of care. During an interview on 05/20/2026 at 08:40 a.m., LVN Q stated on the morning of 04/10/2026, she saw x-ray reports showing Resident #8 had a fracture of her right knee. She stated she went to the resident's clinical chart and learned the resident had a fall on 04/09/2026. She stated she called the MD, read MD the report results and MD ordered the resident's ER transfer. She stated the resident was informed of the fracture and order to transport to the ER. She stated the resident made no mention of pain and when asked, the resident stated her leg was feeling better. She stated once staff began moving the resident to her dressed for the ER, the resident expressed pain to her leg. She stated the resident refused pain medication, but after encouragement the resident accepted PRN Tylenol. She stated she called LVN L and asked if she was aware of the resident's x-ray results, and LVN L told her she had not been aware of the fall and fracture until she herself read the report. She stated LVN L told her that resident slept throughout the night with no complaints of pain. She stated when coming on shift, nurses were expected to read over the 24-hr report which outlined resident incidents, changes of condition, and transfers in and out of the facility. She stated she would have expected LVN L to have shared Resident #8's fall event and incoming x-ray results at shift change on 04/10/2026, but LVN L told her LVN K had not shared the resident's change of condition at shift change on 04/09/2026 and was unaware new orders were needed for the fracture results. She stated the resident returned from the ER the same day with an immobilizer around her right leg and the ER discharges notes indicated the bone break was too small to do surgery. She stated that x-ray results usually took no more than 4-hrs to receive after imaging and if not received, they check the imaging website portal before leaving shift and at the beginning of coming on a shift. She stated it was all the nurses responsibility to check the portal for results. She stated the x-ray results could be texted to the resident's NP or MD from a nurse's phone as a form of physician notification, and all critical labs and x-rays required a phone call to the resident's physician team. She stated the resident's fracture was considered a critical lab and required a phone call to be made. She stated that since the x-rays resulted after hours, a phone call should have been made to the on-call physician team. She stated she would not text a resident's imaging report from her own phone to stay within HIPAA requirements. During an interview on 05/20/2026 at 09:05 a.m., NP A stated on 04/10/2026, she stated the facility informed her Resident #8 had a fall from the bed on 04/09/2026 while the WCN and NP B were in the room to provide wound care She stated MD was notified of the fall and ordered for the resident to receive x-ray imaging. She stated the x-ray images resulted the resident had a fracture and MD ordered the resident's transfer to the hospital on [DATE] for pain. She stated the resident returned to the facility the same day with a right leg immobilizer and pain medication. She stated the pain medication was too strong for the resident who declined administration, and accepted Tylenol as a substitute. She stated the resident was alert, oriented and able to make her needs beknown. She stated that she was not aware of how the resident's all occurred or the details of the bed wheels as locked or unlocked. She stated her expectations were that staff knew locked bed wheels avoided falls and injuries. She stated that the resident had weaknesses on the left side. She stated the resident was not able to hold her own body weight, hold her own weight while positioned on her side with or without holding on to a mobilizer bar, and was not safe as anything could happen resulting in a fall and injury. She stated that the resident could not sustain that position by herself and needed to have staff attended to her at all times while in that position. She stated the resident required multiple accommodations and was a functional paraplegic. She stated on 04/09/2026, she could not recall nor had any text message receipts from LVN K regarding the resident's x-ray results. She stated that she had no issues with staff sending her text messages before 7:00 p.m. She stated after that time, it was her expectation that staff directed critical events to the on-call service. She stated a fracture was a critical event. She stated when waiting on x-ray results, she had the capability to access and view results on the company's online portal. She stated that the x-ray imaging company normally called the facility and faxed the imaging results before the images populated into the online portal. She stated it was her expectation that critical labs and results were immediately reported to her the MD and on-call after hours. She stated the risk of delayed notification could delay injury identification, resident pain, and swelling. She stated the facility was not equipped to handle orthopedic injuries and a fracture required the evaluation of an orthopedic physician. She stated she had in-serviced the facility on the importance of following the proper physician notification procedure for reporting critical events. During an interview on 05/20/2026 at 10:58 a.m., the ADON A stated prior to performing wound care CNAs were trained to make sure a resident received incontinent care and were clean. She stated Resident #8 required 2-staff assistance with incontinence and wound care. She stated the resident's bed was to be moved away from the wall for a staff to be on each side of the bed. She stated the bed wheels should be relocked to ensure the bed would not move and the resident would not slide off the bed. She stated during that care, there was to be a staff member on each side of the resident and one staff person to make physical contact (hands on) with the resident at all times, never taking hands off the resident until the care had completed, and the resident was put into a comfortable position. She stated a resident left on their side with their sacrum facing out, was a position a resident should not be left unsupervised, or unattended. She stated leaving a resident unsupervised without hands on the resident put the resident at risk for anything to happen and the resident to fall to the floor. She stated on the morning of 04/09/2026 CNA A repositioned Resident #8 in preparation for wound care. She stated the WCN entered the room and the resident slid off the bed. She stated when she came on shift on 04/10/2026, LVN Q printed out the resident's x-ray results, and she noti[TRUNCATE

Based on interview and record review, the facility failed to promptly notify the ordering physician, results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner for 1 of 7 residents (Resident #8) reviewed for diagnostic services. The facility failed to ensure LVN K notified the physician/ NP of the Resident #8's femur fracture using the facility's approved notification methods leaving Resident #8 with an undiagnosed/untreated femur (longest bone in th body that extends from the hip to the knee) fracture and in pain documented up to 5 out of 10 for 18 hours before she was transported to the hospital on [DATE]. This failure could place residents who required radiology services at risk for delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, and suffering. Findings included: Record review of Resident #8's Face Sheet dated 05/20/26 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: heart failure, depression, pressure ulcers of the sacrum, left buttock & right buttock, bine infection, muscle weakness and paralysis following a stroke (lack of blood flow to the brain), blood clots to the deep veins in lower extremity, and unspecified femur fracture. Record review of Resident #8's Significant Change in Status MDS assessment dated [DATE], moderately impaired cognition as indicated by a BIMS score of 12 out of 15, use of a wheelchair, total dependence to move from sit to lying, lying to sitting on the side of the bed, and all transfers. Resident #8 could not walk and used a motorized wheelchair. Record review of Resident #8's undated Care Plan downloaded 05/19/26 revealed:Focus- anticoagulant (anti-blood clot) therapy, intervention- avoid activities that could result in injury, take precautions to avoid falls; paraplegia (complete paralysis of lower body including both legs), intervention- obtain and monitor lab/diagnostic work as ordered, assist with ADLs and locomotion as required.Focus- ADL self-care performance deficit, intervention- bed mobility- requires extensive 2 staff participation to reposition and turn in bed; focus- risk for falls, keep furniture in locked position, 2 staff to assist with transfers; focus- fracture of right femur without dislocation, interventions- monitor/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain. Record review of Resident #8's Pain Assessments dated 05/21/26 revealed, - 04/09/26 at 09:04 AM pain level of 4 out of 10.- 04/09/26 at 05:22 PM pain level of 3 out of 10.- 04/10/26 at 10:29 AM pain level of 5 out of 10. Record review of Resident #8's Order Summary Report dated 04/09/26 revealed, an order for an x-ray of the right knee and right hand 2 views. Record review of Resident #8's Radiology Results Report in the dated 04/09/26 revealed,-Procedure: Hand Right. Examination Date: 04/09/26 at 01:09 PM, Reported date: 04/09/26 at 02:50 PM, Observation Value: Right Hand, History: Pain, Findings: There is no evidence of obvious acute fracture or dislocation-Procedure: Knee Right. Examination Date: 04/09/26 at 01:10 PM, Reported date: 04/09/26 at 02:55 PM, Observation Value: Right Knee, History: Pain. Findings: mildly-comminuted (bone is broken and splintered into more than two pieces, though they are tiny) nondisplaced fracture (broken bone pieces that have not shifted out of their normal alignment) seen across distal femoral along the lateral femoral condyle( at the very end of the thighbone, specifically on the outer bump that forms the knee joint) with overlying periarticular soft tissue swelling and effusion noted (inflammation, and excess fluid built up inside the knee joint in response to a fracture). a small, crack in the thighbone at the knee joint, accompanied by welling.-Procedure: Hand Right. Examination Date: 04/09/26 at 01:15 PM, Reported date: 04/09/26 at 03:25 PM, Observation Value: Right Elbow, History: Pain, Findings: There is no evidence of obvious acute fracture or dislocation An observation and interview on 05/19/26 at 10:30 AM revealed, Resident #8 was in her room. She said 6 weeks ago, she fell out of her bed and sustained a hairline fracture. Resident #8 said she was laying on her side awaiting wound care, the staff had their backs to her, when she noticed the bed moved away from the wall and she fell hitting her right knee and elbow. She said she did not get sent to the hospital the day of the fall, she was in pain, crying, and cursing, and the pain was unbearable In an interview on 05/19/26 at 01:47 PM, CNA L said Resident #8 fell out of bed while she laid on her side awaiting wound care unattended. She said when Resident #8 fell, she could hear the resident hollering through the closed door ,and the resident reported pain in her knee. In an interview on 05/19/26 at 02:40 PM, Resident #8 said after the fall (on 04/09/26), she was placed in bed where she was cursing and crying and she was told she needed to get an x-ray with a company that came into the facility. She said the facility gave her acetaminophen for her pain, but it didn't help, so she was crying for 30 minutes and it took a couple of hours for the x-ray to be completed. She said she was sent to the hospital the next day (04/10/26). In an interview on 05/19/26 at 03:28 PM, LVN K said after Resident #8 reported knee pain during an assessment completed after she sustained a fall on 04/09/26, an x-ray was ordered. She said the xray results came out before she left her shift that night so she sent a picture to the NP but she did not speak to the NP, and no orders were received from the NP in response to the result before she left at 10 PM. LVN K said after hours, the facility had an on call physician and since a fracture was considered a critical result and after 9 PM, the on call physician should be contacted if it was emergent. She said she just sent the picture of the results to the NP, she did not think to call the on call physician because the NP knew the resident while the on call physician did not. LVN K said the facility policy, negative [NAME] results required staff to get acknowledgment of the result and the doctors is to be notified either by call or text. She said if a negative finding, like a fracture, was communicated via text, and the staff did not receive acknowledgement or response from the NP, the resident could be placed at risk of worsening conditions, bad swelling, and pain. In an interview on 05/20/26 at 08:22 AM, the MD said she did not recall how she was notified of Resident #8's fall or fracture. She said when a result of a fracture came out, the NP was typically notified first. She stated if they were unavailable, the MD was notified, and if it was after hours, the on call physician was notified. The MD said after 6 PM, the on call physician must be notified as per their provider groups contract with the facility. She said the official method of communication of radiology results was a call being placed to the physician in order to ensure there was a response. The MD said failure to notify a provider of a resident's fracture could place residents at risk of pain. In an interview on 05/20/26 at 08:40 AM, LVN Q said when she looked at Resident #8's records on 04/10/26 at an unknown time in the morning, she saw the resident had a knee fracture, so she called the MD, read the results to her and the MD ordered Resident #8 sent out to the hospital for further evaluation. LVN Q said the night shift nurse did not notify her of the xray results, and she found out Resident #8 had a fracture when she read the xray results herself. She said stat x-rays are usually completed within 4 hours of the order being entered, and staff monitor the radiology reports portal at the beginning and end of their shift for any pending results but she didn't know who monitored it between the shift. She said a fracture was a critical result and staff were expected to call providers for notification of the results. LVN Q said some staff sent the results via text, but she didn't due to it being a HIPAA (health care regulations that restrict the use and communication of private health records) violation. She said if a result came in after hours (after 6 PM), nurses were expected to call the provider on call number to communicate results. In an interview on 05/20/26 at 09:05 AM, the NP said Resident #8 was one of her residents and the resident was a functional paraplegic. She said the resident was unable to hold her body safely on her side and required assistance. The NP said on 04/09/26, she was not aware Resident #8 had a fracture and once she was made aware, the resident was sent to the hospital. She said since Resident #8's fracture results came out after 7 PM, LVN K should not have called her because their provider group had an on call doctor. The NP said negative radiology results of a fracture, required a call to the provider, and during night shift, the on call provider must be notified. She said she was not notified of Resident #8's fracture until 04/10/26, and when the resident returned from the hospital, she had her knee in a splint to limit mobility as well as an order for pain medication. The NP said the facility could not manage an acute fracture, they did not have the equipment such as an immobilizer and orthopedic (medical specialty focused on muscles, bones and joints) so residents must be transferred to the hospital. She said failure to timely transfer residents to the hospital after a sustained fracture, placed them at risk for pain and swelling. In an interview on 05/20/26 at 10:16 AM, the Radiology Provider Staff said typically the diagnostic company made multiple attempts during the day to reach the ordering facility once a negative finding was identified, but the results also populated in the integrated radiology results in the EMR. She said the diagnostic company notified LVN K of Resident #8's femur fracture over the phone on 04/09/26 at 09:39 PM. In an interview on 05/20/26 at 10:58 AM, ADON A said ADONs were responsible for verifying orders were in place after an incident and ensuring all communication between the family and doctors were made, as well as monitoring for pending radiology results. She said she was not there when Resident #8 had a fall, but when she came in, LVN Q actually printed the results out and they called the MD. ADON A said the night nurse (LVN LK) did not communicate to the oncoming nurse (LVN Q) on 04/10/26 about the fracture or pending radiology results because she did not think the night nurse knew. She said no one had told them Resident #8's x-rays had resulted, the radiology result was not included in the 24 hour report (a report that provided a summary of significant changes in resident status) and she should have been in the report. ADON A said she did not know Resident #8 had a fall or pending radiology results, and if she did, she would have called the radiology provider to inquire about result since that was one of her responsibilities as the ADON of that floor. She said when a resident experienced a change of condition such a fall, the nurse first assessed the resident, and everything should be documented in the nursing nurse, incident note and SBAR. ADON A said on the morning of 04/10/26 nothing existed in the EMR regarding Resident #8's fall or fracture. She said if there were pending diagnostic results, she expected nurses to continually call the xray provider to get results, all attempts should be documented in a progress note and the MD must be notified through a call in which the results are read to them. The ADON said failure to call the resident's provider placed residents at risk of deterioration of condition. She said after the incident was investigated they identified that LVN K notified the NP of the results via text, instead of a phone call, she failed to contact the after hours physician and she did not notify the next nurse through walking rounds or documentation. ADON A said after Resident #8's fall and subsequent fracture, LVN K should have called the radiology provider throughout her shift till she got a result, and reported the results directly to the provider. In an interview on 05/20/26 ay 01:36 PM, the DON said he knew Resident #8 had a fall, but didn't know about the fracture until the next day (04/10/26). He said during the IDT morning meeting on 04/10/26 as they reviewed the accident and incidents from the previous day, they identified LVN K had not documented any orders, follow up orders or communication to the provider regarding Resident #8's fall and injury so they contacted the NP and the NP was unaware of the xray results that found a fracture. The DON said LVN K told him she sent a text message to the NP, but the response from the NP was that there was nothing there. He said LVN K sent results for x-rays to the arm/elbow, wrist and knee via text message but the NP did not see the results for the knee xray. He said during the morning meeting on 04/10/26, while reviewing the radiology dashboard, they identified the xray results with the fracture, so he sent the ADON to look into it. In an interview on 05/20/26 at 03:27 PM, LVN L said she worked the night shift (10 PM- 6 AM) on 04/09/26 and on that shift she did not know about Resident #8's fall, pending radiology results, or fracture. She said during the night Resident #8 did not appear to be in pain, she slept all night and she (LVN L) did not learn about the fall until the next day (04/10/26). LVN L said she expected LVN K to have notified her that there were pending or read x-ray results, but she did not tell her anything regarding the fall or fracture, so she did not assess the resident following the fall or ask her about pain. She said she did not check the diagnostic results portal because she didn't know anything was pending, she didn't perform neurological checks on the resident because she didn't know Resident #8 had any injuries before she left her shift. LVN L said if she had received x-ray results after hours she would have called the on call physician. In an interview on 05/22/26 at 11:25 AM, the Administrator said LVN K should have pulled Resident #8's x-ray results on 04/09/26 and called the on-call physician to ensure action was taken. She said Resident #8's x-ray results came out midafternoon but LVN K retrieved the results in the late evening and when she did she should have called the on call physician. The Administrator said she expected documentation to be completed timely and to accurately paint a picture of the situation. She said documentation was used to communicate to other people what actions they need to continue or initiate whatever the situation called for, and failure to document could result in a resident not receiving the care needed and being left uncomfortable and in pain. The Administrator said following Resident #8's fall, the nurse (LVN K) did document or communicate information with her managers and other staff. In an interview of on 05/22/26 at 12:51 PM, the DON said LVN K failed to notify the doctor and didn't do a proper shift report about Resident #8's fracture. He said LVN K told him she looked at Resident #8's radiology report but she didn't necessarily read it, and he expected nursing staff to read the results to understand the severity of the findings. The DON said the nurse (LVN K) was responsible for notifying the ADON of Resident #8's fracture. He said the ADONs and DON are busy, so it is the responsibility of charge nurse to check on pending radiology because they can't stay on top of it. Record review of the facility's policy titled Test Results Policy Statement: The resident's attending physician will be notified of the results of diagnostic tests. 1- results of laboratory, radiological and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility. 2- should the tests be provided to the facility, the attending physician shall be promptly notified of the results. 3- the DON or the charge nurse receiving the test results, shall be responsible for notifying the physician of such test results. Record review of the facility's policy Nurse Shift-to-Shift Communication/Change of Shift Report dated April 2026 revealed, It is the policy of this facility to complete a structured nurse-to-nurse change-of-shift report at every shift change to support resident safety, continuity of care, timely follow-up, regulatory compliance, and accountability. Purpose: 1. Ensure critical resident information is communicated clearly, consistently, and timely between shifts. 2. Reduce missed follow-up, delayed notification, medication/treatment omissions, and preventable adverse events. Change of shift report elements: Labs/diagnostics - Orders pending, specimens to obtain, results requiring review, abnormal values, provider notification, and follow-up appointments. Record review of the 200 Hall [MD] Notification Manual on 05/20/26 at 10:50 AM revealed, Immediate Notification- After Hours 6 PM Weekends/Holidays: a phone number for the on call physician service was listed. Test/Procedure- x-ray, report immediately new or unsuspected finding (fracture0; report next day- old or long standing finding, no change. Change in Condition: When to report to the MD/NP/PA, Immediate Notification- Any symptom, sign or apparent discomfort that is: acute or sudden in onset and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. Signs and Symptoms: Fractures and discoloration- immediate notification of any suspected fracture or discoloration.

Based on interviews and record reviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 9 residents (Resident #8) reviewed for quality of care. The facility failed to properly notify MD of Resident #8's radiology results reporting a fracture to the resident's leg resulting in a delay in the resident's need for hospital transfer (27-hrs.) after a reported fall. This failure placed residents at risk for injuries, infections, unwanted hospitalization, and amputation leading to a decrease in quality of life. Findings Included:Record review of Resident #8's face sheet reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnosis included spinal stenosis (pressure on the spinal cord and nerves), chronic obstructive pulmonary disease (progressive irreversible lung disease that restricts airflow and makes breathing difficult), sacral (pressure ulcer injury to skin and underlying tissues) of sacral region (a large, triangular bone at the base of the spine, positioned just below the lumbar region (lower back) and above the coccyx (tailbone)) and sacrococcygeal region (base of the spine, where the triangular sacrum (the tail end of the lower back) connects to the coccyx (the tailbone)), state 4 (a severe, full-thickness tissue injury where the damage extends deep into muscles, tendons, or bones) obesity (chronic disease of excessive body fat), acute embolism and thrombosis acute embolism and thrombosis (clotting of blood that blocks blood flow) of unspecified deep veins of lower extremity (major blood vessels beneath the deep fascia (3-dimensional web of tissue surrounding, protecting, and supporting muscles, bone, and blood vessels) in the legs), (near-complete paralysis (loss of muscle function) and hemiparesis (partial weakness or loss of strength) following cerebral infarction affecting (blood flow to an area of the brain is interrupted) unspecified side. Record review of Resident #8's Quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 12 reflecting the resident had moderate impaired cognition. Record review of Resident #8's care plan reflected, resident required 2-person assist with mobile transfers by use of mechanical aid sling 11/22/2022 and revised on 11/22/2022, and repositioning and turning in bed date initiated on 11/22/2022 and revised on 05/19/2026. Resident was at risk for falls; staff were to anticipate and meet the resident's needs and keep furniture in locked position 11/10/2022 and revised on 02/15/2023. Goal: the resident will not sustain serious injury through the review date of 08/17/2026. The resident had a mildly comminuted nondisplaced fracture of right distal femur without dislocation and sent to the hospital date initiated on 04/10/2026 and revised on 04/27/2026. Goal: The resident will remain free of complications related to right knee fracture, such as contracture formation, embolism and immobility through review date initiated on 04/10/2026 and revised on 05/04/2026. The resident was on anticoagulant therapy. Resident was of paraplegia status date initiated on 11/10/2022 and revised on 02/15/2023. Goal: Resident to remain free of complications or discomfort related to paraplegia through review date. The resident had ADL self-care performance deficit date initiated on 11/10/2022 and revised on 11/10/2022. The resident uses a wheelchair date initiated on 11/10/2022. Staff were to encourage turning and repositioning resident frequently while in bed date initiated on 06/04/2025. Resident had a low loss air mattress to bed date initiated on 03/26/2025. Record review of Resident #8's Change of Condition Communication dated 04/09/2026 at 09:00 a.m. and created by LVN K, reflected, WCN who witnessed fall, walked in the room and observed the resident positioned on her left side in bed. The resident was alert, bed was noted to be in high position, and resident's right hand on the bed's quarter rail. The WCN placed treatment supplies down on the right side of the bed. Resident's head slightly turned towards WCN, the resident began to slide off the left side of the bed near the wall onto the floor. The bed moved as the resident fell. Pain noted to resident's right elbow, right hand, and right knee. No neurological changes observed. Resident on anticoagulants. No laboratory tests/diagnostic procedures to report. Record review of Resident #8's skin and wound dated 04/09/2026 at 09:13 a.m., created by NP B reflected, resident was unable to be evaluated by the skin and wound team today. Resident declined care after experiencing a fall just prior to wound care team arriving. Record review of Resident #8's pain interview dated 04/09/2026 at 09:18 p.m., reflected resident received Tylenol 500mg 2 tablet by mouth every 4 hours as needed for pain. Record review of Resident #8's progress note dated 04/09/2026 at 09:38 a.m. and created by LVN K reflected, upon walking into resident's room, WCN observed the resident positioned on left side in bed. The bed was noted to be in high position, and resident was alert with her right hand on quarter rail. The resident spoke to WCN while WCN put treatment supplies down on the right side of the bed. As the resident spoke, she slightly turned her head towards WCN and began to slide off the left side of the bed near the wall onto the floor. The bed moved as the resident was falling. WCN attempted to reach the resident to prevent the fall, but the attempt was unsuccessful. LVN K immediately assisted providing vital signs. Resident was assisted from the floor back to the bed x 5. LVN K notified MD, DON, and ADON A and new orders received and noted. Record review of Resident #8's progress note dated 04/09/2026 at 09:38 a.m. and created by NP B reflected, upon walking in the room, NP B observed the resident positioned on left side in bed. The resident was alert. The bed was noted to be in high position with resident's right hand on quarter rail. The resident spoke as treatment supplies were placed down on the right side of the bed. As the resident spoke, she slightly turned her head towards NP B and began sliding off the left side of the bed near the wall onto the floor. The bed moved as the resident fell. NP B attempted to reach resident to prevent fall, but attempt was unsuccessful. Immediate assistance was provided to resident and NP B observed vital signs being taken and the resident was assisted from the floor back to the bed x 5. LVN K notified MD, DON, and ADON A receiving new orders. Record review of Resident #8's progress note dated 04/09/2026 at 09:40 a.m., created by LVN K reflected, MD ordered to administer Tylenol Oral Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain. Record review of Resident #8's April 2026 MAR dated 04/09/2026 at 09:40 a.m., Tylenol Oral Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain. Record review of Resident #8's April 2026 MAR reflected, pain assessment to be completed every shift, for pain, starting 03/04/2026 at 10:00 p.m.Pain dated 04/09/2026, reflected, day pain at a 0, evening at 3, and evening at 0.Pain dated 04/10/2026, reflected, day pain at a 5, evening at 4, and evening at 0.Pain dated 04/11/2026, reflected, day pain at a 0, evening at 2, and evening at 0.Pain dated 04/12/2026, reflected, day pain at a 0, evening at 0, and evening at 0.Pain dated 04/132026, reflected, day pain at a 0, evening at 5, and evening at 0. Record review of Resident #8's progress note dated 04/09/2026 at 01:09 p.m. created by MD reflected, MD examinate resident with new order. Record review of Resident #8's Radiology Results Report in the dated 04/09/26 reflected:- Procedure: Hand Right. Examination Date: 04/09/26 at 01:09 PM, Reported date: 04/09/26 at 02:50 PM, Observation Value: Right Hand, History: Pain, Findings: There is no evidence of obvious acute fracture or dislocation- Procedure: Knee Right. Examination Date: 04/09/26 at 01:10 PM, Reported date: 04/09/26 at 02:55 PM, Observation Value: Right Knee, History: Pain. Findings: mildly-comminuted (bone is broken and splintered into more than two pieces, though they are tiny) nondisplaced fracture (broken bone pieces that have not shifted out of their normal alignment) seen across distal femoral along the lateral femoral condyle( at the very end of the thighbone, specifically on the outer bump that forms the knee joint) with overlying periarticular soft tissue swelling and effusion noted (inflammation, and excess fluid built up inside the knee joint in response to a fracture). a small, crack in the thighbone at the knee joint, accompanied by welling.- Procedure: Hand Right. Examination Date: 04/09/26 at 01:15 PM, Reported date: 04/09/26 at 03:25 PM, Observation Value: Right Elbow, History: Pain, Findings: There is no evidence of obvious acute fracture or dislocation Record review of Resident #8's progress note dated 04/10/2026 at 06:16 a.m., created by LVN L reflected s/p fall day 1/3 no injury and no complins of pain or discomfort. Neuro check continues and vital signs stable. Record review of Resident #8's progress note dated 04/10/2026 at 09:33 a.m., created by LVN L reflected, MD notified of resident's right knee x-ray results - impression, mildly, comminuted nondisplaced fracture, with no evidence of dislocation. New order to transport resident to the ER. Record review of Resident #8's progress note dated 04/10/2026 at 10:48 a.m., reflected ER informed resident in route with right knee fracture. Record review of Resident #8's progress note dated 04/10/2026 at 11:16 a.m., reflected, resident left facility to ER via stretcher with EMS. Record review of Resident #8's Discharge summary dated [DATE] at 11:19 a.m., reflected, resident received new order to send to hospital ER for right knee fracture s/p fall from bed for evaluation. Record review of Resident #8's progress note dated 04/10/2026 at 07:50 p.m., reflected, resident returned to facility with new order Norco 5/323 mg 1 tab every 6 hours as needed for pain (7-10) x 3 days. Resident had splint to her right leg. Resident lying in bed with 4/10 pain. Resident requested only Tylenol. Record review of Resident #8's April 2026 MAR reflected:Tylenol Oral tablet 325 mg (Acetaminophen) give 2 tablets by mouth every 4 hours as needed for pain. Start date 04/03/2026 at 03:45 p.m.04/09/2026 at 09:04 a.m., pain levels: 4, PRN medication received.04/09/2026 at 05:29 p.m., pain levels: 3, PRN medication received.04/10/2026 at 10:29 a.m., pain levels: 5, PRN medication received.04/11/2026 at 04:00 a.m., pain levels: 4, PRN medication received.04/15/2026 at 09:40 a.m., pain levels: 4, PRN medication received.04/18/2026 at 06:00 p.m., pain levels: 4, PRN medication received.04/19/2026 at 01:00 a.m., pain levels: 4, PRN medication received.04/19/2026 at 07:00 p.m., pain levels: 4, PRN medication received.04/23/2026 at 09:40 a.m., pain levels: 5, PRN medication received.04/23/2026 at 08:57 p.m., pain levels: 4, PRN medication received.04/24/2026 at 04:12 p.m., pain levels: 4, PRN medication received.04/24/2026 at 08:51 p.m., pain levels: 3, PRN medication received.04/26/2026 at 02:30 a.m., pain levels: 3, PRN medication received.04/26/2026 at 06:30 pm., pain levels: 4, PRN medication received.04/27/2026 at 03:03 a.m., pain levels: 3, PRN medication received.04/28/2026 at 12:30 a.m., pain levels: 4, PRN medication received.HYDROcodone-Acetaminophen Oral Tablet 5.325 mg, to give 1 tablet by mouth every 6 hours PRN for sever pain 7-10 related to unspecified fracture of unspecified femur, initial encounter for closed fracture state dated 04/11/2026 at 12:15 a.m. and discontinued on 04/25/2026 at 03:35 p.m.04/11/2026 at 12:17 a.m., pain levels: 7, PRN medication received.04/12/2026 at 12:14 a.m., pain levels: 5, PRN medication received.04/13/2026 at 01:23 p.m., pain levels: 5, PRN medication received.04/14/2026 at 07:43 p.m., pain levels: 4, PRN medication received.04/15/2026 at 08:15 p.m., pain levels: 4, PRN medication received.HYDROcodone-Acetaminophen Oral Tablet 5.325 mg, to give 1 tablet by mouth every 8 hours as needed for pain related to unspecified fracture of unspecified femur, initial encounter for closed fracture state dated 04/25/2026 at 03:45 p.m.04/27/2026 at 08:34 a.m., pain levels: 5, PRN medication received.04/27/2026 at 08:15 p.m., pain levels: 4, PRN medication received.04/28/2026 at 09:01 p.m., pain levels: 4, PRN medication received.Right leg splint-monitor skin for any bruising or swelling every shift for femoral fractures, starting 04/21/2026 06:00 p.m. Record review of Resident #8's late entry IDT progress note dated 04/24/2026 at 09:05 a.m. created by DON, reflected on 04/09/2026 at 08:49 a.m., resident rolled from bed to floor in witnessed fall. WCN entered room to provide wound care. Resident was lying on side in preparation for care. Resident inadvertently shifted weight and rolled over side of bed falling between bed and wall. Head to toe assessment completing. A knee injury sustained. Resident complained of pain to right knee. X-rays ordered of leg, hand and foot. Fracture of leg near knee confirmed. Resident sent to ER per resident's request for further evaluation and treatment. Resident returned with mild comminuted, nondisplaced fracture diagnosed. RP notified, therapy consults requested, and care plan reviewed. During an interview on 05/19/2026 at 10:30 a.m., Resident #8 stated on 04/09/2026 at 8:15 a.m., she fell from the bed after CNA A left her positioned on her side awaiting the WCN to provide care to her sacrum area. She stated the bed moved and feels the wheels on her bed were not locked in place. She stated she required 2-persons assistance during incontinent and wound care, and she was not to be left without hands on her until after wound care was completed and she was repositioned to her back in the bed. She stated that she was left alone in the room for 5 to 10 minutes with no staff in the room before WCN and NP B entered the room. She stated she saw the bed moving away from the wall and looked over her right shoulder and saw the WCN and NP B with their backs to her when she spoke out I'm falling and she fell to the floor between the bed and the wall. She stated she landed on her right knee, right elbow, and right hand being careful while falling to keep her head up to prevent injury. She stated she was paralyzed in her lower extremities after suffering 2-strokes and 2-heart attacks. She stated she could not move the left side of her body, and the right side was extremely weak. During an interview on 05/19/2026 at 01:05 p.m., WCN stated on 04/09/2026 at 08:15 a.m., CNA A informed her that Resident #8 was ready for wound care. She stated that her and NP B entered the resident's room and observed the resident positioned on her left side, back to the door. She stated while her and NP B were getting items together for care, she saw the resident looking over the resident's right shoulder vocalized, she was falling and fell to the floor. She stated her and NP B ran over to the floor having to move the bed away from the resident to reach her. During an interview on 05/19/2026 at 1:47 p.m., CNA A stated on 04/09/2026 at 08:00 a.m., her and. CNA B changed Resident #8's brief in preparation for WCN and NP B to perform wound care. She stated they position the resident on her left side with the resident facing the window. She stated she and CNA B had to leave the resident to pass the meal trays. She stated while passing the meal trays, she heard the resident hollering and went to the resident's room and was shocked to see the resident on the floor between the bed and the wall after falling out of bed. During an interview on 05/19/2026 at 2:40 p.m., Resident #8 stated on 04/09/2026, she asked LVN K if they were sending her to the ER for x-rays after the fall. She stated that LVN K told her the facility would be send in their own imaging company to perform the x-rays. She stated she cried for 30 minutes in pain from the fall with a pain rate of 10 out of 10, awaiting x-ray to arrive after several hours. She stated no physician came to assess her and no new orders were received. She stated on 04/10/2026, she learned her x-ray results showed a hairline fracture to her right leg, and the facility sent her to the ER. During an interview on 05/19/2026 at 03:28 p.m., LVN K stated Resident #8 was a resident who required total assistance, could move her hands, could barely move her legs, and had constant pain, and wounds that were healing. She stated on 04/09/2026, at 08:49 a.m., she was called to Resident #8's room and observed the resident on the floor laying on her left side between the bed and the window after having a witnessed fall from the bed. She stated the WCN, NP B, and CNA A were in the room and the resident insisted staff immediately pick her up off the floor immediately. She stated she checked the residents' vital signs and assessed the resident for pain and injury finding no adverse effects from the fall. She stated the resident told her she had fallen on her right hand, knee, and elbow and she was able to move with no pain. She stated she found the resident to have no bruises, bleeding, swelling, or pain. She stated the resident was lifted into bed and told LVA A her knee was hurting. She stated she gave the resident an existing PRN Tylenol and notified NP A. She received an x-ray order for the resident's hand, knee, and elbow. She stated the DON and ADON A were on shift and were notified the resident fell. She stated it took between 1-3 hrs. for x-ray to arrive. She stated a few hours later, the resident complained of pain again, and she administered the resident's PRN Tylenol. She stated the x-ray results came back just before she ended shift at 10:00 p.m. She stated she took a picture of the printed results and sent the results to NP A via text message. She stated NP A responded, Nothing there. and she assumed the NP A was saying that there were no injuries found from the x-ray. She stated she had read the x-rays and saw that there was a fracture to the resident's right leg. She stated she had not questioned NP A's response because she followed the direction of the physicians and the resident's condition had not worsened. She stated had there been swelling she would have called NP A and shared those changes in condition. She stated she left shift and was on vacation for a few days and had not spoken to the NP A, had not called the on-call physician, received no new orders, had not updated the resident on the x-ray results, nor could not recall which on-coming nurse she reported the resident's fall and x-ray results with. She stated the resident's fall was listed on the 24-hr. report and she laid the resident's x-ray results on top of the 24-report for the oncoming nurse to review. She stated she should have called on-call after 9:00 p.m. with emergencies and critical x-rays. She stated because NP A had been most familiar with the resident, NP A was sent the results. She stated because NP A stated nothing there she thought there was no need to report anything to the on-call physicians. She stated the risks of a fracture going untreated could cause the condition to worsen, bad swelling, and pain. She stated that she medicated the resident and the resident had no pain and the resident stated the Tylenol was effective. She stated when she returned to shift on 04/13/2026, she learned the resident had in fact had a fracture and that was communicated to the MD. She stated she was not aware if the resident had been sent to the hospital, because the resident often refused hospital transfers and she thought the resident would not have gone. She stated that the resident had transferred to the hospital on [DATE] and returned the same day with a narcotic prescribed for pain and a splint to stabilize the resident's right leg. She stated she received several in-service trainings on falls, locking bed wheels, repositioning residents, performing neurological checks every 2-hrs. after a fall, falls for residents on anticoagulants, and pain management. During an interview on 05/20/2026 at 08:22 a.m., MD stated that on 04/09/2026 while making rounds she learned of Resident #8's fall and learned NP A ordered x-rays. She stated x-rays that resulted after 06:00 p.m., were to be directed to the on-call physician. She stated it had not been her expectation to send pictures of x-ray results after hours to NP A's cellphone. She stated that the official form of contact for relaying critical reports after hours was by calling the on-call team, allowing them to respond on what to do for the resident next. She stated not following the official form of contact could result in a resident having unmedicated pain, delays in x-ray imaging, and delay in the resident being sent out for higher level of care. During an interview on 05/20/2026 at 08:40 a.m., LVN Q stated on the morning of 04/10/2026, she saw x-ray reports showing Resident #8 had a fracture of her right knee. She stated she went to the resident's clinical chart and learned the resident had a fall on 04/09/2026. She stated she called MD and read MD the report results and MD ordered the resident's ER transfer. She stated she called LVN L and asked if she was aware of the resident's x-ray results, and LVN L was unaware. She stated LVN L told her that the resident slept throughout the night with no complaints of pain. She stated when coming on shift, nurses were expected to read over the 24-hr report which outlined resident incidents, changes of condition, transfers in and out of the facility. She stated she would have expected LVN L to have shared Resident #8's fall event and incoming x-ray results at shift change on 04/10/2026. She stated that LVN K had not shared the information with LVN L to share with her resident's change of condition at shift change on 04/09/2026 and she was unaware of the need for a hospital transfer as a result of fracture results. She stated the resident sent to the ER on [DATE], returning the same day with an immobilizer around her right leg and the ER discharges notes indicated a bone break too small for surgery. She stated that x-ray results usually took no more than 4-hours to receive after imaging. She stated he nurses had the ability to check the imaging portal and see results and all the nurses were responsible to check the portal for results. She stated that x-ray results could be texted to the resident's NP or MD from a nurse's phone as a form of physician notification, and all critical x-rays required a phone call to the resident's physician team. She stated had the resident's x-rays resulted after hours, the nurses were to contact the on-call physician. During an interview on 05/20/2026 at 09:05 a.m., NP A stated on 04/10/2026, she stated the facility informed her Resident #8 had a fall from the bed on 04/09/2026 while WCN and NP B were providing wound care services. She stated MD was notified of the fall and ordered for the resident to receive x-ray imaging. She stated the x-ray images resulted that the resident had a fracture, and MD ordered the resident's transfer to the hospital on [DATE]. She stated the resident returned to the facility the same day with a right leg immobilizer and pain medication. She stated on 04/09/2026, she could not recall nor had any text message receipts from LVN K regarding the resident's x-ray results. She stated that she had no issues with staff sending her text messages before 7:00 p.m. She stated after that time, it was her expectation that staff directed critical events to the on-call service. She stated a fracture was a critical event. She stated when waiting on x-rays to result, she had the capability to access and view results on the company's online portal. She stated that the x-ray imaging company normally called the facility and faxed the imaging results before the images populated into the online portal. She stated the facility had not been equipped to handle orthopedic injuries and a fracture required the evaluation of an orthopedic physician.She stated it was her expectation that critical x-rays were immediately reported to her the MD and if after hours, to on-call. She stated the risk of delayed physician notification could delay injury identification, resident pain, and swelling. She stated she had in-serviced the facility on the importance of following the proper physician notification procedure for reporting critical events. During an interview on 05/20/2026 at 10:58 a.m., the ADON A stated on 04/09/2026, LVN K notified NP A of Resident #8's the fall and NP A ordered x-rays. She stated on 04/10/2026, in the IDT's morning meeting, it was known that the resident had a fall on 04/09/2026, and there were no x-ray results. She stated that LVN Q logged into the imaging portal and printed out the resident x-ray reports. She stated LVN Q notified MD of the results and received an order to send the resident to the ER due to a fracture to the resident's right leg. She stated that LVN Q had told her she had not been made aware of the resident's pending x-rays, and LVN L had not communicated the results at shift change, because LVN L had not received any communication about the event from LVN K at shift change. She stated she looked in the resident's clinical chart and reviewed an in-completed change of condition report, found no skin or pain assessments, and no MD, NP, or on-call physician notification. She stated on 04/10/2026, there were no through notes to know what post fall care the resident received. During an interview on 05/20/2026 at 03:27 p.m., LVN L stated on 04/13/2026, ADON A asked her about Resident #8 post fall events. She stated she learned the resident had a fall on 04/09/2026, and had not been made aware when she came on shift that night at 10:00 p.m. She stated the resident had not expressed any pain and had slept thought the evening. She stated it had been her expectation that LVN K would have informed her for about the fall to perform neuro checks throughout the night and follow-up on x-ray to obtain orders from the on-call physician. During an interview on 05/20/2026 at 01:36 p.m., the DON stated that on 04/09/2026, he was on shift when Resident #8 had a witnessed fall by WCN and NP B. He stated that the resident received an existing PRN medication and LVN K received an order from NP A for an x-ray. He stated on 04/10/2026 during the facility's morning meeting the IDT reviewed the incidents and accident report from 04/09/2026 and found that the resident had no follow-up orders on the radiology dashboard from her fall. He stated the IDT pulled up the resident's clinicals and found there were no orders, follow-up orders, and no communication to the provider documented. He stated ADON A spoke to LVN K and learned NP A ordered x-rays, the x-rays had returned with a fracture result, and LVN K sent NP A a text with the x-ray results. He stated that NP A responded, Nothing there because NP A only saw 1 of 3 screenshotted x-rays and not the x-ray showing the resident leg fracture. He stated LVN K told ADON A she thought NP A would call the oncoming nurse with new orders and LVN K left shift without completing the change of condition report, noting NP A notification, without new orders for the fractured x-ray, and no notes communicating post fall results and findings. He stated it had been his expectation that LVN K would have completed the change of condition report prior to leaving her shift to ensure no information was forgotten, and information was translated accurately for post care purposes. He stated the charging events was not just repository, it served as communications to make care adjustments. He stated on the morning of 04/10/2026, and the resident's knee looked fine and told the resident her knee x-ray had returned showing a fracture. He stated the resident told him she wanted to go to the hospital and she was sent out 911. He stated that the resident returned from the ER the same day with a narcotic pain medication and a soft splint for her right leg. He stated the resident had a prior dx off chronic pain and had a history of refusing narcotic medication due to a constipated side of effect. He stated there were no hospital records received when the resident returned and the facility had to place records request to obtain. He stated that LVN K should have spoken directly to NP A regarding the resident's facture and made notes that the provider's notification was made, noting new orders, and completing the change of condition report. He stated on 04/09/2026, LVN K worked a double shift and was off shift the next day to addend a wedding and assumed she was rushing to complete her duties and get off to attend her event. She stated LVN K had worked for the facility for some time and had no previous incidents. He stated when LVN K returned to shift on 04/13/2026 and received a 1:1 in-service training on proper physician notifications, because LVN K told him she knew the resident had a fracture and sent those results via a text message when LVN K should have spoken to the provider verbally and ensued new orders were received to send the resident to the hospital before she left shift. He stated on 04/10/2026, in-service training began notifying physicians of labs and x-ray reports, and getting physician orders for ER treatment when fractured imaging was received. During an interview on 05/20/2026 at 03:03 p.m., LVN K stated on 04/09/2026 Resident #8 had a fall and she opened a change of condition report, completed the physical post-fall skin and pain assessments, and addressed the resident's pain. She stated the resident stated she hit her knee when she fell. She stated she reported the fall the same day to NP A, DON and ADON A. She stated NP A ordered an x-ray. She stated no one from the imaging laboratory called nor had she spoken to anyone regarding the residents' labs and she checked the radiology portal throughout the shift. She stated she logged in at 09:45 p.m. and 3-imaging reports were available, 1-noting a fracture to the resident's right leg. She stated the fractured results made the x-ray report critical and she printed out the reports, took pictures of the reports with her phone, and sent the reports via text to NP A at 09:51 p.m. She stated at 09:51 p.m., NP A responded back, Nothing there and she assumed that the resident had not had a critical x-ray. She stated because NP A was familiar with the resident, she had not contacted the on-call physicians with the results. She stated she had printed x-ray reports and placed them on the 24-hour report for the on-coming nurse to see and left shift at 10:00 p.m. She stated it had been normal for her to text and not call NP A with critical labs and x-rays such as a fracture. She stated she returned to shift on 04/13/2026 at 08:00 a.m., and learned the resident went to the hospital on [DATE]. She stated she was to complete the assessment documents as soon as resident was stable as it was important to note what may have caused the fall, what information and actions were learned, what actions were taken post fall, who was notified, and what orders were received. She stated she updated the change of condition form on 04/24/2026. She stated the risk of not completely a change of condition report and entering progress notes on the residents' fall could result in no one knowing the resident had a fall, pain could worsen from not being noted and addressed, and result in the IDT asking what took place after the fall. She stated she received an 1:1 in-service training from ADM, DON and ADON A on notifying NP, MD, She stated the in-services covered: reporting critical labs to the o[TRUNCATE

Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals,) for 1 of 1 medical supply reviewed for medication storage and labeling. The facility failed to ensure the medication room was free from expired medical supplies on 05/22/2026. This failure could place residents at risk of using items that were less effective or risky due to a change in their chemical composition (change of a substance into something else, often making it weaker, useless, or harmful), and could cause infections due to compromised sterile equipment. Findings included: An observation of 200 hall's medication cart and interview on 05/22/2026 at 10:58 a.m., revealed staff stored unopened expired eSwab collection tubes (a system of a liquid-based device for collecting and transporting wound cultures) count 13, all expired on 07/12/2025. In an interview on 05/22/2026 at 11:03 a.m., ADON A A stated she checked the medication room for expired medications and supplies two times every week but overlooked the collection tubes. She stated if staff used expired collection tubes you can get false lab readings. She stated the treatment Nurse, or any nurse could use the collection tubes, they and should check those tubes for expiration before they used them. She stated she should have noticed the expired tubes and discarded them.In an interview on 05/22/2026 11:16 a.m., LVN E stated using expired collection tubes could cause inaccurate lab results. She stated lab staff delivered the collection tubes to the nurses at the nursing station when nurses requested them. She stated she did not check the medication room supplies including the collection tubes for expired items. In an interview on 05/22/2026 at 11:20 a.m., the Treatment Nurse stated when she needed collection tubes she ordered them from the lab, and when lab staff delivered them to her, she stored them in her office and inside the treatment cart. She stated when lab delivered collection tubes to the nurses, nurses stored the tubes inside the medication room. She stated she checked the collection tubes she stored in her office and inside the treatment cart monthly for expiration. She stated she did not check or used the collection tubes nurses stored inside the medication room. The treatment Nurse stated if staff used expired collection tubes, then there could be a risk for infection or false results and tests could be incorrect which could lead to lab did not process the intended test. She stated if the lab processed the test it could lead to incorrect results which could result in incorrect treatment. In an interview on 05/22/2026 at 12:40 p.m., the DON stated he expected ADON A A to check the medication room a couple of times a week. He stated she did random audits every week on medication carts and the medication room for expired items. The DON stated he was unaware staff stored expired collection tubes inside the medication room. He stated he expected the Treatment Nurse and the floor nurses to check the collection tubes for expiration dates every shift and before they used them. The DON stated using expired medical supplies could cause inaccurate laboratory results, improper treatment plans and infections. Record reviews of the facility's policies and procedures revealed the facility did not have a policy on storing medical supplies.

Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 8 residents (Resident #4) reviewed for care plan revisions. - The facility failed to ensure Resident #4 care plan was comprehensive and updated to reflect Resident #4's diagnosis of schizophrenia that dated back to 09/13/2021. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings included: Record review of Resident #4's Face Sheet date 05/21/26 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with a primary/principal/admission diagnosis of PVD ( a slow progressive circulation disorder where there is reduced blood flow to the legs and feet), additional admission diagnosis of: vitamin deficiency, and asthma (a chronic breathing disease that makes breathing difficult). Other diagnosis included: anxiety disorder with an onset date of 12/30.24; MDD, recurrent, severe with psychotic symptoms with an onset date of 06/202/22 and Paranoid Schizophrenia (disease in which you see and believe things that are not real) with an onset date of 04/01/23. Record review of Resident #4's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 6 out of 15, resident reported feeling down, depressed, or hopeless several days (2-6 days) in the last 2 weeks, rejection of care 1-3 days, and active diagnosis of PVD, dementia, Parkinson's Disease ( a progressive brain disorder marked by uncontrolled tremors, muscle stiffness and balance issues), anxiety disorder, depression and schizophrenia. Record review of Resident #4's Care Plan printed 05/21/26 revealed, focus- behavior problem of taking other residents items, intervention- assist Resident #4 to develop more appropriate methods of coping and interactions, encourage the resident to express feelings appropriately. Focus- mood problem r/t disease process, interventions- administer medications as ordered. Focus- impaired cognition/thought r/t to dementia, interventions- administer medications as ordered, keep the residents routine consistent. Focus- use of anti-anxiety medications r/t depression, intervention- administer medications as ordered and monitor for side effects and effectiveness. There was no documented focus area for Resident #4's Schizophrenia diagnosis. Record review of Resident #4's Psychiatric Periodic Evaluation dated 09/13/21 revealed, past medical history: dementia with behavioral disturbances, schizophrenic disorder. [AGE] year-old female with past psychiatric history significant for dementia with behavior disturbances, MDD with psychotic features, and generalized anxiety. An observation on 05/19/26 at 11:12 AM revealed, Resident #4 well groomed, well-dressed in no immediate distress, seated in her wheelchair in the activity room. She had nail polish on her nails and said she had no issues or concerns with the facility. The resident appeared confused when asked questions about her mental status. In an interview on 05/22/26 at 01:27 PM, the DON said a resident's care plan served to recognize issues regarding the resident and make a plan to ensure the facility took care of it. He said the care plan must include all diagnoses, goals and specific interventions and failure to develop an accurate care plan placed resident's at risk of not getting the services they should. The DON said a resident with a new diagnosis of schizophrenia should have their care plan updated by the ADON/DON and ultimately the MDS Coordinator. He could not state what the timeline to complete care plan changes were following a new diagnosis. In an interview on 05/22/26 at 03:00 PM, the MDS Nurse said she was responsible for care plan updates. She said a resident's care plan functioned as a plan of care for the resident and addressed identified behaviors, medications, and diagnosis. The MDS Nurse said failure to update the care plan placed residents at risk of staff not knowing how to provide care for the resident and/or not having their needs met. She said Resident #4's care plan should have addressed her diagnosis of schizophrenia, and she could not provide an answer for why the resident's care plan was inaccurate and did not address her diagnosis of schizophrenia. Record review of the facility policy Care Plans, Comprehensive Person-Centered revised 03/2022 revealed, 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. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (2) any specialized services to be provided as a result of PASARR recommendations. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; d. at least quarterly, in conjunction with the required quarterly MDS assessment. Record review of the facility policy Change in a Resident's Condition or Status revised 04/2025 revealed, 2.A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan; and d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 7. In addition to notifying the resident and/or representative, the state mental health agency or state intellectual disability agency will be notified within 24hours of a significant change in the mental or physical condition of a resident with a mental disorder or intellectual disability. 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual.

Based on observation, interview, and record review the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid for 1 of 12 resident (Resident #4) reviewed for PASRR services. - The facility failed to refer Resident #4 to identify and update Resident #4's PL1 when she had a newly evident mental illness diagnoses of MDD with severe psychotic symptoms on 04/29/21 and Schizophrenia in 09/23/21 until 05/21/26, preventing a PASRR (a screening required that ensures individuals with MI or ID/DD are not inappropriately placed in nursing homes and received required specialized services) evaluation and determination of services needed. This failure could place residents with a positive PASRR evaluation at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Record review of Resident #4's Face Sheet date 05/21/26 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with a primary/principal/admission diagnosis of PVD ( a slow progressive circulation disorder where there is reduced blood flow to the legs and feet), additional admission diagnosis of: vitamin deficiency, and asthma (a chronic breathing disease that makes breathing difficult). Other diagnosis included: anxiety disorder with an onset date of 12/30.24; MDD, recurrent, severe with psychotic symptoms with an onset date of 06/202/22 and Paranoid Schizophrenia(disorder where you see things that aren't there and believe things that aren't real) with an onset date of 04/01/23. Record review of Resident #4's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 6 out of 15, resident reported feeling down, depressed, or hopeless several days (2-6 days) in the last 2 weeks, rejection of care 1-3 days, and active diagnosis of PVD, dementia, Parkinson's Disease (a progressive brain disorder marked by uncontrolled tremors, muscle stiffness and balance issues), anxiety disorder, depression and schizophrenia. Record review of Resident #4's Care Plan printed 05/21/26 revealed, focus- behavior problem of taking other residents items, intervention- assist Resident #4 to develop more appropriate methods of coping and interactions, encourage the resident to express feelings appropriately. Focus- mood problem r/t disease process, interventions- administer medications as ordered. Focus- impaired cognition/thought r/t to dementia, interventions- administer medications as ordered, keep the residents routine consistent. Focus- use of anti-anxiety medications r/t depression, intervention- administer medications as ordered and monitor for side effects and effectiveness. There was no documented focus area for Resident #4's Schizophrenia diagnosis. Record review of Resident #4's PASRR Level 1 Screening dated 04/02/20 revealed, is there evidence or and indicator this is an individual that has mental illness- No. Record review of Resident #4's EMR on 05/19/26 revealed, no documented PE and 1 PL1 completed after 04/20/20. Record review of Resident #4's Psychiatric Evaluation dated 04/29/21 revealed, past medical history: MDD. [AGE] year-old female with past psychiatric history. Mood symptoms: depressed mood; Anxiety symptoms: restlessness; psychotic symptoms- no psychotic symptoms noted or reported; Noncompliance with treatment: Medications non-adherence. Record review of Resident #4's Psychiatric Periodic Evaluation dated 09/13/21 revealed, past medical history: dementia with behavioral disturbances, schizophrenic disorder. [AGE] year-old female with past psychiatric history significant for dementia with behavior disturbances, MDD with psychotic features, and generalized anxiety. Record review of Resident #4's PASRR Level 1 Screening created on 05/21/26 at 12:21 PM by the Regional Reimbursement Consultant revealed, is there evidence or and indicator this is an individual that has mental illness- Yes. Record review of Resident #4's Mental Illness/Dementia Resident Review (form 1012) created 05/21/26 at 12:15 PM and signed by the RCC revealed, Complete this form only for nursing facility residents with a current Negative PASRR Level 1 (PL1) Screening for Mental Illness to determine whether to submit a new positive PL1 screening form on the Long Term Care Portal because further evaluation is needed. Section B. Dementia Review: For the purposes of PASRR, dementia is a neurologically driven disease that results in a decline in mental ability severe enough to interfere with independence and daily life. Neither dementia nor psychosis or depression related to dementia is a mental illness. Does this individual have a primary diagnosis of Dementia (or related disorder) as defined above? The major neurocognitive disorder is advanced to the degree that a co-occurring serious mental illness is not likely ever again to be the primary focus of treatment. No, the individual does not have a dementia diagnosis or has a dementia diagnosis, but it is not primary. Complete Section C. The physician does not need to sign Section B.1. Indicate each diagnosis that is applicable for the resident. Each diagnosis selected must be documented in the NF medical record by the admitting, attending, or consulting physician. If yes is checked, and it is a new diagnosis, include the date of onset. Does this individual have a diagnosis of: 1.Schizophrenia: Yes, Date of Onset: 04/01/2023. 2. Mood Disorder (Bipolar Disorder, Major Depression, or other mood disorder): Yes- Date of Onset: 06/20/2022. If any of the responses are YES, the nursing facility needs to complete a new PL1 and Sections D and E of the form. A full PASRR Evaluation will be conducted after the nursing facility submits the new positive PL1. Section D. Nursing Facility Action: A new positive PL1 was submitted on 05/21/2026 according to the instructions in Section C. Section E. Staff Completing Form: [Regional Reimbursement Consultant]. There were no signatures on the physician attestation on section b and section c. An observation on 05/19/26 at 11:12 AM revealed, Resident #4 appeared well groomed, well-dressed in no immediate distress, seated in a wheelchair in the activity room. She had nail polish on her nails and said she had no issues or concerns with the facility. The resident appeared confused when asked questions about her mental status. In an interview on 05/22/26 at 12:15 PM, the MDS Nurse said she had been in her position for 2 years. She said the PASRR was a required form for new admissions to identify MI or IDD and every resident should get an evaluation regardless of where they were prior to admissions. She said when a resident arrived to the facility, she reviewed the PL1 for accuracy and she entered the PL1 into the system with alerted the assessing entity to come in and evaluate a resident for special services. The MDS Nurse said after entry she was responsible for monitoring for new resident orders or diagnosis that would result in a change in their PL1 status, and any changes should be documented on the form 1012 which provided instructions on the next actions to be taken based on the answers to the questions on the form. She said it was important to monitor the resident to ensure the PL1 remained accurate and if any changes occurred a new PL1 must be completed which would trigger the process of a PE. The MDS Nurse said if a new diagnosis of mental illness was missed, and the PL1 was negative, it would not trigger an evaluation of the residents need for specialized services or necessary care. The MDS Nurse said she was responsible for Resident #4's PL1 and monitoring of the residents diagnoses and since the resident had diagnoses of MDD and schizophrenia she should have had a positive PL1 because mental illness would be checked yes. She said she did not know why Resident #4's PL1 was incorrect, or how her new diagnoses of mental illness was missed. In an interview on 05/22/26 at 12:15 PM, the RRC said she started an audit of PASRR accuracy for all residents the previous week. She said yesterday, 05/21/26, she identified Resident #4's PL1 was incorrect, so she completed the form 1012 which indicated the resident needed a new PL1. The newly completed PL1 was positive so she submitted the new PL1 to notify the mental health authority. Record review of the facility PASRR policy dated 01/20/26 revealed, Purpose- The aim of the PASRR program is to identify residents with Mental Illness (MI), IDD or DD/RC and to ensure they are properly placed, whether in community or in a NF and to ensure they receive the services they require for their MI, or ID/DD. Procedure- The MDS Coordinator or designee will input all other PL1s into the online portal on admission. This includes negative preadmission PL1s, and PL1s for residents who qualify for exempted or expedited status. 2. When it is determined that a PL1 was filled out incorrectly, the MDS Coordinator, Social Worker or designee will reach out to the hospital/responsible case worker and ask them to correct the form. a- If the referring case worker is unwilling/unable to correct the PL1 that contains a potential error, the social worker or designee will complete and submit a form 1012 (Ml) or new PL1 (ID/DD). A subsequent positive PL1 will be entered according to 1012 findings (Ml). 3. When it is determined that an individual's diagnosis was changed and/or a state surveyor determines the PL1 was incorrect, the social worker or designee will complete and submit a form 1012 (Ml). A subsequent positive PL1 will be entered according to 1012 findings. Specialized Services: There are 3 types of Specialized Services that may be provided, the facility is responsible for the coordination of these services. 3. LMHA Specialized Services- a. Skills training b. Medication training C. Psychosocial rehabilitation d. Case management and psychiatric examination.

Based on observation, interview, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 25 Residents (Resident #16) reviewed for -pharmacy services. - The facility failed to ensure a tube of numbing medicine, Lidocaine and Prilocaine 2.5%/2.5% was not left unattended on Resident #16's bedside table. This failure could place residents at risk of adverse reactions to medications and misappropriation of medications. Findings include:Record review of Resident #16's Face Sheet dated 05/19/26 revealed, a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of: type 2 diabetes, paralysis of both legs and left sided weakness after a stroke (lack of blood flow to the brain), obesity, MDD, anxiety disorder and partial amputation of the left midfoot. Record review of Resident #16's MDS assessment dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15. Record review of Resident #16's undated Care Plan revealed, focus- left forefoot (front of the foot that included all toes but preserved the heel and ankle), Interventions- Complete Treatment as ordered by MD/NP; focus- Wound Management Post-Surgical -General, intervention- Provide wound care per treatment order. Record review of Resident #16's Census list revealed, she admitted on [DATE], transferred to the hospital on [DATE] and returned to the facility on [DATE]. Record review of Resident #16's Order Summary dated 05/19/26 revealed,- Cleanse Left Foot Amputation Site with wound cleanser, pat dry, apply Xeroform, wrap with kerlix, wrap with elastic bandage every day shift every other day for Surgical Site.- Ertapenem ( IV antibiotic) Use 1 gram intravenously at bedtime for bacterial blood infection until 06/21/2026.There was no prescription for Lidocaine and Prilocaine 2.5%/2.5%. An observation on 05/19/26 at 10:30 AM revealed, Resident #16 was in bed in no immediate distress. There was an open and in-use tube of Lidocaine and Prilocaine 2.5%/2.5% on her bedside table. Resident #16 said part of her foot was amputated and the medicine in the tube of lidocaine/prilocaine was applied by the nurse to her foot. In an interview on 05/19/26 at 01:38 PM, the Wound Care Nurse said Resident #16 did not have a prescription for Lidocaine/Prilocaine and staff had not administered the prescription numbing medication to her foot. She said the resident asked for the cream to be used, so she asked the wound care doctor, but the doctor refused to prescribe the medication, so she should not have had any. An observation and interview on 05/19/26 at 01:48 with the Wound Care Nurse and Resident #16 revealed, the open and in-use tube of Lidocaine and Prilocaine 2.5%/2.5% was laying her bedside table. Resident #16 said she had the cream since she readmitted from the hospital (05/14/26) and it had been on her table since then. The Wound Care Nurse explained to Resident #16 that she could not have the cream at bedside, and removed the cream from the resident's room. In an interview on 05/22/26 at 01:27 PM, the DON said all medications should be stored in locked carts when not under the supervision of staff and staff were expected to observe rooms for anything inappropriate like medications when they rounded on their residents. He said failure to keep medication under direct supervision of staff could result in inappropriate use or application that placed residents at risk of negative clinical effects. Record review of the facility's policy Medication Labeling and Storage' revised 02/2023 revealed, Policy heading- The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

Based on observation , interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 of 3 residents (Residents #25) residents reviewed for pressure ulcers. - The facility failed to ensure the pressure redistributing function of Resident #25's air mattress was not interrupted by a fitted sheet on 05/19/26. This failure could place residents at risk of developing, reopening and worsening of pressure ulcers. Findings includedRecord review of Resident #25's Face Sheet dated 05/21/26 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: type 2 diabetes, and morbid obesity due to excess calories. Record review of Resident #25's Quarterly MDS assessment dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 06 out of 15, lower extremity functional limitations in range of motion on both sides and substantial assistance required to: roll left to right, move from sit to lying, move from lying to sitting on the side of bed. She was totally dependent on staff to stand and transfer, risk of development of pressure ulcers/injuries, and unhealed stage 3 pressure ulcer. Record review of Resident #25's undated Care Plan revealed, focus- impaired physical mobility, intervention- assist resident in performing movements/tasks,. Record review of Resident #25's Wound Assessment Report dated 05/11/26 revealed, a facility acquired stage 3 pressure ulcer to the right buttock that was identified on 11/18/25 had resolved. Record review of Resident #25's Progress Not dated 05/16/26 revealed, the resident had no skin wounds/pressure ulcers. Record review of Resident #25's Order Summary Report dated 05/21/26 revealed- 09/25/25 Pressure relieving mattress to bed. Visual checks every shift-11/13/25 Air Mattress to Bedding: check functionality, normal pressure, correct weight setting every shift. An observation and interview on 05/19/26 at 10:46 AM revealed, Resident #25 in a large bed on an air mattress, with the setting at 450 lbs., in a 25-minute cycle time, alternating pressure, and a fitted sheet on the air mattress. She said she had no current wounds, did not ask for the fitted sheet, and she could not feel the mattress moving up and down, redistributing pressure. In an interview and observation of Resident #25's air mattress on 05/19/26 at 01:44 PM, the Wound Care Nurse said the resident's bed should not have a fitted sheet on because it disrupted the ability of the air mattress to relieve pressure. She said the fitted sheet put residents at risk of skin breakdown. In an interview on 05/22/26 at 01:27 PM, the DON said there should never be a fitted sheet on the air mattress, because the alternating pressure was meant to prevent the development of pressure ulcers, and a fitted sheet disrupted that function. He said when all staff (nurses and CNAs) did rounds with residents, they should have ensured the right sheets were used, but there was no task assigned in the EMR to track it. He said the use of a fitted sheet placed residents at risk of the development or reopening of a healed pressure ulcer. Record review of the facility's policy titled Support Surface Guidelines revised 03/27/25 revealed, Purpose: The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. General Guidelines- 1. Redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Guidelines for Selecting Appropriate Pressure-Relieving Devices 1. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. Interventions/Care Strategies l. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, static air, alternating air, gel, or air-loss device, when lying in bed.

Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to post the Daily Staffing Posting in a location visible to all by posting it on the wall on the left side of the building at the entrance to the 200 Hall.- The facility failed to include the name of the facility, and the total number of hours worked by direct care per shift on the Daily Staffing Posting on 05/19/26 to 05/22/26. These failures could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: An observation on 05/19/26 at 10:19 AM revealed, a common area/dining area immediately after the lobby with a hall to the left leading to the 100 hall and a hall to the left leading to the 200 hall. The Daily Staffing Posting was attached to the wall leading to the 200 hall, and read date DAILY STAFFING POSTING, Unit one two &three date 05-19-26. The posting included shift times of 6 am- 2 pm, 6 am to 6 pm, 2 pm to 10 pm,6 pm to 6 am and 10 pm to 6 pm. The census 130 and the number of each direct care staff ( CNAs, LPNs, RNs) on each shift and total number of each direct care staff category for each day. It did not include the total number or actual hours worked for each type of direct care staff, or the name of the facility. An observation on 05/20/26 at 07:35 AM revealed, a common area/dining area immediately after the lobby with a hall to the left leading to the 100 hall and a hall to the left leading to the 200 hall. The Daily Staffing Posting was attached to the wall leading to the 200 hall, and read date DAILY STAFFING POSTING, Unit one two &three date 05-20-26. The posting included shift times of 6 am- 2 pm, 6 am to 6 pm, 2 pm to 10 pm,6 pm to 6 am and 10 pm to 6 pm. The census 130 and the number of each direct care staff ( CNAs, LPNs, RNs) on each shift and total number of each direct care staff category for each day. It did not include the total number or actual hours worked for each type of direct care staff, or the name of the facility. An observation on 05/21/26 at 04:10 PM revealed, a common area/dining area immediately after the lobby with a hall to the left leading to the 100 hall and a hall to the left leading to the 200 hall. The Daily Staffing Posting was attached to the wall leading to the 200 hall, and read date DAILY STAFFING POSTING, Unit one two &three date 05-21-26. The posting included shift times of 6 am- 2 pm, 6 am to 6 pm, 2 pm to 10 pm,6 pm to 6 am and 10 pm to 6 pm. The census 130 and the number of each direct care staff ( CNAs, LPNs, RNs) on each shift and total number of each direct care staff category for each day. It did not include the total number or actual hours worked for each type of direct care staff, or the name of the facility. An observation on 05/22/26 at 07:44 AM revealed, a common area/dining area immediately after the lobby with a hall to the left leading to the 100 hall and a hall to the left leading to the 200 hall. The Daily Staffing Posting was attached to the wall leading to the 200 hall, and read date DAILY STAFFING POSTING, Unit one two &three date 05-22-26. The posting included shift times of 6 am- 2 pm, 6 am to 6 pm, 2 pm to 10 pm,6 pm to 6 am and 10 pm to 6 pm. The census 130 and the number of each direct care staff ( CNAs, LPNs, RNs) on each shift and total number of each direct care staff category for each day. It did not include the total number or actual hours worked for each type of direct care staff, or the name of the facility. In an interview on 05/22/26 at 11:49 PM, the Staffing Coordinator said she had been in her position for 25 years and her responsibilities included the daily staffing posting and adequate staffing levels. She said the staffing posting must include the type of staff and hours worked, the census, date and the name of the facility. The Staffing Coordinator said the daily staffing posting had been located on the right wall before the 200 hall for as long as she knew, and based on the location of the posting those that went exclusively to the 100 hall would not see the posting. She said the posting did not include the facility name because she must have missed it when she created a new template a few months ago. The Staffing Coordinator said failure to place the staffing posting in a place visible to everyone or have the total number hours actually worked would leave residents and visitors unaware of the staffing for the day. Record review of the facility's policy titled 'Posting Direct Care Daily Staffing Numbers' revised 08/2022, Policy Statement:Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation1. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 2. Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including, but not limited to: assisting with activities of daily living (ADLs), administering medications, supervising care provided by CNAs, and performing nursing assessments. Medication aides, feeding assistants, hospice staff, private duty aides and administrative staff are not calculated in direct care staffing numbers. Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following: a. The name of the facility; b. The current date (the date for which the information is posted); c. The resident census at the beginning of the shift for which the information is posted;

Based on observation, interview, and record review, the facility failed to the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3(Resident #19, Resident #4, and Resident #22) residents reviewed for infection control. The facility failed to have signs to acknowledge EBP for rooms [ROOM NUMBER] needed for PPE. This failure had the potential to result in staff not following appropriate PPE, increasing the risk of transmission of infectious organisms. Findings included: On 12/30/2025 at 9:45 am it was observed room [ROOM NUMBER] had no EBP signage posted outside the room to indicate required PPE, with no equipment placed outside of the room. On 12/30/2025 at 9:48am it was observed room [ROOM NUMBER] had no EBP signage posted outside the room to indicate required PPE, with no equipment placed outside of the room.On 12/30/2025 at 10:02am it was observed room [ROOM NUMBER] had no EBP signage posted outside the room to indicate required PPE, with no equipment placed outside of the room. Record review of Resident #19's undated face sheet revealed he was a [AGE] year-old male with an initial admission date of 04/17/2016, with the most recent admission on [DATE]. Resident #19 had diagnoses of obstructive and reflux uropathy (when urine cannot drain through the urinary tract) and malignant neoplasm of left kidney (kidney cancer). Record review of Resident #19's care plan dated 12/30/2025 reflected the focus for EBP was that staff must use gowns and gloves during high-contact resident contact care activities that could possibly result in transfer of MDROs to hands and clothing of staff. The interventions stated a sign for EBP precautions will be outside residents' room to alert staff of precautions with direct care procedures. Record review of Resident #4's undated face sheet revealed she was a [AGE] year-old female with an initial admission date of 06/04/2025, with the most recent admission on [DATE]. Resident #4 had diagnoses of sepsis (infection in the body), slow transit constipation, and anemia (lower than normal red blood cells). Record review of Resident #4's care plan dated 06/05/2025 revealed the focus for EBP was that staff must use gowns and gloves during high-contact resident contact care activities that could possibly result in transfer of MDROs to hands and clothing of staff. The interventions stated a sign for EBP precautions will be outside residents' room to alert staff of precautions with direct care procedures. Record review of Resident #22's undated face sheet revealed he was a [AGE] year-old male with an initial admission date as 07/31/2025. Resident #22 had diagnosis of heart failure. Record review of Resident #22's care plan dated 08/01/2025 revealed the focus for EBP was that staff must use gowns and gloves during high-contact resident contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff with no interventions. During an interview with LVN M on 12/30/2025 at 10:05am, she stated there is normally a note on the door and she has been in-serviced on precautions within the last 60 days. If the equipment is on the door, use sanitizer before entering the room. If the equipment is in bins outside of the room, they must use gowns, gloves, and masks before entering the room. If the signage is not on the door, she would contact the nurse or the infection control preventionist. During an interview with LVN E on 12/30/2025 at 10:09am, she stated the last in-service for PPE was a few weeks ago. It would depend on what the resident has going on to determine if PPE is needed, but the EBP signage will confirm what is necessary before entering the room. If there is no signage, she would confirm with the infection control preventionist, due to the risk of infection spreading. During an interview with CNA Y on 12/30/2025 at 10:27am, stated before entering the room, the signage will be on the door to clarify if the staff use sanitizer before and after visiting with the resident, who is not on contact. If there are three bins by the door, staff is to use all equipment before entering the room, such as mask, gloves, and gown which indicates the resident is on contact. If the signage is missing, she would speak with the nurse to confirm what is needed before entering the room. The last in-service for EBP was a month ago. The risk of the signage missing is not protecting the resident and herself from infection. During an interview with ADMN on 12/30/2025 at 10:52am, the ADMN said the facility staff discuss anyone in isolation to know who is on EBP and what equipment is needed prior to entering the room. The facility's procedure for EBP is to decide if the equipment is hanging on the door, use sanitizer or wash hands and if there is a bin outside the room door, use everything for isolated residents to protect the residents and staff from possible risk of infection. During an interview with RN C on 12/30/2025 at 11:42am, RN C, who is the facilities infection preventionist, stated the EBP signs have been missing and she does replace them at least once a week. There was an in-service in the month of December on EBP and contact for all staff. She has been replacing EBP signs at least once a week, because they have been disappearing. The residents with missing signage, are not on contact and she clarified the residents are on EBP due to their diagnosis. Before staff or any visitor enter a resident room for isolation there is equipment in a bin outside of the door for gloves, mask, and gown to be put on prior to entering the room. For residents with EBP, if the resident is not touched, it is safe to go in the room. If the sign is missing, the staff/visitor should check with the charge nurse, ADON, or infection preventionist. The risk of no signage on the door is a chance of infection for the residents or staff because the PPE is used to protect the residents from staff. During an interview with CNA J on 12/30/2025 at 1:30pm, CNA J stated EBP is known by the isolation cart outside of the room for PPE usage before entering the room. If the resident is not in isolation, there will be PPE on the door, which is necessary if they need to touch the resident or have any type of physical contact. If the sign is missing, she would check with the charge nurse, ADON, and Infection Preventionist on how to proceed before entering the room. The last in-service for EBP and isolation was a few weeks ago. The risk of the signage not being on the door is infection, bacteria, and transmitting. On 12/30/2025 at 1:57pm it was observed that all rooms needed for EBP had signage on the door. Record review of an in-service dated 10/25/2025 for EBP for contact vs. EBP. It read as. contact requires the box isolation cart (strict) EBP has the hanging equipment on the door. EBP is precautionary. Signage on door for EBP and contact isolation precautions. The in-service was completed by RN C and signed by all staff. Record review of the facility's policy for Enhanced Barrier Precautions, dated for March 2024. EBPs are indicated (when contact precautions do not otherwise apply) for resident with wound and/or indwelling medical device regardless of MDRO colonization.11. Signs are posted in the door or wall outside of the resident room indicating the type of precautions and PPE required.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure the ice machine was free from personal drink items (bottled water) within the stored ice. These failures could place residents at risk for food borne illness. The findings included: During an observation/interview on 03/25/2025 at 08:43 a.m., of the kitchen's initial tour, 1 of 1 ice machines contained a bottled water buried under the ice. Once identified, the Dietary Manager (DM) used the ice scooper and scooped out an 8oz bottle of water. The DM stated that the bottled water should not have been within the ice. He stated he was not aware of who placed the bottled water within the ice. He stated that the reason items were not to be within the ice was to prevent contaminated. Next to the ice machine was a cart full of various beverages all containing ice for the morning meal. He stated that he would inform maintenance to come empty and clean the ice machine immediately and he would report the occurrence to the Administrator (ADM). He stated there was no place in the kitchen area for staff to store food/beverages. He stated that staff do however have an employee breakroom where they were able to store food and drinks. He stated that he would provide a policy for properly storing food in the kitchen. During an interview on 03/25/2025 at 01:03 p.m., both the DM and the Corporate DM stated that they had performed in-services on keeping the ice machine free from items including personal drinks amongst the ice in the ice machine. The Corporate DM stated that maintenance had empty, cleaned, and sanitized the ice machine and she had informed the ADM that the in-service had been completed. She stated that any staff not on shift would have an in-service upon starting their shifts. The DM stated that negative outcomes of storing items in the ice would be contamination, that could compromise resident's immune systems and risk stomach infections. He stated that the kitchen staff had been informed that they were to store personal food and drink items in the employee breakroom, in lockers in the kitchen area, and if staff needed to keep a drink nearby for hydration, they could keep a drink in the DM's office on his desk. During an interview on 03/28/25 at 05:52 p.m., the ADM stated that it was her expectations that all individuals follow proper storage protocol and keep items whether they be personal or food service items in the proper designated place. She stated failure to follow protocols could result in the ice encountering items (bottled waters), the ice becoming non-usable, and requiring that the entire ice machine contents to be disposed of. She stated therefore that items not come into contact with any of the ice in the ice machine. Record review of in-service dated 03/25/2025 instructed by the Corporate DM reflected the in-service topic: Ice Machine and Summary of Subject Material Covered: Drinks Should Not Be Put in the Ice Machines. Record review of Policy titled Food: Safe Handling for Foods from Visitor revised dated 05/2017 revealed: Policy Statement Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. Procedures 1. The facility staff will request that visitors bringing in food, and/or residents that receive food, must notify a member of the nursing or activities departments. 2. The responsible facility staff member will determine whether the food item is for immediate consumption or to be stored for later use. 3. When food items are for immediate consumption the responsible facility staff member will: . 4. When food items are intended for later consumption, the responsible facility staff member will: o Ensure that the food is stored separate or easily distinguishable from the facility food. o Ensure that foods are in a sealed container to prevent cross contamination. o Label foods with the resident name and the current date. o Determine if food items are shelf stable and whether they can be stored in the resident room or stored under refrigeration . Record review of policy titled Food Storage: Dry Food revised dated 05/2017 revealed: Policy Statement All dry goods will be appropriately stored will be appropriately stored in accordance with the Food and Drug Administration (FDA) Food Code .

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 2 (Station 1 medication cart for the front hall and secured unit medication cart for the back hall) of 3 medication carts reviewed. The narcotic box in the medication cart for the back hall in the secured unit contained a pill card for Lorazepam 0.5 mg with a piece of tape over a torn protective seal. The narcotic box in the medication cart for station 1 front hall contained a pill card for Tramadol 50 mg and a pill card for Lorazepam 1mg with torn protective seals. The failures could place all residents at risk of not receiving the therapeutic benefit of medications, infection, adverse reactions to medications and drug diversion. Findings included: Interview and observation on 3/26/2025 at 6:15 AM of the medication cart for the back hall in the secured unit revealed it contained a pill card for Lorazepam 0.5mg. There were 7 tablets, and each tablet was individually sealed. The tablet in the 7th compartment had a torn seal that was closed with a piece of tape. LVN B stated it should not have been taped and the tablet should have been wasted instead. She stated she did not know who taped it or why it was taped. LVN B stated it could be the wrong pill and if given to the resident it could have a negative effect. Interview and observation on 3/26/2025 at 12:30 PM of the medication cart for the station 1 front hall revealed it contained 2 narcotic pill cards with torn protective seals. The Lorazepam 0.5mg pill card contained 23 tablets. Pill compartments #8 and #16 contained round, white tablets with torn seals. The Tramadol 50mg pill card contained 24 tablets. Pill compartment #5 contained a white, oblong tablet with a torn seal. LVN A stated the risks of having the torn seals was that the tablets could pop out, get lost and the resident would lose a pill from that stock. LVN A did not have an answer as to why the seals were torn. LVN A stated she would need to waste the tablets with another nurse. In an interview on 3/26/2025 at 2:30 PM, the DON stated the nurses count the narcotics at the end of every shift and the unit managers will check carts at a minimum once a week. He stated the charge nurses check the narcotics daily. The DON stated tape should not be used and expected the nurses to report torn seals immediately to the DON or manager. He stated this was the first time he had ever heard of tape being used. The DON stated once the backing is damaged, the pill could drop out. He stated the cards are factory sealed and it cannot be accounted for if a pill falls out. He stated the seal may prevent it from falling and anything could get inside the compartment if the seal is torn. He stated the residents must be protected from harm of an unknown pill and to avoid any problems the pills should be wasted if the back of the package was compromised. Record review of the narcotic log sheets for the Lorazepam 0.5mg and Tramadol 50mg in the Station 1 medication cart for the front hall revealed the count was correct. Record review of the facility's policy for Controlled Substances, revised on 08/2020, read in part: Medications classified as controlled substances by the Drug Enforcement Administration (DEA) are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with state and federal laws and regulations .Procedures . 3. All controlled substances, Schedule II-V, are stored and maintained in a locked cabinet or compartment .5. Accurate inventory of all controlled medications is maintained at all times .

Based on interview and record review the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 residents (Resident #119) reviewed for PASRR services. The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #119's Specialized Pressure-Reducing Support Surface Mattress by a specific deadline of 12/04/2024 This failure could place residents with a positive PASRR evaluation at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Record review of Resident #119's face sheet dated 03/26/2025 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included Diabetes Type 2, Pain, Muscle Weakness, Major Depressive Disorder, Severe Intellectual Disabilities, Heart Failure, Pressure Ulcer, Disorder Of The Skin And Subcutaneous Tissue. Record review of Resident #119's PASRR records revealed her PE occurred on 09/27/2024. The IDT meeting to determine which services she needed was held on 11/06/2024. Record review of the PCSP form which summarizes and documents the IDT meeting with the Habilitation Coordinator to plan services reflected it was held on 11/06/2024. The plan was for Resident #119 to receive a Specialized Pressure-Reducing Support Surface Mattress. Interview on 03/27/2025 at 12:45p.m., with MDS A revealed there was initially an issue with Resident #119 having two social security numbers which delayed things. The initial social security number used on the PASRR forms was not the correct one and the process had to be repeated with the correct social security number. The meeting on 11/06/2024 was conducted without an issue. The DOR would be the one responsible for submitting the NFSS after the meeting. Interview on 03/27/2025 at 12:56p.m., with the DO revealed a tracking system of checking the NFSS submission status in the portal on a daily basis. Resident #119 had social security number issues because she had two identities. The initial NFSS had to be withdrawn, and the entire thing repeated and sent in again. A new PE and IDT meeting had to be completed. The DOR was aware that they have 20 business days to submit the NFSS after the IDT meeting. He reported he was not able to get the medical equipment supplier quote within the timeframe to submit the NFSS on time. The resident discharged in February 2025 so the mattress was never ordered and the NFSS was not submitted. Request was made on 3/28/2025 to the Administrator for the policy and procedures for PASRR. The policy provided was Detailed Item by Item Guide for Completing the PASRR Evaluation (PE), from Texas Health and Human Services, dated June 2023. The facility did not provide a written document of the facility's PASRR process. Record review of Companion Guide for Completing the Authorization Request for PASRR Nursing Facility Specialized Services (NFSS) from Texas Health and Human Services, Dated November 2023, revealed a nursing facility has 20 business days from the date of the initial IDT or a specialized services review meeting to initiate all PASRR NFSS recommended and agreed to at the meeting.

Based on observation, interview and record review the facility failed to ensure medical care of each resident was supervised by a physician and a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided orders for the resident's immediate care and needs for one of seven residents (Resident #98) reviewed for physician services . The facility failed to ensure Resident #98 had an order for blood sugar parameters for when to report blood glucose levels to the physician according to their policy. This failure placed residents at risk for potential lack of medical supervision by a physician. The findings were: Record review of Resident #98's face sheet dated 03/27/2025 reflected a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included: Type 2 diabetes mellitus (the body cannot use insulin correctly and sugar builds up in the blood), chronic kidney disease (kidneys aren't working properly and are beginning to lose their function), hemiplegia (is a symptom that involves one-sided paralysis). Record review of Resident #98's quarterly MDS, dated [DATE], reflected Resident #98 had a BIMS score that was 09 out of 15 which suggested moderate cognitive impairment. He had limited range of motion of upper and lower extremities and needed partial/moderate assistance with oral hygiene, needed substantial/maximal assistance with dressing, and was dependent with personal hygiene, toileting, bathing. Review of Resident #98's Care Plan date initiated 01/06/2025, Revision date 03/25/2025 revealed: Focus: Resident #98 has Diabetes Mellitus. Goal: The resident will have no complications related to diabetes through the review date. Intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor/document/report PRN any signs and symptoms of hypoglycemia : sweating, tremor, increased heart rate (tachycardia), nervousness, confusion, slurred speech, lack of coordination, staggering gait. Record review of Resident #98's physician order dated 01/01/2025 review report reflected: Insulin glargine Solution 100 unit/ml Inject 6 units subcutaneously one time a day for diabetes HOLD FOR BLOOD GLUCOSE<100. Record review of Resident #98's physician order dated 01/01/2025 review report reflected: Glucose Oral Tablet Chewable 4 gram give one tablet by day every 24 hours as needed for DM2 for low blood sugar < 70 . Record review of Blood Sugar Summary dated: 03/17/2025 23:09 blood sugar 178 mg/dl 03/17/2025 18:16 234.0 mg/dl 03/17/2025 07:28 blood sugar 330 mg/dl 03/17/2025 05:05 98.0 mg/dl 03/17/2025 00:23 112.0 mg/dl 03/18/2025 23:01 blood sugar 208 mg/dl 03/18/2025 18:00 blood sugar 324 mg/dl 03/18/2025 14:14 blood sugar 284 mg/dl 03/18/2025 07:27 blood sugar 284 mg/dl 03/18/2025 06:00 blood sugar 154 mg/dl 03/19/2025 07:13 blood sugar 254 mg/dl 03/19/2025 07:07 blood sugar 254 mg/dl 03/20/2025 10:35 blood sugar 148 mg/dl 03/21/2025 07:39 blood sugar 329 mg/dl 03/22/2025 08:12 blood sugar 302 mg/dl 03/23/2025 07:36 blood sugar 329 mg/dl 03/25/2025 18:28 blood sugar 315 mg/dl Record review of Resident #98's progress notes dated 03/17/2025-03/25/2025, reflected notification of high blood glucose was not reported to guardian or physician until 03/25/2025. In an observation on 03/25/25 at 09:38 AM with Resident #98. Tube feeding was present, and resident was sleeping, wearing gown. Resident appeared to be resting comfortably. Resident did not wake up during surveyor's conversation with roommate. Linens and resident appeared clean, no odors noted from bed. In an interview on 3/27/2025 at 3:00 pm with ADON #2, Resident #98 receives Lantus (insulin for diabetes) 8 units-daily. ADON #2 stated blood sugar between 200 mg/dl -250 mg/dl should be reported to the doctor. Blood sugar of 310 mg/dl was noted on 3/24/25 and ADON #2, stated there were no high blood sugar parameters ordered to report to the doctor or family. ADON #2 stated for blood sugar greater than 300 mg/dl the doctor should've been notified and perhaps a short acting insulin order could have been obtained. ADON #2 stated adverse effects of not reporting blood sugar of greater than 300 mg/dl are possible worsening of infection, and sepsis (a serious condition that occurs when the body has an extreme reaction to an infection). ADON #2 stated nurse LVN A and LVN C should have reported trending high blood sugar to herself, the doctor, and family. ADON #2 stated she does not recall if there were ever any high blood sugar parameters on the chart that needed to be reported to the doctor. In an interview on 3/28/2025 at 9:01 AM with the MD, she reported if she received a call regarding abnormal blood sugars she would act on it depending on the situation. The MD stated she only wants to be called regarding blood sugars below 70 mg/dl and above 400 mg/dl. The MD was asked about a resident who had a blood sugar in the 100 mg/dl range, and then had blood sugars greater than 300 mg/dl for several days. The MD said she would not anticipate any calls from the facility, this is her standard. The MD did not answer questions about nursing standard of care for reporting high blood sugar greater than 300 mg/dl. The MD reported for high blood sugar in a prerenal (a condition in which kidney dysfunction has occurred because of inadequate blood flow to the kidney tissue) resident, she would expect to see the blood sugar to excrete slower. MD reported she does receive verbal or written communication from the dietician regarding recommendations however attends IDT meetings with dietician and management. The MD stated that Resident # 98 was placed on continuous tube feed, was being treated for infection, and had completed antibiotic medication. She said she would anticipate blood sugar rising and only wanted to be notified of sugars below 70 mg/dl and greater than 400 mg/dl. In an interview on 3/28/2025 at 10:05 AM with LVN C. LVN C stated parameters for high and low blood sugars should be on the chart. LVN C stated when the high and low blood sugar parameters are on the chart she will follow them. LVN C stated she would call the MD for blood sugar orders if not on the chart. LVN C stated she should call the doctor if blood sugar was greater than 300 mg/dl. LVN C reported side effects of high blood sugar would be potential damage to organs and adverse effects would be sweating and agitation. LVN C reported if the resident is diabetic and prerenal more issues with the kidneys would be a potential side effect of high blood sugar. LVN C reported she was last in-serviced regarding insulin administration, monitoring, and reporting within the last week and during orientation. In an interview on 3/28/2025 at 10:40 AM with the DON, he stated high and low blood sugar parameters are typically on the chart and the facility needs to call the MD for orders if they are not on the chart. No call documented observed during the record review. The DON stated the MD meets with the IDT and informs the management of high and low blood sugar parameters. The DON then reports the high and low blood sugar parameters to the nurses. The DON did not answer questions regarding when a nurse should call a doctor if an unusual sugar for the resident is found, and there are no high and low blood sugar parameters on the chart. The DON stated the side effects of high blood sugar are thirst and altered mental status. The DON reported if blood sugars are high for several days, calling the MD is dependent on the resident. The DON stated low blood sugar in the elderly population is worse than high blood sugar. The DON reported if a resident has high blood sugar for several days, the resident may be a symptomatic however, it is dependent on their baseline. The DON reported a high blood sugar in a diabetic, who is prerenal could affect their kidneys. The DON reported there was an in-service for insulin monitoring and reporting yesterday and two months ago. The DON's expectations are nurses should report any radical changes in any blood sugars., The DON stated monitoring of blood sugars is being done daily and he would notify the doctor for any increased blood sugar readings. The DON is not sure if any of his nurses reported blood sugars of 300 mg/dl or higher in Resident# 98 in the past few days. In an interview on 3/28/2025 at 11:07 AM, with Dietitian the Dietitian stated she doesn't know if blood sugar parameters are on the chart. The Dietitian reported she looked at the charts monthly for blood sugars to see what the average range was. The Dietitian reported if she changed a supplement or tube feeding, she would monitor and assess during her next visit to see how the resident is being affected. The Dietician relied on nurses to notify her if there's a change in any type of blood sugars and how the resident is tolerating new changes. The Dietitian reported the ADA gives broad range of reporting to doctor for blood sugars, but is not specific to a resident, however, if a resident is completely out of their range she would anticipate changes to be reported to somebody. The Dietitian reported side effects of high blood sugar would be decreased circulation in the small blood vessels and possible damage to liver and kidneys. The Dietitian reported she does look through the chart to understand why critical values might be documented, and if not able to ascertain information in the chart, she would go to the DON. The Dietician stated she remembered changing the tube feeding product for Resident# 98 on 3/20/2025 and documented blood sugars could be potentially higher. The Dietician reported the blood sugars could be between 119 mg/dl and 330 mg/dl due to change of feeding over 22 hours. The Dietician stated she communicated with the MD when new orders are placed but would not recommend increase blood sugar monitoring as that would be an MD order. In an interview on 3/28/2025 at 11:23 AM, with LVN A stated there should be high and low blood sugar parameters on charts. LVN A stated she would call the MD if blood sugar was higher than 200 mg/dl, if there are no parameters for high blood sugar. LVN A stated side effects of high blood sugar are confusion, diabetic coma, cold clammy skin , and increased thirst. LVN A stated if high blood sugar persisted, it could affect major organs. LVN A stated a diabetic patient who is pre-renal could have further complications with kidneys. LVN A stated her last in-service regarding insulin monitoring and reporting was yesterday and approximately two months ago. LVN A stated she was not sure why she did not report blood sugars of 300 mg/dl for Resident# 98 to the DON or MD. Record review of Diabetes -Clinical Protocol. Treatment/Management #4. The physician will address complications such as dyslipidemia, coronary artery disease, neuropathy and nephropathy based on individual's overall condition, prognosis, function, and treatment preferences. Monitoring and Follow-Up. #1 The Physician will follow up on any acute episodes associated with significant sustained change in blood sugars or significant deterioration of previous glucose control and document resident status at subsequent visits until the acute situation it is resolved. #4 The physician will order desired parameters for monitoring and reporting information related to blood sugar management. #5 The staff will incorporate such parameters into the Medication Administration Record and Care Plan.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents (Resident #6) reviewed for pharmacy services. -The facility failed to give Resident #6 medications as ordered by the physician on 3/25/2025. - The facility failed to maintain accurate records of controlled drugs when LVN B signed out a Lorazepam pill but did not administer it. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of the Admission Record for Resident #6 revealed a [AGE] year-old female admitted to the facility on [DATE] and originally admitted on [DATE]. Her diagnoses included drug induced Parkinsonism (appears like symptom of Parkinson's disease), COPD (chronic obstructive pulmonary disease) (a lung condition caused by damage to the airway), schizophrenia, anxiety, depression, and dementia. Record review of Resident #6's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 out of 15 indicating severe cognitive impairment. Section E - Behavior of the MDS revealed she had physical and verbal behavioral symptoms directed towards others. She had rejected care and wandering behavior. She required supervision by staff for all ADLs. Further review revealed she was receiving Antipsychotic, Antianxiety and Antidepressant medication. Record review of Resident #6's active physician order summary report dated 03/28/2025 revealed an order for Lorazepam 0.5 mg, give one tablet by mouth three times a day for agitation/anxiety, start date 10/14/2024. Record review of Resident #6's undated care plan revealed: Focus - Resident #6 wanders aimlessly r/t dementia and schizophrenia diagnosis. Resident #6 admitted to the secured/memory unit. Interventions included, monitor for fatigue and weight loss. Focus - Resident #6 had mood problems r/t anxiety, insomnia, and depression. Yells out in hall and sings loudly. Refuses care at times and refuses medications. 11/28/24 - she refused all medications. Interventions included, administer medications as ordered. Monitor for side effects and effectiveness. Focus - Resident had potential for behavior problems r/t diagnosis of schizophrenia, history of refusing care, taking items that don't belong to her and aggressiveness. Interventions included, administer medications as ordered. Focus - Resident #6 uses anti-anxiety medications Lorazepam r/t anxiety disorder. Interventions included: Administer Antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Record review of Resident #6's Medication Administration Report dated 03/28/2025 revealed Lorazepam 0.5 mg tablet ordered to be administered on 03/25/2025 at 8:00 PM was corrected to not given by LVN B. Interview and observation on 3/26/2025 at 6:15 AM of the medication cart in the back hall of the secured unit, revealed a Lorazepam 0.5mg blister pack for Resident #6 contained 34 tablets. The narcotic sign out sheet for Resident #6's Lorazepam 0.5mg tablets revealed on 3/25/2025 at 8:00 PM, LVN B signed out one tablet. The amount remaining was recorded as 33 tablets. LVN B stated the tablet was not popped out and she thought she popped it out before giving meds to Resident #6. She stated the missed dose of Lorazepam could affect the resident's behavior. LVN B stated she would write a medication error report and notify Resident #6's physician of the missed dose. Observation on 3/26/2025 at 7:00 AM, revealed Resident #6 was in the dining room of the secured unit with other residents. She was walking around, visiting with other residents, and talking in her language. In an interview on 3/26/2025 at 2:30 PM, the DON stated the nurse is responsible for the narcotic count and the first step of the day would be to count with the next shift. The DON stated any discrepancy should be noted at that time then they would have to find out why a narcotic was not given by checking the MAR and narcotic book. The DON stated he expected the nurses would notify the DON as soon as possible. He stated that each pill must be given the way the doctor ordered. The DON stated the doctor's orders for Lorazepam 0.5mg to be given three times a day was not followed at that time and LVN B missed it. The DON stated it could potentially affect Resident #6 negatively, but she slept through the night, so it did not affect her. He stated she had no anxiety, but the nurses still would need to be consistent to protect the resident. In an interview on 3/28/2025 at 10:00 AM, the DON stated that the basics of medication administration for nurses was the 5 rights: right resident, right medication, right dose, right route, and right time. He stated LVN B was probably not paying attention when dispensing the Lorazepam tablet from the blister pack. Record review of the facility's policy for General Guidelines for Medication Administration, revised on 08/2020 read in part: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and medication distribution system to ensure safe administration of medications without unnecessary interruptions 4. At a minimum, the 5 Rights - right resident, right drug, right dose, right route, and right time - should be applied to all medication administrations and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared and the medication is put away . Record review of the facility's policy for Controlled Substances, revised on 08/2020, read in part: Medications classified as controlled substances by the Drug Enforcement Administration (DEA) are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with state and federal laws and regulations .Procedures .4. Preparation of the dosage form occurs according to the medication administration policy. 5. Accurate inventory of all controlled medications is maintained at all times .

Resident #98 General 03/28/25 01:41 PM resident did not have upper parameter for blood sugar monitoring in MD orders, did call MD for clarification and had high blood sugar for consecutive days.

Based on interview and record review the facility failed to review and revise the person-centered care planning for one (Resident #2) of eight residents reviewed for care plan revision. 1. Resident #2's care plan had not been revised to include behavioral triggers and aggression. On 02/12/24 at 01:50 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/15/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for decreased quality of care and quality of life. Findings included: Resident #2 Record Review of Resident #2's face sheet revealed an eighty-four-year-old man who was admitted to the facility on [DATE]. His admitting diagnoses were schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), generalized anxiety disorder, and hyperlipidemia (high cholesterol). Record review of Resident #2's care plan (completed 7/20/23, revised 01/15/24) revealed that he was incontinent, had a communication problem, had acute/chronic pain, and was a wanderer and elopement risk. No focus areas specified anything regarding resident behaviors. Record Review of Resident #2's BIMS (Brief Interview for Mental Status test, used to get a quick snapshot of a residents cognitive status) revealed a score of 3.0 on a scale range from 1.0- 15.0. Record review of Resident #2's progress notes revealed the following: 07/26/23 documented by a nurse (name unknown): Resident roommate is in dining room eating dinner. And Resident #2 is sitting on roommate bed eating his dinner. Writer explains to resident that's not his bed. Resident #2 states fuck this shit, I can stay in this bed, you can't tell me what the fuck to do! Staff redirects resident, but resident still refuses to go his own bed. Resident #2 states This is my place and all these beds is mine! Writer notifies Administrator of Resident #2 non-compliance to go his own bed. And Resident #2 is getting agitated with staff. Roommate moved to other room due to roommate Resident #2s refusal to go to his own bed. 09/04/23 documented by a nurse (name unknown): Resident in Room and resident very territorial about his room. Even if resident just comes to his doorway. Resident begins to curse stating quotation I don't want any of you bitches coming in my room!. Staff has to redirect resident. Resident states to staff I'm going to kick all you mother fuckers ass!. Staff has to redirect resident. Staff was trying to pick up resident dinner tray from his room. And resident refused to allow staff in room. Resident sat stuff on floor in room, blocking staff from trying to pick up his finished dinner tray in room. Staff again redirected resident. Resident remained verbally combative towards staff. Staff will continue to redirect and monitor. 9/14/23 documented by a nurse (name unknown): Staff has to redirect resident. Resident forgets what side room is on. Resident denies he lives here; staff again redirect their resident. Resident verbally combative towards staff and using profane language too; staff will continue to redirect and monitor. 10/04/23 documented by a nurse (name unknown): Resident stayed in his room asleep all through the night. Earlier during change of shift walking rounds, observed resident blocked his door with bedside table and by opening the rest room door, puts a sling on the door making it difficult to open. He mentioned that he don't like other residents wandering into his room and that's why he wants the door closed. Staff encouraged resident not to put ant thing that will make it difficulty in opening the door for his own safety as well, staff will keep an eye on other residents as to not wander into his room and if by any chance, any resident wanders into his room, to use his call button to call on staff who will assist in getting unwelcomed resident out of his room of which he agreed to. 10/27/23 documented by a nurse (name unknown): Other male resident from other room on station D wandered into room A. Resident #2 yelling at the resident to get out of his room. Staff intervenes to get other resident out of room. When resident #2 picks-up a plastic hanger and starts swinging the hanger towards the staff members only yelling you bitches get the fuck out my room! Writer explains to resident #2 of trying to get other resident out of his room, please be patient. Writer and staff continue to attempt to remove other resident from room. And resident #2 continues to swing plastic hanger toward staff members only referring to staff members as Bitches, Ugly [NAME]! Finally staff able to remove other resident from room and transfer back to their room. Resident #2 didn't exhibit any physical aggression of swinging hanger toward resident; physical aggression of swinging plastic hanger directed only towards staff members; will continue to monitor. 11/03/23 documented by the Social Worker: Staff reports that resident is much calmer but at a time has exhibited threatening behavior including cursing and swinging plastic hangers at staff during intervention with another resident. Met with resident who is alert, able to let staff know of his needs, talking in a very long time, requires assistance and cuing with ADL and encouragement to take his meds. Educated him to refrain from threatening with an object and he doesn't recall any verbal or physical behavior and sits in day area and participates in activities when encouraged. He is under the services of guardianship program message left related to his behavior and referral for further evaluation and treatment. Resident is under psych/ nurse practitioner care for medication and referral to senior psychology for psychological services and to manage plan. Resident to remain in memory care due to wandering risk, full code and LTC. No DC plan. Staff to approach in a calm and non-threatening monitor and redirect as needed. 11/15/23 documented by a nurse (name unknown): resident refuses to take shower according to CNA. Resident frequently urinates on the floor in his room period no other behaviors noted. 11/17/23 documented by a nurse (name unknown): resident refused to take shower/bath. Writer explained the importance of bathing but residents still refused. 11/20/23 documented by a nurse (name unknown): resident refused morning medication despite writer explaining importance of them. Has tendency to spit out medication after putting them in his mouth. Resident currently in his room will continue to monitor. 01/14/24 documented by the Social Worker: staff report that Resident #2 was involved in a physical altercation with another resident and placed under behavioral and safety monitoring. The resident has a long history of mental disorders including paranoid schizophrenia and mood disorder but med intervention in progress. Due to his current behavior, he may need further evaluation for placing self and others in danger. Social workers spoke to behavioral staff to assess for possible inpatient eval and treatment for current signs of mental illness. Behavioral hospital accepted him for care. Nursing notified as accepting psychiatrist, accepting administrator to get transportation and transfer resident to behavioral hospital. Record review of the facility's self-reported incidents in the last 30 days revealed: 01/07/24 at 2pm: Resident #2 and another resident were tugging back and forth over a piece of clothing that came from Resident #2's room, when Resident #2 stumbled backwards and hit his head on the door. Resident #2 was admitted to the hospital with traumatic brain injury assault with brain bleed called subdural hemorrhage (bleeding between the brain and the skull) and subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane). 01/14/23 at 8:50 am: Upon investigation, it was discovered that there was blood leading from Resident #2's room where Resident #3 was found lying down. There was blood in Resident #2's room as well as on the side and bottom of his trash can. Resident #3 does wander into other rooms from time to time and Resident #2 does not want anyone in his room. Resident #3 was found in another room laying down on the floor bleeding and was struck in the face. Laceration (deep cut or tear in skin) to forehead with indentation and hematoma (injury where blood collects and pool under skin), swollen nose with discoloration, skin tear to left cheek, and right foot, great toe skin tear. No fractures reported by the hospital. Record review of Resident #2's psychiatric evaluation visit dated 01/03/24 revealed that there had been no changes in behaviors since his GDR of sertraline. Resident had been calm and no mood adjustments. In the care plan recommendations, it stated that the resident was not an acute danger to himself or others, but this may change due to psycho stressors and treatment compliance. Other recommendations included managing the resident's environment, utilizing behavior interventions for episodic behavior, and provide supportive encouragement to increase socialization. In an interview on 01/26/24 at 10:48 am, Unit Manager stated that since she was promoted into the Unit Manager in November 2023, Resident #2 refused care and was sometimes aggressive with staff, but he was doing well before his most recently reported incident on 01/14/24. Resident #2 was mild mannered and could sometimes be easy to redirect. The unit manager was not aware if Resident #2 had any behavioral ticks and stated that he was in a room without a roommate by chance and not for any specific reason. In an interview on 01/26/24 at 10:53 am, the Unit Manager stated that the facility staff did care plan meetings everyday where they discuss the needs of different residents with the social worker, nurse, and therapist if they were in therapy. The Unit Manager explained that she was responsible for making acute (day to day changes/trends) to the care plan, while each dept head had their own sections for updates. When asked when was the last care plan meeting she attended, she stated that she could not recall attending one for the year of 2024. She explained that the facility had changes in management, and they were working on getting all care plans updated. The Unit manager also stated that the importance of a comprehensive care plan was to outline the care that residents need and to give the floor staff a path for how they were to care for residents. In an interview on 01/26/24 at 11:12 am with CNA A, she stated that Resident #2 was aggressive and thought the facility was his house. Sometimes he would have good days, but he often would get upset or triggered when people would enter his room. She explained that in the past he would try and kick his roommates out, so Resident #2 was now housed in a private room. In an interview on 01/26/24 at 12:39 pm, MDS A stated that when she started at the facility in September 2023, that a lot of care plans had not been completed in some time due to a gap in employment. She explained that she implemented a PIP (performance improvement plan) that trained all staff in an attempt to get things back on track. She sent out daily reminders to alert staff on which care plans needed to be updated. MDS A explained that Resident #2's care plan had not been updated because he was sent out of the facility on 1/14/24 to a behavioral hospital and no one had signed or reviewed his plan of care. MDS A stated that the Unit Manager is responsible for updating the day-to-day changes in resident behaviors in the care plan. For quarterly care plans, MDS A stated that she liked to leave the care plan open for three months post the completion date so that each department head would have enough time to develop or revise the care plan. After the care plan had been revised, the social worker would reach out to the responsible party of the resident and schedule a care plan meeting in person or over the phone. MDS A explained that updates to the care plan are not her responsibility, but she was helping to get the facility up to date. Her priorities were MDS assessments, and she presented to the investigator her MDS assessments, which were last completed in November or December of 2023. In an interview on 01/26/24 at 3:38 pm with the Admin, she stated that she had been employed at the facility since December of 2023. She explained that she was aware that care plans were behind and that the facility had implemented a PIP to get back on track. The Unit Manger of each unit was responsible for updating the care plan with day-to-day changes while each department head was to update the other sections (activities, nursing, dietary, therapy). She explained that the harm in not having updated care plans was that staff would not have special instructions to handle the needs of each resident. Record review of the facility's policy titled Care Plans, Comprehensive Person- Centered, revised March 2022, displayed: a. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. b. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. c. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. d. The interdisciplinary team reviews and updates the care plan: 1. when there has been a significant change in the resident's condition; 2. when the desired outcome is not met; 3. when the resident has been readmitted to the facility from a hospital stay; and 4. at least quarterly, in conjunction with the required quarterly MDS assessment. f. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. This was determined to be an Immediate Threat (IT) on 02/14/24 at 10:45 am. The Admin and Corporate Nurse (CN) were notified. The Admin and Corporate Nurse (CN) were provided with the IT template on 2/14/24 at approximately 10:45 am. The following POR (Plan of removal) submitted by the facility was accepted on 02/16/24 at 01:45 pm. The POR documented: The facility failed: to supervise resident #3 from wandering into resident #2 rooms where she was injured and had to be sent to the hospital. Immediate action: resident #3 discharged to the hospital and resident #2 was sent to Oceans behavioral hospital for evaluation and treatment 1-14-2024. Resident #3 has been discharged not to return discharged on [DATE]. Resident #2 is stable and has not had any further behaviors went to Oceans Behavioral hospital on 1-14-24 and returned on 1-26-2024. Audit on the memory care unit initiated on 2-14-2024 by the in house MDS nurse. 30 residents reside on the memory care unit. The corporate MDS nurse came in on 2/15/2024 to assist with the audit process. All residents on the memory care unit have potential to wander. 13 out of 30 residents identified actively wander in the unit. The care plans for these 13 residents were reviewed and updated. 2/16/2024 Staffing Ratios were reviewed to ensure the facility has adequate staffing ratios. Staffing Ratios for the Memory Care Unit-3 aides 2 nurses and 1 activity staff on unit for increased supervision. This is the normal staffing pattern on the memory Care unit. o 6-2 (3 aides and 2 nurses 1 activity) o 2-10 (3 aides 2 nurses, activity leaves at 6pm) o 10-6 (one nurse and 2 aides) 2/15/2024 Regional MDS coordinator in facility to assist with identifying residents with wandering behaviors to ensure appropriate care planning is in place and accurate. 2/15/2024 Review of the SOM 689 accidents hazards/supervision/devices/with the Clinical team on 2/16/2024 at 0900 the department heads and the clinical team reviewed on the big screen TV the 689 regulation to validate 2-15-2024. This will be accomplished by reading the regulation in full and the critical pathway for Accidents will be reviewed verbally as a team. This will ensure that we have all the elements of training covered in the Pathway and additional training needed if necessary. Medical Director was notified on 2/14/2024 of IJ 689 Follow up with the medical director on 2/15/2024 @ 8:15am on IJ status. AD Hoc QAPI to be held 2/16/2024 with F-689 and SOC update on IJ reviews. An in-service initiated by the memory care RN, ADON - for increased monitoring of wandering residents, in the dining areas, and common areas and re-direction of the resident. All staff on 100-200-and 300 halls were in-serviced because the staff at any given moment could float to another unit. Central Supply and medical records assigned to assist with daily rounding in the unit until all walkie talkies are in place 2-14-2024 to 2-16-2024. New Weekend Supervisor starting on 2/17/2024 to provide supervisory coverage of the buildings on the weekends, 16-hour shifts. Both ladies are already assigned ambassadors to the memory care unit. They round before the morning meeting. After the morning meeting After Lunch And before they leave for the day Both offices are located in the same vicinity of the memory care unit. Walkie talkies (ordered on 2/15/2024) to be delivered on 2/16/2024: to be used by the aides and the nurses to communicate with each other. when a resident wanders from the group setting, during rounds, in passing etc. so that the all staff will be able to keep closer monitoring on the wandering residents. 3 Walkie talkies are being charged for use on 2/15/204 and the other 5 are being delivered on 2/16/2024. Monitoring form initiated for rounds every hour to ensure that nurses can document that they are monitoring and rounding in the unit .at night the nurse will continue with the monitoring while the resident is asleep. 2/15/2024 we will continue the monitoring until we receive the equipment on 2/16/2024 and will continue the rounding until the staff is using the walkie talkies appropriately. CN completed the initial training with the nurses and aides on the use of the walkie talkies . 2 placed on 300 once sufficiently charged. Completion date of training will be completed on 2/16/2024. Following acceptance of the facility's Plan of Removal, the facility was monitored from 02/16/24 to 02/17/24. Monitoring of the plan of removal included: The surveyor confirmed the facility implemented their plan of removal sufficiently from 02/16/24 - 02/17/24 to remove the IJ by: Monitoring Day 1: 02/16/24 Record review of the care plans for residents on the MC unit who have the potential to wander (13) were updated and made available for care staff on PCC through the kiosk. Record review of the in-services conducted 02/13/24 on F-0656 Develop and Implement Comprehensive Care Plans displayed 14 of 14 management, nursing staff, and assistant nursing directors, the social worker, and therapy department heads were educated. Record review of Resident #2's care plan documented that Resident #2 had the potential to be physically aggressive related to history of harm to others and poor impulse control. Interventions included to utilize behavior interventions to manage episodic behaviors, engage calmy in conversation, guide away from source of distress, and intervene before agitation escalates. Care plan also stated the goal for Resident #2 would be no harming of himself or others through the review date. Care plan documented that the resident had the potential to be verbally aggressive and listed interventions such as assess and anticipate resident needs, allow time for the resident to express self and feelings towards the situation, and administer medications as needed. Resident #2 Care plan was updated on 2/12/24. Record review of Resident #2's MDS revealed that this assessment was updated on 01/31/24. In an interview with Resident #2 on 02/14/24 at 11:58am, he stated that he was doing alright and that he was feeling relaxed without any pain. He stated that he vaguely remembered an incident with another resident and a trash can but cannot remember exactly what happened. On 02/15/24 a set of 12 long range rechargeable walkie talkies with batteries were purchased from an online vendor. On 02/16/24, walkie talkies arrived at the facility, were charged, and placed within the MC Unit. Record review of an in-service titled Supervision was started on 02/16/24. This in-service covered reasons why residents wander, hourly rounds on residents and management, redirecting residents who wander, and the use of walkie talkies on the MC Unit. Record review of Resident #2 monitoring sheets displayed that resident was checked every 30 minutes. No new behaviors or changes noted. Record review of newly hired RN weekend supervisor, start date 02/17/24. Sex offender registry, EMR, and license verification report completed. Monitoring Day 2: 02/17/24 Record review of an in-service titled Supervision was completed on 02/17/24. Sign in sheets showed a total of 80 staff who provide direct care or nursing services. In an interview with CNA F on 02/17/24 at 5:30pm, she stated that she worked the 10pm- 6am shift. She was informed on how to use the walkie and the purpose was for staff to be able to monitor residents in the MC Unit who may wander. She explained that sometimes residents will wander because they are looking for family and you may be able to help with a phone call. If a resident is aggressive with another resident, she will intervene to ensure the safety of that resident. If a resident is showing aggression towards herself, she would walk away and reapproach later. In an interview with CNA G on 02/17/24 at 5:35 pm, she stated that she worked the 6pm-2am shift. She explained that a resident may wander because of hunger, or they may need to be changed. If she witnessed this behavior, she would try to redirect them or offer them a snack. She stated she normally worked on a hall without wandering residents, so if she noticed this behavior, she would chart it in PCC and immediately inform her charge nurse. In an interview with CNA H on 02/17/24 at 5:39 pm, she stated that she worked the 2pm- 10pm shift and that she was told to redirect and offer snacks to residents who wander. It was important to know where residents are at all times and wanderers have a wander band that goes off when they come too close the door. If she had a resident that started to walk around aimlessly, she would try to toilet them, offer snacks, and let her charge nurse know. Then she would chart it in PCC. In an interview with LVN B on 02/17/24 at 5:47 pm, she stated that she worked the 6am- 2pm shift. She explained that in the in-service, they talked about the locked unit and that staff was responsible to do checks on residents. They must have a person supervising the MC Unit and they will use the walkies to alert other people that the resident was walking around. The walkie talkies help staff better communicate with each other. In an interview with CNA I on 02/17/24 at 5:53 pm, she stated that she worked the 10pm- 6am shift. She explained that she normally worked the 10pm-2am shift. In the in-services given, she was informed that if she saw a resident wandering, she was to redirect and see if she could meet their needs. She explained that if she noticed a resident on her unit (non MC hall) began to wonder, she would tell her charge nurse immediately of the unusual behavior and chart it in the kiosk. In an interview with LVN C on 02/17/24 at 6:07 pm, she stated that she is a nurse in the MC unit who normally worked the 2pm-10pm shift. She stated that in the in-services, she was taught to redirect all residents who are seen wandering by offering them snacks, toileting, redirection, and assessing pain levels. In an interview with RN A on 02/15/24 at 6:12 pm, he stated that he worked the 2pm to 10pm shift. He explained that if staff saw somebody wondering, they investigate why, and see if they are hungry or want to be changed. Staff will check the diapers to see if they are wet, offer food and snacks, see if they are looking for someone to talk to, or try to find out what they want. The unit was given walkies that work by pushing the side button and talking. MC staff know that his cart is in front of the nurse's station on the MC Unit. If he left to go to another area, MC staff can walkie him. If the aid in the dining area saw a resident in the front room leaving out, all MC staff must acknowledge that that can hear the staff letting them know a resident was on the move and to keep eyes on them. In an interview with LVN D on 02/17/24 at 6:45 pm, she stated that she worked the 6am- 10:30pm shift on Saturday and Sundays. She stated that in the in-service given on 2/16/24, her takeaways were that wandering behaviors in a resident may be related to an underlying factor. Staff should check and see if they resident needs to be changed, offer snacks, monitor their whereabouts, then redirect them. She also explained that the behavior could also be as simple as the resident looking for someone to talk to. She also stated that the MC unit had walkie talkies now, which will help staff communicate on where the residents are and what they may need. In an interview with CNA J on 02/17/24 at 6:50 pm, she stated that she worked the 2pm-10pm shift. She was in serviced on residents who wander and informed to redirect them when this behavior is noticed. She explained that if a resident fights, staff should separate them and try to see if they would like to participate in an activity or if they would like a snack. Immediately after, this behavior should be reported to the nurse and updated on the Kardex in PCC. The Corporate Nurse was informed the Immediate Jeopardy (IJ) was removed on 02/17/24 at 7:00 pm. The facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for two (Resident #2 and #3) of eight residents reviewed for care plans. 1.) The facility failed to update Resident #2's care plan after he demonstrated a history of aggressive behaviors regarding resident care and his personal space to staff and residents. 2.) The facility failed to include that Resident #3 was a fall risk in the care plan. On 02/12/24 at 01:50 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/15/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk by not receiving appropriate treatment and services to meet their needs. Findings included: Resident #2 Record Review of Resident #2's face sheet revealed an eighty-four-year-old man who was admitted to the facility on [DATE]. His admitting diagnoses were schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), generalized anxiety disorder, and hyperlipidemia (high cholesterol). Record review of Resident #2's care plan (completed 7/20/23, revised 01/15/24) revealed that he was incontinent, had a communication problem, had acute/chronic pain, and was a wanderer and an elopement risk. No focus areas specified anything regarding resident behaviors. Record Review of Resident #2's BIMS (Brief Interview for Mental Status test, used to get a quick snapshot of a residents cognitive status) revealed a score of 3.0 on a scale range from 1.0- 15.0. Record review of Resident #2's progress notes revealed the following: 07/26/23 documented by a nurse (name unknown): Resident roommate is in dining room eating dinner. And Resident #2 is sitting on roommate bed eating his dinner. Writer explains to resident that's not his bed. Resident #2 states fuck this shit, I can stay in this bed, you can't tell me what the fuck to do! Staff redirects resident, but resident still refuses to go his own bed. Resident #2 states This is my place and all these beds is mine! Writer notifies Administrator of Resident #2 non-compliance to go his own bed. And Resident #2 is getting agitated with staff. Roommate moved to other room due to roommate Resident #2s refusal to go to his own bed. 09/04/23 documented by a nurse (name unknown): Resident in Room and resident very territorial about his room. Even if resident just comes to his doorway. Resident begins to curse stating quotation I don't want any of you bitches coming in my room!. Staff has to redirect resident. Resident states to staff I'm going to kick all you mother fuckers ass!. Staff has to redirect resident. Staff was trying to pick up resident dinner tray from his room. And resident refused to allow staff in room. Resident sat stuff on floor in room, blocking staff from trying to pick up his finished dinner tray in room. Staff again redirected resident. Resident remained verbally combative towards staff. Staff will continue to redirect and monitor. 9/14/23 documented by a nurse (name unknown): Staff has to redirect resident. Resident forgets what side room is on. Resident denies he lives here; staff again redirect their resident. Resident verbally combative towards staff and using profane language too; staff will continue to redirect and monitor. 10/04/23 documented by a nurse (name unknown): Resident stayed in his room asleep all through the night. Earlier during change of shift walking rounds, observed resident blocked his door with bedside table and by opening the rest room door, puts a sling on the door making it difficult to open. He mentioned that he don't like other residents wandering into his room and that's why he wants the door closed. Staff encouraged resident not to put ant thing that will make it difficulty in opening the door for his own safety as well, staff will keep an eye on other residents as to not wander into his room and if by any chance, any resident wanders into his room, to use his call button to call on staff who will assist in getting unwelcomed resident out of his room of which he agreed to. 10/27/23 documented by a nurse (name unknown): Other male resident from other room on station D wandered into room A. Resident #2 yelling at the resident to get out of his room. Staff intervenes to get other resident out of room. When resident #2 picks-up a plastic hanger and starts swinging the hanger towards the staff members only yelling you bitches get the fuck out my room! Writer explains to resident #2 of trying to get other resident out of his room, please be patient. Writer and staff continue to attempt to remove other resident from room. And resident #2 continues to swing plastic hanger toward staff members only referring to staff members as Bitches, Ugly [NAME]! Finally staff able to remove other resident from room and transfer back to their room. Resident #2 didn't exhibit any physical aggression of swinging hanger toward resident; physical aggression of swinging plastic hanger directed only towards staff members; will continue to monitor. 11/03/23 documented by the Social Worker: Staff reports that resident is much calmer but at a time has exhibited threatening behavior including cursing and swinging plastic hangers at staff during intervention with another resident. Met with resident who is alert, able to let staff know of his needs, talking in a very long time, requires assistance and cuing with ADL and encouragement to take his meds. Educated him to refrain from threatening with an object and he doesn't recall any verbal or physical behavior and sits in day area and participates in activities when encouraged. He is under the services of guardianship program message left related to his behavior and referral for further evaluation and treatment. Resident is under psych/ nurse practitioner care for medication and referral to senior psychology for psychological services and to manage plan. Resident to remain in memory care due to wandering risk, full code and LTC. No DC plan. Staff to approach in a calm and non-threatening monitor and redirect as needed. 11/15/23 documented by a nurse (name unknown): resident refuses to take shower according to CNA. Resident frequently urinates on the floor in his room period no other behaviors noted. 11/17/23 documented by a nurse (name unknown): resident refused to take shower/bath. Writer explained the importance of bathing but residents still refused. 11/20/23 documented by a nurse (name unknown): resident refused morning medication despite writer explaining importance of them. Has tendency to spit out medication after putting them in his mouth. Resident currently in his room will continue to monitor. 01/14/24 documented by the Social Worker: staff report that Resident #2 was involved in a physical altercation with another resident and placed under behavioral and safety monitoring. The resident has a long history of mental disorders including paranoid schizophrenia and mood disorder but med intervention in progress. Due to his current behavior, he may need further evaluation for placing self and others in danger. Social workers spoke to behavioral staff to assess for possible inpatient eval and treatment for current signs of mental illness. Behavioral hospital accepted him for care. Nursing notified as accepting psychiatrist, accepting administrator to get transportation and transfer resident to behavioral hospital. Record review of the facility's self-reported incidents in the last 30 days revealed: 01/07/24 at 2pm: Resident #2 and another resident were tugging back and forth over a piece of clothing that came from Resident #2's room, when Resident #2 stumbled backwards and hit his head on the door. Resident #2 was admitted to the hospital with traumatic brain injury assault with brain bleed called subdural hemorrhage (bleeding between the brain and the skull) and subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane). 01/14/23 at 8:50 am: Upon investigation, it was discovered that there was blood leading from Resident #2's room where Resident #3 was found lying down. There was blood in Resident #2's room as well as on the side and bottom of his trash can. Resident #3 does wander into other rooms from time to time and Resident #2 does not want anyone in his room. Resident #3 was found in another room laying down on the floor bleeding and was struck in the face. Laceration (deep cut or tear in skin) to forehead with indentation and hematoma (injury where blood collects and pool under skin), swollen nose with discoloration, skin tear to left cheek, and right foot, great toe skin tear. No fractures reported by the hospital. Record review of Resident #2's psychiatric evaluation visit dated 01/03/24 revealed that there had been no changes in behaviors since his GDR of sertraline. Resident had been calm and no mood adjustments. In the care plan recommendations, it stated that the resident was not an acute danger to himself or others, but this may change due to psycho stressors and treatment compliance. Other recommendations included managing the resident's environment, utilizing behavior interventions for episodic behavior, and provide supportive encouragement to increase socialization. In an interview on 01/26/24 at 10:48 am, the Unit Manager stated that since she was promoted into the Unit Manager role in November 2023, Resident #2 refused care and was sometimes aggressive with staff, but he was doing well before his most recently reported incident on 01/14/24. Resident #2 was mild mannered and could sometimes be easy to redirect. The unit manager was not aware if Resident #2 had any behavioral ticks and stated that he was in a room without a roommate by chance and not for any specific reason. In an interview on 01/26/24 at 10:53 am, the Unit Manager stated that the facility staff did care plan meetings everyday where they discuss the needs of different residents with the social worker, nurses, and therapist if they were in therapy. The Unit Manager explained that she was responsible for making acute (day to day changes/trends) to the care plan, while each department head had their own sections for updates. She stated that she could not recall attending a care plan meeting for the year of 2024. She explained that the facility had changes in management, and they were working on getting all care plans updated. The Unit manager also stated that the importance of a comprehensive care plan was to outline the care that residents needed and to give the floor staff a path for how they were to care for residents. In an interview on 01/26/24 at 11:12 am with CNA A, she stated that Resident #2 was aggressive and thought the facility was his house. Sometimes he would have good days, but he often would get upset or triggered when people would enter his room. She explained that in the past he would try and kick his roommates out, so Resident #2's roommate was placed in a different room and he was now housed in a private room. In an interview on 01/26/24 at 12:48 pm, MDS A stated that Resident #2's care plan was not completed. She explained that she had opened his care plan to begin updates, but because he was sent out of the facility on 1/14/24 to a behavioral hospital, no one had signed or reviewed his plan of care. MDS A stated that the Unit Manager was responsible for updating the day-to-day changes in resident behaviors in the care plan. For quarterly care plans, MDS A stated that she liked to leave the care plan open for three months post the completion date so that each department head would have enough time to develop or revise the care plan. After the care plan had been revised, the social worker would reach out to the responsible party of the resident and schedule a care plan meeting in person or over the phone. MDS A explained that updates to the care plan were not her responsibility, but she was helping to get the facility up to date. Her priorities were MDS assessments, and she presented to the state investigator her MDS assessments, which were last completed in November or December of 2023. Resident #3 Record Review of Resident #3's face sheet revealed a ninety-two-year-old woman admitted on [DATE]. Her admitting diagnoses were hypertension (high blood pressure), adult failure to thrive, dementia (memory loss), and cognitive communication deficit. Record review of Resident #3's care plan (revised 01/19/24) revealed that she had diagnoses of insomnia, has a behavior problem of sitting on the floor with her legs crossed, and she was at risk for wandering related to cognitive communication deficit, dementia. No focus area was initiated for falls. Record review of Resident #3's Fall risk evaluation (ranged 1.0- 15.0) revealed the following: 1/14/2024 N Adv - Fall Risk Evaluation at Risk 10.0 12/28/2023 N Adv - Fall Risk Evaluation No risk 2.0 12/27/2023 N Adv - Fall Risk Evaluation at Risk 13.0 12/27/2023 N Adv - Fall Risk Evaluation at Risk 14.0 12/25/2023 N Adv - Fall Risk Evaluation at Risk 10.0 12/25/2023 N Adv - Fall Risk Evaluation at Risk 11.0 8/20/2023 N Adv - Fall Risk Evaluation at Risk 14.0 Record review of the facility's Incident and Accident Log from 08/24/23- 01/24/24 for Resident #3 revealed: Injury of Unknown Origin Cause Incidents 09/10/23 12/25/23 Other incidents 01/14/24 In an interview on 01/26/24 at 10:53 am with the Unit Manager, she stated that Resident #3 was a fall risk. In an interview on 01/26/24 at 11:22 am with CNA A, she stated that Resident #3 was a fall risk. In an interview on 01/26/24 at 10:53 am, the Unit Manager stated that the facility staff did care plan meetings everyday where they discuss the needs of different residents with the social worker, nurses, and therapist if they were in therapy. The Unit Manager explained that she was responsible for making acute (day to day changes/trends) to the care plan, while each department head had their own sections for updates. She stated that she could not recall attending a care plan meeting for the year of 2024. She explained that the facility had changes in management, and they were working on getting all care plans updated. Since the Unit Manager had gotten her promotion to this role in 11/2023, she had not noticed any behavior issues with Resident #2. The Unit manager stated that the importance of a comprehensive care plan was to outline the care that residents needed and to give the floor staff a path for how they were to care for residents. In an interview on 01/26/24 at 12:39 pm, MDS A stated that when she started at the facility in September 2023, that a lot of care plans had not been completed in some time due to a gap in employment. MDS A stated that the Unit Manager is responsible for updating the day-to-day changes in resident behaviors in the care plan. For quarterly care plans, MDS A stated that she liked to leave the care plan open for three months post the completion date so that each department head would have enough time to develop or revise the care plan. After the care plan had been revised, the social worker would reach out to the responsible party of the resident, and schedule a care plan meeting in person or over the phone. MDS A explained that updates to the care plan were not her responsibility, but she was helping to get the facility up to date. Her priorities were MDS assessments, and she presented to the state investigator her MDS assessments, which were last completed in November or December of 2023. In an interview on 01/26/24 at 3:38 pm with the Admin, she stated that she had been employed at the facility since December of 2023. She explained that she was aware that care plans were behind and that the facility had implemented a PIP to get back on track. The Unit Manager of each unit was responsible for updating the care plan with day-to-day changes while each department head was to update the other sections (activities, nursing, dietary, and therapy). She explained that the harm in not having updated care plans was that staff would not have special instructions to handle the needs of each resident. Record review of the facility's policy titled Care Plans, Comprehensive Person- Centered, revised March 2022, displayed: 1. The comprehensive, person-centered care plan: a. includes measurable objectives and time frames; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 2. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 3. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 4. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 5. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 6. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. An Immediate Jeopardy (IJ) was determined on 02/12/24. The Admin and Corporate Nurse (CN) were notified. The Admin and Corporate Nurse (CN) were provided a template on 2/12/24 at approximately 1:50 pm. The following POR (Plan of removal) submitted by the facility was accepted on 02/14/24 at 10:53 am. The POR documented: The facility failed to care plan and implement interventions for Resident #2 who had behaviors. Immediate action: F0656- Develop and Implement Comprehensive Care Plans Resident #2 Care plan was updated on 2/12/2024. Audit initiated on 2-12-2024 of residents with behaviors to determine that their plan of care is accurate with interventions. The Nurse Managers, the MDS team, the social workers, the wound care nurse identified 33 care plans for residents with identified behaviors and are in the process of being reviewed. Completion 2/14/2024. The MDS team, ADON#1, ADON#2, ADON#3, the Wound Care Coordinator, the Social Worker, Activities, Dietary, and Therapy, were in-serviced on care planning and comprehensive person-centered care, baseline care plans, and review of the State operation Manual F656. 2-12-2023 Chief Nursing Officer. The floor nurses and the aides will be re-educated on the care plan process as well as how to access the resident care plan in PCC as well as the Kardex. The charge nurse and the aides will be educated on how to notify the DON, the charge nurse, the unit manager, the MDS nurse for any information needed to be added or removed from the plan of care clinical management team. 2-14-2024 The DON/Designee will ensure that care plans are completed timely, the accuracy of the MDS is the responsibility of the person completing the MDS. Care plan will be updated quarterly and as needed with any acute changes prior to the next assessment period. Resident #2 has been readmitted , is stable, and has had no new behaviors. He had medication adjustments in the hospital and was seen by the Geri-med psych team when readmitted . Resident #3 has been discharged . Medical Director was notified on 2/12/2024. The person-centered comprehensive care plan has been reviewed and updated to reflect Resident #2 current medical, physical, mental, and psychosocial needs and status as of February 12, 2024. An in-service for interdisciplinary team members for the regulatory requirement for developing and implementing comprehensive care plans cited under 42 CFR S483.21(b)(1) was completed on February 12, 2024, by Chief Nursing Officer. A performance improvement plan (PIP) for timely completion and review of care plans was initiated on November 21, 2023, with a target completion date of March 04, 2024. The facility team members are actively engaged in the PIP. As of February 12, 2024, the PIP is ongoing and on track. Following the acceptance of the facility's Plan of Removal, the facility was monitored from 02/14/24 to 02/15/24. Monitoring of the plan of removal included: The surveyor confirmed the facility implemented their plan of removal sufficiently from 02/14/24 - 02/15/24 to remove the IJ by: Monitoring Day 1: 02/14/24 Record review of care plans for 33 residents with behaviors were conducted. All care plans were updated by interdisciplinary teams and the MDS Nurse and MDS Coordinator. Record review of the PIP (Performance Improvement Plan) for timely completion and review of care plans (initiated on November 21, 2023) revealed a target completion date of 03/04/24 and was on track. Record review of the in-services conducted 02/13/24 on F-0656 Develop and Implement Comprehensive Care Plans displayed 14 of 14 management, nursing, and assistant nursing directors, the social worker, and therapy department heads were educated. Record review of the in-services conducted 02/13/24 titled How to access care plans for nurse and CNA's revealed 57 nurses and certified nurse aids were educated on how to log into PCC and review each resident's care plan when assisting with care and specified needs. Record review of Resident #2's care plan documented that Resident #2 had the potential to be physically aggressive related to history of harm to others and poor impulse control. Interventions included to utilize behavior interventions to manage episodic behaviors, engage calmly in conversation, guide away from source of distress, and intervene before agitation escalates. Care plan also stated the goal for Resident #2 would be no harming of himself or others through the review date. Care plan documented that the resident had the potential to be verbally aggressive and listed interventions such as assess and anticipate resident needs, allow time for the resident to express self and feelings towards the situation, and administer medications as needed. Resident #2 Care plan was updated on 2/12/24. Record review of Resident #2's MDS revealed that this assessment was updated on 01/31/24. In an interview with Resident #2 on 02/14/24 at 11:58 am, he stated that he was doing alright and that he was feeling relaxed without any pain. He stated that he vaguely remembered an incident with another resident and a trash can but cannot remember exactly what happened. In an interview with Nurse A on 02/14/24 at 12:03 pm, she stated that she worked in the MC Unit, and she was in-serviced on working with behavior management patients, when to review psychotropic medications, and on admission staff are to do the baseline care plans to monitor and see if Residents have any side effects or any behaviors that need to be addressed. If there is any type of new behavior, staff is to first contact the doctor or the psych nurse if it is a psych related issue. Staff will then do a progress note and we do a change in condition in PCC. She stated that nurses may to have get a new medication order from the doctor, then take it from there. If it is a new behavior that required a new intervention, every 15 minutes staff will do close monitoring of those behaviors. She explained that since Resident #2 has returned, he stays in his room, and has not had any behavior issues. He was prescribed Depakote and that has helped a lot. In an interview with LVN A on 02/14/24 at 12:20 pm in the MC unit, she stated that she had received an in-service on safety and aggressive behaviors. She was taught to redirect residents and calm them down. Anytime we see residents not doing what they were supposed to do, we would alert the DON. We know to let the DON know when the behaviors were a danger to the resident. We don't wait until it gets to the climax but if the behavior is escalating. Staff know to review the shift reports to monitor the progress notes. At the end of every shift, we have a report for each resident. We talk about it nurse to nurse and have the report. Then we just keep our eyes open. In an interview on 02/14/24 at 12:30pm in the MC Unit, she stated that in her in-service, she discussed resident behaviors, and they talked about each individual resident in the MC unit. She was asked to pull up the care plan from the kiosk and did so successfully. She stated that she will report any type of change in behavior pattern to her charge nurse immediately. These behaviors could range from a decline in eating or agitation. Day 2: 02/15/24 In an interview with ADON A on 02/15/24 at 12:45 pm revealed that she was in-serviced on updating acute changes in behaviors for all residents and making sure the interventions were followed through. If there were any changes with residents, care staff were to come to nursing managers directly and they can document it on the kiosk with PCC or on the written form kept at the nurse's station. She explained that she gave an in-service to the nurses and CNA's who were assigned to the 200-hall. This in-service covered how to access the resident care plans by using the kiosk and the facility's new Stop and Watch alert tab located on the kiosk which will allow staff to document any changes in behavior. In an interview on 02/15/24 at 12:52 pm with the WCN, she explained that in the most recent in-service, they went over the protocols for going through the care plans during morning meetings and when the doctor comes. During those meetings, staff will talk about what needs to be updated, if there were any changes in conditions, and make sure all updates re done daily. In an interview on 02/15/24 at 12:58 pm with the MDS Nurse and R-MDS Nurse, the following things were revealed: -Each section of the care plan will be done by the IDT team and they must sign off on it. The care plan is to be done after The MDS assessment. The MDS assessment comes directly from PCC. Once the MDS is completed, we roll it over in the care plan. Anything that is acute, or a change should be updated as it comes in. -All acute documentation should be timely and immediately. Updates should be addressed in the first few hours in the care plan. Interventions can be changed or taken away as needed. -Every week a weekly report will be sent out that goes to the Corporate Nurse, the ADON, and certain team members. R-MDS will pull a report for care plans due for that week or change in conditions from PCC. If past due, the report will be highlighted in red on the dashboard. This will allow all staff to go through and make sure they have their section cleared by the review date. This was started on 01/8/24 to help them focus on their needs for that week. -Once the MDS Coordinator and the MDS nurse receive the report, they communicate with the IDT team via email. The MDS Coordinator will open reviews for those residents and the IDT will go in and update that review. This system has become very effective in care plan completions and getting back on track. -The accuracy of care plans will be ensured during the reviews. Once it is signed, the care plan should reflect the most up to date version of the MDS. The care plan review on the MDS side will be done every 92 days, then they will open the care plan to be reviewed by the IDT staff. In an interview with the AD on 02/15/24 at 01:24 pm, she stated that she was shown how to view the care plan on the kiosk, and she was re-educated on putting more information on the care plan and how to enter it so that all care staff were able to view it on PCC at the kiosk. When there was a change in condition, she will report it to the charge nurse and tell it to the DON and the Admin. The AD stated that she reports both verbally and documents in the progress notes under that resident. She explained that she ensured her part was accurate because she goes through each resident on a list and reviewed their behaviors with the two other staff who work in activities. One activities member who provides direct care with residents was also present to provide firsthand information. In an interview on 02/15/24 with the MC Unit Manager, she stated that all staff were made aware of what their responsibilities were in regard to care planning, including antibiotic therapy, falls, behavior changes, and acute changes. Care plan meetings will be done daily. Staff know to notify the Unit Manager. This should also be notated in the nursing notes. In an interview on 02/15/24 started at 2:17 pm with CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, and CNA I, each CNA was able to pull up resident care plans through PCC using the kiosk. The Corporate Nurse was informed the Immediate Jeopardy (IJ) was removed on 02/15/24 at 3:12 PM. The facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure each resident was free from neglect for one (Resident #1) of eight residents whose records were reviewed for abuse and neglect. The facility failed to supervise Resident #3 and Resident #2, which ended in an unwitnessed resident to resident altercation. Resident #3 was struck on the head with a trashcan and sustained a laceration and hematoma to the forehead which required a hospital visit. On 02/14/24 at 10:45 am an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/17/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness their Plan of Removal. This failure affected 2 residents and could place 13 residents who require supervision inside the memory care unit at risk for abuse, neglect, and a decreased quality of life. Findings included: Resident #2 Record Review of Resident #2's face sheet revealed an eighty-four-year-old man who was admitted to the facility on [DATE]. His admitting diagnoses were schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), generalized anxiety disorder, and hyperlipidemia (high cholesterol). Record review of Resident #2's care plan (completed 7/20/23, revised 01/15/24) revealed that he was incontinent, had a communication problem, had acute/chronic pain, and was a wanderer and elopement risk. No focus areas specified anything regarding resident behaviors. Record review of Resident #2's progress notes revealed the following: 07/26/23: Resident roommate is in dining room eating dinner. And Resident #2 is sitting on roommate bed eating his dinner. Writer explains to resident that's not his bed. Resident #2 states fuck this shit, I can stay in this bed, you can't tell me what the fuck to do! Staff redirects resident, but resident still refuses to go his own bed. Resident #2 states This is my place and all these beds is mine! Writer notifies Administrator of Resident #2 non-compliance to go his own bed. And Resident #2 is getting agitated with staff. Roommate moved to other room due to roommate Resident #2s refusal to go to his own bed. 09/04/23: Resident in Room and resident very territorial about his room. Even if resident just comes to his doorway. Resident begins to curse stating quotation I don't want any of you bitches coming in my room!. Staff has to redirect resident. Resident states to staff I'm going to kick all you mother fuckers ass!. Staff has to redirect resident. Staff was trying to pick up resident dinner tray from his room. And resident refused to allow staff in room. Resident sat stuff on floor in room, blocking staff from trying to pick up his finished dinner tray in room. Staff again redirected resident. Resident remained verbally combative towards staff. Staff will continue to redirect and monitor. 9/14/23: Staff has to redirect resident. Resident forgets what side room is on. Resident denies he lives here; staff again redirect their resident. Resident verbally combative towards staff and using profane language too; staff will continue to redirect and monitor. 10/04/23: Resident stayed in his room asleep all through the night. Earlier during change of shift walking rounds, observed resident blocked his door with bedside table and by opening the rest room door, puts a sling on the door making it difficult to open. He mentioned that he don't like other residents wandering into his room and that's why he wants the door closed. Staff encouraged resident not to put ant thing that will make it difficulty in opening the door for his own safety as well, staff will keep an eye on other residents as to not wander into his room and if by any chance, any resident wanders into his room, to use his call button to call on staff who will assist in getting unwelcomed resident out of his room of which he agreed to. 10/27/23: Other male resident from other room on station D wandered into room A. Resident #2 yelling at the resident to get out of his room. Staff intervenes to get other resident out of room. When resident #2 picks-up a plastic hanger and starts swinging the hanger towards the staff members only yelling you bitches get the fuck out my room! Writer explains to resident #2 of trying to get other resident out of his room, please be patient. Writer and staff continue to attempt to remove other resident from room. And resident #2 continues to swing plastic hanger toward staff members only referring to staff members as Bitches, Ugly [NAME]! Finally staff able to remove other resident from room and transfer back to their room. Resident #2 didn't exhibit any physical aggression of swinging hanger toward resident; physical aggression of swinging plastic hanger directed only towards staff members; will continue to monitor. 11/03/23: Staff reports that resident is much calmer but at a time has exhibited threatening behavior including cursing and swinging plastic hangers at staff during intervention with another resident. Met With resident who is alert, able to let staff know of his needs, talking in a very long time, requires assistance and cuing with ADL and encouragement to take his meds. Educated him to refrain from threatening with an object and he doesn't recall any verbal or physical behavior and sits in day area and participates in activities when encouraged. He is under the services of HCGP, message left related to his behavior and referral for further evaluation and treatment. Resident is under psych/ nurse practitioner care for medication and referral to senior psychology for psychological services and to manage plan. Resident to remain in memory care due to wandering risk, full code and LTC. No DC plan. Staff to approach in a calm and non-threatening monitor and redirect as needed. 11/15/23: resident refuses to take shower according to CNA. Resident frequently urinates on the floor in his room period no other behaviors noted. 11/17/23: resident refused to take shower/bath. Writer explained the importance of bathing but residents still refused. 11/20/23: resident refused morning medication despite writer explaining importance of them. Has tendency to spit out medication after putting them in his mouth. Resident currently in his room will continue to monitor. 01/14/24: staff report that Resident #2 was involved in a physical altercation with another resident and placed under behavioral and safety monitoring. The resident has a long history of mental disorders including paranoid schizophrenia and mood disorder but med intervention in progress. Due to his current behavior, he may need further evaluation for placing self and others in danger. Social workers spoke to behavioral staff to assess for possible inpatient eval and treatment for current signs of mental illness. Behavioral hospital accepted him for care. Nursing notified as accepting psychiatrist, accepting administrator to get transportation and transfer resident to behavioral hospital. Record review of the facility's self-reported incidents in the last 30 days revealed: 01/07/24 at 2pm: Resident #2 and another resident were tugging back and forth over piece of clothing that came from Resident #2's room, when Resident #2 stumbled backwards and hit his head on the door. Resident was admitted to the hospital with traumatic brain injury assault with brain bleed called subdural hemorrhage (bleeding between the brain and the skull) and subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane). 01/14/23 at 8:50 am: Upon investigation, it was discovered that there was blood leading from Resident #2's room where Resident #3 was found lying down. There was blood in Resident #2's room as well as on the side and bottom of his trash can. Resident #3 does wander into other rooms from time to time and Resident #2 does not want anyone in his room. Resident #3 was found in another room laying down on the floor bleeding and was struck in the face. Laceration (deep cut or tear in skin) to forehead with indentation and hematoma (injury where blood collects and pool under skin), swollen nose with discoloration, skin tear to left cheek, and right foot great toe skin tear. No fractures reported by hospital. In an interview on 01/26/24 at 10:48 am, Unit Manager stated that since she was promoted into the Unit Manager in November 2023, Resident #2 refused care and was sometimes aggressive with staff, but he was doing well before his most recently reported incident on 01/14/24. Resident #2 was mild mannered and could sometimes be easy to redirect. The unit manager was not aware if Resident #2 had any behavioral ticks and stated that he was in a room without a roommate by chance and not for any specific reason. In an interview on 01/26/24 at 10:53 am, the Unit Manager stated that the facility staff did care plan meetings everyday where they discuss the needs of different residents with the social worker, nurse, and therapist if they were in therapy. The Unit Manager explained that she was responsible for making acute (day to day changes/trends) to the care plan, while each dept head had their own sections for updates. When asked when was the last care plan meeting she attended, she stated that she could not recall attending one for the year of 2024. She explained that the facility had changes in management, and they were working on getting all care plans updated. The Unit manager also stated that the importance of a comprehensive care plan was to outline the care that residents need and to give the floor staff a path for how they were to care for residents. In an interview on 01/26/24 at 11:12 am with CNA A, she stated that Resident #2 was aggressive and thought the facility was his house. Sometimes he would have good days, but he often would get upset or triggered when people would enter his room. She explained that in the past he would try and kick his roommates out, so Resident #2 was now housed in a private room. In an interview on 01/26/24 at 12:48 pm, MDS A stated the Resident #2's care plan was not completed. She explained that she had opened his care plan to begin updates, but because he was sent out of the facility on 1/14/24 to a behavioral hospital, no one had signed or reviewed his plan of care. MDS A stated that the Unit Manager is responsible for updating the day-to-day changes in resident behaviors in the care plan. For quarterly care plans, MDS A stated that she liked to leave the care plan open for three months post the completion date so that each department head would have enough time to develop or revise the care plan. After the care plan had been revised, the social worker would reach out to the responsible party of the resident and schedule a care plan meeting in person or over the phone. MDS A explained that updates to the care plan are not her responsibility, but she was helping to get the facility up to date. Her priorities were MDS assessments, and she presented to the investigator her MDS assessments, which were last completed in November or December of 2023. Resident #3 Record Review of Resident #3's face sheet revealed a ninety-two-year-old woman admitted on [DATE]. Her admitting diagnoses were hypertension (high blood pressure), adult failure to thrive, dementia (memory loss), and cognitive communication deficit. Record review of Resident #3's care plan (revised 01/19/24) revealed that she had a diagnosis of insomnia, had a behavior problem of sitting on the floor with her legs crossed, and she was at risk for wandering related to cognitive communication deficit, dementia. Interventions for wandering included to distract resident with pleasant diversions, provide structured activities, reorientation, and identify pattern of wandering. Record review of Resident #3's progress notes revealed that on 12/30/23 and 01/05/24, resident had to be redirected more than once for wandering the unit common areas and into resident rooms. Record review of the facility's self-reported incident in the last 30 days revealed that on 01/14/23 at 8:50 am: Upon investigation, it was discovered that there was blood leading from Resident #2's room where Resident #3 was found lying down. There was blood in Resident #2's room as well as on the side and bottom of his trash can. Resident #3 does wander into other rooms from time to time and Resident #2 does not want anyone in his room. Resident #3 was found in another room laying down on the floor bleeding and was struck in the face. Laceration (deep cut or tear in skin) to forehead with indentation and hematoma (injury where blood collects and pool under skin), swollen nose with discoloration, skin tear to left cheek, and right foot great toe skin tear. No fractures reported by hospital. In an interview with Unit Manager on 01/26/24 at 10:53 am, she stated that Resident #3 was a wanderer with no history of aggression. Her room was located the opposite side of where she was found on 01/14/24. In an interview on 01/26/24 at 11:12 am with CNA A, she stated that Resident #2 was aggressive and thought the facility was his house. Sometimes he would have good days, but he often would get upset or triggered when people would enter his room. She explained that in the past he would try and kick his roommates out, so Resident #2 was now housed in a private room. She stated that on 01/14/24, Resident #2 was in his room waiting for breakfast and Resident #3 had wandered into his room while she was in a different resident's room, getting them up for breakfast. Resident #2 resided in the very last room on that hall, and he normally would eat his breakfast in solitude inside his room. CNA A said that she did see Resident #3 sitting on the floor of another resident's room (a care planned behavior), but she immediately did not do anything because she did not see any signs of distress and that is what she does. After she finished assisting another resident, she went down the hall to redirect Resident #3 and saw that she was bleeding from her head. She followed a trail of blood across the hall to Resident #2's room and saw that there was blood on the trash can. CNA A called the nurse and Resident #3 was assessed and sent out to the hospital for evaluation. Resident #2 was sent out that day to a behavioral health hospital for medication review and a psychiatric evaluation. The other nurses in the memory care unit did not see the incident and were passing morning medications at that time and no one heard any yells or noises from an altercation. Record review of the facility's policy titled Care Plans, Comprehensive Person- Centered, revised March 2022, displayed: 1. The comprehensive, person-centered care plan: a. includes measurable objectives and time frames; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 2. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 3. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 4. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 5. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 6. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. This was determined to be an Immediate Jeopardy (IJ) on 02/14/24 at 10:45 am. The Admin and Corporate Nurse (CN) were notified. The Admin and Corporate Nurse (CN) were provided with the IJ template on 2/14/24 at approximately 10:45 am. The following POR (Plan of removal) submitted by the facility was accepted on 02/16/24 at 01:45 pm. The POR documented: The facility failed: to supervise resident #3 from wandering into resident #2 rooms where she was injured and had to be sent to the hospital. Immediate action: resident #3 discharged to the hospital and resident #2 was sent to Oceans behavioral hospital for evaluation and treatment 1-14-2024. Resident #3 has been discharged not to return discharged on [DATE]. Resident #2 is stable and has not had any further behaviors went to Oceans Behavioral hospital on 1-14-24 and returned on 1-26-2024. Audit on the memory care unit initiated on 2-14-2024 by the in house MDS nurse. 30 residents reside on the memory care unit. The corporate MDS nurse came in on 2/15/2024 to assist with the audit process. All residents on the memory care unit have potential to wander. 13 out of 30 residents identified actively wander in the unit. The care plans for these 13 residents were reviewed and updated. 2/16/2024 Staffing Ratios were reviewed to ensure the facility has adequate staffing ratios. Staffing Ratios for the Memory Care Unit-3 aides 2 nurses and 1 activity staff on unit for increased supervision. This is the normal staffing pattern on the memory Care unit. o 6-2 (3 aides and 2 nurses 1 activity) o 2-10 (3 aides 2 nurses, activity leaves at 6pm) o 10-6 (one nurse and 2 aides) 2/15/2024 Regional MDS coordinator in facility to assist with identifying residents with wandering behaviors to ensure appropriate care planning is in place and accurate. 2/15/2024 Review of the SOM 689 accidents hazards/supervision/devices/with the Clinical team on 2/16/2024 at 0900 the department heads and the clinical team reviewed on the big screen TV the 689 regulation to validate 2-15-2024. This will be accomplished by reading the regulation in full and the critical pathway for Accidents will be reviewed verbally as a team. This will ensure that we have all the elements of training covered in the Pathway and additional training needed if necessary. Medical Director was notified on 2/14/2024 of IJ 689 Follow up with the medical director on 2/15/2024 @ 8:15am on IJ status. AD Hoc QAPI to be held 2/16/2024 with F-689 and SOC update on IJ reviews. An in-service initiated by the memory care RN, ADON - for increased monitoring of wandering residents, in the dining areas, and common areas and re-direction of the resident. All staff on 100-200-and 300 halls were in-serviced because the staff at any given moment could float to another unit. Central Supply and medical records assigned to assist with daily rounding in the unit until all walkie talkies are in place 2-14-2024 to 2-16-2024. New Weekend Supervisor starting on 2/17/2024 to provide supervisory coverage of the buildings on the weekends, 16-hour shifts. Both ladies are already assigned ambassadors to the memory care unit. They round before the morning meeting. After the morning meeting After Lunch And before they leave for the day Both offices are located in the same vicinity of the memory care unit. Walkie talkies (ordered on 2/15/2024) to be delivered on 2/16/2024: to be used by the aides and the nurses to communicate with each other. when a resident wanders from the group setting, during rounds, in passing etc. so that the all staff will be able to keep closer monitoring on the wandering residents. 3 Walkie talkies are being charged for use on 2/15/204 and the other 5 are being delivered on 2/16/2024. Monitoring form initiated for rounds every hour to ensure that nurses can document that they are monitoring and rounding in the unit .at night the nurse will continue with the monitoring while the resident is asleep. 2/15/2024 we will continue the monitoring until we receive the equipment on 2/16/2024 and will continue the rounding until the staff is using the walkie talkies appropriately. CN completed the initial training with the nurses and aides on the use of the walkie talkies . 2 placed on 300 once sufficiently charged. Completion date of training will be completed on 2/16/2024. Following acceptance of the facility's Plan of Removal, the facility was monitored from 02/16/24 to 02/17/24. Monitoring of the plan of removal included: The surveyor confirmed the facility implemented their plan of removal sufficiently from 02/16/24 - 02/17/24 to remove the IJ by: Monitoring Day 1: 02/16/24 Record review of the care plans for residents on the MC unit who have the potential to wander (13) were updated and made available for care staff on PCC through the kiosk. Record review of the in-services conducted 02/13/24 on F-0656 Develop and Implement Comprehensive Care Plans displayed 14 of 14 management, nursing staff, and assistant nursing directors, the social worker, and therapy department heads were educated. Record review of Resident #2's care plan documented that Resident #2 had the potential to be physically aggressive related to history of harm to others and poor impulse control. Interventions included to utilize behavior interventions to manage episodic behaviors, engage calmy in conversation, guide away from source of distress, and intervene before agitation escalates. Care plan also stated the goal for Resident #2 would be no harming of himself or others through the review date. Care plan documented that the resident had the potential to be verbally aggressive and listed interventions such as assess and anticipate resident needs, allow time for the resident to express self and feelings towards the situation, and administer medications as needed. Resident #2 Care plan was updated on 2/12/24. Record review of Resident #2's MDS revealed that this assessment was updated on 01/31/24. In an interview with Resident #2 on 02/14/24 at 11:58am, he stated that he was doing alright and that he was feeling relaxed without any pain. He stated that he vaguely remembered an incident with another resident and a trash can but cannot remember exactly what happened. On 02/15/24 a set of 12 long range rechargeable walkie talkies with batteries were purchased from an online vendor. On 02/16/24, walkie talkies arrived at the facility, were charged, and placed within the MC Unit. Record review of an in-service titled Supervision was started on 02/16/24. This in-service covered reasons why residents wander, hourly rounds on residents and management, redirecting residents who wander, and the use of walkie talkies on the MC Unit. Record review of Resident #2 monitoring sheets displayed that resident was checked every 30 minutes. No new behaviors or changes noted. Record review of newly hired RN weekend supervisor, start date 02/17/24. Sex offender registry, EMR, and license verification report completed. Monitoring Day 2: 02/17/24 Record review of an in-service titled Supervision was completed on 02/17/24. Sign in sheets showed a total of 80 staff who provide direct care or nursing services. In an interview with CNA F on 02/17/24 at 5:30pm, she stated that she worked the 10pm- 6am shift. She was informed on how to use the walkie and the purpose was for staff to be able to monitor residents in the MC Unit who may wander. She explained that sometimes residents will wander because they are looking for family and you may be able to help with a phone call. If a resident is aggressive with another resident, she will intervene to ensure the safety of that resident. If a resident is showing aggression towards herself, she would walk away and reapproach later. In an interview with CNA G on 02/17/24 at 5:35 pm, she stated that she worked the 6pm-2am shift. She explained that a resident may wander because of hunger, or they may need to be changed. If she witnessed this behavior, she would try to redirect them or offer them a snack. She stated she normally worked on a hall without wandering residents, so if she noticed this behavior, she would chart it in PCC and immediately inform her charge nurse. In an interview with CNA H on 02/17/24 at 5:39 pm, she stated that she worked the 2pm- 10pm shift and that she was told to redirect and offer snacks to residents who wander. It was important to know where residents are at all times and wanderers have a wander band that goes off when they come too close the door. If she had a resident that started to walk around aimlessly, she would try to toilet them, offer snacks, and let her charge nurse know. Then she would chart it in PCC. In an interview with LVN B on 02/17/24 at 5:47 pm, she stated that she worked the 6am- 2pm shift. She explained that in the in-service, they talked about the locked unit and that staff was responsible to do checks on residents. They must have a person supervising the MC Unit and they will use the walkies to alert other people that the resident was walking around. The walkie talkies help staff better communicate with each other. In an interview with CNA I on 02/17/24 at 5:53 pm, she stated that she worked the 10pm- 6am shift. She explained that she normally worked the 10pm-2am shift. In the in-services given, she was informed that if she saw a resident wandering, she was to redirect and see if she could meet their needs. She explained that if she noticed a resident on her unit (non MC hall) began to wonder, she would tell her charge nurse immediately of the unusual behavior and chart it in the kiosk. In an interview with LVN C on 02/17/24 at 6:07 pm, she stated that she is a nurse in the MC unit who normally worked the 2pm-10pm shift. She stated that in the in-services, she was taught to redirect all residents who are seen wandering by offering them snacks, toileting, redirection, and assessing pain levels. In an interview with RN A on 02/15/24 at 6:12 pm, he stated that he worked the 2pm to 10pm shift. He explained that if staff saw somebody wondering, they investigate why, and see if they are hungry or want to be changed. Staff will check the diapers to see if they are wet, offer food and snacks, see if they are looking for someone to talk to, or try to find out what they want. The unit was given walkies that work by pushing the side button and talking. MC staff know that his cart is in front of the nurse's station on the MC Unit. If he left to go to another area, MC staff can walkie him. If the aid in the dining area saw a resident in the front room leaving out, all MC staff must acknowledge that that can hear the staff letting them know a resident was on the move and to keep eyes on them. In an interview with LVN D on 02/17/24 at 6:45 pm, she stated that she worked the 6am- 10:30pm shift on Saturday and Sundays. She stated that in the in-service given on 2/16/24, her takeaways were that wandering behaviors in a resident may be related to an underlying factor. Staff should check and see if they resident needs to be changed, offer snacks, monitor their whereabouts, then redirect them. She also explained that the behavior could also be as simple as the resident looking for someone to talk to. She also stated that the MC unit had walkie talkies now, which will help staff communicate on where the residents are and what they may need. In an interview with CNA J on 02/17/24 at 6:50 pm, she stated that she worked the 2pm-10pm shift. She was in serviced on residents who wander and informed to redirect them when this behavior is noticed. She explained that if a resident fights, staff should separate them and try to see if they would like to participate in an activity or if they would like a snack. Immediately after, this behavior should be reported to the nurse and updated on the Kardex in PCC. The Corporate Nurse was informed the Immediate Jeopardy (IJ) was removed on 02/17/24 at 7:00 pm. The facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 (Resident # 1 and Resident #2) of 5 residents reviewed for environment. -The facility failed to ensure staff had access to memory care Residents #1 and #2, for approximately 50 minutes, in the event of an incident or emergency when their bedroom door became wedged with their bathroom door preventing the bedroom door from opening. On 01/30/24 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/01/24, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk of not receiving appropriate care, interventions, and/or death. The findings included: Resident #1 Record review of Resident #1's Admission Record, dated 01/30/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease (memory loss), insomnia (trouble falling and/or staying asleep), abnormalities of gait and mobility (problems with walking and standing), cognitive communication deficit (difficulty with communication), muscle weakness, and dysphagia (difficulty in swallowing food or liquid). Record review of Resident #1's Quarterly MDS assessment, dated 01/19/24, revealed a BIMS score of 0, indicating severe cognitive impairment. Record review of Resident #1's undated care plan revealed the following: resident had impaired thought processes, ADL self-care performance deficit. Resident required one-person assist as condition warranted with bed mobility, one-person extensive assistance with toilet use, and limited one-person assist as condition warranted due to fluctuation in condition related to disease process with transferring. Resident was at risk for falls and had a potential for uncontrolled pain. Resident #2 Record review of Resident #2's Admission Record, dated 01/30/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included Parkinson's disease (brain disorder that causes involuntary movements), psychosis (conditions in the mind that results in difficulties determining what is real and what is not real), muscle weakness, lack of coordination, and cognitive communication deficit (difficulty with communication). Record review of Resident #2's Quarterly MDS assessment, dated 12/14/23, revealed a BIMS score of 0, indicating severe cognitive impairment. Record review of Resident #2's undated care plan revealed the following: resident had impaired cognitive function, ADL self-care performance deficit and required one-person supervision for transfers and one-person supervision as needed for bed mobility and walking. She had impaired thought processes, a communication problem related to neurological symptoms related to Parkinson's and dementia and was at risk for falls related to decreased safety awareness, gait/balance problems, impaired mobility, and psychoactive drug use. Observation on 01/30/24 at 7:38 a.m., revealed Resident #1 and Resident #2's bedroom door, located in the memory care unit, did not open when the state surveyor attempted to enter their bedroom. The state surveyor notified Nurse A and asked her if she could open the door. Nurse A went to the bedroom door an attempted to open the door but was unsuccessful. Nurse A called out to CNA A who walked over to the door and said she thought the bathroom door was wedged behind the bedroom door which was preventing it from opening. CNA A and Nurse A took turns knocking on the bedroom door and calling out for Resident #2 asking her to open the door. CNA A said Resident #1 was Spanish speaking and did not understand what they were saying. Nurse B went to the residents' door and attempted to open the door and called out for Resident #2 by name. CNA A, Nurse A, and Nurse B were unable to get the residents bedroom door open. The Floor Tech was notified, and he tried to get the door open but was unable. The Floor Tech left and returned shortly with a metal tool that he slid through the door and used to close the bathroom door. Resident #1 and #2's bedroom door was opened at approximately 7:50 a.m. Observation on 01/30/24 at 7:51 a.m., revealed Resident #2 appeared to be asleep in her bed an unaware of what happened. Resident #1 was lying in bed, awake, and unaware of what happened. In an interview on 01/30/24 at 8:35 a.m., CNA A said she had been working at the facility for approximately [AGE] years. She said she was working the 6:00 a.m. to 2:00 p.m. shift today and clocked in at approximately 6:30 a.m. She said she checked on Residents #1 and #2 at approximately 7:00 a.m. but when she went to open their bedroom door, she noticed the bathroom door was wedged behind the bedroom door preventing it from opening. She said she let Nurse A know the door would not open at approximately 7:05 a.m. She said Nurse A and she took turns trying to open the door. She said they also knocked on their bedroom door and called out to Resident #2 many times to open the door. She said Nurse A was also not able to open the door. She said the Floor Tech went and tried to open the door but could not get it to open. She said the Floor Tech went and got equipment to open the door and was able to get the residents bedroom door opened. She said she thinks Resident #2 went to the bathroom, left the restroom door open too far, and then went back to bed. She said if there was any type of emergency, she would not think twice and would go outside to the patio, break the windows, and climb in to get to them and/or get them out of the building. She said she believed it would take approximately 5 minutes for her to do this. She said Resident's #1 and #2 walked without assistance and did not use any assistive devices. She said this was the first time this happened and had not happened before to any other residents. In an interview on 01/30/24 at 10:17 a.m., Nurse A said she had been working at the facility since October 2023. She said she was working the 6:00 a.m. to 2:00 p.m. shift today and arrived at the facility at approximately 6:20 a.m. She said she was at the nurse's station when CNA A told her that Resident #1 and #2's bedroom door would not open. She said she went to the bedroom door and tried to open it, but it would not open. She said she called Resident #2's name, and the resident said huh. She said she told Resident #2 to open the door many times, but she did not open the door. She said she told Nurse B that Resident #2's door would not open. She said she thought maybe something was caught on the door because when she pushed the door it would not open. She said she went to get the Maintenance Director but saw the Floor Tech when she was leaving the memory care unit. She said the Floor Tech called the Maintenance Director, and she told him that the bedroom door would not open when they tried to open it. She said the Maintenance Director told her to give the phone back to the Floor Tech so he could tell him what to do. She said when she gave the phone back to the floor Tech, he walked away and then came back with a tool and opened the door. She said if there was a medical emergency, she would call for another nurse, call 911, call the nursing director, run outside to the back where the residents' bedroom window was located, and break the window if needed, and try to attend to the patient to see what the emergency was . In an interview on 01/30/2024 at 11:12 a.m., the Maintenance Director said he had been working at the facility for approximately 3 years. He said he received a phone call this morning at approximately 7:52 a.m. from the Floor Tech. He said the Floor Tech told him that the restroom door and bedroom door to Resident #1 and 2's room were closed together and would not let the other one open. He said he told him he had to go to the closet and get a metal door opener to get the doors opened. He said this morning, when he received the phone call, was the first time he found out that the bathroom door was not working properly. He said all facility doors were checked monthly. He said in case of an emergency, they would call him, and he would instruct staff on what to do, and if needed he would go to the facility. He said the department heads and some of the facility staff submitted work orders through their online system. He said the other method was by writing a request in the maintenance log located at each nurse's station. He said the bathroom doors had a spring, not a pin, that need to be taken out and readjusted so the bathroom door would shut back on its own faster than the bedroom door opened . In an interview on 01/30/24 at 12:02 p.m., the Floor Tech said he had been working at the facility for approximately 2 years. He said the nurse (could not recall their name) told him Resident #1 and #2's bedroom door could not be opened. He said he called the Maintenance Director who told him to go get a metal tool from the closet located outside. He said he used the metal tool to get the door to open. He said today was the first time he was told that the bathroom door was not working properly . In an interview on 01/30/23 at 4:11 p.m., the Administrator said she had been working at the facility since 12/15/23. She said to her knowledge this type of incident had not happened in the past. She said the Maintenance Director showed her the bathroom door and told her the hinge had gotten off balance/dropped. She said the Maintenance Director showed her that he fixed the door and told her he checked the other doors to make sure it was not happening with any of the other bathroom doors. She said she asked the Maintenance Director if the doorknob could be switched to another shaped doorknob that the resident could still open. She said the Maintenance Director was going to talk to his supervisor about coming up with a solution. She said in case of a medical emergency, her expectation would be for staff to call 911, notify manager, notify maintenance, take the door knob off, and continue to make entry into the room until emergency personnel arrived on scene. She said the fire department was approximately 1 to 2 blocks away and would arrive to the facility quickly . In a follow-up interview on 02/01/24 at 1:38 p.m., CNA A said if staff were unable to access a resident in case of an emergency or incident it could potentially lead to the resident tripping, falling, hitting their head, or cause them to become scared because they were in an unfamiliar place . This was determined to be an Immediate Jeopardy (IJ) on 01/30/24 at 5:25 p.m. The Administrator was notified and provided with the IJ template on 01/30/24 at 5:25 p.m. The following Plan of Removal submitted by the facility was accepted on 01/31/24 at 11:11 a.m. and included: PLAN OF REMOVAL Name of facility: [ ] Date: 1-30-24 IMMEDIATE ACTION: F921: Safe/Functional/Sanitary/Comfortable Environment The Maintenance Director was contacted by phone and made aware of the situation with the door handle hardware for Residents #1 and #2's room at approximately 7:40 am and instructed the floor tech assigned to the 300 hall to free the adjoining door handles from each other and he was successful. The residents inside the room were found to be safe and in no distress. The medical director was notified. Residents were assessed head to toe. Charge nurse completed the assessment on 1-30-24. Families of residents #1 and #2 were notified by charge nurse on 1-30-24. All resident room doors throughout the facility were inspected to ensure there were no issues. All doors were functioning properly. Inspection completed by maintenance director on 1-30-24. The maintenance Director and Regional Director of Physical Facilities were notified of the issue with the door handle hardware for Resident #1 and #2's room and instructed to change all door handles on the bathroom door to doorknobs to ensure that they do not latch on to each other under any circumstances. 23 door handles in total were replaced. Completion date 1-30-24. The maintenance director arrived at the facility to inspect the door and made adjustments to the door hinge to re-align the door so that the door handles do not get caught on each other. An inspection of all doors in the Memory care unit were then inspected to ensure there were no issues to any other doors. All doors were functioning properly. Completion date 1-31-24 Staff in-service initiated on 1-30-24 on what to do in the event of a resident room entry blocked and not able to enter the room in an emergency and non-emergency situation. Initial training conducted by Regional Nurse on 1-30-24 with management team. Staff will receive training in staff meeting by Administrator held on 1-31-24. Completion date will be 1-31-24. On 1-31-24 the management team will conduct a Standards of Care and QAPI ad hoc meeting with the Medical Director to discuss the findings and recommendations will be made and followed through if necessary. A monthly preventative maintenance inspection of resident living area doors and hardware will be implemented effective 1-31-24. This inspection will be conducted by the maintenance director or designee to ensure doors are functioning properly. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from 01/31/24 through 02/01/24. Monitoring of the POR included: Observation on 01/31/24 at 2:14 p.m. revealed all door handles on the bathroom doors located inside the resident(s) room, in the memory care unit, were changed to doorknobs. A total of 23 door handles were changed. Observation on 01/31/24 at 5:10 p.m. revealed all bathroom doors located inside the resident(s) room opened and closed without becoming wedged with the bedroom door. During interviews on 01/31/24 and 02/01/24, the following Nurses and CNAs were able to verbalize an understanding of the steps to take if a resident's room was blocked from entry: Nurses A and B, CNAs A, B, C, D, E and, F . Record review of in-service training titled Steps to Take if Resident Room is Blocked from Entry held with department managers and staff, dated 01/30/24 and 01/31/24, revealed 128 signatures. Record review of Resident #1 and Resident #2's progress notes, dated 01/30/24, revealed they were assessed, and their families were contacted about the incident. Record review of the Foundations of Care Meeting Action Plan, dated 01/31/24, revealed the Medical Director and Nursing Staff were present and no further recommendations were made. The Administrator was notified the Immediate Jeopardy was removed on 02/01/24 at 4:01 p.m. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure a person designated as the infection preventionist had completed specialized training in infection prevention and control for 1 of 1 staff (DON) reviewed for Infection Preventionist qualifications and role. - The facility failed to ensure the DON had completed the required Nursing Facility Infection Preventionist training course IP which resulted in failure to implement an effective Infection Control Program, resulting in Residents #107, #39, #25, #37, #100, #51, #61, #81, #16, #84, #109, #20, and #1 contracting and being treated for scabies. - The facility failed to ensure the Infection Preventionist completed tracking and trending of infections for August through October of 2023. - The facility failed to ensure that there was a qualified Infection Preventionist from November 4th to December 15th 2023. An IJ was identified on 12/15/23. The IJ template was provided to the facility on [DATE] at 03:00 PM. While the IJ was removed on 12/19/23, at 02:39 PM. The facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for itching, discomfort, pain, secondary skin infections and hospitalization . Findings included: Record review of the facility Infection Control Tracking and Trending for August, September and October of 2023 revealed, the tracking and trending was completed retrospectively for those months on 11/08/23 by the DON. Resident #107 Record review of Resident #107's Face Sheet dated 12/18/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of depression, difficulty swallowing, down syndrome, fluid overload, hypertension. The resident had a diagnosis of Atopic dermatitis and congenital ichthyosis (a group of rare skin conditions that cause dry, scaly skin that individuals are usually born with) as of 11/03/23, he did not have a diagnosis of Scabies. Record review of Resident #107's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, substantial/maximal assistance for most ADLs, an indwelling catheter, frequently incontinent of bowel and application of ointments/medications other than to feet. Record review of Resident #107's undated care plan revealed, focus areas of - ID, DD with PASRR services, potential nutritional problems, potential for pressure ulcer development, impaired cognitive function, a communication problem and tube feeding. There was no focus area to address Resident #107's treatment/diagnosis of scabies. Record review of Resident #107's Order Summary dated 12/18/23 revealed, Resident #107 had orders for Permethrin (an insecticide used to treat scabies) on multiple occasions but was only on contact isolation once: - 06/23/23 Permethrin 5% for dermatitis for 2 days: apply to head to toe topically one time only for 2 days. Leave on for 8015 hours. - 07/26/23 Permethrin 5% for pruritus: apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning. - 08/18/23 Permethrin 5% : apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning per dermatologist. - 11/03/23 Permethrin 5% for prophylactic dermatitis for 2 days: apply at bedtime and leave overnight. Rinse of in AM. - 12//11/23 Permethrin 5%c0 apply topically one time for scabies infestation. Leave in for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23 Contact Isolation- use strict contact precautions with protective garments. Record review of Resident #107's Dermatologist Note dated 07/26/23 revealed: Resident #107 was being seen as a referral from the Medical Director for a rash located on the body throughout. The ratch was itchy and red and moderate in severity and it had been present for months. scaling and well demarcated, eczematous patches; differential diagnosis includes irritation dermatitis vs. scabies; plan- Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Follow up in 6 weeks for skin check. Record review of Resident #107's Dermatologist Note dated 11/03/23 revealed: Impression: Eczema associated diagnosis: Scabies; status: worsening, Itch Numerical Rating scale:10; % body surface covered in rash: 70. Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Record review of Resident #107's Physician Note dated 12/13/23 signed by the Medical Director revealed, Resident #107 was seen due to rash noted over the extremities and right should that appeared crusted in nature. Diagnosis/Plan: unspecified dermatitis secondary to scabies infection, was started on permethrin cream, repeat treatment after 7 days, clean linens/clothes, deep clean room and contact isolation precautions in place. Record review of Resident #107's MARs from 06/2023 to 12/2023 revealed: - Jun 2023: Permethrin 5% apply to skin at bedtime for dermatitis for 2 days- it was only applied once on 6/24/23. - July 2023: Permethrin 5 % apply to skin for persistent dermatoses- applied on 07/21/23. Permethrin 5% apply topically for pruritus- applied 7/26/23. - August 2023: Permethrin 5 %- applied 08/18/23 - November 2023: Permethrin 5 % prophylactically for dermatitis for 2 day- was only applied on 11/04/23 - December 2023: Permethrin 5% for scabies infestation use strict contact isolation- applied on 12/11/23 at 10:30 PM. Record review of Resident #107's Progress Notes from 12/22/22 to 12/23/23 revealed the resident's rash : - 06/24/23- generalized rash noted to entire body - 07/17/23- resident noted with recurrent rash to upper extremities - 07/23/23 day 7/7 of prednisone for generalized rash to torso. Area clean with red bumps noted from front/back torso. Resident scratching right front chest. - 08/24/23- generalized rash remains. - 09/12/23- Rash noted all over resident skin. - 11/02/23 at 01:30 AM: generalized rash remains pronounced, - 11/04/23 at 03:17 AM: generalized rash remains pronounced, dry, raised in some areas. - 11/04/23 at 10:15 AM : rash was still present to entire body and has new orders for permethrin 5% cream for 2 days and ammonium lactate 12% cream on shower day which will be on Monday 11/6/2023 - 12/14/23 at 02:30 AM- scaly, shedding, redness/self-inflicted scratches noted to skin. Resident on contact isolation There was only one mention of the resident having scabies on 12/12/23 at 04:01 AM- remain in contact isolation for scabies, permethrin cream applied to the entire body; and Resident #107 was first placed on contact isolation on 12/11/23. Record review of Resident #107's Hospital Wound Care Note dated 12/15/23 at 03:22 PM revealed, consult requested for cracking and flaking of skin with some deeper skin layer involvement. Dry thick crusted skin that extends from the right side of his head, neck, down the right shoulder, armpit, arm, right side of chest and left side of chest and armpit. Possible diagnosis of crusted scabies Record review of Hospital Infectious Disease Progress Note dated 12/17/23 at 07:46 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) and Topical Permethrin for crusted scabies. Record review of Hospital Infectious Disease Progress Note dated 12/18/23 at 05:32 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) for 4 days and Topical Permethrin for 3 days for crusted scabies. Record review of Resident #107's Medical Diagnoses printed 12/23/23 at 11:39 AM revealed, no diagnosis of scabies. An Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #107 was in the bed by the window, he was awake, receiving tube feeding, had a urinary foley catheter and was non interviewable. Resident #107 had fair colored skin with thick, dry, crusty, scaly large areas to the upper body. On both shoulders and upper arms were thick crusty, powdery white areas with red cracks. There were raised red bumps and rash to both forearms and to both upper thighs. The thighs had red scratch marks. The webbing between the thumb and pointer finger on both hands had powdery white irregular bumps. Resident #107 was scratching his groin and upper thighs. The treatment nurse stated he had dermatitis that worsened since he returned from the hospital in October 2023. The treatment nurse stated the rash on Resident #39 and Resident #107 appeared to be the same. She did not mention that Resident #107 had a presumptive diagnosis of scabies or that the resident was being treated for scabies. An Observation and interview on 12/15/2023 at 4:00 PM revealed, Resident #107 in the ICU at the hospital with a diagnosis of respiratory failure and sepsis. Resident #107's room door was open and the resident was intubated The assigned hospital nurse stated when he was admitted on [DATE] d/t low blood pressures and elevated WBC. The hospital nurse stated they were not notified of the resident having scabies. The hospital nurse picked up her phone that was ringing and said it was the wound care nurse on the line who just told her she completed her evaluation done on 12/15/2023 and thought he might have scabies. The hospital nurses closed the resident's door and set up for contact isolation. Isolation signage was put up on the glass door. In an interview on 12/15/23 at 09:25 AM, MA A said she was present on 11/03/23 when Resident #107 saw the dermatologist. She said due to the rash being chronic and the severity of itching as well as the facility informing them other residents had similar rashes the Dermatologist wanted to treat Resident #107 for scabies. She said the MD ordered Permethrin 5% for Resident #107 to be repeated in 7 days. In an interview on 12/20/23 at 07:55 AM, the Hospital Treatment Nurse said when resident #107 arrived to the hospital she observed thick plaques and rashes all over the parts of the body she could see (at least 1/3rd ) and she was surprised. She said the hyperkeratotic presentation and the residents history made her believe he had crusted scabies. Resident #39 Record review of Resident #39's Face Sheet dated 12/23/23 revealed, a 50-year-olf male who admitted to the facility on [DATE] with diagnoses of: chronic pain syndrome, contractures, lack of coordination, anemia and a scabies (onset 12/11/23). Record review of Resident #39's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, dependence for most ADLs and application of ointments/medications other than to feet. Record review of Resident #39's undated Care Plan revealed, focus-impaired visual function, refusal of care (showers/shampoos and general grooming), total assistance with all ADLs except feeding. Focus- actual impaired to skin integrity r/t thick skin and callous buildup to feet, he refuses to shower routinely which precipitates dry skin formation; intervention- identify/document potential causative factors and eliminate/resolver where possible; keep skin clean and dry. Record review of Resident #39's NP Note dated 11/30/23 signed by the NP revealed, skin: chronic seborrheic dermatitis- refuses showers. Record review of Resident #39's NP Note dated 12/08/23 signed by the NP revealed, Diagnosis/Plan: seborrheic dermatitis- refuses showers. There was no documented description of the resident's rash. Record review of Resident #39's MD note dated 12/13/23 and signed by the Medical Director revealed, Resident #39 had a red rash over the extremities of both upper and lower extremities. The resident was on isolation and was started on permethrin for scabies but he continued to refuse showers and application of creams. Diagnosis/plan: unspecified dermatitis secondary to scabies infection, on contact isolation, on permethrin cream repeated after 7 days and room to be deep cleaned and linens washed. Record review of Resident #39's Clinical Census dated 12/23/23 revealed, Resident #39 shared a room with Resident #107 from 10/24/23 until Resident #107 was discharged to the hospital on 12/14/23. Record review of Resident #39's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #39's Progress notes from 12/22/22 to 12/23/23 revealed, Resident #39's had rashes dating back to 06/2023. - 6/13/23 at 04:46 PM- Resident's lower extremities are swollen with wound, Also has rash all over the body but was refusing treatment and medication. - 06/26/2023 at 10:40- The entire body skin observed with rash. There was no other mention of Resident #39 suffering from a rash until 12/14/23 (3 days after being diagnosed with scabies: - 12/14/23- remain in contact isolation/precautions, generalized skin rash remains to the body. Record review of Resident #39's Order Summary dated 12/23/23 revealed, - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. Start date 12/19/23. Record review of Resident #39's December 2023 MAR revealed, -Permethrin 5% topically at bedtime for scabies infestation- applied on 12/11/23 at 9:30 PM and 12/19/23 at 12:16 AM. Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #39 was awake, dressed in a hospital gown and brief and was in the bed by the door. Resident #39's arms, legs and hands were contracted. Resident #39 stated it was ok to look at his skin and that areas on his skin were very itchy. Resident #39 had small, red bumps on the scalp, forehead, cheeks, on both elbows, arms and both lower legs had large red bumps. The treatment nurse stated the redness to the elbows and red areas on his back were not new. The treatment nurse stated the new red bumps appeared sometime last week (12/4/2023 to 12/08/2023). The treatment nurse stated these new red bumps occurred at the same time Resident #107's red bumps appeared. Observation and interview on 12/23/2023 at 12:00 PM, Resident#39 was in contact isolation. He had a plate of food on his chest. He had red bumps on his scalp, face and arms and was unchanged from 12/13/23. He said he did receive the treatment cream, then showers the next day. Resident #39 stated he was told the cream was for scabies. He stated that it started with Resident #107 and maybe from not having the bed linens changed and washed. He stated that the bed linens were changed out daily and his personal belongings were removed. He stated he did not feel as itchy. He stated he was able to sleep through the night but during mornings he would feel itchy when he thinks about it. He stated he will be getting out of isolation soon and was happy about that because he wanted to get his money so he can buy soda. Resident #25 Record review of Resident #25's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of ID, schizophrenia, anemia, anxiety, hallucinations, depression and scabies (onset date 12/11/23). Record review of Resident #25's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, substantial to maximal assistance with most ADLs, and always incontinent of both bladder and bowel. There was no documentation of any applications of ointments/medication to the skin. Record review of Resident #25's undated Care Plan revealed, no related focus areas. There was no mention of any skin issues including rashes and scabies. Record review of Resident #25's Clinical Census revealed, Resident #25 shared a room with Resident #107 since 10/24/23. Record review of Resident #25's NP Note dated 11/27/23 revealed, no documented skin issues. Record review of Resident #25's NP Note dated 11/30/23 revealed- head to toe assessment done due to reports of patient had rash to both sides of his upper and lower extremities. He has elevated red bumps, dry scaly skin scattered to chest, abdominal area, back, both legs and arm but no rashes were observed on the web spaces of his hands, genitals or scalps. Monitor closes due to skin rash issues in the unit. Record review of Resident #25's NP Note dated 12/08/23 revealed, the resident was on hydrocortisone (steroid cream) for skin rash and the rash was unresolved. Record review of Resident #25's NP Note visit date 12/09/23 but signed on 12/18/23 revealed, Resident #25 was noted itching/scratching and had a persistent skin rash likely scabies. Resident #25 was treated with Sulfur 5% nightly for 3 days, with a plan to treat with Permethrin if the rash didn't resolve. Contact Isolation precautions and an oral medication to treat itching. Record review of Resident #25's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #25's Order Summary dated 12/23/23 revealed: - 12/09/23- Sulfur 5% lotion for dermatitis, apply to entire body from neck down, rub in and leave on for 24 hours. - 12/11/23- Permethrin 5%- apply to head to toe topically one time only for scabies infestation. Leave on for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23- Contact Isolation: use strict contact precautions with protective garments, every shift for scabies infestation. Record review of Resident #25's December 2023 MAR revealed, Resident #25 received Permethrin 5% on: - 12/12/23 at 08:43 AM - 12/20/23 at 12:52 AM Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #25 was in the middle bed in a full body, long sleeve jump suite. When the Treatment Nurse removed his body suite, Resident #25 was observed with had light pink, small, raised bumps to both upper arms and on the abdomen. The Treatment Nurse stated he was treated with Hydrocortisone cream beginning 11/30/2023 for a rash to both arms and legs. Resident #37 Record review of Resident #37's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: epilepsy, asthma, arthritis, type 2 diabetes and scabies with an onset date of 12/16/23. Record review of Resident #37's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15, rejection of care, substantial/maximal assistance with most ADLs and application of ointments/medications to skin other than feet. Record review of Resident #37's undated Care Plan revealed, no documented focus areas addressing, skin, rashes or scabies. Record review of Resident #37's Census revealed he shared a room with Resident #107 from 08/28/23 to 09/23/23. Record review of Resident #37's Progress Notes from 12/22/22 to 12/23/23 revealed: - 09/22/23 at 02:33 PM the resident had a new rash to both arms, chest and legs. There was no documentation of the resident being placed on contact isolation. - 09/22/23 at 02:49 PM: Change of condition identified in a change in skin condition, the resident has a personal history of infectious and parasitic diseases. Skin Status Evaluation: itching rash and an order was given for Permethrin 5% to chest both legs and both arms which should be washed of in 8-12 hrs, hydrocortisone 1% cream for 7 days and calamine lotion for 2 weeks. There was no documentation of the resident being placed on contact isolation. - 10/02/23 at 10:34 PM: PERMETHRIN CREAM 5% APPLIED ON RESIDENT ENTIRE BODY THIS SHIFT AND TO BE WASHED OFF IN 8-12HRS. - 10/16/23 Resident on day 5/7 of antibiotics for cellulitis. Rash remains. - 10/18/23 Resident still on antibiotics for cellulitis. Rash still present and some itching noted. - 10/20/23 Resident still noted with rash all over his body and treatments continue - 10/27/23 Resident continues with steroid cream to the body for generalized rash, red raised bumps noted. - 10/40/23 Generalized rash red in color and bumpy. - 11/03/23 Rash present to body, generalized mild redness with complaints of mild itching. - 11/06/23 Rash still visible. - 11/08/23 Resident with generalized rash to body, some itching noted-redirected to avoid infection/pain. - 11/21/23 Resident seen by NP, new orders to apply steroid cream to rash all over his body twice daily for 30 days. - 11/24/23 Rash remains reddened pronounced and generalized. - 11/28/23 Rash remains reddened pronounced and generalized - 12/06/23 Rash remains reddened. Apply steroid cream to torso, back, upper extremities and thighs. - 12/13/23 Resident was on antibiotics for skin cellulitis and generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted. - 12/14/23 Rash with little improvement. - 12/15/23 generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted and worse. - 12/18/23 Day 1 of Permethrin 5% treatment to body An observation and interview on 12/12/23 at 09:55 AM revealed, Resident #37 lying in bed well dressed and well-groomed with rashes/scabs to his arms. When asked about the rash./sores the resident said everything was ok and would not respond further. Record review of Resident #37's NP Note dated 11/28/23 revealed, evaluation of dermatitis. Patient has rash to upper torso. Record review of Resident #37's NP Note dated 12/09/23 revealed, dermatitis unresolved. Record review of Resident #37's NP Note dated 12/12/23 revealed, dermatitis unresolved. Likely scabies infection will treat with Permethrin, repeat dose if not resolved and contact isolation precautions. Record review of Resident #37's Order Summary sprinted 12/23/23 revealed: - 06/23/23 Permethrin 5% for dermatitis, apply for 2 days. - 09/22/23 Permethrin 5%- apply to arms, legs, chest typically one time only written for 2 days. - 10/02/23 Permethrin 5% for scabies - Contact precautions- use contact precautions with protective garments. There are no previous orders for contact precautions - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments Record review of Resident #37's September 2023 MAR printed 12/23/23 revealed: - 09/22/23 Permethrin 5% applied at 04:45 PM. - 09/22/23 to 09/29/23 hydrocortisone 1% to arms, legs, and chest for pruritis at 09:00 AM and 05:00 PM Record review of Resident #37's October 2023 MAR printed 12/23/23 revealed: - 10/02/23 Permethrin 5% applied at 09:29 PM. - 10/26/23 to 10/31/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Record review of Resident #37's November 2023 MAR printed 12/23/23 revealed: - 11/01/23 to 11/06/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Resident #84 Record review of Resident #84's Face Sheet dated 12/19/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of: Parkinson, dementia, depression, communication deficit and scabies with onset of 12/16/23. Record review of Resident #84's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, extensive assistance with most ADLs and application of ointments/medications to the skin other than the feet. Record review of Resident #84's undated Care Plan revealed, no focus areas address rashes, itching or scabies. Record review of Resident #84's Census revealed, he shared a room with Resident #107 from 08/28/23 to 09/23/23 Record review of Resident #84's Progress Notes from 12/22/22 to 12/23/23 revealed, - 09/15/23 Resident noted with rash to entire body. - 10/03/23 Rash red and bumpy in appearance to legs and right thigh. - 10/20/23 Resident still noted with rash all over his body, treatment continues - 10/23/23 Resident given oral steroids for rash to lower legs, and areas of dry skin - 11/03/23 rash to both legs present bumpy and red. - 11/06/23 Dermatology appointment cancelled and will be rescheduled. - 11/16/23 Rash remains reddened, raised and generalized. - 11/30/23 Resident given oral antifungal for rash. - 12/14/23 Resident rash to both legs with little improvement. -12/15/23 Generalized rash/itching remain the same Record review of Resident #84's Order Summary report printed 12/23/23 revealed - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact precautions with protective garments every shift - 12/2/23 Permethrin 5% for scabies. Use contact precautions with protective garments An observation on 12/12/23 at 09:55 AM revealed, Resident # 84 lying in bed with a limited range of motion and wedge pillows propping him up. The resident was observed to have a rash on both his arms and had limited communication capability and all he could say his butt burned. In an interview on 12/12//23 at 10:00 AM, the treatment nurse said Resident #84 was previously treated for wounds on his buttocks but the medication was discontinued because the issue had resolved. She said she would visit the resident to reassess him, and notify the wound care doctor about the resident's complaints. The Treatment Nurse did not address the Resident #84's itching. Resident #20 Record review of Resident #20's Face Sheet dated 12/16/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses: dementia, mood disorder. Anxiety disorder and depression. Record review of Resident #20's 5 day MDS dated [DATE] revealed, severely intact cognition as indicated by a BIMS score of 00 out of 15, partial assistance with most ADLs and no application of ointments/medication to the skin. Record review of Resident #20's undated Care Plan revealed, focus- elopement risk/wanderer onset 04/17/23; intervention- intervene as appropriate, distract resident from wandering by offering pleasant diversion, food, conversations, television or books. The care plan does not address any skin issues. Record review of Resident #20's MD Note dated 12/13/23 revealed, resident was started on a steroid cream for itching for 7 days. Skin: new rash to the back of the hand with some redness around it. Record review of Resident #20's Order Summary dated 12/23/23 revealed: - 11/03/23 Prednisone ( a steroid) 20 mg- 1 tablet one time a day for rash for 3 days. - 11/03/23 Hydrocortisone 1 %- apply topically two times a day for rash/dry skin - 11/03/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/03/23 Prednisone 10 mg- 1 tablet by mouth 1 time a day for rash for 5 days starting 11/08/23. - 11/27/23 Prednisone 20 mg- give 2 tablets by mouth daily for pruritus. - 11/27/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/28/23 Hydrocortisone 1 % for pruritus- apply topically two times a day to torso, both upper and lower extremities. - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact Precautions- use contact precautions with protective garments. - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments scheduled for 12/24/23 An observation and interview on 12/12/23 at 09:45 AM revealed, Resident #20 well dressed, well-groomed in a wheelchair in front of his room. The resident was wearing a long sleeve shirt but a rash could be seen at the end of the sleeve of his right arm and a skin tear on the back of his right arm. When asked questions the resident would only respond that he wanted coffee. An observation on 12/15/23 at 03:00 PM revealed, Resident #20 observed in the dining area with a rash on his right hand and arm, a skin tear to the right hand that appeared to be scabbed. An observation on 12/15/23 at 03:23 PM revealed, Resident #20 ambulating in his wheelchair to the front lobby. The resident attempted to open the office door and was instructed by the DON that he could not be in the hallway because he was on isolation. The resident left the office and headed toward the resident rooms, the DON did not escort the resident back to his room or get assistance from other staff. Resident #20 returned 5 minutes later with a mask on his face. In an observation and interview on 12/16/23 at 12:50 PM, Resident #20's room was observed to be empty and the Isolation signage as well as the bin were no longer at the resident's door. The DON said Resident #20 was removed from isolation because the facility was unable to keep him in his room and the resident roamed the building. An observation on 12/16/23 at 03:55 PM revealed, Resident #20 ambulating in the front lobby trying to get access to the office by pulling the door. Resident #100 Record review of Resident #100's Face Sheet dated 12/23/23 revealed, an [AGE] year-old man who admitted to the facility on [DATE] with diagnoses of: dementia, malnutrition, depression, anxiety and scabies with an onset date of 12/18/23. Record review of Resident #100's MDS (Minimum Data Set) dated 11/4/2023 revealed a BIMS (Brief Interview for Mental Status) score of 0 out of 15 indicating Resident # was severely cognitively impaired. Section GG revealed the resident needed substantial/maximal assistance with toileting, showering/bathing, upper and lower body dressing, and personal hygiene. Section M1200 revealed Applications of ointments/medications other than to feet. Record review of Resident #100's Care Plan dated 4/28/2023 revealed in part . The resident has infection of the skin .the resident will be free from complications related to infection through the review date. Record review of Resident #100's Progress Notes from 12/22/22 to 12/23/23 revealed, - 05/09/23 Permethrin Cream treatment for rash all over body - 09/06/23 Resident receiving topical steroid for body itching, less scratching observed. - 10/16/23 Resident observed multiple times scratching arms and chest - 11/18/23 resident on oral medication for itching and continues to scratch - 12/14/23 mild redness raised area generalized to body. - 12/15/23 red rashes remains on different parts of the body and the resident was now on a topical steroid cream twice daily. - 12/17/23 resident placed on contact isolation precautions. Continues to scratch at sites Record review of resident #100's Orders Summary dared 12/23/23 revealed - 5/8/2023 revealed Permethrin External Cream 5% Apply head to Toes for itching for 2 days. - 12/17/2023 revealed Permethrin Cream 5% apply to affected areas topically at bedtime for scabies. - 12/17/23 Contact isolation-wear protective garments. Resident had no orders for contact isolation in May 2023. Record review of Resident #100's May 2023 MAR revealed, Permethrin was applied on 05/08/23 at 10:00 PM and

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for 13 out of 15 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #51, Resident #61, Resident #81, Resident #84, Resident #95, Resident #100, Resident #107, Resident #109) and 4 of 5 Staff ( CNA AA, CNA BB, CNA CC, CNA D and CNA S) reviewed for infection control. - The facility failed to implement environment controls and surveillance to prevent a scabies outbreak. Resulting in 13 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #51, Resident #61, Resident #81, Resident #84, Resident #100, Resident #107, Resident #109) and 4 Staff ( CNA AA, CNA BB, CNA CC and CNA S). - Administration was aware that residents and staff had contracted the same unspecified rash over multiple months (September through December) and did not implement infection control procedure. - The facility failed to retain an IP with qualified training, complete tracking and trending of infections from August to October of 2023. -CNA D failed to change gloves, perform hand hygiene after peri care and prior to touching clean items for Resident #95 (identified outside of the IJ). -CNA D failed to perform hand hygiene prior to leaving the resident's room after providing peri care to Resident #95 (identified outside of the IJ). An IJ was identified on 12/15/23. The IJ template was provided to the facility on [DATE] at 03:00 PM. While the IJ was removed on 12/19/23, at 02:39 PM. The facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for contracting a severe contagious skin infection, resulting in severe itching, discomfort, pain, decreased quality of life, and hospitalization . Findings included: Record review of the facility Infection Control Tracking and Trending for August, September and October of 2023 revealed, the tracking and trending was completed retrospectively for those months on 11/08/23. Resident #107 Record review of Resident #107's Face Sheet dated 12/18/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of depression, difficulty swallowing, down syndrome, fluid overload, hypertension. The resident had a diagnosis of Atopic dermatitis and congenital ichthyosis (a group of rare skin conditions that cause dry, scaly skin that individuals are usually born with) as of 11/03/23, he did not have a diagnosis of Scabies. Record review of Resident #107's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, substantial/maximal assistance for most ADLs, an indwelling catheter, frequently incontinent of bowel and application of ointments/medications other than to feet. Record review of Resident #107's undated care plan revealed, focus areas of - ID, DD with PASRR services, potential nutritional problems, potential for pressure ulcer development, impaired cognitive function, a communication problem and tube feeding. There was no focus area to address Resident #107's treatment/diagnosis of scabies. Record review of Resident #107's Order Summary dated 12/18/23 revealed, Resident #107 had orders for Permethrin (an insecticide used to treat scabies) on multiple occasions but was only on contact isolation once: - 06/23/23 Permethrin 5% for dermatitis for 2 days: apply to head to toe topically one time only for 2 days. Leave on for 8-14 hours. - 07/26/23 Permethrin 5% for pruritus: apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning. - 08/18/23 Permethrin 5%: apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning per dermatologist. - 11/03/23 Permethrin 5% for prophylactic dermatitis for 2 days: apply at bedtime and leave overnight. Rinse of in AM. - 12//11/23 Permethrin 5% apply topically one time for scabies infestation. Leave in for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23 Contact Isolation- use strict contact precautions with protective garments. Record review of Resident #107's Dermatologist Note dated 07/26/23 revealed: Resident #107 was being seen as a referral from the Medical Director for a rash located on the body throughout. The rash was itchy and red and moderate in severity and it had been present for months. scaling and well demarcated (defined boundaries), eczematous (skin conditions with redness and itching) patches; differential diagnosis includes irritation dermatitis vs. scabies; plan- Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Follow up in 6 weeks for skin check. Record review of Resident #107's Dermatologist Note dated 11/03/23 revealed: Impression: Eczema associated diagnosis: Scabies; status: worsening, Itch Numerical Rating scale:10; % body surface covered in rash: 70. Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Record review of Resident #107's Physician Note dated 12/13/23 signed by the Medical Director revealed, Resident #107 was seen due to rash noted over the extremities and right upper shoulder that appeared crusted in nature. Diagnosis/Plan: unspecified dermatitis secondary to scabies infection, was started on permethrin cream, repeat treatment after 7 days, clean linens/clothes, deep clean room and contact isolation precautions in place. Record review of Resident #107's MARs from 06/2023 to 12/2023 revealed: - Jun 2023: Permethrin 5% apply to skin at bedtime for dermatitis for 2 days- it was only applied once on 6/24/23. - July 2023: Permethrin 5 % apply to skin for persistent dermatoses- applied on 07/21/23. Permethrin 5% apply topically for pruritus- applied 7/26/23. - August 2023: Permethrin 5 %- applied 08/18/23 - November 2023: Permethrin 5 % prophylactically for dermatitis for 2 day- was only applied on 11/04/23 - December 2023: Permethrin 5% for scabies infestation use strict contact isolation- applied on 12/11/23 at 10:30 PM. Record review of Resident #107's Progress Notes from 06/24/23 to 12/23/23 revealed the resident's rash: - 06/24/23- generalized rash noted to entire body - 07/17/23- resident noted with recurrent rash to upper extremities - 07/23/23 day 7/7 of prednisone for generalized rash to torso. Area clean with red bumps noted from front/back torso. Resident scratching right front chest. - 08/24/23- generalized rash remains. - 09/12/23- Rash noted all over resident skin. - 11/02/23 at 01:30 AM: generalized rash remains pronounced, - 11/04/23 at 03:17 AM: generalized rash remains pronounced, dry, raised in some areas. - 11/04/23 at 10:15 AM : rash was still present to entire body and has new orders for permethrin 5% cream for 2 days and ammonium lactate 12% cream on shower day which will be on Monday 11/6/2023 - 12/14/23 at 02:30 AM- scaly, shedding, redness/self-inflicted scratches noted to skin. Resident on contact isolation There was only one mention of the resident having scabies on 12/12/23 at 04:01 AM- remain in contact isolation for scabies, permethrin cream applied to the entire body; and Resident #107 was first placed on contact isolation on 12/11/23. Record review of Resident #107's Hospital Wound Care Note dated 12/15/23 at 03:22 PM revealed, consult requested for cracking and flaking of skin with some deeper skin layer involvement. Dry thick crusted skin that extends from the right side of his head, neck, down the right shoulder, armpit, arm, right side of chest and left side of chest and armpit. Possible diagnosis of crusted scabies Record review of Hospital Infectious Disease Progress Note dated 12/17/23 at 07:46 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) and Topical Permethrin for crusted scabies. Record review of Hospital Infectious Disease Progress Note dated 12/18/23 at 05:32 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) for 4 days and Topical Permethrin for 3 days for crusted scabies. Record review of Resident #107's Medical Diagnoses printed 12/23/23 at 11:39 AM revealed, no diagnosis of scabies. An observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #107 was in the bed by the window, he was awake, receiving tube feeding, had a urinary foley catheter and was non interviewable. Resident #107 had fair colored skin with thick, dry, crusty, scaly large areas to the upper body. On both shoulders and upper arms were thick crusty, powdery white areas with red cracks. There were raised red bumps and rash to both forearms and to both upper thighs. The thighs had red scratch marks. The webbing between the thumb and pointer finger on both hands had powdery white irregular bumps. Resident #107 was scratching his groin and upper thighs. The treatment nurse stated he had dermatitis that worsened since he returned from the hospital in October 2023. The treatment nurse stated the rash on Resident #39 and Resident #107 appeared to be the same. She did not mention that Resident #107 had a presumptive diagnosis of scabies or that the resident was being treated for scabies. An observation and interview on 12/15/2023 at 4:00 PM revealed, Resident #107 in the ICU at the hospital with a diagnosis of respiratory failure and sepsis. Resident #107's room door was open and the resident was intubated The assigned hospital nurse stated when he was admitted on [DATE] d/t low blood pressures and elevated WBC. The hospital nurse stated they were not notified of the resident having scabies. The hospital nurse picked up her phone that was ringing and said it was the wound care nurse on the line who just told her she completed her evaluation done on 12/15/2023 and thought he might have scabies. The hospital nurses closed the resident's door and set up for contact isolation. Isolation signage was put up on the glass door. In an interview on 12/15/23 at 09:25 AM, MA A said she was present on 11/03/23 when Resident #107 saw the dermatologist. She said due to the rash being chronic and the severity of itching as well as the facility informing them other residents had similar rashes the Dermatologist wanted to treat Resident #107 for scabies. She said the MD ordered Permethrin 5% for Resident #107 to be repeated in 7 days. In an interview on 12/20/23 at 07:55 AM, the Hospital Treatment Nurse said when Resident #107 arrived to the hospital she observed thick plaques and rashes all over the parts of the body she could see (at least 1/3rd ) and she was surprised. She said the hyperkeratotic presentation and the residents history made her believe he had crusted scabies. Resident #39 Record review of Resident #39's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: chronic pain syndrome, contractures, lack of coordination, anemia and a scabies (onset 12/11/23). Record review of Resident #39's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, dependence for most ADLs and application of ointments/medications other than to feet. Record review of Resident #39's undated Care Plan revealed, focus-impaired visual function, refusal of care (showers/shampoos and general grooming), total assistance with all ADLs except feeding. Focus- actual impaired to skin integrity r/t thick skin and callous buildup to feet, he refuses to shower routinely which precipitates dry skin formation; intervention- identify/document potential causative factors and eliminate/resolver where possible; keep skin clean and dry. Record review of Resident #39's NP Note dated 11/30/23 signed by the NP revealed, skin: chronic seborrheic dermatitis- refuses showers. Record review of Resident #39's NP Note dated 12/08/23 signed by the NP revealed, Diagnosis/Plan: seborrheic dermatitis- refuses showers. There was no documented description of the resident's rash. Record review of Resident #39's MD note dated 12/13/23 and signed by the Medical Director revealed, Resident #39 had a red rash over the extremities of both upper and lower extremities. The resident was on isolation and was started on permethrin for scabies but he continued to refuse showers and application of creams. Diagnosis/plan: unspecified dermatitis secondary to scabies infection, on contact isolation, on permethrin cream repeated after 7 days and room to be deep cleaned and linens washed. Record review of Resident #39's Clinical Census dated 12/23/23 revealed, Resident #39 shared a room with Resident #107 from 10/24/23 until Resident #107 was discharged to the hospital on 12/14/23. Record review of Resident #39's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #39's Progress notes from 12/22/22 to 12/23/23 revealed, Resident #39's had rashes dating back to 06/2023. - 6/13/23 at 04:46 PM- Resident's lower extremities are swollen with wound, Also has rash all over the body but was refusing treatment and medication. - 06/26/2023 at 10:40- The entire body skin observed with rash. There was no other mention of Resident #39 suffering from a rash until 12/14/23 (3 days after being diagnosed with scabies: - 12/14/23- remain in contact isolation/precautions, generalized skin rash remains to the body. Record review of Resident #39's Order Summary dated 12/23/23 revealed, - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. Start date 12/19/23. Record review of Resident #39's December 2023 MAR revealed, -Permethrin 5% topically at bedtime for scabies infestation- applied on 12/11/23 at 9:30 PM and 12/19/23 at 12:16 AM. Observation and interview on 12/13/2023 at 2:00 PM, of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #39 was awake, dressed in a hospital gown and brief and was in the bed by the door. Resident #39's arms, legs and hands were contracted. Resident #39 stated it was ok to look at his skin and that areas on his skin were very itchy. Resident #39 had small, red bumps on the scalp, forehead, cheeks, on both elbows, arms and both lower legs had large red bumps. The treatment nurse stated the redness to the elbows and red areas on his back were not new. The treatment nurse stated the new red bumps appeared sometime last week (12/4/2023 to 12/08/2023). The treatment nurse stated these new red bumps occurred at the same time Resident #107's red bumps appeared. Observation and interview on 12/23/2023 at 12:00 PM, Resident#39 was in contact isolation. He had a plate of food on his chest. He had red bumps on his scalp, face and arms and was unchanged from 12/13/23. He said he did receive the treatment cream, then showers the next day. Resident #39 stated he was told the cream was for scabies. He stated that it started with Resident #107 and maybe from not having the bed linens changed and washed. He stated that the bed linens were changed out daily and his personal belongings were removed. He stated he did not feel as itchy. He stated he was able to sleep through the night but during mornings he would feel itchy when he thinks about it. He stated he will be getting out of isolation soon and was happy about that because he wanted to get his money so he can buy soda. Resident #25 Record review of Resident #25's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of ID, schizophrenia, anemia, anxiety, hallucinations, depression and scabies (onset date 12/11/23). Record review of Resident #25's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, substantial to maximal assistance with most ADLs, and always incontinent of both bladder and bowel. There was no documentation of any applications of ointments/medication to the skin. Record review of Resident #25's undated Care Plan revealed, no related focus areas. There was no mention of any skin issues including rashes and scabies. Record review of Resident #25's Clinical Census revealed, Resident #25 shared a room with Resident #107 since 10/24/23. Record review of Resident #25's NP Note dated 11/27/23 revealed, no documented skin issues. Record review of Resident #25's NP Note dated 11/30/23 revealed- head to toe assessment done due to reports of patient had rash to both sides of his upper and lower extremities. He has elevated red bumps, dry scaly skin scattered to chest, abdominal area, back, both legs and arm but no rashes were observed on the web spaces of his hands, genitals or scalps. Monitor closes due to skin rash issues in the unit. Record review of Resident #25's NP Note dated 12/08/23 revealed, the resident was on hydrocortisone (steroid cream) for skin rash and the rash was unresolved. Record review of Resident #25's NP Note visit date 12/09/23 but signed on 12/18/23 revealed, Resident #25 was noted itching/scratching and had a persistent skin rash likely scabies. Resident #25 was treated with Sulfur 5% nightly for 3 days, with a plan to treat with Permethrin if the rash didn't resolve. Contact Isolation precautions and an oral medication to treat itching. Record review of Resident #25's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #25's Order Summary dated 12/23/23 revealed: - 12/09/23- Sulfur 5% lotion for dermatitis, apply to entire body from neck down, rub in and leave on for 24 hours. - 12/11/23- Permethrin 5%- apply to head to toe topically one time only for scabies infestation. Leave on for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23- Contact Isolation: use strict contact precautions with protective garments, every shift for scabies infestation. Record review of Resident #25's December 2023 MAR revealed, Resident #25 received Permethrin 5% on: - 12/12/23 at 08:43 AM, and - 12/20/23 at 12:52 AM. Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #25 was in the middle bed in a full body, long sleeve jump suite. When the Treatment Nurse removed his body suite, Resident #25 was observed with had light pink, small, raised bumps to both upper arms and on the abdomen. The Treatment Nurse stated he was treated with Hydrocortisone cream beginning 11/30/2023 for a rash to both arms and legs. Resident #37 Record review of Resident #37's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: epilepsy, asthma, arthritis, type 2 diabetes and scabies with an onset date of 12/16/23. Record review of Resident #37's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15, rejection of care, substantial/maximal assistance with most ADLs and application of ointments/medications to skin other than feet. Record review of Resident #37's undated Care Plan revealed, no documented focus areas addressing, skin, rashes or scabies. Record review of Resident #37's Census revealed he shared a room with Resident #107 from 08/28/23 to 09/23/23. Record review of Resident #37's Progress Notes from 12/22/22 to 12/23/23 revealed: - 09/22/23 at 02:33 PM the resident had a new rash to both arms, chest and legs. There was no documentation of the resident being placed on contact isolation. - 09/22/23 at 02:49 PM: Change of condition identified in a change in skin condition, the resident has a personal history of infectious and parasitic diseases. Skin Status Evaluation: itching rash and an order was given for Permethrin 5% to chest both legs and both arms which should be washed of in 8-12 hrs, hydrocortisone 1% cream for 7 days and calamine lotion for 2 weeks. There was no documentation of the resident being placed on contact isolation. - 10/02/23 at 10:34 PM: Permethrin cream 5% applied on resident entire body this shift and to be washed off in 8-12hrs. - 10/16/23 Resident on day 5/7 of antibiotics for cellulitis. Rash remains. - 10/18/23 Resident still on antibiotics for cellulitis. Rash still present and some itching noted. - 10/20/23 Resident still noted with rash all over his body and treatments continue - 10/27/23 Resident continues with steroid cream to the body for generalized rash, red raised bumps noted. - 10/40/23 Generalized rash red in color and bumpy. - 11/03/23 Rash present to body, generalized mild redness with complaints of mild itching. - 11/06/23 Rash still visible. - 11/08/23 Resident with generalized rash to body, some itching noted-redirected to avoid infection/pain. - 11/21/23 Resident seen by NP, new orders to apply steroid cream to rash all over his body twice daily for 30 days. - 11/24/23 Rash remains reddened pronounced and generalized. - 11/28/23 Rash remains reddened pronounced and generalized - 12/06/23 Rash remains reddened. Apply steroid cream to torso, back, upper extremities and thighs. - 12/13/23 Resident was on antibiotics for skin cellulitis and generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted. - 12/14/23 Rash with little improvement. - 12/15/23 generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted and worse. - 12/18/23 Day 1 of Permethrin 5% treatment to body An observation and interview on 12/12/23 at 09:55 AM revealed, Resident #37 lying in bed well dressed and well-groomed with rashes/scabs to his arms. When asked about the rash/sores the resident said everything was ok and would not respond further. Record review of Resident #37's NP Note dated 11/28/23 revealed, evaluation of dermatitis. Patient has rash to upper torso. Record review of Resident #37's NP Note dated 12/09/23 revealed, dermatitis unresolved. Record review of Resident #37's NP Note dated 12/12/23 revealed, dermatitis unresolved. Likely scabies infection will treat with Permethrin, repeat dose if not resolved and contact isolation precautions. Record review of Resident #37's Order Summary sprinted 12/23/23 revealed: - 06/23/23 Permethrin 5% for dermatitis, apply for 2 days. - 09/22/23 Permethrin 5%- apply to arms, legs, chest typically one time only written for 2 days. - 10/02/23 Permethrin 5% for scabies. - Contact precautions- use contact precautions with protective garments. There are no previous orders for contact precautions. - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments. - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments. Record review of Resident #37's September 2023 MAR printed 12/23/23 revealed: - 09/22/23 Permethrin 5% applied at 04:45 PM. - 09/22/23 to 09/29/23 hydrocortisone 1% to arms, legs, and chest for pruritis at 09:00 AM and 05:00 PM. Record review of Resident #37's October 2023 MAR printed 12/23/23 revealed: - 10/02/23 Permethrin 5% applied at 09:29 PM. - 10/26/23 to 10/31/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Record review of Resident #37's November 2023 MAR printed 12/23/23 revealed: - 11/01/23 to 11/06/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Resident #84 Record review of Resident #84's Face Sheet dated 12/19/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of: Parkinson, dementia, depression, communication deficit and scabies with onset of 12/16/23. Record review of Resident #84's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, extensive assistance with most ADLs and application of ointments/medications to the skin other than the feet. Record review of Resident #84's undated Care Plan revealed, no focus areas address rashes, itching or scabies. Record review of Resident #84's Census revealed, he shared a room with Resident #107 from 08/28/23 to 09/23/23 Record review of Resident #84's Progress Notes from 12/22/22 to 12/23/23 revealed, - 09/15/23 Resident noted with rash to entire body. - 10/03/23 Rash red and bumpy in appearance to legs and right thigh. - 10/20/23 Resident still noted with rash all over his body, treatment continues - 10/23/23 Resident given oral steroids for rash to lower legs, and areas of dry skin - 11/03/23 rash to both legs present bumpy and red. - 11/06/23 Dermatology appointment cancelled and will be rescheduled. - 11/16/23 Rash remains reddened, raised and generalized. - 11/30/23 Resident given oral antifungal for rash. - 12/14/23 Resident rash to both legs with little improvement. -12/15/23 Generalized rash/itching remain the same Record review of Resident #84's Order Summary report printed 12/23/23 revealed - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact precautions with protective garments every shift - 12/2/23 Permethrin 5% for scabies. Use contact precautions with protective garments An observation on 12/12/23 at 09:55 AM revealed, Resident # 84 lying in bed with a limited range of motion and wedge pillows propping him up. The resident was observed to have a rash on both his arms and had limited communication capability and all he could say his butt burned. In an interview on 12/12//23 at 10:00 AM, the treatment nurse said Resident #84 was previously treated for wounds on his buttocks but the medication was discontinued because the issue had resolved. She said she would visit the resident to reassess him, and notify the wound care doctor about the resident's complaints. The Treatment Nurse did not address the Resident #84's itching. Resident #20 Record review of Resident #20's Face Sheet dated 12/16/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses: dementia, mood disorder. Anxiety disorder and depression. Record review of Resident #20's 5 day MDS dated [DATE] revealed, severely intact cognition as indicated by a BIMS score of 00 out of 15, partial assistance with most ADLs and no application of ointments/medication to the skin. Record review of Resident #20's undated Care Plan revealed, focus- elopement risk/wanderer onset 04/17/23; intervention- intervene as appropriate, distract resident from wandering by offering pleasant diversion, food, conversations, television or books. The care plan does not address any skin issues. Record review of Resident #20's MD Note dated 12/13/23 revealed, resident was started on a steroid cream for itching for 7 days. Skin: new rash to the back of the hand with some redness around it. Record review of Resident #20's Order Summary dated 12/23/23 revealed: - 11/03/23 Prednisone ( a steroid) 20 mg- 1 tablet one time a day for rash for 3 days. - 11/03/23 Hydrocortisone 1 %- apply topically two times a day for rash/dry skin - 11/03/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/03/23 Prednisone 10 mg- 1 tablet by mouth 1 time a day for rash for 5 days starting 11/08/23. - 11/27/23 Prednisone 20 mg- give 2 tablets by mouth daily for pruritus. - 11/27/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/28/23 Hydrocortisone 1 % for pruritus- apply topically two times a day to torso, both upper and lower extremities. - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact Precautions- use contact precautions with protective garments. - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments scheduled for 12/24/23 An observation and interview on 12/12/23 at 09:45 AM revealed, Resident #20 well dressed, well-groomed in a wheelchair in front of his room. The resident was wearing a long sleeve shirt but a rash could be seen at the end of the sleeve of his right arm and a skin tear on the back of his right arm. When asked questions the resident would only respond that he wanted coffee. An observation on 12/15/23 at 03:00 PM revealed, Resident #20 observed in the dining area with a rash on his right hand and arm, a skin tear to the right hand that appeared to be scabbed. An observation on 12/15/23 at 03:23 PM revealed, Resident #20 ambulating in his wheelchair to the front lobby. The resident attempted to open the office door and was instructed by the DON that he could not be in the hallway because he was on isolation. The resident left the office and headed toward the resident rooms, the DON did not escort the resident back to his room or get assistance from other staff. Resident #20 returned 5 minutes later with a mask on his face. In an observation and interview on 12/16/23 at 12:50 PM, Resident #20's room was observed to be empty and the Isolation signage as well as the bin were no longer at the resident's door. The DON said Resident #20 was removed from isolation because the facility was unable to keep him in his room and the resident roamed the building. An observation on 12/16/23 at 03:55 PM revealed, Resident #20 ambulating in the front lobby trying to get access to the office by pulling the door. Resident #100 Record review of Resident #100's Face Sheet dated 12/23/23 revealed, an [AGE] year-old man who admitted to the facility on [DATE] with diagnoses of: dementia, malnutrition, depression, anxiety and scabies with an onset date of 12/18/23. Record review of Resident #100's MDS (Minimum Data Set) dated 11/4/2023 revealed a BIMS (Brief Interview for Mental Status) score of 0 out of 15 indicating Resident # was severely cognitively impaired. Section GG revealed the resident needed substantial/maximal assistance with toileting, showering/bathing, upper and lower body dressing, and personal hygiene. Section M1200 revealed Applications of ointments/medications other than to feet. Record review of Resident #100's Care Plan dated 4/28/2023 revealed in part . The resident has infection of the skin .the resident will be free from complications related to infection through the review date. Record review of Resident #100's Progress Notes from 12/22/22 to 12/23/23 revealed, - 05/09/23 Permethrin Cream treatment for rash all over body - 09/06/23 Resident receiving topical steroid for body itching, less scratching observed. - 10/16/23 Re [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure each resident was free from neglect for 13 of 15 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #49, Resident #51, Resident #61, Resident #84, Resident #100, Resident #107, Resident #109) across 3 out of 3 units (100-Hall, 200-Hall and 300 Hall) reviewed for neglect. - The facility failed to take the appropriate actions of: retaining an IP with qualified training, complete tracking and trending of infections from August to October of 2023, treat diagnosed and presumptive scabies ( an infestation with the scabies mite), isolate of resident's with presumptive and diagnosed scabies, implement of environment controls to limit the spread of scabies and infection control surveillance to prevent a scabies outbreak even though the facility administration was aware that residents and staff had contracted the same unspecified rash over multiple months. This failure to take action resulted in multiple residents across multiple units experiencing itching/scratching, being diagnosed and/or treated for scabies and placed on contact isolation. - Resident #107 (100 Hall) was treated unsuccessfully for scabies from 07/2023 to 12/2023, experienced rashes/itching/discomfort and developed crusted scabies (a rare highly contagious hyper-infestation of the scabies mites that usually occurs in immune compromised patients). - Resident #39, who roomed with Resident #107, reported he was very itchy, developed rashes on his entire body, and was diagnosed /treated for scabies. - Resident #25, who roomed with Resident #107, developed rashes on his entire body, and was diagnosed /treated for scabies. - Resident #37 (100 Hall) developed rashes on his trunk, arm, and thigh eventually suffering from a secondary bacterial skin infection (cellulitis) - Resident #100 (300 Hall) developed rashes covering his entire body including his penis, was diagnosed /treated for scabies and placed on contact isolation. - Resident #51 (100 Hall) developed rashes on her abdomen and chest area, experienced itching, was placed on contact isolation and treated for scabies. - Resident #61 (100 Hall) developed rashes on his stomach and complained of itching. - Resident #81 (100 Hall) developed rashes to her arms, trunk, chest and scratching at her skin. - Resident #16 (100 Hall) developed a rash to his stomach, was treated for scabies and placed on contact isolation. - Resident #84 (100 Hall) developed a rash on his stomach, was treated for scabies and placed on contact isolation - Resident #109(100 Hall) developed a rash to his abdomen/trunk, was treated for scabies and placed on contact isolation. - Resident #20 (200 Hall) developed a rash on his arms, was treated for scabies and placed on contact isolation. - Resident #1 (300 Hall) developed a rash and was treated for scabies and was placed on contact isolation. -the facility failed to take prompt actions and identify potential issues early, without Surveyor intervention when Resident #49, who had a tracheostomy (tube inserted into the windpipe to help a person breathe) was observed to be in distress for an unknown period of time. -the facility failed to ensure the oxygen mask was in place to provide continuous oxygen flow to Resident #49 prior to leaving the resident's room. -the facility failed to maintain sterile procedure prior to tracheostomy suctioning for Resident #49. An IJ was identified on 12/18/23. The IJ template was provided to the facility on [DATE] at 04:09 PM. While the IJ was removed on 12/23/23 at 03:20 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for itching, discomfort, pain, secondary skin infections, acute respiratory distress and hospitalization . Findings included: Record review of the facility Infection Control Tracking and Trending for August, September and October of 2023 revealed, the tracking and trending was completed retrospectively for those months on 11/08/23 by the DON. Resident #107 Record review of Resident #107's Face Sheet dated 12/18/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of depression, difficulty swallowing, down syndrome, fluid overload, hypertension. The resident had a diagnosis of Atopic dermatitis (swelling and irritation of the skin) and congenital ichthyosis (a group of rare skin conditions that cause dry, scaly skin that individuals are usually born with) as of 11/03/23, he did not have a diagnosis of Scabies. The resident discharged to the hospital on 12/14/23. Record review of Resident #107's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, substantial/maximal assistance for most ADLs, an indwelling catheter, frequently incontinent of bowel and application of ointments/medications other than to feet. Record review of Resident #107's undated care plan revealed, focus areas of - ID, DD with PASRR services, potential nutritional problems, potential for pressure ulcer development, impaired cognitive function, a communication problem and tube feeding. There was no focus area to address Resident #107's treatment/diagnosis of scabies. Record review of Resident #107's Order Summary dated 12/18/23 revealed, Resident #107 had orders for Permethrin (an insecticide used to treat scabies) on multiple occasions but was only on contact isolation once: - 06/23/23 Permethrin 5% for dermatitis for 2 days: apply to head to toe topically one time only for 2 days. Leave on for 8-145 hours. - 07/26/23 Permethrin 5% for pruritus: apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning. - 08/18/23 Permethrin 5% : apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning per dermatologist. - 11/03/23 Permethrin 5% for prophylactic dermatitis for 2 days: apply at bedtime and leave overnight. Rinse of in AM. - 12//11/23 Permethrin 5% apply topically one time for scabies infestation. Leave in for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23 Contact Isolation- use strict contact precautions with protective garments. Record review of Resident #107's Dermatologist Note dated 07/26/23 revealed: Resident #107 was being seen as a referral from the Medical Director for a rash located on the body throughout. The rash was itchy and red and moderate in severity and it had been present for months. scaling and well demarcated, eczematous patches; differential diagnosis includes irritation dermatitis vs. scabies; plan- Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Follow up in 6 weeks for skin check. Record review of Resident #107's Dermatologist Note dated 11/03/23 revealed: Impression: Eczema associated diagnosis: Scabies; status: worsening, Itch Numerical Rating scale:10; % body surface covered in rash: 70. Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Record review of Resident #107's Physician Note dated 12/13/23 signed by the Medical Director revealed, Resident #107 was seen due to rash noted over the extremities and right upper shoulder that appeared crusted in nature. Diagnosis/Plan: unspecified dermatitis secondary to scabies infection, was started on permethrin cream, repeat treatment after 7 days, clean linens/clothes, deep clean room and contact isolation precautions in place. Record review of Resident #107's MARs from 06/2023 to 12/2023 revealed: - Jun 2023: Permethrin 5% apply to skin at bedtime for dermatitis for 2 days- it was only applied once on 6/24/23. - July 2023: Permethrin 5 % apply to skin for persistent dermatoses (a skin defect)- applied on 07/21/23. Permethrin 5% apply topically for pruritus- applied 7/26/23. - August 2023: Permethrin 5 %- applied 08/18/23 - November 2023: Permethrin 5 % prophylactically for dermatitis for 2 day- was only applied on 11/04/23 - December 2023: Permethrin 5% for scabies infestation use strict contact isolation- applied on 12/11/23 at 10:30 PM. Record review of Resident #107's Progress Notes from 12/22/22 to 12/23/23 revealed the resident's rash : - 06/24/23- generalized rash noted to entire body - 07/17/23- resident noted with recurrent rash to upper extremities - 07/23/23 day 7/7 of prednisone for generalized rash to torso. Area clean with red bumps noted from front/back torso. Resident scratching right front chest. - 08/24/23- generalized rash remains. - 09/12/23- Rash noted all over resident skin. - 11/02/23 at 01:30 AM: generalized rash remains pronounced, - 11/04/23 at 03:17 AM: generalized rash remains pronounced, dry, raised in some areas. - 11/04/23 at 10:15 AM : rash was still present to entire body and has new orders for permethrin 5% cream for 2 days and ammonium lactate 12% cream on shower day which will be on Monday 11/6/2023 - 12/14/23 at 02:30 AM- scaly, shedding, redness/self-inflicted scratches noted to skin. Resident on contact isolation There was only one mention of the resident having scabies on 12/12/23 at 04:01 AM- remain in contact isolation for scabies, permethrin cream applied to the entire body; and Resident #107 was first placed on contact isolation on 12/11/23. Record review of Resident #107's Hospital Progress dated 12/15/23 at 10:22 AM revealed, consult requested for cracking and flaking of skin with some deeper skin layer involvement. Dry thick crusted skin that extends from the right side of his head, neck, down the right shoulder, armpit, arm, right side of chest and left side of chest and armpit. Possible diagnosis of crusted scabies Record review of Resident #107's Hospital Wound Care Note dated 12/15/23 at 03:22 PM revealed, consult requested for cracking and flaking of skin with some deeper skin layer involvement. Dry thick crusted skin that extends from the right side of his head, neck, down the right shoulder, armpit, arm, right side of chest and left side of chest and armpit. Possible diagnosis of crusted scabies Record review of Hospital Infectious Disease Progress Note dated 12/17/23 at 07:46 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) and Topical Permethrin for crusted scabies. Record review of Hospital Infectious Disease Progress Note dated 12/18/23 at 05:32 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) for 4 days and Topical Permethrin for 3 days for crusted scabies. Record review of Resident #107's Medical Diagnoses printed 12/23/23 at 11:39 AM revealed, depression, difficulty swallowing, high blood pressure and atopic dermatitis. There was no documented diagnosis of scabies. An observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #107 was in the bed by the window, he was awake, receiving tube feeding, had a urinary foley catheter and was non interviewable. Resident #107 had fair colored skin with thick, dry, crusty, scaly large areas to the upper body. On both shoulders and upper arms were thick crusty, powdery white areas with red cracks. There were raised red bumps and rash to both forearms and to both upper thighs. The thighs had red scratch marks. The webbing between the thumb and pointer finger on both hands had powdery white irregular bumps. Resident #107 was scratching his groin and upper thighs. The treatment nurse stated he had dermatitis that worsened since he returned from the hospital in October 2023. The treatment nurse stated the rash on Resident #39 and Resident #107 appeared to be the same. She did not mention that Resident #107 had a presumptive diagnosis of scabies or that the resident was being treated for scabies. An observation and interview on 12/15/2023 at 4:00 PM revealed, Resident #107 in the ICU at the hospital with a diagnosis of respiratory failure and sepsis. Resident #107's room door was open and the resident was intubated(a tube into the throat to help breathing). The assigned hospital nurse stated when he was admitted on [DATE] d/t low blood pressures and elevated WBC. The hospital nurse stated they were not notified of the resident having scabies. The hospital nurse picked up her phone that was ringing and said it was the wound care nurse on the line who just told her she completed her evaluation done on 12/15/2023 and thought he might have scabies. The hospital nurses closed the resident's door and set up for contact isolation. Isolation signage was put up on the glass door. In an interview on 12/15/23 at 09:25 AM, MA A said she was present on 11/03/23 when Resident #107 saw the dermatologist. She said due to the rash being chronic and the severity of itching as well as the facility informing them other residents had similar rashes the Dermatologist wanted to treat Resident #107 for scabies. She said the MD ordered Permethrin 5% for Resident #107 to be repeated in 7 days. In an interview on 12/20/23 at 07:55 AM, the Hospital Treatment Nurse said when Resident #107 arrived to the hospital she observed thick plaques and rashes all over the parts of the body she could see (at least 1/3rd ) and she was surprised. She said the hyperkeratotic (a condition that causes skin to thicken in certain places) presentation and the residents history made her believe he had crusted scabies. Resident #39 Record review of Resident #39's Face Sheet dated 12/23/23 revealed, a 50-year-olf male who admitted to the facility on [DATE] with diagnoses of: chronic pain syndrome, contractures, lack of coordination, anemia and a scabies (onset 12/11/23). Record review of Resident #39's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, dependence for most ADLs and application of ointments/medications other than to feet. Record review of Resident #39's undated Care Plan revealed, focus-impaired visual function, refusal of care (showers/shampoos and general grooming), total assistance with all ADLs except feeding. Focus- actual impaired to skin integrity r/t thick skin and callous buildup to feet, he refuses to shower routinely which precipitates dry skin formation; intervention- identify/document potential causative factors and eliminate/resolver where possible; keep skin clean and dry. Record review of Resident #39's NP Note dated 11/30/23 signed by the NP revealed, skin: chronic seborrheic dermatitis ( a chronic inflammatory disorder affecting areas of the head and trunk were glands are located)- refuses showers. Record review of Resident #39's NP Note dated 12/08/23 signed by the NP revealed, Diagnosis/Plan: seborrheic dermatitis- refuses showers. There was no documented description of the resident's rash. Record review of Resident #39's MD note dated 12/13/23 and signed by the Medical Director revealed, Resident #39 had a red rash over the extremities of both upper and lower extremities. The resident was on isolation and was started on permethrin for scabies but he continued to refuse showers and application of creams. Diagnosis/plan: unspecified dermatitis secondary to scabies infection, on contact isolation, on permethrin cream repeated after 7 days and room to be deep cleaned and linens washed. Record review of Resident #39's Clinical Census dated 12/23/23 revealed, Resident #39 shared a room with Resident #107 from 10/24/23 until Resident #107 was discharged to the hospital on 12/14/23. Record review of Resident #39's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #39's Progress notes from 12/22/22 to 12/23/23 revealed, Resident #39's had rashes dating back to 06/2023. - 6/13/23 at 04:46 PM- Resident's lower extremities are swollen with wound., Also has rash all over the body but was refusing treatment and medication. - 06/26/2023 at 10:40- The entire body skin observed with rash. There was no other mention of Resident #39 suffering from a rash until 12/14/23 (3 days after being diagnosed with scabies:) - 12/14/23- remain in contact isolation/precautions, generalized skin rash remains to the body. Record review of Resident #39's Order Summary dated 12/23/23 revealed, - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. Start date 12/19/23. Record review of Resident #39's December 2023 MAR revealed, -Permethrin 5% topically at bedtime for scabies infestation- applied on 12/11/23 at 9:30 PM and 12/19/23 at 12:16 AM. Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #39 was awake, dressed in a hospital gown and brief and was in the bed by the door. Resident #39's arms, legs and hands were contracted. Resident #39 stated it was ok to look at his skin and that areas on his skin were very itchy. Resident #39 had small, red bumps on the scalp, forehead, cheeks, on both elbows, arms and both lower legs had large red bumps. The treatment nurse stated the redness to the elbows and red areas on his back were not new. The treatment nurse stated the new red bumps appeared sometime last week (12/4/2023 to 12/08/2023). The treatment nurse stated these new red bumps occurred at the same time Resident #107's red bumps appeared. Observation and interview on 12/23/2023 at 12:00 PM, Resident#39 was in contact isolation. He had a plate of food on his chest. He had red bumps on his scalp, face and arms and was unchanged from 12/13/23. He said he did receive the treatment cream, then showers the next day. Resident #39 stated he was told the cream was for scabies. He stated that it started with Resident #107 and maybe from not having the bed linens changed and washed. He stated that the bed linens were changed out daily and his personal belongings were removed. He stated he did not feel as itchy. He stated he was able to sleep through the night but during mornings he would feel itchy when he thinks about it. He stated he will be getting out of isolation soon and was happy about that because he wanted to get his money so he can buy soda. Resident #25 Record review of Resident #25's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of ID, schizophrenia, anemia, anxiety, hallucinations, depression and scabies (onset date 12/11/23). Record review of Resident #25's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, substantial to maximal assistance with most ADLs, and always incontinent of both bladder and bowel. There was no documentation of any applications of ointments/medication to the skin. Record review of Resident #25's undated Care Plan revealed, no related focus areas. There was no mention of any skin issues including rashes and scabies. Record review of Resident #25's Clinical Census revealed, Resident #25 shared a room with Resident #107 since 10/24/23. Record review of Resident #25's NP Note dated 11/27/23 revealed, no documented skin issues. Record review of Resident #25's NP Note dated 11/30/23 revealed- head to toe assessment done due to reports of patient had rash to both sides of his upper and lower extremities. He has elevated red bumps, dry scaly skin scattered to chest, abdominal area, back, both legs and arm but no rashes were observed on the web spaces of his hands, genitals or scalps. Monitor closes due to skin rash issues in the unit. Record review of Resident #25's NP Note dated 12/08/23 revealed, the resident was on hydrocortisone (steroid cream) for skin rash and the rash was unresolved. Record review of Resident #25's NP Note visit date 12/09/23 but signed on 12/18/23 revealed, Resident #25 was noted itching/scratching and had a persistent skin rash likely scabies. Resident #25 was treated with Sulfur 5% nightly for 3 days, with a plan to treat with Permethrin if the rash didn't resolve. Contact Isolation precautions and an oral medication to treat itching. Record review of Resident #25's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #25's Order Summary dated 12/23/23 revealed: - 12/09/23- Sulfur 5% lotion for dermatitis, apply to entire body from neck down, rub in and leave on for 24 hours. - 12/11/23- Permethrin 5%- apply to head to toe topically one time only for scabies infestation. Leave on for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23- Contact Isolation: use strict contact precautions with protective garments, every shift for scabies infestation. Record review of Resident #25's December 2023 MAR revealed, Resident #25 received Permethrin 5% on: - 12/12/23 at 08:43 AM - 12/20/23 at 12:52 AM Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #25 was in the middle bed in a full body, long sleeve jump suit. When the Treatment Nurse removed his body suit, Resident #25 was observed with had light pink, small, raised bumps to both upper arms and on the abdomen. The Treatment Nurse stated Resident #25 was treated with Hydrocortisone cream beginning 11/30/2023 for a rash to both arms and legs. Resident #37 Record review of Resident #37's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: epilepsy, asthma, arthritis, type 2 diabetes and scabies with an onset date of 12/16/23. Record review of Resident #37's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15, rejection of care, substantial/maximal assistance with most ADLs and application of ointments/medications to skin other than feet. Record review of Resident #37's undated Care Plan revealed, no documented focus areas addressing, skin, rashes or scabies. Record review of Resident #37's Census revealed he shared a room with Resident #107 from 08/28/23 to 09/23/23. Record review of Resident #37's Progress Notes from 12/22/22 to 12/23/23 revealed: - 09/22/23 at 02:33 PM the resident had a new rash to both arms, chest and legs. There was no documentation of the resident being placed on contact isolation. - 09/22/23 at 02:49 PM: Change of condition identified in a change in skin condition, the resident has a personal history of infectious and parasitic diseases. Skin Status Evaluation: itching rash and an order was given for Permethrin 5% to chest both legs and both arms which should be washed of in 8-12 hrs, hydrocortisone 1% cream for 7 days and calamine lotion for 2 weeks. There was no documentation of the resident being placed on contact isolation. - 10/02/23 at 10:34 PM: PERMETHRIN CREAM 5% APPLIED ON RESIDENT ENTIRE BODY THIS SHIFT AND TO BE WASHED OFF IN 8-12HRS. - 10/16/23 Resident on day 5/7 of antibiotics for cellulitis. Rash remains. - 10/18/23 Resident still on antibiotics for cellulitis. Rash still present and some itching noted. - 10/20/23 Resident still noted with rash all over his body and treatments continue - 10/27/23 Resident continues with steroid cream to the body for generalized rash, red raised bumps noted. - 10/40/23 Generalized rash red in color and bumpy. - 11/03/23 Rash present to body, generalized mild redness with complaints of mild itching. - 11/06/23 Rash still visible. - 11/08/23 Resident with generalized rash to body, some itching noted-redirected to avoid infection/pain. - 11/21/23 Resident seen by NP, new orders to apply steroid cream to rash all over his body twice daily for 30 days. - 11/24/23 Rash remains reddened pronounced and generalized. - 11/28/23 Rash remains reddened pronounced and generalized - 12/06/23 Rash remains reddened. Apply steroid cream to torso, back, upper extremities and thighs. - 12/13/23 Resident was on antibiotics for skin cellulitis and generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted. - 12/14/23 Rash with little improvement. - 12/15/23 generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted and worse. - 12/18/23 Day 1 of Permethrin 5% treatment to body An observation and interview on 12/12/23 at 09:55 AM revealed, Resident #37 lying in bed well dressed and well-groomed with rashes/scabs to his arms. When asked about the rash./sores the resident said everything was ok and would not respond further. Record review of Resident #37's NP Note dated 11/28/23 revealed, evaluation of dermatitis. Patient has rash to upper torso. Record review of Resident #37's NP Note dated 12/09/23 revealed, dermatitis unresolved. Record review of Resident #37's NP Note dated 12/12/23 revealed, dermatitis unresolved. Likely scabies infection will treat with Permethrin, repeat dose if not resolved and contact isolation precautions. Record review of Resident #37's Order Summary sprinted 12/23/23 revealed: - 06/23/23 Permethrin 5% for dermatitis, apply for 2 days. - 09/22/23 Permethrin 5%- apply to arms, legs, chest typically one time only written for 2 days. - 10/02/23 Permethrin 5% for scabies - Contact precautions- use contact precautions with protective garments. There are no previous orders for contact precautions - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments Record review of Resident #37's September 2023 MAR printed 12/23/23 revealed: - 09/22/23 Permethrin 5% applied at 04:45 PM. - 09/22/23 to 09/29/23 hydrocortisone 1% to arms, legs, and chest for pruritis at 09:00 AM and 05:00 PM Record review of Resident #37's October 2023 MAR printed 12/23/23 revealed: - 10/02/23 Permethrin 5% applied at 09:29 PM. - 10/26/23 to 10/31/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Record review of Resident #37's November 2023 MAR printed 12/23/23 revealed: - 11/01/23 to 11/06/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Resident #84 Record review of Resident #84's Face Sheet dated 12/19/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of: Parkinson, dementia, depression, communication deficit and scabies with onset of 12/16/23. Record review of Resident #84's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, extensive assistance with most ADLs and application of ointments/medications to the skin other than the feet. Record review of Resident #84's undated Care Plan revealed, no focus areas address rashes, itching or scabies. Record review of Resident #84's Census revealed, he shared a room with Resident #107 from 08/28/23 to 09/23/23 Record review of Resident #84's Progress Notes from 12/22/22 to 12/23/23 revealed, - 09/15/23 Resident noted with rash to entire body. - 10/03/23 Rash red and bumpy in appearance to legs and right thigh. - 10/20/23 Resident still noted with rash all over his body, treatment continues - 10/23/23 Resident given oral steroids for rash to lower legs, and areas of dry skin - 11/03/23 rash to both legs present bumpy and red. - 11/06/23 Dermatology appointment cancelled and will be rescheduled. - 11/16/23 Rash remains reddened, raised and generalized. - 11/30/23 Resident given oral antifungal for rash. - 12/14/23 Resident rash to both legs with little improvement. -12/15/23 Generalized rash/itching remain the same Record review of Resident #84's Order Summary report printed 12/23/23 revealed: - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact precautions with protective garments every shift - 12/2/23 Permethrin 5% for scabies. Use contact precautions with protective garments An observation on 12/12/23 at 09:55 AM revealed, Resident # 84 lying in bed with a limited range of motion and wedge pillows propping him up. The resident was observed to have a rash on both his arms and had limited communication capability and all he could say his butt burned. In an interview on 12/12//23 at 10:00 AM, the treatment nurse said Resident #84 was previously treated for wounds on his buttocks but the medication was discontinued because the issue had resolved. She said she would visit the resident to reassess him, and notify the wound care doctor about the resident's complaints. The Treatment Nurse did not address the Resident #84's itching. Resident #20 Record review of Resident #20's Face Sheet dated 12/16/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses: dementia, mood disorder, Anxiety disorder and depression. Record review of Resident #20's 5-day MDS dated [DATE] revealed, severely intact cognition as indicated by a BIMS score of 00 out of 15, partial assistance with most ADLs and no application of ointments/medication to the skin. Record review of Resident #20's undated Care Plan revealed, focus- elopement risk/wanderer onset 04/17/23; intervention- intervene as appropriate, distract resident from wandering by offering pleasant diversion, food, conversations, television or books. The care plan does not address any skin issues. Record review of Resident #20's MD Note dated 12/13/23 revealed, resident was started on a steroid cream for itching for 7 days. Skin: new rash to the back of the hand with some redness around it. Record review of Resident #20's Order Summary dated 12/23/23 revealed: - 11/03/23 Prednisone ( a steroid) 20 mg- 1 tablet one time a day for rash for 3 days. - 11/03/23 Hydrocortisone 1 %- apply topically two times a day for rash/dry skin - 11/03/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/03/23 Prednisone 10 mg- 1 tablet by mouth 1 time a day for rash for 5 days starting 11/08/23. - 11/27/23 Prednisone 20 mg- give 2 tablets by mouth daily for pruritus. - 11/27/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/28/23 Hydrocortisone 1 % for pruritus- apply topically two times a day to torso, both upper and lower extremities. - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact Precautions- use contact precautions with protective garments. - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments scheduled for 12/24/23 An observation and interview on 12/12/23 at 09:45 AM revealed, Resident #20 well dressed, well-groomed in a wheelchair in front of his room. The resident was wearing a long sleeve shirt but a rash c [TRUNCATED]

Based on observation, interviews and record reviews the facility failed to ensure that licensed nurses possess the specific competencies and skill sets necessary to provide nursing services to meet the residents' needs safely, and in a manner that promotes each resident's rights, physical and mental well-being as identified through resident assessments, and described in the plan of care for one of 16 (LVN R) facility staff reviewed for competencies and skill sets for assessments, in that: LVN R failed to take prompt actions and identify potential issues early, without Surveyor intervention when Resident #49 was observed to be in distress for an unknown period of time. LVN R failed to ensure Resident #49 was receiving continuous oxygen prior to leaving the resident alone. LVN R failed to ensure sterile gloves were used prior to handling the sterile suction catheter for Resident #49. An Immediate Jeopardy (IJ) situation was identified on 12/17/23. The IJ template was provided to the facility on [DATE] at 11:36 AM. While the IJ was removed on 12/22/23, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility still monitoring the effectiveness of their Plan of Removal. These failures in competencies could place residents at risk of their needs not being met safely, decline in health or hospitalization . Record review of Resident #49's face sheet dated 12/12/2023 revealed a [AGE] year-old female admitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. Her diagnoses included dementia, hypotension (low blood pressure), chronic respiratory failure, tracheostomy status (an airway surgically created through the neck into the windpipe to allow direct access to the breathing tube providing an airway and to remove secretions from the lungs), impaired swallowing, gastrostomy status(a feeding tube inserted through the abdomen to allow administration of nutrition), seizures, metabolic encephalopathy ( brain disturbance caused by conditions that disrupt blood chemistry affecting brain function), traumatic subdural hemorrhage(brain bleed), diabetes and anxiety disorder. Record review of Resident #49's hospital records revealed she was admitted to the hospital on 09/05/2023 for hypoxia (deprivation of oxygen at the tissue level) and hypotension (low blood pressure). The resident had a fever and was having secretions coming out the tracheostomy site. Her diagnoses included septic shock r/t aspiration PNA, acute respiratory failure r/t aspiration PNA and bacterial sepsis (a potentially life threatening infection). The resident was admitted to the ICU and placed on contact and droplet isolation. The resident was discharged to the facility on [DATE] . Record review of Resident #49's quarterly MDS dated [DATE] revealed the resident had minimal difficulty hearing, had no speech, was rarely/never understood, rarely/never understood others and had impaired vision. She required total dependence with one-to-two-person physical assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. She had functional limitations in range of motion d/t impairment on both sides of upper and lower extremities. She had medically complex conditions. Section I of the MDS revealed active diagnoses in the last 7 days included respiratory failure and chronic respiratory failure. Section O of the MDS revealed she required oxygen therapy and tracheostomy care while not a resident and while a resident. Record review of Resident #49's order summary report dated 12/12/2023 revealed the following active physician orders: O2 (oxygen) via tracheostomy @ 28-40% (2-5 L/m) to keep oxygen saturation rate at 92% or greater every shift related to tracheostomy status. Suction tracheostomy PRN for patent airway every shift. Monitor for pain every shift. Tracheostomy care every shift, clean stoma with normal saline, pat dry, change dressing every shift. Turning and repositioning every 2 hours. Ipratropium-Albuterol Solution 3ml inhale orally every 6 hours for SOB/Wheezing, pre-Respiratory Treatment Assessment prior to administering medication. Post Nebulizer Assessment every 6 hours. Record review of Resident #49's undated care plan revealed the following, Focus: The resident had altered respiratory status r/t chronic respiratory failure with trach placement. Interventions included administer medications as ordered, monitor for s/sx of respiratory distress and report to the physician, monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea (temporary cessation of breathing, especially during sleep), prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring; and provide oxygen as ordered. Focus: The resident had a tracheostomy r/t chronic respiratory failure. Interventions included: change oxygen tubing per protocol, change trach tubing and cannula per order, ensure trach ties are secured at all times, humidified oxygen as prescribed and suction as necessary. Focus: The resident had oxygen therapy r/t ineffective gas exchange. Goal: The resident will have no s/sx of poor oxygen absorption through the review date. Interventions included: give medications as ordered, monitor for s/sx of respiratory distress and report to MD, prevent abdominal compression and impaired respiratory functioning by routinely checking the resident's position to prevent sliding down in bed. Further review revealed no interventions to address potential complications such as unplanned extubation, aspiration, respiratory infection, and mucus plugging. Further review revealed no mention of hospitalization on [DATE] when Resident #49 was admitted to the ICU for aspiration PNA and sepsis . In an interview on 12/15/2023 at 7:22AM, LVN R stated she was new and had been working at the facility for only three weeks. LVN R stated she was assigned to the residents in 200 Hall, including the two residents with tracheostomies. LVN R stated she had respiratory care training for tracheostomy residents during orientation and the topics included oxygen, suctioning, trach care, s/s of infection and secretions. LVN R stated the inservice was conducted by Respiratory Therapy and she could not recall the therapist's name. Observation and interview on 12/15/2023 at 7:40 AM revealed Resident #49 in bed and her upper body leaning to her right side with the top of her head against the wall. The head of the bed was raised. The trach mask connected to the oxygen tubing was not over Resident #49's tracheostomy to provide continuous flow of oxygen and the straps on the mask was very loose. Copious amounts of thick, white secretion were inside the tracheostomy tube covering almost the entire opening and dripped down onto the resident's chest. The resident showed visible signs of distress in that her eyes were opened very wide with a fixed stare, her eyebrows furrowed, her chest barely moving, and her upper body bent in awkward position. The resident's arms were bent at the elbows and hands were contracted into fists. LVN R put on clean gloves, straightened the resident's body upright. The oxygen mask was still not over the resident's tracheostomy. LVN R stated the first thing she would do was to check the resident's oxygen saturation rate and check her blood pressure. LVN R stated she would need to get the equipment from down the hall. LVN R positioned the oxygen mask over the resident's tracheostomy after the Surveyor intervened. LVN R left the room. Resident #49's eyes closed, and her facial muscles relaxed. The oxygen was set at 3L/m. Resident #49's respiration rate was shallow at approximately 20 breaths per minute. LVN R returned at 7:47 AM with the O2 sat monitor and automated BP cuff. Resident #49's oxygen saturation rate fluctuated and then settled at 97% - 98%. At 7:55 AM the resident's BP on her left upper arm was 100/60 and pulse was 71 bpm. The opening to the tracheostomy still had thick secretions. At 7:58AM, LVN R stated she was going to suction the resident. She gathered supplies from the room. LVN R washed her hands and placed the sterile tracheostomy care kit on the bedside table. LVN R opened the kit that contained sterile gloves, bottle of sterile NS (normal saline) and a sterile single use suction catheter. LVN R put on the sterile gloves and stated she forgot to turn on the suction machine. LVN R stopped and was looking around the room. LVN R did not move. LVN R stated she had sterile gloves on. The Surveyor intervened and asked if she touched the items outside the sterile field would the gloves be sterile or clean. LVN R stated they would be clean and no longer sterile then she removed the gloves. LVN R removed the plastic dust cover and turned on the suction machine. LVN R held the suction machine tubing and was attempting to place the tubing onto the bedside table. The suction tubing slipped and would not stay put on the table without LVN R holding onto it. After LVN R hesitated, the surveyor asked if the tubing touched the floor would it be clean. LVN R stated it would become dirty. LVN R asked the Surveyor if it was ok to hang the tubing on the IV pole. LVN R hung the tubing on the IV pole. At 8:07AM LVN R washed her hands, put on pair of non-sterile gloves. LVN R opened the sterile suction catheter package and connected it to the suction machine tubing. LVN R opened the bottle of sterile NS and suctioned some of the sterile NS solution. LVN R moved the oxygen trach mask away from the opening of the tracheostomy. LVN R handled the tip of the sterile catheter then positioned it over the resident's tracheostomy, moving the tip closer to the inside of the tracheal tube. The Surveyor intervened prior to LVN R introducing the catheter tip into the resident's tracheal tube. LVN R stated the gloves were not sterile after the Surveyor intervened. LVN R she stated she forgot and needed sterile gloves to prevent infection. LVN R disposed of the gloves and the catheter into the trash. LVN R searched the room and said there were no more sterile suction catheters in the room and that she needed to get another one. LVN R left the room. The oxygen trach mask was not positioned over the resident's tracheostomy. The resident was not receiving the continuous flow of oxygen. The Surveyor intervened, put on clean gloves and quickly placed the mask over the tracheostomy for the resident to start receiving the flow of oxygen again. Resident #49's O2 sat was 98%. LVN R returned with supplies. LVN R stated she just forgot to put the trach mask back on the resident. At 8:15 AM the Surveyor exited the room to find a nurse to assist LVN R with suctioning. In an interview on 12/15/2023 at 8:15 AM, ADON B was walking down the hallway. The Surveyor explained that LVN R may need some assistance. ADON B stated the first thing LVN R should have done was suction Resident #49 to ensure the airway was patent and not blocked with secretions. ADON B stated she just saw another nurse enter Resident #49's room. In an interview on 12/15/2023 at 12:40PM, LVN R stated her shift started at 6:00 AM. LVN R stated she came in late, made her rounds, checked on Resident #49 and found her to be OK. LVN R stated she was not too familiar with Resident #49 and did not know her respiratory status. LVN R stated some s/sx of respiratory distress would be facial expressions, eyes widening and labored breathing. LVN R stated when she first entered the room with the Surveyor, the resident was bent to one side, had increased secretions, and she looked tired. LVN R stated the positioning of the oxygen trach mask was off the resident's tracheostomy and the straps to the trach mask should have been tighter. LVN R stated the straps and trach mask could have become loose during patient care. LVN R stated Resident #49 was supposed to have continuous oxygen and it was the nurse's responsibility to ensure the resident was receiving a continuous flow of oxygen. LVN R stated this was important so not to put the resident into respiratory distress. LVN R stated she should have positioned the oxygen mask back first before leaving the room. LVN R stated she forgot because she was nervous. LVN R stated she suctioned Resident #49 after the Surveyor left the room and that she did not have trouble with the procedure. In an interview on 12/15/2023 at 1:10 PM, the DON stated the first thing the nurse should have done was to get an oxygen saturation reading and suction the resident to prevent respiratory distress. In an interview on 12/16/2023 at 2:15 PM, RN D stated LVN R was a new nurse and panicked. RN D stated some s/sx of respiratory distress would be face changes, change in breathing pattern (which was distress), pain and something that would just not be right with the reident. RN D stated the risks to the resident would be respiratory distress, hypoxia, lethargy (lack of energy), infection d/t copious secretions . RN D stated she would not leave the resident, but instead would call for help and yell if she had to. RN D stated the first thing she would have done would be to increase the oxygen setting to ensure Resident #49 was getting enough oxygen. RN D stated she would not leave the resident without the oxygen mask on first. In a telephone interview on 12/16/2023 at 4:45 PM, RT B stated s/sx of respiratory distress would be changes in breathing pattern, bug eyed, crunched forehead and use of accessory muscles. RT B stated the number one s/sx of respiratory distress was restlessness. RT B stated nurses and RTs were responsible to ensure the resident was safe. RT B stated he would have put the oxygen back on the resident, do an assessment, ensure the tubing was clean, with no kinks then move to the next assessment and suction clearing the airway. In a telephone interview on 12/18/2023 at 11:45 AM, the MD stated Resident #49 was dependent on oxygen and was totally dependent on staff for ADLs. The MD stated she expected that the oxygen would be on all the time. The MD stated Resident #49 was able to tolerate being off oxygen at times, but waxes and wanes. The MD stated the risks if the resident did not receive continuous oxygen would be respiratory distress, trouble breathing, increased respiratory rate, increased crackles, may have excessive secretions. The MD stated sometimes a resident's heartbeat could exceed the normal resting rate and sometimes the blood pressure may change. The MD stated she would expect that nursing staff or RT would suction the resident if there were increased secretions. The MD stated sometimes she may order chest x-rays and/or labs. Record review of LVN R's inservice records for Respiratory Competency Performance for Tracheal Suctioning and Oxygen Administration Competency Review, dated 12/01/2023 and reviewed by a Respiratory Care Practitioner, revealed LVN R was proficient. Record review of the facility's undated procedure titled Skills Checklist - Tracheostomy suctioning, open suction system, read in part: .Objective: To suction a tracheostomy using an open suction system according to the standard of care .perform hand hygiene .Assess the patient's vital signs, breath sounds, respiratory effort and general appearance .remove the lid from the sterile solution and place it upside down on a clean surface .Using sterile technique, open the suction catheter kit and put on gloves. If using individual supplies, open the suction catheter and the gloves, then put on the gloves by first placing the nonsterile glove on your nondominant hand and then placing the sterile glove on your dominant hand. Using your nondominant (nonsterile) hand, pour a small amount of sterile solution into the sterile container. Close the solution bottle using your nondominant hand. Pick up the sterile suction catheter with your dominant (sterile) hand. Coil the catheter around your hand. Using your nondominant (nonsterile) hand, attach the catheter to the tubing. Turn the suction control valve to the on position and set the suction pressure to the lowest possible vacuum pressure needed to effectively clear secretions. Using your dominant (sterile) hand, lubricate the outside of the catheter by dipping in into the sterile solution. With the suction catheter tip in the sterile solution, occlude the suction control valve with the thumb of your nondominant hand; suction a small amount of the solution through the catheter. If the patient has a collar over the tracheostomy tube, move it Preoxygenate the patient with 100% oxygen for 30 to 60 seconds using a handheld resuscitation bag if necessary .Disconnect the handheld resuscitation bag if used. Insert the suction catheter into the tracheostomy tube; don't apply suction while inserting the catheter. Withdraw the catheter while applying intermittent suction and rotating the catheter between your fingertips. Reapply the tracheostomy collar .between suctioning passes . Record review of the facility policy and procedure for Respiratory Assessment, reviewed : April 15, 2016, revealed in part: Introduction .The normal respiratory rate for an average adult was 12 to 20 breaths/minute; however, it's important to know the patient's normal baseline respiratory rate to detect changes in the patient's condition Implementation .Count respirations by observing the rise and fall of the patient's chest during breathing .Identifying Respiratory Patterns: type-Apnea, Characteristics-Periodic absence of breathing, Possible causes-Mechanical airway obstruction, Conditions that affect the brain's respiratory center . This was determined to be an Immediate Jeopardy (IJ) on 12/17/2023 at 11:36 AM. The Administrator was notified. The Administrator was provided the IJ template on 12/17/2023 at 11:36 AM. The POR submitted by the Administrator was accepted on 12/21/2023 at 7:44 PM. The POR revealed: F726 - Nursing Services The facility failed to ensure residents received the necessary services to provide professional standard of care. Immediate Action: Nursing Services 12/17/2023 Resident #49 not in facility 12/20/21 Resident # 49 returned to the facility 12/15/2023 Resident #49 was assessed by the respiratory therapist and the ADON and notified family and physician. 12/17/2023 remaining resident with a trach was immediately assessed by the respiratory therapist in house. Status-stable and no respiratory distress 12-17-2023 12/17/2023 Nurse Identified re-educated on the policy and procedures for respiratory assessment, oxygen therapy, nebulizer therapy, tracheostomy suctioning and tracheostomy care. RRT provided the 1:1 training with return demonstration. 12/17/203 Licensed Staff were provided education on respiratory assessment, signs and symptoms of respiratory distress and how to manage respiratory distress by the RT. Training completion date will be 12/20/2023. All RNs, LVNs, received the training provided by RRT. All departments, housekeeping, dietary, maintenance, receptionist, nurses assistants, physical therapy were educated on signs and symptoms of respiratory distress and to notify the Charge Nurse immediately if respiratory distress was observed. All new hires will be required to complete training prior to job start. Staff education initiated per DON on 12/17/2023 on identifying signs and symptoms of respiratory distress and assessment. Training completion date 12/19/2023 All staff will receive training prior to their next shift. The Medical Director was notified of the IJ on 12/17/2023. Following acceptance of the facility's Plan of Removal, the facility was monitored from 12/21/23 to 12/22/2023. Monitoring of the plan of removal included: The surveyor confirmed the facility implemented their plan of removal sufficiently from 12/21/23 - 12/22/23 to remove the IJ by: Observations on 12/22/2023 at 10:25 AM of the only two residents in the facility with tracheostomies who required oxygen therapy (Resident #49 and Resident #93) revealed the residents were in no visible distress, oxygen trach masks were securely in place over the tracheostomy, no secretions noted, had clean dressings, oxygen settings were set at the physician's prescribed orders and emergency respiratory supplies were in place. The observation demonstrated the facility provided necessary nursing services to meet the resident's respiratory safety needs. In an interview on 12/22/23 at 9:15 AM, ADON B stated after discussion with Surveyor on 12/15/23 at 8:15 AM, she did go into Resident #49's room and that the resident was stable. In a telephone interview on 12/22/23 at 5:00 PM, RN/RCP H stated she did assess Resident #49 after LVN R completed tracheal suctioning on 12/15/23 and stated the resident was stable. The interviews demonstrated the facility followed up to ensure Resident #49 was stable after LVN R completed respiratory care on 12/15/2023. Interviews were conducted with staff, including LVN R, from all three shifts from 12/21/2023 - 12/22/23: DON, 3 RNs, 4 LVNs, 7 CNAs and 1 ancillary staff. Nurses were able to verbalize their understanding regarding resident assessments for the residents with tracheostomies; all aspects of respiratory care including, tracheostomy care, tracheal suctioning, oxygen therapy, nebulizer treatment, ensuring proper fit with the oxygen tracheostomy mask, respiratory assessments, emergency procedures, signs and symptoms of acute respiratory distress; how to manage distress as well as abuse and neglect policies and procedures. CNAs and ancillary staff were able to verbalize their understanding of signs and symptoms of respiratory distress, when to notify the charge nurse. Record review of the facility's policies and procedures for change of condition, revised May 2017; resident assessments, revised March 2022; respiratory assessments, date reviewed April 15, 2016; oxygen administration, revised October 2, 2015; tracheostomy emergencies-dislodgement. Record review of RNs and LVNs competency check lists and training reports conducted 12/15/23 through 12/22/23 for the following: respiratory assessments, signs/symptoms of respiratory distress and how to manage respiratory distress; tracheostomy care; tracheostomy suctioning; oxygen therapy; nebulizer treatments; infection control and conducted by Respiratory Therapists and DON. Record review of LVN R's re-education, competency check list completed on 12/18/23. The Administrator was unavailable. The Chief Officer of Operations was informed the Immediate Jeopardy (IJ) was removed on 12/22/2023 at 5:10 PM. While the IJ was lowered on 12/22/23, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility still monitoring the effectiveness of their Plan of Removal. 41469 47531

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 2 Residents (Resident #49) reviewed for tracheostomy care, in that:. -the facility failed to immediately reposition the oxygen mask over Resident #49's tracheostomy when the resident was found in distress. -the facility failed to immediately suction Resident #49's tracheostomy when the resident was found in distress, with copious (abundant) amounts of secretions at the tracheal tube. -the facility failed to ensure the oxygen mask was in place to provide continuous oxygen flow to Resident #49 prior to leaving the resident's room. -the facility failed to maintain sterile procedure prior to tracheostomy suctioning for Resident #49. An Immediate Jeopardy (IJ) situation was identified on 12/17/23. The IJ template was provided to the facility on [DATE] at 11:36 AM. While the IJ was removed on 12/22/23, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility still monitoring the effectiveness of their Plan of Removal. These deficient practices could place residents who were dependent on oxygen therapy at risk of respiratory distress, respiratory arrest, decline in health and hospitalization . Findings included: Record review of Resident #49's face sheet dated 12/12/2023 revealed a [AGE] year-old female admitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. Her diagnoses included dementia, hypotension (low blood pressure), chronic respiratory failure, tracheostomy status (an airway surgically created through the neck into the windpipe to allow direct access to the breathing tube to provide an airway and to remove secretions from the lungs), impaired swallowing, gastrostomy status (a feeding tube inserted through the abdomen to allow administration of nutrition), seizures, metabolic encephalopathy( brain disturbance caused by conditions that disrupt blood chemistry affecting brain function), traumatic subdural hemorrhage (brain bleed), diabetes and anxiety disorder. Record review of Resident #49's hospital records revealed she was admitted to the hospital on 09/05/2023 for hypoxia (deprivation of oxygen at the tissue level) and hypotension (low blood pressure). The resident had a fever and was having secretions coming out the tracheostomy site. Her diagnoses included septic shock r/t aspiration PNA, acute respiratory failure r/t aspiration PNA and bacterial sepsis (a potentially life threatening infection). The resident was admitted to the ICU and placed on contact and droplet isolation. The resident was discharged to the facility on [DATE] . Record review of Resident #49's quarterly MDS dated [DATE] revealed the resident had minimal difficulty hearing, had no speech, was rarely/never understood, rarely/never understood others and had impaired vision. She required total dependence with one-to-two-person physical assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. She had functional limitations in range of motion d/t impairment on both sides of upper and lower extremities. She had medically complex conditions. Section I of the MDS revealed active diagnoses in the last 7 days included respiratory failure and chronic respiratory failure. Section O of the MDS revealed she required oxygen therapy and tracheostomy care while not a resident and while a resident. Record review of Resident #49's order summary report dated 12/12/2023 revealed the following active physician orders: O2 (oxygen) via tracheostomy @ 28-40% (2-5 L/m) to keep oxygen saturation rate at 92% or greater every shift related to tracheostomy status. Suction tracheostomy PRN for patent airway every shift. Monitor for pain every shift. Tracheostomy care every shift, clean stoma with normal saline, pat dry, change dressing every shift. Turning and repositioning every 2 hours. Further review revealed a physician's order for Ipratropium-Albuterol Solution 3ml inhale orally every 6 hours for SOB/Wheezing, pre-Respiratory Treatment Assessment prior to administering medication. Post Nebulizer Assessment every 6 hours . Record review of Resident #49's undated care plan revealed the following, Focus: The resident had altered respiratory status r/t chronic respiratory failure with trach placement. Interventions included administer medications as ordered, monitor for s/sx of respiratory distress and report to the physician, monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea (temporary cessation of breathing, especially during sleep), prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring; and provide oxygen as ordered. Focus: The resident had a tracheostomy r/t chronic respiratory failure. Interventions included: change oxygen tubing per protocol, change trach tubing and cannula per order, ensure trach ties are secured at all times, humidified oxygen as prescribed and suction as necessary. Focus: The resident had oxygen therapy r/t ineffective gas exchange. Goal: The resident will have no s/sx of poor oxygen absorption through the review date. Interventions included: give medications as ordered, monitor for s/sx of respiratory distress and report to MD, prevent abdominal compression and impaired respiratory functioning by routinely checking the resident's position to prevent sliding down in bed. Further review revealed no interventions to address potential complications such as unplanned extubation, aspiration, respiratory infection, tracheal infection and mucus plugging. Further review revealed no mention of hospitalization on [DATE]. Resident #49 was admitted to the ICU for aspiration PNA and sepsis. In an interview on 12/15/2023 at 7:22AM, LVN R stated she was new and had been working at the facility for only three weeks. LVN R stated she was assigned to the residents in 200 Hall, including the two residents with tracheostomies. LVN R stated she had respiratory care training for tracheostomy residents during orientation and the topics included oxygen, suctioning, trach care, s/s of infection and secretions. LVN R stated the inservice was conducted by Respiratory Therapy and she could not recall the therapist's name. Observation and interview on 12/15/2023 at 7:40 AM revealed Resident #49 in bed and her upper body leaning to her right side with the top of her head against the wall. The head of the bed was raised. The trach mask connected to the oxygen tubing was not over Resident #49's tracheostomy to provide continuous flow of oxygen and the straps on the mask was very loose. Copious amounts of thick, white secretion were inside the tracheostomy tube covering almost the entire opening and dripped down onto the resident's chest. The resident showed visible signs of distress in that her eyes were opened very wide with a fixed, glassy stare, her eyebrows furrowed, her chest barely moving, and her upper body bent in an awkward position. The resident's arms were bent at the elbows and her hands were contracted into fists. LVN R put on clean gloves, straightened the resident's body upright. The oxygen mask was still not over the resident's tracheostomy. LVN R stated the first thing she would do was to check the resident's oxygen saturation rate and check her blood pressure. LVN R stated she would need to get the equipment from down the hall. LVN R positioned the oxygen mask over the resident's tracheostomy after the Surveyor intervened. LVN R left the room. Resident #49's eyes closed, and her facial muscles relaxed. The oxygen was set at 3L/m. Resident #49's respiration rate was shallow at approximately 20 breaths per minute. At 7:47 AM LVN R returned with the O2 sat monitor and automated BP cuff. Resident #49's oxygen saturation rate fluctuated and then settled at 97% - 98%. At 7:55 AM the resident's BP on her left upper arm was 100/60 and pulse was 71 bpm. The opening to the tracheostomy still had thick secretions. At 7:58AM, LVN R stated she was going to suction the resident. She gathered supplies from the room. LVN R washed her hands and placed the sterile tracheostomy care kit on the bedside table. LVN R opened the kit that contained sterile gloves, bottle of sterile NS (normal saline) and a sterile single use suction catheter. LVN R put on the sterile gloves and stated she forgot to turn on the suction machine. LVN R stopped and was looking around the room. LVN R stated she had sterile gloves on. The Surveyor intervened and asked if she touched the items outside the sterile field would the gloves be sterile or clean. LVN R stated they would be clean and no longer sterile then she removed the gloves. LVN R removed the plastic dust cover and turned on the suction machine. LVN R held the suction machine tubing and was attempting to place the tubing onto the bedside table. The suction tubing slipped and would not stay put on the table without LVN R holding onto it. After LVN R hesitated, the surveyor said if the tubing touched the floor would it be clean. LVN R stated it would become dirty. LVN R asked the Surveyor if it was ok to hang the tubing on the IV pole. LVN R hung the tubing on the IV pole. At 8:07AM LVN R washed her hands, put on pair of non-sterile gloves. LVN R opened the sterile suction catheter package and connected it to the suction machine tubing. LVN R opened the bottle of sterile NS and suctioned some of the sterile NS solution. LVN R moved the oxygen trach mask away from the opening of the tracheostomy. LVN R handled the tip of the sterile catheter then positioned it over the resident's tracheostomy, moving the tip closer to the inside of the tracheal tube. The Surveyor intervened prior to LVN R introducing the catheter tip into the resident's tracheal tube. LVN R stated the gloves were not sterile after the Surveyor intervened. LVN R stated she forgot and needed sterile gloves to prevent infection. LVN R disposed of the gloves and the catheter into the trash. LVN R searched the room and said there were no more sterile suction catheters in the room and that she needed to get another one. LVN R left the room. The oxygen trach mask was not positioned over the resident's tracheostomy. The resident was not receiving the continuous flow of oxygen. The Surveyor intervened, put on clean gloves and quickly placed the mask over the tracheostomy for the resident to start receiving the flow of oxygen. Resident #49's O2 sat was 98%. LVN R returned with supplies. LVN R stated she just forgot to put the trach mask back on the resident . At 8:15 AM the Surveyor exited the room to find a nurse to assist LVN R with suctioning. In an interview on 12/15/2023 at 8:15 AM, ADON B was walking down the hallway. The Surveyor explained that LVN R may need some assistance. ADON B stated the first thing LVN R should have done was suction Resident #49 to ensure the airway was patent and not blocked with secretions. ADON B stated she saw another nurse just then enter Resident #49's room. In an interview on 12/15/2023 at 12:40PM, LVN R stated her shift started at 6:00 AM. LVN R stated she came in late, made her rounds, checked on Resident #49 and found her to be OK. LVN R stated she was not too familiar with Resident #49 and did not know her respiratory status. LVN R stated some s/sx of respiratory distress would be facial expressions, eyes widening and labored breathing. LVN R stated when she first entered the room with the Surveyor, the resident was bent to one side, had increased secretions, and she looked tired. LVN R stated the positioning of the trach mask was off of the resident's tracheostomy and the straps to the trach mask should have been tighter. LVN R stated the straps and trach mask could have become loose during patient care. LVN R stated Resident #49 was supposed to have continuous oxygen and it was the nurse's responsibility to ensure the resident was receiving a continuous flow of oxygen. LVN R stated this was important so not to put the resident into respiratory distress. LVN R stated she should have positioned the oxygen mask back first before leaving the room. LVN R stated she forgot because she was nervous. LVN R stated she suctioned Resident #49 after the Surveyor left the room and that she did not have trouble with the procedure. In an interview on 12/15/2023 at 1:10 PM, the DON stated the first thing the nurse should have done was to get an oxygen saturation reading and suction the resident to prevent respiratory distress . In an interview on 12/16/2023 at 2:15 PM, RN D stated LVN R was a new nurse and panicked. RN D stated some s/sx of respiratory distress would be face changes, change in breathing pattern (which was distress), pain and something that would just not be right with the resident. RN D stated the risks to the resident would be respiratory distress, hypoxia, lethargy, infection d/t copious secretions. RN D stated she would not leave the resident, but instead would call for help and yell if she had to. RN D stated the first thing she would have done would be to increase the oxygen setting to ensure Resident #49 was getting enough oxygen. RN D stated she would not leave the resident without the oxygen mask on first. In a telephone interview on 12/16/2023 at 4:45 PM, RT B stated s/sx of respiratory distress would be changes in breathing pattern, bug eyed, crunched forehead and use of accessory muscles. RT B stated the number one s/sx of respiratory distress was restlessness. RT B stated nurses and RTs were responsible to ensure the resident was safe. RT B stated he would put the oxygen back on the resident, do an assessment, ensure the tubing was clean, with no kinks then move to the next assessment and suction clearing the airway. In a telephone interview on 12/18/2023 at 11:45 AM, the MD stated Resident #49 was dependent on oxygen and was totally dependent on staff for ADLs. The MD stated she expected that the oxygen would be on all the time. The MD stated Resident #49 was able to tolerate being off oxygen at times, but waxes and wanes. The MD stated the risks if the resident did not receive continuous oxygen would be respiratory distress, trouble breathing, increased respiratory rate, increased crackles, may have excessive secretions. The MD stated sometimes resident's heartbeat could exceed the normal resting rate and sometimes the blood pressure may change. The MD stated she would expect that nursing staff or RT would suction the resident if there were increased secretions. The MD stated sometimes she would order chest x-rays and/or labs. The MD stated she was not aware that Resident #49 had any issues on 12/15/2023 but there were other physicians that could have been notified. In an interview on 12/21/2023 at 12:19 PM, CNA EE stated she was assigned to Resident #49 and stated the nursing staff must do everything for her as she cannot do for herself. CNA EE stated the resident cannot move her legs, she can move one arm more than the other, when the Surveyor asked if the resident was able to move her limbs. CNA EE stated the signs of distress she saw were when she moved Resident #49's right leg for example and she heard the resident make a noise, sometimes she may cough and sometimes she would raise her eyebrows up and down. Record review of the facility's undated policy and procedure titled Skills Checklist - Tracheostomy suctioning, open suction system, read in part: .Objective: To suction a tracheostomy using an open suction system according to the standard of care .perform hand hygiene .Assess the patient's vital signs, breath sounds, respiratory effort and general appearance .remove the lid from the sterile solution and place it upside down on a clean surface .Using sterile technique, open the suction catheter kit and put on gloves. If using individual supplies, open the suction catheter and the gloves, then put on the gloves by first placing the nonsterile glove on your nondominant hand and then placing the sterile glove on your dominant hand. Using your nondominant (nonsterile) hand, pour a small amount of sterile solution into the sterile container. Close the solution bottle using your nondominant hand. Pick up the sterile suction catheter with your dominant (sterile) hand. Coil the catheter around your hand. Using your nondominant (nonsterile) hand, attach the catheter to the tubing. Turn the suction control valve to the on position and set the suction pressure to the lowest possible vacuum pressure needed to effectively clear secretions. Using your dominant (sterile) hand, lubricate the outside of the catheter by dipping in into the sterile solution. With the suction catheter tip in the sterile solution, occlude the suction control valve with the thumb of your nondominant hand; suction a small amount of the solution through the catheter. If the patient has a collar over the tracheostomy tube, move it Preoxygenate the patient with 100% oxygen for 30 to 60 seconds using a handheld resuscitation bag if necessary .Disconnect the handheld resuscitation bag if used. Insert the suction catheter into the tracheostomy tube; don't apply suction while inserting the catheter. Withdraw the catheter while applying intermittent suction and rotating the catheter between your fingertips. Reapply the tracheostomy collar .between suctioning passes . Record review of [NAME] Manual of Nursing Practice 11th Edition, Philadelphia, 2019 Wolters Kluwer, editor [NAME] M. Nettina, Chapter 10 Respiratory Function and Therapy, General Procedures and Treatment Modalities, read in part: .Types of Airways .6. Tracheostomy tube .a. Permits mechanical ventilation and facilitates secretion removal b. Can be for long-term use c. Bypasses upper airway defenses, increasing susceptibility to infection .Mobilization of Secretions - The goal of airway clearance techniques was to improve clearance of airway secretions, thereby decreasing obstruction of the airways. This serves to improve ventilation and gas exchange .Suctioning through an Endotracheal or Tracheostomy tube .4. Maintain sterile technique while suctioning . This was determined to be an Immediate Jeopardy (IJ) on 12/17/2023 at 11:36 AM. The Administrator was notified. The Administrator was provided the IJ template on 12/17/2023 at 11:36 AM. The POR submitted by the Administrator was accepted on 12/21/2023 at 12:20 PM. The POR revealed: F695 - Respiratory Care The facility failed to ensure that the resident received the necessary treatment and services in accordance with professional practice. 12/15/2023 Resident #49 was assessed by the respiratory therapist and the ADON and notified family and physician. 12/17/2023 Resident #49 not in facility 12/20/2023 Resident returned to the facility. 12/17/2023 remaining resident with a trach was immediately assessed by the respiratory therapist in house. Status-stable and no respiratory distress 12-17-2023 12/17/2023 Identified Nurse re-educated on the policy and procedures for respiratory assessment, oxygen therapy, nebulizer therapy, tracheostomy suctioning and tracheostomy care. Respiratory Therapist provided the 1:1 training with return demonstration. 12/17/203 All Nurses received training respiratory assessment, signs and symptoms of respiratory distress and how to manage respiratory distress. The training also covered principals of oxygen therapy nebulizer Therapy, suctioning, tracheostomy care and emergency care. All nurses are responsible for providing tracheostomy care to residents. Training completion date will be 12/20/2023. New Hire nurses will receive training on respiratory assessment, signs and symptoms of respiratory distress and how to manage respiratory distress. All nurses are provided as well as trach training that was provided by the respiratory therapist. CNAs, and all ancillary departments were educated on sign and symptoms of respiratory distress when to notify the Charge Nurse if respiratory distress was observed. Training was provided by Rn/RCP H and RT B. The training was completed on 12/19/23. The charge nurse will ensure that the resident with trach was monitored with her clinical rounds and note any respiratory distress based on their individual needs of the resident and prn as indicated. The monitoring of trach patients are completed routinely in the shift and prn as indicated by resident clinical condition. The charge nurse will observe the resident to ensure trach collar was in place and resident was receiving adequate oxygen and trach was clear of excessive secretions. Resident with trach will be suctioned per physician orders and as needed based off of the clinical changes in the resident. All new hires will be required to complete training prior to job start. Staff education initiated per DON on 12/17/2023 on identifying signs and symptoms of respiratory distress and assessment. Training completion date 12/19/2023 All nursing staff will receive training prior to their next shift. The Medical Director was notified of the IJ on 12/17/2023. The facility QAPI team reviewed the Respiratory Treatment and Care Policies on 12/20/2023. Monitoring of the plan of removal included: Following acceptance of the facility's Plan of Removal, the facility was monitored from 12/21/23 to 12/22/2023. The surveyor confirmed the facility implemented their plan of removal sufficiently from 12/21/23 - 12/22/23 to remove the IJ by: Observations on 12/22/23 of the only two residents in the facility with tracheostomies who were receiving oxygen therapy. In an interview on 12/22/23 at 9:15 AM, ADON B stated after discussion with Surveyor on 12/15/23 at 8:15 AM, she did go into Resident #49's room and that the resident was stable. In a telephone interview on 12/22/23 at 5:00 PM, RN/RCP H stated she did assess Resident #49 after LVN R completed tracheal suctioning on 12/15/23 and stated the resident was stable. Interviews were conducted with staff, including LVN R, from all three shifts from 12/21/2023 - 12/22/23: DON, 3 RNs, 4 LVNs, 2 RTs, 7 CNAs, 1 ancillary staff. Nurses were able verbalize their understanding regarding resident assessments for the residents with tracheostomies; all aspects of respiratory care including, tracheostomy care, tracheal suctioning, oxygen therapy, nebulizer treatment, ensuring proper fit with the oxygen tracheostomy mask, respiratory assessments, emergency procedures, signs and symptoms of acute respiratory distress as well as abuse and neglect policies and procedures. CNAs and ancillary staff were able to verbalize their understanding of signs and symptoms of respiratory distress, when to notify the charge nurse. Record review of the December 2023 physician orders, MAR/TAR, progress notes, physician notes and hospital records for the two residents (#49 and #93) with tracheostomies requiring oxygen therapy. Record review of the facility's policies and procedures for change of condition, revised May 2017; resident assessments, revised March 2022; respiratory assessments, date reviewed April 15, 2016; oxygen administration, revised October 2, 2015; tracheostomy emergencies-dislodgement. Record review of staff, competency check lists and training reports conducted 12/15/23 through 12/22/23 for the following: respiratory assessments, signs/symptoms of respiratory distress and how to manage respiratory distress; tracheostomy care; tracheostomy suctioning; oxygen therapy; nebulizer treatments; infection control and conducted by Respiratory Therapists and DON. Record review of LVN R's re-education, competency check list completed on 12/18/23. QAPI meeting worksheet dated 12/20/23, included respiratory care/respiratory distress, abuse/neglect, infection control was attended and signed by: Administrator, DON, ADON, IP, Wound care nurse, Social Services, Activities, Housekeeping Director, Maintenance Director, Medical Records Director, and Medical Director. The Administrator was unavailable. The Chief Officer of Operations was informed the Immediate Jeopardy (IJ) was removed on 12/22/2023 at 5:10 PM. While the IJ was lowered on 12/22/23, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility still monitoring the effectiveness of their Plan of Removal.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 (Resident #1) of 7 residents, reviewed for medications. -The facility failed to provide Resident #1 with a [MEDICATION NAME] for back pain as prescribed by his physician. -The facility failed to notify Resident #1's physician and re-order the [MEDICATION NAME] from the pharmacy. This failure affected 1 resident and placed him at risk of inadequate therapeutic outcomes and a decline in health. The findings included: Resident #1 Record review of face sheet for Resident #1 revealed he was a [AGE] year-old male admitted on 1/6/18 and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed he had a BIMS of 9 indicating moderate cognitive impairment. He was on a scheduled pain med regimen and did not receive non-medication intervention for pain. Record review Resident #1's care plan updated 10/1/19 read in part . Problem/Need - 10/1/19 C/O pain to lumbar/spine . Goal - Pain will be reported at acceptable level to resident x 90 days . Approaches - Attempt and document effectiveness of non-pharmacological interventions as appropriate (breathing, imagery, reposition, heat, ice) . Report unrelieved or unacceptable levels of pain to MD as needed . Notify family/responsible party of changes as needed . Apply [MEDICATION NAME] per order . Record review of physician phone order dated 11/28/19 read in part . 1. Biofreeze gel 5% apply topical to back at morning and night for back pain. 2. Lidodrm patch 5% apply one patch topical on night, off in the morning . pain . Record review of Resident #1's physician orders [REDACTED]. Record review of the shipping manifest dated 11/29/19 from the facility's pharmacy revealed Resident #1 had 5 individual patches of [MEDICATION NAME] 5% (700 mg) delivered on 11/29/19 at 13:12:42 to the facility. Record review of Resident #1's Physician order [REDACTED]. . [MEDICATION NAME] %5 patch patch apply one patch on at night off in the norming for pain . order date 12/2/19 . Sore throat [MEDICATION NAME] give one [MEDICATION NAME] by mouth twice daily PRN sore throat . order date 10/18/18 . Other chronic pain . Tylenol Ex-Str 500 mg caplet give 1 caplet by mouth twice daily (not to exceed 3G [MEDICATION NAME] in 24 hrs) . order date 5/21/19 . Tylenol 325 mg tablet give 2 tablets by mouth to equal 650 mg every 6 hours as needed for pain (not to exceed 3G [MEDICATION NAME] in 24 hrs) . order date 5/21/19 . Fever . Tylenol 325 mg tablet give 2 tablets by mouth to equal 650 mg every 6 hours as needed for pain (not to exceed 3G [MEDICATION NAME] in 24 hrs) . order date 5/21/19 . Assess resident for pain qshift Record Pain Scale (0-10) 0=No Pain 10=Excruciating Pain Monitor Pain Q Shift . order date 1/8/18 . Record review of Resident #1's MAR indicated [REDACTED]#1's [MEDICATION NAME] for pain was not administered. The explanation was Waiting on Supply or Other. Record review of Resident #1's facility Administration Record for the month of (MONTH) 2019 (e-MAR), read in part . 9:07 PM, 12/7/19, (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . scheduled for 12/7/19 8:00 p.m. was not administered - Other . MA B .8:47 AM, 12/8/19, (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) . waiting on supply . MA A . 8:25 AM, 12/9/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) . waiting on supply nurse aware . MA A . 7:56 PM, 12/9/19 (Scheduled: 8:00 PM,12/7/19 [MEDICATION NAME] 5% patch) Was not administered - Other . MA D . 9:11 AM, 12/10/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) . not applied . MA A . 7:36 PM, 12/10/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) .was not administered - Other . MA D .9:08 AM, 12/11/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) . waitin on supply 2/10 nurse aware . MA A . 7:36 PM, 12/11/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . was not administered - Other . MA D . 8:24 AM, 12/12/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) . not applied . MA A .7:42 PM, 12/12/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . was not administered - Other . MA D .8:21 AM, 12/13/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) .not apilled . MA A . 8:06 PM, 12/13/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . was not administered - Other . MA D .8:37 PM, 12/15/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . was not administered - Other . MA B .8:28 AM, 12/16/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) . not applied ,,, MA A . 8:30 PM, 12/16/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . Status Update: Administered to Status Removed . Addendum: Not given . MA D .8:31 PM, 12/16/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . was not administered - Other . MA D . 8:47 AM, 12/17/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) .not apply . MA A . Record review of Resident #1's Comprehensive Pain (MDS) data set [DATE] revealed he had experienced pain within the last 5 days. Resident #1 described his back pain as . stabbing pain that comes and goes . Interview on 12/17/19 at 11:44 a.m. with Resident #1, he said his only concern was the pain in his back. He said he usually got a pain patch put on at night but he did not get it last night. He said he got Tylenol but it does not last more than a few hours. He said the staff did not come back and ask him how strong his pain was. He said there was a cream that the staff put on, but it does not last long either. He said he had a cream in in his drawer that he used sometimes He said a family member brought it to him and he keeps it in the room. He said the staff, who he was not able to identify, would rub the cream from his drawer on his back. Observation at the same time on 12/17/19 revealed a container of Aspercreme in the bedside dresser drawer. Interview on 12/17/19 at 12:02 p.m. with Resident #1's family member, she said the resident has complained to her about his back pain and she purchased an over-the-counter muscle cream that he keeps in his room. She said he mentioned that the Tylenol helped a little, but the pain would come back. She said she thought the facility helped to manage his pain with his medications. She said she the facility did not tell her that Resident #1 had any problems with his insurance paying for medications. Interview on 12/17/19 at 5:34 p.m. with Resident #1's family member, she said she bought some over-the-counter cream because the Tylenol did not work. She said she brought Aspercreme for Resident #1 and he kept it in a drawer in his room. Interview on 12/17/19 at 1:08 p.m. with MA A, she said she did not have [MEDICATION NAME]es for Resident #1 on her cart. She said she did not remove a patch from the him this morning. She said he had been out of the [MEDICATION NAME] for a few days. She said the patch should have been applied each night. She said the medication aide or the nurses would reorder medication that ran out. She said she does not check effectiveness of the pain medication, the nurses do. Interview on 12/17/19 at 1:15 p.m. with LVN A, she said Resident #1 told her this morning that the pain medication he used today works a little bit on and off. She said she did not take off a patch from Resident #1's back today. She said the resident was out of the patches. She said he needed prior authorization from the doctor to get more. She said she notified the doctor last week. She said Resident #1's insurance did not pay for the patches. She said that DON and ADON were aware of the issue. She looked at the pharmacy shipping manifest and said 5 [MEDICATION NAME]es were delivered for Resident #1 on 11/29/19. After reviewing Resident #'1's (MONTH) MAR, she said she did not know why the two different staff had signed the MAR indicated [REDACTED]. She said that was the weekend staff. She said an ''X was marked in the box when the medication is not available and that staff person is able to put the reason why. She was not able to say what other non-pharmacological methods were tried to relieve Resident #1's back pain. She said physician orders [REDACTED]. Interview on 12/17/19 at 1:44 p.m. with MC Mgr., she said Resident #1's [MEDICATION NAME] was placed on Resident #1 for 5 consecutive days (12/1/19 to 12/6/19) at 8 p.m. She said it was taken off at 8 a.m. After reviewing the shipping manifest for the delivered [MEDICATION NAME] for Resident #1, she did not have an explanation for why the (MONTH) 2019 MAR for Resident #1 indicated he had received the patch on 12/8 and 12/14. She said there were no other patches delivered or available after 12/6/19. She said it was her responsibility to check orders along with ADON and DON. She also said it was the responsibility of the medication aide to inform the nurses if a medication was out. She said physician orders [REDACTED]. She said they did not discuss Resident #1's medication. She said she was not aware he did not have the patches or needed an authorization to order it. She said the medication aides and nurses should let her know and she could order it. She said if needed the doctor should have been called to get authorization for the pain patch or get a new medication. She said the facility did not have this medication or alternative in the e-kit. She said she was not aware if any non-pharmacalogical methods were attempted for Resident #1's back pain. Interview on 12/17/19 at 2:00 p.m. with ADON, she said no one had communicated to her that Resident #1 was out of the [MEDICATION NAME]. She said the medication aide would need to inform the nurse and the nurse should then notify the doctor. She said if the same medication could not be obtained then, we would call the doctor to get a substitute. She said all active orders should be followed until changed. She said the doctor should have been notified before the medication was out. She said it was our responsibility to ensure medications are available for the residents. She said staff should follow the resident's care plan. She said the nurse and the medication aide should have called Resident #1's physician and notified him that Resident #1 did not have [MEDICATION NAME]es. She said Resident #1's physician had not been notified that he was out of the patches prior to today. Interview on 12/17/19 at 2:20 p.m. with the Administrator, she said if a medication is out, the medication aide should make sure it gets ordered. She said we should not let a medication run out. She said the medication aide should have notified the nurse to re-ordered the medication as soon as possible. She said if there was a serious problem, like insurance issues, they should make sure the DON was aware. She said if the resident's insurance won't pay for the medication needed or waiting on authorizations then the facility needs to pay for it. She said a resident should not go without their medications. She said staff should follow the resident's care plan. She said she talked to the MC Mgr. the [MEDICATION NAME] or its equivalent was not typically kept in the e-kit. Interview was attempted on 12/17/19 at 2:10 p.m. with MA B, a message was left for MA B requesting a call-back and giving the surveyors state phone number. Interview was attempted on 12/17/19 at 12:01 p.m., 2:07 p.m. and 3:40 p.m. to MA C, the phone had a message indicating it was not able to receive calls at this time. A voicemail message was left with the surveyor state cell phone number requesting a call-back. Record review of facility policy on Administering Medication (revised (MONTH) 2010) read in part . Medication shall be administered in a safe and timely manner, and as prescribed . 3. Medication must be administered in accordance with the orders, including required time frame . Record review of facility policy on Pain Management Standards of Practice (revised 4/2019) read in part . Standard of practice . The facility's goal is to ensure all residents receive appropriate pain relief measures to assure that the resident pain does not affect their ability to function within their designated goals for functional ability .

Based on observation, interview, and record review the facility failed to 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 for 1 (Resident #1) of 7 residents reviewed for pain management. -The facility failed to ensure Resident #1's pain patch prescription was refilled to provide pain management for 11 days. This failure affected 1 resident and placed him at risk of inadequate therapeutic outcomes and a decline in health. The findings included: Resident #1 Record review of face sheet for Resident #1 revealed he was a [AGE] year-old male admitted on 1/6/18 and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed he had a BIMS of 9 indicating moderate cognitive impairment. He was on a scheduled pain med regimen and did not receive non-medication intervention for pain. Record review Resident #1's care plan updated 10/1/19 read in part . Problem/Need - 10/1/19 C/O pain to lumbar/spine . Goal - Pain will be reported at acceptable level to resident x 90 days . Approaches - Attempt and document effectiveness of non-pharmacological interventions as appropriate (breathing, imagery, reposition, heat, ice) . Report unrelieved or unacceptable levels of pain to MD as needed . Notify family/responsible party of changes as needed . Apply [MEDICATION NAME] per order . Record review of physician phone order dated 11/28/19 read in part . 1. Biofreeze gel 5% apply topical to back at morning and night for back pain. 2. Lidodrm patch 5% apply one patch topical on night, off in the morning . pain . Record review of Resident #1's physician orders [REDACTED]. Record review of the shipping manifest dated 11/29/19 from the facility's pharmacy revealed Resident #1 had 5 individual patches of [MEDICATION NAME] 5% (700 mg) delivered on 11/29/19 at 13:12:42 to the facility. Record review of Resident #1's Physician order [REDACTED]. . [MEDICATION NAME] %5 patch patch apply one patch on at night off in the norming for pain . order date 12/2/19 . Sore throat [MEDICATION NAME] give one [MEDICATION NAME] by mouth twice daily PRN sore throat . order date 10/18/18 . Other chronic pain . Tylenol Ex-Str 500 mg caplet give 1 caplet by mouth twice daily (not to exceed 3G [MEDICATION NAME] in 24 hrs) . order date 5/21/19 . Tylenol 325 mg tablet give 2 tablets by mouth to equal 650 mg every 6 hours as needed for pain (not to exceed 3G [MEDICATION NAME] in 24 hrs) . order date 5/21/19 . Fever . Tylenol 325 mg tablet give 2 tablets by mouth to equal 650 mg every 6 hours as needed for pain (not to exceed 3G [MEDICATION NAME] in 24 hrs) . order date 5/21/19 . Assess resident for pain qshift Record Pain Scale (0-10) 0=No Pain 10=Excruciating Pain Monitor Pain Q Shift . order date 1/8/18 . Record review of Resident #1's MAR indicated [REDACTED]#1's [MEDICATION NAME] for pain was not administered. The explanation was Waiting on Supply or Other. Record review of Resident #1's facility Administration Record for the month of (MONTH) 2019 (e-MAR), read in part . 9:07 PM, 12/7/19, (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . scheduled for 12/7/19 8:00 p.m. was not administered - Other . MA B .8:47 AM, 12/8/19, (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) . waiting on supply . MA A . 8:25 AM, 12/9/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) . waiting on supply nurse aware . MA A . 7:56 PM, 12/9/19 (Scheduled: 8:00 PM,12/7/19 [MEDICATION NAME] 5% patch) Was not administered - Other . MA D . 9:11 AM, 12/10/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) . not applied . MA A . 7:36 PM, 12/10/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) .was not administered - Other . MA D .9:08 AM, 12/11/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) . waitin on supply 2/10 nurse aware . MA A . 7:36 PM, 12/11/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . was not administered - Other . MA D . 8:24 AM, 12/12/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) . not applied . MA A .7:42 PM, 12/12/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . was not administered - Other . MA D .8:21 AM, 12/13/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) .not apilled . MA A . 8:06 PM, 12/13/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . was not administered - Other . MA D .8:37 PM, 12/15/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . was not administered - Other . MA B .8:28 AM, 12/16/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) . not applied ,,, MA A . 8:30 PM, 12/16/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . Status Update: Administered to Status Removed . Addendum: Not given . MA D .8:31 PM, 12/16/19 (Scheduled: 8:00 PM, 12/7/19 [MEDICATION NAME] 5% patch) . was not administered - Other . MA D . 8:47 AM, 12/17/19 (Scheduled: 8:00 AM, 12/7/19 [MEDICATION NAME] 5% patch) .not apply . MA A . Record review of Resident #1's Comprehensive Pain (MDS) data set [DATE] revealed he had experienced pain within the last 5 days. Resident #1 described his back pain as . stabbing pain that comes and goes . Interview on 12/17/19 at 11:44 a.m. with Resident #1, he said his only concern was the pain in his back. He said he usually got a pain patch put on at night but he did not get it last night. He said he got Tylenol but it does not last more than a few hours. He said the staff did not come back and ask him how strong his pain was. He said there was a cream that the staff put on, but it does not last long either. He said he had a cream in in his drawer that he used sometimes He said a family member brought it to him and he keeps it in the room. He said the staff, who he was not able to identify, would rub the cream from his drawer on his back. Observation at the same time on 12/17/19 revealed a container of Aspercreme in Resident #1's bedside dresser drawer. Interview on 12/17/19 at 12:02 p.m. with Resident #1's family member, she said the resident has complained to her about his back pain and she purchased an over-the-counter muscle cream that he keeps in his room. She said he mentioned that the Tylenol helped a little, but the pain would come back. She said she thought the facility helped to manage his pain with his medications. She said she the facility did not tell her that Resident #1 had any problems with his insurance paying for medications. Interview on 12/17/19 at 5:34 p.m. with Resident #1's family member, she said she bought some over-the-counter cream because the Tylenol did not work. She said she brought Aspercreme for Resident #1 and he kept it in a drawer in his room. Interview on 12/17/19 at 1:08 p.m. with MA A, she said she did not have [MEDICATION NAME]es for Resident #1 on her cart. She said she did not remove a patch from the him this morning. She said he had been out of the [MEDICATION NAME] for a few days. She said the patch should have been applied each night. She said the medication aide or the nurses would reorder medication that ran out. She said she does not check effectiveness of the pain medication, the nurses do. Interview on 12/17/19 at 1:15 p.m. with LVN A, she said Resident #1 told her this morning that the pain medication he used today works a little bit on and off. She said she did not take off a patch from Resident #1's back today. She said the resident was out of the patches. She said he needed prior authorization from the doctor to get more. She said she notified the doctor last week. She said Resident #1's insurance did not pay for the patches. She said that DON and ADON were aware of the issue. She looked at the pharmacy shipping manifest and said 5 [MEDICATION NAME]es were delivered for Resident #1 on 11/29/19. After reviewing Resident #'1's (MONTH) MAR, she said she did not know why the two different staff had signed the MAR indicated [REDACTED]. She said that was the weekend staff. She said an ''X was marked in the box when the medication is not available and that staff person is able to put the reason why. She was not able to say what other non-pharmacological methods were tried to relieve Resident #1's back pain. She said physician orders [REDACTED]. Interview on 12/17/19 at 1:44 p.m. with MC Mgr., she said Resident #1's [MEDICATION NAME] was placed on Resident #1 for 5 consecutive days (12/1/19 to 12/6/19) at 8 p.m. She said it was taken off at 8 a.m. After reviewing the shipping manifest for the delivered [MEDICATION NAME] for Resident #1, she did not have an explanation for why the (MONTH) 2019 MAR for Resident #1 indicated he had received the patch on 12/8 and 12/14. She said there were no other patches delivered or available after 12/6/19. She said it was her responsibility to check orders along with ADON and DON. She also said it was the responsibility of the medication aide to inform the nurses if a medication was out. She said physician orders [REDACTED]. She said they did not discuss Resident #1's medication. She said she was not aware he did not have the patches or needed an authorization to order it. She said the medication aides and nurses should let her know and she could order it. She said if needed the doctor should have been called to get authorization for the pain patch or get a new medication. She said the facility did not have this medication or alternative in the e-kit. She said she was not aware if any non-pharmacalogical methods were attempted for Resident #1's back pain. Interview on 12/17/19 at 2:00 p.m. with ADON, she said no one had communicated to her that Resident #1 was out of the [MEDICATION NAME]. She said the medication aide would need to inform the nurse and the nurse should then notify the doctor. She said if the same medication could not be obtained then, we would call the doctor to get a substitute. She said all active orders should be followed until changed. She said the doctor should have been notified before the medication was out. She said it was our responsibility to ensure medications are available for the residents. She said staff should follow the resident's care plan. She said the nurse and the medication aide should have called Resident #1's physician and notified him that Resident #1 did not have [MEDICATION NAME]es. She said Resident #1's physician had not been notified that he was out of the patches prior to today. Interview on 12/17/19 at 2:20 p.m. with the Administrator, she said if a medication is out, the medication aide should make sure it gets ordered. She said we should not let a medication run out. She said the medication aide should have notified the nurse to re-ordered the medication as soon as possible. She said if there was a serious problem, like insurance issues, they should make sure the DON was aware. She said if the resident's insurance won't pay for the medication needed or waiting on authorizations then the facility needs to pay for it. She said a resident should not go without their medications. She said staff should follow the resident's care plan. She said she talked to the MC Mgr. the [MEDICATION NAME] or its equivalent was not typically kept in the e-kit. Interview was attempted on 12/17/19 at 2:10 p.m. with MA B, a message was left for MA B requesting a call-back and giving the surveyors state phone number. Interview was attempted on 12/17/19 at 12:01 p.m., 2:07 p.m. and 3:40 p.m. to MA C, the phone had a message indicating it was not able to receive calls at this time. A voicemail message was left with the surveyor state cell phone number requesting a call-back. Record review of facility policy on Administering Medication (revised (MONTH) 2010) read in part . Medication shall be administered in a safe and timely manner, and as prescribed . 3. Medication must be administered in accordance with the orders, including required time frame . Record review of facility policy on Pain Management Standards of Practice (revised 4/2019) read in part . Standard of practice . The facility's goal is to ensure all residents receive appropriate pain relief measures to assure that the resident pain does not affect their ability to function within their designated goals for functional ability .

Based on observation, interview, and record review the facility failed to have a system to prevent, identify, investigate, and control infections/communicable diseases for all residents and failed to follow standard and transmission-based precautions to prevent the spread of infections for 4 (Residents #24, #18, #37, and #11) of 24 residents reviewed for infection control. -The facility staff failed to maintain standard precautions of infection control during care of residents. -The facility failed to investigate residents with new rashes after Resident #24 began treatment for [REDACTED]. -The facility failed to diagnose Resident #18's scabies from 7/1/19 to 9/6/19. Resident #18. -The facility failed to investigate 3 other residents with rashes when Resident #18 was diagnosed with [REDACTED]. -The facility failed to track the location and implement transmission-based precautions when residents #24, #18, #37, and #11 developed signs and symptoms of a persistent itchy rash. Theses failures affected 4 residents and placed them at risk of an infection and reduced quality of life. Findings included: Resident #24 Record Review of Resident #24's face sheet revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #24's quarterly MDS assessment dated [DATE] revealed he had long and short term memory problems and severely impaired cognitive skills. No rashes were identified. Record Review of Resident #24's Care Plan dated 5/6/19 revealed a [DIAGNOSES REDACTED]. Record Review of Resident #24's Nursing Notes revealed the following: -3/1/19 at 6:28 a.m. written by LVN R, read in part . resident is on day 10/10 of topical cream for body rash . -3/4/19 at 8:10 a.m. written by LVN V, read in part . resident post cream application, noted sill itching, mild rashes, noted to some body area, agitated during care, up in dining room . 3/10/19 at 10:48 a.m. written by LVN ZZ, read in part . resident scratching continuously all over. Refused [MEDICATION NAME] to relieve itching . -3/22/19 at 3:09 p.m. written by LVN V, . resident went to dermatology appointment, scheduled by family, new orders noted and in place. [MEDICATION NAME] .1% cream (used to treat a variety of skin conditions, e.g., [MEDICAL CONDITIONS], allergies [REDACTED]. -4/1/19 at 10:22 a.m. written by LVN V, read in part . [MEDICATION NAME] cream .1% continued . -5/6/19 at 9:44 a.m. written by LVN V, read in part . resident oop with (family member) to dermatology appt as scheduled due to non-improving rashes to his body as ordered . -5/20/19 at 10:11 p.m. written by LVN Y, read in part . resident noted to be scratching his legs. Attempt to put cream on legs res began screaming out and refused. Neuro vitals completed. No apparent distress noted . -6/3/19 at 12:18 p.m. written by LVN V, read in part . [MEDICATION NAME] 0.1% cream applied topically, resident refused . -8/16/19 at 10:35 a.m. written by LVN V, read in part . resident's family member called and notified about arranging f/u appointment with dermatology and notify nursing staff so that transport can be arranged . -8/16/19 at 10:53 p.m. written by LVN H, read in part .cream to dry skin/make an appt for dermatologist . -9/5/19 at 1:56 p.m. written by LVN V, read in part . resident has dermatology appt with doctor (name) scheduled by family to on 9/16/19 at 10 am p/u by Right Choice at 9 a.m. Interview on 9/13/19 at 10:43 a.m. with the DON, he said Permitherin Cream was used for scabies. He said he was unsure if there were a different use for the medicated cream. He said no staff had informed him of a [DIAGNOSES REDACTED]. He said he had not reported the 2 confirmed cases to health officials. The DON said he was not familiar with what a scabies rash looked like but did provide an in-service staff on scabies. He said he instructed the staff to inform him, the resident family, and the resident doctor. DON said not everyone with a rash should be tested for scabies. He said not all rashes are scabies. He said the residents who were diagnosed with [REDACTED]. The DON said scabies was diagnosed on ly through a skin scraping. He said scabies can spread if undiagnosed or not treated. DON said anyone who had not had a skin scraping could not be ruled out as scabies. He said he does not suspect anyone has scabies other than the residents who had already been diagnosed . He said it was very difficult to identify a regular rash from a scabies rash. He said that testing for scabies had not been done because treatment should be tried first. Interview on 9/13/19 at 11:10 a.m. with the Administrator, she said that she did care that there were residents who have had rashes for weeks and have not been tested for scabies. She said that she was working with medical directed and regional nurse and skin assessments have been started. She said that once a resident appears to have scabies, a dermatology appointment would be made, and usually they have to wait a few weeks. She said a skin assessments tracking form was created (MONTH) 15th when the doctor came and discussed the skin rashs. Scabies does have the potential to effect all areas of the facility. Anytime someone has a change of condition, it should be addressed immediately. Interview with Medical Director on 9/13/11:44 a.m., he said that based on having the knowledge of a [DIAGNOSES REDACTED]. He said that it would be up to the facility protocol and policy as to whether or not the residents who have rashes should be on contact isolation or not, pending skin scraping appointment. Interview with Medical director on 9/13/19 at 2:21 p.m., he said that he was aware there was a delay of proper treatment for [REDACTED]. Resident #18 Record review of Resident # 18's face sheet revealed she [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #18's annual MDS dated [DATE], revealed an unknown BIMS, indicating resident was not interviewable. She needed limited assistance of 1 staff with bathing. Record review of Resident #18's care plan dated 8/1/19 read in part . impaired skin integrity as evidence by a visible rash with additional risks related to itching . [DIAGNOSES REDACTED]. dated 9/6/19 . Resident #18's current Physician order [REDACTED]. Resident #18's Prescription Patient Handout revealed that [MEDICATION NAME] 5% topical cream is used for Scabies. Scabies was an infestation of mites that was very contagious and household contacts should be treated. Observation on 9/11/19 at 1:58 p.m. at Resident #18's room, revealed isolation gowns placed in the trash receptacle and a sign indicating the resident was on contact isolation. Interview on 9/11/19 at 1:58 p.m. with LVN F, said the gowns were to be removed and placed in a biohazard container and not the trash receptacle. Interview on 9/11/19 at 2:00 p.m. with CNA CC, she said all linen and isolation equipment trash were to be placed in the two biohazard boxes in the bathroom. She said staff were to remove the gowns in the bathroom and place them in the biohazard box. Interview on 9/12/19 at 11:48 a.m. with PT Supervisor, she said that yesterday, she realized that 2 of her therapists went into a Resident's room to provide therapy for her roommate who was on contact isolation. The therapists geared up and then threw the gowns into the regular trash. They did not throw them away in the biohazards bin provided in the bathroom. An in-service and training was completed for all therapy staff on contact isolation procedures. Record Review of Resident #18's Nursing Notes revealed the following: -7/1/19 at 2:40 p.m. written by LVN F, read in part . Resident is alert and oriented x 3, skin is warm and dry to touch, boil to inner aspect of left knee, rash to chest area, hip and back per report and wound care nurse notified. T 98.2 . -7/1/19 at 7:18 p.m. written by LVN M, read in part . Resident noted rash to upper left chest area, upper back area and left hip and boil with redness to left inner knee but no drainage noted. (name) visited and examine resident and new orders received to 1) start [MEDICATION NAME] 100 mg 1 tab . bid x 10 days 2) start [MEDICATION NAME] 25 mg bid x5 days . [MEDICATION NAME] 100 mg given from the [NAME] kit and [MEDICATION NAME] 25 mg . was also given with no adverse reactions. Resident with no c/o any pain. Temp 88.3 . -7/2/19 at 2:05 p.m. written by ADON RN, read in part . IDT meeting held to discuss resident. Resident has boil to left inner thigh. Stared on [MEDICATION NAME] 100 mg po bid x 10 days and [MEDICATION NAME] 25 mg po bid x5 days. Also started on [MEDICATION NAME] cream bid x7 days due to rash. Area dry with redness noted. Wound care consult done . -7/8/19 at 7:58 p.m. written by LVN M, read in part . Doctor (name) visit and new order noted to continue [MEDICATION NAME] cream 0.5% to apply on the left thigh bid x7 days for rash. Resident also continues on ABT [MEDICATION NAME] 100 mg . bid day 8/10 for boil to inner left knee with no adverse reactions noted. Resident with no c/o pain or discomfort . -7/23/2019at 1:26 p.m. written by LVN F, read in part . Resident is alert and oriented x 3, complained of 3/10 pain to red swollen area to left hip; NP for (name) visited, and new order received for TAO to apply to left hip area TID x 7 days and for wound care nurse to evaluate. Resident continues on [MEDICATION NAME] and [MEDICATION NAME] for pain . -7/31/19 at 10:56 p.m. written by LVN M, read in part . Resident was c/o back itching real bad and upon assessment she is noted to have some red area to back, chests, abdomen, and both arms. Dr. Patel in the facility and notified of same and she examined the resident and gave order to start Tiamcinolone 0.5% ointment bid x 10 days for rash. -8/20/19 at 7:58 p.m. written by LVN M, read in part . Resident was seen earlier by N/P for Dr. Patel and new order noted for [MEDICATION NAME] ointment 0.5%, apply to back bid x 7 days, DX: Rash . -9/5/19 at 3:53 p.m.; completed by ADON RN, read in part . Resident had dermatology appointment today. Went with resident to appointment due to rash concern. Resident was seen by dermatology and skin scraping was performed. Resident was diagnosed with [REDACTED]. Medications was ordered from pharmacy and awaiting delivery. To be applied by nursing management in the morning to ensure cream applied to entire body. Resident placed on contact isolation until treatment is finished . Interview on 9/12/19 at 12:08 p.m. with CNA X, she said she gave Resident #18 a shower on 9/10/19 in the shower room that all the residents use. She said she had not any training on how to prevent the spread of scabies. She said she went to her own doctor because she got the rash also. She said she was treated for [REDACTED]. She was told not to say that it was scabies by the facility management. She said the rashes on residents and staff was still a problem at the facility. Interview on 9/12/19 at 12:12 p.m. with CNA CC, she said she had seen rashes on a lot of residents including Resident #18. She said Resident #18 was diagnosed with [REDACTED].#18 and sprayed the shower down with disinfectant afterwards. She stated she was trained to disinfect the shower. She said the protocol was no different for residents on isolation. Resident #37 Record review of Resident #37's face sheet revealed he was [AGE] years old and was re-admitted to the facility on [DATE]. Resident #37's [DIAGNOSES REDACTED]. Record Review of Resident #37 's care plan dated 8/16/10 had a concern of rash to posterior buttocks and interventions included to apply [MEDICATION NAME] ointment as directed. Record Review of Resident #37's TAR dated 9/2019, read in part . [MEDICATION NAME] 0.5% ointment to be applied to buttock, hips and dorsal thigh twice daily for [DIAGNOSES REDACTED]. Observation and Interview on 9/12/19 at 3:15 p.m. of Resident #37 which included a skin assessment completed by DON, revealed Resident #37 had small scattered red raised areas on his chest and buttocks. During the assessment Resident #37 said that the rash areas were very itchy. He said the rash started about 3 weeks ago. Interview with DON on 9/12/19 at 3:15 p.m., he said Resident #37's rash was improving with the [MEDICATION NAME] cream. He said Resident #37 skin rash did not need to be tested for scabies since the rash was improving. DON said Resident #37 did not have scabies and did not need to be tested . Interview on 9/13/19 at 11:10 a.m., the Administrator said she was not aware of Resident #37's rash. Scabies had the potential to effect all areas of the facility. Anytime someone has a change of condition, it should be addressed immediately. Record review of a Quality Assurance IDT concern for residents with rashes initiated in (MONTH) 2019. The report had a skin assessment for Resident #37 dated 9/9/19. Resident #37's rash was on his torso and buttocks. The QA IDT did not identify Resident #37's rash on the tracking or trending form. Resident #11 Record Review of Resident #11's face sheet revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #11's quarterly MDS assessment dated [DATE] revealed he had moderately impaired cognitive skills. No rashes were checked on his assessment. Record review of Resident #11's care plan included a number of different interventions for skin. They included 9/10/19 rash to trunk. 7/19/19: apply [MEDICATION NAME] Cream completed 8/2/19. 7/26/19: Apply Vaseline to dry skin x 14 days. 9/1/19: Administer [MEDICATION NAME] per orders. Record review of Resident #11's (MONTH) 2019 physician's orders [REDACTED]. Record Review of Resident #11's Nursing Notes revealed the following notes: -7/23/19 at 6:12 a.m., written by LVN R, read in part . Topical [MEDICATION NAME] cream application to chest and both upper arms continue as ordered . -7/25/19 at 6:18 a.m. written by LVN R, read in part . Resident continue on topical [MEDICATION NAME] cream and [MEDICATION NAME] oral therapy day 2/5 for itching . -7/26/19 at 5:44 a.m. written by LVN R, read in part . [MEDICATION NAME] cream application for skin rash on going on day 6/14 and [MEDICATION NAME] oral therapy on day 2/5 for itching in progress . -9/12/2019 at 6:02 p.m. written by ADON RN, read in part . was reported that resident had a rash. Resident was assessed in his room by myself and DON full head to toe assessment was done with no rash noted. Asked resident if he had a rash, he stated that he has itching at times. Explained to resident that we did not see any rash on his body. Resident stated that after he eats certain things he begins to itch. Asked resident if he was itching now and he stated no. Asked resident when does he have itching? He stated he things it's from eating oranges. Asked resident to refrain from eating oranges or orange juice for a week to see if his itching improves . -9/13/19 at 1:22 p.m. written by LVN V, read in part . resident continue with [MEDICATION NAME] cream application as ordered for body rash day 3/10 improvement noted, will continue to monitor . Record Review of Resident #11's Medical Progress Note revealed the following: -8/1/19 - rash and itching improving. -8/21/19 - rash is noted. -9/3/19 - rash is improving. Observation and Interview on 9/10/19 at 10:53 a.m. with Resident #11, he said that he was itching all over his body and it won't go away. Observation of LVN V skin assessment revealed Resident 11's had red dots on his neck and back. Interview on 9/12/19 at 10:04 a.m. with LVN V, she said she was aware of the itching and red spots on Resident #11's body. She said the resident had been treated for [REDACTED]. She said the treatment that Resident #11 received, helped with the rash and it had improved when the resident was compliant with treatment. Observation and Interview on 9/13/19 at 9:43 a.m. with Resident #11 and LVN V skin assessment. Resident #11 had a red raised area on the right side of chest, red scabbed area on the right armpit, old scratches on his back, and small scabbed area on upper left leg with a scratch beside the scabbed area. Resident #11 said his skin was itching badly on his left leg and under his arm pits and said he had had the rash for 3-4 weeks. LVN V said Resident #11's rash was being treated with [MEDICATION NAME] cream the rash was improving with the cream. Interview on 9/13/19 at 10:43 a.m., the DON said Resident #11 did not have a rash. DON said he believed Resident #11's rash was related to an allergic reaction to oranges. The DON said he and ADON RN completed a skin assessment on Resident #11 on 9/12/19 and 9/13/19 and did not see a rash on the resident. The DON said scabies was diagnosed on ly through a skin scraping. He said scabies can spread if undiagnosed or not treated. DON said anyone who had not had a skin scraping could not be ruled out as scabies. He said he does not suspect anyone has scabies other than the residents who had already been diagnosed . He said it was very difficult to identify a regular rash from a scabies rash. He said that testing for scabies had not been done because treatment should be tried first. Interview on 9/10/19 at 10:56 a.m. with Resident #11's family member, she said she took Resident #11 to the doctor. She said the doctor saw the resident's rash and said it was not bed bugs. The doctor ordered a cream for the spots on his skin to rule out allergies [REDACTED]. The family member said the cream was not working, rash was not improving. Interview on 9/12/19 at 9:37 a.m. with CNA HH, she said she bathed Resident #11 in the shower room. She said the resident had bumps on his chest and complained that the area was burning. She said no transmission-based precautions were put into place while giving the resident a shower. Interview on 9/13/19 at 10:43 a.m. with the DON, he and ADON RN completed an assessment on Resident #11 on 9/12/19 about 1:00 p.m. and on 9/13/19 and did not see a rash on the resident. The DON said Resident #11 did not have a rash. He said he believes Resident #11's rash was related to an allergic reaction to oranges. Interview on 9/12/19 at 3:15 p.m. with the DON, he said the infection control IDT was made up of the DON, ADONs, and infection control physician. He said there were no issues when the infection control doctor reviewed the infection control tracking and trending. The DON said in-services were started on 9/5/19 after two residents were diagnosed with [REDACTED]. Interview on 9/12/19 at 9:37 a.m. with CNA HH, she said in (MONTH) 2019 she was diagnosed with [REDACTED]. She said ADON RN said that it was nothing. CNA HH said she worked consistently with a resident who had a rash. She said she was not aware if the resident was diagnosed with [REDACTED]. CNA HH said she went to the doctor and he ordered a treatment for [REDACTED]. CNA HH said she showed LVN V the cream she was ordered, and CNA HH told the nurse she had scabies. She said she was not told to take time off because of the [DIAGNOSES REDACTED]. Interview on 9/12/19 at 10:04 a.m., LVN V said she was aware of the [DIAGNOSES REDACTED]. LVN V said CNA HH was not getting treatment from the facility, but had gone to her personal physician for treatment. She said if a resident was diagnosed with [REDACTED]. LVN V said she had an in-service on infection control and scabies since the diagnoses. The in-service was done by the DON. She said she thought all the residents should be on the infection control protocol. Interview on 9/13/19 at 8:35 a.m. with ADON RN, she said he was aware of the rashes on the residents. He said he took four residents to the dermatologist for a skin scraping because he wanted to make sure the skin scraping was done. He did not provide the test results or the date of the tests. He said only 3 residents were tested because one Resident's rash had already healed. ADON RN said there was no record of any staff getting scabies. He said staff that took the residents to the doctor had to bring something back. He said residents with a rash did not need to go on isolation until scabies was diagnosed . Interview on 9/13/19 at 10:43 a.m. with the DON, he said Permitherin cream is used for scabies. He said he was unsure if there is any other use for the cream. He said there were no staff that reported scabies to him. He said that if someone had scabies they would not be working at the facility until treated. DON said if staff verbalized they had a rash or scabies, they would be removed from duty regardless of the documentation provided. He said he was not too familiar with the [DIAGNOSES REDACTED]. The DON said he was not familiar with what a scabies rash looked like. He said he did inservice staff on scabies. He explained to the staff that if they see a rash they need to notify DON, family and the physician. DON said not everyone with a rash should be tested for scabies. He said not all rashes were scabies. He said residents who were diagnosed with [REDACTED]. The DON said scabies diagnosed on ly through a skin scraping. He said scabies could spread if undiagnosed or not treated. DON said anyone who had not had a skin scraping could not be ruled out as scabies. He said he does not suspect anyone has scabies other than the residents who had already been diagnosed . He said it is very difficult to identify a regular rash from a scabies rash. He said that testing for scabies had not been done because treatment should be tried first. Interview on 9/13/19 at 11:10 a.m. with Administrator, she said that she did care that there were residents who have had rashes for weeks and have not been tested for scabies. She said that she was working with medical director, the regional nurse, and skin assessments have been started. She said that once a resident appears to have that tracking of scabies, a dermatology appointment was made and usually they have to wait a few weeks. She said a tracking form was created (MONTH) 15th when Doctor (name) came and discussed the skin rashes. She was not aware of Resident #37's rash. Scabies did have the potential to effect all areas of the facility. Anytime someone has a change of condition, it should be addressed immediately. Interview on 9/13/11:44 a.m. with Medical Director, he said that based on the knowledge of [DIAGNOSES REDACTED]. He said that it would be up to the facility protocol and policy as to whether or not the residents who have rashes should be on contact isolation or not, pending skin scraping appointment. Interview with Medical director on 9/13/19 at 2:21 p.m., he stated that he is aware there is a delay of proper treatment for [REDACTED]. Record review of Infection Control Program Standard Practice updated 11/2017 read in part . Standard of Practice: is to prevent the spread of infection and provide appropriate education for staff and residents concerning infection control. To monitor infections and facility areas of infection and provide isolation precautions . To provide a method of tracking and trending all infections in the facility and improve the steps of identifying areas of needed intervention . Procedure: All infection data will be entered into the Resident Infection Report in the electronic health record . Notification of family and physician will be done according to regulatory requirements and documented in the clinical record. All isolation precautions and hand washing techniques for staff and residents shall follow the CDC guidelines . Infection Control QA meetings and utilized for intervention, tracking, investigation and trending . Any infection intervention and recommendation form generated by the committee shall be initiated and completed promptly by the nursing staff to reduce the risk of further infection . The infection control program will be guided by recommendations via the CDC website .

Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents/hazards and supervision in that: - The facility failed to ensure Resident #1's bathroom was free of hazards after the sink was observed broken. There was shattered porcelain pieces covering the floor and exposed plumbing and jagged portions of the sink that remained sticking out from the wall. The broken sink portions on the floor were partially covered by a sheet and not removed from the bathroom by staff. - The facility, being aware of Resident #1's [MEDICAL CONDITION] of constantly washing his hands and clothing in the bathroom, did not supervise or implement measures to protect Resident #1 from injury from the broken sink. Resident #1 was not moved to an alternate safe environment and was left in his bedroom with the door closed unsupervised. Resident #1 was heard during the night moving about in his room but staff failed to visually monitor him for hours. - Resident #1 received a very deep gash covering the entire width of the bottom heel of his foot from stepping on the jagged pieces of porcelain on the floor. Resident #1 was transferred to the hospital for treatment after the staff finally observed him. It was determined that an Immediate Jeopardy (IJ) existed from 10/09/2018 and was removed on 10/12/2018 due to the facility having implemented actions that removed the IJ prior to the beginning of the investigation. This failure affected one resident and placed additional residents at risk for injury, decline, delayed treatment, pain, and hospitalization due to the facility's lack of supervision and efforts to keep the environment free of hazards. Intake # and # Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility 6/2/18. His [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS (minimum data set) dated 9/03/18 revealed Resident#1 had a BIMS (brief interview mental status) score of 1 indicating severe cognitive impairment. He required supervision for walking in his room and limited assistance for personal hygiene. His balance was not steady, but he was able to stabilize without staff assistance. He had no impairment with ROM. Record review of Resident #1's Care Plan dated 6/13/18 and updated 10/11/18, read in part Resident #1 has a compulsive disorder that causes him to be overly concerned with cleanliness. He will wash his hands over 50 times a day. He removes all clothing when toileting and will wash his personal clothing in face basin frequently when he thinks they are soiled . Approaches: Face bowl/sink replaced in cabinet to provide some stability to prevent coming detached from wall; Nursing, SS and Activities will attempt to get resident involved in another way to complete his same rituals of washing his clothing; Q 1-hour checks until further notice . Resident #1 is at risk for injury r/t falls . Approaches include ensuring safe environment, free of clutter, adequate lighting and clean spills promptly . Record review of facility monitoring sheet which included date, time, temperature, pulse, respirations, blood pressure, pain level, pupils, motor function, speech and level of consciousness for Resident #1 starting on 10/11/18 at 2:00 p.m. and ending on 10/12/18 at 8:45 p.m. Record review of Resident #1's clinical file revealed . 9/17/18 - resident broke the cover of the toilet by throwing it into the sink, cracked the sink. The sink was replaced and toilet tank cover was bolted down . Record review of nurses' notes dated 10/9/18 at 9:34 p.m. by LVN A reads CNA reported resident broke sink in bathroom. Upon checking, resident found sitting in chair naked. Bathroom sink shattered. When asked what happened resident said he was washing his clothes. Patient teaching given on the importance of resident not washing clothes in bathroom to avoid any fall hazards. Resident assisted with placing clothes on. Walks around room stable, no signs of complications noted. Order placed for maintenance. Will continue to monitor. Record review of nurses' notes dated 10/10/18 at 4:57 a.m. by LVN B reads @ (at) 0430 (4:30 a.m.) entered room and noted dried blood on floor. On previous shift, resident broke his bathroom sink; shattering it. Porcelain glass noted on floor. Resident cut his right heel on glass, receiving a deep laceration. Resident also has a small laceration to the back of his head, situated a few inches behind right ear. When asked resident how he received the injuries, resident stated he broke his sink and cut his foot. Called responsible party. No answer. Notified MD (name), awaiting response. Will notify DON and Unit Manager. VS: 128/79-85-18-98.3 Record review of nurses' notes dated 10/10/18 7:37 a.m. by LVN B reads Received order from MD (name) to send the resident to hospital for evaluation and treatment. Called EMS for transport. Arrived and transported resident to hospital at 0635 (6:30 a.m.) Oncoming nurse given report. Record review of the facility Resident Incident Report for Resident #1 dated 10/10/18 by LVN B reads in part . Incident level: non-witnessed . Narrative of incident and description of injuries: . @0430 (4:30 a.m.) entered room and noted dried blood on floor. On previous shift, resident broke his bathroom sink, shattering it. Porcelain glass noted on bathroom floor, resident stepped on glass . Right heel laceration. Small laceration to the back of his head, few inches behind right ear . Immediate actions taken: . Right heel cleansed with normal saline, gauze applied and kerlix dressing. Area to back of head dried blood noted to neck. Notified MD. Received order to send to hospital for evaluation and treatment . Record review of Resident #1's Provider Investigation Report dated 10/10/18 . Investigation summary: Resident broke the ceramic sink in his bathroom, which resulted in lacerations of his foot. Injury to head is old but reopened. He was apparently washing his clothes in the bathroom sink. Night nurse made round and found blood on the floor and completed assessment. Resident stated he broke the sink which caused a laceration to his foot. He was transferred to the hospital for sutures and he returned to the facility the same day . Provider Action Taken Post-Investigation: In-service done with all caregivers to monitor resident and prompt cleaning of any hazard material in a timely manner . In-Service training provided to CNA A, CNA B, CNA C, and additional staff included: Any broken item (sink, w/c, lift, etc.) must be cleaned up or removed immediately to prevent injury. (MONTH) also be put on TELS to inform maintenance, but must be cleaned up first. If needed, move resident temporarily to another room. Resident safety first . Incident & Accident process/Changes of Condition process - the purpose of the incident and accident process is to ensure the facility environment is free from accident hazards over which the facility has control and that each resident receives adequate supervision and assistive devices to prevent avoidable accidents according to regulatory guidelines . In-Service training provided to LVN B, LVN C on 10/11/18 included: 1:1 Safety of Residents, removal of hazardous items; I/A; Supervision of Residents . In-Service training provided to staff on 10/12/18 included: Incident/Accident, Follow-up in Morning Meeting . Supervision - making rounds, make rounds and check on residents every two hours. Notify our supervisor of any change of condition observed immediately . Employee Counseling/Disciplinary Report for LVN A signed 10/10/18 . Continued problem(s) will result in the following action by the facility: Termination . Employee Counseling/Disciplinary Report for CNA A signed 10/10/18 . Continued problem(s) will result in the following action by the facility: Termination . Record review of signed statement dated 10/11/18 by LVN A reads On Tuesday (MONTH) 9, (YEAR) CNA reported resident (Resident #1) had broken sink in personal bathroom. Writer went to room for further investigation. Resident found walking around room naked. Physical assessment performed, no signs injuries noted. Resident denied any pain or discomfort. Resident then questioned what happened. He states he was trying to wash his clothes. Assisted to be dressed. Broken sink with water noted to bathroom floor. Small broken pieces picked up and discarded. Portion of sink still connected to plumbing on wall. Water turned off. Sink covered with blanket pushed as far possible to corner. Excess water cleaned from floor by towels and blankets. High priority maintenance request placed for resident's bathroom. Supervisor notified. Call placed to RP, nurse note charted on resident. Supervision continued by staff members throughout remainder of shift. Resident remained stable with no complications noted. Night shift CNA arrived and instructed to keep close supervision on resident due to sink portion still connected. Went back to resident's room where resident was assisted to bed at 10:15 p.m. Still no signs of injury observed. Bed positioned low wit call light in reach. Fall mats in place. Light stayed on to prevent any hazards. CNA reminded to watch resident closely. Writer left resident in bed with stable conditions noted. Incident charted and placed on 24-hour reports. Record review of the facility's time card report revealed LVN A clocked out at 10:19 p.m. on 10/9/18 and LVN B clocked in at 10:21 p.m. on 10/9/18. Record review of the station 3 24-hour report dated 10/9/18 and noted page 1 of 1 revealed no documentation on Resident #1. Interview with the DON on 10/24/18 at 10:15 a.m. who said the incident with Resident #1 happened on the 2-10 shift and the staff did not notify him of the incident immediately. He said it was only after he arrived at work the next morning (10/10/18) that he found out. He said the resident had never been aggressive towards other residents but that he did recently break the top of the toilet tank when he took it off to wash his clothes inside the tank. The facility bolted down the toilet tank cover, so he couldn't remove it anymore. Interview on 10/24/18 at 1:22 p.m. with CNA A via telephone call was attempted. Message left requesting a call-back and giving surveyor state cell phone number - no call-back was received by surveyor. Interview on 10/24/18 at 1:24 p.m. with LVN A via telephone call was attempted. Message left requesting a call-back and giving surveyor state cell phone number - no call-back was received. Interview with the DON on 10/24/18 at 2:06 p.m. who said LVN A and CNA A were both suspended pending the outcome of the investigation and then terminated. The 10-6 nursing staff from station 3 were suspended pending investigation and brought back to work after being re-educated. Interview with LVN C on 10/24/18 at 2:19 p.m. who said LVN A was on a break when CNA A came to him and said Resident #1 broke the sink. He said he took Resident #1 with him and told CNA A to clean up the bathroom. He said Resident #1 kept trying to go back to his room so he called Resident #1's RP because he was going to move him to the memory care unit until his room could be repaired but he didn't get an answer so he took him to the dining room and gave him snacks and kept him out of his room until LVN A returned to the station. He said he informed her, and she immediately went to Resident #1's room to make sure CNA A had cleaned it up. He said Resident #1 had no injuries on the 2-10 shift before he left, and he thinks it happened on the 10-6 shift. Interview on 10/24/18 at 2:25 p.m. with the Administrator who was employed at the facility when the incident occurred. revealed he was unsure of when Resident #1 was actually injured. He said the staff knew he broke his sink and did not call him, but he would have expected them to call the Administrator and DON to let them know what the plan was and then notify the physician. He said Resident #1 was very [NAME]D, and would not stay in bed. The staff did not do anything to keep him from injuring himself and did not report it to himself and the DON for hours. He said he had pictures of the laceration on Resident #1's heel as well as pictures of the bathroom showing the broken sink and Resident #1's room. When asked if he taken the pictures he said LVN B took the pictures. Review of the pictures provided by the complainant revealed a picture of the room that showed large amounts of bloodstains on the floor. The bloody areas covered the entire room from wall to wall where it was evident the resident had paced around the room with the gash in his foot. There was a picture of the resident's shoe that showed a large amount of blood. The bathroom showed the spreading of the blood over a sheet that was partially covering the shattered porcelain sink that covered approximately half the floor. The picture of the injury showed a long gash that was very deep that encompassed the entire width of the lower bottom of the heel of the resident's foot. Interview with LVN B on 10/26/18 at 5:39 a.m. who said when she arrived for her shift LVN A was leaving and neither LVN A or LVN C were on station 3 and the keys were on the cart in the med room. She said LVN A didn't tell her Resident #1's sink was shattered to pieces and on the floor of the bathroom. She said she made rounds and checked Resident #1 around 10:30 p.m., he was in bed with the covers pulled up, and in no distress. She said she checked on him again around 2:00 a.m. and he was in no distress. She said around 2:30 a.m. she heard him up moving about in his room and talking to himself. She stated this was what he normally would do. The resident would walk around his room and then go into the bathroom around that time every night, so this was not out of the ordinary for him to do it this particular night. LVN B continued the interview and said CNA B began passing ice around 4:00 a.m. and when she opened his door around 4:30 a.m. she had a look of shock on her face. LVN B said she immediately ran to Resident #1's room and saw a trail of blood on the floor. She said she got him to lie down and saw he had cut his heel. She opened the bathroom door and saw the sink shattered on the floor in a pile in a corner next to the tub partially covered with a blanket. She called all of her aides and they stabilized the resident who was becoming combative. She said she cleaned and dressed his heel but he removed the dressing, so she re-dressed it and had CNA C stay with him one on one while she contacted the doctor, responsible party, and an ambulance. She said she did not call 911 because she thought Resident #1 was stable, so she just called the non-emergency ambulance service. Interview with CNA C on 10/26/18 at 5:56 a.m. who said he was working on the other end of the hall, clocked in at 10:06 p.m., and checked his residents. He said LVN A only told him Resident #1 didn't want to sleep, she never said anything about his sink being broken. He said the other 10-6 CNA called in, so they had another CNA come from station 2 and he told her about the residents and then went back to work with his residents. He said around 4:00 a.m. CNA B called him and said she needed help. He said he walked in and there was blood all over the floor and it was sticky and dry. He said LVN B took pictures and Resident #1 was very combative, so he helped her with him while she dressed his wounds. He walked in the bathroom and it was full of blood and water, so he and CNA B cleaned it up and he stayed with Resident #1 until he left for the hospital. Interview with CNA B on 10/26/18 at 6:04 a.m. who said station 3 is not her usual station but she was told to come work on station 3 because the other CNA called in. She said she is not familiar with the residents, so she took CNA C with her on her initial rounds to tell her about the residents. She said when they got to Resident #1's room around 11:00 p.m. CNA C said he could be violent, so she told him he would need to go in with her and they went in and Resident #1 was in bed but restless. She said there was no blood on the floor and he wasn't injured, and the bathroom door was closed. She said she didn't check on him again until she passed ice around 4:30 a.m. and when she opened the door there was blood everywhere, so she called the nurse and they went in and cleaned him up. She said she opened the bathroom door, saw blood and the sink shattered on the floor with sheets on it. Interview with Maintenance Director on 10/29/18 at 11:35 a.m. who said the staff put the maintenance request in the computer system as a high priority, but he didn't get the request until he arrived on the morning of 10/10/18 when he immediately went to Resident #1's room to take care of it. He said the staff should have called him immediately because he only lives 12 minutes from the facility and he would have come in that evening to make sure it was cleaned up and fixed. He said they frequently call him after hours and he comes back in, so he isn't sure why they didn't call him and only put it in the computer. Observation of Resident #1 on 10/29/18 at 12:21 p.m. revealed the resident in the dining room eating lunch, dressed appropriately and well groomed, with his right foot bandaged. Interview on 10/29/18 at 12:15 p.m. with Nursing Services ADON who said they do not have a specific policy for communicating between shifts. They just use the 24-hour report. She did not elaborate on how the staff was trained on this process when asked. Record review of the facility's policy on Incident and Accident Process revised (MONTH) (YEAR) read in part . Purpose: . The purpose of the Incident and Accident Process is to ensure the facility environment is as free from accident hazards over which the facility has control and that each resident receives adequate supervision and assistive devices to prevent avoidable accidents according to regulatory guidelines for F689. . Process: Incidents and Accidents Follow-up . 2. Unusual occurrence events, incidents and accidents noted by facility staff will be reported to the nurse caring for the resident for completion of the Incident & Accident report in the QA module of the electronic health record (EHR) . 8. Follow-up for all incidents and related changes of condition will be noted on the 24-hour report for a minimum of 72 hours and documented in the medical record . Record review of the facility's policy on Abuse Prohibition dated (MONTH) (YEAR) and revised (MONTH) (YEAR) read in part . Standard of Practice: . The resident has the right to be free from mistreatment, neglect and misappropriation of property. . Standard of Practice: Components of the Abuse Prohibition Plan . IV. Identification: . A. The facility will be proactive in identifying events and occurrences that may contribute to abuse, neglect . including but not limited to the following possible indicators: - Physical injury of a resident of unknown source . VI. Protection: . In order to provide protection to the resident during an investigation of abuse, neglect or exploitation the following will be done: - Temporary one on one supervision of a resident . The facility implemented actions to correct the deficient practice which began on 10/9/2018 and the following actions were verified during this investigation visit: Observations began on 10/24/2018 continuing through 10/29/2018 on all three shifts revealed all the resident use bathroom sinks in the facility were securely attached to the walls. There were no loose or broken sinks accessible by residents. Observations continued of the environment revealed there were no accident hazards identified that were not attended by the staff immediately or secured away from residents. Record review of LVN A and CNA A employee files revealed these staff were suspended on 10/10/2018 pending the outcome of the investigation and after investigation were terminated without ever returning to work. Employee counseling and disciplinary report date 10/10/18 verified the terminations. Record review of LVN B and CNA B employee files revealed they were suspended pending the outcome of the investigation and brought back following one on one in-service on 10/11/2018 including safety of residents, removal of hazardous items, incidents and accidents and supervision of residents. Interview with the DON and Administrator at the time of the incident revealed that the facility had a QA meeting on 10/10/2018 and decided to place the sink in an enclosed cabinet to provide more stability. This was completed on 10/10/2018 and was verified by observation of the sink and interview with the Maintenance Director. Review of the facility documentation revealed Resident #1 was placed on 15-minute checks for 72 hours and then hourly monitoring starting 10/11/18 at 2:00 p.m. through 10/12/18 ending at 8:45 p.m. The facility Administrator was relieved of his duties by the Regional Director of Operations on 10/12/18. This was verified by interview with the Regional Director of Operations on 10/26/2018 at 10:26 a.m. Record review of the facility In-service forms revealed facility training on: 10/10/2018 topic: removing any broken item and cleaning up any remnants of broken item immediately. Move resident to safe area, put in call to maintenance. Resident safety first. 10/10/2018 topic: Incident/Accident process, change of condition process. 10/11/2018 topic: Safety of Residents, removal of hazardous items, supervision of residents. 10/12/18 topic: Incident/Accident follow up in morning meetings. 10/12/18 Supervision making rounds every two hours, notifying supervisors of any changes of condition. Shift to shift reporting In-service sheets revealed large number of facility staff were in-serviced on 10/10/18, 10/11/18 and 10/12/2018. Interviews with Administrator confirmed all staff were trained prior to working their next shift. Interview on 10/29/2018 with the Interim Administrator revealed he was monitoring staff and ensuring they had a morning clinical meeting to review everything on the 24-hour report and an afternoon stand-down meeting to review any incidents that have occurred throughout the day. Interview with the DON was monitoring his staff by monitoring the time clock reports, 24 -hour reports, calling in for each shift change to speak to nurses and coming in during off- hours. Interviews were conducted throughout the investigation with 2 LVN's and 3 CNA's on the 6-2 shift, 2 LVN'S and 4 CNA's on the 2-10 shift and 1 LVN and 3 CNA's on the 10-6 shift revealed all had been in-serviced on the following items: Incident and accident process including follow-up Accidents and hazards and adequate supervision of residents Broken equipment, cleaning up broken items and notification of maintenance Resident safety Caring for residents with dementia Making rounds and checking on residents every two hours Notifying supervisor immediately of any changes of condition observed Change of shift report When interviewed staff were able to describe procedures concerning identifying and reporting environmental hazards and broken equipment along with the routine supervising of residents and ensuring resident's safe environment. An IJ was determined to have existed from 10/09/2019 to 10/12/2018. The IJ was removed on 10/12/2018 based on the above measures that the facility implemented.

Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents/hazards and supervision in that: -Resident #1 had a fall after a transfer to her wheelchair resulting in a [MEDICAL CONDITION] fibula and tibia (leg). This failure affected 1 resident who depended on the assistance of the staff at risk of being neglected and not receiving the care and assistance needed to prevent a decline in health. Intake Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility 3/5/18 and re-admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's MDS (minimum data set) dated 10/02/18 revealed Resident#1 had a BIMS (brief interview mental status) score of 9 indicating moderate cognitive impairment. She required extensive assistance for bed mobility and was totally dependent on staff for transfers. The resident could not walk, used a wheelchair for locomotion on/off the unit, and her lower extremities were impaired on both sides. There were no falls noted. Record review of Resident #1's Care Plan dated 3/29/18 revealed Resident #1 was identified at risk for falls and be transferred by 2 staff using a mechanical device. Interview on 9/25/18 at 10:50 a.m. with Resident #1 who said she told LVN A that her wheel chair was not secure because it did not have the leg rests on it, but he ignored her. She said the staff had to take the legs off the wheelchair to get her into it. She said LVN A pushed her wheelchair forward and her right leg became pinned under the wheelchair. When her leg was pinned under the wheelchair, she asked CNA A to help her as she was falling out of the wheelchair. The staff put her into bed and her leg started to swell. Interview with LVN B on 9/25/18 at 11:20 a.m. who said Resident #1 always uses the foot rests on her wheelchair. Interview with CNA C on 9/25/18 at 11:46 a.m. who said Resident #1 will ask her if she was in the wheelchair right and to put the foot petals on her wheelchair. Interview with ADON on 9/25/18 at 12:20 p.m. he stated Resident #1 usually has the foot rests on her wheelchair. Resident #1 is able to tell you what she needs and will remind staff about the foot rests. Interview with CNA A on 9/25/18 at 1:05 p.m. she stated she and LVN A were getting Resident #1 up and she did not have the foot rests on the wheelchair. Resident #1 told them she was sliding out of the wheelchair. CNA A said she attempted to keep Resident #1 from falling, but they had not put the foot rests on the wheelchair because they were in the room with the resident. When Resident #1 slid out of the wheelchair, the resident went down really fast and she heard a pop. Telephone interview with LVN A on 10/7/18 at 7:30 p.m. who said the CNA A came to get him because she needed to change Resident #1's mattress. LVN A stated CNA A got the mechanical lift to get Resident #1 from the bed to the wheelchair. He said Resident #1 fell while he was out of the room. LVN A stated they immediately put her back into bed. He called the Physician and a and a x-ray was ordered. The x-ray revealed a fracture on her right leg. Record review of Nurse notes dated 9/7/18 at 11:01 p.m. revealed the tech arrived for stat X ray to right leg at 10 p.m. At 10:37 p.m. x ray results were received and indicated a fracture to Right tibia and fibula. Record review of Nursing Note on 9/8/18 1:47 a.m. reads @10:30 pm received report from offgoing nurse that @ 7 pm staff x 2 got resident up in wc using the Hoyer Lift for Bed Mattress Exchange and resident slid out of chair . Offgoing Nurse received XRay Result which show she has a Fracture to the right tibia and fibula per report. Nurse called Dr. (name) and now awaiting call return . @ 12:25 AM Staff assisted EMS with transfer from bed to gurney. Resident departed and transported to hospital (name) . Record Review of Radiology Report dated 9/7/18 10:34 p.m. Results: There is a fracture involving right proximal tibia and proximal fibula with modest displacement. The knee and ankle joins are intact in alignment . Interview with CNA D on 10/7/18 at 7:45 p.m. who said on that day the Resident #1 did not ask for her leg rests on the wheelchair, she started wiggling, and she fell . Interview with Physical Therapist on 10/10/18 at 10:05 a.m. who said Resident #1 needed to have her legs elevated to help reduce the [MEDICAL CONDITION] in her legs, and prevent sacrum sitting. If Resident #1 was not properly positioned in the wheelchair it, would cause her to fall. Resident #1 does not have lower body strength and unable to lift her legs because of Neurosarcodosis ([MEDICAL CONDITION] disease that affects the nervous system). Record review of Safe Patient Handling and Transfer Policy revision date 11/13 reads .B. Patient Handling and Moement Requirements: 3. Use mechanical lifting devices and other approved handling aids in accordance with instructions and training .E. Mechanical lifting devices (for those facilities that have): . 3. All patient transfes with mechanical lifts will be done wit a minimum of two persons or as specified in the patient's plan of care. There were 6 facility residents reviewed.

Based on observation, interview, and record review, the facility failed to ensure that the resident had the right to make choices about healthcare services that were significant to the resident for 8 (Residents #1, #2, #3, #4, #5, #6, #7, and #9) of 10 residents reviewed for self determination, in that: Residents #1, #2, #3, #4, #5, #6, #7, and #9 who were competent to make their own decisions, were not given the right to choose their psychiatric and psychological care and providers. These failures affected 8 residents and placed 13 additional residents who receive psychology services and 47 additional residents who receive psychiatry services at risk of not being able to choose who is providing their psychiatric and psychological services, which could contribute to a lack of information and unmet needs. Findings included: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year old male who admitted on [DATE] and readmitted on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Record review of Resident #1's care plan dated 2/16/2016 and last reviewed on 3/19/18 revealed: Problem: Risk for complication related to [MEDICAL CONDITION] medications, [DIAGNOSES REDACTED]. Goal: Resident #1 will have fewer indicators of depression. Approach: psych referrals as signs warrant. Senior psych to evaluate and treat as indicated. Interview on 4/4/18 at 1:12pm with Resident #1 revealed he liked his psychologist that he had for the past 7 years, going on 8. He indicated that when the psychologist started working with him he had a lot of fear and behavioral concerns such as running nurses and staff out of his room or cuss at them. He indicated the therapist had been helpful in that he didn't have these behavioral concerns anymore and was able to deal with some of the fear now. Resident #1 stated it makes me sad, I don't know why I can't pick between the new people or the therapist I have now. He indicated that he did not want to see a new therapist and would refuse care by a new therapist. Record review of a facility concern investigation form on 3/6/18 completed by Resident #1's psychologist which revealed he would like to continue care with his psychologist because he has trust in her and his counselor has helped him. He indicated that when he first got to the facility he got very angry and had outbursts but she has helped with that. He revealed he has seen her for almost 7 years. There was no resolution identified on this form nor was a resolution date signed. Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year old male who admitted on [DATE]. Resident #2's [DIAGNOSES REDACTED]. Record review of Resident #2's care plan dated 6/9/2017 and last reviewed on 4/10/18 revealed: Problem: Risk for alteration in psychosocial well-being related to resident has history of [MEDICAL CONDITION]. Goal: Resident #2 will be free from signs of psychosocial distress. Approach: Allow/ encourage resident to express feelings related to current condition as needed. Provide 1:1 emotional support as needed. Problem: Risk for alteration in mood/ behaviors related to history of depression and bi-polar disorder. Goal: Behaviors will be easily altered with staff interventions. Mood/ behaviors will not interfere with daily routine and quality of life. Senior psych to evaluate and treat as indicated. Approach: Refer to psych services as needed with exacerbation or inability to effectively redirect behaviors. Record review of a typed formal complaint date unknown by Resident #2 indicated that the psychologist had helped him with his [MEDICAL CONDITION] depression through extensive sessions of psychotherapy and did not believe it was fair to have to begin the process again with someone new. Resident #2 wrote he did not understand why he was forced to change to another psychology and psychiatry provider. The letter indicated that he was told by the Administrator if he was to continue to see psychology services it would have to be as an outpatient and he would have to pay out of his own pocket. In the letter he noted the psychology and psychiatry service had been providers for the nursing facility for over [AGE] years and there was no consultation or feedback from any of the residents by the facility before the change. He revealed it would take the new psychiatric and psychology group years not weeks nor months to familiarize themselves with his underlying issues and long mental health history. Further review revealed the typed document was signed by Resident #2. Observation and interview with Resident #2 on 4/4/18 at 12:37pm revealed when the surveyor entered the room the resident was lying on his bed and had tears in his eyes. He stated there had been a significant change with his continuity of care at the nursing facility recently. He said that the nursing facility was now letting go of the psychologist and psychiatrist. Resident #2 stated he was not notified by the nursing facility of the change of psychiatry/ psychology services. He revealed the psychologist informed him of the change sometime in (MONTH) (YEAR) during one of their sessions. Resident #2 explained that sometime after that, the Administrator came to him and talked to him about needing to try with the new company, but it had caused increased anxiety for him. During the same interview, Resident #2 stated he had been seeing the same psychiatrist and psychologist for about a year and felt comfortable with the services they provided. He explained he had a history with the psychologist and she had been a big help in dealing with his wife's passing. Resident #2 also stated the psychiatrist and psychiatric nurse practitioner had also been wonderful. He revealed that the doctor had adjusted his meds and his [MEDICAL CONDITION] had been stable. He said that he feared a manic or depressive episode with the new change. He stated he did not want to start over with a new psychologist or psychiatrist. An interview on 4/19/18 at 10:00am with Resident #2 revealed he continued to see the same therapist at the facility. He stated the psychiatrist did not come to the facility anymore so he made himself an appointment and went to the doctor's office on 4/10/18. He explained he set up his own arrangements for a ride to the doctor's office because he felt the facility would prevent him from going to the appointment. An interview with the DON on 4/19/18 at 1:12pm revealed Resident #2 made himself an appointment with the psychiatrist that used to be at the facility and seen him on 4/10/18. He indicated that his son took him to the appointment. The DON revealed that the nursing facility was not aware of the appointment until the resident returned. Resident #3 Record review of Resident #3's face sheet revealed a [AGE] year old female who admitted on [DATE] and readmitted on [DATE]. Resident #3's [DIAGNOSES REDACTED]. Record review of Resident #3's care plan dated 9/8/15 revealed: Problem: Exhibits alteration in mood/ behavior as evidence by: has anxiety about health conditions, level of care, helplessness, and getting to [MEDICAL TREATMENT] on time. Goal: Mood/ behaviors will not interfere with daily routine and quality of life. Approach: Listen to resident concerns and reassure resident and provide much independence as needed. Senior psych to evaluate and treat as indicated. Refer to psychiatric services as needed with exacerbation or inability to effectively redirect behaviors. Interview on 4/4/18 at 1:31pm, Resident #3 revealed she felt like the nursing facility was stripping the her rights away. She stated she only received psychology services and had been seeing the therapist for over 6 years. She said she couldn't imagine seeing another therapist. She revealed that the nursing facility asked her this morning if she wanted to change providers to the new one but she indicated she wanted to continue therapy with the therapist she had been seeing. Resident #3 explained she was informed of the change by her psychologist sometime in (MONTH) (YEAR). Resident #3 stated she went to the administrator with a typed formal complaint and then again about a week later to discuss her concern. During the same interview, Resident #3 revealed the Administrator told her that if her therapist wanted to continue to practice at the facility, then she needed to go work for the new company. She said this had caused a feeling of helplessness because she felt they had stripped her of all her rights. She also stated that the Administrator had been trying scare tactics by telling Resident #3 if the nursing facility was to close down in 30 days, you wouldn't know what to do, would you? She explained that the Administrator was not looking out for the best interest of the residents and she felt forced into the change. Resident provided surveyor with a typed formal complaint. Record review of this complaint dated 3/12/18, revealed Resident #3 would cease any psychiatric/ psychological services if she could not continue with the previous company. She indicated she had been seeing the same psychologist for several years and had no desire in starting over with another counselor. Record review of the nursing facility concern investigation form dated 3/22/18, report taken by the Administrator for Resident #3 revealed the resident was concerned of a change in psychological services. Explained company was hiring a new service that would provide or exceed the current psychological services. Results of the investigation revealed resident given an explanation of new services if she agreed to use them. If Resident #3 did not agree, facility could make arrangements for her to see the former provider offsite. Resolution of the report revealed Resident #3 was aware of the change, she would consider making the change after speaking with the new service. A note on the bottom stated resident aware of the contract. Resolution completed by Administrator on 3/22/18. Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year old male who admitted on [DATE]. Resident #4's [DIAGNOSES REDACTED]. During an interview on 4/4/18 at 3:48pm with Resident #4, he revealed he had no identified concerns with his psychiatrist. He indicated he was not aware that there would be a change in his psychiatry services. Record review on 4/19/18 of Resident #4's psychiatric notes revealed he was seen on 3/19/18, 3/8/18, 2/19/18, 2/9/18, 1/22/18, 1/11/18 and 12/21/17 for routine follow-up care. Further review revealed Resident #4 had not seen the new contracted psychiatrist since the change in services. During an interview on 4/19/18 at 1:15pm, the DON revealed Resident #4's primary care physician changed the way psychiatry services would be done with the new company. The DON stated the physician informed the facility and the new psychiatric company that if a resident was stable on medications, they would continue to be monitored by the primary care physician unless there was a change in the resident's mental status. At that time, the primary care physician would be notified and a psychiatry consult would be ordered. DON explained at this time Resident #4 had not seen the new psychiatrist. Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year old male who admitted on [DATE] and readmitted on [DATE]. Resident #5's [DIAGNOSES REDACTED]. An interview on 4/19/18 at 10:36am with Resident #5 revealed he had been a resident at the facility since 2009. He stated he was still being seen by his psychologist and would like to continue services with her. He explained he was comfortable with this therapist and would be pissed if he had to switch. He revealed he became aware of the change in providers by his psychologist. Record review of a nursing facility concern investigation form dated 3/19/18 completed by Resident #5 revealed he wanted to stay with his current psychologist. He stated he had seen the same counselor for years. Signed by Resident #5. No resolution identified nor was it signed with a resolution completed date. Record review of Resident #5's clinical record revealed he was seen by the new psychiatry service on 4/6/18 for an initial consult. Resident #6 Record review of Resident #6's face sheet revealed a [AGE] year old female who admitted on [DATE] and readmitted on [DATE]. Resident #6's [DIAGNOSES REDACTED]. An interview on 4/19/18 at 10:13am with Resident #6 revealed she had seen the same psychologist for the last [AGE] years. She indicated the last time she saw the therapist was on 4/16/18. She stated the therapist was her best friend and she did not like having to switch psychologists. She revealed if it was her choice, she would love to keep the same psychologist. She stated switching psychology services would cause her to be in distress. She explained she was also seen by psychiatry and had to switch to the new psychiatrist. She said she did not want the facility to switch her services. Record review of Resident #6's clinical record revealed she was seen by the new psychiatry services on 4/6/18. Resident provided surveyor with a hand written letter. Record review of of this letter completed by Resident #6 on 3/15/18 revealed she had been seeing the psychologist for [AGE] years. She stated that the nursing facility was doing extensive damage to her. Resident #6 signed the form stating she was very upset and unhappy. Record review of a nursing facility investigation form on 3/26/18 completed by the Administrator for Resident #6 revealed a concern that the resident did not want the new psychological services as part of her care. Resolution revealed no reason to move forward since the resident stated she does not want current psychological services to leave, however this was a corporate decision. She is not obligated to have the new customer to see her. Resolution completed by the Administrator on 3/26/18. Resident #7 Record review of Resident #7's face sheet revealed a [AGE] year old female who admitted on [DATE] and readmitted on [DATE]. Resident #7's [DIAGNOSES REDACTED]. An interview on 4/19/18 at 10:25am with Resident #7 revealed she does not have psychiatry services, but does have psychology services. She stated she has been seeing the same psychologist since she has been at the facility. She said she last saw the psychologist last week. She explained she likes her therapist she has been seeing and would like to keep her. She revealed she would be mad if she had to switch to a new therapist. She revealed she became aware of the change by her therapist. Resident #9 Record review of Resident #9's face sheet revealed a [AGE] year old male who admitted on [DATE] and readmitted on [DATE]. Resident #9's [DIAGNOSES REDACTED]. During an interview with Resident #9 on 4/19/18 at 10:03am revealed he had seen a psychiatrist about 3 weeks ago. He indicated he had been at the facility since 2003 and stated this psychiatrist was the best he ever had. He revealed he was not made aware of the change in services. He explained the thought of switching to a new psychiatrist scared him because he had adjusted well with the psychiatrist. Record review of Resident #9's clinical record revealed he was seen by the new psychiatrist on 4/6/18. Interview on 4/4/18 at 10:10am. the Administrator revealed the nursing facility changed psychiatric and psychology services at the beginning of (MONTH) (YEAR). He indicated that the former psychology and psychiatric services were two different entities and did not communicate resident concerns with each other or with the nursing facility. The Administrator revealed he broke the contract with psychology and psychiatry to go with a new psychiatric and psychology service that was under one umbrella. He stated the nursing facility had the right to change contracts with a 30 day notice to the former providers. During the same interview, the Administrator explained the new psychiatric and psychology provider did not want another counselor in the facility because they did not want the residents to have duplicate services. The Administrator stated Nowhere does it say the nursing facility needs to maintain these services per resident request. He indicated there were a few residents who voiced concerns but we talked to them and told them they could go outside the facility to see the provider. He explained that the resident's needs would be met with this new company, but indicated a few of the residents were not convinced. The Administrator stated that if a resident refused to have psychology services the concern would be sent to the doctor and a referral to the local psych hospital would be made if needed. During another interview on 4/4/18 at 2:40pm, the Administrator revealed the former social worker was supposed to inform the residents of the change of psychiatric/ psychological services. He indicated that the facility did not give official written notice of the change, but the facility can. When asked how many residents were negatively affected by the service disruption, the Administrator explained that three residents who received psychology services were affected and he was unsure how many residents who received psychiatry services were affected. Record review of a letter posted in numerous resident rooms on 4/5/18 revealed the following: First let me apologize for the lateness of this letter regarding informing you of a change in our psychiatry and psychological services. I had thought the social worker had informed you that we are changing the current service to a new psychiatrist, nurse practitioner and psychological services on (MONTH) 2, (YEAR). The social worker was given the responsibility to assure you were notified of the change. You are not required to see the new physician, nurse practitioner or psychological services, however we strongly suggest that you consider the new service. Further review revealed the letter was signed by the Administrator. Record review of a letter from the nursing facility to the psychiatrist on 2/28/18 revealed an official notice to terminate the contract with services as geriatrics psychiatrist effective 3/31/18 signed by the Administrator. Record review of a letter from the nursing facility to the psychology service dated 2/28/18 revealed an official notice to terminate the contract with psychological effective 3/31/18 signed by the Administrator. Record review of a contract with the psychology/ psychiatry group with the nursing facility dated 11/8/07 revealed under Section #5: If the The Facility terminates this Agreement, the patients and/ or families may request the continuation of The Company's services. The The Facility will not interfere with the patient/ doctor relationship in any manner that will be detrimental to the patient's best interest. If the appropriate staff to request that this interference stop. IF the behavior does not cease after these appropriate measures are taken, it is reasonable to discuss such interference with the Texas Department of Human Services and the Texas Board of Medical Examiners. An Interview on 4/5/18 at 11:45am with the Psychologist revealed she had continued to come to the facility after the contract termination date. She indicated she contacted the Board of Psychology which explained to her that it would be considered abandonment of patient care if she did not continue to see her residents. She stated the Administrator gives her grief every time she comes to visit her patients and is in fear he is going to prevent her from entering the facility to visit with her patients in the near future. She explained she felt the Administrator was still allowing her to see her patients because he was being investigated by state and the new company had not come to the facility to see the residents yet. The Psychologist stated that a family member had discussed the letter regarding the change of services and stated to her that they felt pressured to go with the new service by the way the letter was written. Record review of the nursing facilities concern investigation form dated 3/19/18 completed by the Administrator for multiple under resident's name which revealed residents expressed concerns over psychological services they would prefer to keep. The Administrator documented that he told the ombudsman that services were changing since the facility couldn't get psychiatry to consent to CMS guidelines of medication reductions. The form revealed psychological services was doing their job. Under resolution completed by the Administrator on 3/22/18, revealed the facility had the right to change services. If the psychologist wished to stay, she could apply for a position with the new contracted company or the residents could go see her at their own expense. Facility was providing services under state and federal statutes. Record review of nursing facility concern investigation form on 3/29/18 revealed a concern was placed by the ombudsman and psychological services. The form stated 2 members from psychological services and the ombudsman volunteer came to the administrator's office regarding the contractual agreement and they believed we could not send a notice we were giving notice of ending their contract. I pulled the contract and showed them we have every right to give notice without cause. There was a discussion held that they had contacted the legal department regarding the legality of given notice. At that time I ended the conversation. The 2 persons from psychological services stated they have a legal right to continue to see the residents and I explained yes but not in the facility since they no longer had a contract. Report taken by the Administrator and resolution completed on 3/29/18 by the Administrator. Interview on 4/6/18 at 2:55pm with the Corporate Nurse and Administrator revealed the facility wanted to switch companies because the psychiatrist had identified concerns that the nursing facility did not identify and the psychiatrist did not attend the behavior meetings. The Administrator indicated that initially the residents did not have a choice, but the psychologist was continuing to come to the facility and stated that she can continue to see her residents. The Corporate Nurse and Administrator stated they could not identify which residents were seen by the psychiatrist or psychologist until 4/6/18 at 11:00am when the former company gave them a list of residents to talk to about the change. During an interview on 4/19/18 at 1:43pm, the Administrator revealed the list of residents who received psychiatric services was provided by the pharmacy. Facility policy on Resident Rights Standard of Practice with an origination date of (MONTH) (YEAR) and a review date of (MONTH) (YEAR) revealed the following: Standard of Practice Explanation and Compliance Guidelines: #2. Information about resident rights and responsibilities will be given to the resident both orally and in writing. Resident Rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Planning and Implementing Care: The resident has the right to be informed of, and participate in, his or her treatment, including: a. The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition . iii. The right to be informed, in advance, of changes to the plan of care. c. The right to be informed in advance, of the care to be furnished and the type of care giver or professional that will furnish the care. According to a list provided by the Administrator, 53 residents received psychiatric services and 29 residents received psychology services with the former contracted services.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care for 8 (Residents #1, #2, #3, #4, #5, #6, #7, and #9) of 10 residents reviewed for resident rights, in that: Residents #1, #2, #3, #4, #5, #6, #7, and #9 were not notified of a change in psychiatric and psychological services. These failures affected 8 residents and placed 13 additional residents who receive psychology services and 47 additional residents who receive psychiatry services at risk of not being informed of who is providing their psychiatric and psychological services. Findings included: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year old male who admitted on [DATE] and readmitted on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Record review of Resident #1's care plan dated 2/16/2016 and last reviewed on 3/19/18 revealed: Problem: Risk for complication related to [MEDICAL CONDITION] medications, [DIAGNOSES REDACTED]. Goal: Resident #1 will have fewer indicators of depression. Approach: psych referrals as signs warrant. Senior psych to evaluate and treat as indicated. Interview on 4/4/18 at 1:12pm with Resident #1 revealed he liked his psychologist that he had for the past 7 years, going on 8. He indicated that when the psychologist started working with him he had a lot of fear and behavioral concerns such as running nurses and staff out of his room or cuss at them. He indicated the therapist had been helpful in that he didn't have these behavioral concerns anymore and was able to deal with some of the fear now. Resident #1 stated it makes me sad, I don't know why I can't pick between the new people or the therapist I have now. He indicated that he did not want to see a new therapist and would refuse care by a new therapist. Record review of a facility concern investigation form on 3/6/18 completed by Resident #1's psychologist which revealed he would like to continue care with his psychologist because he has trust in her and his counselor has helped him. He indicated that when he first got to the facility he got very angry and had outbursts but she has helped with that. He revealed he has seen her for almost 7 years. There was no resolution identified on this form nor was a resolution date signed. Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year old male who admitted on [DATE]. Resident #2's [DIAGNOSES REDACTED]. Record review of Resident #2's care plan dated 6/9/2017 and last reviewed on 4/10/18 revealed: Problem: Risk for alteration in psychosocial well-being related to resident has history of [MEDICAL CONDITION]. Goal: Resident #2 will be free from signs of psychosocial distress. Approach: Allow/ encourage resident to express feelings related to current condition as needed. Provide 1:1 emotional support as needed. Problem: Risk for alteration in mood/ behaviors related to history of depression and bi-polar disorder. Goal: Behaviors will be easily altered with staff interventions. Mood/ behaviors will not interfere with daily routine and quality of life. Senior psych to evaluate and treat as indicated. Approach: Refer to psych services as needed with exacerbation or inability to effectively redirect behaviors. Record review of a typed formal complaint date unknown by Resident #2 indicated that the psychologist had helped him with his [MEDICAL CONDITION] depression through extensive sessions of psychotherapy and did not believe it was fair to have to begin the process again with someone new. Resident #2 wrote he did not understand why he was forced to change to another psychology and psychiatry provider. The letter indicated that he was told by the Administrator if he was to continue to see psychology services it would have to be as an outpatient and he would have to pay out of his own pocket. In the letter he noted the psychology and psychiatry service had been providers for the nursing facility for over [AGE] years and there was no consultation or feedback from any of the residents by the facility before the change. He revealed it would take the new psychiatric and psychology group years not weeks nor months to familiarize themselves with his underlying issues and long mental health history. Further review revealed the typed document was signed by Resident #2. Observation and interview with Resident #2 on 4/4/18 at 12:37pm revealed when the surveyor entered the room the resident was lying on his bed and had tears in his eyes. He stated there had been a significant change with his continuity of care at the nursing facility recently. He said that the nursing facility was now letting go of the psychologist and psychiatrist. Resident #2 stated he was not notified by the nursing facility of the change of psychiatry/ psychology services. He revealed the psychologist informed him of the change sometime in (MONTH) (YEAR) during one of their sessions. Resident #2 explained that sometime after that, the Administrator came to him and talked to him about needing to try with the new company, but it had caused increased anxiety for him. During the same interview, Resident #2 stated he had been seeing the same psychiatrist and psychologist for about a year and felt comfortable with the services they provided. He explained he had a history with the psychologist and she had been a big help in dealing with his wife's passing. Resident #2 also stated the psychiatrist and psychiatric nurse practitioner had also been wonderful. He revealed that the doctor had adjusted his meds and his [MEDICAL CONDITION] had been stable. He said that he feared a manic or depressive episode with the new change. He stated he did not want to start over with a new psychologist or psychiatrist. An interview on 4/19/18 at 10:00am with Resident #2 revealed he continued to see the same therapist at the facility. He stated the psychiatrist did not come to the facility anymore so he made himself an appointment and went to the doctor's office on 4/10/18. He explained he set up his own arrangements for a ride to the doctor's office because he felt the facility would prevent him from going to the appointment. An interview with the DON on 4/19/18 at 1:12pm revealed Resident #2 made himself an appointment with the psychiatrist that used to be at the facility and seen him on 4/10/18. He indicated that his son took him to the appointment. The DON revealed that the nursing facility was not aware of the appointment until the resident returned. Resident #3 Record review of Resident #3's face sheet revealed a [AGE] year old female who admitted on [DATE] and readmitted on [DATE]. Resident #3's [DIAGNOSES REDACTED]. Record review of Resident #3's care plan dated 9/8/15 revealed: Problem: Exhibits alteration in mood/ behavior as evidence by: has anxiety about health conditions, level of care, helplessness, and getting to [MEDICAL TREATMENT] on time. Goal: Mood/ behaviors will not interfere with daily routine and quality of life. Approach: Listen to resident concerns and reassure resident and provide much independence as needed. Senior psych to evaluate and treat as indicated. Refer to psychiatric services as needed with exacerbation or inability to effectively redirect behaviors. Interview on 4/4/18 at 1:31pm, Resident #3 revealed she felt like the nursing facility was stripping the her rights away. She stated she only received psychology services and had been seeing the therapist for over 6 years. She said she couldn't imagine seeing another therapist. She revealed that the nursing facility asked her this morning if she wanted to change providers to the new one but she indicated she wanted to continue therapy with the therapist she had been seeing. Resident #3 explained she was informed of the change by her psychologist sometime in (MONTH) (YEAR). Resident #3 stated she went to the administrator with a typed formal complaint and then again about a week later to discuss her concern. During the same interview, Resident #3 revealed the Administrator told her that if her therapist wanted to continue to practice at the facility, then she needed to go work for the new company. She said this had caused a feeling of helplessness because she felt they had stripped her of all her rights. She also stated that the Administrator had been trying scare tactics by telling Resident #3 if the nursing facility was to close down in 30 days, you wouldn't know what to do, would you? She explained that the Administrator was not looking out for the best interest of the residents and she felt forced into the change. Resident provided surveyor with a typed formal complaint. Record review of this complaint dated 3/12/18, revealed Resident #3 would cease any psychiatric/ psychological services if she could not continue with the previous company. She indicated she had been seeing the same psychologist for several years and had no desire in starting over with another counselor. Record review of the nursing facility concern investigation form dated 3/22/18, report taken by the Administrator for Resident #3 revealed the resident was concerned of a change in psychological services. Explained company was hiring a new service that would provide or exceed the current psychological services. Results of the investigation revealed resident given an explanation of new services if she agreed to use them. If Resident #3 did not agree, facility could make arrangements for her to see the former provider offsite. Resolution of the report revealed Resident #3 was aware of the change, she would consider making the change after speaking with the new service. A note on the bottom stated resident aware of the contract. Resolution completed by Administrator on 3/22/18. Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year old male who admitted on [DATE]. Resident #4's [DIAGNOSES REDACTED]. During an interview on 4/4/18 at 3:48pm with Resident #4, he revealed he had no identified concerns with his psychiatrist. He indicated he was not aware that there would be a change in his psychiatry services. Record review on 4/19/18 of Resident #4's psychiatric notes revealed he was seen on 3/19/18, 3/8/18, 2/19/18, 2/9/18, 1/22/18, 1/11/18 and 12/21/17 for routine follow-up care. Further review revealed Resident #4 had not seen the new contracted psychiatrist since the change in services. During an interview on 4/19/18 at 1:15pm, the DON revealed Resident #4's primary care physician changed the way psychiatry services would be done with the new company. The DON stated the physician informed the facility and the new psychiatric company that if a resident was stable on medications, they would continue to be monitored by the primary care physician unless there was a change in the resident's mental status. At that time, the primary care physician would be notified and a psychiatry consult would be ordered. DON explained at this time Resident #4 had not seen the new psychiatrist. Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year old male who admitted on [DATE] and readmitted on [DATE]. Resident #5's [DIAGNOSES REDACTED]. An interview on 4/19/18 at 10:36am with Resident #5 revealed he had been a resident at the facility since 2009. He stated he was still being seen by his psychologist and would like to continue services with her. He explained he was comfortable with this therapist and would be pissed if he had to switch. He revealed he became aware of the change in providers by his psychologist. Record review of a nursing facility concern investigation form dated 3/19/18 completed by Resident #5 revealed he wanted to stay with his current psychologist. He stated he had seen the same counselor for years. Signed by Resident #5. No resolution identified nor was it signed with a resolution completed date. Record review of Resident #5's clinical record revealed he was seen by the new psychiatry service on 4/6/18 for an initial consult. Resident #6 Record review of Resident #6's face sheet revealed a [AGE] year old female who admitted on [DATE] and readmitted on [DATE]. Resident #6's [DIAGNOSES REDACTED]. An interview on 4/19/18 at 10:13am with Resident #6 revealed she had seen the same psychologist for the last [AGE] years. She indicated the last time she saw the therapist was on 4/16/18. She stated the therapist was her best friend and she did not like having to switch psychologists. She revealed if it was her choice, she would love to keep the same psychologist. She stated switching psychology services would cause her to be in distress. She explained she was also seen by psychiatry and had to switch to the new psychiatrist. She said she did not want the facility to switch her services. Record review of Resident #6's clinical record revealed she was seen by the new psychiatry services on 4/6/18. Resident provided surveyor with a hand written letter. Record review of of this letter completed by Resident #6 on 3/15/18 revealed she had been seeing the psychologist for [AGE] years. She stated that the nursing facility was doing extensive damage to her. Resident #6 signed the form stating she was very upset and unhappy. Record review of a nursing facility investigation form on 3/26/18 completed by the Administrator for Resident #6 revealed a concern that the resident did not want the new psychological services as part of her care. Resolution revealed no reason to move forward since the resident stated she does not want current psychological services to leave, however this was a corporate decision. She is not obligated to have the new customer to see her. Resolution completed by the Administrator on 3/26/18. Resident #7 Record review of Resident #7's face sheet revealed a [AGE] year old female who admitted on [DATE] and readmitted on [DATE]. Resident #7's [DIAGNOSES REDACTED]. An interview on 4/19/18 at 10:25am with Resident #7 revealed she does not have psychiatry services, but does have psychology services. She stated she has been seeing the same psychologist since she has been at the facility. She said she last saw the psychologist last week. She explained she likes her therapist she has been seeing and would like to keep her. She revealed she would be mad if she had to switch to a new therapist. She revealed she became aware of the change by her therapist. Resident #9 Record review of Resident #9's face sheet revealed a [AGE] year old male who admitted on [DATE] and readmitted on [DATE]. Resident #9's [DIAGNOSES REDACTED]. During an interview with Resident #9 on 4/19/18 at 10:03am revealed he had seen a psychiatrist about 3 weeks ago. He indicated he had been at the facility since 2003 and stated this psychiatrist was the best he ever had. He revealed he was not made aware of the change in services. He explained the thought of switching to a new psychiatrist scared him because he had adjusted well with the psychiatrist. Record review of Resident #9's clinical record revealed he was seen by the new psychiatrist on 4/6/18. Interview on 4/4/18 at 10:10am. the Administrator revealed the nursing facility changed psychiatric and psychology services at the beginning of (MONTH) (YEAR). He indicated that the former psychology and psychiatric services were two different entities and did not communicate resident concerns with each other or with the nursing facility. The Administrator revealed he broke the contract with psychology and psychiatry to go with a new psychiatric and psychology service that was under one umbrella. He stated the nursing facility had the right to change contracts with a 30 day notice to the former providers. During the same interview, the Administrator explained the new psychiatric and psychology provider did not want another counselor in the facility because they did not want the residents to have duplicate services. The Administrator stated Nowhere does it say the nursing facility needs to maintain these services per resident request. He indicated there were a few residents who voiced concerns but we talked to them and told them they could go outside the facility to see the provider. He explained that the resident's needs would be met with this new company, but indicated a few of the residents were not convinced. The Administrator stated that if a resident refused to have psychology services the concern would be sent to the doctor and a referral to the local psych hospital would be made if needed. During another interview on 4/4/18 at 2:40pm, the Administrator revealed the former social worker was supposed to inform the residents of the change of psychiatric/ psychological services. He indicated that the facility did not give official written notice of the change, but the facility can. When asked how many residents were negatively affected by the service disruption, the Administrator explained that three residents who received psychology services were affected and he was unsure how many residents who received psychiatry services were affected. Record review of a letter posted in numerous resident rooms on 4/5/18 revealed the following: First let me apologize for the lateness of this letter regarding informing you of a change in our psychiatry and psychological services. I had thought the social worker had informed you that we are changing the current service to a new psychiatrist, nurse practitioner and psychological services on (MONTH) 2, (YEAR). The social worker was given the responsibility to assure you were notified of the change. You are not required to see the new physician, nurse practitioner or psychological services, however we strongly suggest that you consider the new service. Further review revealed the letter was signed by the Administrator. Record review of a letter from the nursing facility to the psychiatrist on 2/28/18 revealed an official notice to terminate the contract with services as geriatrics psychiatrist effective 3/31/18 signed by the Administrator. Record review of a letter from the nursing facility to the psychology service dated 2/28/18 revealed an official notice to terminate the contract with psychological effective 3/31/18 signed by the Administrator. Record review of a contract with the psychology/ psychiatry group with the nursing facility dated 11/8/07 revealed under Section #5: If the The Facility terminates this Agreement, the patients and/ or families may request the continuation of The Company's services. The The Facility will not interfere with the patient/ doctor relationship in any manner that will be detrimental to the patient's best interest. If the appropriate staff to request that this interference stop. IF the behavior does not cease after these appropriate measures are taken, it is reasonable to discuss such interference with the Texas Department of Human Services and the Texas Board of Medical Examiners. An Interview on 4/5/18 at 11:45am with the Psychologist revealed she had continued to come to the facility after the contract termination date. She indicated she contacted the Board of Psychology which explained to her that it would be considered abandonment of patient care if she did not continue to see her residents. She stated the Administrator gives her grief every time she comes to visit her patients and is in fear he is going to prevent her from entering the facility to visit with her patients in the near future. She explained she felt the Administrator was still allowing her to see her patients because he was being investigated by state and the new company had not come to the facility to see the residents yet. The Psychologist stated that a family member had discussed the letter regarding the change of services and stated to her that they felt pressured to go with the new service by the way the letter was written. Record review of the nursing facilities concern investigation form dated 3/19/18 completed by the Administrator for multiple under resident's name which revealed residents expressed concerns over psychological services they would prefer to keep. The Administrator documented that he told the ombudsman that services were changing since the facility couldn't get psychiatry to consent to CMS guidelines of medication reductions. The form revealed psychological services was doing their job. Under resolution completed by the Administrator on 3/22/18, revealed the facility had the right to change services. If the psychologist wished to stay, she could apply for a position with the new contracted company or the residents could go see her at their own expense. Facility was providing services under state and federal statutes. Record review of nursing facility concern investigation form on 3/29/18 revealed a concern was placed by the ombudsman and psychological services. The form stated 2 members from psychological services and the ombudsman volunteer came to the administrator's office regarding the contractual agreement and they believed we could not send a notice we were giving notice of ending their contract. I pulled the contract and showed them we have every right to give notice without cause. There was a discussion held that they had contacted the legal department regarding the legality of given notice. At that time I ended the conversation. The 2 persons from psychological services stated they have a legal right to continue to see the residents and I explained yes but not in the facility since they no longer had a contract. Report taken by the Administrator and resolution completed on 3/29/18 by the Administrator. Interview on 4/6/18 at 2:55pm with the Corporate Nurse and Administrator revealed the facility wanted to switch companies because the psychiatrist had identified concerns that the nursing facility did not identify and the psychiatrist did not attend the behavior meetings. The Administrator indicated that initially the residents did not have a choice, but the psychologist was continuing to come to the facility and stated that she can continue to see her residents. The Corporate Nurse and Administrator stated they could not identify which residents were seen by the psychiatrist or psychologist until 4/6/18 at 11:00am when the former company gave them a list of residents to talk to about the change. During an interview on 4/19/18 at 1:43pm, the Administrator revealed the list of residents who received psychiatric services was provided by the pharmacy. Facility policy on Resident Rights Standard of Practice with an origination date of (MONTH) (YEAR) and a review date of (MONTH) (YEAR) revealed the following: Standard of Practice Explanation and Compliance Guidelines: #2. Information about resident rights and responsibilities will be given to the resident both orally and in writing. Resident Rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Planning and Implementing Care: The resident has the right to be informed of, and participate in, his or her treatment, including: a. The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition . iii. The right to be informed, in advance, of changes to the plan of care. c. The right to be informed in advance, of the care to be furnished and the type of care giver or professional that will furnish the care. According to a list provided by the Administrator, 53 residents received psychiatric services and 29 residents received psychology services with the former contracted services.

Based on observation, interview, and record review the facility failed to ensure residents were free from abuse and neglect for two (Resident #1 and #2) of two residents reviewed for abuse and neglect, in that: -The facility failed to have staff trained to enter and follow up on recommendations of the IDT into the TMHP LTC Portal. -As a result, Resident #1 did not receive her customized wheelchair that was recommended by the IDT 5 months ago. -CNA 1 verbally abused Resident #2. These failures affected 2 residents and placed 5 additional residents at risk of not receiving PASRR services necessary for a higher quality of life. These failures also placed 45 additional residents on station 2 at risk of staff mistreatment and mental anguish. Findings include: Resident #1 Record review of Resident #1's clinical file revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #1's initial IDT meeting dated 5/17/17 revealed her guardian agreed to alternate placement assistance and sought to place Resident #1 in a community facility. Record review of Resident #1's PASRR Individual Service Plan dated 5/25/17 revealed her service planning team and guardian felt she would benefit if moved to a personal group home setting which would include her own room. For this move, Resident #1 would require a customized wheelchair for mobility. Record review of Resident #1's Service Planning Team (SPT) meeting notes dated 10/16/17 revealed the meeting was held to add a customized wheelchair through PASRR specialized services to Resident #1's plan. The facility had previously submitted a request through Medicaid and it was denied. The Social Worker reported that a Durable Medical Equipment (DME) company had already been out to the facility to measure Resident #1 and that her current Broda Chair would no longer be used because it did not meet her needs. The Senior Service Coordinator (SSC) informed the facility to make her aware when the chair was purchased and delivered so that the HCS enrollment meeting could be scheduled, as that (the wheelchair) was the only thing they were waiting for at the moment for her transition into the community. Record review of the TMHP Medicaid Portal History list revealed that the first form submission for Resident #1's specialized wheelchair was dated 12/12/17. In a telephone interview on 3/14/18 at 3:32 pm the PASRR representative stated the first request for the specialized wheelchair was entered into the TMHP portal on 12/12/17. The request was denied because the DME supplier documentation, MSRP, and signatures were missing. A reason for denial was provided to the facility and they were given the opportunity to submit the requested material by 12/21/17. Due to the facility not providing the MSRP manufacturer letter by 12/21/17 the request was denied. Record review of Resident #1's Quarterly SPT meeting notes dated 1/19/18 revealed the ongoing issue with getting Resident #1's customized wheelchair was discussed. The Social Worker noted that Therapist #1 was now responsible for inputting the information into Simple Online Portal and last check she was still waiting on the quote from the DME company. The SSC mentioned that Resident #1 still had her slot to transition into the community and was just awaiting her customized wheelchair so the enrollment meeting could be scheduled. Record review of Resident #1's Progress Notes dated 1/19/18 revealed a care plan meeting was held during which her guardian indicated they were still waiting for the customized wheelchair before arranging discharge of the resident. Record review of Resident #1's care plan dated 1/25/18 revealed she was at risk for injury related to falls as evidenced by spastic movements, extensive assist with mobility and transfers, poor trunk and extremity positioning control. The Goal was for the resident to be up daily in a specialized wheelchair as a safe sitting device daily during this quarter. Observation and attempted interview on 3/14/18 at 9:16 am revealed Resident #1 was sitting in a Broda chair in station 2's lounge area. She was leaning toward the right side of the chair and making jerking movements. She made eye contact, but did not respond to questions. Continued observation at 5:14 pm revealed Resident #1 was sitting in a Broda chair in her room. She was leaning to the left side of the chair and had her legs extended on her roommate's bed. In an interview on 3/14/18 at 12:08 pm, the Social Worker stated Resident #1 needed the specialized wheelchair because her current Broda chair was not meeting her needs. He said she had difficulty sitting straight in the Broda chair and needed a chair that was more conforming to her posture. He said the facility was trying to place her in a group home that specialized in similar disabilities however she had not been placed in the home because they were waiting on the chair. Once the chair was received, Resident #1 could be placed in the home. During the same interview, the Social Worker explained he was responsible for submitting PASRR specialized services through the Simple Online Portal but did not receive much training. He stated Therapist #1 recently resubmitted all of the forms after the denial in (MONTH) and a form not accepted error was received on 3/13/18. The Social Worker stated the error was due to an invalid NPI number. He also believed there was a communication problem with Simple Online Portal and TMHP Portal. In an interview on 3/14/18 at 12:26 pm, Therapist #1 stated she was provided access to the Simple Online Portal at the end of (MONTH) and received no training. She submitted forms for Resident #1's specialized wheelchair in the Simple Online Portal at the end of February. She stated there were login issues with the Portal and when the Social Worker went to check the status of the submission a week later, no submission was found. She resubmitted the information for the specialized wheelchair on 3/7/18 and again on 3/12/18. An alert/form not accepted error was received on 3/13/18 due to an invalid NPI number. Therapist #1 stated her responsibility was to check the status of the submission and monitor for any discrepancies on the Simple Online Portal. In an interview on 3/14/18 at 3:45 pm the PASRR representative stated she spoke with the Administrator on 3/9/18 and offered assistance with the submission for Resident #1's customized wheelchair. She said no one from the facility called for help. The PASRR representative stated the only submissions visible in the TMHP portal from the facility were on 12/12/17 and 3/14/18. She explained if an error message appears due to invalid/missing information, the request will not go through to the TMHP portal until it is corrected. In an interview on 3/14/18 at 4:01 pm the Social Worker stated that he had worked with Resident #1 for a year and a half and failed to get Resident #1 to change her facial expressions. In an interview on 3/14/18 at 4:58 pm, Therapist #1 stated the rehabilitation department placed Resident #1 in a tilt in space trial chair for one day in January. The chair placed the resident in her proper position. Therapist #1 stated Resident #1 smiled and that was the first time she saw her change emotion. In an interview on 3/14/18 at 5:40 pm, LVN 1 stated she felt the Broda chair was not appropriate for Resident #1. She said the resident leaned a lot in the chair and did not have good posture. In an interview on 3/14/18 at 7:00 pm the Administrator stated his staff informed him that the request for Resident #1's customized wheelchair was submitted into the Simple Online Portal and had no knowledge of it being missing until the PASRR representative contacted him on 3/9/18. The Administrator stated he believed there was a system error. Record review of Resident #1's Simple LTC PASRR Nursing Facility Specialized Services request from 3/13/18 revealed, status: form not accepted; the following errors were returned from TMHP: (Fatal) CMWC/DME Referring Physician Military Spec Code or Referring Physician License Number is missing or invalid. Resident #2 Record review of Resident #2's clinical file revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's most recent MDS dated [DATE] revealed a BIMS score of 13 which indicated he was cognitively intact. He was totally dependent on staff for transfers, dressing, toilet use, and bathing and required extensive assistance with personal hygiene. He exhibited verbal behavioral symptoms toward others daily. Record review of Resident #2's care plan dated 10/26/17 revealed he had impaired cognition as evidenced by short term memory loss, yelling and aggression with staff at times. Resident has [DIAGNOSES REDACTED]. Approach resident warmly and positively. During an observation on 3/14/18 at 8:54 am CNA 1 was observed walking down the 200 hallway using profane language in a loud voice. CNA 1 appeared frustrated. During an observation on 3/14/18 at 8:56 am the Surveyor heard someone yelling in the 200 hallway. The Surveyor proceeded down the hall and observed CNA 1 yelling at Resident #2 as she was rolling him out of his room. CNA 1 yelled at Resident #2, I know how to do my job, don't tell me how to do my job. I am only one person. During an interview on 3/14/18 at 8:58 am immediately after the incident, Resident #2 stated he was seeking help from CNA 1 and she told him she was doing her job. He said CNA 1 had a bad attitude with him and made him feel bad and like he was a little kid. Resident #2 stated that CNA 1 had previously yelled at him and told him to shut up. During an interview on 3/14/18 at 9:04 am CNA 1 stated this was her 3rd day working on the 200 hall. She heard Resident #2 yelling in the hallway saying someone help me fix my bed. She told Resident #2 to stop all of that yelling. CNA 1 said she told the resident that she does certain things at specific times but he wanted immediate attention and had a tendency to nag. CNA 1 felt she was talking to the resident in a normal manner. When CNA 1 was informed that she was heard using profane language in the hallway, CNA 1 responded, Oh, I said that? During an interview on 3/14/18 at 9:40 am CNA 2, who was present in the hallway at the time of the incident, stated she heard CNA 1 say to Resident #2, I got this. CNA 2 stated that CNA 1 appeared frustrated and her voice was a little elevated. CNA 2 explained that she would personally never talk to a resident like that. During an interview on 3/14/18 at 10:15 am the Surveyor informed the Administrator of the incident. The Administrator stated that someone had already told him and he would be bringing CNA 1 into the office. During an interview on 3/14/18 at 11:23 am LVN 2 stated CNA 1 was recently moved from station 1 to station 2 because CNA 1 was not listening to the charge nurse. LVN 2 stated that CNA 1 would scream and talk loud to residents and employees. CNA 1 had a shout voice and would not act professionally toward residents and employees. LVN 2 also stated that CNA 1 would not answer call lights promptly and would leave residents dirty. During an interview on 3/14/18 at 4:55 pm Resident #2 stated he told the Social Worker earlier that day that CNA 1 was talking to him in a heavy voice and told him to get out of the room with a mean and rude attitude. He stated CNA 1 was loud and yelling. Resident #2 stated as a direct result of the incident, CNA 1 made him feel disrespected, bad, and like a little bitty child. Resident #2 said CNA 1 had acted like that several times in the past and he had reported her actions to his nurse. During an interview on 3/14/18 at 7:29 pm the Interim DON stated CNA 1 was moved from station 1 to station 2 because she would talk back and was rude to the nurses. The Interim DON stated CNA 1's interaction with residents had been okay and he had never seen her argue with a resident until the incident this morning. He stated he was present for the tail end of the incident and heard CNA 1 and Resident #2 going back and forth about the bed. He stated that CNA 1 was talking loud to the resident, but didn't believe she was yelling. The Interim DON stated that immediately after the incident he reported it to the Administrator because it was verbal abuse. During an interview on 3/14/18 at 7:50 pm the Administrator stated the Interim DON informed him of the verbal altercation earlier that morning but did not state he was a witness. Record review of CNA 1's employee file revealed a start date of 3/29/17. Further review revealed a performance evaluation dated 2/14/18 revealed in part, Cooperation: might be better, calm not exhibited. During a phone interview on 3/15/18 at 11:18 am the Administrator stated when he learned of the allegation he spoke with CNA 1, suspended her pending the investigation, and reported the incident. The Administrator stated the verbal abuse happened but Resident #2 only said he felt demeaned around the time of the incident yesterday (3/14/18) at 10:30 am. The Administrator stated that Resident #2 was observed throughout the day on 3/14/18 and the morning of 3/15/18 and did not display any [MEDICATION NAME] effects of emotional distress from the incident. The facility's Abuse Prohibition Standards of Practice policy revised in 11/17 revealed in part: Each resident has the right to be free from verbal, sexual, physical, and mental abuse . The resident has the right to be free from mistreatment, neglect and misappropriation of property. The following standards of practice will be operationalized in order that residents will not be subject to abuse by anyone, including, but not limited to, facility staff . III. Prohibition of Abuse: The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: 1. Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents. 2. Recognize signs of burnout, frustration and stress in employees that may lead to abuse. 3. Supervise staff to identify appropriate behaviors, such as using derogatory language .while giving care A Simple LTC list and a facility census provided by the Interim DON on 3/14/18 revealed the facility had 6 residents with a positive PASRR Evaluation and 47 residents on the 200 hall.

Based on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for one (Resident #1) of one resident reviewed for PASRR services, in that: -The facility failed to have staff trained to enter and follow up on recommendations of the IDT into the TMHP LTC Portal. -As a result, Resident #1 did not receive her customized wheelchair that was recommended by the IDT 5 months ago. This failure affected one resident by preventing her from being discharged into the community for a better quality of life and placed 5 residents at risk of not receiving necessary services. Findings include: Resident #1 Record review of Resident #1's clinical file revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #1's initial IDT meeting dated 5/17/17 revealed her guardian agreed to alternate placement assistance and sought to place Resident #1 in a community facility. Record review of Resident #1's PASRR Individual Service Plan dated 5/25/17 revealed her service planning team and guardian felt she would benefit if moved to a personal group home setting which would include her own room. For this move, Resident #1 would require a customized wheelchair for mobility. Record review of Resident #1's Service Planning Team (SPT) meeting notes dated 10/16/17 revealed the meeting was held to add a customized wheelchair through PASRR specialized services to Resident #1's plan. The facility had previously submitted a request through Medicaid and it was denied. The Social Worker reported that a Durable Medical Equipment (DME) company had already been out to the facility to measure Resident #1 and that her current Broda Chair would no longer be used because it did not meet her needs. The Senior Service Coordinator (SSC) informed the facility to make her aware when the chair was purchased and delivered so that the HCS enrollment meeting could be scheduled, as that (the wheelchair) was the only thing they were waiting for at the moment for her transition into the community. Record review of the TMHP Medicaid Portal History list revealed that the first form submission for Resident #1's specialized wheelchair was dated 12/12/17. In a telephone interview on 3/14/18 at 3:32 pm the PASRR representative stated the first request for the specialized wheelchair was entered into the TMHP portal on 12/12/17. The request was denied because the DME supplier documentation, MSRP, and signatures were missing. A reason for denial was provided to the facility and they were given the opportunity to submit the requested material by 12/21/17. Due to the facility not providing the MSRP manufacturer letter by 12/21/17 the request was denied. Record review of Resident #1's Quarterly SPT meeting notes dated 1/19/18 revealed the ongoing issue with getting Resident #1's customized wheelchair was discussed. The Social Worker noted that Therapist #1 was now responsible for inputting the information into Simple Online Portal and last check she was still waiting on the quote from the DME company. The SSC mentioned that Resident #1 still had her slot to transition into the community and was just awaiting her customized wheelchair so the enrollment meeting could be scheduled. Record review of Resident #1's Progress Notes dated 1/19/18 revealed a care plan meeting was held during which her guardian indicated they were still waiting for the customized wheelchair before arranging discharge of the resident. Record review of Resident #1's care plan dated 1/25/18 revealed she was at risk for injury related to falls as evidenced by spastic movements, extensive assist with mobility and transfers, poor trunk and extremity positioning control. The Goal was for the resident to be up daily in a specialized wheelchair as a safe sitting device daily during this quarter. Observation and attempted interview on 3/14/18 at 9:16 am revealed Resident #1 was sitting in a Broda chair in station 2's lounge area. She was leaning toward the right side of the chair and making jerking movements. She made eye contact, but did not respond to questions. Continued observation at 5:14 pm revealed Resident #1 was sitting in a Broda chair in her room. She was leaning to the left side of the chair and had her legs extended on her roommate's bed. In an interview on 3/14/18 at 12:08 pm, the Social Worker stated Resident #1 needed the specialized wheelchair because her current Broda chair was not meeting her needs. He said she had difficulty sitting straight in the Broda chair and needed a chair that was more conforming to her posture. He said the facility was trying to place her in a group home that specialized in similar disabilities however she had not been placed in the home because they were waiting on the chair. Once the chair was received, Resident #1 could be placed in the home. During the same interview, the Social Worker explained he was responsible for submitting PASRR specialized services through the Simple Online Portal but did not receive much training. He stated Therapist #1 recently resubmitted all of the forms after the denial in (MONTH) and a form not accepted error was received on 3/13/18. The Social Worker stated the error was due to an invalid NPI number. He also believed there was a communication problem with Simple Online Portal and TMHP Portal. In an interview on 3/14/18 at 12:26 pm, Therapist #1 stated she was provided access to the Simple Online Portal at the end of (MONTH) and received no training. She submitted forms for Resident #1's specialized wheelchair in the Simple Online Portal at the end of February. She stated there were login issues with the Portal and when the Social Worker went to check the status of the submission a week later, no submission was found. She resubmitted the information for the specialized wheelchair on 3/7/18 and again on 3/12/18. An alert/form not accepted error was received on 3/13/18 due to an invalid NPI number. Therapist #1 stated her responsibility was to check the status of the submission and monitor for any discrepancies on the Simple Online Portal. In an interview on 3/14/18 at 3:45 pm the PASRR representative stated she spoke with the Administrator on 3/9/18 and offered assistance with the submission for Resident #1's customized wheelchair. She said no one from the facility called for help. The PASRR representative stated the only submissions visible in the TMHP portal from the facility were on 12/12/17 and 3/14/18. She explained if an error message appears due to invalid/missing information, the request will not go through to the TMHP portal until it is corrected. In an interview on 3/14/18 at 4:01 pm the Social Worker stated that he had worked with Resident #1 for a year and a half and failed to get Resident #1 to change her facial expressions. In an interview on 3/14/18 at 4:58 pm, Therapist #1 stated the rehabilitation department placed Resident #1 in a tilt in space trial chair for one day in January. The chair placed the resident in her proper position. Therapist #1 stated Resident #1 smiled and that was the first time she saw her change emotion. In an interview on 3/14/18 at 5:40 pm, LVN 1 stated she felt the Broda chair was not appropriate for Resident #1. She said the resident leaned a lot in the chair and did not have good posture. In an interview on 3/14/18 at 7:00 pm the Administrator stated his staff informed him that the request for Resident #1's customized wheelchair was submitted into the Simple Online Portal and had no knowledge of it being missing until the PASRR representative contacted him on 3/9/18. The Administrator stated he believed there was a system error. Record review of Resident #1's Simple LTC PASRR Nursing Facility Specialized Services request from 3/13/18 revealed, status: form not accepted; the following errors were returned from TMHP: (Fatal) CMWC/DME Referring Physician Military Spec Code or Referring Physician License Number is missing or invalid. A list provided by the Interim DON on 3/14/18 revealed the facility had 6 residents with a positive PASRR level II Evaluation.

Based on interview and record reviews the facility failed to ensure that based on a resident's comprehensive assessment, a resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; for 2 of 4 residents (Resident #1 and CR #2) reviewed for nurtrition and hydration, in that: -The facility failed to initiate Resident #1's recommended diet change resulting in a 13.8% weight loss in 30 days and 26.8% weight loss in 180 days. - The facility failed to monitor CR #2's weight monthly and notify the dietitian when the resident began to refuse pleasure feedings so the resident's [DEVICE] feeding could be recalculated to provide increased nutrition to prevent weight loss and increase wound healing. This failure affected 1 discharged resident and 1 current resident and placed 16 additional residents who received enteral feedings at risk of weight loss, a decline in health and wound healing, and illness caused by malnutrition. Findings include: Resident #1 Record review of Resident #1's Face Sheet dated 2/20/18 revealed an admission date of [DATE] and a readmission date of [DATE] with a [DIAGNOSES REDACTED]. Further review revealed Resident #1 passed away in the facility on 2/18/18. Record review of Resident #1's care plan dated 12/27/17 revealed a problem/ need for hospice due to terminal/ end stage diagnosis. The nursing facility identified under this section of the care plan to: 1) modify the diet as needed and 2) Encourage fluid and nutrition as tolerated and appropriate. Further review revealed: Problem/ need last updated on 7/25/17 revealed risk for alteration in nutrition related to resident receives all nutritional thru a [DEVICE]. Resident has multiple wounds, needs higher protein intake. Has a history of malnutrition. Approaches for his care were to: 1) Notify MD, family, responsible party of changes as needed, 2) Monitor weights per protocol, and 3) Diet per order: [MEDICATION NAME]. Review of the physician's orders [REDACTED].#1 revealed hospice was ordered on [DATE]. Review of Resident #1's weights provided by the DON on 2/20/18 revealed a weight in (MONTH) 8, (YEAR) of 106.8 lbs. and a weight in (MONTH) 7, (YEAR) of 92.1 lbs. (-14.1 lbs.), a significant weight loss of 13.76% in 1 month. Record review of Resident #1's Weight Loss Tube Feeding Review completed by the Dietician on 2/9/18, revealed a 30 day significant weight loss of 14.7 lbs. (-13.8%) x 30 days and (-26.8 %) x 180days. The Dietician was unable to review Resident #1's weight change in 90 days due to missing weights. The Dietitian noted in her review that Resident #1 had a small frame/ stature and extensive wounds (10 total) and hospice status. She recommended that his feeding run longer throughout the day allowing for an adequate amount of time for bowel rest as calculated. She also recommended discontinuing [MEDICATION NAME] at 50ml/ hour x 16 hours per day due to inadequate enteral infusion with significant weight loss. She recommended [MEDICATION NAME] 1.5 at 50ml/ hour x 20 hours/ day to provide 1500kcal, 62g protein. The goal was no significant weight loss of greater than or equal to 5% x 30 days, tube feeding tolerance, and wound support. Record review of Resident #1's MAR and physician orders [REDACTED]. Interview with the Dietitian on 2/21/18 at 10:15am revealed she had recently completed a weight review on Resident #1 on 2/9/18 with dietary recommendations. She revealed Resident #1 was receiving [MEDICATION NAME] formula via [DEVICE] and he was only getting 80% of his calories and 60% of his daily protein needs with this formula. She indicated Resident #1 had a significant weight loss in the last 30 days and recommended a change in formula to [MEDICATION NAME] 1.5 at 50ml/ hour for 20 hours. She indicated she was not made aware if those recommendations were ordered by the physician. She further stated the nursing facility staff did not consult with her when a resident had a weight gain or weight loss, she would find any weight changes when she conducted her reviews. Interview with DON on 2/21/18 at 1:25pm revealed the DON indicated that he had spoken to the Dietitian regarding Resident #1's weight loss and then called hospice on 2/7/18. The DON revealed he never followed up with hospice nor did hospice follow-up with the DON related to Resident #1's weight loss. Interview with the ADON on 2/21/18 at 1:27pm revealed he had noted the recommendation by the Dietitian, but no further documentation was indicated that the physician or hospice were made aware of the new dietary recommendations. The ADON stated maybe the doctor did not want to make the dietary change, plus he was on hospice. Interview with the DON on 2/21/18 at 4:06pm revealed he was not aware of what a Weight Variance Committee or intervention and Recommendation Sheet was per the nursing facility's policy. He explained residents weights were discussed with the IDT in a Standards of Care Meeting held daily. He identified Resident #1 had been discussed in this meeting on 12/13/17 due to concerns of 14 ulcers and a re-admission weight of 114lbs. The ADON stated in that meeting, the MD recommended hospice for Resident #1. The ADON stated on 2/7/18 Resident #1 was again discussed in the meeting due to multiple wounds and weight loss. He stated that hospice should have been notified regarding Resident #1's weight loss to determine if any changes should be made. Record review of Resident #1's Nursing Note dated 2/7/18 at 3:04pm by the DON which indicated hospice was notified of the resident's weight loss of 14.7 lbs. Further review revealed the DON consulted with hospice that the [DEVICE] feedings were only 16 hours and may need to be adjusted. Per the nursing note the hospice nurse indicated she would discuss with the hospice MD and call back. There was no follow up documentation in the chart of this concern. CR #2 Record review of CR #2's Face Sheet dated 2/14/18 revealed an admission date of [DATE] and a readmission date of [DATE]. CR #2's [DIAGNOSES REDACTED]. Further review revealed that CR #2 discharged from the facility on 2/12/18 to the local hospital. Record review of CR #2's weights in the electronic health record on 2/14/18 revealed the following weights: 8/1/17 179.0 lbs. 12/5/17 141.7 lbs. 1/8/18 137.9 lbs. (-41.1 lbs in 5 months, -22.96%) 2/7/18 132.9 lbs. Record review of CR #2's MDS dated [DATE] revealed a weight of 142. No identified weight loss was documented. Record review of CR #2's most recent MDS completed on 2/8/18 revealed a weight of 133 and no identified weight loss or gain was documented. Record review of CR #2's Dietitian Note on 10/27/17 revealed the resident was on [MEDICATION NAME] for osteo[DIAGNOSES REDACTED]. The Dietitian indicated CR #2 was receiving [MEDICATION NAME] 1.2 at 60ml/ hour x 22 hours to provide 1584 kcal and 73g of protein. The Dietitian also noted CR #2 also received a pleasure feeding tray and consumed 50% average intake. The Dietitian indicated the current enteral feeding and pleasure tray were meeting CR #2's nutritional needs. The Dietitian indicated she would continue to monitor CR #2's PO intake. Record review of CR #2's (MONTH) (YEAR) MAR revealed an order for [REDACTED]. It was identified that each shift marked CR #2 receiving 480ml except on 2/4/18 morning shift when CR #2 only received 320ml. It was identified that CR #2 received approximately 1440kcal per day, which was 144kcals per day and approximately 1000kcals per week short of his nutritional needs. Interview with DON and ADON on 2/14/18 at 4:47pm revealed CR # 2's pleasure feedings were not in the system. DON revealed CR #2 had been sleeping more. DON also indicated CR #2 was receiving IV antibiotics due to pneumonia and had not wanted to eat. The DON did not relay if this information concerning the pleasure feedings were communicated to the Dietitian or Physician. Interview with the DON on 2/20/18 at 4:03 pm revealed monthly weights were routine for all residents with no concern for weight loss. New admissions would be weighed weekly x 4 weeks. DON indicated there was a separate book for weights and the Dietitian was aware of this book. DON stated weekly weights were not entered into the resident's electronic health record because it would change the formula for the monthly weights. Interview with LVN #1 on 2/21/18 at 9:15am revealed the restorative aides obtain weights for all the residents and then she receives the weights to make sure they are all done. LVN #1 revealed the weights are then given to the ADON who follows through for a change in weight. She revealed the dietitian is at the nursing facility on Tuesday/ Wednesday or Thursday. LVN #1 indicated the dietitian was aware of the weights through the weight book and she gives a copy to the dietary food manager. Interview with the Dietitian on 2/21/18 at 10:15 am revealed the facility did not have a weight for CR #2 for (MONTH) (YEAR) and (MONTH) (YEAR). The Dietitian did identify a weight for CR #2 in (MONTH) (YEAR) of 146.3 after he was readmitted from the hospital. She stated she was not aware of the CR #2's weight loss because without the weights for (MONTH) and October, he did not trigger for a weight loss on the spreadsheet she used for concerns. The Dietitian indicated no one at the nursing facility gives her a report for weight gain or loss. She indicated she makes a list herself. She stated she was not aware of CR #2's weight loss or she would have conducted a consult. Interview with LVN #1 on 2/21/18 at 1:54 pm revealed the dietitian could get resident weights from her if it was not in the electronic medical record. She indicated CR #2's weight on 9/27/17 was 128.5lbs. upon re-admission from the hospital and on 10/4/17 was 147 lbs. LVN #1 revealed she or the DON would typically enter the weight into the electronic health record. She was unsure why CR #2's weights were not entered into the electronic health record for September, October, or (MONTH) (YEAR). Interview with the DON on 2/21/18 at 4:06pm revealed a Standards of Care Meeting discussed CR #2 on 1/10/18. He indicated the IDT noted CR #2 was recently diagnosed with [REDACTED]. The IDT wanted to continue current wound care. On 1/31/18 another IDT Standards of Care Meeting was held and they discussed CR #2 due to multiple wounds and a weight loss of 5.0 lbs. The IDT concerns identified in the meeting were: CR #2 was on IV [MEDICATION NAME] and fluids, had failure to thrive, the facility would continue to monitor BMP, [MEDICATION NAME] was discontinued, and CR #2 received contracture management. Record review of CR #2's Care Plan dated (MONTH) (YEAR), revealed the following: Onset date 10/17/17 - Problem/ need: Risk for complications associated with tube feedings. Goal: Free from complications associated with tube feeding x 90 days. Will safely consume pleasure foods as allowed x 90 days. Approach: Tube feeding as ordered: [MEDICATION NAME] 1.2 and Notify MD, family, responsible party of changes as needed. Onset date 3/20/17 - Problem/need: Risk for alteration in nutrition related to need for mechanical soft diet with risk of complications from imbalanced nutrition related to [DIAGNOSES REDACTED]. Goal: Will consume greater than or equal to 50% offered meals every day x 90 days. Will tolerate least restrictive diet x 90 days. Approach: Notify MD, family, responsible party of changes as needed. Diet as ordered [MEDICATION NAME] 1.2 with pleasure trays: Puree with honey thick liquids. Offer alternates or supplement with < 50% consumption. Monitor weights per protocol. Record review of Weight Policy dated 09/15 revealed in part: 10. Dietary will obtain the monthly weights and enter them into electronic health record for calculation of the monthly variance report. 11. Residents triggering a significant weight variance defined as 5% in 1 month, 7.5 in 3 months, &/ or 10% in 6 months will be addressed by the Weight Variance Committee and placed on Weekly Weight monitoring. 12. Each resident will have an Intervention and Recommendation Sheet initiated and updated each week until weight stabilizes or another plan is formulated (ex. Hospice). 14. The weekly weights are to be entered in the electronic health record and review the Weight Variance Committee weekly. 15. Resident Care Plans shall be updated and documentation of the interventions maintained as part of the medical record. Recommendations made by the weight variance committee will be implemented within 72 hours. The dietary manager and / or nursing supervisor will be responsible for ensuring recommendations are implemented and followed up accordingly. The 24 hour report must be noted of all outstanding recommendations not yet answered. The facility's CMS 672 dated 2/12/18 revealed 16 residents received nutrition via an enteral feeding tube.

Based on observation, interview and record review the facility failed to ensure each resident receives the necessary care and services to attain or maintain the highest practicable physical level in accordance with the comprehensive plan of care for 1 of 2 Residents reviewed for respiratory care (Resident CR #10) The facility failed to monitor CR #10 ' s temperature and oxygen saturation rates every shift and the resident was sent to the hospital where he was diagnosed with [REDACTED]. The failure affected 1 resident and placed the other 13 residents that received respiratory care at risk of respiratory decline, respiratory infections and discomfort. Complaints # 5 and 3 The findings include: Resident CR# 10 Record review of the face sheet for Resident CR#10 revealed a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident was transferred to the hospital on [DATE], assessed in the emergency roiagnom on [DATE] at 12:50 am and diagnosed with [REDACTED]. Further review of the hospital history and physical dated 01/18/12 for CR # 10 revealed documentation including: " ... this was a [AGE] year old male admitted through emergency room with altered mental state. He had purulent urine and [MEDICAL CONDITION] after changing the catheter , he had 4 liters of urine output. He also has pneumonia . The patient has previous history of [MEDICAL CONDITIONS]. After he was found to be very acidotic with his pH was 7.06 and PCO2 was 101, he was intubated. He is quadriplegic secondary to his spinal cord injuries due to a motor vehicle accident. He has stage IV sacral decubitus, osteo[DIAGNOSES REDACTED] of the sacrum. Impression and management : 1. Altered mental state secondary [MEDICAL CONDITION]. Extensive sacral decubitus. 3. other medical problem is [MEDICAL CONDITION], on ventilator at this time. 4. Respiratory acidosis. His peak is much improved at this time which is 7.35. The patient has been seen by pulmonology ... " In a phone interview on 01/26/12 the family member revealed that she was on her way to the hospital as CR #10 was being removed from life-support related to his decline and she was told CR#10 would die after the life-support was removed. Observation on 01/19/12 at 9:15 am of CR#10 with hospital RN in a negative air controlled intensive care room. Resident was on a ventilator for mechanical assisted breathing and had multiple bags of fluids infusing through multiple tubes connected to his body. The indwelling urinary catheter was connected to urinary collection device containing, golden colored clear appearing urine. The RN removed the buttock dressing to reveal a large open sacral area, that had odor and the bone was visible. The RN said, it was about 20 cm and it had undermining. The RN displayed multiple wounds on the body and said that the hospital took multiple pictures because of the extent and severity of the wounds. Record review of the Admission MDS assessment with assessment reference date of 11/22/11 revealed active [DIAGNOSES REDACTED].#1 to #7. Assessment section for cognitive patterns revealed resident interviewable with a BIMS score of 15 of 15. Resident mood was assessed as feeling down and behavior was assessed with [REDACTED]. Functional status section was assessed as total assistance with 2 person assist for all activities of daily living. Eating was assessed as total dependence, full staff performance every time and range of motion was assessed as impairment on both sides for upper and lower extremities. Assessment of bladder and bowel revealed resident had an indwelling urinary catheter and was incontinent of bowel. The skin condition assessment revealed resident at risk for developing pressure ulcer and resident had a stage 1 or higher pressure ulcers with 1 stage IV pressure ulcer on admit. Skin /ulcer treatments assessment included; pressure reducing device for bed, nutrition/hydration, and ulcer care. Record review of the facility's Admission (MDS) data set [DATE] for Resident CR#10 revealed the resident assessment included, resident was alert, oriented to person and time. Resident had a non-productive cough, pink skin and was absent of [MEDICAL CONDITION]. The urine was clear, amber absent of sediment and resident had an indwelling urinary catheter. The full body inspection revealed 2 neck wounds noted on the posterior neck area and sacral areas. Record review of the facility's History and physical dated 11/11/11 for CR# 10 revealed previous medical history of [REDACTED].Has had [MEDICAL CONDITION] removed, presents with Halo traction and body brace intact. He was oriented and alert times 3. [DIAGNOSES REDACTED]. 2. [MEDICAL CONDITION], 3. [MEDICAL CONDITIONS] continue medications, INH, [MEDICATION NAME] (Vitamin B-6), 7. MAI ([DIAGNOSES REDACTED] avian intercellular bacteria)-continue [MEDICATION NAME] for 10 days, 11. Sacral wound- continue santyl and monitor, on air mattress and wound care, Record review of the admission orders [REDACTED] - [MEDICATION NAME] (for MAI) 250 mg, take one tablet po every day for 14 days, -[MEDICATION NAME] (treat [MEDICAL CONDITION]) 600 mg, 1 tablet po every day, -[MEDICATION NAME](treat [MEDICAL CONDITION]) 300 mg 1 tablet po every day, -[MEDICATION NAME] ( [MEDICAL CONDITION] treat )1,500 mg 1 tablet po every day, -[MEDICATION NAME]( [MEDICAL CONDITION]) 25 mg , 1 tablet po HS, - [MEDICATION NAME] (anti-depressant)200 mg 1 tablet po every day, -Sacrum wound cleanse with normal saline . Apply santyl to entire wound. Apply sensi care to skin around the wound . Apply 2 to 3 gauze moistened with Dakins to wound bed , cover with abdominal pad twice daily. Record review of the initial plan of care for CR # 10 revealed the following problems dated 11/10/11; -problem of Infection due to wound, goal was infection will be resolved by completion of antibiotic. The interventions included, assess response to therapy and vital signs, administer antibiotic as ordered, treatment given as ordered, -problem of pressure ulcer location at sacrum and back of neck. The goal was pressure ulcer will show improvement. The interventions included, treatment as ordered, conduct weekly skin assessments and document, turn and reposition every 2 hours. Record review of the TARS dated 12/11 and 01/12 for CR# 10 revealed intervention to monitor temperature and oxygen saturation rates every shift. The documentation revealed initials in boxes and no temperatures or saturation rate were documented. Record review of the nurse notes dated 12/20/11 to 01/18/12 for CR#10 revealed documentation including an entry on 12/20/11 at 10:00am of resident resistant to be turned and repositioned as complained of pain when being turned. An entry on 12/26/11 at 12:00 pm revealed CR#10 refused care from CNA and further review of the entry revealed, another CNA was assigned to Resident and resident refused care and refused to be repositioned and turned. Record review of the RCP for CR#10 revealed no care plan for refusal of care and only the following problems; 1. Problem dated 11/10/11 of Resident has a pressure ulcer-stage III head/neck and stage IV sacral. The goal was skin will remain clean and area will decrease in size and/or heal through next review . The approaches included; 1) Perform treatment per order... 2) Encourage dietary/fluid intake .... 4) Assist with turn/repositioning every 2 hours and PRN, 5) Provide pressure relieving device for bed and wheel chair, 2. Problem dated11/28/11 of resident has staged wound. The goal was resident will not experience discomfort and further infection. The approaches included; -Keflex 500 mg QID for 7 days, - Vital signs as ordered, -pain medication as ordered, -monitor effectiveness of antibiotic, pain medication, -notify MD as indicated, -wound treatment as ordered, 3. problems dated 12/19/11 of resident is at risk for adverse reactions to [MEDICATION NAME] 100 mg po BID for 2 months and Bactrim DS one tablet po BID for 2 months related to wound infection and osteo[DIAGNOSES REDACTED] ( bone infection). The goal was to resolve infection ...resident will not have any adverse reaction to antibiotic therapy. The approaches included; -give meds as ordered, monitor lab results... -monitor for adverse reactions Record review of physician orders [REDACTED]. Record review of the TARS dated 01/12 for CR# 10 revealed intervention to monitor temperature and oxygen saturation rates every shift. The documentation revealed initials in boxes and no temperatures or saturation rate were documented. In an interview on 01/26/12 at 12:30 pm with the DON and the Administrator the DON was asked where the Resident vital signs and oxygen saturation rates were documented and she said in the Accu Nurse system. The DON went to get the vital signs and oxygen saturation data for CR # 10. The DON returned to say there was no data for resident temperature or oxygen saturation rates on the system and there was no data for those interventions. The Administrator reviewed the nurse notes and said that resident was monitored as temperatures were documented. Record review of the nurses notes dated 1/12/12 revealed that an employee from the health department called the facility requesting information on CR #10 related to his history of TB. The health deparment requested copies of chest X rays, and sputum results. The facility received orders from the attending physician to obtain chest X rays and laboratory testing. Record review of chest X ray completed on 1/12/12 and faxed to the facility on [DATE] revealed: "...lung volumes decreased...this could be related to rib deformities, however further workup is required...Impression:...recommend CT scan for further evaluation as [MEDICAL CONDITION] cannot be excluded completely based on this examination...Further review of the X ray result, nurses notes and physician orders [REDACTED]. Record review of the nurse notes dated 12/09/11 to 01/17/12 for CR# 10 revealed documentation of entries of resident temperature and oxygen saturation rates on; -12/12/11 at 10:00am, temperature was 98.9 F and resident had a productive cough, -12/20/11 at 4:30 am, temperature was 98.1 F, -12/20/11 at 10:00am, temperature was 97.7 F, -12/21/11 at 4:00 am, temperature was 97.6 F, -12/22/11 at 9:00am ,temperature was 98.4 F, -12/23/11 at 10:00am, temperature was 98.3 F, -12/26/11 at 6:00am, temperature was 97.7 F, -12/26/11 at 10:00am, temperature was 98.0 F, -12/28/11 at 10:00am,temperature was 98.3 F, -12/29/11 at 9:00 am, temperature was 97.9 F, -12/30/11 at 9:00 am, temperature was 98.2 F, -01/02/12 at 9:00am, temperature was 98.2 F, -01/03/12 at 9:00 am, temperature was 98.2 F, -01/04/12 at 5:00 am, temperature was 98.6 F, -01/05/12 at 9:00 am, temperature was 97.6 F, -01/09/12 at 9:00 am, temperature was 98.2 F, -01/11/12 at 9:00 am, temperature was 97.9 F, -01/13/12 at 9:00 am, temperature was 98.5 F, -01/16/12 at 9:00 am, temperature was 98.0 F, -01/17/12 at 10:30 am, temperature was 98.9 F, and the oxygen saturation rate was 85%. This was the only oxygen saturation level documented on the clinical record. CR #10 was sent to the hospital on [DATE]. Record review of the facility's policy and procedure on Catheter care, Urinary dated 10/10 contained documentation including; -Reporting: ...2. report other in formation in accordance with facility policy and professional standards of practice. Record review of the monthly physician orders [REDACTED]. Record review of the urine analysis for CR #10 revealed initial results on 11/14/11 of cloudy urine with many bacteria present and final results released on 11/16/11 with pseudomonas aeruginosa (bacteria) present and documentation in lower corner revealed inititals and was dated 11/16/2011. Further review of records revealed no new orders for laboratory results. Record review of the facility's infection control log dated 11/01/11 to 01/25/12 revealed no documentation of an entry for CR# 10's urinary infection or any respiratory infection. Record review of the facility's policy and procedure on Catheter care, Urinary dated 10/10 contained documentation including; -Reporting: ...2. report information in accordance with facility policy and professional standards of practice. Record review of the facility's policy and procedure on pain management dated 10/10 revealed documentation including; Documentation- 2. Upon completion of assessment ,the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. Refer to CMS F 314 for additional evidence. The CMS 672 revealed 14 residents require respiratory care.

Based on observation, interview and record review the facility failed to provide the necessary treatments and services to promote healing , prevent infection and prevent new sores from developing for 2 of 4 residents (Residents #1 and #3) and 1 closed record (CR# 10) reviewed for pressure ulcers as evidenced by; -CR # 10 was admitted to facility on 11/10/11 and did not received necessary treatments to promote healing and prevent infections. CR #10 stage IV sacral wound increased in size while in the facility, he developed a wound infection and osteo[DIAGNOSES REDACTED] (bone infection) on sacrum. CR #10 was admitted to the hospital with [REDACTED]. -Resident #1 was admitted with pressure ulcers and the facility failed to repositioned at least every 2 hours per resident care plan; provide pressure ulcer wound treatment that incorporate appropriate infection control practices and failed to conduct and document skin assessments. One pressure sore had increase in size. -Resident #3 had facility acquired pressure ulcers and they failed to reposition at least every 2 hours per resident care plan; provide pressure ulcer wound treatment that incorporate appropriate infection control practices and failed to conduct and document skin assessments. Pressure sore had increase in size. The failure affected 2 Residents, 1 discharged resident and had the potential to place 9 other Residents with pressure ulcers at risk for infection, worsening of pressure sores, development of new pressure sores, and a decline in health. Complaints # 5 and # 3 The findings include: Resident CR# 10 Record review of the face sheet for Resident CR#10 revealed [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident was transferred to hospital and assessed in emergency roiagnom on ,[DATE] /11 at 12:50 am and diagnosed with [REDACTED]. Post investigation interview on 01/26/12 with family member revealed she was on her way to hospital as resident was being removed from life-support related to decline and she was told CR#10 would die after the life-support was removed. Observation on 01/19/12 at 9:15 am of CR#10 with hospital RN in a negative air controlled intensive care room. Resident was on a ventilator for mechanical assisted breathing and had multiple bags of fluids infusing through multiple tubes connected to his body. The RN removed the buttock dressing to reveal a large open sacral area , that had odor and the bone was visible. The RN said, it was about 20 cm and it has undermining. The RN displayed multiple wounds on the resident ' s body and said that the hospital took multiple pictures of the wounds because the extent of the wounds and the number of the wounds. The sacral pressure ulcer measurements were recorded as 19 cm (L) by 18 cm (W) and depth was 2cm. Record review of the facility's Admission (MDS) data set [DATE] for Resident CR#10 revealed 2 neck wounds noted on the posterior neck area and sacral areas. The pressure ulcer assessment section revealed a score or 11. A score greater than 7 indicates the resident is at risk for ulcers and a care plan was indicated. Record review of the facility's History and physical dated 11/11/11 for CR# 10 revealed he was in a multi-vehicle accident in 07/11.Has had [MEDICAL CONDITION] removed, presents with Halo traction and body brace intact. 11. Sacral wound- continue santyl and monitor, on air mattress and wound care, Record review of the admission orders [REDACTED] -Sacrum wound cleanse with normal saline . Apply santyl to entire wound. Apply sensi care to skin around the wound. Apply 2 to 3 gauze moistened with Dakins to wound bed , cover with abdominal pad twice daily. Record review of the physician telephone order dated 11/11/11at 2:40 pm for CR# 10 revealed; 1. Cleanse sacral ulcer with wound cleanser. Apply santyl (topical medication) to wound base, pack with 4 by 4 gauze and cover every day. 2. Discontinue previous wound orders with Dakins... Record review of the initial plan of care for CR # 10 revealed the following problems dated 11/10/11; -problem of Infection due to wound, goal was infection will be resolved by completion of antibiotic. The interventions included, assess response to therapy and vital signs, administer antibiotic as ordered, treatment given as ordered, -problem of pressure ulcer location at sacrum and back of neck. The goal was pressure ulcer will show improvement. The interventions included, treatment as ordered, conduct weekly skin assessments and document, turn and reposition every 2 hours. -problem of potential for skin break down due to bed bound. The goal was resident will have no skin breakdown. The interventions included weekly skin assessment and document ,keep clean and dry, Record review of the Admission MDS assessment with assessment reference date of 11/22/11. Assessment of cognitive patterns revealed resident interviewable with a BIMS score of 15/15 to indicate he was cognitively intact. Resident mood was assessed as feeling down and behavior was assessed with [REDACTED]. Functional status was assessed as total assistance with 2 person assist for all activities of daily living, range of motion was assessed as impairment on both sides for upper and lower extremities. Assessment of bladder and bowel revealed resident had an indwelling urinary catheter and was incontinent of bowel. The skin condition assessment revealed resident at risk for developing pressure ulcer and resident had a stage 1 or higher pressure ulcers with 1 stage IV pressure ulcer on admission. Skin /ulcer treatments assessment included; pressure reducing device for bed, nutrition/hydration, and ulcer care. Record review of the resident care plan for CR#10 revealed no care plan for refusal of care, the resident care plan revealed documentation for the following problems; 1. problem dated 11/10/11 of Resident has a pressure ulcer-stage III head/neck and stage IV sacral. The goal was skin will remain clean and area will decrease in size and/or heal through next review . The approaches included; 1) perform treatment per order... 2) Encourage dietary/fluid intake .... 3) Keep family/RP, MD informed of resident's progress, 4) Assist with turn/repositioning every 2 hours and PRN, 5) Provide pressure relieving device for bed and wheel chair, 2. problem dated11/28/11 of resident has staged wound. The goal was resident will not experience discomfort and further infection. The approaches included; -Keflex 500 mg QID for 7 days, - Vital signs as ordered, -pain medication as ordered, -monitor effectiveness of antibiotic, pain medication, -notify MD as indicated, -wound treatment as ordered, 3. problems dated 12/19/11 of resident is at risk for adverse reactions to [MEDICATION NAME] 100 mg po BID for 2 months and Bactrim DS one tablet po BID for 2 months related to wound infection and osteo[DIAGNOSES REDACTED] ( bone infection). The goal was to resolve infection ...resident will not have any adverse reaction to antibiotic therapy. The approaches included; -give meds as ordered, monitor lab results... -monitor for adverse reactions -isolate according to facility policy, -follow universal/standard precaution to prevent cross contamination and spread of infection. Record review of the facility's Nurse notes dated 11/11/11 at 9:45 am revealed resident was admitted on [DATE] and presented with wounds to sacrum , stage IV, measuring 11 by 11 by 2.8, red with slough in places. He also has 2 wounds to the back of his head/neck...... All wounds had santyl applied and clean dressings applied. Record review of the facility's Weekly pressure ulcer progress dated 11/11/11 for Resident CR#10 revealed sacral pressure ulcer measured 11 cm (L) by 11 cm (W) by 2.8 cm in depth. Record review of the Wound care specialist evaluation with initial assessment dated [DATE] revealed sacral wound size measured at 18cm (L) by 20cm (W) by 5 cm in depth. Recommendation was to reposition resident per facility protocol. The wound care physician removed some thick adherent and devitalized tissue. Record review of the Wound care specialist evaluation dated 12/14/11 for CR# 10 revealed sacral wound size measured as 22cm (L) by 18cm (W) by 2.7 cm in depth. reposition per facility protocol. The wound care physician removed necrotic tissue and established the margins of viable tissue. Documentation revealed the wound deteriorated and reason for deterioration was non-compliance of patient. Recommendations were documented as reposition per facility policy and conduct culture and sensitivity of wound. (laboratory assessment). Record review of the sacral wound culture laboratory results of specimen collected on dated 12/15/11 for CR#10 revealed sacral pressure ulcer was infected with proteus mirabelis bacteria. Record review of the laboratory results for the sacrum bone biopsy for CR #10 conducted on 12/14/11 revealed acute osteo[DIAGNOSES REDACTED]. Record review of the facility's infection control log dated 11/01/11 to 01/19/12 revealed an entry for CR# 10 of skin infection of Proteus mirabilis(bacteria) with an onset date of 12/15/11 and documentation revealed an antibiotic was given and status was open. Record review of the monthly physician orders dated 01/12 for CR #10 included orders dated 12/19/11 for antibiotics of [MEDICATION NAME] and Bactrim DS to be administered BID for 2 months related to wound infection Record review of the nurse notes dated 12/20/11 to 01/18/12 for CR#10 revealed documentation including an entry on 12/20/11 at 10:00am of resident resistant to be turned and repositioned as complained of pain when being turned. An entry on 12/26/11 at 12:00 pm revealed CR#10 refused care from CNA and further review of the entry revealed, another CNA was assigned to Resident and resident refused care and refused to be repositioned and turned. Record review of the Psychoactive Medication Monthly Flow Records dated 11/11,12/11 and 01/12 for CR#10 revealed blank/undocumented forms. Record review of the hospital history and physical dated 01/18/12 for CR # 10 revealed documentation including this was a [AGE] year old male admitted through emergency room with altered mental state. He has stage IV sacral decubitus, osteo[DIAGNOSES REDACTED] of the sacrum. Impression and management : 1. Altered mental state secondary [MEDICAL CONDITION]. Extensive sacral decubitus. 3. other medical problem is [MEDICAL CONDITION], on ventilator at this time. Record review of the hospital sacral decubitus wound culture results dated 01/19/12 for CR # 10, revealed bacteria of Proteus mirabilis and [MEDICATION NAME]. Resident #1 Record review of the facility face sheet for Resident #1 revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the quarterly MDS assessment dated [DATE] for Resident # 1 revealed Resident was assessed with [REDACTED]. The BIMS score was scored at 9 out of 15 to indicate moderately impaired cognitive level. Assessment of resident functional status revealed resident bed mobility was assessed as extensive assistance by 2 person assist. Resident was assessed as total dependence for all activities of daily living, resident had an indwelling urinary catheter and was always incontinent of bowel. Assessment of skin conditions revealed resident at risk for developing pressure ulcer and resident has stage 1 or higher pressure ulcers, with 3 stage IV ulcers present. Skin treatments were to provide pressure relieving device for bed, nutrition/hydration, ulcer care, and apply ointments/medications. Observation on 01/19/12 at 11:15 am of Resident #1 revealed positioned on back with head of bed elevated at 45 degrees, knees were tilted to the left, no positioning devices with resident and an unused pillow was lying at the foot of bed. Observation on 01/19/12 at 12:00 pm, 1:00 pm of Resident #1 revealed resident position was unchanged and at 2:00 pm resident position was unchanged from previous observation at 11:15 am but a pillow was positioned under resident's right arm. Interview on 01/26/12 at 7:00 am with CNA A about the repositioning of dependent Residents, the CNA was asked if the head set(Accu Nurse system) tells her when to go and reposition a resident and she said, " no, it does not come on at a certain time and tell us to do something with a certain resident. We hear the information about the resident care needs when we start in the morning". CNA A was asked if she had a form or any notes about what residents needed to have done and she said ,"No, we have to remember". CNA A was asked about repositioning of assigned residents on 01/19/12, how she and her partner were busy with resident care and some dependent residents were not observed to have been repositioned at least every 2 hours and she said, " we were very busy". Interview on 01/26/12 at 7:10 am with CNA B about the repositioning of dependent residents, CNA B was asked if the head set ( AccuNurse system) tells the CNA what care the residents need and CNA B said, the information was told in the head set when we start in the morning but we have a print out of the information to follow for resident care. Interview on 01/26/12 at 7:25 am with CNA C she said the Accunurse does not come on the headset at a specific time and tell us to position a specific resident at a specific time. There were no other forms or papers to help us with the resident care . " The nurse was supposed to give us a print out but I don't have any list or paper. " CNA C was if there were times that residents were not repositioned every 2 hours and CNA C said some residents require more time and sometimes we need to search for supplies such as pillows, so we get behind. In a discussion on 01/26/12 at 7:45 am with CNA D about the repositioning of dependent Residents, the CNA was asked if the headset ( Accunurse program tells her when to go and reposition a resident and she said, " no, it does not come on at a certain time and tell us to do something with a certain resident. We hear the information about the resident care needs when we start in the morning". CNA D was asked if she had a form or any notes about what residents need to have done and she said, " I have no other forms or papers to help with resident care, the nurse is to give us a list or print-out". Observation on 01/26/12 at 9:15 am of LVN E administering pressure ulcer wound treatment to Resident #1's left hip. LVN E removed soiled dressing that presented an open area that was absent of odor and presented minimal discharge. The LVN E said," it ' s stage IV", without de-gloving, conducting hand hygiene or applying new gloves, LVN E used wound cleanser moistened gauze and wiped around the outer wound edge then wiped towards the center of the wound 8 times without changing position of the gauze or acquiring new gauze. The LVN took a new gauze and wiped from the outside area of the wound towards the inside area of the wound in a circular motion. LVN E measured the left hip pressure ulcer as 3.5cm (L) by 2.5 (W) cm. No depth measurement was conducted. Without de-gloving, conducting hand hygiene or applying new gloves LVN E applied the new dressing to the pressure ulcer and secured it with tape. LVN E conducted hand hygiene, applied new gloves and proceeded to conduct pressure wound treatment on the right hip. LVN E removed the old soiled dressing from the right hip area and revealed an open area with visible bone that was non-odiferous. LVN E said the wound was a stage III and the LVN E measured the right hip pressure ulcer as 3.5 cm (L) by 4 cm (W). No depth measurement was conducted. LVN E, without de-gloving and conducting hand hygiene applied the new dressing to the wound. LVN E then de-gloved, conducted hand hygiene, applied new gloves and taped the dressing to the skin. LVN E de-gloved conducted hand hygiene, applied new gloves and removed a soiled, old dressing from the sacral area. The sacral area presented with an open area, absent of odor. Without de-gloving, conducting hand hygiene and applying new gloves LVN E took wound cleanser moistened gauze and wiped across the wound twice. LVN E took a new gauze and pat dry on the wound 7 times without changing the position of the gauze or using new gauze. LVN E took new gauze and pat several times on the wound without changing the position of the gauze or using new gauze. LVN E measured the area as 3.4 cm by 3.5 cm and no depth measurement was conducted. LVN E without de-gloving, conducting hand hygiene and applying new gloves, applied the new dressing on the sacral ulcer and secured it with tape. Interview on 01/26/12 at 9:50 am with LVN E about how to clean a wound she said wound was wiped at the outer edges to clean the slough off then wipe towards the inside of the wound. She said, " I generally wipe the wound 3 times , at the outer edge, then the edge of the other side and then the inside. LVN E was asked how she cleans a wound and she said, " From the outside to the inside ". LVN E was asked how many times she should wipe the wound with same the gauze and she said once. LVN E was asked why she was observed wiping the wounds more than once, she said she didn't think she wiped the wounds more than once with the same gauze. LVN E was asked when she should change her gloves during the wound treatment procedure and she said " after I touch the person. " LVN E was asked why she didn't change her gloves during the wound treatment procedure and she said, "I thought I did". LVN E was asked when she had received In-service on how to conduct wound treatment procedure and she said "I'm not sure " . Record review of the Resident care plan dated 06/10/11 for resident # 1, with recent review date of 12/05/11 and documented to continue. The problem of actual pressure ulcer related to stage IV to right, left hip and sacrum. The approaches included body audits (assessments) per protocol and document, turn and reposition every 2 hours. Further review of the resident care plan revealed a problem of current skin problems dated 11/09/11 and the approaches included perform treatments per orders. Record review of the physician monthly recap orders dated 01/12 for Resident # 1 revealed; -reposition resident every 2 hours, -cleanse right hip with wound cleanser, apply santyl with [MEDICATION NAME] and cover every day, -cleanse left hip with wound cleanser, apply santyl with [MEDICATION NAME] and cover every day, -cleanse sacral ulcer with wound cleanser , apply santyl with [MEDICATION NAME] every day until healed. Record review of the facility's weekly skin condition observations dated 12/12/11 to 01/26/12 for Resident # 1 revealed the onset date was 05/25/11 and following wound measurements of (L) by (W) by (D) occurred on, 1. The mid sacral pressure ulcer measurements on; -01/02/12 of sacral wound were 3.5 cm by 3.5cm by 0.10 cm, stage IV, -01/12/12 of sacral wound were 3.0 cm by 3.0 cm by 0.10 cm, stage IV, -01/18/12 of sacral wound were 3.5 cm by 4.0 cm by 0.20 cm, stage IV, 2. The left hip pressure ulcer measurements on; -01/02/12 were 3.2 cm by 2.0 cm by 0.3 cm, stage IV, -01/12/12 were 3.0 cm by 2.0 cm by 0.5cm, stage IV, -01/18/12 were 3.0 cm by 2.0 cm by 0.6 cm, stage IV. ,. Record review of the treatment records dated 01/12 for Resident # 1 from 01/01/12 to 01/26/12 revealed the documentation for wound treatment on 01/19, 01/21 and 01/22/12 was blank and undocumented. Record review of the weekly skin assessments form dated 01/12 for Resident #1 revealed blank, undocumented second and third week assessment areas. Resident #3 Record review of the monthly recap orders dated 12/11 for Resident #3 revealed [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the significant change in status MDS dated [DATE] for Resident # 3 revealed the assessment of cognitive function was assessed as severely impaired cognition for daily decision-making. Assessment of functional status revealed resident required extensive assistance by 2 persons for all ADL and bed mobility. Assessment of range of motion revealed impairment on one side for upper and lower extremity. Resident was assessed with [REDACTED]. The assessment of skin conditions revealed resident was assessed as at risk for development of pressure ulcer. Resident had no pressure ulcer on prior assessment and resident has stage 1 or higher pressure ulcer was documented as no. Observation on 01/19/12 at 10:50 am of Resident # 3 in bed, positioned on back with the head of the bed elevated 45 degrees and observations at 12:00 pm, 1:10 pm and 2:10 pm revealed her position remained unchanged. Observations on 01/25/12 at 8:10 am of Resident # 3 positioned in geri-chair with back of chair elevated at 45 degree angle with legs elevated. Further observations at 9:10 am, 10:00 am and 11:05am revealed Resident position was unchanged. Observation on 01/26/12 at 9:00am of Resident #3 revealed resident positioned in a geri-chair with legs elevated . Observations at 11:15 am, 12:10 pm,1:00pm revealed Resident's position remained unchanged. Observation on 01/26/12 at 2:00 pm of Resident #3 revealed Resident was in bed on back with head of bed elevated 30 degrees. Interview on 01/26/12 at 7:15 am with CNA F about the repositioning of dependent Residents, the CNA was asked if the head set tells her when to go and reposition a resident and she said,"it tells us in the resident review of care first thing when we come on but it doesn't tell us specific resident needs such as repositioning at a specific time. We must remember from the review earlier at the beginning of the day". CNA F was asked if she had any other form or check list to use to review resident care needs and she said there are no other information sheets or list. We know what resident needs and it ' s also common sense". Observations on 01/19/12 at 2:40 pm of LVN G administering wound care to Resident # 3. RN H was present to assist with positioning of the resident. LVN G collected the dressing supplies, unpackaged gauze, unwiped wound cleanser spray bottle and placed them on the un-wiped, unprotected over the bed table. The Resident had an episode of bowel incontinence and resident was cleaned. After the incontinent care, LVN G conducted hand hygiene and applied new gloves, then removed the old soiled dressing from resident's left medial buttock to reveal an open area with serous(watery) discharge. LVN G took wound cleanser bottle and sprayed the gauze. Then he took the moistened gauze in his hands and wiped twice across the wound. LVN G took a new gauze, wiped once across the wound then changed position of the gauze and pat on the wound three times without changing position of the gauze or using new gauze. LVN G measured the wound as 2.1 cm long by 0.8 cm wide and the depth of 0.1 cm was measured using an applicator. LVN de-gloved , conducted hand hygiene and applied new gloves LVN G took a new gauze, wiped the wound then took another gauze and pat dry three times on the wound without changing position of the gauze or using new gauze. LVN G without degloving , conducting hand hygiene and applying new gloves ,took un-wiped scissors and cut the dressing, applied it to the wound, covered it with gauze and secured it the dressing with tape. The LVN G was asked what stage was the wound and LVN G said,"stage II skin breakdown " . Resident was repositioned, to reveal open area on the right medial buttock. LVN G de-gloved, conducted hand hygiene, applied new gloves and measured the wound as 1.8cm in length by 0.5cm in width and the depth was 0.25cm. LVN G said it was a stage II wound. LVN G de-gloved, conducted hand hygiene and applied new gloves. LVN G took wound cleanser moistened gauze and wiped around the area once, then took a new gauze and pat the inside of the wound and disposed it. LVN G took a new gauze pat dry inside the wound twice without changing position of the wound or using a new gauze with each pat. The LVN G without degloving, conducting hand hygiene and applying new gloves collected the new dressing and applied the new dressing to the wound, covered it with gauze and secured it in place with tape. In an interview on 01/19/12 at 3:45 pm with LVN G about wound care procedure and In-service, the LVN G was asked when he received in-service on wound treatment procedure and the LVN G said before Christmas. The LVN G was asked how he cares for the wound cleanser bottle and he said," I just put it back in the cart ". LVN G was asked how he cleaned the wound and he said he wipes from inside to out and dries the wound the same way. LVN G was asked how many times he wiped with a gauze on a wound and he said once then dispose in the red bag. LVN G was asked why he was observed wiping a wound more than one time with the same gauze and he said he was trying to get the wound edges clean. The LVN G was asked why he was observed cleaning or drying the wound using a gauze more than one wipe and he said, " It was a mistake " . The LVN G then said he should change gloves after the old dressing was removed , conduct hand hygiene and apply new gloves and after he finished the dressing he disposes of gloves and conducts hand hygiene. Record review of the resident care plan dated 11/12/11 for Resident #3 with the last date of review documented as 01/19/12 and status was to continue. The RCP revealed the problem identification of resident had non-pressure ulcer on right and left buttocks. Goal was documented as skin will remain clean and dry and area will decrease in size and /or heal through next review. The approaches included; perform treatment as ordered. Assist with turn/repositioning every 2 hours and PRN, use padding between pressure areas and positioning devices for proper body alignment. Further review of the RCP revealed a problem resident had potential for skin breakdown related to immobility, incontinence of bowel. The goal was for resident to be free from preventable skin breakdown or excoriation. The approaches included; position resident frequently and PRN, Conduct weekly skin assessments. The problem was documented as reviewed on 01/19/12. After this review the MDS/ care plan nurse was asked for the completed care plan for Resident #3, the actual pressure ulcer problem and no other new care plans for pressure ulcers was received. Record review of the physician orders dated 01/12 for Resident # 3 revealed cleanse right and left buttocks with wound cleanser, pat dry, apply collasorb and cover every day. Record review of the facility's weekly skin condition observations dated 01/02/12 to 01/26/12 for Resident # 3 revealed the onset date was 11/21/11 and following wound measurements of (L) by (W) by (D) occurred on, -01/02/12 of right medial buttock wound were 2.5 cm by 1.5cm, no depth was documented and no stage of wound was documented, -01/18/12 of right medial wound were 3.0 cm by 2.0 cm, no depth was of wound documented and no stage was documented, Record review of the facility's weekly skin condition observations dated 01/02/12 to 01/26/12 for Resident #3 revealed the onset date was 11/21/11, was a pressure ulcer and the following wound measurements of (L) by (W) by (D) occurred on, -01/02/12 of left medial buttock wound were 2.20 cm by 1.50 cm by 0.10 cm depth and stage 3 was documented; -01/12/12 of left medial buttock wound were 1.8 cm by 1.5cm by 0.10cm depth was documented and no stage of wound was documented, -01/18/12 of left medial wound were 3.0 cm by 2.0 cm by 0.10 cm depth and stage 3 was documented, Record review of the Wound Physician evaluations dated 11/30/11 to 01/04/12 revealed the left buttock wound as a pressure wound and the right buttock wound as a shearing wound. The duration of both wounds was documented as 9 days on 11/30/11. Record review of the weekly skin assessment form dated 01/12 for Resident # 3 revealed the assessment was documented in the week 1 area but it was undated. All other weekly assessment areas were blank/undocumented. In an interview on 01/25/12 at 10:25 am with the DON about what staff should do for pressure ulcer prevention and management. The DON said the staff should frequently turn and reposition residents when they make rounds every 2 to 3 hours. The staff need to encourage residents to eat to help wound healing, frequent baths and total care are required. The staff float heels, use pillows and positioning devices. During this interview the DON was asked about how staff are to conduct wound care. The DON was asked how the nurse is to clean a pressure ulcer and she said, with a circular motion and always from the inside to the outside of the wound. The DON was asked how many times should the nurse wipe a wound with a gauze and she said, the gauze position should be changed or the gauze should be discarded and a new gauze used with each wipe. The DON was asked when should the nurse change gloves when doing a wound treatment and she said, the nurse starts with hand hygiene and applies new gloves. The nurse removes the old dressing and the nurse degloves, conducts hand hygiene and applies new gloves. The nurse cleans the wound then degloves, conducts hand hygiene and applies new gloves. The nurse degloves, conducts hand hygiene and applies new gloves and applies the new dressing to the wound. The DON was asked when are staff expected to conduct hand hygiene and she said when the gloves are removed the staff must do hand hygiene then apply new gloves. The DON was asked how the nurse conducts a pressure ulcer measurement. The DON said, the length, width and depth are measured. The nurse using a measuring circle or tape measure takes the length and the width measurements. The depth measurement is taken with an applicator and measured with the tape measure. The DON was asked if the depth was measured by pushing the plastic circular measuring device into the wound and she said, the circular thing is not used to take the depth measurement. In a discussion on 01/26/12 at 12:30 pm with the DON and the Administrator about the headset (Accunurse system) used by staff. The Administrator and DON were told that the staff interviews conducted, revealed the system did not tell the staff at specific times about the need to provide certain care such as repositioning of a resident at a certain time and the staff said they had to remember the care residents needed. The Administrator said," we are [MEDICATION NAME]. I had IT yesterday put into the program the information to reposition, so it be told to staff". During this discussion the DON was asked where are the Resident vital signs and oxygen saturation rates documented and she said in the Accu Nurse system. The DON went to get the vital signs and oxygen saturation data for CR # 10 and she returned to say there was data for those interventions. Further discussion occurred related to when should resident's skin be assessed and the DON said, weekly skin assessments are to be conducted on all residents and documented each week on the weekly skin assessment form and it ' s on the skin assessment book on the station. The DON was informed that weekly skin assessments appeared to be missing on some of the sampled Residents. The DON said the wound treatment nurse had been away for almost 2 weeks, she further said a skin sweep was done as part of other plan of correction so some of the assessments were probably in her office. The DON was asked about provision of recent wound treatment In service for the nurses and the DON said, the facility had just recently started an evaluation of all licensed staff and were working through staff to determine competency. The DON later provided copies of skin assessments conducted on some residents in the previous week. Record review of

Based on interview and record review, the facility failed to consult the physician when 1 of 3 sampled residents with indwelling catheters (CR #1) had a significant change in the amount of his urine output, blood in his urine, and low blood pressure. This failure to consult the physician caused a delay in treatment, possibly contributed to the death of 1 resident and placed 118 residents at risk of physical decline and delay of treatment. Findings include: Intake # 2 Intake # 2 was received on [DATE]. Resident CR # 1 was a [AGE] year old male who was a victim of an aggravated assault in [DATE]. He sustained a gunshot wound to the head resulting in total paralysis from the waist down. Resident CR # 1 was admitted to the facility on [DATE]. The issues identified in the intake were as follows: 1. Failure of the staff to respond in a timely manner to Resident CR #1's requests for assitance when he was in pain, 2. Failure of the staff to provide to the family and to document accurate information regarding the resident's urine output and blood in the urine, 3. Failure to provide care and services in a timely manner resulting in hospitalization and subsequent death. During a telephone interview on [DATE] at 2:30 P.M. with a familly member she stated was very upset with the facility and that Resident CR # 1 had a lot of problems with his care. She went on to say that the staff frequently ignored his requests for help and that he was "at their mercy ' because he was paralyzed. She stated CR # 1 had sent her several text messages the night before he was sent to the hospital that indicated he was in pain and no one would help him. The family member stated she was very frustrated because she was so worried about the resident's urine output and blood pressure. No one would answer the phone at the facility and when they did answer the phone, no one could provide information about her son. The family member stated she placed a call to the physician about 5: 45 AM and left a message. She spoke with the NP around 8:45 AM and then went to the facility. The family member said when she arrived at the facility on the morning on [DATE], she found Resident CR #1 " cold, sweaty, and clammy. " She said she immediately went and asked LVN # 2 to come and assess him. His blood pressure was very low and 911 was called very shortly after this occurred. Review of the facility admission information for Resident CR# 1 revealed he was [AGE] years old and was admitted on [DATE]. His medical history included a history of a craniotomy surgery 6 months prior as a result of a gunshot wound to the head. In addition he had [DIAGNOSES REDACTED]. Review of the resident ' s admission MDS, dated [DATE], revealed he was alert, oriented and independent with respect to daily decision making skills. This same assessment revealed that Resident CR # 1 required extensive assistance for all ADLs due to his paralysis and had intermittent catherization for urine elimination. Review of the physician orders for Resident CR #1 revealed an order dated [DATE] that read: " Foley catheter output every shift. " On [DATE] at 1:45 PM during an interview with the ADON, she stated that indwelling catheter output was recorded on the " Accunurse " system. Review of the documentation of Resident CR #1' s urinary output documented on the facility [DATE] " Accunurse " system revealed the following urinary output recording: [DATE] (day shift): 160 cc [DATE] (day shift): 50 [DATE] (night shift):100 cc Review of the nursing notes dated [DATE] and [DATE] failed to reveal documentation that the physician had been notified of the urinary output documented above. Review of the nurse ' s notes dated [DATE] at 4:25 P.M. revealed the " Foley cath was leaking; Foley was inspected and appeared clogged and occluded, Foley was irrigated ....and clog did not resolve ...Foley and was D/C..XXX,[DATE] cc -1 cc of blood noted on urine return... " Continued review of the nurses notes revealed on [DATE] at 5:10 P.M. : " 250 cc of blood tinged urine in the Foley bag.. " Both of the nurse ' s notes were signed by LVN # 3. There was no documentation that the physician was informed of the blood in the urine. Further review of the nurses notes dated [DATE] at 5:30 A.M read " F/C (Foley catheter) in place in place drained small amount of urine blood tinged ... " this note was signed by LVN # 1. Review of the nursing notes for [DATE] revealed 5 documented blood pressure readings for Resident CR # 1: ,[DATE], ,[DATE], ,[DATE],,[DATE], and ,[DATE]. Review of the nursing notes revealed a decline in the systolic blood pressure for Resident CR #1 on [DATE]. On [DATE], the resident ' s blood pressure was ,[DATE]. On [DATE]: ,[DATE], ,[DATE], and ,[DATE]. Review of the [DATE] MAR for Resident CR #1 had been receiving [MEDICATION NAME] 100mg every 6 hours for high blood pressure. Review of the same MAR for date [DATE] revealed the Midnight and 6A.M. doses of [MEDICATION NAME] 100 mg were circled as not given. The reverse side of the MAR had documentation by LVN # 1 that indicated the medication was withheld due to low blood pressure readings of ,[DATE] and ,[DATE] respectively. [MEDICATION NAME] was a medication used to treat high blood pressure. There were no other blood pressures documented on the MAR. Review of the MAR revealed no blood pressure parameters ordered by physician as to when to hold the medication or to consult the physician. Review of the facility nurse ' s notes for Resident CR #1 revealed the following: " [DATE]: 5:30 A.M ...Labatrol (sic) 100 mg tab po not given per schedule due to low B/P ,[DATE].. " this notation was signed by LVN # 1. LVN # 1 made an additional note in that same paragraph dated [DATE] (untimed) that Resident CR # 1 had a BP of " ,[DATE]. " Review of LVN # 1 ' s nursing notes dated [DATE], 5:30 A.M. read: " ...AM nurse to F/U with MD. " Review of the facility 24 Hour Report Log, dated [DATE] written by LVN #1 revealed: " ,[DATE]: Resident CR #1 ...please follow up with MD regarding low blood pressure and blood noted from Foley catheter. " Review of the nursing notes for [DATE] for the day shift revealed no documentation that the physician was notified of the blood pressure readings or the medication being withheld. Further review of the record revealed Resident CR #1 was transported to the hospital on [DATE]. On [DATE] at 11:15 A.M., during an interview with LVN # 3 he stated he cared for Resident CR #1 during the evening shift on [DATE]. LVN # 3 stated he did not report the blood in the urine to the physician because it did not continue. During an interview on [DATE] at 1:20 P.M. with LVN # 1, she stated she worked the night shift from 10 PM until 6 AM and took care of Resident CR #1 on [DATE]. LVN # 1 said she remembered something about a CNA and 300 cc of urine that night but she was not sure about this. The LVN #1 could not verify the amount of output of urine that Resident CR #1 had on her shift on [DATE]. LVN # 1 said that urine output was documented on the MAR and nurse ' s notes; she failed to mention " accunurse " documentation. On [DATE] the documentation of urine output for the night shift for Resident CR #1 was inconsistent: in the nurses ' notes " small amount of urine ... " , on the Treatment Administration Record (TAR) there was 200 cc documented, and on the " Accurnurse, " documentation, there was 820 cc urine documented. LVN # 1 was unable to state which was the correct output. During an interview on [DATE] at 1:20 P.M. LVN # 1 stated she worked the night shift from 10 PM until 6 AM and took care of Resident CR #1 on [DATE]. LVN # 1 said she had been told by the previous shift nurse (LVN # 3) that the resident ' s " blood pressure had been fluctuating " on the evening shift. LVN # 1 said she " withheld the blood pressure medication twice during the night because Resident CR #1 ' s pressure was too low. " LVN # 1 went on to say she was trained to inform the physician when a medication was held but in this case, the " morning nurse was going to follow up. " LVN # 1 said she documented the need for MD follow up in her nursing notes and also in the 24 hour report. During an interview with LVN # 2 on [DATE] at 10:55 A.M., she stated she worked the day shift on [DATE], the day Resident CR #1 was sent to the hospital. LVN # 2 said she was told of the low blood pressure readings on the night shift for Resident CR #1 and she also saw the nursing note requesting " AM nurse to follow up with MD. " LVN # 2 said she did not notify the physician because " when I took his blood pressure at 8A.M. it was OK and there was no reason to call. " The blood pressure recorded on [DATE] at 8 AM by LVN # 2 was " ,[DATE]. " LVN # 2 went on to say she did not remember seeing the 24 Hour report that documented the need to follow-up with the MD. LVN # 2 reported that when she saw Resident CR #1 on the morning of -[DATE] at 8 AM " he was tired but alert and eating breakfast. " LVN # 1 said at 9:45 A.M that same day, the Nurse Practitioner (NP) telephoned the facility because Resident CR #1 ' s mother had called the NP and expressed concerns about her son ' s condition overnight. LVN # 2 went on to say that on [DATE] at about 10:45 A.M, Resident CR #1 ' s mother came to the nurses station and told them her son " didn ' t look good " and asked LVN # 2 to come to the room. LVN # 2 said when she got to the room, Resident CR #1 " had clammy skin, was sweaty and was ' in and out ' of it. " LVN # 2 said she took his blood pressure twice and it was low " ,[DATE]. " Review of the EMS ambulance record dated [DATE] revealed documentation by the paramedics that 11:20 A.M that Resident CR #1 had altered mental status and a blood pressure of 50/ palpable. It was noted there was blood in the indwelling catheter drainage bag. During an interview with the NP on [DATE] at 2:10 P.M., she stated she last saw Resident CR #1 on Thursday, [DATE]. She said that he was awake, alert and up in a chair talking about physical therapy. The NP went on to say " his labs were good at that time and I had no concerns. " The NP said that Resident CR #1 ' s mother telephoned her office exchange during the night in [DATE] and left a message. The mother was concerned that her son had no urine output during the night. The NP said when she got the message at about 9AM, she immediately called the facility and spoke with LVN # 2 and asked about Resident CL # 1 ' s urine output. The NP said LVN # 2 told her there was about 300 cc of urine in the drainage bag and some blood in the urine. The NP verified the resident was still on an antibiotic and ordered bladder irrigation with antibiotics. The NP went on to say that she was surprised she had not received any telephone calls from the facility regarding any issues related to Resident CR #1 after she saw him on [DATE]. In addition, she said that what the resident ' s mother told her about the resident ' s condition was completely different than what the nurses were telling her. The NP went on to say that she was " flabbergasted at the change in his condition; it was like a night and day difference. " The NP went on to say the only reason she called the facility on [DATE] was in response to the mother ' s expressed concerns. The NP reported that it was also the mother who called and informed her Resident CR #1 was transported to the ER; the facility did not call her. On [DATE] at 1:30 P.M. during an interview with the DON, she stated she would expect the physician to be notified any time a blood pressure medication was held due to a low blood pressure reading. During the same interview the DON stated she would " expect the nurses to know a resident ' s normal voiding patterns and report any change from this. " The DON then went on to say she would expect the nurses to report an output of 100 cc or less in an 8 hour shift to the physician. The DON said that indwelling catheter urine output was recorded in the " Accunurse " documentation system by the nurses. Seven (7) licensed nurses were interviewed on [DATE] through [DATE] regarding the facility policy and practice of reporting urine output to the physician. The nurses interviewed stated they would report a urine output at or below the following levels in an 8 hour shift: ADON: 200 cc or less LVN # 1 ([DATE]): less than 100 cc LVN # 2 ([DATE]): 100 to 150 cc; then said 300 cc LVN# 3 ([DATE]): 30 cc LVN 4 ([DATE]):150 cc LVN # 5 ([DATE]): " if scarce; less than 50 cc " LVN # 6 ([DATE]): less than 200 cc Five (5) licensed nurses were interviewed on [DATE] through [DATE] regarding where Foley urine output was documented. The following nurses said Foley catheter output was documented in: LVN # 1: MAR and nurses notes LVN # 3: nurse ' s notes LVN # 4: only on MAR LVN # 5 " usually on TAR " also " Accunurse " LVN # 6: MAR/TAR Hospital record and care: Review of the hospital record revealed Resident CR #1 arrived in the ER via ambulance on [DATE] and was immediately assessed by the ER physician at 11:35 A.M. At the time of arrival his B/P was ,[DATE]. Resident CR #1 was stabilized, placed on a mechanical ventilator and admitted to the ICU. Resident CR #1 subsequently suffered a cardiopulmonary arrest and died on [DATE] at 3:41 P.M. On [DATE] at 11:45 A.M., during an interview with the hospital ER physician, he stated he was the doctor who treated Resident CR #1 when he came into theER on [DATE]. The physician said he clearly remembered the patient and his care. He went on to say Resident CR #1 was in septic shock upon arrival and in acute [MEDICAL CONDITION]. His WBCs were over 21,000 (indicating severe infection) and potassium was 6.1 ( " acute kidney failure " ). The ER doctor went on to say they administered 2,000 cc of fluid IV and there was " hardly any urine output, indicating severe dehydration. " The doctor said on that same day in the ER, he had reviewed records for Resident CR #1 from a recent hospitalization and that he had been fairly stable upon discharge. The ER physician said he was " shocked that a [AGE] year old male with a healthy heart could go that bad so quickly. There had to be obvious signs that were missed such as changes in mental status, blood pressure, and urine output. " Review of the facility policy titled " Interact, " dated [DATE], under the section tiled " Change In Condition " , read: " When to report to the MD/NP/PA ...Immediate Notification: a sign or apparent discomfort that is...a marked change in relation to usual symptoms and signs ... " Review of the facility policy titled " Change in a Resident ' s Condition or Status, " revised [DATE], read: Our facility shall promptly notify ... (the) Attending Physician of changes in the resident ' s medical/mental condition or status ...1. The Nurse Supervisor./Charge Nurse will notify the resident ' s Attending Physician ..when there has been: ...d. A significant change in the resident ' s physical ...condition e. A need to alter the resident ' s medical treatment significantly ... " The facility roster listed a census of 119.