Every finding on record at Avir at Bay City

Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions in accordance with professional standards for 4 of 8 medication carts reviewed for medication storage in that: Medication Carts #1, #2, #3 and #4 contained medications that did not have an open date written on the bottles. The failure to date opened medications placed residents at risk for receiving expired, contaminated, or ineffective medications which could result in medication errors, infection, delayed treatment or adverse drug outcome.Findings:On 2/25/2026 at 10:20 a.m., during a medication storage observation of Medication Cart #1 located on the 400 Hall, in the presence of the DON and RN I, the following medications were observed without a documented date indicating when the medications were opened: Valproic acid solution 250/5ml. (used to treat various types of seizure disorders). Dayquil, Severe Cold and flu (used to treat nose stuffiness, relieve coughing, and ease pain and fever). Nystatin powder 1,000,000iu. (it is used to treat skin infections caused by yeast). Zinc oxide pastes skin protectant with menthol. (is used to protect, soothe and heal the skin, also used in the prevention and treatment of skin breakdown). Triple antibiotic ointment (it is used to help prevent bacterial infection in minor skin injuries). Prevent Silicone cream. (skin protectant that temporarily protects and helps relieve chapped or cracked skin) On 2/25/2026 at 10:51 a.m., during a medication storage observation of Medication Cart #2 located on the 300 Hall, in the presence of the DON and LVN J, the following medications were observed without a documented date indicating when the medication was opened: Two Albuterol Sulfate Inhalation Aerosol 90mcg per activation (used to treat or prevent bronchospasm, or narrowing of the airways in the lungs, relaxes muscles in the airways and increases air flow to the lungs). Valproic acid solution 250/5ml (used to treat various types of seizure disorders). All day Allergy, Cetirizine Hydrochloride (used to treat cold or allergy symptoms such as sneezing, itching, watery eyes, or runny nose). Promethazine/Codeine solution (is a combination medicine used to treat cold or allergy symptoms such as runny nose, sneezing, and cough). ConvaTec Stomahesive Paste 2-ounce tube (used in filling uneven skin surface around the stoma to create a secure seal, preventing leakage and irritation). On 2/25/2026 at 11:03 a.m., during a medication storage observation of Medication Cart #3 located on the 500 Hall, in the presence of the DON and MA L, the following medications were observed without a documented date indicating when the medication was opened: Collagenase Santyl ointments 250 units/30g (is used to treat severe burns or skin ulcers in adults. Santyl helps remove dead skin tissue and aid in wound healing). Silver sulfadiazine cream, USP 1% (is commonly used to treat and prevent wound infections in people with severe burns). Albuterol sulfate inhalation solution 2.5mg/3ml (used to treat or prevent bronchospasm, or narrowing of the airways in the lungs, relaxes muscles in the airways and increases air flow to the lungs). Ammonium Lactate cream 12% (is used to treat dry, scaly, itchy skin). Zinc Oxide 20% cream. (is used primarily to protect, soothe and heal the skin, also used in the prevention and treatment of skin breakdown). Fluticasone Propionate Nasal spray, USP. 50mcg per spray (is used to treat nasal congestion, sneezing, runny nose, and itchy or watery eyes caused by seasonal or year-round allergies). Miebo drops 1.3gm/ml (is a prescription eye drop used to treat the signs and symptoms of dry disease). Nitroglycerin 0.4mg/hr. (skin patch) is used to prevent attacks of chest pain). Pantoprazole Sodium 40mg delayed release oral suspension. (used to treat certain stomach and esophagus problems (such as acid reflux). It works by decreasing the amount of acid your stomach makes. Famotidine tablet 10mg (is used to prevent and relieve heartburn due to acid indigestion). Two packets of Alendronate sodium tablets, USP 70mg (is a medication that strengthens bones and reduces the risk of fractures by slowing bone loss). Mucus relief, Guaifenesin 400mg (is used as an expectorant to relieve chest congestion by thinning and loosening mucus, making it easier to cough up). Brimonidine tartrate/Timolol Maleate ophthalmic solution 0.2%/0.5% 5ml (is an eye drop used to treat increase pressure in the eye). Two packets of Linzess capsules (is used to treat certain types of constipation. Constipation is a condition in which you may have fewer bowel movements than expected, or you may have stools that are hard, dry, lumpy, or painful or difficult to pass). Bisacodyl 5mg, stimulant laxative enteric coated tablets (is a laxative that stimulates bowel movements). Cyclosporine ophthalmic emulsion, 0.05% (is used to treat chronic dry eye syndrome by increasing tear production and reducing inflammation in the eyes). On 2/25/2026 at 11:18 a.m., during a medication storage observation of Medication Cart #4 located on the 500 Hall, in the presence of the DON and LVN K, the following medications were observed without a documented date indicating when the medication was opened: Collagenase Santyl ointments 250 units/30g (is used to treat severe burns or skin ulcers in adults, also used to help remove dead skin tissue and aid in wound healing). Albuterol sulphate inhalation sodium, 0.083% 3ml (is used to treat or prevent narrowing of the airways in the lungs, relaxes muscles in the airways and increases air flow to the lungs). Antimicrobial skin and wound gel. Triple antibiotic ointment (is used to help prevent bacterial infection in minor skin injuries). Triad Hydrophilic wound dressing (is used to manage moisture-prone wounds and protect peri wound skin from irritation and maceration). Dakin's solution (is a diluted sodium hypochlorite solution, is primarily used for cleaning and disinfecting wounds to prevent or treat infections).Therahoney gel (is used to help wound heal, helps debride - remove dead tissue) naturally. Antidiarrheal - Loperamide HCL tablets 2mg (used to treat loose stool or to reduce the amount of stool). On 2/25/2026 at 10:25 a.m., an interview was conducted with RN I. RN I stated that she did not know which staff member opened the medications without documenting an opened date. When asked about the potential consequences of failing to document an opened date, RN I stated that without an opened date, it may result in the administration of an expired medication. RN I further stated that administration of an expired medication could negatively affect a resident's health condition. On 2/25/2026 at 10:51 a.m., an interview was conducted with LVN J. LVN J acknowledged that, in accordance with facility policy and safe medication administration practices, all medications were required to be dated upon opening. LVN J stated she did not know which staff member opened the medications without documenting the opened date. She stated that she discovered the medications had already been opened without a date and indicated there was no way to determine when they were opened. LVN J stated she would discard the medications and ensure that replacement medications were dated at the time of opening. When asked about the potential risk to residents if medications were opened and not dated, she stated that without an opened date, staff would not be able to determine when the medication has expired. LVN J further stated that administering expired medications could cause residents to become ill. She explained that once medications expire, their strength and effectiveness may be reduced, which could result in harm to residents. On 2/25/2026 at 11:03 a.m., an interview was conducted with MA L. MA L Acknowledged responsibility for not ensuring that opened medications contain a documented date open. She confirmed that facility policy required staff to document the dates when medications were opened. MA L stated she did not know which staff member opened the medications without documenting the opened date. MA L further stated that if medications were not dated upon opening, there was a risk that residents could receive medications that were expired or contaminated. She acknowledged that administration of expired or contaminated medications could negatively impact or complicate a resident health condition. On 2/25/2026 at 11:18 a.m., an interview was conducted with LVN K. LVN K stated that she did not know which staff member opened the medications without documenting an opened date. She confirmed that staff were expected to know that medications must be dated at the time they were opened, in accordance with facility policy and the standard medication administration practices. LVN K stated that when medications were not dated upon opening, there was a risk that medication could become contaminated or exceed the recommended timeframe for use. She further stated that if such medication was administered to a resident, it may not be effective and could delay the resident's healing or recovery. On 2/25/2026 at 11:20 a.m., an interview was conducted with DON. The DON confirmed that in accordance with CMS regulations and the facility policy, all medications were required to be dated at the time of opening. The DON stated that all licensed nursing staff and the medication aides were expected to be aware of this requirement. The DON further stated she would initiate in- service education for nursing staff and medication aides to address the identified concerns and reinforce proper medication labeling and handling procedures. Review of the facility policy and procedure titled Medication Labeling and Storage revised February 2023 revealed: Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: . expiration date, when applicable.

Based on interviews and record review, the facility failed to document evidence of receiving or refusal of influenza or pneumococcal immunization for 5 of 5 residents reviewed for immunizations (Resident#12, Resident #2, Resident #39, Resident #7, and Resident #5). The facility failed to document evidence in the electronic medical record the offering or the refusal of the influenza and pneumococcal immunization status for Resident #12 and Resident #2. The facility failed to document evidence in the electronic medical record the offering or the refusal of the pneumococcal immunization status for Resident #7, Resident #39, and Resident #5. The failures could place residents at risk of contracting viral illness, influenza or pneumococcal disease, or of not being informed of the benefits and risk which could cause respiratory complications and lead to potential adverse health outcomes. Record review of Resident #12's face sheet dated 2/26/2026 revealed a [AGE] year-old female admitted into the facility on 2/12/2026 with diagnoses that included Unspecified Atrial Fibrillation (irregular heart beat), Type 2 diabetes mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), Hypertensive Heart Disease with heart failure (a condition where the pressure inside the blood vessels is too high leading to heart strain and the heart can't pump blood effectively). Record review of Resident #12's electronic record revealed no documented evidence of the facility offering or the refusal of influenza or pneumococcal vaccines. Record review of Resident #2's face sheet dated 2/26/2026 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (a group of diseases affecting the lungs), Essential Hypertension (a type of high blood pressure that does not have a known cause), and Type 2 Diabetes Mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels). Record review of Resident #2's Comprehensive MDS dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment. Section O of Resident #2's Comprehensive MDS dated [DATE] indicated that he was not up to date with both influenza and pneumococcal vaccinations and had declined the offer of both the influenza and pneumococcal vaccines. Record review of Resident #2's electronic record did not reveal documented evidence of Resident #2's refusal of the influenza or pneumococcal vaccines. Record review of Resident #7's face sheet dated 2/26/2026 revealed a [AGE] year-old male was originally admitted into the facility on 6/24/2025 and readmitted on [DATE] with diagnoses that included Paraplegia (a condition where the legs are unable to move due to damage to the spinal cord), Heart Failure (a condition where the heart is unable to pump enough blood to meet the body's needs, leading to fatigue and shortness of breath), Type 2 Diabetes Mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), and Essential Hypertension (a type of high blood pressure that does not have a known cause). Record review of Resident #7s quarterly MDS dated [DATE] revealed a BIMS score of 12 which indicated moderate cognitive impairment. Section O of Resident #7's quarterly MDS indicated that Resident #7 was not up to date with pneumococcal vaccination and declined the offer of the pneumococcal vaccination. Record review of Resident #7's electronic record did not reveal documented evidence of Resident #7's refusal of the pneumococcal vaccine. Record review of Resident #39's face sheet dated 2/26/2026 revealed a [AGE] year-old female originally admitted into the facility on 1/20/2021 and readmitted on [DATE] with diagnoses that included Polyneuropathy (a condition involving damage to the peripheral nervous system affecting sensory and motor functions), Dementia (a general term for a range of conditions affecting memory, thinking, and social abilities), and Heart Failure (a condition where the heart is unable to pump enough blood to meet the body's needs, leading to fatigue and shortness of breath). Record review of Resident #39's quarterly MDS dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. Section O of Resident #39's quarterly MDS dated [DATE] indicated Resident #39 was not up to date on her pneumococcal vaccination and had declined the pneumococcal vaccine. Record review of Resident #39's electronic medical record did not reveal documented evidence of Resident #39's refusal of the pneumococcal vaccine. Record review of Resident #5's face sheet dated 2/26/2026 revealed a [AGE] year-old female admitted to the facility originally on 10/14/2025 and readmitted on [DATE] with diagnoses that included non-traumatic intracerebral hemorrhage (a condition where bleeding occurs directly into the brain tissues not due to external injury), End Stage Renal Disease (refers to the most severe stage of kidney disease where the kidneys can no longer filter waste effectively), Type 2 Diabetes Mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), and Epilepsy (brain disorder caused by abnormal electrical activity in the brain). Record review of Resident #5's Comprehensive MDS dated [DATE] indicated a BIMS score of 11 which indicated moderate cognitive impairment. Section O of Resident #5's Comprehensive MDS dated [DATE] indicated that Resident #5 was not up to date with the pneumococcal vaccination and had declined the offer of the Pneumococcal vaccine. Record review of Resident #5's electronic medical record did not reveal documented evidence of Resident #5's refusal of the pneumococcal vaccine Interview with the ADON on 2/26/2026 at 9:32 am revealed she was the infection preventionist for the facility and was responsible for immunization compliance along with the DON. The ADON stated that a resident's immunization status should be listed in the immunization tab of the electronic record but sometimes it was in the notes section. The ADON stated that all residents were offered immunizations for influenza, pneumococcal, and covid on admission. The ADON stated that the facility had an influenza vaccination event that ran from October 2025 to November 2025. The ADON stated that she was working on a pneumococcal vaccination event for the residents. The ADON states the events were done because the facility didn't stock the influenza or pneumococcal vaccines, but the facility could order the vaccines as needed. When asked if there was a specific number that was needed to have a vaccination event occur, the ADON did not provide a number. The ADON was asked to provide documentation of offering, administration or refusal of the influenza and pneumococcal vaccines for Residents#12, Resident #7, Resident #39, Resident #2, and Resident# 5, but stated she was unable to locate the information. The ADON stated the facility went through a change of software in April of 2025 and resident data crossed over completely. When asked how she monitored immunization compliance for the residents, the ADON did not have an answer. The ADON stated she knew this was an area that needed attention. When asked what the risk was associated with not assessing immunization compliance, the ADON stated the resident could be vaccinated twice for the same illness, the residents could get sick with a preventable disease, or the resident could receive vaccinations that were contraindicated. Interview with the DON on 2/26/2026 at 11:41 am revealed the DON stated there was a facility wide influenza event in October and November of 2025. The DON stated that not all the influenza immunization records had been uploaded into Point Click Care {PCC.} which is the facility's electronic record software system. The DON stated that she was aware that some residents needed pneumococcal vaccinations and there was a plan to get a mass vaccination event conducted at the facility. The DON stated immunization documentation was an area that she was aware of that needed attention and was working on getting immunizations uploaded and updated. The DON stated she was in the process of getting a pneumococcal vaccination event scheduled. The DON stated that the facility began using a new software program and it had affected how immunization dates and refusals were placed into the new system. The DON stated the risk of not having up to date immunization records for residents could possibly lead to preventable illness, or unnecessary vaccinations. Record review of facility policy statement, undated and titled Influenza, Prevention and Control of Seasonal revealed in part. all residents and staff are offered the vaccine prior to the onset of the influenza season. Record review of facility policy titled Pneumococcal Vaccine dated 2001 revealed in part. all residents are offered pneumococcal vaccines to aid in the preventing pneumonia/pneumococcal infections.

Based on interview and record reviews, the facility failed to implement their policy to ensure residents were offered, received, or refused Covid-19 immunization, for 3 of 5 residents who were reviewed for immunization compliance. (Resident #12, Resident #7, and Resident#2). The facility failed to document in Resident #12, Resident #7, and Resident #2's electronic medical records for having received or having had not received the Covid-19 immunization due to medical contraindication or refusal.This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Record review of Resident #12's face sheet dated 2/26/2026 revealed a [AGE] year-old female admitted into the facility on 2/12/2026 with diagnoses that included Unspecified Atrial Fibrillation (irregular heart beat), Type 2 diabetes mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), Hypertensive Heart Disease with heart failure (a condition where the pressure inside the blood vessels is too high leading to heart strain and the heart can't pump blood effectively). Record review of Resident #12's electronic record revealed no documented evidence that revealed her immunization status for Covid-19.Record review of Resident #7's face sheet dated 2/26/2026 revealed a [AGE] year-old male was originally admitted into the facility on 6/24/2025 and readmitted on [DATE] with diagnoses that included Paraplegia (a condition where the legs are unable to move due to damage to the spinal cord), Heart Failure (a condition where the heart is unable to pump enough blood to meet the body's needs, leading to fatigue and shortness of breath), Type 2 Diabetes Mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), and Essential Hypertension (a type of high blood pressure that does not have a known cause). Record review of Resident #7s quarterly MDS dated [DATE] revealed a BIMS score of 12 which indicated moderate cognitive impairment. Record review of Resident #7's electronic medical record revealed no documented evidence that revealed Resident #7's immunization status Covid-19. Record review of Resident #2's face sheet dated 2/26/2026 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (a group of diseases affecting the lungs), Essential Hypertension (a type of high blood pressure that does not have a known cause), and Type 2 Diabetes Mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels). Record review of Resident #2's Comprehensive MDS dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #2's electronic medical record revealed no documentation that revealed Resident #2's immunization status against Covid-19. Interview with the ADON on 2/26/2026 at 9:32 am revealed she was the infection preventionist for the facility and was responsible for immunization compliance along with the DON. The ADON stated that a resident's immunization status should be listed in the immunization tab of the electronic record but sometimes is in the notes section. The ADON stated that all residents are offered immunizations for influenza, pneumococcal, and covid on admission. The ADON stated on 2/26/2026 a Covid Clinic took place at the facility in January 2025. The ADON stated that at that time, the facility used an electronic medical record software called the Matrix system which is no longer being utilized in the facility. The ADON stated that the facility now used a newer electronic medical record software program called Point Click Care {PCC }. The ADON stated that immunizations that were administered or refused were not transferred over into the PCC. The ADON stated that this was still a work in progress. When asked to provide any documentation of covid vaccine administration or refusal of for Resident #12, Resident #7, and Resident #2, the ADON stated she could not locate the information. The ADON stated that another Covid Clinic would be scheduled but was waiting until there were multiple residents who needed the immunization. When asked what was the number that was needed before a Covid Clinic could take place, the ADON was unable to give a specific number of residents. When asked what the risk were associated with not assessing immunization compliance for Covid, the ADON stated the resident could be vaccinated twice for the same illness, the residents could have gotten sick with a preventable disease, or the resident could have received vaccinations that were contraindicated.Interview with the DON on 2/26/2026 at 1:01 pm revealed that overall immunizations was an area that needed attention for compliance. The DON stated that the system change from Matrix to PCC was causing a problem with documentation of covid vaccine administrations and refusals. The DON stated that sometimes residents were already immunized against Covid prior to admission, and but records were not consistently updated in the electronic medical record. The DON stated it was a work in progress. The DON stated the risk of not having up to date immunization records for residents could possibly lead to preventable illness, or unnecessary vaccinations . Record review of facility policy titled Coronavirus Disease (COVID-19) -Vaccination of Residents dated 2001 revised May 2023, revealed in part.The resident's medical record includes documentation that indicates at a minimum.signed consent.#2 prior vaccination or refusal.

Based on interview and record the facility failed to review and revised the person-centered comprehensive care plan for 1 (Resident #22) of 5 residents reviewed for comprehensive care plan revisions.The facility failed to update Resident #22's care plan to reflect the status of Resident #22's NPO status. This failure could place residents at risk of not receiving the appropriate care and interventions they need. Record review of Resident #22's face sheet dated 2/26/2026 revealed a [AGE] year old male admitted to the facility originally on 8/7/2024 and readmitted on [DATE] with diagnoses that included Parkinson's Disease (a progressive movement disorder of the nervous system that worsens over time), Dysphagia Oropharyngeal phase (the inability to swallow food or drink), and Unspecified Dementia (a decline in cognitive function affecting memory, thinking, behavior, and the ability to perform everyday activities).Record review of Resident #22's Order Summary dated 2/26/2026 revealed a dietary order of a NPO diet with a start date of 2/18/2026. Resident #22 had a current order of Jevity 1.5 ml at 69 ml per hour via a gastrostomy tube (a feeding tube that goes through the skin of the belly into the stomach for feedings) stationary pump. Record review of Resident #22's most recent comprehensive care plan obtained 2/25/2026 revealed that Resident #22 was at risk for aspiration (when food, liquid, or other material accidentally gets into your windpipe and lungs) and listed interventions that included monitoring oral intake and reporting to the MD as needed for signs and symptoms of aspiration. Additionally, interventions included to encourage Resident #22's intake of nutritional supplements between meals. Record review of a nursing progress note dated 2/17/2026 revealed that Resident #22 was readmitted to facility and was NPO. Interview with the MDS nurse on 2/25/2026 at 11:59 am revealed she was responsible for all resident care plans. The MDS nurse stated that Resident #22's care plan did not accurately reflect the care needed that Resident #22 required. The MDS nurse stated that the entire facility required new care plans due to the new software system and that it was a heavy load. The MDS nurse stated that Resident #22's care plan did not reflect the recent change to NPO that was given after Resident #22's most recent hospitalization. The MDS stated that the risk of not having a care plan that reflected the current needs of the residents could lead to missed services and interventions that could lead to a resident not receiving the appropriate care they need. Interview with ADON on 2/26/2026 at 9:15 am revealed that she was not responsible for care plans and stated the MDS nurse was responsible for creating and updating care plans. Interview with the DON on 2/26/2026 at 1:01 pm revealed that she did not know too much about care plans nor does she create or revise them. The DON stated the MDS nurse was responsible for updating care plans to reflect any significant changes in the care of the residents. Record review of the facility policy statement, undated, and titled Comprehensive Assessments revealed in part. assessments are used to develop, review and revise the resident's comprehensive care plan. The facility policy statement did not specifically address the revision of comprehensive care plans.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours 7 days a week reviewed for RN coverage for 5 of 30 days reviewed for nursing services. (11/9/24, 11/10/24, 11/23/24, 11/24/24 and 11/30/24). The facility failed to have an RN for 8 consecutive hours 7 days a week for 5 days from November 9, 2024, through November 10, 2024, November 23, 2024, through November 24, 2024, and November 30, 2024. This failure could place residents at risk of lack of nursing oversight and a higher level of care. Findings included: Record review of a Detailed Calculated Time form from 11/1/24 through 11/30/24 indicating RN hours worked indicated no RN hours for 11/9/24, 11/10/24, 11/23/24, and 11/24/24. The report indicated less than 8 hours a day worked on 11/30/24- 2.25 hours. Further review of the report indicated the DON did not work any hours on 11/9/24, 11/10/24, 11/23/24, 11/24/24, and 11/30/2024. Record Review of the facility's Civil Rights form (3761) (Texas Health and Human Services form that list the facility staff to ensure the facility is not violating the Civil Rights of staff hired) not dated, indicated the following: 4 RNs 9 LVNs 34 Direct Care Staff 14 Dietary 11 Housekeeping & Laundry 12 All Others Interview with ADON A on 12/5/24 at 3:30 PM she said if there was a last minute call-in, the facility will call their own staff first and if their on-call staff cannot come in, they would call an agency for nurses. Interview with DON on 12/5/24 at 4:50 pm, she said the facility has one full-time RN and a PRN RN that works nights. The DON said she would come in and assist if there was no RN on duty. The DON said the facility also used an agency for RN staff if needed. The DON said she did not think there was a risk to the resident if a nurse was not on duty. She said some of their LVNs were better workers than their RNs. A policy for RN coverage was requested on 12/5/24 at 4:27 PM, the Administrator stated in an email the facility does not have a policy on RN staffing, they followed the state rules and regulations. Record review of Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities (February 2023 Revision). F727: RN 8 Hrs./7days/Wk., Full Time DON . Policy read in part . Except when waived . the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .

Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #11 and Resident #45) of 25 residents reviewed for pharmacy services. The facility failed to ensure Resident #11's medications were reordered timely to prevent the medications being unavailable for administration to the resident. The facility failed to administer two doses of Hydrocodone-acetaminophen- Schedule II tablet; 10-325 mg; oral on 12/04/2024 at 1 AM and 7 AM for Resident #11. The facility failed to monitor the blood pressure and pulse before administering Diltiazem (a blood pressure (BP) medication given to control high blood pressure and chest pain) and Amiodarone (prevents fast or irregular heartbeat) to Resident #45 as ordered by the physician. The facility failed to monitor the blood pressure and pulse before administering Losartan (a blood pressure (BP) medication given to control high blood pressure and chest pain) and Metoprolol (prevents fast or irregular heartbeat and relax blood vessels) to Resident #11 as ordered by the physician. These failures could place residents at risk for adverse effects of pain, discomfort, increase side effects, not receiving the therapeutic effects of the medication, and a decline in health. The findings were: Record review of Resident #11's Admission Record revealed Resident #11 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11 had diagnoses of Pain in left shoulder,and Other chronic pain, Hypertensive heart disease with heart failure (high blood pressure), Paroxysmal atrial fibrillation (a type of irregular heartbeat, or arrhythmia, that occurs in brief episodes that last less than seven days), and Heart failure (a serious condition that occurs when the heart is unable to pump enough blood to meet the body's needs), Record review of Resident #11's Medication Administration Record (MAR) read in part . The resident had a scheduled medication of Hydrocodone-acetaminophen- Schedule II tablet; 10-325 mg; 1 tablet; oral. The MAR noted under Scheduled Start Date/Time, 12/04/2024 at 01:00, Not Administered: Drug/Item Unavailable Comment: MD ordered but med has not arrived from pharmacy- LVN B and on 12/04/2024 at 07:00, Not Administered: Other Comment: pending delivery. CN aware of unavailability- CMA A . Record review of Resident #11's MDS dated [DATE] noted the resident had a BIMS score of 12 indicating some cognitive impairment and had Other Chronic Pain. Resident #11 received scheduled pain medication regimen. The MDS did not indicate a frequency of the pain. Record review of Resident #11's Care Plan, undated read in part . Problem: Resident has Dx /Hx of chronic pain with potential for breakthrough issues. Goal: Resident will verbalize reduction of pain. Approach: Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. Resident is at risk for deterioration in ADLs RT Chronic pain . Record review of Physician Order Report dated 11/05/2024 - 12/05/2024 read in part . Prescription 12/19/2023 - Open Ended. hydrocodone-acetaminophen - Schedule II tablet; 10-325 mg; amt: 1 tablet; oral Special Instructions: FOR PAIN. [DX: Sciatica (A severe pain that radiates from the back into the hip and outer side of the leg caused by compression of the sciatic nerve), unspecified side]. Every 6 Hours; 01:00, 07:00, 13:00, 19:00 . Ordered by MD B. Record review of secure text dated 11/30/2024 at 2:30 PM sent by CMA A to NP noted that Resident #11 needed a refill on their Hydrocodone-acetaminophen. The NP acknowledged the text with a thumbs up emoji at 2:55 PM. Record review of secure text dated 12/01/2024 at 7:47 AM sent by CMA A to NP. The NP replied at 3:25 PM that she had sent the prescription refill to MD A yesterday. Interview on 12/05/2024 at 12:53 PM with Charge Nurse/LVN A. She said Medication Aides ordered medications for the medication cart. The medications have a reorder sticker and a date to reorder them by. She said the nurses also reorder medications. She said for controlled substances, the facility used a system called Signal to text the doctor or Nurse Practitioner. She said when reordering medications, you put the patient's name, dose and frequency and let the NP/doctor know the resident needs more medications, and the doctor sent the order to the pharmacy. She said she reviewed the medications cart weekly and looked at the dates on all medications. She said on her days off, on 12/02, staff messaged the doctor that the facility needed more of the resident's medication. She said the CMA A did not order the medication within seven days of the medication running out. She said the morning of 12/04/2024 when she came into work, CMA A notified her that Resident #11 was out of their Hydrocodone-acetaminophen. Charge Nurse/LVN A called MD A and notified her of needing more Hydrocodone-acetaminophen. She said the Hydrocodone-acetaminophen arrived at 1 PM on 12/04/2024. She said the resident received their Hydrocodone-acetaminophen on their next dose at 1 PM on 12/04/2024. She said the resident never stated she was in pain. She said she ordered medications and restocked her medication cart weekly. She said it was a few months ago since she was trained on ordering medications and following physician's orders. She said the DON, ADON, Administrator, and her as a charge nurse were responsible for oversight to ensure staff followed physician's orders. She said she oversaw the Medication Aides. She said the risk to residents when protocol or policy regarding following physician's orders were not followed could be physical harm, and or mental harm. Interview on 12/05/2024 at 1:25 PM with CMA- A. She said on the blister pack there was a sticker that had an order after date. If a medication needed to be refilled, then she placed that reorder sticker on a medication refill sheet and sent the order to the pharmacy. Then if she worked the next day, she followed up with the night nurse to determine if the medication arrived because deliveries were at night. She said she ordered the Hydrocodone-acetaminophen for Resident #11. She said she followed up on the medication ordered with the NP. She said last week she worked the weekend 11/30- 12/01/2024 and she told the NP after 6pm on 12/01/2024 that the resident needed a refill on Resident #11's Hydrocodone-acetaminophen. She said if a resident needed a narcotic refilled, she had to ask NP for a refill. She said the NP told her ok on 11/30/2024 then she waited for the medication to arrive to the facility. She said she followed up with the NP on 12/01/2024. She said she was off on 12/02/2024 and 12/03/2024. She said she also notified the charge nurse on 12/03/2024. She said she administered medications to Resident #11. She did not recall when she last had training on orderings meds and following physician's orders. She said the DON was responsible for ensuring policy was followed for ordering meds and following physician's orders. She said if she saw medications were getting short then she would report to the charge nurse and if the charge nurse did not want to listen then she went to the DON. She said the risk to residents if staff did not follow physician's orders was the residents did not get their medications and then the residents could get sick, or the residents could be in pain. Interview on 12/05/2024 at 1:37 PM with DON. When reordering medications, she said if a resident's medication was a controlled substance, then the Medication Aide informed the nurse, and the nurse informed the doctor. The doctor then sent a written prescription into the pharmacy, then the facility waited for the medication to come in. She said the facility had e-kits, but Hydrocodone-acetaminophen not included. She said the resident's Hydrocodone-acetaminophen ran out on 12/03/202 and the Medication Aide should have contacted ADON B, then notified the NP on 12/02/2024 to reorder the Hydrocodone-acetaminophen. The medication had not arrived at the facility by 12/03/2024. Charge Nurse/LVN A and the NP sent the script to the pharmacy on 12/03/2024. She said she thought the failure occurred because NP did not send the script to the pharmacy in time to get the medication for Resident #11. She said she was responsible for oversight to ensure staff followed all clinical protocol and policy. She said the risk to residents of not following physician's orders depended on the situation. She said with medications, the resident could be in pain and the worst thing that could happen to the resident was pain for the resident. Interview on 12/05/2024 at 1:45 with CMA A, Charge Nurse/LVN A, and the DON. CMA A said she text the NP on 11/30 about reordering medications and followed up on 12/01/2024. The DON said ADON B followed up with the NP on 12/02/2024. Interview on 12/05/2024 at 2:16 PM ADON B. She said the Medication Aides and nurses reordered medications. She said for controlled substance there were no refills, the Medication Aides notified the nurse, to then notify the doctor to renew the prescription. She said she notified MD A who worked with MD B. Interview on 12/05/2024 at 2:41 PM with CMA A. She said Resident #11 had 4 or 5 tablets of Hydrocodone-acetaminophen left when she notified MD A on 11/30/2024. She said her procedure was to notify NP and at that time MD A had an emergency. She said normally she notified MD A when a controlled medication needed to be refilled. She said she did not have the number for MD B and NP. She said the nurse had MD B's number. She said there was no restriction from her getting MD B's number. She said she would not normally contact MD B and it was easier to get a hold of MD A. Record review of Resident #11's Physician Orders, dated 10/06/23 with an open-end date; Metoprolol Tartrate tablet; 25 mg; amount: 0.5 tab; oral. Special Instructions: give 25mg 1/2 tab to equal 12.5 mg total dose. Hold for SBP <110 OR HR <60. Give at noon. Record review of Resident #11's Physician Orders, dated 03/14/2024 with an open-end date, reflected losartan tablet; 50 mg; amount: 1 tablet; oral. Special Instructions: Hold for SBP <110; Once A Day at 18:00. Record review of Resident #11's Medication Administration Record (MAR) dated 11/5/2024 - 12/5/2024 reflected, the resident was administered Metoprolol and Losartan by MA C with the same blood pressure and pulse reading for both medication administration times on the following days: November 8th: 12:00 PM & 6:00 PM B/P -148/63 and Pulse-66 November 10th: 12:00 PM & 6:00 PM B/P - 132/64 and Pulse-67 November 23rd: 12:00 PM & 6:00 PM B/P- 137/62 and Pulse- 78 November 27th: 12:00 PM & 6:00 PM B/P-133/88 and Pulse-63 November 28th: 12:00 PM & 6:00 PM B/P-146/63 and Pulse-67 December 2nd: 12:00 PM & 6:00 PM B/P-147/60 and Pulsie-67 December 3rd: 12:00 PM & 6:00 PM B/P-136/64 and Pulse-69 Record review of Resident #45's face sheet, dated 12/05/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to carry out daily tasks:), Hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs.) Generalized anxiety disorder, and major depressive disorder. Record review of Resident #45's quarterly MDS assessment, dated 11/14/24, reflected a BIMS score of 10 out of 15, which indicated moderate cognitive impairment. The resident was independent and required set-up assistance from staff with ADL care. Record review of Resident #45's care plan with a revision date of 09/19/2024 reflected a potential for complications, signs and symptoms related to diagnosis of hypertension. Resident receives anti-hypertensive and is at risk for side effects. Approach: Administer medications as ordered and monitor; Monitor and report BP as ordered. Notify MD of significant abnormalities. Record review of Resident #45's Physician Orders, dated 11/14/2024, revealed, Diltiazem HCl tablet; 60 mg; amount: 1 Tab; oral; three times a day with Special Instructions: Hold for systolic Blood Pressure <100 and apical pulse is <60 Record review of Resident #45's Physician Orders, dated 11/14/2024, Amiodarone tablet; 200 mg; 1 TABLET; oral; twice a day; Special Instructions: HOLD for PULSE < 60. Record review of Resident #45's Medication Administration Record (MAR) dated 11/5/2024 - 12/5/2024 reflected, the resident was administered Diltiazem and Amiodarone by MA C with the same blood pressure (B/P) and pulse reading for 2 of 3 medication administration times on the following days: November 8th: 7:00AM & 3:00 PM B/P -164/98 and Pulse-93 November 10th: 7:00AM & 3:00 PM B/P - 136/77 and Pulse-74 November 18th: 7:00AM & 3:00 PM B/P -148/76 and Pulse-82 & (3:00 PM) Pulse-66 November 23rd: 7:00AM & 3:00 PM B/P- 133/61 and Pulse- 86 November 27th: 7:00AM & 3:00 PM B/P-133/88 and Pulse-77 November 28th: 7:00AM & 3:00 PM B/P-140/77 and Pulse-82 December 2nd: 7:00AM & 3:00 PM B/P-137/68 and Pulsie-63 December 3rd: 7:00AM & 3:00 PM B/P-114/67 and Pulse-70 Attempted telephone interview on 12/05/24 at 1:16 PM MA C regarding vital signs prior to administration of anti-hypertensive and cardiac medication administration. No response. left Voice mail message. Interview 12/05/24 at 1:57 PM with LVN A. She said the expectation was for the MA's to take vital signs (Blood pressure (B/P's) and pulse) prior to medication administration as ordered by the physician. She said if they do not check a resident B/P and pulse and a parameter was required for medication administration, it can drop the resident's B/P too low due to the initial dose given. The risk of them administering the med could include weakness, dizziness, or passing out. The worst thing that could happen is the blood pressure dropping too low and the resident could die. Interview 12/05/24 at 2:00 PM with ADON B, who has been at the facility for 1 week. She said the staff should perform vital signs (v/s) prior to admin of B/P meds due to parameters. She said you should not use the same v/s from the initial dose. She said not doing v/s prior could cause the resident to be overmedicated. She said the worst thing that could happen would be the B/P was so low that a resident could code. Interview on 12/05/24 at 2:09 PM with DON regarding B/P prior to Hypertension medication. She said that the B/P should be done prior to administration if there are parameters. She said the risk of not doing vital signs would be bottoming out which means the resident can become hypotensive. Interview on 12/05/24 at 2:16 PM with Regional Nurse, who said the staff should follow orders as written by the physician. She said the staff would not know the parameters if B/P was not taken. She said the risk was a lower B/P and the resident may become lethargic or have a lower B/P than desired and the resident could lead the resident to be transferred out of the facility to the hospital. Interview on 12/05/24 at 2:21 PM with Interim Administrator, who said her expectation was for the nursing staff to check V/S as indicated on the orders. She said possible contraindications would be the resident could become lethargic and their v/s could be lower than normal levels. She said she was unsure as the worse that could happen. Record review of the facility's Administering Medications policy, revised dated December 2012, read in part . Policy Interpretation and Implementation. 8, The following information must be checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the kitchen. The facility failed to ensure on 12/03/2024 at 8:15 AM that a container of bacon grease, chicken noodle soup and French toast were labeled and dated with the preparation date and expiration date. The facility failed to ensure a bag of open tortillas was sealed. The facility failed to ensure the label on the ground beef in the freezer was legible. These failures had the potential to place residents at risk of serious complications from foodborne illness because of their compromised health status. Record review of Food Receiving and Storage policy dated November 2022 read in part . Foods shall be received and stored in a manner that complies with safe food handling practices. 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). 7. Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded . Findings include: Interviews and observations on 12/03/2024 beginning at 8:15 AM with the Dietary Manager. The refrigerator had a container of what the Dietary Manager identified as bacon grease, chicken noodle soup and French toast did not reflect the preparation and expiration dates During the walkthrough of the freezer, a bag of tortillas was observed unsealed. The Dietary Manager identified ground beef that had a label but was illegible. Interview on 12/04/2024 at 2:48 PM with the Dietary Manager. She said the policy or procedure for prepared food was it needed to be labeled and dated with the preparation date and expiration date, and ensure the foods were sealed with a lid. She said what happened this survey was an employee forgot or was distracted. She said she in-serviced the kitchen staff on labeling and storing foods. She said she was last in-serviced on food storage and labeling 30 days ago. She said kitchen staff were in-serviced monthly. She said she was responsible for oversight to ensure staff followed protocol. She said the risk to the residents if policy or protocol was not followed was a possibility of contamination. She said the worst thing that could happen to residents when proper protocols are not practiced was diarrhea or stomach issues. U.S. Food and Drug Administration Food Code dated 2022 read in part . 3-305.11 (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . TAC Ch. 228 Subchapter A read in part . (a) The purpose of this chapter is to implement Texas Health and Safety Code, Chapter 437, Regulation of Food Service Establishments, Retail Food Stores, Mobile Food Units, and Roadside Food Vendors. (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code. (c) The department does not adopt by reference the following sections, paragraphs, and subparagraph of the FDA Food Code, 3-202.13, 3-202.14(C), 3-202.18(A), 5-102.11, 5-102.13, 5-102.14, 5-104.11(B)(1), 6-101.11(B), 6-202.18, 8-201.11, 8-202.10, 8-203.10, 8-302.11-14, 8-303.10-30, 8-304.10, 8-304.20, 8-401.10, 8-401.20, 8-402.10, 8-402.20-40, 8-403.40, and 8-501.10-40, and the definitions for accredited program, drinking water, food establishment, game animal, general use pesticide, public water system, regulatory authority, safe material, service animal, and vending machine location. (d) In the event of a conflict, Texas law and rules in this chapter prevail over the adopted Food Code .

Based on observation, interview and record review, the facility failed to ensure the coordination of assessments with the Pre-Admission Screening and Resident Review (PASRR) program was provided for 1 of 4 residents reviewed for PASRR screenings (Resident #49). The facility did not correctly identify Resident #49 as having mental illness in his PASRR Level 1 Screening. This failure could place residents with documented mental illness diagnoses at risk of not receiving needed care and services in the appropriate setting. Findings included: Record review of Resident #49's face sheet, not dated revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement), psychosis (a mental disorder characterized by a disconnection from reality), scabies (a contagious skin condition caused by microscopic mites), muscle weakness, Dementia (a group of thinking and social symptoms that interferes with daily functioning), traumatic brain injury, chronic kidney disease, Rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet) and anemia. Record review of physician orders dated 3/21/24 indicated Resident #49 was prescribed Sertraline 100 mg once daily and Trazadone 50 mg once daily for depression. Record review of quarterly MDS dated [DATE] indicated Resident #49 had a BIMS of 2 which indicated severe cognitive impairment. Resident #49 had active diagnoses of depression and psychotic disorder and was taking an antidepressant. Record review of Resident #49's care plan dated 9/13/24 indicated Resident #49 received antidepressant medication r/t dx depression. Approaches included: assess/record effectiveness of drug treatment, monitor and report signs of sedation, hypotension, or anticholinergic symptoms, and pharmacy consultant review. Record review of the PASRR level1 screening from the hospital dated 3/20/2024 indicated Resident #49 was negative for mental illness, intellectual disability, and developmental disability. Record review of the PASRR level 1 screening dated 12/5/24 indicated Resident #49 was negative for mental illness, intellectual disability, and developmental disability. Observation and interview with Resident #49 on 12/3/24 at 10:15 am, he was sitting on a chair in the activity room, watching an aide pass out jig saw puzzles to other residents. This surveyor asked how he was, Resident #49 said he was fine. He did not answer any more questions, he sat at the chair observing other residents. Interview with the MDS Coordinator on 12/5/24 at 11:41 am, she said the PASRR Level 1 form for Resident #49 was copied from the PASRR form that came from the hospital . The MDS Coordinator said the process for PASRR assessments was to look at the clinicals from where the resident came from and use the diagnoses from the resident's face sheet. She said she was solely responsible for PASRR assessments. She said the risk to the resident when not assessed correctly would be they could miss out on services provided by the state. Interview with the Regional Reimbursement Consultant on 12/5/24 at 3:10 pm, she said when a new resident comes into the facility, the PASRR assessment should be conducted that first day. She said staff should look at the referral packet and supporting diagnoses as well. If the resident triggered a positive PASRR this would get submitted to the appropriate agency. She said the risk to the resident would be they would not qualify for services they may need. The Regional Reimbursement Consultant said MDS Coordinator is responsible for the PASRR assessments, and the Administrator looks behind the MDS Coordinator for completed assessments. A policy for Resident Assessments was requested from the Administrator on 12/5/24 at 10:05 am but was not provided.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 7% based on 2 errors out of 28 opportunities, which involved 1 of 4 residents (Residents #45) reviewed for medication errors. 1. The facility failed to ensure MA A administered the correct dose of Clonazepam to Resident #45. 2. The MA failed to administer Methimazole to Resident #45 according to physician orders and administered the medication after meal instead of before meal. These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications. Findings include: Record review of Resident #45's face sheet, dated 12/05/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to carry out daily tasks:), Hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs.) Generalized anxiety disorder, and major depressive disorder. Record review of Resident #45's quarterly MDS assessment, dated 11/14/24, reflected a BIMS score of 10 out of 15, which indicated moderate cognitive impairment. The resident was independent and required set-up assistance from staff with ADL care. Record review of Resident #45's, care plan dated 06/12/24, indicated she had a history of anxiety and on antianxiety medication. Her interventions were to Monitor for drug use effectiveness and adverse consequences, and monitor resident's mood and response to medication. Record review of Resident #45's Physician Orders starting 11/15/24 reflected an active order for clonazepam tablet; 0.5 mg; amount: 1/2 TABLET; oral [DX: Generalized anxiety disorder] Twice A Day. There was also an active order with a start date of 12/03/24 for Methimazole tablet; 5 mg; amount: 1 Tablet; oral with special instructions to administer 1 hour before meals. Record review of Resident #45's MAR starting 11/15/24 reflected the Clonazepam 0.5 mg; amount: 1/2 TABLET; oral administered twice a day. Record review of Resident #45's MAR starting 12/03/24 reflected methimazole tablet; 5 mg; 1 Tablet; oral; administered twice a day 1 hour before meals. During medication pass observation on 12/05/24 at 8:39 AM, MA A administered Clonazepam 0.5 mg tablet and Methimazole 5mg tablet. Resident was observed with breakfast tray on bedside table with 75% of her breakfast eaten. MA proceeded to administer her medication to include the Clonazepam 0.5 tab. Interview on 12/05/24 at 9:31 AM, MA A said she had been working at the facility since 2021. She said she did on-boarding training and medication competences during that time but had not had any recent training on medication administration. She said Clonazepam was administered to Resident #45 for anxiety. She said she was unaware she was supposed to administer Clonazepam .25 mg instead of the Clonazepam 0.5 mg tablet because the tablet was already scored. She said she should have clarified the order with the nurses before administration. She said the risk of too much Clonazepam could cause side effects, including lethargy and dizziness. MA A said she should have administered the Methimazole as ordered. She said all medications should be administered as ordered by the physician. She said the purpose of this medication was to maintain appropriate thyroid levels and said the risk of not administering the medication before meals could lead to the medication not working properly. Interview on 12/05/24 at 9:49 AM with LVN A, who said MA A informed her today that she was administering the incorrect dosage for the Clonazepam. She said she would contact the attending physician to clarify the orders and make the corrections on the MAR and with the Pharmacy. She also said that she was informed that Methimazole was not being administered before meals as ordered. She said thyroid medications should be administered as ordered due to metabolism of the medication. She said it can interfere with absorption and not work properly, which could ultimately lead to a thyroid storm and/or hospitalization . Telephone Interview with the NP on 12/05/24 at 10:23 AM regarding the administration of Methimazole after meals. She said it does not really matter if the medication was administered before meals, like levothyroxine. However, the order said to take 60 mins before meals, and it should be administered as directed. Regarding the Clonazepam 0.5mg PO give 1/2 tab, it also should be administered as ordered. Interview on 12/05/24 at 12:37 PM with ADON A, who said her expectation of the staff was reading the MAR and clarifying orders with the ADON or DON before administering medication. She said the Methimazole should be administered as ordered to achieve the greatness effectiveness of the medication. She said she was unaware of the MA's quarterly or annual re-education. She said administering medications not as ordered can cause the resident not to receive a therapeutic dose, but it can also cause a resident to overdose and increase side effects such as drowsiness, confusion, dizziness and possible falls. Interview on 12/05/24 at 12:41 PM with the DON, who has been at the facility for 3 months. She said her expectation was to administer medications as ordered. She said the staff should check the MARs against the order and clarify the order. She said Clonazepam can cause increase drowsiness, and increase dizziness, and hallucinations, which can cause falls. Record review of the facility's Administering Medications policy, revised dated December 2012, read in part . Policy Interpretation and Implementation 20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered, f. Any results achieved and when those results were observed, g. The signature and title of the person administering the drug .

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 1 (Resident #69) of 5 resident reviewed for infection control. The facility failed to ensure that CNA A, used appropriate PPE during urinary catheter care to Resident #69. These failures could place residents at-risk for infection due to improper care practices. Findings Included: Record review of Resident #36's face sheet dated 12/03/2024 revealed resident was admitted to the facility on [DATE], age [AGE] years old. Resident #69 had a diagnosis of Malignant neoplasm of liver (a cancerous tumor that can start in the liver or spread to the liver from another part of the body). Record review of Resident #69 doctor's order dated 11/19/2024 revealed that Resident was ordered Enhanced Barrier Precautions for Foley Catheter. Enhanced Barrier Precautions for a Foley urinary catheter means that healthcare workers should wear a gown and gloves when performing any high-contact care activities related to the catheter, such as changing the drainage bag or manipulating the catheter itself, as the presence of an indwelling catheter puts a patient at higher risk of acquiring or transmitting multidrug-resistant organisms (MDROs) and requires extra precaution to prevent infection. Observation on 12/05/2024 at 12:00pm, of urinary catheter care provided to Resident #69 by CNA A who did not implement Enhanced Barrier Precautions for urinary catheter care of Resident #69 while providing urinary catheter care the resident. After entering Resident #69's room, CNA A donned gloves but failed to donn (put on) a gown prior to providing urinary catheter care. CNA A provided urinary catheter care, by cleaning the urinary catheter, handling the bag, and emptying urine from the drainage bag without implementing the recommended Enhanced Barrier Precautions of wearing a gown. Interview on 12/05/2024 at 12:20pm, CNA A confirmed that Enhanced Barrier Precautions should be maintained for Resident #69. CNA A stated Resident #69 was on Enhanced Barrier Precautions for urinary catheter. CNA A stated that she was knowledgeable and had been trained on the facility's infection control policy. CNA A was able to articulate knowledge related to what PPE (gown and gloves) should be used when providing care for residents who are on Enhanced Barrier Precaution. CNA A stated that when the donning of PPE is not implemented infection could spread to other residents and staff. Interview with the DON on 12/05/2024 at 1:10pm, who stated that she did not know why CNA A did not implement Enhanced Barrier Precautions and donn proper PPE when providing care to Resident #69. The DON stated that Resident #69 was on Enhanced Barrier Precautions for urinary catheter. The DON stated that CNA A should have donned PPE (gown and gloves) prior to entering the resident's room and when she provided urinary catheter care. The DON stated that staff had been trained on infection control and transmission-based precautions. The DON stated that when the donning of PPE is not implemented infection could spread to other residents and staff. The DON stated that all staff are responsible for ensuring that transmission-based precautions are implemented. Interview on 12/05/2024 at 1:45pm, with the Infection Preventionist, who stated that staff had been trained on infection control and transmission-based precautions. The Infection Preventionist stated that Resident #69 was on Enhanced Barrier Precautions for urinary catheter. The Infection Preventionist, stated that CNA should have donned PPE (gown and gloves) prior to entering the resident's room and when she provided care. The Infection Preventionist stated that when the donning of PPE is not implemented infection could spread to other residents. The surveyor requested the facility policy related to Infection Control and Transmission Based Precautions. The Infection Preventionist stated all staff are responsible for ensuring that transmission-based precautions are implemented. The Infection Preventionist stated additional training would be provided. The Infection Preventionist stated that all staff are offered refresher training courses and in services to ensure that staff are continually reminded of policies and procedures. Record review of staff trainings revealed that staff was on Infection Prevention and Enhanced Barrier Precautions on 10/15/2024 and 11/20/2024. Record review of the facility's provided policy, titled Enhanced Barrier Precautions, dated 03/2024, indicated . Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply .Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.).

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1 as identified in the Care Area Assessment of the Admission MDS assessment. This failure could place residents at risk of not having personalized plans developed to address their specific care needs. Findings included: Record review of Resident 1#'s undated face sheet revealed an [AGE] year-old male admitted on [DATE] with a readmission on 09/02/2024 and primary diagnosis of Chronic diastolic congestive heart failure (a condition that occurs when the left ventricle of the heart becomes stiff and can't relax properly between heartbeats.) Record review of Resident 1's Admission MDS assessment, dated 06/21/2024, reflected the resident was assessed in section C with a BIMS score of 05 that indicated severe cognitive impairment. Section V for CAA summary reflected additional care areas of cognitive loss/dementia, visual function, communication, ADL Functional/Rehabilitation Potential, Urinary Incontinence, Falls, Nutritional Status, Pressure Ulcer, Psychotropic Drug Use, and Pain. Record review of Resident #1's undated Care Plan reflected a plan of care only for the category Nutritional Status: Problem Start Date: 06/19/2024 Resident is at risk for weight loss due to new admit to facility. Resident is currently on Dys (Dysphagia) advanced diet, thin liquids. Created: 06/19/2024 Long Term Goal Target Date: 09/16/2024 Resident weight will be stable through the next review date Created: 06/19/2024 Approach Start Date: 06/19/2024 Honor Resident's food preferences to the best of our ability. Notify MD, RD and RP of any significant weight changes. Honor Resident's diet as ordered. RD will assess resident quarterly or as needed. Created: 06/19/2024 In an interview and observation on 09/12/2024 at 1:20 pm, of Resident#1 in his room at the facility. He said that he did not have any care concerns. In an interview on 09/12/2024 at 2:25 p.m. with the MDS Coordinator, she said that she was an LVN, and started at the facility in May of 2021. She said that she was tasked to complete all MDS assessments and comprehensive care plans for the facility. She said that the comprehensive care plan is due within 21 days of admission and the care plan was based on what is triggered on the CAAs of the MDS. She said that anything that is on the CAAs summary should be on the comprehensive care plan. She said that the purpose of the comprehensive person-centered care plan was to have a plan of care for the resident with goals and interventions based on the care areas. She said that if a resident does not have a comprehensive person centered care plan there could be an issue treating the resident, and care could be missed by nursing staff. She said that no one reviews her work to ensure that care plans are completed with accuracy. She said that on 09/11/2024 the administrator told her to update the care plan of Resident #1 as instructed by the facility's corporate nurse (RNC). She said that she completed the Admission MDS and comprehensive care plan for Resident #1. She said that when she went to review the care plan there was only a focus for nutritional status. She said that the IDT participants are the DON, ADON, Activities, Dietary Manager, Director of Rehabilitation and Social Worker. She said that the focus of each department is addressed during the IDT, and she is responsible for putting the information provided from each department in the care plan. She said that she did not complete the careplan for Resident #1 and it was an oversight. She said that the DON is oversight for the care plans, and the DON at the time of Resident #1's admission was the corporate nurse (RNC). She said that it was no one's job but hers, and it was on her that Resident #1 did not have a comprehensive care plan after the MDS was completed on 06/21/2024. In an interview on 09/12/2024 at 3:07pm with the Administrator, he said that he started on 08/26/2024. He said that the MDS Coordinator completes all comprehensive care plans for the facility. He said that Resident #1 did not have a care plan as of yesterday (9/11/24) that was comprehensive and person centered and it was an oversight. He said that it was brought to his attention by RNC who told him to have the MDS Coordinator update the care plan. He said that the DON has oversight for care plans, and at the time of Resident #1's admission it would have been RNC. He said that he was not the Administrator at the time that Resident #1 admitted to the facility. He said that he was the Administrator when Resident #1 discharged to the hospital from 08/30/2024-09/01/2024. He said that if a resident has a change of condition or goes out to the hospital the care plan should be updated and reviewed in the morning stand up meeting attended by each department head upon readmission. He said that Resident #1 had a readmission and the error should have been caught during the clinical review of the records of Resident #1 at the time of his re-admission that Resident#1 did not have a comprehensive careplan completed after the admission MDS was finalized. He said that the purpose of a comprehensive, person-centered care plan is to ensure measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs are developed and implemented for each resident. He said that the risk to a resident without a comprehensive person-centered care plan is that the resident may not receive care that is tailored to their needs. Interview on 09/12/2024 at 3:09pm with the RNC, who said that she was a registered nurse and has worked for the facility's corporate entity for 9 years. She was the interim DON until the current DON started on 09/10/2024. She said that she noticed that Resident #1 did not have comprehensive care plan on 09/11/2024, that addressed all his care areas. She said that she told the MDS Coordinator to complete it, and it was an oversight. She said that she was the oversight to ensure that the MDS Coordinator was completing the care plans, she should have been auditing the care plans, and she would start auditing. She said that the error with the care plan of Resident #1 should have been corrected when reviewed at the weekly quality of care meeting with all department heads present. She said that the purpose of a comprehensive person-centered care plan was to provide accurate care to the resident. She said that the risk to the resident would be that the nurses would not have a readily accessible plan of care for the resident's care areas but there would not be a delay in care. Record review of the Policies and Procedures titled, Care Plans, Comprehensive Person-Centered dated March 2022 read in part .Policy Statement .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan 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 21days after admission. 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, 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; .c. when the resident has been readmitted to the facility from a hospital stay; .

Based on interview, observation, and record review, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment, for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1 within 7 days of the completed Admission MDS assessment and no more than 21 days after admission. This failure could place residents at risk for not receiving the required person-centered care. The findings were: In an interview and observation on 09/12/2024 at 1:20 pm, of Resident#1 in his room at the facility. He said that he did not have any care concerns. In an interview on 09/12/2024 at 2:25 p.m. with the MDS Coordinator, she said that she was an LVN, and started at the facility in May of 2021. She said that she was tasked to complete all MDS assessments and comprehensive care plans for the facility. She said that the comprehensive care plan is due within 21 days of admission. She said that the purpose of the comprehensive person-centered care plan was to have a plan of care for the resident with goals and interventions based on the care areas. She said that if a resident does not have a comprehensive person centered care plan there could be an issue treating the resident, and care could be missed by nursing staff. She said that no one reviews her work to ensure that care plans are completed with accuracy. She said that on 09/11/2024 the administrator told her to update the care plan of Resident #1 as instructed by the facility's corporate nurse (RNC). She said that she completed the Admission MDS and comprehensive care plan for Resident #1. She said that Resident#1 admitted on [DATE], the admission MDS was completed on 6/21/2024, and she did not complete the careplan until 09/11/2024 to include all the areas from the CAA. She said that she did not complete the careplan for Resident #1 and it was an oversight. She said that the DON is oversight for the care plans, and the DON at the time of Resident #1's admission was the corporate nurse (RNC). She said that it was no one's job but hers, and it was on her that Resident #1 did not have a comprehensive care plan after the MDS was completed on 06/21/2024. In an interview on 09/12/2024 at 3:07pm with the Administrator, he said that he started on 08/26/2024. He said that the MDS Coordinator completes all comprehensive care plans for the facility. He said that Resident #1 did not have a care plan as of yesterday (9/11/24) that was comprehensive and person centered and it was an oversight. He said that it was brought to his attention by RNC who told him to have the MDS Coordinator update the care plan. He said that the DON has oversight for care plans, and at the time of Resident #1's admission it would have been RNC. He said that he was not the Administrator at the time that Resident #1 admitted to the facility. He said that he was the Administrator when Resident #1 discharged to the hospital from 08/30/2024-09/01/2024. He said that if a resident has a change of condition or goes out to the hospital the care plan should be updated and reviewed in the morning stand up meeting attended by each department head upon readmission. He said that Resident #1 had a readmission and the error should have been caught during the clinical review of the records of Resident #1 at the time of his re-admission that Resident#1 did not have a comprehensive careplan completed after the admission MDS was finalized. He said that he was unsure of when the comprehensive care plan should be completed after a resident is admitted to the facility but it should be done according to the policy. He said that the risk to a resident without a comprehensive person-centered care plan is that the resident may not receive care that is tailored to their needs. Interview on 09/12/2024 at 3:09pm with the RNC, who said that she was a registered nurse and has worked for the facility's corporate entity for 9 years. She was the interim DON until the current DON started on 09/10/2024. She said that she noticed that Resident #1 did not have comprehensive care plan on 09/11/2024, she told the MDS Coordinator to complete it, and it was an oversight. She said that she was the oversight to ensure that the MDS Coordinator was completing the care plans, she should have been auditing the care plans, and she would start auditing. She said that the comprehensive care plan should be completed within 21 days. She said that the error with the care plan of Resident #1 should have been corrected when reviewed at the weekly quality of care meeting with all department heads present. She said that the purpose of a comprehensive person-centered care plan was to provide accurate care to the resident. She said that the risk to the resident would be that the nurses would not have a readily accessible plan of care for the resident's care areas but there would not be a delay in care. Record review of the Policies and Procedures titled, Care Plans, Comprehensive Person-Centered dated March 2022 read in part .Policy Statement .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .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 21days after admission.

Based on observation, interview, and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 resident of 17 residents (Resident #1) reviewed for quality of care. The facility failed to assess Resident #1, who was prescribed daily anticoagulant medication, before lifting her up off the floor when she had an unwitnessed fall and sustained facial injuries and a bleeding hematoma to the back of her head. An Immediate Jeopardy (IJ) was identified on 02/22/2024. The IJ template was provided to the facility on [DATE] at 3:22 p.m. While the IJ was removed on 02/24/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective. These failures placed residents who experience falls with injuries at risk of further injury, pain and delayed medical treatment. Findings include: Record review of Resident#1 face sheet on 02/22/24 revealed that she was an [AGE] year-old white female that was originally admitted to the facility 10/01/22. She has the diagnoses of Alzheimer (A progressive disease that destroys memory and other important mental functions), Pneumothorax, unspecified (A condition when air leaks into the space between the lungs and chest wall), Acute kidney failure (A condition in which the kidneys suddenly can't filter waste from the blood), Hypokalemia (A blood level that is below normal in potassium), and bipolar disorder(A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident#1's Quarterly MDS, dated [DATE] revealed Resident #1 BIMS score was determined to be three due to cognitive impairment. MDS completed by staff, which indicated Resident#1 had memory problems and was severely impaired cognitively. Resident#1 did exhibit behavioral symptoms of wandering and required supervision and one-person physical assist for ADLs. Record review of Resident #1's care plan dated 01/10/24 indicated she had impaired communication, evidenced by: resident having difficulty making herself understood and understanding others. Also, Resident #1 was care planned for bleeding because she was prescribed Plavix. Interventions include administer medications as ordered, engage the resident in simple structured activities that avoid overly demanding tasks, watch for bleeding, blood in urine, and blood in stool. Record review of Resident#1 physician's orders dated 10/19/22 revealed that she was prescribed blood thinner Plavix 75mg per day and she should be monitored for bleeding, blood in urine, and blood in stool. Observation of video pertaining to Resident#1's fall dated 2/5/24 revealed that she was on the floor and CNA-B came into the room and lifted Resident#1 off the floor before she had been assessed by a Nurse. In an interview with LVN-A on 02/21/24 at 6:51pm she stated CNA B notified her that Resident#1 was in the room of another resident on the floor. LVN-A stated before she was able to get to the memory care unit, Resident#1 had been lifted from the floor of the other resident's room and placed in her own bed, which was next door. LVN-A stated during the assessment of Resident#1 she discovered that Resident#1 had a bump and laceration to the back of her head and the right side of her head, and she had a bump and laceration to her right cheek and right side of her eye with bruising. LVN-A stated the facility protocol was not followed regarding this incident. She stated that CNA-B should not have lifted Resident#1 off the floor before she was assessed. LVN-A said lifting a resident off the floor before they are properly assessed puts the resident in danger of more severe injuries because you don't know the extent of their injuries due to the fall. In an interview with CNA-B on 02/22/24 at 9:58 am she stated that she was doing her rounds when she saw Resident#1 in the room of another resident. She said that Resident#1 was on the floor at the foot of a bed. She said she sent LVN A, who was also responsible for caring for resident on another hall, a text message, letting her know what happened. CNA-B stated that Resident#1 was trying to get up off the floor. She said she left the room to check on other residents and when she returned to Resident #1, she was still trying to get off the floor. She said she was afraid that Resident#1 would fall again so she lifted Resident#1 off the floor and took her back to her room and laid her in the bed. CNA-B stated she noticed that Resident#1 had blood coming from the back of her head. In an interview with the facilities' DON on 02/22/24 at 11:51am she stated that facility policy states that when there is an unwitnessed fall that a resident must be assessed before they are lifted from the floor. She said that the reason that a resident must be assessed is because the extent of their injuries is unknown and that by lifting them from the floor could cause more severe injuries. She said she was aware CNA-B lifted Resident #1 off the floor prior to a nursing assessment because she saw the incident on video. She said she conducted an in-service on falls after the incident, but CNA-B did not attend. In an interview with LVN-B on 02/22/24 at 11:45am she stated that she had reported to the Administrator and DON that more staff were needed on the Memory Care Unit, because having one staff assigned to Memory Care Unit was not safe for the residents and was not fair to staff. LVN-B also said that during the night shift there are more falls and because of that, more staff was needed. In an interview with the facilities' DON on 02/22/24 at 11:51am she stated that having one staff assigned to the Memory Care Unit during the hours of 6:00pm to 6:00am with eighteen residents was sufficient. The DON stated staff had complained that more staff was needed in the memory care unit on the night shift. The DON stated she did not go to the Memory Care Unit during the night shift to validate staff complaints, however, specific resident's psychotropic medications were adjusted. Record review of Resident#1's nurses note dated 02/05/2024 written by LVN A read in part, Resident#1 was found on the floor in another resident's room by CNA B. She had a bump and laceration to the back of her head. She also had a bump and laceration to her right check and right eye. She is being sent to the ED because she is on blood thinners. The provider, responsible party and DON were notified. have sustained a small gash or laceration to her right upper brow. She was awake and alert. In an interview on 2/21/24 at 6:30pm LVN A said she was notified by CNA B that Resident #1 was in the room of another resident on the floor. LVN A said that CNA B told her that she had lifted Resident#1 off the floor and placed her in her bed and that Resident#1 had two bumps to her head that were bleeding. LVN A was asked if it was proper protocol for a resident to be lifted off the floor before being assessed by a Nurse and she said no it's not proper protocol to move a resident before they are assessed. LVN A was asked what the risk is of moving a resident before they are accurately assessed. She stated that the resident may have a fracture, dislocation, or other more serious injuries. LVN A stated that she examined Resident #1 and called the facility Doctor, DON, and Responsible party. LVN A said that she was given orders by the facility Doctor to send Resident#1 to the Hospital. This was determined to be an Immediate Jeopardy (IJ) on 02/22/2024 at 3:22 p.m. The VP of Operations, the DON, and the Regional Reimbursement Consultant were notified. The VP of Operations was provided with the IJ template on 02/22/2024 at 3:22 p.m. A Plan of Removal was requested at that time. The following Plan of Removal submitted by the facility was accepted on 02/23/2024 at 6:06 p.m.: The Plan of Removal was accepted on 02/23/24. An Immediate Jeopardy (IJ) was identified on 02/22/2024. The IJ template was provided to the facility on [DATE] at 3:22 p.m. While the IJ was removed on 02/24/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective. Facility Plan to ensure compliance: Plan to remove immediate jeopardy. The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for Resident#1 who was found in the room of another resident on the floor bleeding from her head on 02/05/24. The facility failed to assess Resident #1 before she was lifted from the floor. F684 On 2/22/24, the director of nursing/designee completed an assessment of resident #1 for changes in condition, no concerns were identified. Resident #1 fall assessment and care plan were reviewed. The director of nursing/designee completed assessments on all residents on secure unit for any changes in condition, no concerns identified. The director of nursing/designee reviewed falls for the last thirty (30) days to determine timely notifications and that facility policy was followed, no concerns were noted. Fall assessments and care plans for residents with a previous history of falls and at risk of falls from wandering were reviewed and updated as needed. This was completed on 2/22/24. The VP-Regional Director in-serviced C.N.A. 1:1 on fall management/changes in condition, and notification to a licensed nurse to assess a resident before moving resident. It was completed on 2/22/2024. Current nurse staffing ratios are sufficient to cover the facility and will be reviewed during the QAPI meeting to revise depending on current facility census. The current staffing ration has been determined sufficient to meet the needs of every resident in the facility and will be reviewed in QAPI meeting for any changes. Medical Director was notified by Vice-President, Regional Director on 2/22/24 of Immediate Jeopardy and plan of removal. Starting on 2/22/24, the Director of Nursing and the Vice-President, Regional Director, initiated in-service with facility staff on adequate supervision and the policy regarding a change in condition specifically related to the fall policy. Included in the training was not moving a resident before a licensed nurse assessed the resident. Staff were also educated at this time on the facility protocol of having two (2) staff members on the Secured Unit. The staff will first call out for a licensed nurse, if no response they will call via phone, if no response, a staff member will stay with the resident while another staff member goes to notify the licensed nurse that help is needed. The in-services will be by DON/Designee, including PRN staff, agency, and weekends staff. On 2/23/24, the Regional Nurse Consultant in-serviced the Director of Nursing and nursing management on completing the post-fall observation after a resident fall in the morning clinical meeting to determine new interventions and update the care plan. The staff nurses are completing and have been trained on post fall assessment to include immediate interventions by the DON on 2/22/24. An Ad-Hoc QAPI meeting was held 2/22/24, with the Medical Director, VP and Regional Director, and the Director of Nursing to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. On 2/22/24, the Director of Nursing/Designee will interview at least 5 staff members on compliance with the education. The VP-Regional Director will be responsible for ensuring this plan is completed on 2/22/2024. Monitoring: Observation of the facility on 02/24/2024 from 12:50 a.m. until 2:45 a.m. revealed there were always two staff members inside the locked memory care unit. Before LVN E left the unit for any reason, he called another staff to go to the unit and stay until he returned. Record review of facility document, Quality Assessment and Performance Improvement Plan dated 02/22/2024 at 5:14 p.m. revealed the facility's management team met with their medical director regarding in-services, assessments, and audits necessary to remove immediacy. Record review of 'In-service Training Report dated 02/22/2024 revealed CNA B was educated by the VP of Operations regarding falls, the locked unit, and changes in resident conditions. The document read in part, When a resident is found on the floor (fallen), go to the resident, stay with the resident. Do not move the resident. Activate the call light (if in the room), call (yell) for help; use your cellular phone to call the facility or 911. Once the LVN/RN arrives at the scene, she takes charge. Wait for further directions. The secure unit will be always staffed with two staff members. If one staff comes off the unit, that staff must be replaced until they return to the unit . Record review of 'In-service Training Report dated 02/22/2024 revealed LVN A was educated by the VP of Operations regarding falls, the locked unit, and changes in resident conditions. The document read in part, When a resident is found on the floor (fallen), go to the resident, stay with the resident. Do not move the resident. Activate the call light (if in the room), call (yell) for help; use your cellular phone to call the facility or 911. Once the LVN/RN arrives at the scene, they take charge. Wait for further directions. Do not move the resident until the nurse gives direction. Record review of 'In-service Training Report dated 02/22/2024 revealed all facility staff were educated by the DON regarding falls management and changes in resident conditions. Record review of 'In-service Training Report dated 02/22/2024 revealed all facility staff were educated by the Regional Reimbursement Consultant regarding secure unit staffing. The document read in part, The secure unit will be always staffed with two staff members. If one staff member needs to exit the unit, they must have another staff member relieve them, until they return to the unit. Record review of 'In-service Training Report dated 02/23/2024 revealed all facility nurses were educated by the DON regarding post fall assessments. The documents read in part, The charge nurse is to complete the Post Fall Assessment as soon as practical, by the end of shift, along with progress note. The charge nurse is to implement the doctor recommendations and to include the immediate intervention with the DON. Record review of 'In-service Training Report dated 02/23/2024 revealed all facility nurses were educated by the DON regarding post fall assessments. The documents read in part, The events will be reviewed in the morning meeting every business day of the week to identify a fall. The director of nursing or nurse management will then open the post fall observation and complete the fall history, validate doctor and responsible party notifications, and develop an intervention for the fall and update the care plan. The IDT should participate in developing new interventions. The care plan will be updated during the meetings by nursing management. Record review of -service: Post-Fall Assessment to Director of Nursing and Nursing Management dated 02/23/2024 revealed the nursing managers, including the DON, ADON, and the MDS LVN were educated by the Regional Nurse Consultant regarding post-fall assessments. Record review of facility documents titled; Wound Location Chart dated 02/22/2024 revealed all memory care residents (18), including Resident #1, were assessed from head to toe with all skin injuries/variances noted. There were no necessary changes to any of the residents' care plans. Record review of an audit of all recent facility falls (01/23/2024 - 02/23/2024) revealed 7 of the 18 falls during the that time occurred in the locked memory care unit on varied shifts (4 were during the night shift). There were no necessary changes to any of the residents' care plans. Record review of Compliance Interviews F-684 dated 02/22/2024 revealed the DON tested five staff regarding recent in-services. All five staff answered the questions correctly with no concerns. Interviews were conducted on 02/24/2024 from 12:50 a.m. until 1:00 p.m. with staff on both shifts (6:00 a.m. - 6:00 p.m. and 6:00 p.m. - 6:00 a.m.) including the VP of Operations, the Regional Reimbursement Consultant, DON, LVN A (night shift), CNA B (night shift), LVN C (day shift), LVN D (night shift), LVN E (night shift), CNA F (night shift), LVN G (night shift), CNA H (night shift), CNA I (night shift), CNA J (day shift), CNA K (day shift), CNA L (day shift), Housekeeper M (day shift), and LVN N (day shift) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. The VP of Operations, the Regional Reimbursement Consultant, DON, LVN A, CNA B, LVN C, LVN D, LVN E, CNA F, LVN G, CNA H, CNA I, CNA J, CNA K , CNA L, Housekeeper M, and LVN N were able to explain the importance of assessing residents for injuries and other complications before moving them after they experience falls, staying with the resident after they experience falls, requesting assistance from a nurse or other staff by utilizing the call light system, yelling for help, or using personal cellular phone devices, and ensuring there is adequate staffing (at least two staff) in the locked memory care unit at all times during the night shift. The VP of Operations and the Regional Reimbursement Consultant were informed the Immediate Jeopardy was removed on 02/24/2024 at 1:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy 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 observation, interview, and record review, the facility failed to ensure one resident (Resident #2) of five residents reviewed for physician orders received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. -Resident #2 was given supplements for colonoscopy preparation but had no order for them. -The colonoscopy preparation supplement had been ordered for a different resident. The deficient practice could place residents at risk of ingesting medications not prescribed resulting in severe abdominal distress and diarrhea. Findings include: Record review of the Face Sheet (printed 11/22/2023) for Resident #2 revealed she was [AGE] years old, and was originally admitted to the facility on [DATE]. Diagnoses included, but were not limited to, unspecified psychosis, dysphagia (difficulty swallowing), and dementia. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #2 was rarely understood, and rarely understood others. The MDS reflected the resident exhibited severely impaired cognitive skills for daily living. Record review of the Care Plan (edited 10/17/2023) for Resident #2 revealed the resident was at risk for nutritional deficit and weight loss related to having severe dementia. An 'approach' read, in part, .diet and supplements as ordered by MD. In an interview via telephone on 11/21/2023 at 9:21 a.m., a family member of Resident #2 said the resident was prepped for a colonoscopy, but she did not have one scheduled. The family member said she received an email from the facility asking what time the colonoscopy appointment was. She said Resident #2 was drained and agitated. Observation on 11/21/2023 at 11:50 a.m. revealed Resident #2 was in her room. She was not interviewable. Her sitter was in the room with her. In an interview on 11/21/2023 at 11:50 a.m., Resident #2's sitter said the next morning the resident had low strength and had diarrhea. In an interview on 11/21/2023 at 2:49 p.m. LVN A said Resident #2 received a bowel prep about a week earlier. She said Resident #2 returned from a doctor's appointment on 10/23/2023 with instructions for bowel prep. She said she taped the instructions onto the 24-hour report. She said the night nurse gave the bowel prep at midnight. She said the facility staff was not able to locate the instructions later that day. She said she looked on the computer for the time of the transport but did not see it. She then called the family member, and the family member was unaware of any colonoscopy appointment. When the hospital was called, they confirmed there was no colonoscopy appointment. Record review of the NN dated 11/10/2023 at five minutes past midnight for Resident #2 revealed LVN B administered the bowel prep. The NN dated 11/10/2023 at 1:11 a.m. for Resident #2 read in part, .Res tol [Resident tolerating] bowl [sic] prep well. cont [continue] to prep for colonoscopy. It was signed by LVN B. The NN dated 11/10/2023 at 2:00 a.m. read in part, .Bowl [sic] prep completed. Res had multiple BM. It was signed by LVN B. LVN B was not available for interview. In an interview on 11/22/2023 at 2:00 p.m., the DON said Resident #2 and Resident #3 had both went to GI doctor appointments on the same day. When they returned to the facility, the paperwork instructions got mixed up. She said there was no name and no date on the instruction sheet for bowel preparation. The DON said an order was not transcribed into the chart. She said the night nurse (LVN B) saw the paperwork in Resident #2's chart and gave the bowel prep with Resident #2's medications. The DON said the next morning Resident #2's family member called, and it was discovered Resident #2 had been given the bowel prep. The physician was notified, and the resident was provided with Pedialyte to rehydrate her. The DON said Resident #2 had diarrhea as if she was going to have the colonoscopy. Resident #3 was not given the bowel prep but did not have the colonoscopy due to waiting for cardiology clearance. As of exit, the bowel preparation instruction sheet was not provided by the facility. The facility policy entitled Medication and Treatment Orders (revised February 2014) read in part, .Orders for medications and treatments will be consistent with principals of safe and effective order writing .3. Drug and biologicals must be recorded on the Physician's Order Sheet in the resident's chart.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (Resident #1) of five residents reviewed on the secured unit for adequate supervision to prevent accidents. The facility failed to ensure resident safety, as evidenced by: -The door of the nurses' office on the secured unit was open and accessible to residents. -Resident #1, a confused resident, was in close proximity to a bag of medications on the nurses' desk, with no staff within line of sight of the nurses' office. The deficient practice placed residents at risk for ingesting medications that could be detrimental to his or her health, resulting in illness or hospitalization . Findings included: Record review of the Face Sheet for Resident #1 (printed 11/22/23) revealed she was [AGE] years old,and was originally admitted to the facility on [DATE]. She resided on the secured unit. Diagnoses included, but were not limited to, paranoid schizophrenia, bipolar disorder, and mood disorder. Record review of the annual MDS assessment dated [DATE] revealed Resident #1 scored 1 of 15 on the BIMS, indicative of severe cognitive impairment. The MDS reflected the resident exhibited inattention and disorganized thinking. The MDS reflected Resident #1 was able to propel her wheelchair with limited assist from one person. Resident #1 did not have functional limited range of motion of any extremities. Record review of the Care Plan for Resident #1 (edited 10/17/2023) revealed the resident could propel her wheelchair short distances without the assist of staff. The Care Plan reflected Resident #1 had a memory/recall deficit, and was disoriented to date/time, and had short-term memory loss. The 'Goal' read, in part, .Resident will non sustain serious injury due to memory/recall deficit. The 'Approach' read, in part, .Ensure resident's areas are free of hazards. Observation on 11/21/2023 at 2:31 p.m., revealed the door of the nurses' station on the 300 Hall (secured unit) was open. A plastic bag of medications was observed to be on the chair just inside the doorway. Resident #1 was observed in the hallway in her wheelchair. She was independently propelling her wheelchair. There was no staff within visibility of the nurses' station or Resident #1. The surveyor monitored the medications and resident. Observation on 11/21/2023 at 2:39 p.m., revealed staff was visible in the dining room, at the opposite end of the hallway from the nurses' station. Observation on 11/21/2023 at 2:41 p.m., revealed the Administrator was in the main area of the facility, visible through the window of the door of the secured unit. The surveyor asked him to come to the unit. The Administrator entered the secured unit. He acknowledged the bag of medications was unattended in the nurses' station. He locked the door and exited the unit. Observation and interview on 11/21/2023 at 2:42 p.m. revealed the Administrator returned to the secured unit with LVN A. LVN A said she usually kept the nurses' station door closed, but she had been called to a meeting. When asked what could have happened, LVN A replied that the resident may or may not have entered the room and may or may not have ingested the medications. Observation on 11/21/2023 at 2:43 p.m. revealed LVN A took inventory of the medications, which were not prescribed for Resident #1 included the following: Resident #1 included the following: -19 Hydrochlorothiozide (HCTZ) 25 mg (diuretic) tablets, -24 Gabapentin 400 mg (anticonvulsant) tablets, -18 Zoloft 50 mg (antidepressant) tabs, -10 Losartan Potassium 10 mg (for treating high blood pressure) tablets, -21 Risperdal 1 mg (antipsychotic) tablets, -30 Atorvastatin 10 mg (reduces Cholesterol) tablets, -13 Amlodipine 10 mg (to treat chest pain) tablets, -13 Protonix 40 mg (to treat reflux) tablets, -28 Latuda 40 mg (antipsychotic) tablets, -19 Topiramate 50 mg (anticonvulsant) tablets, -21 Naproxen 250 mg (treats pain and inflammation) tablets, -27 Depakote 250 mg (preventative medication for seizures) tablets, and -1 Fluconazole spray (antifungal). Interview on 11/22/2023 at 2:00 p.m., the DON revealed she said the door of the secured unit nurses' station should have been locked. She said the resident could have ingested the medications and had side effects. The facility policy entitled Storage of Medications (revised April 2007) read, in part, .The facility shall store all drugs and biologicals in a safe, secure and orderly manner .2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use .

Based on interview and record review the facility failed to ensure the services of a registered nurse for at least eight consecutive hours a day, seven days a week for 10 days in April 2023 and two days in May 2023 of 60 days reviewed for RN coverage. The facility failed to ensure RN coverage for all Saturdays and Sundays in April 2023 and one Saturday and one Sunday in May 2023. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Record review of CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 3, 2023, run date 10/20/2023 revealed RN coverage was triggered (four or more days within the quarter were with no RN coverage). Record review of the monthly staffing schedule dated April 2023 revealed no RN coverage on the following dates: Saturday April 1, 2023; Sunday April 2, 2023; Saturday April 8, 2023; Sunday April 9, 2023; Saturday April 15, 2023 Sunday April 16, 2023; Saturday April 22, 2023; Sunday April 23,2023; Saturday April 29, 2023; and Sunday April 30, 2023. Record review of the monthly staffing schedule dated May 2023 revealed no RN coverage on the following dates: Saturday May 13, 2023 and Sunday May 14, 2023. Record review of the facility daily staffing sheet for April 2023 revealed no RN coverage on Saturdays and Sundays. Record review of the facility daily staffing sheet for May 2023 revealed no RN coverage on Saturday May 13, 2023, and Sunday May 14, 2023. In an interview on 10/26/2023 at 3:05 PM, the DON stated there were no RN's scheduled on the weekends in April. In an interview and record review on 10/27/2023 at 9:30 AM, the DON reviewed the monthly and daily staffing schedule for April and May. The DON stated the schedules did not have any RN coverage in April on the weekends. The DON stated there was one weekend May 13 and 14 they did not have an RN to work. The DON stated it was hard to find an RN to work on the weekend. The DON stated they posted and were actively looking for RN's. The DON stated she will meet with the administrator and corporate to ensure weekend RN coverage. The DON stated the importance of having the RN was the RN provided the needed resident care, supervision, assessments. The DON stated the RN needed to be available for resident changes in condition. The DON stated the risk of no RN was the LVN could not provide the care the RN could. During the interview the DON stated the facility did not have a staffing or RN coverage policy. The DON stated the facility followed the guidelines for staffing. In an interview on 10/27/2023 at 10:25 AM, the Regional Nurse Consultant stated we have PRN (as needed) RNs. The Regional Nurse Consultant stated the PRN RNs did not want to work weekends. As the interview continued, she stated the importance of an RN was for oversight needed on the shift. The nurse consultant stated the risk of no RN was there would be no RN available if needed for resident care. The nurse consultant stated the administrator was responsible for staffing. In an interview on 10/27/2023 at 10:48 AM, CNA E stated she worked as the staffing coordinator. CNA E stated the RN was needed to be available for resident emergencies. CNA E stated the RN may be needed to make emergency decisions the LVN could not. CNA E stated when a staff member called out sick the administrator and the DON were notified to find the coverage to replace them. CNA E stated the administrator was responsible for the RN coverage. In an interview on 10/27/2023 at 11:08 AM, the administrator stated they hired RN's. The administrator stated they will continue to recruit and retain the staff. The administrator stated the importance of the RN on site was for clinical oversight. As the interview continued the administrator stated the risk was a negative outcome for the resident. The administrator stated he was responsible for ensuring sufficient RN staffing. No staffing policy was provided prior to exit.

Based on interview, and record review, the facility failed to ensure that licensed nursing staff have the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 18 residents (Resident #52) reviewed for nursing competency, in that: -The facility failed to ensure LVN C was competent in medication administration skills by failing to perform pre and post treatment vital signs, observing resident while administering Handheld nebulizer treatment, and documenting that the medication was administered and completed. These failures could put residents at risk for inadequate care, result in ineffective treatment, worsening of symptoms and/or medical complications. Findings included: Record review of Resident #52's electronic medical record revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #52's diagnoses included Chronic obstructive pulmonary disease (Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing, Cerebral infarction (Also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it.), Chronic systolic congestive heart failure (Systolic heart failure is a specific type of heart failure that occurs in the heart's left ventricle.). Record review of Resident #52's Order Summary Report dated 09/13/23 revealed he was to receive Ipratropium-Albuterol Solution 0.5-2.5 mg in 3 ml inhalation every four hours as needed for shortness of breath via Handheld nebulizer (HHN), with HHN tubing change every Sunday. Record review of Resident #52's TAR dated 10/01/23-10/25/23 revealed the nursing staff had not documented breathing treatments of Ipratropium-Albuterol Solution by HHN, and there was no tubing change by a nurse during this period (10/01/23-10/25/23). His Pre and post vitals were also not documented on the TAR per policy. LVN C was the nurse for the 10/25/23 night shift. In an interview 10/25/23 at 11:07 a.m., the DON stated that she has been working at the facility for three weeks. The DON stated that if medication was left in the chamber overnight, it could cause the resident to have an adverse reaction to the medication, and the resident would potentially not get what they need, which could cause a decline in health. The DON reviewed the record, and confirmed there was no documentation of vital signs on the MAR/TAR at the time LVN C stated that she gave Resident #52 his HHN treatment. The DON stated the facility will implement an Inservice on HHN administration this week. In a phone interview with LVN C (night shift nurse 6 p.m.-6a.m.) on 10/26/23 at 10:09 a.m., who has worked at the facility for 15 months revealed that the clear solution in the nebulizer chamber was Ipratropium-Albuterol Solution 0.5-2.5 mg in 3 ml. LVN C stated, I usually give him his nebulizer at night around 9:00 p.m. before he goes to bed. LVN C stated, I leave it for him to take it, because that is how I was taught. LVN C stated that she didn't return to the resident's room to see if he had completed the treatment because he wasn't in distress and was asleep. LVN C stated that she never received an in-service on how to administer HHN treatments at this facility but was taught previously. LVN C stated that if she doesn't provide Resident #52 with his HHN treatment that he can become short of breath. In an interview 10/26/23 at 10:27 a.m. the ADON stated that a nurse should stay in the room when a resident was using the inhaler. Vital signs should be done before and after treatment, and the nurse should clean and dry the nebulizer after each treatment and returned to proper storage. The ADON stated, If the nurse doesn't document on the MAR/TAR that the HHN tubing was changed or the medication was administered, then it was not done. She also stated that if a resident doesn't get medication as ordered, it can cause an exacerbation. Review of the facility''s Handheld nebulizer policy titled Administering Medication through a Small Volume (Handheld) Nebulizer indicated the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Steps in procedure: 17. Remains with resident for treatment. 18. Approximately five minutes after treatment begins (or sooner if clinical judgement indicates) obtain resident's pulse. 23. Administer therapy until medication is gone. 26. Obtain post-treatment pulse, respiratory rate, and lung sounds. 30. Change equipment and tubing every seven days, or accordance to facility protocol. The facility''s Medication Administration policy showed . Medication Administration 2. Obtain and record any vital signs as necessary prior to medication administration. 4. Medications are to be administered at the time they are prepared. Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medication report off-duty without first recording the administration of any medication. 4. The resident's MAR/TAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration and time. Initial on each MAR/TAR are verified with a full signature in the space provided or on the nursing care center's master employee signature log. 5. When PRN medication is administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. b. Complaint or symptoms for which the medication was given. c. Results achieved from giving the dose and the time results were noted. d. Signature or initial of person recording administration and signature or initials of person recording effects. 6. Once removed from package/container, unused medication doses shall be disposed of according to the nursing care center policy.

48863 Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include administering of medications to meet the needs of 1 resident (Resident #52) of 18 residents reviewed for pharmacy handheld nebulizer treatments, in that: -Resident #52's scheduled medication was not administered timely and according to facility policy. -The facility failed to change Resident #52's HHN equipment weekly per policy. This deficit practice could affect the resident by not receiving a therapeutic dose and could prevent the resident from receiving the highest possible benefit from their medication. Findings included: Record review of the Face Sheet dated 10/25/23 reflected Resident #52 was a [AGE] year-old male admitted [DATE] with diagnoses of (Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing, Cerebral infarction (Also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it.), Chronic systolic congestive heart failure (Systolic heart failure is a specific type of heart failure that occurs in the heart's left ventricle.). Observation on 10/25/23 at 8:25 a.m., revealed Resident #52 was receiving a Hand-Held Nebulizer (HHN) treatment. LVN B was in the room and removed the nebulizer treatment. LVN B asked, Where did you get this from? Resident stated that it was from last night. LVN B threw the HHN tubing and mask in the trash. 2-3 mls of clear solution were noted in chamber. Resident #52 stated I have been on the machine for the last 15 minutes. An interview and observation with Resident #52 10/25/23 at 8:32 a.m., revealed he was having shortness of breath (SOB) last light and asked for his breathing treatment. He stated that he got his treatment nightly. He stated that he asks for his nebulizer treatment, because it's hard to breath because I have a mass on my lungs. He stated that he has an upcoming appointment with his lung doctor to check his lungs. LVN B was in the room with Resident #52. He stated that he had been using his nebulizer for 15 minutes. LVN B asked Resident #52 if he had any complaints of SOB or respiratory distress. Resident #52 denied SOB. Respirations were unlabored, and Oxygen saturation (O2 sats) were at 97% and pulse was 68 beats per min. In an interview on 10/25/23 at 9:17 a.m., LVN B said she was an agency nurse that started working at the facility on 10/09/2023. She stated that she didn't give Resident #52 the nebulizer treatment this morning, and that the nebulizer treatment was from the night nurse. LVN B stated that nebulizer wasn't working properly and at its peak, if the resident was using the HHN for 15 mins and medication was still in the chamber. LVN B stated, if you keep refilling and a combining new medication with the old medication, it may cause toxicity. LVN B was also asked if the tubing was recently changed, and if she saw a date on the tubing. LVN B stated that she could not read the date on the tubing to verify the date it was changed, and if there was a date on the tubing, but it should be changed weekly. Observation on 10/25/23 at 9:18 a.m., revealed the DON in Resident #52's room. She was also unable to verify date on the HHN tubing. In an interview with the DON on 10/25/2023 at 9:19 a.m., she stated that it looks like it has been wiped off and I can't tell the date. She stated, it's not our policy to date the tubing. The DON stated that the documentation of the weekly tubing change and medication administration should be initialed on the MAR/TAR. In an interview on 10/25/23 at 11:07 a.m. the DON stated that she has been working at the facility for three weeks. The DON stated that if medication was left in the chamber overnight, it could cause he resident to have an adverse reaction to the medication, and the resident was potentially not getting what they need, which can cause a decline in health. DON stated the facility will implement an in-service on HHN this week. In a phone interview with LVN C (night shift nurse 6 p.m.-6a.m.) on 10/26/23 at 10:09 a.m., who has worked at the facility for 15 months, revealed that the clear solution in the nebulizer chamber was Ipratropium-Albuterol Solution 0.5-2.5 mg in 3 ml. LVN C stated I usually give him his nebulizer at night around 9:00 p.m. before he goes to bed. LVN C stated, I leave it for him to take it, because that is how I was taught. LVN C stated that she didn't return to the resident's room to see if he had completed the treatment because he wasn't in distress and was asleep. LVN C stated that she never received an in-service on how to administer HHN treatments at this facility but was taught previously. An interview 10/26/23 at 10:27 a.m. ADON stated that a nurse should stay in the room when a resident was using the nebulizer. Vital signs should be done before and after treatment, and the nurse should clean and dry the nebulizer after each treatment and returned to proper storage. The ADON stated that if a resident doesn't get medication as ordered, it can cause an exacerbation. Record review of Resident #52's Order Summary Report dated 09/13/23 revealed he was to receive Ipratropium-Albuterol Solution 0.5-2.5 mg in 3 ml inhalation every four hours as needed for shortness of breath via Handheld nebulizer (HHN). Record review of Resident #52's TAR dated 10/01/23-10/25/23 revealed the nursing staff had not documented breathing treatments of Ipratropium-Albuterol Solution by HHN, and there was no tubing change by a nurse during this period (10/01/23-10/25/23). Review of the facility's respiratory policy titled Administering Medication through a Small Volume (Handheld) Nebulizer indicated the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Steps in procedure: 17. Remains with resident for treatment. 18. Approximately five minutes after treatment begins (or sooner if clinical judgement indicates) obtain resident's pulse. 23. Administer therapy until medication is gone. 26. Obtain post-treatment pulse, respiratory rate, and lung sounds. 30. Change equipment and tubing every seven days, or accordance to facility protocol. The facility's Medication Administration policy showed . Medication Administration 2. Obtain and record any vital signs as necessary prior to medication administration. 4. Medications are to be administered at the time they are prepared. Documentation: 2. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medication report off-duty without first recording the administration of any medication. 7. The resident's MAR/TAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration and time. Initial on each MAR/TAR are verified with a full signature in the space provided or on the nursing care center's master employee signature log. 8. When PRN medication is administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. b. Complaint or symptoms for which the medication was given. c. Results achieved from giving the dose and the time results were noted. d. Signature or initial of person recording administration and signature or initials of person recording effects. 9. Once removed from package/container, unused medication doses shall be disposed of according to the nursing care center policy.

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 securely in locked compartments for one (Nurse medication cart 500 Hall) of 7 medication carts observed for storage of medications. The facility failed to ensure the nurse 500 hall medication cart was secured when unattended. This failure could place residents at risk for loss of medications, resident's safety, and drug diversion. Findings included: An observation on the 500 hall on 10/24/2023 at 4:16 PM, revealed LVN D at the nurse medication cart for 500 hall. The medication cart was parked in the hall in front of room [ROOM NUMBER]. As the observation continued LVN D walked into room [ROOM NUMBER]. LVN D closed the room door. The medication cart was observed unlocked and unattended. There were no residents, visitors, or staff in the hall at this time. An observation and interview on 10/24/2023 at 4:19 PM, revealed LVN D returned to the medication cart. LVN D stated she expected to come right back to the medication cart. LVN D stated she was going to lock the medication cart when she returned. LVN D stated the nurse working on the medication cart was responsible for making sure it was locked before leaving it. The LVN stated the risk of the cart not being locked was that anyone could take something out of the medication cart. The LVN stated next time she needed to make sure the medication cart was locked before leaving. Inventory on 10/24/2023 at 4:20 PM, of the Nurse Medication Cart 500 Hall accompanied by LVN D revealed: -First Drawer: Insulin syringes Glucagon (emergency treatment for low blood glucose) Injection Lovenox (anticoagulant medication) injection Insulin (medication to lower high blood glucose) -Second drawer: Colace (stool softener for constipation) Nystatin (treats fungal and yeast infections) oral solution. Mylanta (antacid) Individual Resident medication containers Locked Narcotic Drawer with three controlled medications: 1) Hydrocodone with Tylenol (narcotic pain medication), 2) Clonazepam (controlled medication for seizures, panic disorders and anxiety), 3) Tramadol (controlled medication for moderate to severe pain) -Third drawer: Wound care supplies Creams and ointments -Fourth drawer: Medication and dressing supplies During an interview on 10/25/2023 at 8:42 AM, the DON stated she expected all medication carts to be locked when left unattended. The DON stated the medication carts were monitored by nurses and nursing administration daily by doing random rounds. The DON stated the risk was a resident could get a medication out of the cart they should not have. The DON stated the nurse working on the medication cart was responsible for making sure the medication cart was locked before leaving it. The DON stated to prevent this again we will educate. During an interview on 10/25/2023 at 8:59 AM, the Administrator stated he expected the medication carts to be locked when the staff was not working at the cart. The Administrator stated the risk was someone could remove something. The Administrator stated monitoring the medication cart was done randomly by the nurses and nursing administration. The Administrator stated the nurse working on the medication cart was responsible for making sure the medication cart was locked. The Administrator stated they will inservice the staff to prevent this again. The Administrator stated when the nurse closed the door the medication cart was out of site. During an interview on 10/26/2023 at 10:28 AM, the facility pharmacy nurse consultant stated the medication carts were to be locked when not in use and out of site. The pharmacy nurse consultant stated the risk was someone could take something out of the cart. As the interview continued, she stated the goal of locking the medication cart was to prevent someone from getting into the medication carts who should not have access. Record review of the facility's policy, Security of Medication Cart. Revised Dated April 2007 read in part Policy Statement The medication cart shall be secured during medication passes. Policy Interpretation and Implementation 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.4. Medication carts must be securely locked at all times when out of the nurse's view .

Based on interview and record review, the facility failed to maintain accurate and complete medical records in accordance with accepted professional standards of practice. The facility did not maintain medical records that were accurately documented for 1 of 3 (Resident #6) residents reviewed for DNR status, in that: -The facility failed to ensure Resident #6's electronic records were correctly updated and complete with a Full Code/DNR status. -The facility failed to ensure Resident #6s DNR/Full Code status was correctly verified based on the order in the electronic medical record (EMR). This failure could place residents at risk for inaccurate clinical records regarding effective Full Code and/or DNR status. The findings included: Record review of Resident #6's face sheet dated 10/27/2023 revealed: Resident # 6 was a [AGE] year-old Female, with an original admitted to the facility of 01/14/2020, and most recently admitted [DATE]. Diagnoses included Type 2 Diabetes Mellitus (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel.), Congestive Heart failure (Heart failure occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.), Primary hypertension, Malignant Neoplasm (Malignant Neoplasm are cancerous tumors. They develop when cells grow and divide more than they should. Malignant Neoplasms can spread to nearby tissues and to distant parts of your body.) and End stage renal disease (End-stage renal disease (ESRD), also called end-stage kidney disease or kidney failure, occurs when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state. In end-stage renal disease, your kidneys no longer work as they should to meet your body's needs.). Record review of Resident #6's MDS, Section C under Cognitive Patterns revealed a BIMS score of 10 (Moderately Impaired). Record review of Resident #6's Physician Orders dated 10/12/2023 revealed Resident #6's DNR status was uploaded into Resident #6's Electronic Medical Records. Record review of Resident # 6's EMR revealed no signed consent from family or doctor in the chart. Resident #6's paper chart, care-plan, and profile in the EMR showed Full Code. During an interview on 10/27/23 at 9:29 a.m., the DON stated Resident #6 was s a full code status even though there was an order for DNR status in her chart. The DON stated that it was her responsibility to follow up and update the status in the EMR. She stated the negative impact to residents were, the staff would not know whether a resident is a full code or DNR. The DON stated someone could have mistaken resident that is a Full Code status as being a DNR status or vice versa. This could upset the family members and resident if the code status was not followed. The DON stated she will follow-up with family and physician and will do an in-service with the staff on code status. During an interview on 10/27/2023 at 12:01 p.m., the Regional Nurse stated the DNR status was to be reviewed on admission or readmission and was to be documented on the face sheet, orders and care plans. The only person that should change the code status should be the DON or Administration. She stated that they run a report in the morning with the code status of all residents. She stated that she audited the chart this weekend and noticed that the order and profile, and care plan was different but didn't follow-up. She stated, there was no signed consent, no care plan, face sheet, or out of hospital DNR, making the resident a full code. In an interview with the Regional Nurse followed-up on 10/27/2023 at 1:08 p.m., regarding the code status, she stated that she contacted the family about the DNR, and they will come in on Monday to sign the DNR paperwork .

The facility failed to ensure all residents were provided with a discharge summary for an anticipated discharge for two (CR #1 and CR #3) of six residents reviewed for discharge requirements. -CR #1 was discharged on [DATE] to a hotel and facility failed to provide CR#1 with Post-Discharge Plan of Care. -CR #3 was discharged on [DATE] with no documentation of any pre-discharge planning, discharge summary, and an incomplete plan. On 8/25/2023 at 2:17 PM an Immediate Jeopardy (IJ) was identified for discharges. While the IJ was lowered on 8/29/2023 at 10:29 AM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of further unsafe discharge and potential physical, mental, and/or psychosocial harm. Findings include: CR #1 On 08/24/23 at 12:05 p.m. CR# 1 was observed asleep in a local hospital room. He had an IV antibiotic hanging that appeared to be finished. Interview on 8/24/2023 at 12:45 PM CR #1 said he did not remember getting a letter from the nursing home. He said he thought he was going to an appointment. He said the facility staff did not tell him where he was going to stay. He said the facility told him he had to leave because he had not paid. He said he had his friend pick him up. He said the facility staff told him if he and his friend did not leave, they would call the police and have him arrested for trespassing, so they left, and his friend took him to a hotel. Record review of CR #1's face sheet revealed an [AGE] year-old man who was admitted on [DATE] and discharged on [DATE]. The face sheet documented his diagnoses included moderate protein-calorie malnutrition (a state of nutrition in which an imbalance of energy, protein, and/or other nutrients cause measurable adverse effects on the body), anemia (lack of healthy red blood cells or hemoglobin), dysphagia (difficulty and/or discomfort in swallowing), mild cognitive impairment (an early stage of memory loss or other cognitive ability loss), muscle wasting (loss of muscle leading to shrinkage) and atrophy (progressive and degenerative shrinkage of muscle), and Methicillin-Resistant Staphylococcus Aureus (MRSA-a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections.) Record review of CR #1's Quarterly MDS dated [DATE] revealed his BIMS score was 10, indicating cognitive impairment. The MDS documented he had no potential indicators of psychosis, behaviors affecting others, rejection of care, or wandering and/or elopement behaviors. Per the MDS, CR #1 required one-person supervision with bed mobility, transfers, locomotion, and eating. The MDS revealed he required one person assistance with walking, but he rarely walked in his room, and did not walk in the corridors. The MDS documented he required extensive one-person assistance with dressing, toileting, and personal hygiene. Per the MDS, CR #1 was frequently incontinent of bladder and bowel, but was not on a toileting program. The MDS revealed he was on a mechanically altered diet. The MDS documented he was at risk for pressure ulcer/injury but did not have any. Per the MDS, he received diuretic medications four of the seven days prior to the assessment. The MDS revealed he had received speech therapy for 157 minutes over five days during of the seven days prior to the assessment. Record review of CR #1's care plan dated 6/28/2023 included a focus on his hearing loss with interventions including ensuring the staff had his attention prior to speaking, repetition of phrases as needed, and clear speaking. The care plan documented a focus on his resistance to care, specifically bathing, with interventions including consistent care, provision of control, avoidance of power struggles, and allowing options. The care plan included a focus on his falls including injury with interventions including provision of toileting, monitoring when out of bed, ensuring the floor was clean, ensuring the bed was in the lowest position, provision of a mobility device, reminding CR #1 to not ambulate without assistance, and analyzing causes of his falls. The care plan revealed a focus on his memory recall problems with interventions including ensuring his area was free of hazard, ensuring his assistive devices were in good condition, redirect the residents when in unsafe areas, and ensuring he wore proper footwear. The care plan included a focus on his ADL decline with interventions including use of a wheelchair and instruction on its use. Record review of CR #1's medication review dated 8/28/2023 revealed he was prescribed acetaminophen extra strength 500mg tablet, one tablet every six hours as needed for pain, aspirin delayed release tablet 81mg tablet once tablet once daily at 9:00 AM, atorvastatin (antihyperlipidemic used to lower cholesterol) 40mg tablet one tablet once daily at 7:00 PM, furosemide (diuretic used to decrease excess water in the body to lower blood pressure) 40mg tablet one tablet once daily, metoprolol tartrate (beta blocker used to treat high blood pressure) 25mg tablet one tablet twice daily at 9:00 AM and again at 5:00 PM, and potassium chloride (used to treat and prevent low blood potassium levels) 10mEq one tablet twice daily at 9:00 AM and again at 5:00 PM. Record review of CR #1's medical records revealed an order dated 5/1/2023 that he may have his medications altered by crushing, opening, or administering in fluid or foods unless contraindicated. The facility was unable to provide a completed post-discharge plan of summary for CR #1. CR#1's signed and dated (5/20/22) admission packet noted the facility would assist CR #1 in making arrangements for discharge. Record review of CR #1's progress note dated 8/16/2023 noted his PCP was at the facility to assess and discharge him. Per the note, CR #1 nodded his understanding of the discharge. The note revealed LVN C assisted CR #1 to a friend's car and CR #1 left. Record review of CR #1's progress note dated 8/17/2023 revealed a late entry for 8/16/2023. The note documented on 8/16/2023 CR #1's discharge order would be at his PCP's office in one week's time. PCP informed LVN C that CR #1 was leaving with a friend. The PCP spoke with the facility's administration to ensure CR #1's safety at discharge. The note revealed the PCP spoke with CR #1's friend who reported he would take CR #1 with him. The note documented the PCP requested CR #1's friend to call the PCP with any concerns for CR #1's health. Record of CR #1's financial note dated 8/24/2023 revealed a note on 7/15/2023 which documented the facility's former BOM had discussions about past due payments and was taken to the bank for a withdrawal. The notes documented a note on 8/3/2023 that a thirty-day notice follow-up was conducted by the Administrator. Per a note dated 8/4/2023 the former BOM contacted 211 and was informed the Medicaid application would not be processed until 8/31/2023. CR #3 Record review of CR #3's face sheet dated 8/26/2023 revealed an [AGE] year-old man admitted on [DATE] and discharged on [DATE]. The face sheet documented his diagnoses included hemiplegia (one-sided paralysis) and hemiparesis (weakness on one side of the body) following cerebral infarction (a loss of blood flow to part of the brain), hypertension (high blood pressure), atherosclerotic hear disease (condition causing arteries to narrow), chronic systolic heart failure (condition in which the left ventricle of the heart is weak), and benign prostatic hyperplasia (condition in which the flow of urine is blocked due to the enlargement of prostate gland). Record review of CR #3's MDS revealed admission MDS dated [DATE] revealed a BIMS score of 10 indicating some cognitive impairment. The MDS documented he had no potential indicators of psychosis, behaviors affecting others, rejection of care, or wandering and/or elopement behaviors. Per the MDS, CR #3 required one or more person assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. The MDS revealed he did not walk. The MDS documented CR #3 was always incontinent of bladder and bowel, but he was not on a toileting program. Per the MDS he received OT and PT. Record review of CR #3's care plan dated 8/4/2023 revealed a focus on his ADL deficit with interventions including allowing him extra time to complete ADL's and monitoring for pain when he was completing ADL's. The care plan documented a focus on his potential bleeding because of anticoagulant therapy with interventions including medication administration, monitoring for signs or symptoms of bleeding and/or pulmonary embolism, reviewing and monitoring lab reports, and notification of change. The care plan included a focus on CR #3's potential to fall with interventions including analyzation of falls for possible causes, ensuring his bed was in the lowest position, and provision of proper footwear. Record review of CR #3's physician's order report dated 8/26/2023 revealed orders including PT and OT, a regular diet with thin liquids, monitoring for signs or symptoms of side effects of medications, and weekly skin assessments. The report documented prescriptions including atorvastatin (antihyperlipidemic used to lower cholesterol) 40mg tablet one tablet at 7:00 PM, finasteride (prostatic hypertrophy agent type II 5-alpha reductase inhibitor used to shrink and enlarged prostate) 5mg tablet one tablet at 9:00 AM, venlafaxine (antidepressant used to treat depression) 75mg tablet one tablet every eight hours, Xarelto (direct factor Xa inhibitor used to prevent blood clots from forming) 20mg tablet one tablet at dinner, and carvedilol (alpha-beta blocker used to treat high blood pressure) 6.25mg tablet one tablet twice daily at 9:00 AM and 5:00 PM. Record review of CR #3's discharge plan of care dated 8/26/2023 revealed the discharge assessment occurred on 8/21/2023 at 2:07 PM. The plan of care documented it was completed by the MDS LVN. Per the plan of care, CR #3 was discharged to the facility. The plan of care revealed a note that he was discharged to the assisted living facility by wheelchair, denied any discomfort, and was awake and alert at discharge. The plan of care included sections for the following: Observation details; Discharge Equipment Needs; Home Health Services/Referrals; Medication Upon Discharge; Nutritional Needs Upon Discharge; Post-discharge Appointments/Follow-up Visits; Post-discharge Wound Care/Treatments; ADL's; Special Instructions Upon Discharge; and Documents Given Upon Discharge. None of those sections were completed. Interview on 08/23/23 at 3:40 p.m. a family member said they would check on CR #1 at the hotel. The family member said if CR #1 required medical attention they would take him to the hospital. Interview on 8/23/2023 at 4:50 PM the Admin said the resident owed $50k. He said CR#1 did not pay and would not provide information for the insurance application. He said the physician assessed him and said he was okay to discharge. He said there was an order from the Physician to discharge CR #1. Interview on 08/24/23 at 11:35 a.m. with CNA A revealed the resident was sometimes incontinent and needed assist with changing his brief. Interview on 08/24/23 at 11:40 a.m. with MA B revealed the resident told her They put him out. She said his medications were in the medication room after he discharged . The hospital Charge Nurse said CR# 1 was admitted the previous day (8/23/23), via ER. She said CR# 1 knew his name and DOB but did not know time of day. He was admitted with altered level of consciousness and pneumonia. She said a friend brought him from his hotel. Interview on 08/24/23 via telephone with LVN C revealed there was no paperwork sent with CR #1 when he discharged . He was not provided with medications. LVN C said CR #1 did not sign anything at the time of his discharge. Interview on 08/24/23 at 1:57 p.m. with the Administrator revealed he said there was an order from the PCP to discharge CR #1. He said the PCP assessed him. The Admin said the facility did not send medications with residents upon discharge. He said the PC would call the pharmacy with prescriptions. The Admin was not sure if the PCP called in the prescriptions. Interview on 8/24/2023 at 2:56 PM with the CNC, she said the facility attempted to provide CR #1 his medications but he refused to take them. Regional Nurse said the facility failed to document his refusal to take the medications. Regional Nurse said CR #1 often refused to take his medications. Interview on 8/24/2023 at 5:11 PM with The PCP, she said she had been called by the facility administrator at 4:45 PM on 8/16/2023 and informed that CR #1 was discharging that day. The PCP said she asked the administrator if the discharge would be safe because of CR #1's previous history. The PCP said she asked where CR #1 was being discharged to. The PCP said she was informed by the administrator that the discharge would be safe and CR #1 would be checking into a motel. The PCP said she then came to the facility and found CR #1 sitting with a friend. The PCP said CR #1 was upset, and he told The PCP that he had to leave the facility because he was trespassing. The PCP said she was told by CR #1's friend that if he and CR #1 did not leave the administrator was going to call the police on CR #1 for trespassing. The PCP said she was upset by this. The PCP said she told CR #1 the police would not arrest him because he had done nothing wrong and had lived at the facility for a long time. The PCP said she told CR #1 he had not committed any crimes. The PCP said CR #1's friend said he and CR #1 were just going to leave and go to a motel. The PCP said she asked what they would do after the motel. The PCP said CR #1's friend said they would take him to another nursing facility. The PCP said she informed them that getting CR #1 admitted to another nursing facility would be difficult. The PCP said she informed them that they did not have CR #1's paperwork and records. The PCP said she asked them to leave a bag of CR #1's belongings in case he wanted to return to the facility. The PCP said the following morning, 8/17/2023, she reviewed the facility's EMR and found no numbers to contact CR #1 or his friend. The PCP said she was concerned because she could not contact them to ensure his safety. The PCP said on 8/18/2023 CR #1 and his friend came to her office and told her CR #1 wanted to return to the facility. The PCP said she contacted the administrator and was informed CR #1 could return as long as he had the correct information for Medicaid. The PCP said she informed CR #1 and his friend of this and she thought CR #1's friend understood, but was not sure if CR #1 did. The PCP said CR #1 has dementia. The PCP said on 8/23/2023 CR #1's friend returned to the facility and again said CR #1 wanted to return to the facility. The PCP said she contacted the facility's admissions coordinator to assist in obtaining the needed paperwork for CR #1's return. The PCP said later on 8/23/2023 she went to the hospital and found CR #1 in the emergency room . The PCP said CR #1 did not appear as he did on 8/18/2023. The PCP said CR #1 appeared to look confused and drawn out. The PCP said she called the facility admitting personnel today and again asked if he could return to the facility. The PCP said the admission personnel said as long as the Medicaid information was correct, CR #1 could return. The PCP said she saw CR #1 at the hospital again on 8/24/2023. The PCP said he appeared to have better cognition in the morning, but was sedated in the afternoon. The PCP said an MRI had been ordered and CR #1 refused. The PCP said she ordered Xanax for CR #1 and he still refused the MRI. The PCP said CR #1's current low sodium may be related to his discharge because he may not have received the nutrients he would have at the hospital. The PCP said she did not think the pneumonia was caused by a lack of medication. Interview on 8/25/2023 at 7:45 AM with The CNC, she said the facility does not have a standardized training for discharging residents. Interview on 8/26/2023 at 8:37 AM with the DON, she said she had been employed by the facility since 4/20/2023. The DON said her training consisted of one-to-one training with corporate staff reviewing the DON manual. The DON Said the discharge team typically consisted of the administrator, the business office, and the MDS nurse. The DON said the nurses are responsible for creating the discharge plan of care and the discharge summary. The DON said the discharge plan of care documents who picked the resident up, what mode of transportation the used to resident leave the facility, who accompanied the resident, medications, orders for post-discharge medical appointments, dietary orders, and what assistance is needed in ADL's. The DON said if a resident was not provided a discharge plan of care, he/she/they may not have the information he/she/they required, including information related to the resident's post-discharge care, medications, and post-discharge medical appointments. The DON said if a resident did not receive the discharge plan of care the resident's continuation of care could be interrupted. The DON said if a resident was discharged without a plan of care, to a hotel, and that resident required assistance with eating and medications, that would be concerning. The DON said it would be concerning because that resident may not have their medications or have the means to take the medications. Interview on 8/26/2023 at 10:18 AM with the Admin, revealed he had been employed by the facility since 11/2022. The Admin said CR #1's discharge had been an ongoing concern. The Admin said the facility had been working on CR #1's payment status for some time. The Admin said CR #1 kept saying he would pay his outstanding balance. The Admin said the payment situation went on for months. The Admin said the facility ultimately could no longer allow CR #1 to remain without payment and he was given notice. The Admin said CR #1 continued to say he would provide the past-due payments needed. The Admin said CR #1 would change his plan from paying the past-due balance and leaving. The Admin said during the thirty days after CR #1 was given a thirty-day notice he failed to provide the facility with all the information needed to obtain payment, or repayment of the past-due balance. The Admin said after the thirty days CR #1's friend was contacted. The Admin said the friend was aware CR #1 either had to provide the information needed to obtain insurance payment or pay the past-due amount, or CR #1 would have to leave the facility. The Admin said CR #1 said he was going to his house. The Admin said CR #1's friend said he would take CR #1 to his home. The Admin said on the day of the discharge the plan changed, and CR #1 decided he and his friend said would stay go to a motel, and CR #1's friend would stay with him at the motel. The Admin said the plan was for CR #1 to stay at a hotel for one night then go to another nursing facility. The Admin said prior to the discharge The PCP was notified. The Admin said The PCP wanted to complete an in-person discharge assessment. The Admin said the PCP came to the facility, CR #1 informed her that he would be going to a motel for one night, then admitting to another nursing facility. The Admin said the PCP completed a discharge order with instructions to come for a follow-up appointment the following week. The Admin said the PCP wrote CR #1 one prescription when he discharged . The Admin said the following day CR #1 went to another nursing facility and refused to provide them the information to obtain insurance payment and did not admit. The Admin said The PCP saw CR #1 in her office, and he said he would be coming to the scheduled follow-up appointment with the information needed to readmit to the facility. The Admin said the facility's back-up plan during the time after the thirty-day notice was given was for CR #1 to leave and go home. The Admin said CR #1's friend reported CR #1's home was not livable, but CR #1 could live with the friend. The Admin said on the day of the discharge that plan changed to going to a hotel for one night and then admitting to another nursing facility. The Admin said prior to discharging, CR #1 received all of his medications for that day. The Admin said CR #1's friend reported he would be able to assist CR #1 with his crushed medications and altered diet if needed. The Admin said CR #1 and the friend were instructed to call The PCP with any concerns of any kind. The Admin said the facility was never informed of CR #1 having any concerns or issues with his crushed medications or altered diet. The Admin said CR #1's discharge was safe because there was an order for discharge and instructions to reach out to The PCP for any concerns, even though CR #1 had no means to crush his medications or alter his diet's texture. Interview on 8/26/2023 at 11:35 AM with the CNC revealed the facility did not complete the discharge plan, or discharge planning documentation for CR #3. Record review of the facility's Discharge Summary and Plan policy dated December 2012 revealed a policy statement which read When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The policy included information related to the discharge summary and plan, the post-discharge plan, and the notice of discharge. The policy documented that the discharge summary would include a recapitulation of the resident's stay at the facility and final summary of the resident's status at the time of discharge. The discharge summary for the resident included the following: medical conditions; medical status; mental and physical status; sensory and/or physical impairments; special treatments; mental and psychosocial status; discharge potential; and dental condition. The post discharge plan for the resident required the following: a description of the resident's and the family's preferences for care; description of how the resident and family will access such services; description of how the care should be coordinated; the identity of the specific resident needs after discharge; and a description of how the resident and family need to prepare for the discharge. Per the policy, the resident or representative should provide the facility with a minimum of 72 hours' notice of discharge to ensure an adequate discharge plan is created. This was determined to be an Immediate Jeopardy (IJ) on 8/25/2023 at 2:17 PM. The Administrator , DON, and CNC were notified. The Administrator was provided the Immediate Jeopardy template on 07/29/23 at 2:22 PM. The following Plan of removal submitted by the facility was accepted on 8/27/2023 at 2:37 PM: FACILITY: Colonial Living and Rehabilitation Bay City Facility ID Number: SURVEY TYPE: Complaint Survey SURVEY DATE: 8/25/23 Plan for REMOVAL Plan to remove immediate jeopardy. The facility failed to provide one resident with a discharge summary for an anticipated discharge. F661 On 8/25/2023 the Administrator notifies Medical Director of immediate jeopardy. On 8/25/2023 Director of Nursing/Designee contacted Hospital, where he is currently, to ensure that resident is currently safe. On 8/25/2023 Director of Nursing/Designee assessed all residents in the facility who have a plan to discharge in the next 30 days, including residents returning to the Assisted Living Facility to ensure that they have been given reasonable and appropriate notice. No concerns were noted with the residents who have a plan to discharge in the next 30 days. Resident records were reviewed who discharged to the community in the last 30 days to ensure they received a discharge summary, if not follow up was completed to ensure resident is safe, they have medications, and a follow-up has been done with a physician or an appointment was scheduled. This will be completed 8/26/2023. On 8/25/2023 RNC (Regional Nurse Consultant) will complete in-service with Director of Nursing, and Administrator on discharge planning process, including ensuring resident receives a discharge summary to include taking medications and support services are provided if indicated before discharge and that all residents have reasonable and appropriate notice before discharge. Discharge planning will include notifying the physician to receive an order for discharge and all of the needs are anticipated for the resident with interventions put in place before discharge. This was completed 8/25/2023. On 8/25/2023 DON/Designee reviewed all residents in the facility who may wish to discharge from the facility. IDT will review all residents requesting to discharge from the facility to ensure residents have reasonable and appropriate notice, discharge summary, discharge orders, discharge assessment and care plan is updated for the discharge. This was completed 8/25/2023. Starting on 8/25/2023 the Director of Nursing/Designee will initiate in-service with nurses, including new hires, PRN, and agency staff on adequate discharge planning and preparation to include discharge summary, discharge assessment, safe discharge location, discharge medication, reasonable notice and that they have received an order from the MD and will train staff before returning to work. This was completed 8/25/2023. Ad-Hoc QAPI meeting was held on 8/25/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Regional Nurse Consultant, and MDS Coordinator to review the deficiency and the plan for removal of immediacy. The Administrator will be responsible for ensuring this plan is completed on 8/25/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring: Record review on of the POR binder for Discharge IJ revealed audits completed for all planned discharges completed, discharges planned to be completed, and review of discharges to the community in the previous month. The audits were updated on 8/27, 8/28, and 8/29/2023. Interview on 8/28/2023 at 12:41 PM with ALVN J, she said had recently received in-service training at the facility on infection control and discharge planning. ALVN J said she had been instructed during in-service training related to discharge planning that the nurse completing a discharge must ensure the resident's PCP had provided discharge orders and the resident is stable for discharge. ALVN J said the training also enforced that the discharging nurse must ensure the resident, resident's family, and/or RP is provided with the discharge summary, medications, treatments, and/or supplies for any treatments at discharge. ALVN J said the training required the discharging nurse to make notifications to the DON and PCP that the resident was discharging. ALVN J said when the resident discharged , the discharging nurse would review the summary, follow-up appointments, treatments, and medications with the resident and/or resident's RP. ALVN J said following this, she would obtain signatures from the resident and/or RP. ALVN J said if the discharge was unsafe, she would notify the DON and PCP immediately, then she would wait for further orders regarding the discharge. ALVN J said a discharge could be unsafe if the resident did not have a place to discharge to, did not know he/she/they were leaving or who he/she/they were leaving with, did not have supplies, follow-up care was missing, and/or there was a lack of continuity of care. Interview on 8/28/2023 at 1:01 PM with LVN S revealed she had been employed by the facility for a little less than one year. LVN S said she had spent one week shadowing another charge nurse prior to working on the floor independently. LVN S said the facility staff assist her in any way she needs. LVN S said her primary duties as an LVN were to ensure resident safety, providing wound care, medication administration, and ensuring residents were fed when needed. LVN S said she had recently had an in-service training related to discharge planning. LVN S said the training instructed the nurses to complete the discharge summary and plan of care prior to the resident's discharge, including all areas of the discharge summary and plan of care. LVN S said the training instructed the nurses to ensure the residents were leaving in a safe manner, print the discharge summary and plan of care, review those with the resident and/or RP. LVN S said prior to any discharge, the PCP must provide discharge orders for that resident. LVN S said a discharge could be unsafe if the resident was being discharged to a verbally abusive person, a person who was obviously under the influence of alcohol or other substance, and/or the resident was being discharged to an unsafe environment. LVN S said if she felt the discharge was unsafe, she would not discharge the resident, but she would contact the DON and PCP to discuss further options. Interview on 8/28/2023 at 1:17 PM with ALVN E revealed she worked at the facility quite frequently. ALVN E said her primary duties at the facility included supervising the CNA's and MA's, ensuring medications were administered appropriately, ensuring residents' ADL's were performed, and resident safety. ALVN E said she recently received in-service training at the facility related to infection control, cigarettes, and discharge planning. ALVN E said she was informed during the discharge planning in-service that the nurse responsible for discharging a resident must complete the discharge summary and plan of care, including the resident's vitals and ensuring a safe discharge. ALVN E said prior to any discharge, the resident's PCP must provide a physician's order for the discharge. ALVN E said when a resident is discharged , he/she/they must be provided their medications, belongings, and/or notification of follow-up appointments which had been scheduled. ALVN E said she would ask questions of the resident and/or RP to determine if the discharge was safe. ALVN E said a discharge could be unsafe because the resident had no where to discharge to or was discharging to an unsafe environment, the resident did not have medications, the resident had no assistance for ADL's or medication administration, and/or the resident had no assistance of any kind where they were discharging to. ALVN E said if a resident's discharge was unsafe, she would call the PCP and DON and wait for further instructions. ALVN E said if a resident insisted on discharging to an unsafe placement, the resident would be discharging AMA. ALVN E said care plans ensured the residents received the services and treatments required for their care. ALVN E said the MDS coordinator was responsible for ensuring a care plan was created. ALVN E said if she determined a resident did not have a care plan she would inform the DON. ALVN E said if a resident did not have a care plan, that resident could have negative outcomes including death. ALVN E said a resident may receive the wrong diet and choke on un-pureed foods or aspirate on thin liquids. ALVN E said she had never seen any inappropriate behaviors between any residents, residents and family, or residents and staff. Interview on 8/28/2023 at 1:50 PM with MDS LVN , she said she had received an in-service training related to discharge planning. MDS LVN said the training reviewed the discharge planning process. MDS LVN said the process included receiving the physician's orders, creating the discharge summary and plan of care, and documenting the process. MDS LVN said she would be responsible for beginning the process. MDS LVN said the IDT would open the discharge documents,

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 who was diagnosed with dementia and resided in the facility's secured unit was not dropped off without a caregiver from the facility or a family member present at the doctor's office scheduled appointment. Resident #1 eloped from the doctor's office and was later reported to be found at a family member's house. An immediate jeopardy (IJ) was identified on 04/08/2022. While IJ was removed on 04/16/2022 at 12:12 p.m. the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimum harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed facility residents with dementia and impaired cognition at risk of neglect and elopement for lack of supervision during any appointment. Findings included: Record review of Resident #1 's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (a brain disorder), dementia with behavioral disturbance (thinking and social symptoms that interferes with daily functioning), [CONDITION(S)] disorder (mental disorder that causes unusual shifts in mood), [CONDITION(S)] (a serious mental disorder where reality is interpreted abnormally), and [CONDITION(S)] (self-reported thoughts of suicidal behaviors). Record review of Resident #1's quarterly MDS dated [DATE] revealed BIMS of 15 indicated intact cognition. Further review revealed resident needed one person supervision with all care with one person assistance, and occasionally incontinent of bladder. Record review of Resident #1's care plan dated 12/18/21 revealed the resident was on [CONDITION(S)] drugs, was at risk of gait disturbance, and behavioral impairment. She also had a behavior problem of socially inappropriate, verbally abuse, wandering, sexually inappropriate behaviors. Interventions: intervene as needed to protect the right and safety of others. Further review revealed the resident was at risk for elopement related to exit seeking. Intervention: provide staff supervision for when attending an out-of-facility activity. Record review of Resident #1's elopement observation dated 04/08/22 revealed reason for placement related to behavior management, dementia, needed supervision, resident safely secure on unit. Staff never to leave resident unattended when out of secure unit and at risk for elopement. Record review of Incident report dated 03/11/22 revealed on revealed Resident #1 who resides in the locked unit and required supervision was sent to the doctor's appointment on 03/11/22 unsupervised. She left the doctor's office and asked a stranger for a ride to a family member's home, which the stranger did. Record review of Resident #1's departmental notes dated 3/2/22 documented by LVN B (agency nurse) read in part . responsible party was notified that Resident #1 had a doctor's appointment on 3/11/22 at 10:00 a.m. Interview on 3/30/2022 at 12:25 p.m. with LVN A she said on the day (03/11//22) of Resident #1's doctor's appointment the doctor's office called and said the resident refused to be seen, they rescheduled the appointment, and the resident left the office. She said the resident went outside and asked strangers (a couple) to drop her off at her sister's house, and the wife told the husband to go and drop her off, which he did. The resident's sister called the facility and said the resident was at her house. Interview on 3/30/22 at 11:24 a.m., the Administrator said Resident #1 had an appointment with a gynecologist. Her family member was notified on 3/2/22 when the appointment was made for 3/11/22 at 10:00 a.m., but the family member was frustrated and upset because the nurses did not remind her to be at the doctor's office on the day of the appointment. The Administrator said the nurse should have called and notified the responsible party and ensured she would be at the doctor's office before the resident was sent out. She also said the driver should have made sure the family member was at the doctor's office before she left the resident at the doctor's instead of dropping her off at the entrance door of the building. She said the resident refused to see the doctor and left the office. When she came outside, she asked a couple to give her a ride to her sister's house, and the husband gave her a ride to her sister's house. She said this negligence could have caused harm to the resident. The facility had two opportunities to prevent what happened, and both staff failed to protect the resident who had impaired memory. Interview on 3/30/22 at a12:10 p.m., with the van driver she said when she took Resident #1 to her appointment, she stopped the van and assisted the resident out of the truck, and the resident walked into the building by herself. She said she did not know that the resident's family was not going to be at the doctor's office because the nurse did not tell her about it. She said she did not walk her into the doctor's office because she had another resident in the van that was going to another appointment. The van driver said she was the one who checks the appointment calendar every day, and when residents are ready for their appointment, the nurse will let her know, and the aide or she would escort the resident to the van. Then she will drop the resident for the appointment and come back later to pick the resident up when the doctor's office calls the facility. She said it was the nurse's responsibility to notify the resident's family that the resident was about to leave for an appointment and to meet the resident at the doctor's office. The van driver said if the resident could stay by herself, she would walk the resident into the doctor's office and leave. If the resident could not be left by herself, she would remain with the resident until the family comes or stay with the resident throughout her visit and take the resident back to the facility. She said the nurse would tell her if the resident needed supervision at the doctor's office or not. She said, to her understanding, Resident #1 was able to wait by herself because that was what she was told, but she could not remember who told her. She said it was a miscommunication because she would have walked her to the doctor's office and made sure her sister was in the doctor's office. If she was not there, she would have taken the resident and asked the doctor's office to call the facility and reschedule her appointment. The driver said this mistake put the resident at risk for harm or even death. Interview on 3/30/2022 at 12:25 p.m. with LVN A, she said she was not the one that made the appointment for Resident #1, but she was the nurse who sent Resident #1 to her doctor's appointment. She said when an appointment is made, it is put on the log for the driver, and the responsible party is notified. If the resident's family wants to be at the appointment, it will be documented. She said there was nothing written on the log that Resident #1's family member wanted to go. She said if it were documented, she would have called the responsible party and notified that the resident was about to be leaving the facility and for her to meet the resident at the doctor's office. She said she was under the impression that the driver would stay with the resident because most places she worked do not leave residents by themselves. She said they now have a new rule after the incident that the driver must have somebody to stay with the resident. They had an in-service on transportation of residents from the Memory Care Unit must be accompanied by staff. She said the mistake of not notifying the responsible party and the driver, who did not wait with the resident put the resident in harm's way (resident could get physically hurt, kill or missing). She said she had not had any in-service on transferring and monitoring the resident on doctor's visits. LVN A said the Administrator said Resident # 1 was in memory care because she has diagnoses of memory problem and mental problems and she was under supervision when she goes outside to smoke or go to the courtyard. Interview on 3/30/21 at 2:14 p.m., the DON said Resident #1's doctor's office called on 03/11/22 at 10:15 a.m., because the resident refused care and walked out of the office. The resident's family member called at 11:00 a.m., and said the resident was dropped off at her house by a stranger. The DON said the nurse should have called the responsible party after she made an appointment for Resident #1's doctor's visit and made sure a family member would be at the doctor's and document it on the resident's progress note. The nurse also puts the appointment on the 24-hour report until the resident goes to the appointment. Then call a day before the appointment and make sure they have somebody to meet the resident at the doctor's office. They also have a staff to stay with the resident if the family cannot come to the appointment. She said there was negligence in that the nurse who made the appointment did not document if the responsible party would be at the doctor's office, and the sending nurse did not call the responsible party and notify her that the resident was going to the doctor's office and remind her to be at the office. At the same time, the driver did not walk a resident from the memory care unit into the doctor's office and did not stay with her. She said all of these placed the resident in harm's way, which could have cost her life. She said she knew that the facility would be cited. She said she had not in-serviced the staff on elopement before the incident but had one after the incident. she also said whenever a resident goes out for appointment a CNA would accompany and supervise the resident. During an observation and interview on 3/30/22 at 4:30 p.m. Resident #1 said she became sick (back and waist pain) at the doctor's office, and she told the doctor's office to call the facility. They called, and the facility did not answer. Resident #1 said the doctor's office called again while she was still there and made her another appointment for 4/18/22, and they told the facility to come and pick her up, but still, the driver did not come, and that was when she left the office because she was in pain and could not wait anymore for the driver. She said she was tired of waiting, so she left and asked the people she met outside to take her to her sister's house. She said she had not met the couple before, but they were nice to her. Interview on 3/30/22 at 4:36 p.m., the van driver said the doctor's office did call her to pick up Resident #1. She said she found out the resident left the doctor's office, and she went back to the facility. Interview on 3/30/22 at 5:21 p.m. the Administrator said the facility does not have a policy on monitoring residents when they are out of the facility or a transportation policy. She said the transportation calendar and the 24-hour reports are shredded every day after use, and it does not matter anyway because the negligence did occur. She knew the facility would be cited because it is what it is. Record review of facility's policy on safety and supervision dated 2001MED - PASS, Inc. (Revised December 2007) read . our facility strives to make the environment as free from accident hazards as possible . resident safety and supervision and assistance to prevent accidents are facility wide priorities . On 04/08/2022 at 5:24 p.m. the facility Administrator and DON were notified that immediate jeopardy was identified due to above findings. IJ template was provided at this time and plan of removal was requested. The facility's plan of removal was accepted after several revisions on 04/12/2022. The plan of removal reads as follows: 3/30/22 Physical head to toe assessment was completed upon Resident #1 returning to facility by the DON with no findings of harm. In-services are completed immediately regarding elopement, patient safety, abuse, and neglect by the nursing department with all staff including transportation CNA. The family and physician were notified, and the self-report completed and submitted to HHSC. 4/8/22 6pm. Completed BIMS assessments and elopement assessments on Resident #1 by the social services director and MDS nurse. All other residents were assessed for elopement, BIMS, and diagnosis for appropriate placement as needed by the Social Services Director and MDS nurse. Notification made to Medical Director, of Immediate Jeopardy on April 8, 2022, 5:58 p.m. 4/8/22 6pm. In-services were conducted by Administrator with Nurses, CNAs, and transportation aid including any direct care staff, regarding elopement risk-elopement policy, resident safety and supervision, resident rights-exercise of rights, dementia- resident off of memory care unit and Customer Service- policy and procedure for answering phones. 4/8/22 Quality Assurance Assessment Meeting conducted with action plan developed. This occurred on April 7, 2022. The interdisciplinary Team consists of Administrator, DON, Human Resources, ADON, DOR., Marketing, MDS, Social Services, Dietary Manager, Colonial Area Director, Medical Director, and Asst. Medical Director. 4/9/22 Management team was in the building to ensure all staff were in serviced prior to beginning their shift. DON monitored 24-hour reports to ensure no incidents occurred, no appointments were made for residents and no residents were out of the facility without proper documentation according to the new policy and procedure for safety and supervision of residents, and scheduling resident appointments. The social worker completed BIMS on all residents. MDS completed all elopement risk assessments to ensure resident safety was addressed throughout the facility. We continued in-service follow-up on answering phones timely and customer service. 4/10/22 Management team was in the building for ongoing education of new procedures for appointments, elopement risks, transportation, patient safety, resident rights, dementia, and customer service. The DON performed return demonstrations on answering the phones timely, customer service and continued training on policy and procedure including documentation on residents being outside of the facility. Facilities Plan to ensure compliance quickly: Social Worker or designee will schedule appointments outside of the facility. The family will be notified of the appointments. If the family is not in attendance on arrival, staff members will not leave the resident unattended unless cognitively intact. Social Services/designee will assess resident cognitive status and elopement risk quarterly and with any change of condition by verifying that the resident is alert and oriented to person, place, time, and situation. As Social Services/designee makes appointments the elopement risk and BIMs score will be placed on the transportation appointment book as well as the 24-hour report as, so ALL staff is aware of needs of resident. The appointment book will be kept at the nurse's station for any after hour calls/ emergency appointments. The nurses have BIMs/elopement assessments available at the nurse's station and will be added to Matrix as soon as available. This will be discussed in morning meeting for the current day as well as the upcoming day. The DON or designee will discuss upcoming appointments as well as be reviewed by the administrator. Family members will be reminded of appointments by the social worker, if family is not available another staff will be attending, and resident will not be left alone. The director of nursing will be responsible for monitoring the 24-hour report to ensure that all appointments have staff that are aware of needs of specific residents. Beginning on 04/08/2022. The Activity Director will have resident council meeting 04/11/2022 to assess if residents have any concerns during facility assisted transports and ensure residents understand who to voice concerns to. No Staff will be allowed to come back to work until after in servicing is complete. Surveyor monitored the plan of removal for effectiveness as follows: Record review of facility resident audits, assessment, cognitive status, and elopement assessment, revealed all the residents in the facility were assessed and the residents at elopement risk were placed on the elopement binder and they have to be accompanied to out of facility appointments The binders were placed at the nursing stations. Record review of facility's staff training log revealed the following trainings were documented as provided to staff: procedure for making appointments, notifying responsible parties of appointments procedure timely and ascertaining who will accompany residents, resident sign in and out log, telephone etiquette, elopement, resident rights, abuse/neglect, van driver policy and procedure training, safety and supervision, and memory care resident supervision. On 04/13/2022, four nurses (LVNs) were interviewed between 10am and 3:00pm on above trainings. Two-night staff (CNAs) were interviewed between 11:00pm and 11:45pm. All interviewed staff expressed understanding of trainings provided above. On 04/13/2022 at 12:30 p.m., the facility Van Driver was interview on the facility's new procedure for resident appointments. She expressed understanding of plan of removal trainings provided to her. On 4/14/2022 between 9:30am and 11:00am, three nurses (LVNs) were interviewed on the facility's new procedure for resident appointments. All staff interviewed expressed adequate understanding of plan of removal trainings provided to them. On 4/14/2022 at 10:43 a.m., interim Administrator said all staff were in-serviced on the plan of removal and facility's new system. DON will monitor future appointments. Interim Administrator will oversee the plan of removal completion and implementation. On 4/14/2022 at 11:54 a.m., the DON was interviewed on the plan of removal trainings provided to staff. She said she monitored the 24-hour reports for resident scheduled appointments and checks nurse calendars to confirm. The DON said she also checks the Van Driver's appointment binder daily and meets with the Bus Driver to go over daily assignments. On 04/15/2022, MDS, ADON (LVNs) and social worker were interviewed between 12:21pm and 1:10 pm on above trainings. All interviewed staff expressed understanding of trainings provided above. On 04/16/2022 at 12:12 p.m. the interim Administrator was notified that Immediate jeopardy was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the of the corrective systems.

Based on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 10 residents (Resident #4) reviewed for pressure ulcers. 1. The facility failed to identify unstageable pressure sores on both of Resident #4's heels which developed into necrosis of the bone (the death of bone tissue due to a lack of blood supply). 2. The facility failed to effectively assess and put interventions in place for Resident #4 to prevent pressure ulcers from further developing After hospital care, Resident #4 was readmitted back to the facility where he developed a stage II pressure sore to the sacral area which was identified by the wound physician three days after readmission, An Immediate Jeopardy (IJ) was identified on 9/2/21. While the IJ was removed on 9/6/21, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the facility continued to evaluate their plan of removal for effectiveness . These failures could place residents at risk of wound development, wound deterioration, a decline in health, possible hospitalization and infection. Findings include: Record review of Resident #4's, undated, face sheet revealed an [AGE] year-old male, initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Quarterly Minimal Data Set (MDS) assessment, dated 7/21/21, revealed the resident's cognitive skills for daily decision making was severely impaired, the resident was totally dependent on 1 staff for bed mobility, dressing, toilet use and personal hygiene. Resident #4 was at risk of developing pressure injuries, but had no unhealed pressure injuries. Record review of Resident #4's care plan revealed: * (Problem Onset: 8/13/21). Problem: Impaired skin integrity as evidenced by unstageable pressure ulcer injuries to right and left heel due to eschar with additional risks related to need for extensive assist with ADL's especially bed mobility, malnutrition, incontinence and peripheral vascular disease (Problem Onset: 8/17/21). Problem: Open area to coccyx. Approaches: weekly skin checks, Report signs of infections (odor, increase drainage, pain or redness). * (Problem onset: 4/15/21). Problem: At risk for impaired skin integrity as evidenced by need for assistance with bed mobility, decreased ADL function . Approaches: weekly skin checks, promote adequate nutrition and hygiene, incontinent care as needed, skin assessment quarterly and as needed. Record review of Resident #4's Departmental notes, dated 7/2/21 - 7/29/21, revealed no documentation of skin concerns. Record review of Resident #4's Treatment Administration Record, dated July 2021, revealed: * Skin hydration with A&D ointment to BLE daily. Start date 7/15/21. Review revealed skin hydration administered 7/15/21 - 7/31/21. * Weekly Skin inspection to be performed Q Monday. Start date: 7/15/21. Review revealed skin inspection competed on 7/19/21 by LVN B and on 7/26/21 by LVN D. Record review of Resident #4's Skin Inspection report, dated 7/20/21 and completed by LVN B, revealed Skin Status: Skin intact. Record review of Resident #4's Skin Inspection report, dated 7/27/21 and completed by LVN B, revealed Skin Status: Skin intact. Record review of Resident #4's Treatment Administration Record, dated August 2021, revealed: Weekly skin inspection to be performed Q Monday. Start date: 7/15/21. Review revealed assessment completed 8/2/21 by LVN B. Record review of Resident #4's Skin Inspection report, dated 8/3/21 and completed by LVN B, revealed Skin Status: Skin intact. Record review of Resident #4's Departmental notes, dated 8/6/21 written by LVN C, revealed .Resident was vomiting, percutaneous endoscopic gastrostomy (PEG) tube feeding was put on hold. This nurse was informed that Resident showing change in condition. This nurse went to resident's room, resident not responsive, eyes open, moderate amount of light brown colored emesis on resident's gown. Loose stools, dark colored down to resident's knees. Resident's vitals checked. Blood pressure 87/79, Pulse 88, Temperature 98.7. Respiration 22 even and unlabored. Notified Physician to send to ER . Record review of Resident #4's hospital clinical record, dated 8/6/21, revealed: * History and physical: Chief complaint - Patient is an [AGE] year old gentleman, came to the hospital with [CONDITION(S)] .Patient has a necrotic wound to the right heel. Patient also has severe [CONDITION(S)]. * General appearance: Musculoskeletal: necrotic wound to the right heel. * Diagnosis, Assessment and Plan: (1) Septic shock. Status: acute. (2) Acute Kidney Injury. Status: Acute. (3) Urinary Tract Infection. Status: Acute. (6) Foot ulcer with necrosis of bone. * Laboratory tests: White Blood Count 15.4 (normal range: 4.5 - 11.0), Urine White Blood Count (WBC) Too numerous to CNT/hpf. * Problems: (1) Pressure injury of skin with infection. Record review of Resident #4's Departmental notes, dated 8/14/21 written by LVN C, revealed .Resident arrived to facility via EMS .Assessment done at this time Respiration even and unlabored. Lung sounds clear in all lobes. Resident respiration even and unlabored .Resident has brief on, no redness noted to peri area. Resident skin warm and dry. Resident has dressing to bilateral feet with date 8/13/21.Both dressings removed, resident with unstageable to left heel, minimal drainage noted 10 X 9.5 X0 .Right heel noted to have dried blister, not open, no drainage . Record review of Resident #4's Skin Inspection report, dated 8/13/21 and completed by LVN C, revealed Skin Status: Skin not intact - existing. Record review of Resident #4's Braden Risk Assessment Report, dated 8/13/21, revealed: * Risk score: 10 * Risk level: High * Activity: Bedfast - confined to bed. * Mobility: Very limited. Makes occasional slight changes in body extremity position but unable to make frequent or significant changes independently. Record review of Resident #4's Wound Assessment Report, dated 8/13/21, revealed: * Wound type: Pressure ulcer * Wound location: bottom of left heel * Date wound identified: 8/6/21 * Present upon admission: No * Assessment Occasion: New wound * Stage: Unstageable due to suspected deep tissue injury. * Measurement: Length: 10 CM Width 9.5 CM Record review of Resident #4's Wound Assessment Report, dated 8/13/21, revealed: * Wound type: Pressure ulcer * Wound location: Right pad of foot * Date wound identified: 8/6/21 * Present upon admission: No * Assessment Occasion: Re-assessment * Stage: Unstageable due to suspected deep tissue injury. * Measurement: Length: 4 CM Width 2.2 CM Record review of Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] * Skin hydration with A&D ointment to BLE daily. Start date 8/13/21. * Weekly Skin inspection to be performed Q Monday. Start date: 8/13/21 * Left heel - cleanse with normal saline. Pat dry. Apply [MEDICATION(S)]. Cover with xeroform and wrap with kerlix every day. Start date: 8/13/21. * Right lateral foot. Cleanse with normal saline. Pat dry. Apply [MEDICATION(S)] and leave open to air daily. Start date: 8/13/21. * [MEDICATION(S)] 500 mg tablet (1) per Peg tube twice daily for 10 days. Start date: 8/13/21. Stop date: 8/23/21. * [MEDICATION(S)] Double Strength Tablet (1) per Peg tube twice daily for 10 days. Start date: 8/13/21. Stop date: 8/23/21. Record review of Resident #4's Treatment Administration Record, dated August 2021, revealed: * Skin hydration with A&D ointment to BLE daily. Start date: 8/13/21. Review revealed Skin hydration completed. * Left heel - cleanse with normal saline. Pat dry. Apply [MEDICATION(S)]. Cover with xeroform and wrap with kerlix every day. Start date: 8/13/21. Review revealed treatment administered on 8/14/21 - 8/17/21. * Right lateral foot - cleanse with normal saline. Pat dry. Apply [MEDICATION(S)] and leave open to air daily. Start date: 8/13/21. Review revealed treatment completed 8/14/21 - 8/17/21. * Record review of Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] * [MEDICATION(S)] 500 mg tab (1) per Peg tube twice daily for 10 days. Start date: 8/13/21. Stop date: 8/23/21. Review revealed medication administered 8/14/21- 8/16/21. * [MEDICATION(S)] Double Strength Tablet (1) per Peg tube twice daily for 10 days. Start date: 8/13/21. Stop date: 8/23/21. Review revealed medication administered 8/14/21- 8/16/21. Record review of Resident #4's Wound Physician note, dated 8/16/21, revealed: * Wound location: left heel. Wound type: Pressure. Stage: unstageable. Measurement: 5 X 7 X 0.1. Drainage: scant. Treatment: Collagen to surrounding open. [MEDICATION(S)] to eschar. QD and PRN. * Wound location: Right buttock. Wound type: Pressure. Stage: 2. Measurement: 0.5 X 1.0 X 0.1. Drainage: minimal. Treatment: Collagen. QD and PRN. * Wound location: Right lateral foot. Wound type: Pressure. Stage: 2. Measurement: 3.5 X 2 X 0.1. Drainage: minimal. Treatment: Collagen. QD and PRN. Observation of Resident #4 on 8/17/21 at 2:23 PM revealed resident in bed, dressing to right and left heels in place. LVN G present during observation and performed wound care as ordered on left heel and right lateral foot. Record review of facility's Wound and Skin Status Report, dated 8/17/21, revealed in part: * Name: [Resident #4] * Date identified/Present upon admit: 8/6/21/No * Date of last assessment and Length X Width X Depth: 8/13/21 and 4.10 X 2.20 X 0.00 * Location: Right pad of foot * Stage: Unstageable - suspicious of DTI * Treatment: right lateral foot cleanse with normal saline. Pat dry, apply [MEDICATION(S)] and leave open to air dry daily. Record review of facility's Wound and Skin Status Report, dated 8/17/21, revealed in part: * Name: [Resident #4] * Date identified/Present upon admit: 8/6/21/No * Date of last assessment and Length X Width X Depth: 8/13/21 and 10.0 X9.5 X 0.0 * Location: Left bottom of heel * Stage: Unstageable - suspicious of DTI * Treatment: left heel - cleanse with normal saline. Pat dry. Apply [MEDICATION(S)]. Cover with xeroform and wrap with kerlix every day. Record review of Resident #4's Departmental notes, dated 8/18/21, revealed .Resident lying in bed with eyes closed .continues on antibiotics X 2. [MEDICATION(S)] for [CONDITION(S)]-resistant Staphylococcus aureus ([CONDITION(S)]) to wound and [MEDICATION(S)] for [CONDITION(S)] . Record review of Resident #4's Bath/Shower Completion Form, dated 8/18/21, revealed an open area. Record review of Resident #4's Bath/Shower Completion Form, dated 8/23/21, revealed no skin conditions were checked off. Record review of Resident #4's Bath/Shower Completion Form, dated 8/25/21, revealed no skin conditions were checked off. Record review of Resident #4's Bath/Shower Completion Form, dated 8/26/21 and 8/27/21, revealed an open area. Record review of facility's Wound and Skin Status Report, dated 9/5/21, revealed in part: * Name: [Resident #4] * Date identified/Present upon admit: 8/6/21/No * Date of last assessment and Length X Width X Depth: 8/30/21 and 6.00 X 7.5 X 0.0 * Location: Left bottom of heel * Stage: Unstageable - Slough/Eschar * Wound bed/Drainage: 10% granulation * Treatment: cleanse wound to left heel with wound cleanser. Pat dry with gauze. Apply [MEDICATION(S)] to eschar and collagen to surrounding. Record review of facility's Wound and Skin Status Report, dated 9/5/21, revealed in part: * Name: [Resident #4] * Date identified/Present upon admit: 8/6/21/No * Date of last assessment and Length X Width X Depth: 8/30/21 and 2.5 0 X 0.5 X 0.10 * Location: Right pad of foot * Stage: 3 * Wound bed/Drainage: 100% granulation * Treatment: cleanse wound to right lateral foot with wound cleanser. Pat dry with gauze. Apply collagen and calcium alginate. In an interview with the ADON on 8/17/21 at 3:05 PM, she stated on 8/6/21, LVN C was assigned to Resident #4, however; LVN E identified Resident #4 had a wound to the heel and asked LVN C about the treatment. LVN C then stated she was unaware of a wound, and there was no treatments for a wound. The nurses proceeded to observe the resident and identified a dressing to the left heel. The ADON further explained she was subsequently made aware of the wounds to Resident #4's heel, and immediately began an investigation to determine when the wound developed and why there were no treatment orders in place. She further stated Resident #4 was sent to the hospital on 8/6/21 due to low BP. The ADON explained during the facility's investigation, LVN B was terminated upon discovering LVN B documented that Resident #4's skin was intact, when the resident did have open areas. In an interview with LVN E on 8/18/21 at 12:22 PM, she stated on 8/6/21 she was on the hall and was approached by a CNA (could not recall which CNA) letting her know of a bandage to Resident #4's heel. LVN E proceeded to look at the resident's heel, removed the bandage and saw it was an open wound which was pretty nasty. LVN E described the wound as purulent drainage and foul odor, which she proceeded to clean up. The nurse assigned to Resident #4 that day was LVN C, she informed LVN C about the wound, and LVN C stated she knew nothing about it, she did not know how the bandage got on the heel, and there were no orders to treat the wound at the time of the discovery. LVN C further stated she would take care of the Resident. In an interview with the ADON on 8/18/21 at 3:10 PM, she stated she was not aware of Resident #4's heels until it was brought to her attention on 8/6/21, and on that day a skin assessment was completed, and there was no sacral wound. Resident #4 was sent to the hospital on 8/6/21 and returned to the hospital on 8/13/21. ADON further explained that it was not until 8/16/21 when the resident was seen by the Wound Physician, a sacral would was identified and measured at a Stage 2, 0.5 X 1 X 0.1. In an interview on 9/1/21 at 11:40 AM with the ADON, Resident #4's shower sheets for July and August 2021 were requested. At 2:46 PM ADON provided shower sheets dated 8/18/21, 8/23/21, 8/26/21 and 8/27/21. At 3:33PM the ADON stated facility staff were unable to locate Resident #4's shower sheets for July and part of August. In a phone interview with LVN C on 9/1/21 at 12:31PM, she stated she worked with Resident #4 on the day he was sent to the hospital (8/6/21). LVN C explained prior to 8/6/21 she had not seen any skin issues with Resident #4 and had not been informed of anything new skin issues. Earlier in the day on 8/6/21 the resident was identified to have a wound to the heel, and a skin assessment was completed. Later in the day, she was called by a CNA and informed Resident #4 was throwing up. She proceeded to assess the resident, his BP was about 80/70, the ADON was made aware and EMS was called. When EMS arrived at the facility, the resident's BP was 50/40, and the resident was transported to the hospital. LVN C stated she later contacted the hospital to follow up on the resident's status and was informed the resident was septic. LVN C explained when Resident #4 readmitted from the hospital, he had no open areas or wounds, only the areas to the left and right heels. She stated there was nothing on the resident's back, bottom or his elbows. She stated she did not see anything on the coccyx and knew nothing about it. In a phone interview with LVN D on 9/1/21 at 12:51 PM, she stated she worked with Resident #4 a few times, but could not recall if she did Resident #4's skin assessment in July and could not recall if he had any skin issues. She further stated she could not remember if the resident had any issues with the heels prior to going to the hospital, and no CNA's mentioned any skin issues to her. LVN D explained when Resident #4 readmitted to the facility from the hospital on 8/13/21, he had a bandage on the sacrum, she removed the bandage and saw there was nothing under it. She stated she guessed the bandage was there as a preventative measure. In an interview with CNA F on 9/1/21 at 4:33 PM, she explained during the early part of July, she went in to give Resident #4 a bed bath and saw he had a band-aid on his heel, she removed the band-aid, wiped the area to clean it and saw it was a red opened area, but it was not bleeding. She explained when she wiped the area, a red substance smeared on the towel. CNA F stated she proceeded to tell LVN B about her observation of Resident #4's heel and the nurse stated she would take a look at it. CNA F stated when Resident #4 readmitted to the facility from the hospital, he had a bandage to his bottom, the nurse removed it, but there was nothing under the bandage, and she saw no issues with his skin. In a phone interview with the Wound Physician on 9/1/21 at 4:25 PM, she explained she was unaware of the process the facility had in place for identifying wounds. The Wound Physician explained 8/16/21 was the first time she saw Resident #4 when she identified the wound to the buttock, she also stated she was unsure if the wound to the buttocks could have been identified earlier. She was not aware of any skin issues to Resident #4's heels until the resident readmitted to the facility from the hospital. In an interview with the facility DON on 9/2/21 at 1:49 PM, she stated she first started working in the facility on 7/26/21, however; did not have computer access for the first 2 weeks of hire, and was unable to go into the electronic medical records to review resident records. On 8/6/21, the ADON informed her of Resident #4's heels, and immediately started a skin sweep of the entire facility and did not identify any new pressure ulcers. She further explained that the expectation was for CNA's to inform the nurses of any changes they identify during showers or care, and for the nurses to follow up and make the ADON and DON aware of any new findings, however, she was not made aware of any skin issues with Resident #4 prior to 8/6/21. In an interview with the facility's Previous Administrator on 9/2/21 at 2:10 PM, she stated during her time at the facility (4/13/21 - 7/2/21) morning meetings were held every morning, and the IDT would discuss skin issues. She stated she could not recall Resident #4 being discussed with any skin concerns. She further explained per the DON at the time (Previous DON), the facility was down to only 3 wounds and Resident #4 was not one of them. She stated wounds improved and she had no knowledge of anything else. In an interview with the Administrator on 9/2/21 at 2:30 PM, she stated she was made aware of Resident #4's heels and the resident was subsequently sent to the hospital, LVN B was immediately terminated because she failed to document a change in Resident #4's skin condition, and failed to follow up. The Administrator further stated a skin sweep was completed of all residents in the facility and no new pressure ulcers were identified. She explained on 8/25/21, the failure was addressed in a QA meeting with all department heads, and the wound physician, and staff in-services were initiated. In an interview with the facility's Previous DON on 9/2/21 at 3:15 PM, she stated she worked in the facility from June 2020 until July 22, 2021. She explained during her time at the facility she was responsible for overseeing the nurses and for making sure skin issues were addressed. She explained every day, she would pull a report from the EMR to review for any new skin concerns which were documented and followed up with the nurses to assure follow up had been completed. She stated she stayed on top of wounds and was never made aware of any wound concerns regarding Resident #4. Surveyor attempted to reach LVN B for a phone interview on 8/17/21, 8/18/21, 9/1/21 and 9/2/21. All attempts were unsuccessful, and no calls were returned. Record review of the facility's policy titled Skin System Policy and Procedure, revised 11/17, revealed in part .Policy: 1. Residents who enter the facility without a pressure sore will not develop a pressure sore unless the individual's clinical condition demonstrates it was unavoidable .Procedure: 8. Upon identification of skin/wound impairment the nurse will: complete the SBAR (situation, background, assessment and recommendation tool) and obtain orders from the physician for care in accordance with the formulary guidelines for the identified wound as approved by the physician . Record review of the facility's policy titled Change in a Resident's Condition or Status, revised May 2017, revealed in part .Policy Interpretation and Implementation: . 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. B. Impacts more than one area of the resident's health status . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition/status This was determined to be an Immediate Jeopardy (IJ) on 09/02/21 at 12:31 PM. The Administrator was notified. The Administrator was provided with the IJ template on 09/02/2021 at 12:31 PM. The following Plan of Removal submitted by the facility was accepted on 09/03/21: The plan of removal included the following: Allegation of Credible Compliance 09/03/2021 Immediate Interventions: 1. Notification made to Medical Director, of Immediate Jeopardy on [DATE] 11:18am 2. Quality Assurance and Assessment Meeting conducted with action plan developed. This occurred at [DATE]. 3. A complete skin sweep of the entire building was completed on [DATE] by charge nurses from each hallway under the direction of DON and ADON. No new skin alterations were identified. 4. Residents that have altered skin integrity have been re-reviewed by the Interdisciplinary Team (IDT) to ensure appropriate interventions were in place and that and care plans are updated to reflect current interventions. Completed on [DATE]. The Interdisciplinary Care Team consists of: a. Administrator b. Director of Nursing c. Director of Rehab Services d. Assistant Director of Nursing e. Infection Preventionist f. Activities Director g. Dietary Manager h. Social Services i. Medical Director j. Nurse Practitioner 5. Resident skin alterations and interventions will be monitored by visual observations 1 time daily by Director of Nursing, and/or ADON and/or Infection Preventionist for 4 weeks. The Wound Physician will round weekly on residents identified by the IDT team with skin alterations and provide timely documentation to the facility, with consultation as needed. Training: 1. An immediate in-service was initiated on by Nurse Management Team on the importance of skin assessment, interventions and supporting documentation to be completed by [DATE]. Steps for Wound Documentation Inservice Upon admission, readmission, return from hospital, or ER observation a complete head to toe skin assessment will be completed. * Notify the DON and Administrator immediately * Document the identified altered skin integrity in the wound care module * Call the physician and notify of wound, obtain wound care treatment orders * Obtain a wound physician consult order and obtain consent * Write a telephone order for treatment and consult * Notify the family of wound, treatment, and facility plan of care. * Identify probably cause of and possible other risk factors * Identify areas of prevention and put in place such as float heels, air mattress, w/c cushion, other protective devices * Initiate a care plan * Assigned nurse will follow the Skin Inspections Schedule located in the 24-hour book and document weekly skin inspection in the wound module. * Known altered skin integrity will be assessed weekly by assigned nurse and documented in the wound module following the weekly wound calendar in American Health Tech. Nurse Managers will use Skin Inspection Schedule and AHT wound assessment calendar as audit tools. Nurse Manager will place initials next to each completed task to signify compliance. When you find a newly identified alteration on current residents in skin integrity including skin tears, bruises, open areas, the following steps will be completed. * Initiate a SBAR and notify the DON and Administrator immediately * Initiate an Incident/Accident Report for any newly identified skin tears or bruises * Document the identified altered skin integrity in the wound care module * Call the physician and notify of wound, obtain wound care treatment orders * Obtain a wound physician consult order and obtain consent * Write a telephone order for treatment and consult * Notify the family of wound, treatment, and facility plan of care. * Identify probably cause of and possible other risk factors * Identify areas of prevention and put in place such as float heels, air mattress, w/c cushion, other protective devices * Initiate care plan * Assigned nurse will follow the Skin Inspections Schedule located in the 24-hour book and document weekly skin inspection in the wound module. * Known altered skin integrity will be assessed weekly by assigned nurse and documented in the wound module following the weekly wound calendar in American Health Tech. * Nurse Managers will use Skin Inspection Schedule and American Health Tech. wound assessment calendar as audit tools. Nurse Manager will place initials next to each completed task to signify compliance. 2. A post-test and return demonstration will be completed by all licensed nursing staff to ensure competency. Continued in-servicing will be conducted if needed based on test score. Test scores will be accepted when employee gets 100% of questions correct. 3. New staff will receive in-servicing prior to orientation on the floor to include agency staff. PRN staff will not be allowed to work in the facility until they have completed in-service training and have a score of 100% on the post-test and return demonstration upon their next scheduled shift. 4. A listing of current employees will be used to track in-service completion. 5. The Certified Nurse Aides have been receiving ongoing training on newly implemented shower sheets and the importance of identifying new skin alterations and notifying charge nurses and re-training on the stop and watch process which identifies any changes in condition by the DON and ADON to be completed by 9/5/2021. The certified nurse aides will be provided with applicable interventions via shift change and the certified nurse aide care guide. Monitoring: 1. The Charge nurse will notify Nursing Administration (DON/ADON/ Infection Preventionist (IP) when a new skin alteration is identified to determine if the appropriate process have been followed. 2. Administrator, or appointed designee, will review this process in the Abbreviated Quality Assurance Meeting scheduled 5 times per week (Monday through Friday) to monitor for compliance, to assess the appropriateness of the intervention, and to make changes based on the interdisciplinary team's decisions. (Sign in Sheet) In the abbreviated Quality Assurance Meeting, the process will be reviewed for any new alteration in skin integrity and if any additional clarification is needed this will be completed. The Nurse Aids, Medication Aides, and nurses will be notified of any intervention changes once the meeting has ended. DON, ADON will be responsible for communicating this information to the staff providing direct care to the resident discussed in the daily meeting. 3. An audit log will be utilized to track that planned interventions for Residents with skin alterations that are currently in place through visual observation. Nurse Managers will use Skin Inspection Schedule and AHT wound assessment calendar as audit tools. Nurse Manager will place initials next to each completed task to signify compliance. This will be conducted by Director of Nursing Assistant Director of Nursing, and Infection Preventionist. 4. The Shower Sheets and the Stop and Watch documentation provided from the Certified Nurse Aides will be reviewed in the Abbreviated Quality Assurance Meeting which occurs daily Monday through Friday and documentation and interventions will be reviewed by the DON and ADON. The Medical Director will be involved through the Quality Assurance and Performance Improvement (QAPI) process with ongoing training as needed. [The Facility]will have all aspects of the plan implemented by [DATE] and the Administrator will be responsible for this implementation. Monitoring: The Plan to lower the Immediate Jeopardy had been implemented by: Interviews and observations of 3 residents with pressure ulcers were made on 9/3/21 - 9/5/21 between the hours of 9:00 AM - 6:30 PM. The observations revealed the residents had pressure reducing mattresses, staff were turning and repositioning them, and using other pressure reducing devices such as pillows, positioning wedges, etc. Interviews with the residents revealed they received appropriate wound care and were assisted timely with repositioning. Facility staff were interviewed on 9/4/21 - 9/6/21 over completed in-services, new plans, new tools and new policies developed. Staff interviewed included the Administrator, DON, ADON, 4 nurses (2 from night shift 6PM - 6AM and 2 from day shift 6AM - 6PM) and 4 CNA's (2 from each shift). All staff interviewed voiced understanding of new policies and plan developed to monitor wound management program. Nursing staff were aware of their responsibilities in wound management, knowledge of assessment tools, and what to do and how to care for residents who develop new wounds or wounds worsen. Staff were also able to voice responsibility to review residents' records and orders and who to report any discrepancies or clarifications to. Record review was completed for the 3 residents with pressure ulcers and revealed facility staff had assessed residents for wounds, completed updated Braden scales, completed updated weekly skin assessments, completed wound assessments and updated care plans with individualized interventions. Record review of the facility's Assessment Schedule for September 2021 dated 9/3/21 revealed a tool created for the administrative staff to check off on once scheduled assessments are completed. Record review of the facility's new Weekly Skin Inspection Schedule revealed room numbers of residents whose skin assessments were due each day and shift. Record review of Weekly skin review of completed 9/3/21 - 9/5/21 revealed assessments were completed per the schedule and documented. Record review of in-services completed by nursing staff revealed: Steps for Wound Management (9/3/21), New shower sheets (9/3/21), Change of Condition (9/2/21), Return Demonstration of Comprehension of Wound Assessment Manager 9/6/21. The Administrator and DON were notified the IJ was removed on 9/6/21 at 2:27 PM. The facility remained out of compliance at [TRUNCATED]

Based on interview and record review, the facility failed to implement the comprehensive person-centered care plan for 1 of 5 residents reviewed (Resident #1) for care plans. -Facility staff did not implement Resident #1's care plan to have two staff assistance with bed mobility resulting in a left knee and [MEDICAL CONDITION] and hemotoma on her forehead. This failure affect 1 resident and placed her at risk of not receiving staff assistance with her needed care. The findings included: Resident #1 Record review of Resident #1's face sheet revealed she was a [AGE] year-old female admitted to the facility originally 12/10/10 and re-admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed she had a BIMS score of 00 indicating severely impaired cognition. She was totally dependent on 2 staff to help with bed mobility. This included how the resident turned from side to side and how she was positioned while in bed. Record review of Resident #1's care plan dated 4/5/19 and reviewed 6/16/19 read in part . Need: I require assist with ADL Function. Bed Mobility: Total Assist: 2 . Record Review of Resident #1's MAR (Medication Administration Record) for the month of (MONTH) 2019 revealed and order for [MEDICATION NAME] 15 mg tablet sublinguial PRN every 2 hours for pain/shortness of breath and was administered on 6/12/19. Record review of Resident #1's nurses' notes by LVN A dated 6/17/19 revealed, in part, . 6/16/19 - 9:20 p.m. Resident bed lining was being changed. Resident was moved over too close to the edge of the bed and resident went onto the floor .Resident was noted on the floor next to her bed lying on her left side with her face to the floor. Resident was assessed and noted elevated knot to the center of her forehead going towards the left eye .Some moans so given PRN medications for comfort . Record review of Resident #1's x-rays dated 6/17/19 for hip/pelvic, right knee, and head CT revealed the following: Findings Right Hip - Comminuted right [MEDICAL CONDITION] extending into the greater trochanter Findings Right Knee - Right distal femoral fracture extending into the knee joint Findings Head CT - Left frontal scalp hematoma without underlying fracture. Record review of CNA - ADL tracking form for Resident #1 dated (MONTH) 2019 revealed NA A documented on the form Resident #1 was assisted with bed mobility on 6/16/19 4/2. The numbers 4/2 indicated that Resident #1 was totally dependent on one staff member during care on 6/16/19. Interview on 7/30/19 at 9:33 a.m., RN A said she worked on 6/17/19 from approximately 7:45 a.m. - 7:00 p.m. She said she received shift change report from LVN A that Resident #1 fell from her bed during incontinent care. She was told NA A was changing the resident. She said also it was reported to her that Resident #1 vomited earlier in the morning between 4 a.m. and 5 a.m. She said PCP A was aware of the incident. She said she continued to complete neuro checks and provide pain medication. RN A said she noticed bruising on Resident #1's face. She said the resident was stable. She said the Hospice Case Manager ordered an x-ray and CT scan between 11:30 a.m and 12:00 p.m. RN A said she made a call to PCP A and left a message around 1:30 p.m. She said she texted PCP A and she went to the office, which was next door to the facility and left a sticky note. She said then she talked with the former DON B and she told her that she was not able to get in touch with PCP A even after going over to her office. She said they decided to get the x-rays anyway. She said she saw Resident #1's leg swelling later that afternoon. She said the family requested Resident #1 be sent out the ER. The x-rays were completed and the resident was still sent out to the ER. Interview on 7/30/19 at 12:01 p.m. via the phone with LVN A said NA A assisted Resident #1 with incontinent care. She said she worked 6 p.m. Sunday 6/16 to 6 a.m. Monday 6/17. She said NA A came to the nurses' station and told her the resident had fallen from the bed. LVN A said she went to assess Resident #1 in her room and she was face down on the floor next to the bed. She said she checked Resident #1's vitals and did an assessment and they put her back in the bed. She said she helped NA A finish incontinent care for Resident #1. LVN A said the resident did have a bump on her head. She said she could not remember if Resident #1 required 1 or 2 people to assist. She said they followed the ADL book and care plan. She said if the care plan says 2 assist then NA A should have had 2 people. She told PCP A how the resident fell and about the bump on the resident's head. LVN A said she asked PCP A if the Resident #1 needed to be sent to the hospital. The PCP said Resident #1 was receiving hospice services and it was the hospice company's decision about getting x-rays and sending the resident to the hospital. LVN A said she monitored the resident throughout the night and the resident vomited early on Monday 6/17/19. PCP A and the Hospice were notified again. The hospice nurse manager said she was on a death call and would call back. PCP A said to hold her feedings. The nurse notified the hospice about stopping the feeding. The hospice nurse manager said they would get there when they could. Hospice was aware that the facility had not been able to contact family. Interview on 7/30/19 at 2:07 p.m. with NA A said she worked 2 p.m. - 10 p.m. on 6/16/19. She said she looked a resident's size to determine if she needs the help of another staff when a resident needed to be changed. She said if the resident can't help then she would get another staff. NA A said she was told by nurses and CNAs that if she did not feel comfortable with changing a resident then she could get a partner. NA A said on the day she was changing Resident #1's linens and brief she was alone in the room. She said she rolled Resident #1 away from her to roll she sheet under her and as she did that the resident fell off the bed onto the floor. She said she noticed the resident had bump in the middle of her forehead. We had more training about making sure the resident was in the middle of the bed but not on following care plans or fall prevention. NA A said nurses don't review care plans with NAs. Interview on 7/30/19 at 2:39 p.m., the ADON said NA A turned Resident #1 on to her side away from NA A and the resident rolled over to the floor. She said to each his own when a CNA or NA is decides if they need 1 or 2 staff to change a resident while in bed. She said if it's not a physician's orders [REDACTED]. She said you just judge on how the person looks. After reviewing Resident #1's care plan she said nobody did her with 2 people we just did one. She said if the care plan said 2 then NA A should have used another person. She said staff have a care plan book they should follow. Interview on 7/30/19 at 3:39 p.m. Administrator A said staff should follow the care plan for all residents. Preferably two if the care plan calls for that. He said he expected staff to follow the care plan for Resident #1. Interview on 7/31/19 at 9:57 a.m. via phone with Hospice Aide said she was told by staff on 6/17/19 between 8 a.m. and 9 a.m. of the fall when she arrived at the facility on 6/17/19 to give the resident a bed bath. She said as she was giving the bed bath to Resident #1 that she noticed the bruising on her forehead and swelling of her right knee. Interview on 7/31/19 at 12:54 p.m. with Administrator A , Administrator B and the DON, they said the ADL book should match the care plan. RNs were responsible for each hall and ensuring CNAs and NAs were following the care plan. They said they needed to look at the ADL book and care plan and define what we are training on. Record review of facility policy on Care Plans (revised (MONTH) 2009) revealed in part the following: Policy Interpretation and implementation: 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to the MDS . 3. Each resident's comprehensive care plan is designed to : Aid in preventing or reducing declines in the resident's functional status and/or functional levels

Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of five residents reviewed for accidents (Resident #1). -The facility failed to ensure 2 staff provided incontinent care for Resident #1 to prevent an accident resulting in a knee and [MEDICAL CONDITION] and a hematoma to the forehead. This failure affected 1 resident and placed her at risk of not receiving adequate supervision and assistance. The findings included: Resident #1 Record review of Resident #1's face sheet revealed she was a [AGE] year-old female admitted to the facility originally 12/10/10 and re-admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed she had a BIMS score of 00 indicating severely impaired cognition. She was totally dependent on 2 staff to help with bed mobility. This included how the resident turned from side to side and how she was positioned while in bed. Record review of Resident #1's care plan dated 4/5/19 and reviewed 6/16/19 read in part . Need: I require assist with ADL Function. Bed Mobility: Total Assist: 2 . Record review of Resident #1's nurses' notes dated 6/17/19 revealed, in part, . 6/16/19 - 9:20 p.m. Resident bed lining was being changed. Resident was moved over too close to the edge of the bed and resident went onto the floor .Resident was noted on the floor next to her bed lying on her left side with her face to the floor. Resident was assessed and noted elevated knot to the center of her forehead going towards the left eye .Some moans so given PRN medications for comfort . Record review of Resident #1's x-rays dated 6/17/19 for hip/pelvic, right knee, and head CT revealed the following: Findings Right Hip - Comminuted right [MEDICAL CONDITION] extending into the greater trochanter Findings Right Knee - Right distal femoral fracture extending into the knee joint Findings Head CT - Left frontal scalp hematoma without underlying fracture. Record review of CNA - ADL tracking form for Resident #1 dated (MONTH) 2019 revealed NA A documented on the form the Resident #1 was assisted with bed mobility on 6/16/19 4/2. The numbers 4/2 indicated that Resident #1 was totally dependent on one staff member during care on 6/16/19. Interview on 7/30/19 at 9:33 a.m., RN A said she worked on 6/17/19 from approximately 7:45 a.m. - 7:00 p.m. She said she received shift change report from LVN A that Resident #1 fell from her bed during incontinent care. She was told NA A was changing the resident. She said also it was reported to her that Resident #1 vomited earlier in the morning between 4 a.m. and 5 a.m. She said PCP A was aware of the incident. She said she continued to complete neuro checks and provide pain medication. RN A said she noticed bruising on Resident #1's face. She said the resident was stable. She said the Hospice Case Manager ordered an x-ray and CT scan between 11:30 a.m and 12:00 p.m. RN A said she made a call to PCP A and left a message around 1:30 p.m. She said she tried to text PCP A and she went to the office, which was next door to the facility and left a sticky note. She said then she talked with the former DON B and she told her that she was not able to get in touch with PCP A even after going over to her office. She said they decided to get the x-rays anyway. She said she saw her leg swelling later that afternoon. She said the family requested Resident #1 be sent out the ER. The x-rays were completed and the resident was still sent out to the ER. Interview on 7/30/19 at 12:01 p.m. via the phone with LVN A said NA A assisted Resident #1 with incontinent care. She said she worked 6 p.m. Sunday 6/16 to 6 a.m. Monday 6/17. She said NA A came to the nurses' station and told her the resident had fallen from the bed. LVN A said she went to assess Resident #1 in her room and she was face down on the floor next to the bed. She said she checked Resident #1's vitals and did an assessment they put her back in the bed. She said she helped NA A finish incontinent care for Resident #1. LVN A said the resident did have a bump on her head. She said she could not remember if Resident #1 required 1 or 2 people to assist. She said they followed the ADL book and care plan. She said if the care plan says 2 assist then NA A should have had 2 people. She told PCP A how the resident fell and the bump on the resident's head. LVN A said she asked PCP A if the Resident #1 needed to be sent to the hospital. The PCP said Resident #1 was receiving hospice services and it was the hospice company's decision about getting x-rays and sending the resident to the hospital. LVN A said she monitored the resident throughout the night and the resident vomited early on Monday 6/17/19. PCP A and the Hospice were notified again. The hospice nurse manager said she was on a death call and would call back. PCP A said to hold her feedings. The nurse notified the hospice about stopping the feeding. The hospice nurse manager said they would get there when they could. Hospice was aware that the facility had not been able to contact family. Interview on 7/30/19 at 2:07 p.m. with NA A said she worked 2 p.m. - 10 p.m. on 6/16/19. She looks a resident's size to determine if she needs the help of another staff when a resident needed to be changed. She said if the resident can't help then she would get another staff. NA A said she was told by nurses and CNAs that if she did not feel comfortable with changing a resident then she could get a partner. NA A said on the day she was changing Resident #1's linens and brief she was alone in the room. She said she rolled Resident #1 away from her to roll she sheet under her and as she did that the resident fell off the bed onto the floor. She said she noticed the resident had bump in the middle of her forehead. We had more training about making sure the resident was in the middle of the bed but not on following care plans or fall prevention. NA A said nurses don't review care plans with NAs. Interview on 7/30/19 at 2:39 p.m., the ADON said NA A turned Resident #1 on to her side away from NA A and the resident rolled over to the floor. She said to each his own when a CNA or NA is decides if they need 1 or 2 staff to change a resident while in bed. She said if it's not a physician's orders [REDACTED]. She said you just judge on how the person looks. After reviewing Resident #1's care plan she said nobody did her with 2 people we just did one. She said if the care plan said 2 then NA A should have used another person. She said staff have a care plan book they should follow. Interview on 7/30/19 at 3:39 p.m. Administrator A said staff should follow the care plan for all residents. Preferably two if the care plan calls for that. He said he expected staff to follow the care plan for Resident #1. Interview on 7/30/19 at 5:36 p.m. via phone with PCP A said it was reported to her that Resident #1 fell out of the bed onto the floor during incontinent care. She said it was reported to her that the resident was alert and oriented and had a bruise on her forehead. She said she did not instruct the staff to send the resident out to the ER. She said the resident's mental status was not altered. She said the resident was on hospice and she usually had the facility check with hospice before sending out. She said this was not an emergency. Interview on 7/31/19 at 12:26 p.m. via phone, the hospice case manager said she was notified about Resident #1's fall on 6/17/19. She said she did not need to make a visit based on the report that the resident was stable. She said she received another call and it was reported the resident had vomited and later was informed that Resident #1's leg was swollen. She told the facility she would come when she could. She said she arrived around 11 a.m. on 6/17/19 and assessed the resident. She said vitals were good. She said RN A was working on getting orders for x-rays and CT scan. She said the resident had bruising on her forehead, her leg was swollen and her great right toe was bruised. She said the resident grimaced in pain and moaned during her assessment. Interview on 7/31/19 at 12:54 p.m. with Administrator A , Administrator B and the DON, they said the ADL book should match the care plan. RNs were responsible for each hall and ensuring CNAs and NAs were following the care plan. They said they needed to look at the ADL book and care plan and define what we are training on. Record review of facility policy on Falls and Fall Risk Management (revised (MONTH) 2006) revealed in part the following: . staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview and record review, it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for two (Residents #5 and #20) of 3 residents reviewed for evacuation procedures. -The Administrator and the DON failed to implement the facility's Policy and Procedure on evacuation of residents in case of an emergency for 2 bariatric residents who's beds would not fit thru the door in case of an emergency and require total assistance for transfers. -The Administrator and the DON failed to provide training to 13 employees (CNAs AA, BB, T, S, MA H, the DON, ADON, MS, RN MDS coordinator, The Administrator and LVNs unit manager A and B) on how to safely evacuate Resident #5 and #20. -The Administrator and the DON failed to ensure that the facility had the necessary equipment for transfers and mobile devices in the facility. The facility only had one Hoyer lift to assist 6 residents with their transfer needs. An Immediate Jeopardy (IJ) was identified on 10/30/2014 at 3:20 p.m. While the IJ was removed on 10/31/14 at 4:40 p.m., the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimum harm due to facility needing more time to monitor the plan of removal for effectiveness. The facility's failure affected 2 residents and could affect any of the other 84 residents by placing them at risk for harm and/or injury during emergency situations. Findings included: Resident #5: Review of Resident # 5's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #5 ' s current weight was 481 lbs. In an interview with Resident #5 on 10/28/14 at 5:20 p.m. regarding her transfer needs, Resident #5 said she was only transferred via Hoyer lift, placed on a stretcher and transported to [MEDICAL TREATMENT] by the Emergency Medical Technicians three times per week. Resident #5 said she did not have a wheelchair in her room because she did not owned one. Resident # 5 said the facility did not want a motorized wheelchair and the facility had not order a wheelchair for her yet. Observation on 10/30/14 at 11:20 a.m. revealed the Maintenance Supervisor (Maintenance Supervisor) measured Resident # 5's bariatric bed. The bed was 50 1/4" (inches) wide. The Maintenance Supervisor measured the door that exited Resident # 5's room and it measured 41" wide. Resident #20: Review of Resident # 20's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] . Resident # 20's [DIAGNOSES REDACTED]. Observation and interview on 10/28/14 at 9:10 a.m. of Resident #20 during initial tour of the facility revealed he was in his room lying in his bariatric bed with the television on in the room. LVN H said Resident #20 had [MEDICAL CONDITION]. He required total assistance with all of his ADL's and transfers. She said he was transferred via Hoyer lift daily to his Geri-chair for activities and meals in the dining room. Interviews on 10/29/14 and 10/30/14 with CNAs AA, BB, T, S, MA H, the ADON, and the MDS coordinator revealed that they had were not aware on how to remove parts of the bariatric bed to push out of the door in case of an emergency for Resident #5 and #20. The interviews revealed that staff would use a sheet to transfer the residents to the floor and dragged them out of the room. Record review of the facility Disaster Plan dated 2003 and provided by the facility upon request revealed no plan to remove residents in bariatric beds to a place of safety in case of emergency. In an interview with LVN Unit Managers A & B on 10/30/14 at 10:10 a.m. both said Resident #5's bed looks as if it could be made smaller in width to fit through the doorway, however neither knew how to make it smaller. Both said they would call the company to see how the bariatric bed works. Further observation and interview with the Maintenance Supervisor on 10/30/14 at 11:20 a.m., inside Resident #5 ' s room, he said in case of emergency they would have to put Resident #5 on a Hoyer lift. The Maintenance Supervisor tried to dismantle and reduce Resident #5 ' s bed but could not; the Maintenance Supervisor said he did not know how to operate the bariatric bed. In an interview with the DON on 10/30/14 at 1:30 p.m. she said she been in the facility for 2 months and there has not been no in-services on safety evacuations done since she got here. She said she was aware that the facility had only one Hoyer lift. The DON said she had planned to get more Hoyer lifts pending corporate approval and she may get one before the end of the year. Regarding the evacuation of bariatric residents, the DON said she expected the staff to get the residents to the floor and get them out. An IJ was identified on 10/30/14 at 3:20 p.m. and the Administrator was informed at that time. On 10/30/14 at 5:30 pm, after the IJ was identified, CNA AA presented a copy of an undated document titled " Evacuation of Obese Residents in Emergency Situations " Review of the document revealed in part: " ...this facility intends that its residents are cared for safely ...bariatric residents often have special needs which must be recognized and planned for accordingly ...2. May be evacuated by pushing the bed directly to safety through the door. In some instances the bed may be too large to fit through existing doorways and exits. To address this issue the maintenance department will implement the following procedure; A. each bed with be measured...doorway in room will be measure ...walkways and ramps will be measured ...B. if bed is found to be too large to fit through the door, traverse, or walkway maintenance will affix a pink florescent dot sticker to the head of those beds. This will service as an indicator to staff ...3. If bed cannot fit through a door or walkway the staff will first attempt to transfer the resident into a wheelchair or Geri-chair. This should be done using a lift if possible. If the other options are not possible the resident should be evacuated using a blanket drag ...staff will be in-service upon hire, annually, and as needed in how to use lifts, transfer, and move residents that require bariatric care ..." Observations and interviews conducted on 10/29/14 and 10/30/14 revealed that bariatric beds for Residents #5 and #20 did not have a pink dot at the head of the bed. The Maintenance Supervisor was not aware of the procedures to evacuate bariatric residents or his involvement in the plan, and staff was not aware of the evacuation plan for these residents. In an interview on 10/31/14 at 1:25 p.m. the Administrator stated she did not know the bariatric beds would not fit through the door until the survey team pointed it out. The Administrator stated she started working with the facility on 10/6/14 and the DON was on 8/15/14. The Administrator said that this IJ occurred because the previous Administrator did not follow the policy and procedure on Resident #5 and #20. In an interview on 10/31/14 at 2:00 p.m. with the DON she stated that she believed the IJ happen because the state survey team wanted a more specific evacuation plan. She then stated that she did not know if any in-services were done when the residents were admitted as she was not working at the facility when the residents were admitted . The facility provided a Plan of Removal (POR) on 10/30/14 at 6:40 PM. A revised POR was accepted on 10/31/14 at 2:30 PM. The POR included in part: Specific Problem: Failure to have Evacuation plan for obese Residents during Emergency situation. - Resident #20 in room [ROOM NUMBER] B current weight 253 lbs has a bariatric bed which has been replaced with Camtek Bariatric bed ( current facility bed) which properly broken down measures:37 3/4" width and fits through the residents doorway which measures: 41 3/8'' width. Resident #20 height of 6'2' the Camtek bed measures 87 1/2" in length. Evacuation of resident #20 can occur via Camtek bed and /or Geri-chair which he utilizes daily for meals and activities. Resident#20 can be evacuated via bed or 2 person transfer of resident via Hoyer lift to Geri Chair. - Resident #5 in room [ROOM NUMBER] B current weight 481 lbs has a fixed Bariatric bed which is being replaced with a RecoverCare Ambassor 1200 series Bariatric bed, which when properly broken down measures: 37 3/4" in width and fits through residents doorway which measures 41 3/8". Air mattress will remain in place. Bed can be moved through emergency double doors without occlusion. Recovercare Bariatric bed will be placed into service for Resident #20 when resident is agreeable to transfer onto this surface. Bariatric wheelchair has also been placed into room; Resident can be safely transferred to her Bariatric Wheelchair via Bariatric Hoyer lift with 2person assistance for evacuation if needed. RecoverCare bed was ordered and delivered to facility on 10/30/14. Resident can be safely evacuated via bed or Bariatric wheelchair. 2 person transfer of resident via Hoyer lift to a Bariatric wheelchair. - All facility staff will be in-serviced on the evacuation plan for Bariatric residents, evacuation measures for all Bariatric residents will be posted to the inside of their closet door with instructions on operation and breakdown of bed. Any staff who does not attend the training on 10/31/14 will not be allowed to work until such training has been completed by them. (Initiated 10/30/14, completed by 10/31/14). - Facility ordered a second Hoyer lift from RecoverCare on 10/30/14 which was delivered and placed into service on 10/30/14. All other residents who require transfer out of bed via Hoyer lift are in standard beds and evacuation of these residents can safely occur in their beds. - Care plan of current and future Bariatric Residents will reflect the individual evacuation plan for each resident. (Initiated 10/30/14 and completed 10/31/14). EVACUATION PLAN: - All Bariatric residents will have evacuation measures posted to the inside of their closet door with instructions on proper operation and/or breakdown of specific bed. - Residents found to be bed fast may be evacuated by pushing the bed directly to safely through the door. - In the event the bedfast residents ' beds cannot fit through a door or walkway the staff will first attempt to transfer the resident into a wheelchair or Geri-chair. This should be done using a lift if possible. If the other options are not possible the residents should be evacuated using a blanket drag. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Observation on 10/31/14 at 12:45 PM revealed the Maintenance Supervisor training staff to ensure safe breakdown of Resident # 5's bariatric bed in order for safe evacuation. Staff made return demonstrations that were observed by the survey team. Interview on 10/31/14 at 2:25 p.m. with MA D said Resident #20 was transferred via Hoyer lift to his Geri-chair daily. She was able to state the steps and demonstrate how to make his bariatric bed small enough to fit through his doorway if needed. She said it would take 2 plus staff members to transfer Resident #20 via sheet if the Hoyer lift was not available or if his bariatric bed could not be made smaller to fit through his door. Fifteen staff members from different shifts and departments to include 10 staff from nursing, one staff from maintenance, 3 staff from housekeeping and social services, were interviewed. All had been trained and knew the steps to take to evacuate a bariatric resident from the facility. Review of facility In-Service on evacuation procedure and regarding breakdown of the bariatric bed dated 10/31/14 reflected approximately 93% (95 staff members) of staff had been trained. The Administrator and DON were informed on 10/31/14 at 4:20 PM that the IJ was removed; however the facility remained out of compliance at a pattern level and a severity of potential for more that minimum harm due to facility needing more time to monitor the plan of removal for effectiveness. According to a list provided by the facility had three bariatric residents. The total census was 86.

Based on observation, interview, and record review, the facility failed to develop and implement written plans and procedures to meet all potential emergencies for 2 of 3 bariatric residents reviewed for evacuation procedures. (Resident #5 and #20) Resident #5 and #20 used bariatric beds (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese individuals) that were wider than the doorway. Both residents also require the use of a Hoyer lift to be transferred out of bed and the facility only had one Hoyer lift in the building. The facility did not have a disaster plan to address evacuation of morbidly obese residents. An Immediate Jeopardy (IJ) was identified on 10/30/2014 at 3:20 p.m. While the IJ was removed on 10/31/14 at 4:40 p.m., the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimum harm due to facility needing more time to monitor the plan of removal for effectiveness. These deficient practices affected 2 residents and placed an additional 4 residents that require the use of a Hoyer lift for transfers, at risk of delay and prevent the safe, rapid, and efficient evacuation from the facility in the event of an emergency. Findings include: Resident #5 Review of Resident # 5's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #5 ' s current weight was 481 lbs. Observation on 10/28/14 at 8:45 a.m. and 5:00 p.m. revealed Resident # 5 lying on her back in a bariatric bed. On 10/30/14 at 8:20 a.m. Resident #5 was lying in bed eating breakfast. Review of Resident # 5's care plan dated 3/4/14 revealed that Resident #5 had an ADL deficit due to [MEDICAL CONDITION]. Interventions included for the resident to be bathed three (3) times per week, provide incontinent care every two hours and as needed, assist with grooming, hygiene, indwelling catheter care and dressing. Staff will totally assist Resident # 5 with transfers using the Hoyer lift. There was no care plan to address the use of a bariatric bed. Record review of Resident #5's physician's orders [REDACTED]. In an interview with Resident #5 on 10/28/14 at 5:20 p.m. regarding her transfer needs, Resident #5 said she was only transferred via Hoyer lift, placed on a stretcher and transported to [MEDICAL TREATMENT] by the Emergency Medical Technicians three times per week. Resident #5 said she did not have a wheelchair in her room because she did not owned one. Resident # 5 said the facility did not want a motorized wheelchair and the facility had not order a wheelchair for her yet. Observation on 10/30/14 at 11:20 a.m. revealed the Maintenance Supervisor (Maintenance Supervisor) measured Resident # 5's bariatric bed. The bed was 50 1/4" (inches) wide. The Maintenance Supervisor measured the door that exited Resident # 5's room and it measured 41" wide. Further observation and interview with the Maintenance Supervisor on 10/30/14 at 11:20 a.m., inside Resident #5 ' s room, he said in case of emergency they would have to put Resident #5 on a Hoyer lift. The Maintenance Supervisor tried to dismantle and reduce Resident #5 ' s bed but could not; the Maintenance Supervisor said he did not know how to operate the bariatric bed. In an interview with CNA AA on 10/30/14 at 9:28 a.m. regarding evacuation in case of emergency with residents using the bariatric beds, CNA AA said she would grab a sheet and put under Resident #5 to help and drag her on the floor and out of the room. CNA AA said she did not know how the bed worked, or if parts could be removed to push the bed out of the room. CNA AA also said that the facility only had one Hoyer lift. In an interview with Unit Managers A & B on 10/30/14 at 10:10 a.m. they both said that Resident #5's bed looked as if it could be made smaller in width by removing parts to fit through the doorway. They both stated they did not know how to make it smaller. Both said they would have to call the company to see how the bariatric bed worked. In an interview with CNA S on 10/30/14 at 11:30 a.m. CNA S said in case of emergency she did not know how to operate the bariatric beds, and said the bed was too big to push it out the door. CNA S said they always use the Hoyer lift for Resident #5 and that is what she would use in an emergency. CNA S said nobody had shown her how to work the bariatric bed. She only knew how to use the remote control up and down. Resident #20 Review of Resident # 20's face sheet reflected a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #20 current weight 253 lbs and his height was 6 ' 2 ". Record review of Resident # 20's care plan dated 9/18/14 revealed the resident had an ADL deficit due to [MEDICAL CONDITION]. Interventions included Resident to be bathed three (3) times per week, provide incontinent care every two hours and as needed, assist with grooming, hygiene and dressing. Staff will totally assist Resident # 20 with transfers using the Hoyer lift out of bed. Record review of Resident #20's physician's orders [REDACTED]. Observation and interview on 10/28/14 at 9:10 a.m. of Resident #20 during initial tour of the facility revealed he was in his room lying in his bariatric bed with the television on in the room. LVN H said Resident #20 had [MEDICAL CONDITION]. He required total assistance with all of his ADL's and transfers. She said he was transferred via Hoyer lift daily to his Geri-chair for activities and meals in the dining room. During confidential group interviews on 10/29/14 at 9:00 a.m. with 8 alert residents, 3 of the 8 residents (including Resident #20) said the staff told them they had to wait for call lights to be answered and to get assistance because the facility only had one Hoyer lift in the building. Resident #20 said he was transferred via Hoyer lift by 2 staff members daily. He said he was transferred several times each day to go to the activities and for his noon and dinner meals in the dining room and he had to wait for at times. In an interview with the ADON on 10/30/14 at 10:30 a.m. she said in case of emergency, she would use the Hoyer lift or use a sheet to transfer bariatric residents to the floor and then pull/slide them out of the room. In an interview with the MDS coordinator on 10/30/14 at 11:10 a.m. she said the facility had 6 residents that required the use of a Hoyer lift and 3 residents on bariatric beds. She said that 1 of the 3 residents on bariatric beds did not require the use of a Hoyer lift and could be assisted out of bed in case of emergency. The MDS coordinator said she would have to check and see if the facility had trained the staff on evacuation for bariatric residents. In an interview with the lead CNA BB on 10/30/14 at 11:35 a.m. CNA BB said she really did not know how to move the bariatric beds. In case of a fire or emergency she would have to use the sheets or Hoyer lift to pull her out. CNA BB said she would call the maintenance to help to help with the bariatric bed. CNA BB said they only have one Hoyer lift and they really have not had any training with the bariatric beds. In an interview with the lead MA H on 10/30/14 at 11:35 a.m. MA H said in case of emergency with the resident on bariatric beds, she would team up with other employees and use a sheet to transfer them out. In an interview with lead CNA T on 10/30/14 at 12:00 p.m. CNA T said in case of emergency with the resident on bariatric beds, she would use a sheet to move them out. Record review of the facility Disaster Plan dated 2003 and provided by the facility upon request revealed no plan to remove residents in bariatric beds to a place of safety in case of emergency. In an interview with the DON on 10/30/14 at 1:30 p.m. she said she been in the facility for 2 months and there has not been any in-services on safety evacuations done since she got here. She said she was aware that the facility had only one Hoyer lift. The DON said she had planned to get more Hoyer lifts pending corporate approval and she may get one before the end of the year. Regarding the evacuation of bariatric residents, the DON said she expected the staff to get the residents to the floor and get them out. An IJ was identified on 10/30/14 at 3:20 p.m. and the Administrator was informed at that time. On 10/30/14 at 5:30 pm, after the IJ was identified, CNA AA presented a copy of an undated document titled " Evacuation of Obese Residents in Emergency Situations " Review of the document revealed in part: " ...this facility intends that its residents are cared for safely ...bariatric residents often have special needs which must be recognized and planned for accordingly ...2. May be evacuated by pushing the bed directly to safety through the door. In some instances the bed may be too large to fit through existing doorways and exits. To address this issue the maintenance department will implement the following procedure; A. each bed with be measured...doorway in room will be measure ...walkways and ramps will be measured ...B. if bed is found to be too large to fit through the door, traverse, or walkway maintenance will affix a pink florescent dot sticker to the head of those beds. This will service as an indicator to staff ...3. If bed cannot fit through a door or walkway the staff will first attempt to transfer the resident into a wheelchair or Geri-chair. This should be done using a lift if possible. If the other options are not possible the resident should be evacuated using a blanket drag ...staff will be in-service upon hire, annually, and as needed in how to use lifts, transfer, and move residents that require bariatric care ..." Observations and interviews conducted on 10/29/14 and 10/30/14 revealed that bariatric beds for Residents #5 and #20 did not have a pink dot at the head of the bed. The Maintenance Supervisor was not aware of the procedures to evacuate bariatric residents or his involvement in the plan, and staff was not aware of the evacuation plan for these residents. The facility provided a Plan of Removal (POR) on 10/30/14 at 6:20 PM. A revised POR was accepted on 10/31/14 at 2:30 PM. The POR included in part: Specific Problem: Failure to have Evacuation plan for obese Residents during Emergency situation. - Resident #20 in room [ROOM NUMBER] B current weight 253 lbs has a bariatric bed which has been replaced with Camtek Bariatric bed ( current facility bed) which properly broken down measures:37 3/4" width and fits through the residents doorway which measures: 41 3/8'' width. Resident #20 height of 6'2' the Camtek bed measures 87 1/2" in length. Evacuation of resident #20 can occur via Camtek bed and /or Geri-chair which he utilizes daily for meals and activities. Resident#20 can be evacuated via bed or 2 person transfer of resident via Hoyer lift to Geri Chair. - Resident #5 in room [ROOM NUMBER] B current weight 481 lbs has a fixed Bariatric bed which is being replaced with a RecoverCare Ambassor 1200 series Bariatric bed, which when properly broken down measures: 37 3/4" in width and fits through residents doorway which measures 41 3/8". Air mattress will remain in place. Bed can be moved through emergency double doors without occlusion. Recovercare Bariatric bed will be placed into service for Resident #20 when resident is agreeable to transfer onto this surface. Bariatric wheelchair has also been placed into room; Resident can be safely transferred to her Bariatric Wheelchair via Bariatric Hoyer lift with 2person assistance for evacuation if needed. RecoverCare bed was ordered and delivered to facility on 10/30/14. Resident can be safely evacuated via bed or Bariatric wheelchair. 2 person transfer of resident via Hoyer lift to a Bariatric wheelchair. - All facility staff will be in-serviced on the evacuation plan for Bariatric residents, evacuation measures for all Bariatric residents will be posted to the inside of their closet door with instructions on operation and breakdown of bed. Any staff who does not attend the training on 10/31/14 will not be allowed to work until such training has been completed by them. (Initiated 10/30/14, completed by 10/31/14). - Facility ordered a second Hoyer lift from RecoverCare on 10/30/14 which was delivered and placed into service on 10/30/14. All other residents who require transfer out of bed via Hoyer lift are in standard beds and evacuation of these residents can safely occur in their beds. - Care plan of current and future Bariatric Residents will reflect the individual evacuation plan for each resident. (Initiated 10/30/14 and completed 10/31/14). EVACUATION PLAN: - All Bariatric residents will have evacuation measures posted to the inside of their closet door with instructions on proper operation and/or breakdown of specific bed. - Residents found to be bed fast may be evacuated by pushing the bed directly to safely through the door. - In the event the bedfast residents ' beds cannot fit through a door or walkway the staff will first attempt to transfer the resident into a wheelchair or Geri-chair. This should be done using a lift if possible. If the other options are not possible the residents should be evacuated using a blanket drag. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Observation on 10/31/14 at 12:45 PM revealed the Maintenance Supervisor training staff to ensure safe breakdown of Resident # 5's bariatric bed in order for safe evacuation. Staff made return demonstrations that were observed by the survey team. Interview on 10/31/14 at 2:25 p.m. with MA D said Resident #20 was transferred via Hoyer lift to his Geri-chair daily. She was able to state the steps and demonstrate how to make his bariatric bed small enough to fit through his doorway if needed. She said it would take 2 plus staff members to transfer Resident #20 via sheet if the Hoyer lift was not available or if his bariatric bed could not be made smaller to fit through his door. Fifteen staff members from different shifts and departments to include 10 staff from nursing, one staff from maintenance, 3 staff from housekeeping and social services, were interviewed. All had been trained and knew the steps to take to evacuate a bariatric resident from the facility. Review of facility In-Service on evacuation procedure and regarding breakdown of the bariatric bed dated 10/31/14 reflected approximately 93% (95 staff members) of staff had been trained. In an interview on 10/31/14 at 1:25 p.m. the Administrator stated she did not know the bariatric beds would not fit through the door until the survey team pointed it out. The Administrator stated she started working with the facility on 10/6/14 and the DON on 8/15/14. The Administrator said that she believed this IJ occurred because the previous Administrator did not follow the policy and procedure on Resident #5 and #20 before she started working with the facility. In an interview on 10/31/14 at 2:00 p.m. with the DON she stated that she believed the IJ happen because the state survey team wanted a more specific evacuation plan. She then stated that she did not know if any in-services were done when the residents were admitted as she was not working at the facility when the residents were admitted . The Administrator and DON were informed on 10/31/14 at 4:20 PM that the IJ was removed; however the facility remained out of compliance at a pattern level and a severity of potential for more that minimum harm due to facility needing more time to monitor the plan of removal for effectiveness. According to list provided by the facility, three residents required use of a bariatric bed and 4 additional residents require the use of a Hoyer lift for transfers.

Based on observation, interview, and record review, the facility failed to ensure 14 of 14 employees reviewed for emergency procedures had been trained in all aspects of the facility's emergency and disaster preparedness plan. (CNAs AA, BB, T and S, MA H, the DON, the ADON, Maintenance Supervisor, RN MDS Coordinator and unit manager A and B, LVN F, CNA B and CNA V ) IJ related: The facility did not provide training to 11 employees (CNAs AA, BB, T, S, MA H, the DON, ADON, Maintenance Supervisor, RN MDS coordinator and LVNs unit manager A and B) on how to safely evacuate Resident #5 and #20, who required total assistance with Hoyer lift transfers and used bariatric beds that were wider than the doorway. Non-IJ related: LVN F, CNA B, CNA V did not know how to handle a bomb threat. An Immediate Jeopardy (IJ) was identified on 10/30/2014 at 3:20 p.m. While the IJ was removed on 10/31/14 at 4:40 p.m., the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimum harm due to facility needing more time to monitor the plan of removal for effectiveness. The facility's failure affected 2 residents and placed the other 84 residents at risk for harm and/or injury during emergency situations. Findings include: Resident #5 Review of Resident # 5's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #5 ' s current weight was 481 lbs. Observation on 10/28/14 at 8:45 a.m. and 5:00 p.m. revealed Resident # 5 lying on her back in a bariatric bed. On 10/30/14 at 8:20 a.m. Resident #5 was lying in bed eating breakfast. In an interview with Resident #5 on 10/28/14 at 5:20 p.m. regarding her transfer needs, Resident #5 said she was only transferred via Hoyer lift, placed on a stretcher and transported to [MEDICAL TREATMENT] by the Emergency Medical Technicians three times per week. Resident #5 said she did not have a wheelchair in her room because she did not owned one. Resident # 5 said the facility did not want a motorized wheelchair and the facility had not order a wheelchair for her yet. Observation on 10/30/14 at 11:20 a.m. revealed the Maintenance Supervisor (Maintenance Supervisor) measured Resident # 5's bariatric bed. The bed was 50 1/4" (inches) wide. The Maintenance Supervisor measured the door that exited Resident # 5's room and it measured 41" wide. Further observation and interview with the Maintenance Supervisor on 10/30/14 at 11:20 a.m., inside Resident #5 ' s room, he said in case of emergency they would have to put Resident #5 on a Hoyer lift. The Maintenance Supervisor tried to dismantle and reduce Resident #5 ' s bed but could not; the Maintenance Supervisor said he did not know how to operate the bariatric bed. In an interview with CNA AA on 10/30/14 at 9:28 a.m. regarding evacuation in case of emergency with residents using the bariatric beds, CNA AA said she would grab a sheet and put under Resident #5 to help and drag her on the floor and out of the room. CNA AA said she did not know how the bed worked, or if parts could be removed to push the bed out of the room. CNA AA also said that the facility only had one Hoyer lift. In an interview with Unit Managers A & B on 10/30/14 at 10:10 a.m. they both said that Resident #5's bed looked as if it could be made smaller in width by removing parts to fit through the doorway. They both stated they did not know how to make it smaller. Both said they would have to call the company to see how the bariatric bed worked. In an interview with CNA S on 10/30/14 at 11:30 a.m. CNA S said in case of emergency she did not know how to operate the bariatric beds, and said the bed was too big to push it out the door. CNA S said they always use the Hoyer lift for Resident #5 and that is what she would use in an emergency. CNA S said nobody had shown her how to work the bariatric bed. She only knew how to use the remote control up and down. Resident #20 Review of Resident # 20's face sheet reflected a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #20 current weight 253 lbs and his height was 6 ' 2 ". Observation and interview on 10/28/14 at 9:10 a.m. of Resident #20 during initial tour of the facility revealed he was in his room lying in his bariatric bed with the television on in the room. LVN H said Resident #20 had [MEDICAL CONDITION]. He required total assistance with all of his ADL's and transfers. She said he was transferred via Hoyer lift daily to his Geri-chair for activities and meals in the dining room. In an interview with the ADON on 10/30/14 at 10:30 a.m. she said in case of emergency, she would use the Hoyer lift or use a sheet to transfer bariatric residents to the floor and then pull/slide them out of the room. In an interview with the MDS coordinator on 10/30/14 at 11:10 a.m. she said the facility had 6 residents that required the use of a Hoyer lift and 3 residents on bariatric beds. She said that 1 of the 3 residents on bariatric beds did not require the use of a Hoyer lift and could be assisted out of bed in case of emergency. The MDS coordinator said she would have to check and see if the facility had trained the staff on evacuation for bariatric residents. In an interview with the lead CNA BB on 10/30/14 at 11:35 a.m. CNA BB said she really did not know how to move the bariatric beds. In case of a fire or emergency she would have to use the sheets or Hoyer lift to pull her out. CNA BB said she would call the maintenance to help to help with the bariatric bed. CNA BB said they only have one Hoyer lift and they really have not had any training with the bariatric beds. In an interview with the lead MA H on 10/30/14 at 11:35 a.m. MA H said in case of emergency with the resident on bariatric beds, she would team up with other employees and use a sheet to transfer them out. In an interview with lead CNA T on 10/30/14 at 12:00 p.m. CNA T said in case of emergency with the resident on bariatric beds, she would use a sheet to move them out. Record review of the facility Disaster Plan dated 2003 and provided by the facility upon request revealed no plan to remove residents in bariatric beds to a place of safety in case of emergency. In an interview with the DON on 10/30/14 at 1:30 p.m. she said she been in the facility for 2 months and there has not been any in-services on safety evacuations done since she got here. She said she was aware that the facility had only one Hoyer lift. The DON said she had planned to get more Hoyer lifts pending corporate approval and she may get one before the end of the year. Regarding the evacuation of bariatric residents, the DON said she expected the staff to get the residents to the floor and get them out. An IJ was identified on 10/30/14 at 3:20 p.m. and the Administrator was informed at that time. On 10/30/14 at 5:30 pm, after the IJ was identified, CNA AA presented a copy of an undated document titled " Evacuation of Obese Residents in Emergency Situations " Review of the document revealed in part: " ...this facility intends that its residents are cared for safely ...bariatric residents often have special needs which must be recognized and planned for accordingly ...2. May be evacuated by pushing the bed directly to safety through the door. In some instances the bed may be too large to fit through existing doorways and exits. To address this issue the maintenance department will implement the following procedure; A. each bed with be measured...doorway in room will be measure ...walkways and ramps will be measured ...B. if bed is found to be too large to fit through the door, traverse, or walkway maintenance will affix a pink florescent dot sticker to the head of those beds. This will service as an indicator to staff ...3. If bed cannot fit through a door or walkway the staff will first attempt to transfer the resident into a wheelchair or Geri-chair. This should be done using a lift if possible. If the other options are not possible the resident should be evacuated using a blanket drag ...staff will be in-service upon hire, annually, and as needed in how to use lifts, transfer, and move residents that require bariatric care ..." Observations and interviews conducted on 10/29/14 and 10/30/14 revealed that bariatric beds for Residents #5 and #20 did not have a pink dot at the head of the bed. The Maintenance Supervisor was not aware of the procedures to evacuate bariatric residents or his involvement in the plan, and staff was not aware of the evacuation plan for these residents. The facility provided a Plan of Removal (POR) on 10/30/14 at 6:20 PM. A revised POR was accepted on 10/31/14 at 2:30 PM. The POR included in part: Specific Problem: Failure to have Evacuation plan for obese Residents during Emergency situation. - Resident #20 in room [ROOM NUMBER] B current weight 253 lbs has a bariatric bed which has been replaced with Camtek Bariatric bed ( current facility bed) which properly broken down measures:37 3/4" width and fits through the residents doorway which measures: 41 3/8'' width. Resident #20 height of 6'2' the Camtek bed measures 87 1/2" in length. Evacuation of resident #20 can occur via Camtek bed and /or Geri-chair which he utilizes daily for meals and activities. Resident#20 can be evacuated via bed or 2 person transfer of resident via Hoyer lift to Geri Chair. - Resident #5 in room [ROOM NUMBER] B current weight 481 lbs has a fixed Bariatric bed which is being replaced with a RecoverCare Ambassor 1200 series Bariatric bed, which when properly broken down measures: 37 3/4" in width and fits through residents doorway which measures 41 3/8". Air mattress will remain in place. Bed can be moved through emergency double doors without occlusion. Recovercare Bariatric bed will be placed into service for Resident #20 when resident is agreeable to transfer onto this surface. Bariatric wheelchair has also been placed into room; Resident can be safely transferred to her Bariatric Wheelchair via Bariatric Hoyer lift with 2person assistance for evacuation if needed. RecoverCare bed was ordered and delivered to facility on 10/30/14. Resident can be safely evacuated via bed or Bariatric wheelchair. 2 person transfer of resident via Hoyer lift to a Bariatric wheelchair. - All facility staff will be in-serviced on the evacuation plan for Bariatric residents, evacuation measures for all Bariatric residents will be posted to the inside of their closet door with instructions on operation and breakdown of bed. Any staff who does not attend the training on 10/31/14 will not be allowed to work until such training has been completed by them. (Initiated 10/30/14, completed by 10/31/14). - Facility ordered a second Hoyer lift from RecoverCare on 10/30/14 which was delivered and placed into service on 10/30/14. All other residents who require transfer out of bed via Hoyer lift are in standard beds and evacuation of these residents can safely occur in their beds. - Care plan of current and future Bariatric Residents will reflect the individual evacuation plan for each resident. (Initiated 10/30/14 and completed 10/31/14). EVACUATION PLAN: - All Bariatric residents will have evacuation measures posted to the inside of their closet door with instructions on proper operation and/or breakdown of specific bed. - Residents found to be bed fast may be evacuated by pushing the bed directly to safely through the door. - In the event the bedfast residents ' beds cannot fit through a door or walkway the staff will first attempt to transfer the resident into a wheelchair or Geri-chair. This should be done using a lift if possible. If the other options are not possible the residents should be evacuated using a blanket drag. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Observation on 10/31/14 at 12:45 PM revealed the Maintenance Supervisor training staff to ensure safe breakdown of Resident # 5's bariatric bed in order for safe evacuation. Staff made return demonstrations that were observed by the survey team. Interview on 10/31/14 at 2:25 p.m. with MA D said Resident #20 was transferred via Hoyer lift to his Geri-chair daily. She was able to state the steps and demonstrate how to make his bariatric bed small enough to fit through his doorway if needed. She said it would take 2 plus staff members to transfer Resident #20 via sheet if the Hoyer lift was not available or if his bariatric bed could not be made smaller to fit through his door. Fifteen staff members from different shifts and departments to include 10 staff from nursing, one staff from maintenance, 3 staff from housekeeping and social services, were interviewed. All had been trained and knew the steps to take to evacuate a bariatric resident from the facility. Review of facility In-Service on evacuation procedure and regarding breakdown of the bariatric bed dated 10/31/14 reflected approximately 93% (95 staff members) of staff had been trained. In an interview on 10/31/14 at 1:25 p.m. the Administrator stated she did not know the bariatric beds would not fit through the door until the survey team pointed it out. The Administrator stated she started working with the facility on 10/6/14 and the DON on 8/15/14. The Administrator said that she believed this IJ occurred because the previous Administrator did not follow the policy and procedure on Resident #5 and #20 before she started working with the facility. In an interview on 10/31/14 at 2:00 p.m. with the DON she stated that she believed the IJ happen because the state survey team wanted a more specific evacuation plan. She then stated that she did not know if any in-services were done when the residents were admitted as she was not working at the facility when the residents were admitted . The Administrator and DON were informed on 10/31/14 at 4:20 PM that the IJ was removed; however the facility remained out of compliance at a pattern level and a severity of potential for more that minimum harm due to facility needing more time to monitor the plan of removal for effectiveness. Non-IJ: In an interview on 10/28/14 at 2:00 PM, LVN F said in case of a bomb threat she would call the police and 911. She stated she would check their policy because she was not sure of how to handle it. In an interview on 10/28/14 at 2:20 PM, CNA V said in case of a bomb threat she would call the police and the nurses. She said she had in-services on disaster planning two week ago. In an interview on 10/29/14 at 12:35 PM, CNA B said in case of a bomb threat she would call 911 and evacuate the residents. She said she was re-hired a month ago and had in-services on disaster planning a month ago. In an interview on 10/29/2014 at 10:00 am, the Maintenance Supervisor said he was one of the staff members in charge of the disaster plan training. Record review of the personal file for LVN F revealed a date of hire of 8/13/13. Record review of CNA B personnel file revealed she was hired on 10/7/14. Record review of CNA V personnel file revealed she was hired on 8/19/14. In an interview on 9/29/2014 at 2:15 PM, the Maintenance Supervisor stated disaster preparedness training is performed every 3 months. He stated staff was verbally trained and also given handouts on disaster preparedness. Copies of training and handouts were requested. Copies of disaster plan training were requested but not received before the exit. The only documentation provided by the Maintenance Supervisor was copies of disaster plan section to address bomb threats/detonations. Record review of the "Quick Plan Overview", not dated, documented the following (in-part): "The following procedure shall serve as a guideline of center personnel and departments in the event of a fire, disaster or any emergency regarding evacuation and relocation of facility residents or personnel. Special points of interest: What you are responsible for during a fire: Knowing the location and operation of all fire extinguishers and fire alarm boxes. Evacuation procedures: if evacuation is ordered, evacuate resident according: ambulatory, wheelchair, then bedfast, bomb threat : if you are the employee taking the phone call with a bomb threat, be calm, courteous, listen and do not interrupt the caller. According to list provided by the facility, three residents required use of a bariatric bed and 4 additional residents require the use of a Hoyer lift for transfers.

Based on interview and record review the facility failed to ensure 1 of 22 residents (Resident #4) reviewed for pain assessment received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: --Resident #4, who had a Stage III pressure ulcer and was receiving daily wound treatment, was not being assessed for pain and did not receive pain medications before treatments. This failure affected 1 resident and placed 5 other residents with pressure ulcers at risk of a diminish quality of life, increased risk for pain and decline in overall well-being. Findings include: Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year old female with an admission date of [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed that Resident #4 required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #4 was also incontinent of bowel and bladder. Further record review of the MDS Assessment revealed that under Section M, Resident #4 had a Stage III Pressure Ulcer. Further review of Section J revealed resident had pain and received routine and as needed pain medication. Record review of Resident #4's care plan dated 09/4/14 revealed that the resident was at risk for pain due to pressure ulcer. Observation on 10/29/14 at 10:20 a.m. of LVN J providing pressure sore treatment for [REDACTED]. Resident #4 was frowning and grimacing when the soiled dressing was been removed from the wound. When LVN J was removing the soiled dressing the foam was stuck in the wound. Observation at that time revealed LVN J continued to remove the soiled dressing and clean the wound. Resident #4 was still grimacing and LVN J did not asked Resident #4 if she was in pain. LVN J did not ask Resident #4 if she had receive pain medication that morning nor did she offer her pain medication during the removal of the soiled dressing and the cleaning of the wound. In an interview 10/29/14 at 10:25 a.m. with Resident #4 she was asked if she was in pain. Resident #4 replied that she was in pain. Further interview with Resident #4 revealed that she did not receive her routine pain medication that morning or any other pain medication before treatment. Further observation on 10/29/14 at 10:30 a.m. revealed that LVN J asked Resident #4 if she was in pain when she had finished cleaning the wound and was wrapping the left lateral foot. At that point Resident #4 said yes that she was in pain. LVN J told her that when she was finished with the treatment and she would get something for her pain. Record review of Resident #4's physician ' s recap order for October 2014 revealed an order for [REDACTED]. as needed for pain. Record review of the MAR for October 2014 revealed that Resident #4 did not receive [MEDICATION NAME] 50 mg on 10/29/14 at 7:00 a.m. or any of her as needed pain medications. Further review revealed that she only received [MEDICATION NAME] before her treatments 20 out of 28 days in October 2014. In an interview on 10/29/14 at 10:45 a.m. with LVN J she stated that she did not give any pain medication to Resident # 4 because she never complained of pain. She stated that Resident #4 told her she bumped her foot that morning when she was transferring from her bed to her wheelchair and it was hurting her. At that point LVN J was asked by the Surveyor if Resident #4 was grimacing when she was removing the soiled dressing and cleaning the wound and LVN J said, "yes". Record review of Resident #4's controlled drug medication sheet revealed that [MEDICATION NAME] 10/325 mg 1 tab was given on 10/29/14 at 11:00 a.m. after the wound treatment. During an interview with MA C on 10/29/14 at 11:10 a.m. she stated Resident #4 was not given her [MEDICATION NAME] that morning because it was not available and it was on order and she was waiting on the nurse to get the medication. During an interview with Unit Manager A on 10/29/14 at 11:15 a.m. she stated that the medication was on order and it had just arrived at the facility. Record review of the facility policy on pain assessment revised on 08/2002 revealed in part the purpose of this procedure is to assess the resident pain level and provide optimal comfort through a pain control plan...continuing assessment of the pain management program will ocurr daily and will focus on the effectiveness of the program and the comfort level of the resident...pain will be assessed and documented at regular intervals, as necessary and in accordance with the plan..." CMS 672 revealed there were 6 residents with pressure sores.

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to prevent the development and promote the healing of pressure ulcers for two of seven residents (Resident #7 and 2) who were reviewed for pressure ulcers. Facility had no system in place to track the progress of wounds to ensure treatments were effective for resident # 7 and 2. Residents # 7 and 2's dietary recommendations to promote wound healing were not implemented. Resident #7's wounds deteriorated. This failure affected 2 residents and placed 4 other residents with pressure ulcers at risk of developing and/or worsening of pressure ulcers. Findings included: Resident # 7: Record review of Resident #7 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident # 7's MDS assessment dated [DATE] revealed no pressure ulcer. Record review of Resident # 7 ' s wound care specialist evaluation dated 9/17/14 revealed wound of the right posterior thigh- cluster wound: 3.6 by 2.2 by 0.1 cm with areas surface of 0.25 cm. Observation on 10/29/14 at 12: 00P.M., during wound care revealed Resident # 7 had a cluster of Stage IIs on her right gluteal fold area and two Stage IIs on her left gluteal fold area with yellow slough on wound bed. Both areas were reddened with wound surroundings macerated. Cluster of Stage IIs on her right gluteal fold area had heavy drainage. Interview following wound care observation on 10/29/14 at 12:00P.M., RN A agreed pressure ulcer to Resident # 7 ' s left gluteal folds had heavy drainage. She explained the dressing change was ordered once daily but the wound could benefit from more than once a day dressing change to help keep it dry. RN A said the wound specialist was supposed to visit the residents today but did not. RN A said the wound appeared to have deteriorated compared to the last time she worked on the unit. She reported the right side looked better but there was more skin maceration on the left. She reported Resident # 7 was not always compliant with repositioning but she will suggest twice daily dressing changes to the wound specialist to help keep the wound dry. Record review of Resident # 7 ' s care plan 9/22/14 revealed the resident have potential for skin breakdown related to decreased range of motion/immobility , incontinent of bowel and contractures. Goal and approaches were outlined which did not address the resident ' s bilateral gluteal area stage II pressure ulcers. Record review of Resident # 7 ' s wound assessment report dated 10/14/14 revealed Resident had pressure ulcer on her bilateral gluteal area (posterior upper thighs).Wound side was 3 cm by 3.7 cm by 0.2 cm , granulation was 60% with cluster wound and progress documented was deteriorated. Record review of Resident # 7 ' s TAR dated October 2014 revealed " cleanse stage II to right posterior thigh with wound cleanser, apply calcium alginate with silver and cover with dressing daily. Record review of Resident # 7 ' s TAR dated October 2014 also revealed " cleanse stage II to left buttocks, apply calcium alginate with silver and dressing daily." Record review of Resident #7 ' s dietician recommendation dated 10/20/14 revealed: continue weekly weights and protein supplement 30ml three times daily for weight loss and wounds. Further review of file and resident ' s nurses' notes revealed no evidence that the facility implemented the above dietary recommendations. Interview on 10/30/14 at 10:18A.M., Unit manager B said the charge nurses were required to do weekly skin assessments. She said she looked through Resident # 7 ' s record in search of her weekly skin assessments. Unit manager B reported that one assessment was missed this week but should be done weekly; she explained this should help track the wounds. Interview on 10/30/14 at 11:00A.M., the DON said the facility's tracking system wasto use the progress of the wounds using the wound specialist report (which she presented when asked). The DON said the wound specialist was in the facility today but did not do wound round because of survey. Record review of Resident # 7 ' s record revealed no wound progress report, there were no documentation of onset of wounds and its progress in the resident ' s record. Resident # 2 Record review of Resident # 2's face sheet revealed [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the MDS assessment dated [DATE] revealed Resident # 2 was severely impaired for cognition and dependent on staff for all ADLs. Further review revealed a Stage IV pressure ulcer measuring 06.4cm by 05.7cm by 01.4cm. Record review of Resident # 2 ' s TAR dated October 2014 revealed apply [MEDICATION NAME] ( antimicrobial) powder to wound bed, on buttocks, pack with calcium alginate and cover with boarded foam daily. Record review of Resident # 2 ' s MAR indicated [REDACTED]. Ordered 10/3/14 for wound infection and completed on 10/17/14. Further review of the MAR indicated [REDACTED]. Bactrim DS one tablet by mouth twice daily for 10 days. Medication was completed 10/3/14. Record review of Resident #2 ' s dietician recommendation dated 10/20/14 revealed: fortified meal plan with meals, Vitamin C 500 mg twice daily, multivitamin one daily, mighty shake twice daily and protein supplements 30 ml twice daily. Further reviews of Resident # 2 ' s record revealed above recommendations were not implemented. Record review of Resident #2 ' s wound care specialist evaluation dated 6/25/14 revealed sacral stage IV pressure ulcer measuring 6.4 cm by 5.7 cm by 1.4 cm with undermining of 3.5 cm at 4 o ' clock. Wound had 30 % thick adherent devitalized necrotic tissue and 70% granulation tissue. Specialist signed off on this wound care following this evaluation following admission on hospice for end stage dementia. Record review of Resident #2 ' s care plan dated 10/3/14 revealed impaired skin integrity as evidenced by Stage IV decubitus to sacrum, 9/22/14 -infection to Stage IV , Bactrim DS started for 10 days. Care plan update on 10/3/14 revealed Bactrim DS for 14 days for wound infection. Observation on 10/29/14 at 9:58A.M., revealed Resident # 2 had a Stage IV pressure ulcer to sacral area. Pressure ulcer was about the side of a fist, wound bed had yellowish slough with necrotic edges. Wound had heavy drainage, soiled dressing was heavily saturated. Wound had a foul smell and appeared infected. Further observation revealed Resident #2 had a Stage II to her right heel. Record review of Resident # 2 ' s hospice notes documentation from 6/3/14 to 10/30/14 revealed no description of the Resident # 2 ' s pressure ulcers. There were no documented sizes or progress of wound. Further review of notes revealed: 6/3/14 - Stage 3 not measured 6/30/14 - Stage 4 not measured 7/09/14 - Stage 4 not measured 10/05/14 Stage 4 not measured and not healing 10/13/14 Stage 4, not healing and not measured. Wound margin-tunneling locations-right. Undermining locations -all edges. 10/15/14 stage 3-4 sacrum pressure ulcer, not healing and not measured. Interview on 10/29/14 at 10:20 A.M., RN A said the resident did not have any wound care progress report from the staff. She said she did not always worked in that hall and so she did not consistently cared for Resident # 2. RN # A said the resident had multiple wound infections lately and the wound did not look better. Interview on 10/30/14 at 9:40 A.M., the DON said the resident was receiving wound consults until she was admitted to hospice services. She said the wound care specialist was tracking the progress of the wound. The DON provided wound specialist reports and hospice reports upon admission to hospice. Review of the forms revealed the wound specialist signed off on the wound care, but facility and hospice did not track the progress of the wound to ensure effective treatment. Resident # 2 's condition deteriorated on 10/29/14 and passed away on 10/30/14 at 10:04 A.M. Record review of facility ' s policy on prevention of pressure ulcer dated February 2014 revealed " dietician will assess nutrition and hydration to make recommendation based on the individual resident assessment, monitor nutrition and hydration status . Administer vitamins, mineral and protein supplement in accordance with physician orders [REDACTED]. Facility CMS form 672 dated 10/28/14 listed 6 residents with pressure ulcers.