Every finding on record at Avir at Grapevine

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 12 of 74 days (01/12/25, 01/25/25, 01/26/25, 02/22/25, 02/23/25, 03/01/25, 03/02/25, 03/08/25, 03/09/25, 03/15/25, 03/16/25, and 05/18/25) reviewed during a look back period from 01/01/25 to 09/14/25 for weekend coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 01/12/25, 01/25/25, 01/26/25, 02/22/25, 02/23/25, 03/01/25, 03/02/25, 03/08/25, 03/09/25, 03/15/25, 03/16/25, and 05/18/25. This failure could place residents at risk of not having their nursing and medical needs met and improper care.Findings included:Record review of facility RN Coverage, period from 01/04/25 to 09/14/25, reflected the following: - Sunday 01/12/25 - No RN - Saturday 01/25/25 - Time in 18:00 (6:00 PM) - Out Time 23:00 (11:00 PM); Time in 23:30 (11:30 PM) - Out time 6:15 AM (01/26/25 Sunday). 5 hours and 30 minutes were worked on 01/25/25 Saturday. - Sunday 01/26/25 - Time in 18:00 (6:00 PM) - Out Time 23:00 (11:00 PM); Time in 23:30 (11:30 PM) - Out time 6:30 AM (01/27/25 Monday). 5 hours and 30 minutes were worked on 01/26/25 Sunday.- Saturday 02/22/25 - Time in 18:00 (6:00 PM) - Out Time 23:00 (11:00 PM); Time in 23:30 (11:30 PM) - Out time 6:45 AM (02/23/25 Sunday). 5 hours and 30 minutes were worked on 02/22/25 Saturday.- Sunday 02/23/25 - Time in 18:15 (6:15 PM) - Out Time 23:15 (11:15 PM); Time in 23:45 (11:35 PM) - Out time 6:30 AM (02/24/25 Monday). 5 hours and 30 minutes were worked on 02/23/25 Sunday.- Saturday 03/01/25 - Time in 18:00 (6:00 PM) - Out Time 23:00 (11:00 PM); Time in 23:30 (11:30 PM) - Out time 6:45 AM (03/02/25 Sunday). 5 hours and 30 minutes were worked on 03/01/25 Saturday.- Sunday 03/02/25 - Time in 18:00 (6:00 PM) - Out Time 23:15 (11:15 PM); Time in 23:45 (11:35 PM) - Out time 7:30 AM (03/03/25 Monday). 5 hours and 30 minutes were worked on 03/02/25 Sunday.- Saturday 03/08/25 - No RN- Sunday 03/09/25 - Time in 5:53 PM - Out Time 10:00 PM; Time in 10:30 PM - Out time 6:32 AM (03/10/25 Monday). 5 hours and 37 minutes were worked on 03/09/25 Sunday.- Saturday 03/15/25 - Time in 6:07 PM - Out time 6:46 AM (03/16/25 Sunday). 5 hours and 53 minutes were worked on 03/15/25 Saturday.- Sunday 03/16/25 - Time in 6:05 PM - Out time 7:26 AM (03/17/25 Monday). 5 hours and 55 minutes were worked on 03/16/25 Sunday.- Sunday 05/18/25 - Time in 5:27 PM - Out time 6:28 AM (05/19/25 Monday). 6 hours and 33 minutes were worked on 05/18/25 Sunday.Interview on 09/18/25 at 3:17 PM, the Staffing Coordinator revealed she had been employed since April 2025. She stated she was responsible for completing the nursing staffing schedules. She stated when she was hired, she was told the facility did not have a Staffing Coordinator from October 2024 through April 2025. She stated she was not sure who was responsible for completing the nursing schedules prior to her being hired. The Staffing Coordinator stated she was aware there should be an RN for 8 consecutive hours. She stated when she was hired she was never aware of the facility having any issues with RN coverage. She stated the potential risk of not having an RN would be LVNs not able to do things that an RN could do. Interview on 09/18/25 at 3:37 PM, the DON revealed he had been employed for 11 months. He stated the Staffing Coordinator was responsible for completing the nursing schedules. The DON stated he was aware of the 8 consecutive hours; however, he was not aware the facility had no 8 consecutive hours RN coverage for the above days. The DON stated he would review the days that were missing. Follow-up interview on 09/18/25 at 4:22 PM, the DON revealed he reviewed the RN coverage, and he was not aware the facility did not have an RN for 8 consecutive hours on the days provided. He stated the ADONs and himself were responsible for reviewing schedules. The DON stated RNs were able to provide more appropriate care in case of an emergency. Interview on 09/18/25 at 4:28 PM, the Administrator revealed she was aware of the 8 consecutive hours for RN coverage. She stated she had been employed since March 2025. The Administrator stated she was aware of the facility having problems with RN coverage but it was not a consistent issue. The Administrator stated the Staffing Coordinator was responsible for completing the nursing schedules and the ADONs were responsible for reviewing them. The Administrator stated there would always be a potential risk for not having an RN in the facility. Interview on 09/18/25 at 4:36 PM, ADON C revealed the Staffing Coordinator was responsible for completing nursing staffing schedules. She stated the ADONs and DON were responsible for reviewing the schedules once completed. She stated she was aware of the requirement of having an RN for 8 consecutive hours but was not aware of facility having an issue with RN coverage. The ADON C stated there could always be a potential risk of not having an RN for 8 consecutive hours. She stated RN were able to do more things than an LVN could do and responsibilities. Record review of facility Staffing, Sufficient and Competent Nursing policy, revised August 2022, reflected the following: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater for two of three staff LVN B and MA E which resulted in a 17.95% medication error rate after 39 opportunities with 7 errors for three of five residents (Residents#4, #10 and #59) observed for medication pass. 1.The facility failed to ensure MA E administered the correct eye drop for Resident #59 at 07:46 AM. 2. The facility failed to ensure MA E administered Dextromethorphan-Guaifenesin Oral Tablet 20-400 MG (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours for cough for Resident #4 at 07:46 AM. 3. LVN B failed to follow the physician orders for flushing Resident #10's gastrostomy tube with 10 mL (or prescribed amount) of water between medications when he administered medication, failed to administer all the medications by gravity, and failed to check gastrostomy tube placement before medication administration at 08:46 AM. These failures could place residents at risk of physical and chemical incompatibility, leading to an altered therapeutic response and put residents who received medications via gastrostomy tube at risk for gastronomy tube blockage and medication interaction. Findings included:1. Record review of Resident #59's quarterly MDS assessment, dated 06/17/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. The assessment reflected the resident cognition severely impaired with BIMS score of 3. The resident had diagnoses which included Glaucoma (a group of eye diseases that damage the optic nerve, which carries visual information from the eye to the brain). Record review of Resident #59's September 2025 Physician Orders reflected there were orders to administer latanoprost 0.05 MG/ML Ophthalmic Solution 1 drop each eye at bedtime. Observation on 09/17/2025 7:46 AM revealed MA E prepared medications for resident #59. She took latanoprost 0.05 MG/ML Ophthalmic Solution to resident room. She sanitized and put on gloves and explained the procedure to resident#59. She administered 1 drop to each eye and left the resident comfortable. Interview with MA E on 09/17/25 at 8:08 AM revealed she knew resident was supposed to get two different types of eyes drops medications and she did not confirm the eye drops and the medication administration record to confirm the name and time. She stated she knew she was supposed to compare the MAR and the medication on hand, but she did not. She stated she knew she was supposed to follow the five rights for medication administration the right patient, the right drug, the right time, the right dose, and the right route but she was nervous. She stated she only checked the time, and she saw two eye drops were due at 08:00AM and she did not notice she administered latanoprost 0.05 MG/ML Ophthalmic Solution 1 drop each eye which was supposed to be administered at bedtime instead of Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) Instill 1 drop in both eyes two times a day for Glaucoma which was also on hold . She stated failure to check the MAR against the available medication could lead to medication error and administration of the wrong medication at the wrong time. 2.Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included hypertension (high blood pressure) and heart failure (a serious condition but not the same as a heart attack, where blood flow to the heart is suddenly blocked). He had a BIMS score of 13 which indicated his cognition was intact. Record review of Resident #4's September 2025 Physician Orders reflected there were orders for Dextromethorphan-Guaifenesin Oral Tablet 20-400 MG (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours for cough. Observation on 09/17/25 at 07:58 AM revealed MA E did not administer Dextromethorphan-Guaifenesin Oral Tablet 20-400 MG (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours for cough for Resident #4 at 07:46 AM scheduled for 08:00AM. Interview with MA E on 09/17/25 at 08:39 AM revealed she did not administer Dextromethorphan-Guaifenesin Oral Tablet 20-400 MG (Dextromethorphan-Guaifenesin) morning dose because she did not have it in her cart. She stated she was previously off work and 09/17/25 was her first day after being off and she could not tell when it ran out and whether it was reordered. She stated she knew she was supposed to notify the nurse, but she did not, she said she forgot. She stated failure to administer medication could lead to a resident not getting the required therapy. She stated she was aware Resident #4's medications came from hospice and her nurse was supposed to call and notify hospice for delivery. Interview with LVN K on 09/17/25 02:50PM revealed he was the charge nurse and stated MA E had not notified him of the missing dose of Dextromethorphan-Guaifenesin Oral Tablet 20-400 MG (Dextromethorphan-Guaifenesin) for Resident #4. He stated failure to be notified so that he can call Hospice for refill could lead to medication error and Resident #4 not getting the needed therapy. He stated he would call Hospice so that it can be delivered for the evening dose. 3. Record review of Resident #10's quarterly MDS assessment, dated 08/07/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. The assessment reflected the resident's cognition status was not documented because (resident is rarely/never understood). The resident had diagnoses which included anemia (condition characterized by a lower-than-normal number of red blood cells, or a deficiency of hemoglobin, which carries oxygen in the blood and dysphagia (difficulty swallowing solids, liquids, or both). The nutritional approaches revealed feeding tube. Record review of Resident #10's September 2025 Physician Orders reflected there were orders for very shift Flush feeding tube with 10 cc water between each medication and 30 cc water before and after med administration. Observation on 09/17/2025 8:47 AM revealed LVN B prepared medications outside resident's room. He sanitized and prepared the following medications: Esomeprazole 40 MG Granules Oral Suspension 1 packet mix with 6-8 OZ water via g-tube for Gerd. Magnesium oxide 400 MG Oral Tablet via g-tube for supplement. Iron Supplement Oral Solution 220 (44 Fe) MG/5ML (Ferrous Sulfate). Give 5 ml via G-Tube one time a day for supplement. Metoclopramide HCl Oral Tablet 5 MG. Give 5 mg via G-Tube two times a day for GERD (a digestive condition where stomach contents flow back up into the esophagus, causing irritation and discomfort). Polyethylene Glycol Powder (Polyethylene Glycol 1450) Give 17 gram via G-Tube in the morning for constipation. Multivitamin Oral Liquid (Multiple Vitamins w/Minerals) Give 15 ml via G-Tube in the morning for supplement. LVN B put the medications in different cups. LVN B crushed the medication and put it in separate cups, mixed with 5 mls water. He washed hands and put on gloves and gown and went to Resident #10's room. LVN B positioned Resident #10 in an upright position. LVN B did not check for the gastrostomy tube placement. He did not flush the gastrostomy tube with 30 ml of water, he administered medication one at a time through plugging, he did not flush the gastrostomy tube with water between each medication. LVN B flushed the gastrostomy tube with 30 ml of water after administering al of the medication, and he left the resident comfortable. He removed the gloves and gown, and he washed hands. Interview with LVN B on 09/17/2025 9:26 AM, revealed he was aware of the order to flush gastrostomy tube between medication, and after medication administration through gastrostomy tube for Resident #10. He said he forgot to flush the gastrostomy tube between medication administration. LVN B stated failure to check orders and flush in between the medication could lead to medication interactions. He stated he was also supposed to administer all the medication by gravity and not plunging. He stated the risk of plunging could lead to rupture of the Balloon (usually at the end of the tube it keeps the tube in place and prevents it from being accidentally pulled out) . He stated he was also supposed to check the gastronomy tube placement before medication administration, and he assumed since he had checked earlier that morning, he was okay to administer medication without checking for residual. He could not tell what time he had checked for gastronomy tube placement. He stated failure to check to for placement could lead to aspiration. He stated he had received training on medication administration via gastrostomy tube. Interview with DON on 09/18/2025 8:52 AM revealed his expectation was nurses are supposed to check the patency and placement before they administer medication. He stated the risk of not checking will be aspiration, nausea and vomiting. He stated he expected his staff to flush the gastronomy tube before, between medication administration and after medication administration. He stated failure to flush between medication would cause gastronomy tube clogging and possible medication interaction. She stated the risk of not flushing before between and after medication administration would be gastronomy tube being clogged and medication interactions. He stated he also expected his staff to administer medication through gravity not plunging as the best standard practice. He stated the risk of plunging is adding more air to Resident #10's stomach and could risk nausea and vomiting. He stated he was responsible of monitoring the nurses and the MA on medication administration. He stated he had done skill check with LVN B on 06/17/25 on gastronomy medication administration and in-service on MA E on medication administration on 07/02/25.Interview with the DON on 09/18/25 at 09:02AM revealed his expectation was for MA E to notify the charge nurse, when she discovered she did not have the morning dose for Resident #4 for follow up with pharmacy and notify the doctor so that the medication could have been put on hold or discontinued until available. He stated hospice was called and they delivered the evening dose and Residnet#4 only missed the morning medication. He stated the risk of Resident #4 missing the morning medication would be not getting the appropriate therapy. He stated the facility had done in-service, but he could not recall when. Interview with the DON on 09/18/25 at 09:15AM revealed his expectation was for MA E to follow the 5 rights of medication administration for the right patient, right time, right dose, right route and right drug. He stated he expected MA E to administer what is on the medication administration record not what she had on the cart. He stated the risk of not following the orders could lead to wrong medication and adverse effects. Record review of facility in-service dated 07/02/25 titled medication administration revealed Nurses and medication aide should always follow 5 rights of medication patient, medication, dosage, route, time and documentation. When medication is missing to the cart we must replace immediately if it is Over the counter or call pharmacy. If unavailable call the doctor to get an order to hold med until available. Medication should be administered as ordered and in timely manner. LVNB and MA E were in attendance. Record review of the facility training dated 06/17/25 revealed LVN B did skill check on gastrostomy tube management. Record review of the facility Administering Medication through an enteral tube policy dated February 2015 revealed the following: 18. Confirm placement of feeding tube per physician's order. 25.Administer medication by gravity flow. 27.When the last of the medication begins to drain from the tubing, flush the tubing with 15ml of warm room temperature tap water (or prescribed amount).

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (Nurses' medication cart for Hall 200) reviewed for medication storage. The facility failed to ensure the nurses' medication cart for 200 halls did not contain medications that were expired. This failure could place residents at risk of adverse medication reactions. Findings included:Observation on 09/17/2025 11:49 AM, revealed the nurses' medication cart for 200 Hall with LVN K had the following medication that had expired. 1. 1 packet Midodrine 2.5mgs tablets with use by date of 07/23/25 2. 1 packet Ibuprofen 400mgs tablets with use by date of 09/05/25 3. 1 bottle of nitroglycerin 0.4mgs tablet with expiry date 07/20/25 4. 1 packet Meclizine 25mgs with use by 07/16/25 Interview on 09/17/2025 12:17 PM with LVN K revealed it was the responsibility for all nurses to check carts for expired medications every shift, but he did not check the whole cart that morning. He stated the risk of not checking the carts for expired medication if administered they will not be effective. He stated he had done training on labelling and storage. Interview with ADON on 09/18/2025 2:52 PM revealed her expectation was all nurses to check their carts every shift for expired medication. She stated it was her and the DON's responsibility to audit carts, but she has not been auditing, and she had no reason. She stated the risk of not checking and removing expired medication from the cart if administered they might not be effective. Interview with the DON on 09/18/2025 3:41 PM, he stated the nurses were responsible for checking their carts every shift for expired medications. He stated it was the responsibility of nursing management to check and audit the carts after the nurses. The DON stated the last time he checked the carts was 09/16/25 and he missed the expired medications. The DON said the facility had in-serviced staff checking and removal of expired medications, but he could not recall the date and no training was provided. Record review of the Medication Storage and labelling policy dated February 2021 revealed the following: 3. If facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroy these items .

Based on observation, interview, and record review the facility failed to provide a private meeting space for the residents' monthly council meetings for 7 of 7 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.Findings included:During a confidential resident group interview with seven residents on 09/17/25 at 1:45 PM, the facility arranged for the meeting to be held in an open dining room located next to the facility kitchen and main entrance hall. There were no doors that could be closed to ensure the residents' privacy during the meeting. There were no signs indicating a resident council meeting was being held. During the meeting, staff were observed walking through the main hall while the meeting was in progress and kitchen staff stepping out of the kitchen to grab the tray carts. The seven residents in attendance all reported that their monthly resident council meetings were held in this open dining room area. The residents stated the monthly meetings were being held in the conference room, but the conference room was too cold for them. Interview on 09/18/25 at 2:21 PM with the Activity Assistant revealed resident council meetings were being held in the conference room, but residents began to complain about the room being cold. She stated the resident council meetings had been held in the dining room since June 2025. The Activity Assistant stated she would post signs or use the dry eraser board to notify facility staff of an active resident council meeting being held. She stated she was not aware of resident council meetings needed to be in a private setting. The Activity Assistant stated there was no risk to the residents if they were not provided with a private setting. Interview on 09/18/25 at 4:31 PM with the Administrator revealed resident council meetings had been held in the dining room area. She stated since the Activity Director left around May or June 2025 the resident council meetings had been in the dining room. The Administrator stated she was aware of the requirement of providing residents with a private area; however, she was not sure why it was not done. She stated a potential risk would be residents not having privacy to talk. Record review of the resident council minutes for May 2025 through August 2025 reflected there were no documented requests for a private meeting area. Record review of the facility's current, undated Statement of Resident Rights the following: .privacy, including privacy during visits and telephone calls. Record review of the facility Activity Programs, revised June 2018, reflected the following: Activity programs are designed to meet the interests of and support the physical, mental, and psychological well-being of each resident 14. Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met. The facility's policy did not address resident council meetings.

Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 16 residents (Resident #16) reviewed for comprehensive care plans.The facility failed to develop a comprehensive care plan addressing weight loss for Resident #16. This failure could place residents at risk of not having their individual needs met and not receiving necessary care and services.Findings included: Record review of Resident #16's quarterly MDS assessment, dated 06/26/25, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident diagnoses included Alzheimer's Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), malnutrition, hypothyroidism (thyroid gland does not make and release enough hormone into your bloodstream), gastro-esophageal reflux disease without esophagitis (stomach acid flows back up into the esophagus and causes heartburn), dysphagia (difficulty or discomfort in swallowing) and hypertension (high blood pressure). The MDS reflected Resident #16's BIMS was not completed due to resident is rarely/never understood. Resident #1 did not exhibit wandering behaviors. The MDS Section K - Swallowing/Nutritional Status - Weight Loss reflected Resident #16 had loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #16's care plan, dated 06/06/25, did not reflect Resident #16 being at risk of weight loss. Record review of Resident #16's physician orders, dated 07/01/24, reflected orders for the following: Regular diet, Mechanical Soft texture, Regular Liquids consistency.for all meals diet HOUSE shake 8 oz PO three times a day for risk of malnutrition Supplement dated 09/09/2025.Record review of Resident #16's weight records reflected the following weights:03/04/25 - 155.8 pounds 08/05/25 - 147.2 pounds09/03/25 - 143.3 pounds09/18/25 - 149.0 poundsBetween 03/04/25 and 09/18/25, Resident #16 had an 4.46% weight loss in 6 months. From 08/08/25 to 09/18/25, Resident #16 had a 1.22% weight gain. Observation and interview on 09/16/25 at 2:18 PM revealed Resident #16 was in the dining room playing with cards and was smiling when approached. Resident #16 stated he was doing well; however, he was unable to answer further questions. Resident #16 complexion showed no signs of illness or deficiency.Observation of lunch meals on 09/17/25 and 09/18/25 revealed Resident #16 ate about 75% to 100% of his meal. Resident #16 was observed drinking his house shakes as well. Interview on 09/18/25 at 11:36 AM, LVN A revealed she was the nurse assigned to Resident #16. LVN A stated Resident #16 eats about 75% to 100% of his meals and received a house shake with his meals. She stated Resident #16 weights were checked monthly. LVN A reviewed Resident #16's weights and stated resident was slowly losing weight but was not a significant weight loss. She stated Resident #16 was seen by the Dietitian and Nurse Practitioner. LVN A stated Resident #16 does not appear he had lost any weight. LVN A stated Resident #16 was at risk of weight loss and it should be care planned. LVN A reviewed Resident #16's care plan and stated the resident care plan did not address his weight loss or interventions. LVN A stated the ADONs were responsible for reviewing and updating care plans. She stated weight loss should be care planned so that the staff can monitor weights and put interventions in place, so residents do not lose anymore. Observation on 09/18/25 at 11:43 AM revealed Resident #16 was weighed standing up and weighed 149.0 pounds. Interview on 09/18/25 at 11:50 AM, ADON D revealed she was the ADON assigned to the memory care unit. She stated Resident #16 had not been triggered for significant weight loss. ADON D reviewed Resident #16's weights and stated resident was slowly losing weight; however, Resident #16 eats 75% to 100% of his meals and received a health shake for each meal. ADON D stated any resident who was at risk of weight loss should be care plan for it. ADON D reviewed Resident #16's care plan and stated the resident care plan did not address any weight loss. She stated she was not aware Resident #16 was not care plan for it. She stated the ADONs and the DON were responsible for care plans. ADON D stated the potential risk for not care planning weight loss would be staff not able to monitor and would not be aware of any interventions for resident not to lose weight. Interview on 09/18/25 at 12:10 PM, the DON revealed the MDS Coordinator was responsible for reviewing and updating care plans. He stated his expectations were for care plans to be completed correctly and updated with the resident plan of care and interventions. He stated it was his responsibility to ensure care plans were completed. He stated if a resident was at risk of weight loss it was expected for it to be care planned. The DON stated he was aware of Resident #16's weight loss and a IDT meeting was held and interventions were put in place. He stated Resident #16 was at risk of weight loss, malnutrition and loss of appetite. The DON stated the potential risk of resident not being care plan for weight loss would be staff not being aware of the interventions. Interview on 09/18/25 at 1:07 PM, the Dietitian revealed Resident #16 had not had a significant weight loss. She stated Resident #16 was receiving 3 house shakes a day for an extra 200 calories. She stated Resident #16 weight was unavoidable due to age related, diagnosis, resident was more of the thinner side and muscle loss of not moving a lot. The Dietitian stated around April and May the facility had issues with the weight scales, and they had the weight scales calibrated. Interview on 09/18/25 at 4:18 PM, MDS Coordinator revealed she had been employed for 3 weeks. She stated she was responsible for care plans and the ADONs and DON were responsible for reviewing them and updating care plans. MDS Coordinator stated residents at risk of weight loss should be care plan for it. She stated she was not aware Resident #16 did not have a are plan for weight loss. She stated the potential risk would be staff not aware of the interventions that were put in place. Record review of facility Care Plans, Comprehensive Person-Centered policy, revised date March 2022, reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to revise and review the care plan for 1 of 5 residents (Resident #10) reviewed for comprehensive care plans timing and revision. The facility failed to revise and review Resident #10's care plan to include his physician orders to have a 70 ml water flush during his tube feedings. This failure could lead to the residents not receiving appropriate hydration intake. Findings included:Record review of Resident #10's MDS assessment reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10's MDS assessment, dated 08/07/25, reflected Resident #10's BIMS score of 00 indicating resident was not able to complete the interview. Resident #10's MDS indicated he had parenteral/IV feeding and feeding tube while a resident of the facility. His diagnoses included paraplegia (inability to move or control the legs and lower body), contracture of muscle right and left lower leg (muscles or other tissues tighten or shorten causing deformity), unspecified protein-calorie malnutrition (inadequate intake of protein and calories), dysphagia (difficulty swallowing), gastrostomy status (an opening in the stomach through the abdominal wall, allowing for the placement of a feeding tube) . The MDS reflected Resident #10 was dependent on staff for eating and all activities of daily living skills. Record review of Resident #10's care plan further indicated Resident #10 had an Activity of Daily Living Skills performance deficit. Goal: will maintain or improve current level of function in eating. Interventions included eating: required 1 staff assistance. Resident #10's care plan also noted he required tube feeding related to Dysphagia calorie requirements changed and new order received for 1. Nutren 2.0 at 44mL/hr x 22hr 2. Water flush at 50mL/hr x 22hr. Provides 1936kcal, 968mL formula, 1770ml Total water. Revision on: 04/18/2025 Goal: Resident #10 will remain free of side effects or complications related to tube feeding. Interventions included to clean insertion site daily as ordered, monitoring for signs and symptoms infection or breakdown such as redness, pain, drainage, swelling, and/or ulceration and report to physician if symptoms arise. Discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications. Monitor/document/report to Physician PRN: Aspiration- fever, Short of Breath, Tube dislodged. Infection at tube site, Self-extubation (patient deliberately removes their own tubing), Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. NPO status Revision on 04/23/2025 1. Nutren 2.0 at 44mL/hr x 22hr 2. Water flush at 50mL/hr x 22hr. Provides 1936kcal, 968mL formula, 1770ml Total water (not counting med flushes). Obtain and monitor lab/diagnostic work as ordered. Report results to Physician and follow up as indicated. Provide local care to G-Tube site as ordered and monitor for signs and symptoms of infection. Registered Dietitian to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. The resident is dependent with tube feeding and water flushes. See physician orders for current feeding orders. The resident needs assistance with tube feeding and water flushes. See physician orders. for current feeding orders. The resident needs the Head of Bed elevated 30 degrees during and thirty minutes after tube feed. Record review of Resident #10's care plan also indicated Resident #10 has alteration in gastrointestinal status (G-Tube) related to Dysphagia; Nutren 2.0 at 44 cc/hr x 22 hours and 100 water flush every hour. Goal: Resident #10 will remain free from discomfort, complications, signs, or symptoms related to gastrointestinal alterations. Interventions included Keep Head of Bed elevated. Give medications as ordered. Monitor/document side effects and effectiveness. Monitor vital signs as ordered/per protocol and record. Notify physician of significant abnormalities (rapid pulse, shallow, rapid, or labored respirations, low blood pressure). Obtain and monitor lab/ diagnostic work as ordered. Report results to physician and follow up as indicated. Revision on: 05/08/2025. Record review of Resident #10's physician's order for feeding revealed one time a day Nutren 2.0 at 44mL/hr via PEG, up at 1200pm until total volume of 968mL has been infused. Provides 1936kcal. FWF 70mL/hr x 22hrs. Total volume= 1540mL fluid. Enteral Feed Active 9/16/2025 12:00 9/16/2025. Observation of Resident #10 on 09/16/25 at 11:18 AM revealed him sitting in the television room. Resident #10 was not connected to his tube feeding machine, it was left in his room. Resident #10's tube feeding machine was currently off, the formula bag was dated 9/15/25 12:30 PM with rate of 44ml, water was dated 09/15/25 12:30 PM rate 70ml. Observation of Resident #10 on 09/16/2025 at 1:12 PM revealed him in the bed with staff checking for tube placement, residual and connecting the tube for his feeding. Observation of Resident #10 on 09/16/2025 at 1:54 PM revealed Resident #10 in bed, observation of feeding machine revealed 44ml 1698, water flush 70 ml. Resident #10's formula bag or water bag did not indicate the date, time, initials, or rate. Observation and Interview on 09/17/2025 at 12:15 PM with LVN B revealed that Resident #10 had been on an alternative formula until the Nutren 2.0 was available, allowing for changes with his feedings and water flushes. LVN B stated any changes with Resident #10's formula or water flow rate should be updated in the care plan by the nursing staff which could include the charge nurse, ADON C or the DON. LVN B stated not doing so could place Resident #10 at risk of receiving the wrong flow rate. Interview on 09/18/25 2:02 PM with ADON C revealed nursing staff were responsible for updating acute changes on the care plan and the MDS Coordinator was responsible for updates during comprehensive reviews. The ADON stated she was not aware that Resident #10's care plan was updated with accurate water flushing. ADON C stated not having the care plan updated could place Resident #10 at risk for not getting the correct amount of hydration. Interview on 09/18/25 at 2:45 PM with the DON revealed Resident #10 had use of tube feeding machine, his expectation was if there was a change in condition or resident status the charge nurse was responsible for updating the care plan. The DON stated when there were any updates or changes, it was brought to the morning meetings and discussed daily. The DON stated a change in formula or water flush rates would be something that he would expect the charge nurse to update on the care plan and the ADON C or himself would review. The DON stated not updating the care plan could place residents at risk of not receiving the personalized care they desire. Interview on 09/18/25 at 4:18 PM with the MDS Coordinator revealed she had been employed for 3 weeks. She stated she was responsible for care plans and the ADONs and DON were responsible for reviewing them and updating care plans. MDS Coordinator stated residents on tube feeding and water flushes should be care planned for it. She stated she was not aware Resident #10's care plan was not updated with the new orders for water flushes. The MDS Coordinator stated, she updated care plans quarterly during the care plan meetings when the resident, family and staff are together to discuss residents' required care. She stated the potential risk would be staff not aware of the interventions that were put in place and dehydration. Record review of facility Care Plans, Comprehensive Person-Centered policy, revised date March 2022, reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with subsection (a) of this section for the following activities of daily living, hygiene (grooming) for 1 of 5 residents (Resident #67) reviewed for ADL care. The facility failed to provide Resident #67 assistance with nail care. Resident #67 nails were observed to be about half inch long with black debris under nails on both hands. This failure could place the residents at risk for decreased feelings of self-worth and infection. Findings included:Record review of Resident #67's Quarterly MDS assessment, dated 08/02/25, reflected the resident was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted [DATE]. Resident #67 had cognition intact with a BIMS score of 99 (indicating he was not able to complete interview). Resident #67 was dependent on staff with shower/bathe self, and personal hygiene. Active diagnosis included Non- Alzheimer's Dementia (memory loss), bipolar disorder (mood swings of emotional highs and lows). Record review of Resident #67's current, undated care plan reflected Resident #67 had a self-care performance deficit. The resident required more assistance /cueing with activities of daily living skills. The care plan reflected: Goal: [Resident #67] will maintain current level of function in personal hygiene. Interventions included Bathing/Showering: Check nail length, trim and clean on shower days and as needed. Staff will be aware that resident require more assistance with activities of daily living and provide additional cueing and redirection. Observation and interview on 09/16/25 at 2:06 PM with Resident #67 revealed him in his room sitting in his wheelchair. His nails were at least half inch long with black debris underneath and around the nail bed. Resident #67 stated he was unsure of the last time staff assisted with trimming or cleaning his nails. According to Resident #67 his nails were long and would not mind if someone helped him to cut them down, however he was not bothered by them being dirty. Interview on 09/18/25 at 10:24 AM with the Staffing Coordinator revealed Resident #67's nails were dirty and need to be trimmed. The Staffing Coordinator further stated [Resident #67] is a combative person, however when I care for him I usually will take a towel and clean up under his nails. Nail days are on Sundays, CNAs are responsible for cleaning nails, if residents are not diabetic, on Monday, Wednesday, and Fridays during his shower. The Staffing Coordinator stated not providing nail care to residents could place them at risk for infections, especially someone like Resident #67 because he is a digger, so that is poop underneath his nails. Interview on 09/18/25 at 10:37 AM with CNA F revealed she was not currently working with Resident #67, but resident nail care was to be completed during shower days. She stated she usually paid attention to resident nails daily and would clean or trim them if needed. CNA F revealed it was the responsibility of the aides to complete nail care and grooming for residents on their respective halls and not doing so placed residents at risk of scratching or cutting themselves or others. Interview on 07/24/25 at 1:26 PM with ADON C and the DON revealed they both expected residents to have hand hygiene which included nail care. ADON C stated it was the responsibility of the CNAs to complete nail care if residents were not diagnosed with Diabetes, otherwise the charge nurse would trim and clean resident nails, or resident would be referred to podiatry. According to the DON, previously there was an CNA that was responsible for completing nail care on all residents, that was her specific task, however she has been on maternity leave, so the failure is that no one else has been assigned or has continued that task. Both ADON C and the DON stated not having a plan in place to continue nail care for residents placed them at risk of infections and skin tears. Record review of the facility's Activities of Daily Living (ADL), Supporting policy, updated February 2025, reflected: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene - (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, based upon the comprehensive person-centered care plan and the residents' choices for 1 of 3 residents (Residents #52) reviewed for wounds. The facility failed to follow physician orders for the treatment of the surgical wound on Resident #52's left foot, to include failing to properly wrap the foot and ensure the nurses initialed and dated the dressing. This failure could place residents at risk of not receiving the care and services to meet their needs. Findings included:Record review of Resident #52's MDS, dated [DATE], reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #52 had a BIMS score of 14 indicating his cognition was intact. The assessment reflected Resident #52 had a surgical wound with treatments that included pressure reducing device for bed, turning/repositioning program, nutrition, or hydration intervention to manage skin problems, surgical wound care. Diagnoses included Amputation (surgical removal of a limb or body part), encounter for other orthopedic aftercare (used when patients require follow up care after orthopedic procedures or treatments), other chronic osteomyelitis (bone infection that is not completely cured after treatment and can reoccur), right ankle and foot, lack of coordination, acquired absence of other left toes, unsteadiness on feet. Record review of Resident #52's care plan, undated, reflected: Resident has an acquired amputation of Left, forefoot amputation related to gangrene. Measurement 14 X 2 X not measurable cm. Goal: The resident will exhibit adequate coping skills dealing with loss of limb and rehabilitation. The resident will have an acceptable level of comfort and have well-controlled phantom pain. Surgical site will heal with no complications. Interventions included check and document on wound daily for signs and symptoms of infection, drainage, bleeding, any breakdown of skin and impaired circulation (edema or pain). Encourage resident to be an active participant in the rehabilitation process, to set goals that rea realistic and achievable. Give analgesics as ordered by physician. Monitor/document for side effects and effectiveness. Physical therapy and occupational therapy to evaluate and treat as ordered. Apply lodosorb (a gel containing cadexomer iodine use to treat wounds) daily and wrap with gauze roll and apply kerlix. Record review of Resident #52 care plan, undated, reflected Resident has an actual impairment to skin integrity of the left distal foot r/t postsurgical wound. Goal: Resident will have no complications r/t post-surgical wound of the left distal foot. Interventions included: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of injury. Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration to physician. Record review of Resident #52's care plan, undated, reflected Resident has a post-surgical wound of the right, medial foot. Resident's post-surgical wound of the right medial foot will have no complications. Interventions included: Encourage good nutrition and hydration in order to promote healthier skin. Monitor/document location, size, and treatment of wound. Report abnormalities, failure to heal, signs and symptoms of infection, maceration to physician. Record review of Resident #52's physician orders, dated 09/11/25, reflected: 1. Post-surgical wound of the left, distal foot: Cleanse area with N/S, pat dry and apply. Iodosorb and cover with alginate as then wrap with kerlix For 30 days every day shift every Monday, Wednesday, Friday for surgical wound on the left distal foot for 30 Days start date 09/12/25 - 10/12/252. Post-surgical wound of the right, medial foot: Cleanse area with N/S, pat dry and apply iodosorb once daily and cover with kerlix and ace wrap. every day shift every Mon, Wed, Fri for Wound Active 09/11/2025 start 09/12/2025 with no end date. Observation and interview on 09/16/25 at 11:43 AM revealed Resident #52 lying in bed, according to Resident #52 he has had all his toes removed during surgeries. Observation of resident's right foot revealed there was no dressing. Resident #52 stated his right foot has healed and looked good so staff was no longer wrapping his right foot. Resident #52 stated he had a surgical wound on his left foot, observation revealed the wrap to be loosely wrapped around Resident's left foot and ankle. There was a deep red area at the toes, gauze was not in place and the wrap was not supporting the wound. According to Resident #52 the deep red color at the toe area was betadine. Resident #52 stated there was a guy that came in and changed it on 09/14/25, and it had not been changed since. Resident #52 denied any pain. Interview on 09/18/2025 at 10:22 AM with the Wound Care Nurse revealed he has had only 2 days into the wound nurse position. The Wound Care Nurse stated he was aware that Resident #52 had a wound to his left foot due to his toes being removed. The Wound Care Nurse stated Resident #52 had orders for treatment on Monday, Wednesday, and Friday. According to the Wound Care Nurse he was responsible for providing wound care for residents, however if he was not in the building charge nurses would complete the care. Observation and interview on 09/18/25 at 2:30 PM with the Wound Care Nurse revealed Resident #52's left foot was fully wrapped with an intact dressing. The toe area had soiled through dressing and onto the top sheet. The Wound Care Nurse stated he last changed Resident #52's dressing on 09/17/25. When asked about the time prior, he stated, it was 09/15/25. The Wound Care Nurse further expressed the manner in which Resident #52's left foot was dressed and wrapped when he entered on 09/17/25 was not ok, he stated that the dressing must have came off over night and the nurse on the floor redressed it. The Wound Care Nurse stated when wound care was provided by himself or charge nurse staff initials and date must be identified on the wound. The Wound Care Nurse stated he was responsible for ensuring Resident #52's treatment and dressing was completed according to physician orders, not doing so placed Resident #52 at risk for infections and missed treatments. Interview on 09/18/2025 at 2:35 PM with ADON C revealed she was not aware of any concerns with Resident #52's wound or dressing. ADON C stated it was her expectation that the Wound Care Nurse provided treatment for Resident #52's wound care according to physician orders. ADON C further stated nurses were also responsible to address any dressing concerns if the Wound Care Nurse was not present, once treatment was completed staff initials and the date should be indicated on the wound dressing along with updated clinical records that treatment had been completed. ADON C stated when staff do not place their initials or the date on the dressing it placed residents at risk of infections. Interview on 09/18/25 at 3:52 PM with the DON revealed the Wound Care Nurse was responsible for wound care treatments, if the Wound Care Nurse was not available charge nurses were responsible for treatment if there was a need. The DON stated he expected wounds to be treated according to the physician order, after treatment staff were to include their initials and the date. The DON stated staff not including their initials and the date placed residents at risk of infection and missed treatments. Record review of the facility's current, undated Wound Care policy and procedure, reflected the following: The purpose of this procedure is to provide guidelines for the care for wounds to promote healing.

Based on observation, interview and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #10) reviewed for tube feeding management.The facility failed to label and date Resident #10's tube feeding formula and water bags to indicate when the feeding was started.This failure could place residents receiving tube feedings at risk of gastrointestinal disturbances (relating to the stomach and the intestines), and bacterial infection. Findings included:Record review of Resident #10's MDS quarterly assessment, dated 08/07/25, reflected Resident #10 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10's MDS assessment reflected Resident #10's BIMS score of 00 indicating resident was not able to complete the interview. Resident #10's MDS indicated he had parenteral/IV feeding and feeding tube while a resident of the facility. His diagnoses included paraplegia (inability to move or control the legs and lower body), contracture of muscle right and left lower leg (muscles or other tissues tighten or shorten causing deformity), unspecified protein-calorie malnutrition (inadequate intake of protein and calories), dysphagia (difficulty swallowing), gastrostomy status (an opening in the stomach through the abdominal wall, allowing for the placement of a feeding tube). The MDS reflected Resident #10 was dependent on staff for eating and all activities of daily living skills. Record review of Resident #10's care plan, last reviewed/revised 10/05/21, revealed Resident #10 had an impaired nutritional status. Goal: Resident #10's intake of nutrients will meet metabolic needs . Interventions included to consult a dietician per order. Educate Resident to consume high-calorie foods first. Encourage intake of nutritional supplements between meals. Record review of Resident #10's care plan further indicated Resident #10 had an Activity of Daily Living Skills performance deficit. Goal: will maintain or improve current level of function in eating. Interventions included eating: required 1 staff assistance. Record review of Resident #10's care plan also indicated Resident #10 has alteration in gastrointestinal status (G-Tube) related to Dysphagia; Nutren 2.0 at 44 cc/hr x 22 hours and 100 water flush every hour. Goal: Resident #10 will remain free from discomfort, complications, signs, or symptoms related to gastrointestinal alterations. Interventions included Keep Head Of Bed elevated. Give medications as ordered. Monitor/document side effects and effectiveness. Monitor vital signs as ordered/per protocol and record. Notify physician of significant abnormalities (rapid pulse, shallow, rapid, or labored respirations, low blood pressure). Obtain and monitor lab/ diagnostic work as ordered. Report results to physician and follow up as indicated. Revision on: 05/08/2025.Resident #10's care plan also noted he required tube feeding related to Dysphagia calorie requirements changed and new order received for 1. Nutren 2.0 at 44mL/hr x 22hr 2. Water flush at 50mL/hr x 22hr. Provides 1936kcal, 968mL formula, 1770ml Total water. Revision on: 04/18/2025 Goal: Resident #10 will remain free of side effects or complications related to tube feeding. Interventions included to Clean insertion site daily as ordered, monitoring for signs and symptoms infection or breakdown such as redness, pain, drainage, swelling, and/or ulceration and report to physician if symptoms arise. Discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications. Monitor/document/report to Physician PRN: Aspiration- fever, Short of Breath, Tube dislodged. Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. NPO status Revision on 04/23/2025 1. Nutren 2.0 at 44mL/hr x 22hr 2. Water flush at 50mL/hr x 22hr. Provides 1936kcal, 968mL formula, 1770ml Total water (not counting med flushes). Obtain and monitor lab/diagnostic work as ordered. Report results to Physician and follow up as indicated. Provide local care to G-Tube site as ordered and monitor for signs and symptoms of infection. Registered Dietitian to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. The resident is dependent with tube feeding and water flushes. See physician orders for current feeding orders. The resident needs assistance with tube feeding and water flushes. See physician orders for current feeding orders. The resident needs the Head of Bed elevated 30 degrees during and thirty minutes after tube feed.Record review of Resident #10's physician's order for feeding revealed one time a day Nutren 2.0 at 44mL/hr via PEG, up at 1200pm until total volume of 968mL has been infused. Provides 1936kcal. FWF 70mL/hr x 22hrs. Total volume= 1540mL fluid. Enteral Feed Order Active as of 9/16/2025. Observation of Resident #10 on 09/16/25 at 11:18 AM revealed him sitting in the television room. Resident #10 was not connected to his tube feeding machine, it was left in his room. Observation of Resident #10's room revealed his tube feeding machine was currently off, the formula bag was dated 9/15/25 12:30 PM with rate of 44ml, water was dated 09/15/25 12:30 PM rate 70ml.Observation of Resident #10 on 09/16/2025 at 1:12 PM revealed him in the bed with staff checking for tube placement, residual and connecting the tube for his feeding. Observation of Resident #10 on 09/16/2025 at 1:54 PM revealed Resident #10 in bed, observation of feeding machine revealed 44ml 1698, water flush 70 ml. Resident #10's formula bag or water bag did not indicate the date, time, initials, or rate.Observation and interview on 09/17/2025 at 12:15 PM with LVN B revealed him working with Resident #10. LVN B checked for placement of the feeding tube, checked for residual, and connected Resident #10 to the tube feeding machine. LVN B was observed prior to leaving the room writing information on the formula bag and the water bag. Interview with LVN B revealed he did not write Resident #10's name, date, flow rate, his initials or the time formula was administered on either bag on 09/17/25. According to LVN B every feeding and water bag should have written the patient's name, date, time, the flow rate, and nurse initials so that the next nursing staff could follow up if needed. LVN B stated he was responsible for ensuring the clinical information was on both the formula and water bags, however thought it was done for each administration. LVN B stated not doing so could place residents with feeding tubes at risk of receiving the wrong flow rate, malnutrition, or dehydration.Interview on 09/18/25 2:02 PM with ADON C revealed Resident #10 was on tube feeding 22 hours a day, his machine was turned off at 10:00 AM and turned back on at 12:00 PM. ADON C stated nursing staff were responsible for taking Resident #10 off his feeding machine, hooking him back to his feeding machine with a new bag of formula and water according to physician orders. ADON C stated nurses from the next shift, ADON C and the DON were responsible to follow up and monitor residents throughout their shifts to ensure residents on tube feedings were provided with the correct formula and flow rates. ADON C stated her expectations included checking for placement of the tube, checking for residual and connecting the feeding tube. ADON C further stated she expected nurses to include clinical information on the formula and the water bag that included resident name, date, time, flow rate and nurse initials. ADON C stated not doing so placed Resident #10 at risk of feeding from outdated formula and water, diarrhea, infections, and unwanted side effects. ADON C stated nurse from the next shift, ADON C and the DON were responsible to follow up and monitor residents throughout their shifts. During an interview on 09/18/25 at 3:52 PM with the DON revealed he was aware Resident #10 utilized tube feeding for nutrition. The DON stated nurses on the floor were responsible for ensuring resident name, date, time, flow rates and staff initials were written on the formula and water bags during administration. The DON said it was important for Resident #10's tube feeding to have been properly labeled, not doing so placed him at risk of feeding errors and not following physician orders. Record review of the facility's policy revised November 2014, updated February 2025 Physician Orders policy reflected: Purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services. Enteral Orders - when recording orders for enteral tube feedings, specify the type of feedings, specify the type of feeding, amount, frequency of feeding and rationale if as needed. The order should always specify the amount of flush following the feeding. Record review of the facility's policy revised November 2018, Enteral Nutrition revealed The recommendation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment and is consistent with current standards of practice.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 2 residents (Residents #4 and #52) reviewed for infection control during medication administration. MA E failed to disinfect the blood pressure cuff in between blood pressure checks for Resident #4 and Resident #52. These failures could place residents at risk of cross-contamination which could result in infections or illness. Findings included: Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included hypertension (high blood pressure) and heart failure (a serious condition but not the same as a heart attack, where blood flow to the heart is suddenly blocked). He had a BIMS score of 13 which indicated his cognition was intact. Record review of Resident #52's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #52 had diagnoses which included hypertension (high blood pressure). He had a BIMS score of 14 which indicated his cognition was intact. Observation on 09/17/25 at 7:58 AM revealed MA E did not disinfect the blood pressure cuff after she checked the blood pressure for Resident #52. She went directly from Resident #52's room to Resident #4's room and checked Resident #4's blood pressure without disinfecting the blood pressure cuff. Interview with MA E on 09/17/25 at 8:39 AM revealed she did not disinfect the blood pressure cuff between Residents #52 and #4. She stated she knew she was supposed to disinfect between residents. She stated she forgot because she was nervous. She stated failure to disinfect between residents could lead to cross contamination and infection. She stated she had done training on infection control, on her other job. Interview with the DON on 09/18/25 9:07 AM revealed his expectation was for staff to disinfect blood pressure cuffs between each resident due to risk of cross contamination and infection. He stated the facility had done in-services on disinfecting of equipment, but he could not recall when. He stated he was supposed to be doing spot checks on staff for equipment disinfection, but he could not recall when he checked on staff last. Record review of the facility's training records for infection control, dated 07/02/25, revealed (disinfect the blood pressure cuff between residents) MA E, was not in attendance. Record review of the facility's policy for standard precautions, dated 2022, reflected, 5. Resident-Care Equipment: - Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's one and only kitchen reviewed for food and nutrition services. The facility failed to ensure the four steamtable compartments in the kitchen were clean and free of debris before food was placed in them.This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included:Observation on 07/09/25 at 9:10 AM of the facility's only kitchen revealed the four steamtable compartments had food and debris floating in them.Observation on 07/09/25 at 11:00 AM of the facility's only kitchen revealed the four steamtable compartments had food and debris floating in them. The steamtables had the following: the first one had a tray of sausage jambalaya; the second one had capri vegetables and fortified mashed potatoes; the third one had mechanical soft sausage jambalaya and brown gravy; the fourth one had pureed vegetables, pureed bread, Salisbury steaks, and pureed jambalaya.Interview on 07/09/25 at 11:15 AM with the DM revealed she saw the food and debris in the steamtable compartments and mentioned that they would be cleaned after the lunch service had ended. Interview on 07/09/25 at 12:30 PM with the DM revealed normally the steamtable compartments were cleaned at the end of each shift, which would have been after lunch and after dinner. The DM said usually it was the cook who cleaned the steamtable compartments. The DM said the steamtable compartments did not get cleaned between breakfast and lunch services. The DM said she normally checked the steamtable compartments daily to ensure they were cleaned as they were supposed to be. The DM said she saw the food and debris floating in the steamtable compartments before the lunch service earlier, but the lunch meal was already on the line waiting to be served. The DM said the steamtable compartments should be cleaned before food was placed on it to be served. The DM said if the steamtable compartments were not cleaned, bacteria could get in the food. The DM said all staff had been trained to ensure the steamtable compartments were cleaned before service and that was her expectation. Review of the facility's Environment policy, dated May 2014, reflected: 1. The Food Service Director will insure [sic] that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces .

Based on observation, interview, and record review, the facility failed to ensure the menus were followed for 1 (the lunch meal on 07/09/25) of 1 meal reviewed for food and nutrition services.The facility did not serve the posted lunch menu of cornbread and seasoned okra. This failure could affect all residents in the facility, who eat from the kitchen, by placing them at risk of not knowing what was going to be served for that meal. Findings included:Observation on 07/09/25 at 10:15 AM of the menu posted in the dining room reflected for 07/09/25 the following: Sausage Jambalaya, Seasoned Okra, Cornbread, and a Brownie.Review of the facility's Week-At-A-Glance 2025 Week 3 for Wednesday reflected the following: Sausage Jambalaya, Seasoned Okra, Cornbread, Double Chocolate Brownie.Interview on 07/09/25 at 10:40 AM with Resident #1 revealed when he received his food, he was not sure what would be served because the menu did not match what was served to him often. Interview on 07/09/25 at 10:45 AM with Resident #2 revealed when she received her food, she was not sure what would be served because the menu did not match what was served to her. Observation and interview on 07/09/25 at 11:00 AM with the DM revealed the steamtables in the kitchen had the following food items which would be served for lunch: sausage jambalaya, sliced bread, and capri vegetables which included green beans, carrots, squash, and zucchini. Interview on 07/09/25 at 12:30 PM with the DM revealed she always tried to follow the menu and serve what was on it for the residents. The DM said for today's (07/09/25) lunch meal, she did substitute the cornbread with sliced bread and okra with capri vegetables. The DM said she had to do that because the cornbread box that was delivered appeared as if it was open so it was not usable and it was not replaced in time to serve it with the meal. The DM said as for the okra, it was used for another meal earlier in the week and she did not have enough to serve with lunch today (07/09/25). The DM said the if the kitchen did not serve what was posted on the menu, it could be confusing for residents because it did not match. The DM said the cook posted the menu, but if there were changes that needed to be made, she usually included that in the posted menu so residents knew what they would be served that day. The DM said she expected the menu to match what the residents were being served that day. The DM said all staff had been trained to make sure that the posted menu matched what was being served for that meal that day.Review of the facility's Menus policy, dated May 2014, reflected: .6. Menus are served as written, unless changed in response to preference, unavailability of an item, or a special meal.8. Menus are posted in the nutrition services department, dining rooms and resident/patient care areas.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 1 resident (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure MAs and nurses were following physician orders for administering Resident #1's Lidocaine Patch 4%, which was used for preventing pain, on 05/04/25. This failure could put residents at risk of not receiving their medications as ordered. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 03/24/25, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included age-related osteoporosis without current pathological fracture (a condition where bone density and mass decrease significantly due to the natural aging process, increasing the risk of fractures). The resident's cognition was moderately impaired with a BIMS score of 8. The MDS reflected the resident received a scheduled pain medication regimen. Record review of Resident #1's care plan, dated 08/15/24, reflected Resident #1 has Acute Pain / Chronic Pain. Goal:-she Will Report Satisfactory Pain Control. Interventions:- Educate Resident / Representative on prescribed analgesics and / or anti-inflammatory medications Record review of Resident #1's May 2024 Physician Orders dated 1/24/2025 reflected the following: Lidocaine Pain Relieving External Patch 4% (Lidocaine). Apply to right hip 1 patch topically one time a day for PAIN and remove per schedule. Record review of Resident #1's May 2025 MAR revealed reflected LVN C worked on 05/04/25 and had signed on the MAR that he had removed the resident's patch at 5:59 PM. Observation on 05/06/25 at 11:40 AM revealed Resident #1 had two lidocaine external patches on her right hip, one was dated 05/04/25 and the other was dated 05/06/25. The resident's skin was intact. Observation and interview with MA B on 05/06/25 at 11:50 AM revealed Resident #1 had two lidocaine patches on the right hip. MA B stated Resident #1s patch was supposed to be applied in the morning at 6:00 AM and then removed at 5:59 AM as per the order. She stated it was the responsibility of the nurse and herself to apply and remove the patch. She stated she worked on 05/04/25 and the patch was applied by the night shift nurse before she left after her shift and that evening she had left early. She expected the nurse to remove the patch because they use the same MAR and anytime the patch was due for application or removal it will pop on the electronic record showing as due. She stated she was the one that applied the patch on 05/05/25 and denied seeing the one dated 05/04/25. She stated failure to remove an old patch before applying a new could lead to overdose. She had done in-service on medication administration. An interview was attempted via telephone with LVN C on 05/06/25 at 2:20 PM; however, the attempt was not successful. A voicemail message was left without a return call back from LVN C. Interview with RN D on 05/06/25 at 2:57 PM revealed she was the one, who had removed the patch 05/05/25 in the evening, for Resident #1. She stated she did not see the old patch dated 05/04/25. RN D stated she was aware she was supposed to remove the old patch before administering the new one. She stated the risk of not removing the old patch was over medication and skin irritation. RN D stated she had done in-services on medication administration. Interview with the DON on 05/06/25 at 4:34 PM revealed his expectation was that nurses and MAs should remove the old patch before applying the new patch. He stated failure to remove the old patch would lead to overdose and skin irritation. He stated facility had done in-service on medication administration but not on patches removal. Record review of the facility medication administration in-service record, dated 04/23/25, reflected MA B, LVN C and RN D were in attendance. Record review of the facility's current Pharmacy Services policy, dated April 2019, reflected: .4.Medications are administered in accordance with prescriber orders, including any required time frame The policy did not address patch administration and removal. The DON stated they did not have a policy that addressed patch removal.

Based on interview and record review, the facility failed to ensure personnel provided basic life support, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 8 residents (Resident #11) reviewed for CPR. LVN A failed to initiate CPR when Resident #11 did not have a State recognized advance directive which meant the resident was a Full Code status, and he was found on the floor on the fall mat with his face noted to be reddish purple, weak pulse with no obvious respirations or breathing patterns noted. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:45 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could affect the residents by placing them at risk for a delay in intervention and life-saving treatments, which could result in death. Findings included: Record review of Resident #11's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke, heart failure, high blood pressure, diabetes, aphasia (language disorder), alcohol abuse, other psychoactive substance abuse, and cerebral ischemia (condition where the brain does not receive enough blood flow, leading to a lack of oxygen and nutrients). Resident #11's cognition was moderately impaired with a BIMS score of 11. The MDS further reflected the resident required assistance with most all ADLs. Record review of Resident #11's care plan revised on [DATE] reflected he was a full code. Interventions included to initiate basic life support CPR if the resident was without a heartbeat or not breathing. Record review of Resident #11's progress notes dated [DATE] documented by LVN A reflected the following: 8:45 PM Upon walking halls in observation of residents, this nurse, upon peeping into res room, noticed resident in prone position while on landing mat appearing asleep. Called res name while attempting to clear visual of res and/or breathing pattern while entering room. After reaching resident, head noted on pillow slightly tilted, face abnormal in color appearing reddish purple. Neck palpated. Weak pulse ascertained. Sternal rub to no avail. No obvious respirations or breathing pattern noted. Nurses X2 assisted res to bed as other nursing staff initiated Emergency response while simultaneously checking resident's code status. During this time at res bedside, O2 initiated and continued efforts were made to arouse res. by this nurse. Res, per demographics in echart, reported to be a DNR as relayed by additional staff. 9:00 PM Emergency response noted in facility in resident's room. Writer informed first responders of said code status as documented in echart. Cpr initiated by fire dept pending receipt of physical copy of advance directives with md signature. This nurse continued to obtain signed verification of code status while calling resident's [family] several times at both listed numbers to no avail. Resuscitation efforts continued awaiting requested info. Spoke with Resident #11's [friend] first contact to notify of incident. Speaker was aware of res code status but did not know specifics, he stated. [sic]Contnued to try to reach [family] in which after approximately 15 min did answer. Was informed by resident's [family] who is listed as surrogate per [county] stated in hospital dnr received upon admission [DATE] that is was resident's wishes to decline life saving measures in the event res codes or is incapacitated, he explained. Per fire dept, they were attempting to reach [family] in which I did notably transfer call to fireman to confirm res code status as explained. [Family] spoke with said fireman in which he stated twice that I was his father's request to not be resuscitated. Emergency did inform res [family] that they would be ceasing resuscitation in 15 min 9:15 PM .Cellphone was brought to this nurse by fire dept in which their medical director stated the requirements of dnr also informing me that the issue 'would be moved up' in chain due to our inability to produce said document During conversation with their medical director I, in fact had located hospital dnr signed by NP with surrogate [family] present and in aggreeance with resident's wishes to not perform 'life saving measures' decision was made by the fire dept to transfer res to ER also stating 'we would probably get a visit tomorrow morning' This nurse stated to fire dept [family] was awaiting on line in which he then informed to tell [family] they were transferring him to hospital after obtaining signs of life after resuscitation because we could not produce documentation Record review of Resident #1's monthly physician orders for February 2025 reflected LVN B input an DNR order on [DATE]. Further review of Resident #1's electronic health record reflected there was not a State recognized Advance Directive nor an Out-of-Hospital DNR for Resident #1. Record review of Resident #11's hospital form titled Medical Orders for Scope of Treatment dated [DATE] signed by a nurse practitioner reflected A Do Not Attempt Resuscitation/Allow Natural Death .D. Direct conversation with surrogate decision-maker/proxy for incapacitated patient Surrogate/Proxy Name: [Resident #1's family] Relationship: Adult Child Primary Contact Number: Designated in: Texas Statutory Surrogate Signature of Physician [NP] Date and Time: [DATE] 4:08 PM Record review of Resident #11's Fire Department Run Form dated [DATE] reflected the following: A Physician Resuscitation Order: Has no pulse or is not breathing. Do Not Attempt Resuscitation/Allow Natural Death Narrative: Subjective Medic was called for a reported breathing problem at 1500 [Facility] in the [City]. Call notes stated 'faintly breathing//currently getting oxygen', 'patient is confused' 'patient has dementia'. On arrival, a [AGE] year old male made was found in cardiac arrest. Staff stated the patient has a DNR. Staff later stated they could not find the DNR. Multiple attempts to contact patient's family were unsuccessful. Objective: At 20:57, the patient was lying supine on the bed. A NRB was on the patient's face, placed by staff, with oxygen connected but no staff was nearby. Initial assessment revealed the patient was pulseless and apneic (a condition where breathing temporarily ceases). The patient's skin was mottled by warm. The patient had no visible trauma or external bleeding. Assessment: The field impression of the patient was Cardiac Arrest Plan: Upon finding the patient pulseless and apneic a 4-lead was established (a diagnostic tool that uses four electrodes to record the heart's electrical activity) and the patient was confirmed to be in asystole (a cardiac arrest that occurs when the heart stops beating and there is no electrical activity. After the staff stated that they could not find the DNR, the patient was transferred to the ground and CPR was initiated. Using the face sheet, family was contact was attempted but failed After 15 minutes of ACLS (Advanced Cardiac Life Support- a set of medical procedures and skills used to treat cardiac emergencies) the patient had a rhythm change for asystole to PEA (Pulse Electrical Activity - type of cardiac arrest where the heart's electrical activity is present, but there is no pulse) Due to the change in rhythm and rate of PEA, medical direction instructed us to transport the patient to the ER No further change in rhythm was noted throughout transport. Upon arrival at the ER the resident was transferred from the stretcher to the hospital bed The medical director checked heart motion and continued CPR for two more minutes before ending resuscitation attempts. Multiple attempts to contact LVN A on [DATE] and on [DATE] were unsuccessful. Attempts to contact Resident #11's family on [DATE] were unsuccessful. Interview on [DATE] at 1:21 PM with the Social Worker revealed Resident #11 was a full code and did not have DNR paperwork. The Social Worker said someone in the family said they had been discussing Resident #11 become a DNR but that was a far as that went, and nothing else was said . Interview on [DATE] at 4:24 PM with LVN C revealed LVN A said she was making rounds, [DATE], when she found Resident #11 unresponsive, and he had gone to assist and noticed he had a weak pulse. The resident's lips were blue, and he was not responding. LVN C said they checked the computer, and it showed the resident was a DNR and 911 was called. When EMS arrived, they asked for Resident #11's DNR paperwork and they were not able to produce it, so EMS started CPR as LVN A and LVN C continued to look for the DNR. LVN C said that because they thought Resident #11 was a DNR, the AED machine was not applied. LVN C further stated he heard one of the EMS staff members say Resident #11 had flatlined when they put the machines on the resident . Interview on [DATE] at 1:29 PM with the ADON revealed she was not aware CPR had not been initiated on Resident #11 on [DATE] and if the resident was a full code, then CPR should have been initiated . Interview on [DATE] at 2:07 PM with the DON revealed he was told Resident #11 had coded, [DATE], and had been found unresponsive. The DON said the resident just returned from the hospital, [DATE], and with a DNR but it was not an Out of Hospital DNR. Based on the progress notes, had read Resident #11 had a weak pulse, put oxygen on, and staff dialed 911. The DON said it appeared the AED was not used because the resident still had a pulse. The DON also said it appeared LVN A was unsure if Resident #11 was a full code. The DON further stated the staff could have used the AED machine to confirm the resident had a pulse . The DON further stated CPR should have been initiated if a resident was a full code or the code status was unknown. Interview on [DATE] at 5:47 PM with the Administrator revealed the EMS had met with her, because they had a concern, because the staff had gone back and forth whether Resident #11 was a DNR on [DATE]. The Administrator said it appeared they had a hospital DNR on file and the nurse, LVN A, did not know it was not valid in a nursing home. The EMS told her they required an Out of Hospital DNR and the facility staff should have started CPR when Resident #11 was found unresponsive . Interview on [DATE] at 1:18 PM with the Physician revealed Resident #11 was known to the facility and the nurses assumed the resident was a DNR because the resident had a hospital DNR. He said he was glad the resident was not revived because everyone knew that is what Resident #11 wanted. The Physician said nursing homes required Out of Hospital DNR's and that paperwork should be done when the residents were admitted . He further stated if the residents were a full code, CPR should be initiated if they code. Interview on [DATE] at 9:08 AM with the EMS Captain revealed they were called to the facility for a resident having difficulty breathing. When EMS arrived, they found Resident #11 with oxygen on a high flow, and he was not breathing. When the EMS crew put the monitors on the resident, he was flatlined. The EMS staff asked the facility staff if Resident #11 was a full code or a DNR. They were told the resident was a DNR but 20 or 30 minutes later the facility staff were still trying look for the DNR paperwork. When the facility staff finally said they found the DNR it was make shift from a nurse practitioner that was not valid in the state of Texas for a nursing home. He said Texas required an Out of Hospital DNR in a nursing home, otherwise the residents were a full code. The EMS Captain stated they were not able to get a heart beat on the resident and he had to be transported because they were able to get a PEA . They were not able to get in touch with the family so there was no one that could tell them to stop CPR. The EMS Captain further stated, after the incident, he met with the Administrator because he had been concerned there was so much confusion on whether a resident was a DNR or a full code. Record review of the facility's policy titled Emergency Procedure-Cardiopulmonary Resuscitation revised on ,d+[DATE] reflected the following: .6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR .7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR An Immediate Jeopardy/Immediate Threat was identified on [DATE]. The Administrator and DON were notified of the Immediate Jeopardy on [DATE] at 4:36 PM. The IJ template was provided to the facility on [DATE] at 4:45 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on [DATE] at 9:00 AM and reflected the following: Immediate Corrective Action for residents affected by the alleged deficient practice: On [DATE] the resident was noted to be in a prone position appearing asleep during staff rounds. The staff member entered the room and checked the resident who was noted with weak pulse but was unresponsive to sternal rub. At this time the facility called 911, while checking residents code status. The resident was placed on oxygen and efforts were made to arouse the resident who had a pulse. EMS arrived at the facility and began resuscitation efforts for the resident, who was taken to [Hospital] by the EMS team. Actions taken to prevent a serious adverse outcome from recurring: This deficient practice had the potential to affect all residents who reside in the facility, the EMS Captain visited the facility on [DATE] to discuss the incident with the administrator. At this time the administrator completed a code status audit of all residents residing in the facility. All were found to have the appropriate documentation in the miscellaneous section of the chart listed as advanced directives or out of hospital DNRs. The administrator also had the social worker complete a chart audit to double-check that no code statuses were missed. On [DATE] the administrator reached out to the EMS captain to inform him of the results of the audit and thank him for the collaboration with the facility. The director of nursing started an education on Code Status and CPR on [DATE], education continues at present. The director of nursing and administrator were educated by vice president of clinical services on the topics of: Code Status, Out of Hospital DNRs, when to initiate CPR, and when to apply the AED. This education took place on [DATE]. New training initiated on [DATE] will include all nurses. They will be educated on identifying the appropriate code status including out of hospital DNR vs. Hospital DNR, when to initiate CPR, and how to use the AED correctly. The nursing staff checks all residents for orders and appropriate paperwork on code status upon admission/readmission to the facility. This is checked again by the nurse management team in the morning meeting, and the social worker in weekly audits. The administrator and social services director will continue to audit code statuses weekly. All results will be discussed monthly in QAPI. The Medical Director was notified of the deficiency (F678) on [DATE]. When Actions will be complete: The [Facility] will have completed education by [DATE], if any staff member working in the facility is unable to be educated, they will be removed from the schedule until training has been provided. The [facility] requests the removal of the immediate jeopardy on [DATE]. Monitoring of the facility's Plan of Removal included the following: Record review of the facility DNR audit dated [DATE] revealed all residents had the appropriate paperwork if they were a DNR. Record review of 12 current facility residents on [DATE] revealed they had the correct code status, physician order, and Out of Hospital DNR in their clinical file. Record review of in-services dated [DATE] reflected staff were educated on code status, Out of Hospital DNRs, when to initiate CPR, and when to apply the AED. They were also educated to check all residents' orders and appropriate paperwork on code status before they input the order. Interview on [DATE] from 9:53 am to 4:00 PM with staff from various shifts were the Administrator, DON, ADON, LVN A, LVN B, LVN C, LVN D, LVN E, RN F, LVN G, and LVN H. All staff stated they were educated on the following: - On code status - Full code/DNR - Identify the difference between a hospital and Out of Hospital DNR - When to initiate CPR - If code status is unclear, resident is a full code until further notice and CPR will be initiated. - How to apply and use the AED - Verify through orders and paperwork a resident's code status before it is put in the computer system. Interview on [DATE] at 2:28 PM with the Social Worker she was responsible for conducting weekly DNR audits to ensure each resident had the correct code status. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:45 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #6) reviewed for abuse. The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 pushed her on 01/21/25, causing Resident #6 to fall which resulted in a pelvic fracture. An IJ was identified on 03/12/25. The IJ template was provided to the facility on [DATE] at 4:51 PM. While the IJ was removed on 03/13/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk for abuse. Findings included: Record review of Resident #6's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #6's significant change in status MDS Assessment, dated 01/29/25, reflected she had a BIMS score of 06, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included unspecified fracture of sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) and depression. Record review of Resident #6's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #6] had a fall. Was accidentally pushed by another resident. Sent to ER. Record review of Resident #6's Progress Notes reflected the following: 01/21/25 5:36 PM - Resident was pushed to floor by another resident, resident was crying stating her hip hurt, resident was assessed, assisted from floor to dining chair, pain medication administered. DON, MD and RP notified. Stat hip x-ray ordered. Resident is now sittingin [sic] dinning [sic] area, away from other resident eating dinner. Resident stated she has no pain at this time and will let staff know if her hip starts to hurt again. This entry was written by LVN Z. 01/21/25 11:11 PM - X-ray performed at this time awaiting for results. This entry was written by LVN Y. 01/22/25 2:15 AM - Result viewed, No acute fracture, dislocation, destructive bony process noted, result will be relayed to MD by incoming nurse. This entry was written by LVN Y. 01/22/25 9:15 AM - Resident has been sent out to [Hospital X] r/t uncontrolled pain (L) hip. Resident is status post fall 1/22/25. STAT Xray result (L) hip shows No Acute Fracture, Dislocation or destructive bony process. Resident c/o pain (L) hip, Tramadol 50mg prn and Tylenol 650mg was administered for pain. Medication was not effective, resident unable to ambulate as she normally does. Notified [the DON] and resident sent out to ER for [NAME] evaluation. [Resident #6's RP] was also notified. This entry was written by LVN W. 01/25/25 12:15 PM - Resident arrived facility [sic] from [Hospital X] by ambulance via stretcher accompanied by [Resident #6's RP] DX open displaced fracture of anterior wall of left acetabulum [an anterior wall acetabular fracture is a break in the front column of bone or area around the bony rim (wall) of your hip socket].Resident [sic] assisted in bed by two nurses, complained of some little pain, tylenol [sic] 650 mg prn given with positive outcome . This entry was written by LVN V. Record review of Resident #6's hospital records, dated 01/30/25, reflected the following: As Per admission history and physical dated 1/22/2025 Patient is a 84 y.o. female has a past medical history of Dementia (HCC). admitted after fall at care facility resulting in pelvic fracture and difficulty ambulating. [Resident #6's RP] reports [Resident #6] was previously independent, 'very active' and 'walks on her own'. Recently completed PT at facility and 'checked all the boxes', discharged from therapy last Friday [01/17/25]. Fall mechanism- patient reports being pushed by 'lady' and feeling pain 'from the back'. [Resident #6's RP] unaware of circumstances, states facility noticed fall and difficulty walking. Hospital Course/Summary: Ptient [sic] presented after fall unable to bear weight. Found to acute minimally displaced fractures of the anterior left acetabulum, left inferior pubic ramus [describes a type of crack or break in a person's pelvis] and left sacrum . Record review of Resident #6's Radiology Results Report, dated 01/21/25, reflected: Procedure: HIP UNI W OR W/O PELVIS 2-3 V .INTERPRETATION: Findings: No acute fracture, dislocation or destructive bony process. No soft tissue abnormally. Osteopenia. Mild degenerative changes. Conclusion: No acute osseous abnormality. Interview on the phone on 02/27/25 at 11:15 AM with Resident #6's RP revealed Resident #6 was pushed by a different resident and her pelvis was fractured as a result. Resident #6's RP said Resident #6 was admitted to the hospital and the fracture did not require screws or any surgery, so the doctor said it was going to heal on its own. Resident #6's RP said before the incident, Resident #6 was able to walk around freely without the use of a walker or wheelchair and now she was no longer mobile, requiring the use of a wheelchair. Resident #6's RP said Resident #6 was able to stand and take some steps, but it hurt the resident and she was not like she was before. Observation and interview on 02/27/25 at 11:57 AM with Resident #6 revealed she was sitting in a wheelchair at the nurse's station. Resident #6 said she was not in any pain, had never had a fall, and would never let anyone push her. Resident #6 did not appear to be in any pain. Record review of Resident #7's face sheet, dated 02/27/25, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #7's Quarterly MDS Assessment, dated 01/24/25, reflected she had a BIMS score of 03, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included heart failure, non-Alzheimer's dementia, and depression. Record review of Resident #7's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #7] accidentally pushed another resident to the floor. Education completed, Redirected as needed. Goal: [Resident #7] will not harm self or others through the review date. Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #7's Progress Notes reflected the following entries: 01/21/25 5:25 PM - Resident pushed another resident to the floor, no injuries noted to this resident. Resident was separated from resident she pushed to floor. DON, MD, and RP notified. This entry was written by LVN Z. 01/23/25 4:06 PM - .Patient is seen per staff request due to reports of combativeness, and agitation. Patient is up in the dining area, calm at the moment, and in no distress at this time. She reportedly pushed another resident who sustained injuries, requiringhospitalization [sic]. Patient presents with spontaneous disruptive mood, and combativeness. She is alert to self, and unwilling or unable to participate in the assessment at this time .Chart reviewed, medication profile reviewed .Upon review, based on presenting will further increase Depakote and start patient on Atarax 10 mg twice daily as needed for anxiety. Primary nurse notified, will monitor closely. This entry was written by NP LL. Observation and interview on 02/27/25 at 2:00 PM with Resident #7 revealed she was sitting in a chair at a table with other residents around her. Resident #7 said she was doing good today and did not appear to have any behaviors. Interview on 02/27/25 at 11:57 AM with LVN Z revealed she was passing medications when Residents #6 and #7 were having an argument and Resident #7 stood up. LVN Z said before she could get to the area where the residents were at, Resident #7 ended up pushing Resident #6. LVN Z said she assessed Resident #6, gave her some pain medication, took her to her room to assess her, and then brought her back to the dining room to eat dinner and everything was fine. LVN Z said she did not see any obvious signs of injuries and Resident #6's pain seemed to be managed. LVN Z said a STAT x-ray was ordered for Resident #6, she notified Resident #6's RP, the DON, the ADON, and the doctor of the incident. LVN Z said during the assessment, there was not any discoloration or bruising to make her think something was injured but the resident did have a slight limp when she pivoted to sit in the chair. LVN Z said before the incident, Resident #6 was completely and independently ambulatory but the next day she was not able to walk so that nurse on shift sent her to the hospital. LVN Z said at the hospital, they found out she had a pelvic fracture. LVN Z said Resident #7 had not been physically aggressive towards other residents before, only combative during care with staff. LVN Z said Resident #7 did get upset though when people were talking around her, thinking that they were talking to her. LVN Z said she knew the Administrator was the abuse coordinator for the facility and that a resident-to-resident altercation that resulted in injuries would be considered abuse. Interview on 02/27/25 at 12:23 PM with CNA V revealed it was around dinner time while staff were serving trays, and Resident #7 was talking to the air and yelling, and some residents were replying back to her. CNA V said they were trying to calm the residents down and telling them to relax when all of a sudden, she saw Resident #7 get up and storm over to push Resident #6 down. CNA V said she went over to stay at Resident #6's side until LVN Z came over. CNA V said after LVN Z took over, she went to check on Resident #7 who was in her room upset but wanted to be left alone. CNA V said Resident #6 looked like she was injured after being pushed because she was shouting and screaming in pain. CNA V said before the incident occurred, Resident #6 was up and walking around and did not need a wheelchair or walker. CNA V said Resident #7 did not have any physically aggressive behaviors before this incident. CNA V said she knew to report abuse to the Administrator who was the abuse coordinator for the facility. Interview on 02/27/25 at 2:36 PM with the DON revealed he received a report that Resident #6 had a fall and then the resident complained of pain and was sent to the ER. The DON said that another resident (Resident #7) had pushed Resident #6 and she fell . The DON said Resident #6 had a pelvic fracture. The DON said he was notified immediately after it happened and when Resident #6 was sent to the ER. The DON said Resident #7 was a little feisty with staff during care but had never attacked another resident. The DON said he was not sure what happened to make Resident #7 push Resident #6 but that it was an accident and was not intentional. The DON said he talked to Resident #7, and she did not mean to hurt anyone, but a resident-to-resident altercation was considered abuse. The DON said he would have to ask the Administrator if she reported the situation or not. The DON said all residents had the right to be free from abuse and all staff were responsible for making sure residents were free from abuse. The DON said Resident #6 was harmed from the situation because she suffered a pelvic fracture and now required the use of a wheelchair. The DON said Resident #6 was independently ambulatory before the incident. Interview on 02/27/25 at 3:03 PM with the Administrator revealed what she understood was the situation happened in the hallway, LVN Z was standing there and talking with Resident #6 when Resident #7 walked past and bumped her, causing Resident #6 to fall and sustained a fracture. The Administrator said when she spoke to the staff about it, she did not get the impression that it was intentional. The Administrator said Resident #6 was able to ambulate independently before the incident and since the fracture occurred she now used a wheelchair. The Administrator said she did not complete an investigation into what happened because of what she was told by the staff. The Administrator said she only talked to LVN Z about the incident but was not aware she did not see what had happened. The Administrator said she did not speak with CNA V who witnessed the incident between the two residents. The Administrator said she only knew that Resident #6 had a fall, and an x-ray was ordered which had negative results, but she was still complaining of pain. The Administrator said since she was still complaining of pain the facility sent her to the ER and that was when they found out about the fracture. The Administrator said if LVN Z documented that Resident #7 pushed Resident #6 then that was intentional and had a different connotation than an accidental bumping into each other. The Administrator said with the new information regarding the situation, it was considered abuse between two residents. The Administrator said she would have wanted staff to report the incident to her immediately. The Administrator said if she had known the details of the incident, she would have reported it to HHSC. The Administrator said all residents had the right to be free from abuse, even from other residents. The Administrator said everyone was responsible for making sure residents were free from abuse. The Administrator said the purpose of keeping residents safe from abuse was to ensure their continued health and safety. Interview on 03/12/25 at 1:08 PM with LVN W revealed while he did not directly work with Resident #7, he worked on the secured unit and was familiar with her. LVN W said he had never seen or heard about Resident #7 being physically aggressive towards a resident prior to the 01/21/25 incident. LVN W said if Resident #7 started to get agitated he would try to calm her down by redirecting her away from the area or removing the other residents from the area. LVN W said he had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. Interview on 03/12/25 at 1:28 PM with CNA Q revealed while she did not directly work with Resident #7, she worked on the secured unit and was familiar with her. CNA Q said she had never seen or heard about Resident #7 being physically aggressive towards a resident. CNA Q said when Resident #7 started to get agitated she would try to calm her down by redirecting her away from the area or removing the other residents from the area. CNA Q said she had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. Interview on the phone on 03/12/25 at 1:40 PM with RN R revealed she cared for Resident #7 before and knew that sometimes she would get aggressive towards others by yelling at them. RN R said when Resident #7 started to get agitated she would try to calm her down by redirecting her away from the area or removing the other residents from the area. RN R said she had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. Interview on the phone on 03/12/25 at 1:54 PM with CNA S revealed she cared for Resident #7 and knew she had behaviors of yelling at others. CNA S said she had not seen Resident #7 be physically aggressive towards anyone at the facility. CNA S said when Resident #7 started to get agitated she would try to calm her down by redirecting her away from the area or removing the other residents from the area. CNA S said she had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. Interview on 03/12/25 at 2:00 PM with RA T revealed she cared for Resident #7 and knew that she had behaviors of yelling at others. RA T said she had not seen Resident #7 be physically aggressive towards anyone at the facility. RA T said when Resident #7 started to get agitated she would try to calm her down by redirecting her away from the area or removing the other residents from the area. RA T said she had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. Record review of the facility's Course Completion History report from 09/12/24 to 03/12/25 regarding Abuse, Neglect, and Exploitation Training reflected the following: LVN Z had completed the trainings on 11/30/24 and 02/2/25; CNA V had completed the training on 02/11/25. Record review of the facility's incidents/accidents report from 11/27/24 to 02/27/25 reflected there were no other situations that involved Resident #6 or Resident #7. Record review of the facility's policy, revised September 2022, and titled Identifying Types of Abuse reflected: 1. Abuse of any kind against residents is strictly prohibited .4. 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .5. Abuse toward a resident can occur as: a. resident-to-resident abuse . An IJ was identified on 03/12/25. The IJ template was provided to the facility on [DATE] at 4:51 PM. While the IJ was removed on 03/13/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 03/13/25 at 9:45 AM and reflected the following: .F600 Plan of Removal 03/12/2025 Immediate Corrective Action for residents affected by the alleged deficient practice: On 01/21/25 resident #7 was noted to be walking towards her room, at this time she pushed past resident #6 who fell to the ground. Residents were separated by the nurse and redirected. At this time the staff assisted resident #6 up and assessed her, she was medicated for pain. Stat X-rays were called, initial series was negative for fracture. Upon further complaints of pain, the resident was sent to the hospital for additional imaging. The DON, MD, and daughter were notified. These revealed a pelvic fracture for which no surgery was necessary. Resident #6 returned to the facility with no additional injuries noted. Actions taken to prevent a serious adverse outcome from recurring: This alleged deficient practice had the potential to affect all residents who reside in the facility. The medical director was notified of the IJ by assistant director of nursing. On 01/21/2025 MDS nurse care planned a new behavior of aggressiveness towards other residents. With interventions of a psych consult and redirection when agitated, this has not been displayed since the initial incident. Staff will be able to identify this behavior and de-escalation techniques in the future based on the resident's care plan and Kardex. Education on de-escalation techniques will be provided to all staff. A psychiatric consult was called by the medical director for resident #7 to review medications and behaviors, this was completed the next day on 01/22/2025. On 03/12/2025 the Administrator and Director of Nursing were educated on abuse and neglect, resident to resident altercations, and de-escalation of resident behaviors. This was done by the VP of Clinical Operations. Staff were previously trained on abuse and neglect as well as de-escalation of resident behaviors in December, by the administrator and DON and through [facility training software] in January and February. We will continue to educate new staff as they are hired. New educations on abuse and neglect, resident to resident altercations, and de-escalation of resident behaviors were started on 03/12/2025. These were implemented by the DON and the administrator; all staff will be educated prior to the start of their next shift. An Ad Hoc QAPI meeting was held on 03/12/2025 to inform all the management team. The DON and ADON will review resident behaviors daily in morning clinical meetings while viewing the 24-hour report/EMR and then weekly in IDT. This will be monitored monthly in QAPI. When Actions will be complete: The [Facility Name] will have completed staff education by 03/13/2025, if any staff member working in the facility is unable to be educated, they will be removed from the schedule until training has been provided. The [Facility Name] requests the removal of the immediate jeopardy on 03/12/2025. Monitoring of the facility's Plan of Removal included the following: Interviews with the following staff from 03/13/25 at 9:46 AM to 2:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on de-escalation techniques for when a resident has aggressive behaviors towards another resident, abuse and neglect, and resident-to-resident altercations: LVN D, LVN G, LVN U, CNA BB, CNA CC, CNA DD, RA EE, CNA FF, CNA GG, CNA HH, CNA II, MA JJ, RN KK, LVN W, CNA V, CNA Q, CNA M, RA T, the ADON, the DON, and the Administrator. Record review of an in-service sign in sheet, dated 03/12/25, and titled Resident to Resident Abuse reflected 52 staff had been in-serviced. Record review of an Ad Hoc QAPI Agenda, dated 03/12/25, reflected all IDT members were in attendance. Record review of an in-service sign in sheets, dated 03/12/25, and titled Abuse, Neglect, and Misappropriation Policy and Redirection of a resident that is becoming combative with others, reflected both the DON and Administrator had signed. An IJ was identified on 03/12/25. The IJ template was provided to the facility on [DATE] at 4:51 PM. While the IJ was removed on 03/13/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 5 of 40 residents (Residents #3, #5, #8, #9, and #10) and one unit reviewed for a clean environment. 1. The facility failed to keep the Memory Care Unit was free of offensive odors. 2. The facility failed to ensure Residents #3, #5, #8, #9, and #10 rooms were kept in a sanitary and comfortable manner. This failure could place the residents at risk of exposure to infectious material and decreased feelings of self-worth. Findings included: Observation on 02/27/25 at 10:00 AM revealed upon entry to the Memory Care Unit there was a urine odor throughout the unit. Two housekeepers were cleaning rooms on the unit. Observation on 02/27/25 from 10:00 AM-10:30 AM Residents #3, #5, #8, #9, and #10 rooms had dead bugs, food particles, dirt, and debris at the head of the beds and between the bed and the wall. Observation on 02/27/25 at 10:30 AM a third housekeeper and the Housekeeping Supervisor joined the other two housekeepers in cleaning the unit. Interview on 02/27/25 at 12:00 PM with the Housekeeper revealed there were two housekeeprs assigned to the unit every day. He stated they were responsible for cleaning the high touch items like handrails, sweeping and mopping the floors of the resident's rooms, emptying the trash and cleaning the bathrooms. He stated they usually did not pull all the furniture and beds and clean behind them unless they have been told to deep clean a specific room. Interview on 02/27/25 at 12:27 PM with the Housekeeping Supervisor revealed there were two housekeepers assigned to the Memory Care Unit every day and they were responsible for cleaning each room and the common areas. Each housekeeper was also to do a deep clean in one room each day. A deep clean meant moving all furniture, beds, et cetera and cleaning under and behind them. She stated the residents deserved a clean room to prevent insect infestation and for their dignity. She stated she was responsible for following up on the housekeepers and which room they had deep cleaned that day, but she did not track them. Record review of the facility's Resident Rights policy, dated February 2021 reflected: .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence .

Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 8 residents (Resident #12) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #12's debit card when it was taken by CNA I. The noncompliance was identified as past noncompliance. The noncompliance began on 09/18/24 and ended on 09/18/24. The facility had corrected the noncompliance before the abbreviated survey began. This failure could place residents at risk of misappropriation of property. Findings included: Record review of Resident #12's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included diabetes, multiple sclerosis (a chronic autoimmune disease that affects the central nervous system), and anxiety disorder. The resident had a BIMS score of 14 which indicated her cognition was intact. Record review of the facility's Provider Investigation Report dated 09/26/24 reflected the following: [Resident #12's] [family] called to report the resident's debit card stolen and it had been used at three locations in [city] [business] - $54.00 [business] - $157.00 [business] - $48.00 On 09/18/24 the photos from the [business] were sent to the administrator. The DON identified the staff member [CNA I] At the time [CNA I] was suspended and when asked to provide a statement did not [CNA I] has been terminated, the staff have been educated on abuse, neglect, and misappropriation. Interview on 02/27/25 at 11:18 AM with Resident #12 revealed she was in her room in her wheelchair. The resident said her [family] had called her and asked if she had her debit card because it appeared it had been used at several businesses. Resident #12 said she usually kept her card in her purse in the top drawer of her night stand and when she went to look for it, it was not there and there was also $20 missing from her purse. The resident also said it appeared to have been a new staff member that had not worked at the facility long and the day after the incident, a police officer had gone to talk to her about the theft. Interview on 02/28/25 at 1:49 PM with Resident #12's family revealed the resident had a fanny pack in the drawer of her night stand where she kept some of her personal belongings. The family said they noticed there were some charges at three businesses that appeared to be suspicious. so He called the facility so they could check if her debit card was still in the resident's possession, and they noticed it was gone. One of the businesses were able to share their camera footage where the facility management was able to recognize CNA I as the one who had taken and used the debit card. The family also said the debit card was frozen and he pressed charges in hopes that it would not happen to anyone else. Interview on 02/28/25 at 2:28 PM with the Social Worker revealed she had been made aware a staff member had taken and used Resident #12's debit card. She said she did not participate in the investigation but had interviewed other alert and oriented residents to ensure there were no other missing personal belongings and there were no other concerns noted. Interview on 02/28/25 at 2:49 PM with the ADON revealed she had been made aware by the Administrator that CNA I had taken Resident #12's debit card and used it because they had recognized her in the business video footage. The ADON said CNA I was new to the facility and had only worked at the facility for about two weeks. The ADON further stated she was responsible for in-servicing the staff on abuse, neglect, and misappropriation. Interview on 02/28/25 at 3:11 PM with the Administrator revealed Resident #12's family called the facility and asked if someone could check the resident's purse to see if her debit card was in there. The staff went to go look and they were not able to find it anywhere in the resident's room. The family made her aware there had been some fraudulent charges made to the account, so they began their investigation. The Administrator said they had checked the facility camera footage to see what staff had entered the room that day and when the business shared their video footage, they were able to recognize CNA I as the staff member who had used the stolen card. CNA I was called and asked to give a statement, but she refused and denied the allegations even after she was told she had been identified in the business footage. CNA I was terminated, and the rest of the facility staff were re-in-serviced on abuse, neglect, and misappropriation. Interviews with other residents revealed there were no other concerns with misappropriation. Attempts to interview CNA I on 02/28/25 were unsuccessful as the phone number was no longer active. Record review of the facility's policy titled Identifying Exploitation, Theft, and Misappropriation of Resident Property dated April 2021 reflected the following: .1. Exploitation, theft, and misappropriation of resident property are strictly prohibited .4. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent Record review of the facility's in-service titled Abuse; Identifying Exploitation, Theft, Misappropriation dated 09/18/24 revealed 25 staff members participated. Interview on 02/28/25 from 9:53 PM to 2:49 PM with the ADON, LVN B, Activity Director, Housekeeper J, Housekeeper K, Floor Tech, MA L, Restorative Aide, CNA M, CNA N, CNA O, CNA P, LVN D, LVN E, RN F, LVN G, and LVN H revealed they were in-serviced on the types on abuse, neglect, and misappropriation. All staff were able to name the different types of abuse, define misappropriation, and to report any type of abuse to the Administrator who was the abuse coordinator. Record review of CNA I's personnel file revealed she was terminated on 09/18/24 for theft of Resident #12's debit card. Interview on 02/27/25 and 02/28/25 with 12 alert and oriented residents revealed they did not have any concerns/issues with theft or misappropriation.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and misappropriation for 1 of 2 incidents (Resident #6) reviewed for reporting. 1. The facility failed to implement its policy by ensuring LVN Z and CNA V reported an incident of resident-to-resident abuse immediately to the Administrator, who was the Abuse Coordinator, on 01/21/25 when Resident #7 pushed Resident #6, causing her to fall and sustain a pelvic fracture. 2. The Administrator failed to investigate an incident of abuse when Resident #6 was pushed by Resident #7 on 01/21/25 and sustained a pelvic fracture. 3. The Administrator failed to report to HHSC when Resident #7 pushed Resident #6 causing Resident #6 to sustain a pelvic fracture. This failure could place the residents in the facility at risk of continued abuse. Findings included: Record review of the facility's Identifying Types of Abuse policy, revised September 2022, reflected: 1. Abuse of any kind against residents is strictly prohibited .4. 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .5. Abuse toward a resident can occur as: a. resident-to-resident abuse . Record review of the facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating policy, revised September 2022, reflected: Policy statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation; Reporting Allegations to the Administrator and Authorities, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, reflected: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of property and exploitation. This includes but is not limited to freedom of corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; .2. Develop and implement policies and procedures to prevent and identify: a. abuse or mistreatment of residents . Record review of Resident #6's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #6's significant change in status MDS Assessment, dated 01/29/25, reflected she had a BIMS score of 06, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included unspecified fracture of sacrum and depression. Record review of Resident #6's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #6] had a fall. Was accidentally pushed by another resident. Sent to ER. Record review of Resident #6's Progress Notes reflected the following: 01/21/25 5:36 PM - Resident was pushed to floor by another resident, resident was crying stating her hip hurt, resident was assessed, assisted from floor to dining chair, pain medication administered. DON, MD and RP notified. Stat hip x-ray ordered. Resident is now sittingin [sic] dinning [sic] area, away from other resident eating dinner. Resident stated she has no pain at this time and will let staff know if her hip starts to hurt again. This entry was written by LVN Z. 01/21/25 11:11 PM - X-ray performed at this time awaiting for results. This entry was written by LVN Y. 01/22/25 2:15 AM - Result viewed, No acute fracture, dislocation, destructive bony process noted, result will be relayed to MD by incoming nurse. This entry was written by LVN Y. 01/22/25 9:15 AM - Resident has been sent out to [Hospital X] r/t uncontrolled pain (L) hip. Resident is status post fall 1/22/25. STAT Xray result (L) hip shows No Acute Fracture, Dislocation or destructive bony process. Resident c/o pain (L) hip, Tramadol 50mg prn and Tylenol 650mg was administered for pain. Medication was not effective, resident unable to ambulate as she normally does. Notified [the DON] and resident sent out to ER for [NAME] evaluation. [Resident #6's RP] was also notified. This entry was written by LVN W. 01/25/25 12:15 PM - Resident arrived facility [sic] from [Hospital X] by ambulance via stretcher accompanied by [Resident #6's RP] DX open displaced fracture of anterior wall of left acetabulum [an anterior wall acetabular fracture is a break in the front column of bone or area around the bony rim (wall) of your hip socket].Resident [sic] assisted in bed by two nurses, complained of some little pain, tylenol [sic] 650 mg prn given with positive outcome . This entry was written by LVN V. Record review of Resident #6's hospital records, dated 01/30/25, reflected the following: As Per admission history and physical dated 1/22/2025 Patient is a 84 y.o. female has a past medical history of Dementia (HCC). admitted after fall at care facility resulting in pelvic fracture and difficulty ambulating. [Resident #6's RP] reports [Resident #6] was previously independent, 'very active' and 'walks on her own'. Recently completed PT at facility and 'checked all the boxes', discharged from therapy last Friday [01/17/25]. Fall mechanism- patient reports being pushed by 'lady' and feeling pain 'from the back'. [Resident #6's RP] unaware of circumstances, states facility noticed fall and difficulty walking. Hospital Course/Summary: Ptient [sic] presented after fall unable to bear weight. Found to acute minimally displaced fractures of the anterior left acetabulum, left inferior pubic ramus [describes a type of crack or break in a person's pelvis] and left sacrum . Record review of Resident #6's Radiology Results Report, dated 01/21/25, reflected: Procedure: HIP UNI W OR W/O PELVIS 2-3 V .INTERPRETATION: Findings: No acute fracture, dislocation or destructive bony process. No soft tissue abnormally. Osteopenia. Mild degenerative changes. Conclusion: No acute osseous abnormality. Interview on the phone on 02/27/25 at 11:15 AM with Resident #6's RP revealed Resident #6 was pushed by a different resident, and her pelvis was fractured as a result. Resident #6's RP said Resident #6 was admitted to the hospital. The RP stated the fracture did not require screws or any surgery, so the doctor said it was going to heal on its own. Resident #6's RP said before the incident, Resident #6 was able to walk around freely without the use of a walker or wheelchair, and now she was no longer mobile, requiring the use of a wheelchair. Resident #6's RP said Resident #6 was able to stand and take some steps, but it hurt the resident. She stated Resident #6 was not like she was before. Observation and interview on 02/27/25 at 11:57 AM with Resident #6 revealed she was sitting in a wheelchair at the nurses' station. Resident #6 said she was not in any pain, had never had a fall, and would never let anyone push her. Resident #6 did not appear to be in any pain. Record review of Resident #7's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #7's Quarterly MDS Assessment, dated 01/24/25, reflected she had a BIMS score of 03, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included heart failure, non-alzheimer's dementia, and depression. Record review of Resident #7's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #7] accidentally pushed another resident to the floor. Education completed, Redirected as needed. Goal: [Resident #7] will not harm self or others through the review date. Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #7's Progress Notes reflected the following: 01/21/25 5:25 PM - Resident pushed another resident to the floor, no injuries noted to this resident. Resident was separated from resident she pushed to floor. DON, MD, and RP notified. This entry was written by LVN Z. 01/23/25 4:06 PM - .Patient is seen per staff request due to reports of combativeness, and agitation. Patient is up in the dining area, calm at the moment, and in no distress at this time. She reportedly pushed another resident who sustained injuries, requiringhospitalization [sic]. Patient presents with spontaneous disruptive mood, and combativeness. She is alert to self, and unwilling or unable to participate in the assessment at this time .Chart reviewed, medication profile reviewed .Upon review, based on presenting will further increase Depakote and start patient on Atarax 10 mg twice daily as needed for anxiety. Primary nurse notified, will monitor closely. This entry was written by NP LL. Interview on 02/27/25 at 11:57 AM with LVN Z revealed she was passing medications when Residents #6 and #7 were having an argument, and Resident #7 stood up. LVN Z said before she could get to the area where the residents were at, Resident #7 ended up pushing Resident #6. LVN Z said she assessed Resident #6, gave her some pain medication, took her to her room to assess her, and then brought her back to the dining room to eat dinner and everything was fine. LVN Z said she did not see any obvious signs of injuries and Resident #6's pain seemed to be managed. LVN Z said a STAT x-ray was ordered for Resident #6, she notified Resident #6's RP, the DON, ADON, and the doctor of the incident. LVN Z said during the assessment, there was not any discoloration or bruising to make her think something was injured but the resident did have a slight limp when she pivoted to sit in the chair. LVN Z said before the incident, Resident #6 was completely and independently ambulatory, but the next day she was not able to walk so that nurse on shift sent her to the hospital. LVN Z said at the hospital, they found out she had a pelvic fracture. LVN Z said Resident #7 has not been physically aggressive towards other residents before, only combative during care with staff. LVN Z said Resident #7 did get upset though when people were talking around her, thinking they were talking to her. LVN Z said she knew the Administrator was the Abuse Coordinator for the facility and that a resident-to-resident altercation that resulted in injuries would be considered abuse. LVN Z said she would report that situation to the Administrator, but she did not think it was abuse at the time so she did not immediately report the situation. LVN Z said because Resident #7 had dementia and was very confused, she did not think it would be considered abuse at the time. Interview on 02/27/25 at 12:23 PM with CNA V revealed it was around dinner time while staff were serving trays, and Resident #7 was talking to the air and yelling and some residents were replying back to her. CNA V said they were trying to calm the residents down and telling them to relax. CNA V said all of a sudden, she saw Resident #7 get up and storms over to push Resident #6 down. CNA V said she went over to stay at Resident #6's side until LVN Z came over. CNA V said after LVN Z took over, she went to check on Resident #7 who was in her room upset but wanted to be left alone. CNA V said Resident #6 looked like she was injured after being pushed because she was shouting and screaming in pain. CNA V said before the incident occurred, Resident #6 was up and walking around and did not need a wheelchair or walker. CNA V said Resident #7 did not have any physically aggressive behaviors before this incident. CNA V said she knew to report abuse to the Administrator who was the abuse coordinator for the facility. CNA V said she was not sure why she did not report the situation to the Administrator . CNA V said when the situation happened between Residents #6 and #7 she had only been working at the facility for a couple of weeks. Interview on 02/27/25 at 2:36 PM with the DON revealed he received a report that Resident #6 had a fall and then the resident complained of pain and was sent to the ER. The DON said that another resident (Resident #7) had pushed Resident #6 and she fell . The DON said Resident #6 had a pelvic fracture. The DON said he was notified immediately after it happened and when Resident #6 was sent to the ER. The DON said Resident #7 was a little feisty with staff during care, but she had never attacked another resident. The DON said he was not sure what happened to make Resident #7 push Resident #6, but it was an accident and was not intentional. The DON said he talked to Resident #7, and she did not mean to hurt anyone. The DON said a resident-to-resident altercation was considered abuse. The DON said he would have to ask the Administrator if she reported the situation or not. The DON said all residents had the right to be free from abuse and all staff were responsible for making sure residents were free from abuse. The DON said Resident #6 was harmed from the situation because she suffered a pelvic fracture and now required the use of a wheelchair. The DON said Resident #6 was independently ambulatory before the incident. Interview on 02/27/25 at 3:03 PM with the Administrator revealed what she understood was that the situation happened in the hallway, LVN Z was standing there and talking with Resident #6 when Resident #7 walked past and bumped her, causing Resident #6 to fall and sustained a fracture. The Administrator said when she spoke to the staff about it, she did not get the impression that it was intentional. The Administrator said Resident #6 was able to ambulate independently before the incident and since the fracture occurred she now used a wheelchair. The Administrator said she did not complete an investigation into what happened because of what she was told by the staff. The Administrator said she only talked to LVN Z about the incident but was not aware that she did not see what had happened. The Administrator said she did not speak with CNA V who witnessed the incident between the two residents. The Administrator said she only knew that Resident #6 had a fall and an x-ray was ordered which had negative results but she was still complaining of pain. The Administrator said since she was still complaining of pain the facility sent her to the ER and that was when they found out about the fracture. The Administrator said if LVN Z documented that Resident #7 pushed Resident #6 then that was intentional and has a different connotation than an accidental bumping into each other. The Administrator said with the new information regarding the situation, it was considered abuse between two residents. The Administrator said she would have wanted staff to report the incident to her immediately. The Administrator said if she had known the details of the incident she would have reported it to HHSC. The Administrator said all residents had the right to be free from abuse, even from other residents. The Administrator said everyone was responsible for making sure that residents were free from abuse. The Administrator said the purpose of keeping residents safe from abuse was to ensure their continued health and safety. The Administrator said all staff were responsible for reporting abuse to her immediately. The Administrator said if staff were not immediately reporting abuse to her then that could pave the way for people to be injured or harmed in some way or for abuse to continue. The Administrator said she expected all staff to follow the facility's abuse policy. The Administrator said she would have completed an investigation into the situation had she known about the details beforehand. The Administrator said her investigation would have included resident records, witness statements, safe surveys, assessments, and education with staff. The Administrator said if there was not an investigation into what happened, there would not be measures in place to make sure residents were safe from abuse. The Administrator said if she did not know what happened she could not fix it. The Administrator said she and the DON would be responsible for completing the investigation together. Record review of the facility's Course Completion History report from 09/12/24 to 03/12/25 regarding Abuse, Neglect, and Exploitation Training reflected the following: LVN Z had completed the trainings on 11/30/24 and 02/2/25; CNA V had completed the training on 02/11/25.

Based on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse were immediately report, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the Administrator of the facility and to other officials including the State Survey Agency (HHSC) in a timely manner for 1 of 3 residents (Resident #6) reviewed for abuse. 1. LVN Z and CNA V failed to report an incident of resident-to-resident abuse immediately to the Administrator, who was the Abuse Coordinator, on 01/21/25 when Resident #7 pushed Resident #6, causing her to fall and sustain a pelvic fracture. 2. The Administrator failed to report to HHSC within 2 hours of Resident #6 being pushed by Resident #6 causing her to sustain a pelvic fracture. The failure could place residents at risk of serious harm or neglect. Findings included: Record review of Resident #6's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #6's significant change in status MDS Assessment, dated 01/29/25, reflected she had a BIMS score of 06, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included unspecified fracture of sacrum and depression. Record review of Resident #6's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #6] had a fall. Was accidentally pushed by another resident. Sent to ER. Record review of Resident #6's Progress Notes reflected the following: -Resident was pushed to floor by another resident, resident was crying stating her hip hurt, resident was assessed, assisted from floor to dining chair, pain medication administered. DON, MD and RP notified. Stat hip x-ray ordered. Resident is now sittingin [sic] dinning [sic] area, away from other resident eating dinner. Resident stated she has no pain at this time and will let staff know if her hip starts to hurt again. Written by LVN Z on 01/21/25 at 5:36 PM. -X-ray performed at this time awaiting for results. Written by LVN Y on 01/21/25 at 11:11 PM. -Result viewed, No acute fracture, dislocation, destructive bony process noted, result will be relayed to MD by incoming nurse. Written by LVN Y on 01/22/25 at 2:15 AM. -Resident has been sent out to [Hospital X] r/t uncontrolled pain (L) hip. Resident is status post fall 1/22/25. STAT Xray result (L) hip shows No Acute Fracture, Dislocation or destructive bony process. Resident c/o pain (L) hip, Tramadol 50mg prn and Tylenol 650mg was administered for pain. Medication was not effective, resident unable to ambulate as she normally does. Notified [the DON] and resident sent out to ER for [NAME] evaluation. [Resident #6's RP] was also notified. Written by LVN W on 01/22/25 at 9:15 AM. -Resident arrived facility [sic] from [Hospital X] by ambulance via stretcher accompanied by [Resident #6's RP] DX open displaced fracture of anterior wall of left acetabulum [an anterior wall acetabular fracture is a break in the front column of bone or area around the bony rim (wall) of your hip socket].Resident [sic] assisted in bed by two nurses, complained of some little pain ,tylenol [sic] 650 mg prn given with positive outcome . Written by LVN V on 01/25/25 at 12:15 PM. Record review of Resident #6's hospital records, dated 01/30/25, reflected the following: As Per admission history and physical dated 1/22/2025 Patient is a 84 y.o. female has a past medical history of Dementia (HCC). admitted after fall at care facility resulting in pelvic fracture and difficulty ambulating. [Resident #6's RP] reports [Resident #6] was previously independent, 'very active' and 'walks on her own'. Recently completed PT at facility and 'checked all the boxes', discharged from therapy last Friday [01/17/25]. Fall mechanism- patient reports being pushed by 'lady' and feeling pain 'from the back'. [Resident #6's RP] unaware of circumstances, states facility noticed fall and difficulty walking. Hospital Course/Summary: Ptient [sic] presented after fall unable to bear weight. Found to acute minimally displaced fractures of the anterior left acetabulum, left inferior pubic ramus [describes a type of crack or break in a person's pelvis] and left sacrum . Record review of Resident #6's Radiology Results Report, dated 01/21/25, reflected: Procedure: HIP UNI W OR W/O PELVIS 2-3 V .INTERPRETATION: Findings: No acute fracture, dislocation or destructive bony process. No soft tissue abnormally. Osteopenia. Mild degenerative changes. Conclusion: No acute osseous abnormality. Interview on the phone on 02/27/25 at 11:15 AM with Resident #6's RP revealed Resident #6 was pushed by a different resident and her pelvis was fractured as a result. Resident #6's RP said Resident #6 was admitted to the hospital and the fracture did not require screws or any surgery so the doctor said it was going to heal on it's own. Resident #6's RP said before the incident, Resident #6 was able to walk around freely without the use of a walker or wheelchair and now she is no longer mobile, requiring the use of a wheelchair. Resident #6's RP said Resident #6 was able to stand and take some steps but it hurt the resident and was not like she was before. Observation and interview on 02/27/25 at 11:57 AM with Resident #6 revealed she was sitting in a wheelchair at the nurse's station. Resident #6 said she was not in any pain, had never had a fall, and would never let anyone push her. Resident #6 did not appear to be in any pain. Record review of Resident #7's face sheet, dated 02/27/25, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #7's Quarterly MDS Assessment, dated 01/24/25, reflected she had a BIMS score of 03, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included heart failure, non-alzheimer's dementia, and depression. Record review of Resident #7's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #7] accidentally pushed another resident to the floor. Education completed, Redirected as needed. Goal: [Resident #7] will not harm self or others through the review date. Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #7's Progress Notes reflected the following: -Resident pushed another resident to the floor, no injuries noted to this resident. Resident was separated from resident she pushed to floor. DON, MD, and RP notified. Written by LVN Z on 01/21/25 at 5:25 PM. - .Patient is seen per staff request due to reports of combativeness, and agitation. Patient is up in the dining area, calm at the moment, and in no distress at this time. She reportedly pushed another resident who sustained injuries, requiringhospitalization [sic]. Patient presents with spontaneous disruptive mood, and combativeness. She is alert to self, and unwilling or unable to participate in the assessment at this time .Chart reviewed, medication profile reviewed .Upon review, based on presenting will further increase Depakote and start patient on Atarax 10 mg twice daily as needed for anxiety. Primary nurse notified, will monitor closely. Written by NP LL on 01/23/25 at 4:06 PM Observation and interview on 02/27/25 at 2:00 PM with Resident #7 revealed she was sitting in a chair at a table with other residents around her. Resident #7 said she was doing good today and did not appear to have any behaviors. Interview on 02/27/25 at 11:57 AM with LVN Z revealed she was passing medications when Residents #6 and #7 were having an argument and Resident #7 stood up. LVN Z said before she could get to the area where the residents were at, Resident #7 ended up pushing Resident #6. LVN Z said she assessed Resident #6, gave her some pain medication, took her to her room to assess her, and then brought her back to the dining room to eat dinner and everything was fine. LVN Z said she did not see any obvious signs of injuries and Resident #6's pain seemed to be managed. LVN Z said a STAT x-ray was ordered for Resident #6, she notified Resident #6's RP, the DON, ADON, and the doctor of the incident. LVN Z said during the assessment, there was not any discoloration or bruising to make her think something was injured but the resident did have a slight limp when she pivoted to sit in the chair. LVN Z said before the incident, Resident #6 was completely and independently ambulatory but the next day she was not able to walk so that nurse on shift sent her to the hospital. LVN Z said at the hospital, they found out she had a pelvic fracture. LVN Z said Resident #7 has not been physically aggressive towards other residents before, only combative during care with staff. LVN Z said Resident #7 does get upset though when people were talking around her, thinking that they were talking to her. LVN Z said she knew the Administrator was the abuse coordinator for the facility and that a resident-to-resident altercation that resulted in injuries would be considered abuse. LVN Z said she would report that situation to the Administrator but did not think it was abuse at the time so she did not immediately report the situation. LVN Z said because Resident #7 had dementia and was very confused she did not think it would be considered abuse at the time. Interview on 02/27/25 at 12:23 PM with CNA V revealed it was around dinner time while staff were serving trays, and Resident #7 was talking to the air and yelling and some residents were replying back to her. CNA V said they were trying to calm the residents down and telling them to relax. CNA V said all of a sudden, she saw Resident #7 get up and storms over to push Resident #6 down. CNA V said she went over to stay at Resident #6's side until LVN Z came over. CNA V said after LVN Z took over, she went to check on Resident #7 who was in her room upset but wanted to be left alone. CNA V said Resident #6 looked like she was injured after being pushed because she was shouting and screaming in pain. CNA V said before the incident occurred, Resident #6 was up and walking around and did not need a wheelchair or walker. CNA V said Resident #7 did not have any physically aggressive behaviors before this incident. CNA V said she knew to report abuse to the Administrator who was the abuse coordinator for the facility. CNA V said she was not sure why she did not report the situation to the Administrator. Interview on 02/27/25 at 2:36 PM with the DON revealed he received a report that Resident #6 had a fall and then the resident complained of pain and was sent to the ER. The DON said that another resident (Resident #7) had pushed Resident #6 and she fell . The DON said Resident #6 had a pelvic fracture. The DON said he was notified immediately after it happened and when Resident #6 was sent to the ER. The DON said Resident #7 was a little feisty with staff during care but has never attacked another resident. The DON said he was not sure what happened to make Resident #7 push Resident #6 but that it was an accident and was not intentional. The DON said he talked to Resident #7 and she did not mean to hurt anyone, but a resident-to-resident altercation was considered abuse. The DON said he would have to ask the Administrator if she reported the situation or not. The DON said all residents had the right to be free from abuse and all staff were responsible for making sure residents were free from abuse. The DON said Resident #6 was harmed from the situation because she suffered a pelvic fracture and now required the use of a wheelchair. The DON said Resident #6 was independently ambulatory before the incident. Interview on 02/27/25 at 3:03 PM with the Administrator revealed what she understood was that the situation happened in the hallway, LVN Z was standing there and talking with Resident #6 when Resident #7 walked past and bumped her, causing Resident #6 to fall and sustained a fracture. The Administrator said when she spoke to the staff about it, she did not get the impression that it was intentional. The Administrator said Resident #6 was able to ambulate independently before the incident and since the fracture occurred she now used a wheelchair. The Administrator said she did not complete an investigation into what happened because of what she was told by the staff. The Administrator said she only talked to LVN Z about the incident but was not aware that she did not see what had happened. The Administrator said she did not speak with CNA V who witnessed the incident between the two residents. The Administrator said she only knew that Resident #6 had a fall and an x-ray was ordered which had negative results but she was still complaining of pain. The Administrator said since she was still complaining of pain the facility sent her to the ER and that was when they found out about the fracture. The Administrator said if LVN Z documented that Resident #7 pushed Resident #6 then that was intentional and has a different connotation than an accidental bumping into each other. The Administrator said with the new information regarding the situation, it was considered abuse between two residents. The Administrator said she would have wanted staff to report the incident to her immediately. The Administrator said if she had known the details of the incident she would have reported it to HHSC. The Administrator said all residents have the right to be free from abuse, even from other residents. The Administrator said everyone was responsible for making sure that residents were free from abuse. The Administrator said the purpose of keeping residents safe from abuse was to ensure their continued health and safety. The Administrator said all staff were responsible for reporting abuse to her immediately. The Administrator said if staff were not immediately reporting abuse to her then that could pave the way for people to be injured or harmed in some way or for abuse to continue. The Administrator said she expected all staff to follow the facility's abuse policy. The Administrator said she would have completed an investigation into the situation had she known about the details beforehand. The Administrator said her investigation would have included resident records, witness statements, safe surveys, assessments, and education with staff. The Administrator said if there was not an investigation into what happened, there would not be measures in place to make sure residents were safe from abuse. The Administrator said if she did not know what happened she could not fix it. The Administrator said she and the DON would be responsible for completing the investigation together. Record review of the facility's policy, revised September 2022, and titled Identifying Types of Abuse reflected: 1. Abuse of any kind against residents is strictly prohibited .4. 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .5. Abuse toward a resident can occur as: a. resident-to-resident abuse . Record review of the facility's policy, revised September 2022, and titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating reflected: Policy statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation; Reporting Allegations to the Administrator and Authorities, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . Record review of the facility's policy, revised April 2021, and titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program reflected: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of property and exploitation. This includes but is not limited to freedom of corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; .2. Develop and implement policies and procedures to prevent and identify: a. abuse or mistreatment of residents . Record review of the facility's Course Completion History report from 09/12/24 to 03/12/25 regarding Abuse, Neglect, and Exploitation Training reflected the following: LVN Z had completed the trainings on 11/30/24 and 02/2/25; CNA V had completed the training on 02/11/25.

Based on observations, interviews, and record review the facility failed to investigate and report an allegation of abuse for 1 of 3 residents (Resident #6) reviewed for abuse allegations. The Administrator failed to investigate an incident of abuse when Resident #6 was pushed by Resident #7 on 01/21/25 and sustained a pelvic fracture. This failure could place residents at risk of harm and injuries related to abuse and a delay in investigating. Findings included: Record review of Resident #6's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #6's significant change in status MDS Assessment, dated 01/29/25, reflected she had a BIMS score of 06, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included unspecified fracture of sacrum and depression. Record review of Resident #6's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #6] had a fall. Was accidentally pushed by another resident. Sent to ER. Record review of Resident #6's Progress Notes reflected the following: -Resident was pushed to floor by another resident, resident was crying stating her hip hurt, resident was assessed, assisted from floor to dining chair, pain medication administered. DON, MD and RP notified. Stat hip x-ray ordered. Resident is now sittingin [sic] dinning [sic] area, away from other resident eating dinner. Resident stated she has no pain at this time and will let staff know if her hip starts to hurt again. Written by LVN Z on 01/21/25 at 5:36 PM. -X-ray performed at this time awaiting for results. Written by LVN Y on 01/21/25 at 11:11 PM. -Result viewed, No acute fracture, dislocation, destructive bony process noted, result will be relayed to MD by incoming nurse. Written by LVN Y on 01/22/25 at 2:15 AM. -Resident has been sent out to [Hospital X] r/t uncontrolled pain (L) hip. Resident is status post fall 1/22/25. STAT Xray result (L) hip shows No Acute Fracture, Dislocation or destructive bony process. Resident c/o pain (L) hip, Tramadol 50mg prn and Tylenol 650mg was administered for pain. Medication was not effective, resident unable to ambulate as she normally does. Notified [the DON] and resident sent out to ER for [NAME] evaluation. [Resident #6's RP] was also notified. Written by LVN W on 01/22/25 at 9:15 AM. -Resident arrived facility [sic] from [Hospital X] by ambulance via stretcher accompanied by [Resident #6's RP] DX open displaced fracture of anterior wall of left acetabulum [an anterior wall acetabular fracture is a break in the front column of bone or area around the bony rim (wall) of your hip socket].Resident [sic] assisted in bed by two nurses, complained of some little pain ,tylenol [sic] 650 mg prn given with positive outcome . Written by LVN V on 01/25/25 at 12:15 PM. Record review of Resident #6's hospital records, dated 01/30/25, reflected the following: As Per admission history and physical dated 1/22/2025 Patient is a 84 y.o. female has a past medical history of Dementia (HCC). admitted after fall at care facility resulting in pelvic fracture and difficulty ambulating. [Resident #6's RP] reports [Resident #6] was previously independent, 'very active' and 'walks on her own'. Recently completed PT at facility and 'checked all the boxes', discharged from therapy last Friday [01/17/25]. Fall mechanism- patient reports being pushed by 'lady' and feeling pain 'from the back'. [Resident #6's RP] unaware of circumstances, states facility noticed fall and difficulty walking. Hospital Course/Summary: Ptient [sic] presented after fall unable to bear weight. Found to acute minimally displaced fractures of the anterior left acetabulum, left inferior pubic ramus [describes a type of crack or break in a person's pelvis] and left sacrum . Record review of Resident #6's Radiology Results Report, dated 01/21/25, reflected: Procedure: HIP UNI W OR W/O PELVIS 2-3 V .INTERPRETATION: Findings: No acute fracture, dislocation or destructive bony process. No soft tissue abnormally. Osteopenia. Mild degenerative changes. Conclusion: No acute osseous abnormality. Interview on the phone on 02/27/25 at 11:15 AM with Resident #6's RP revealed Resident #6 was pushed by a different resident and her pelvis was fractured as a result. Resident #6's RP said Resident #6 was admitted to the hospital and the fracture did not require screws or any surgery so the doctor said it was going to heal on it's own. Resident #6's RP said before the incident, Resident #6 was able to walk around freely without the use of a walker or wheelchair and now she is no longer mobile, requiring the use of a wheelchair. Resident #6's RP said Resident #6 was able to stand and take some steps but it hurt the resident and was not like she was before. Observation and interview on 02/27/25 at 11:57 AM with Resident #6 revealed she was sitting in a wheelchair at the nurse's station. Resident #6 said she was not in any pain, had never had a fall, and would never let anyone push her. Resident #6 did not appear to be in any pain. Record review of Resident #7's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #7's Quarterly MDS Assessment, dated 01/24/25, reflected she had a BIMS score of 03, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included heart failure, non-alzheimer's dementia, and depression. Record review of Resident #7's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #7] accidentally pushed another resident to the floor. Education completed, Redirected as needed. Goal: [Resident #7] will not harm self or others through the review date. Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #7's Progress Notes reflected the following: -Resident pushed another resident to the floor, no injuries noted to this resident. Resident was separated from resident she pushed to floor. DON, MD, and RP notified. Written by LVN Z on 01/21/25 at 5:25 PM. - .Patient is seen per staff request due to reports of combativeness, and agitation. Patient is up in the dining area, calm at the moment, and in no distress at this time. She reportedly pushed another resident who sustained injuries, requiringhospitalization [sic]. Patient presents with spontaneous disruptive mood, and combativeness. She is alert to self, and unwilling or unable to participate in the assessment at this time .Chart reviewed, medication profile reviewed .Upon review, based on presenting will further increase Depakote and start patient on Atarax 10 mg twice daily as needed for anxiety. Primary nurse notified, will monitor closely. Written by NP LL on 01/23/25 at 4:06 PM Observation and interview on 02/27/25 at 2:00 PM with Resident #7 revealed she was sitting in a chair at a table with other residents around her. Resident #7 said she was doing good today and did not appear to have any behaviors. Interview on 02/27/25 at 11:57 AM with LVN Z revealed she was passing medications when Residents #6 and #7 were having an argument and Resident #7 stood up. LVN Z said before she could get to the area where the residents were at, Resident #7 ended up pushing Resident #6. LVN Z said she assessed Resident #6, gave her some pain medication, took her to her room to assess her, and then brought her back to the dining room to eat dinner and everything was fine. LVN Z said she did not see any obvious signs of injuries and Resident #6's pain seemed to be managed. LVN Z said a STAT x-ray was ordered for Resident #6, she notified Resident #6's RP, the DON, ADON, and the doctor of the incident. LVN Z said during the assessment, there was not any discoloration or bruising to make her think something was injured but the resident did have a slight limp when she pivoted to sit in the chair. LVN Z said before the incident, Resident #6 was completely and independently ambulatory but the next day she was not able to walk so that nurse on shift sent her to the hospital. LVN Z said at the hospital, they found out she had a pelvic fracture. LVN Z said Resident #7 has not been physically aggressive towards other residents before, only combative during care with staff. LVN Z said Resident #7 does get upset though when people were talking around her, thinking that they were talking to her. LVN Z said she knew the Administrator was the abuse coordinator for the facility and that a resident-to-resident altercation that resulted in injuries would be considered abuse. LVN Z said she would report that situation to the Administrator but did not think it was abuse at the time so she did not immediately report the situation. LVN Z said because Resident #7 had dementia and was very confused she did not think it would be considered abuse at the time. Interview on 02/27/25 at 12:23 PM with CNA V revealed it was around dinner time while staff were serving trays, and Resident #7 was talking to the air and yelling and some residents were replying back to her. CNA V said they were trying to calm the residents down and telling them to relax. CNA V said all of a sudden, she saw Resident #7 get up and storms over to push Resident #6 down. CNA V said she went over to stay at Resident #6's side until LVN Z came over. CNA V said after LVN Z took over, she went to check on Resident #7 who was in her room upset but wanted to be left alone. CNA V said Resident #6 looked like she was injured after being pushed because she was shouting and screaming in pain. CNA V said before the incident occurred, Resident #6 was up and walking around and did not need a wheelchair or walker. CNA V said Resident #7 did not have any physically aggressive behaviors before this incident. CNA V said she knew to report abuse to the Administrator who was the abuse coordinator for the facility. CNA V said she was not sure why she did not report the situation to the Administrator. Interview on 02/27/25 at 2:36 PM with the DON revealed he received a report that Resident #6 had a fall and then the resident complained of pain and was sent to the ER. The DON said that another resident (Resident #7) had pushed Resident #6 and she fell . The DON said Resident #6 had a pelvic fracture. The DON said he was notified immediately after it happened and when Resident #6 was sent to the ER. The DON said Resident #7 was a little feisty with staff during care but has never attacked another resident. The DON said he was not sure what happened to make Resident #7 push Resident #6 but that it was an accident and was not intentional. The DON said he talked to Resident #7 and she did not mean to hurt anyone, but a resident-to-resident altercation was considered abuse. The DON said he would have to ask the Administrator if she reported the situation or not. The DON said all residents had the right to be free from abuse and all staff were responsible for making sure residents were free from abuse. The DON said Resident #6 was harmed from the situation because she suffered a pelvic fracture and now required the use of a wheelchair. The DON said Resident #6 was independently ambulatory before the incident. Interview on 02/27/25 at 3:03 PM with the Administrator revealed what she understood was that the situation happened in the hallway, LVN Z was standing there and talking with Resident #6 when Resident #7 walked past and bumped her, causing Resident #6 to fall and sustained a fracture. The Administrator said when she spoke to the staff about it, she did not get the impression that it was intentional. The Administrator said Resident #6 was able to ambulate independently before the incident and since the fracture occurred she now used a wheelchair. The Administrator said she did not complete an investigation into what happened because of what she was told by the staff. The Administrator said she only talked to LVN Z about the incident but was not aware that she did not see what had happened. The Administrator said she did not speak with CNA V who witnessed the incident between the two residents. The Administrator said she only knew that Resident #6 had a fall and an x-ray was ordered which had negative results but she was still complaining of pain. The Administrator said since she was still complaining of pain the facility sent her to the ER and that was when they found out about the fracture. The Administrator said if LVN Z documented that Resident #7 pushed Resident #6 then that was intentional and has a different connotation than an accidental bumping into each other. The Administrator said with the new information regarding the situation, it was considered abuse between two residents. The Administrator said she would have wanted staff to report the incident to her immediately. The Administrator said if she had known the details of the incident she would have reported it to HHSC. The Administrator said all residents have the right to be free from abuse, even from other residents. The Administrator said everyone was responsible for making sure that residents were free from abuse. The Administrator said the purpose of keeping residents safe from abuse was to ensure their continued health and safety. The Administrator said all staff were responsible for reporting abuse to her immediately. The Administrator said if staff were not immediately reporting abuse to her then that could pave the way for people to be injured or harmed in some way or for abuse to continue. The Administrator said she expected all staff to follow the facility's abuse policy. The Administrator said she would have completed an investigation into the situation had she known about the details beforehand. The Administrator said her investigation would have included resident records, witness statements, safe surveys, assessments, and education with staff. The Administrator said if there was not an investigation into what happened, there would not be measures in place to make sure residents were safe from abuse. The Administrator said if she did not know what happened she could not fix it. The Administrator said she and the DON would be responsible for completing the investigation together. Record review of the facility's Course Completion History report from 09/12/24 to 03/12/25 regarding Abuse, Neglect, and Exploitation Training reflected the following: LVN Z had completed the trainings on 11/30/24 and 02/2/25; CNA V had completed the training on 02/11/25. Record review of the facility's policy, revised September 2022, and titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating reflected: Policy statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation; Reporting Allegations to the Administrator and Authorities, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .Investigation Allegations: 1. All allegations are thoroughly investigated. The administrator initiates investigations.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a change in the resident's condition or a need to alter treatment for one (Resident #1) of three residents reviewed for physician consultation. LVN A failed to consult with the physician for Resident #1 when the resident had a change of condition on 06/15/24. Resident #1 displayed signs and symptoms of pain when her left leg was touched on 06/15/24 at 7:45 PM. The physician was not notified the resident had a change of condition until the next morning 06/16/24 at approximately 6:00 AM and ordered x-rays, which reflected the resident had a left hip fracture, and she was sent to the hospital for evaluation and treatment. An Immediate Jeopardy (IJ) situation was identified on 0719/24. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The failure placed residents at risk for delayed physician intervention. Findings included: Record review of Resident #1's MDS assessment, dated 06/24/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, arthritis, hip fracture, Alzheimer's disease, non-Alzheimer's dementia, vitamin D deficiency, hypocalcemia (calcium deficiency), and cognitive communication deficit. Resident #1 had long and short- term memory impairment and decision making was severely impaired. Resident #1 had unclear speech and rarely understood/understands. The MDS further reflected the resident was in a manual wheelchair and dependent for all ADLs. Record review of Resident #1's care plan, revised 07/29/21, reflected she had a communication problem related to dementia. Interventions included to monitor and document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. Record review of Resident #1's progress notes, dated 06/15/24, documented by LVN A reflected: Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed. At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to oncoming nurse to monitor resident discomfort if worsens to report to NP/MD. Record review of Resident #1's x-ray report, dated 06/16/24, reflected: .EXAM: Pelvis and left hip HISTORY: Pain .FINDINGS: There is a fracture involving the proximal left femur centered within the intertrochanteric space. There does appear to be approximately a centimeter of shortening as well as a few degrees of varus angulation. There is no dislocations. A significant joint effusion is not seen. Mild symmetric osteoarthritis is seen . IMPRESSION: 1. Proximal left femur fracture . Record review of Resident #1's hospital records, dated 06/16/24, reflected Resident #1 had been diagnosed with an acute fracture of the left proximal femur (hip fracture). Record review of the facility's Provider Investigation Report, dated 06/17/24, reflected the following: .This resident is a 60 yo (year old) female who resides on the secured unit. The resident ambulates independently on the unit. This resident also ambulates in a wheelchair. This resident has dementia, osteoarthritis, and vitamin D deficiency. The weekend RN supervisor informed this admin that x-rays were ordered due to a resident possible leg fracture .On-coming aide notified charge nurse that during peri care resident was favoring her left leg. Charge nurse stated that resident is non-verbal and that she would monitor resident throughout her shift. Charge nurse indicated that resident slept through the night. Facility received x-rays, indicating possible fracture . Observation on 07/02/24 at 10:00 AM of Resident #1 revealed she was in a low bed with her eyes closed. After knocking, the resident's name was called out, but Resident #1 barely opened her eye, closed them right away and did not speak. Interview on 07/02/24 at 10:54 AM CNA B stated she was making her rounds on, 06/15/24, around 7:45 PM. She went in to change Resident #1 and when she started peri care, Resident #1 yelled out like she was in pain, so she went to get LVN A. At that time both the CNA B and LVN A tried to assist the resident to a standing position and Resident #1 yelled again. and They noted something was wrong, and it appeared like her left foot was hurting so she was put back in bed. Resident #1 was not able to speak therefore could not tell them what was wrong. CNA B said it was not normal for Resident #1 to yell out when she was being changed. CNA B further stated she worked from 7:00 PM to 7:00 AM and during the night she continued to monitor Resident #1. and during her brief change, the resident did not groan or appear to be in pain the remainder of her shift. Record review of LVN A's undated handwritten and signed statement reflected the following: To whom it may concern, Cc: [Resident #1] Upon my shift on June 15th, this writer [LVN A] noted patient sitting on w/c but seems sleepy (eyes closed). Notified nurse aide to lay patient in bed. During rounds for incontinent care with nurse aide, noted facial grimacing when touching pt on left leg but since patient is non-verbal, assessed pt left extremities no bruises noted, or any other skin issues. Layed [laid] pt comfortably in bed, while continuous monitoring, pt slept all night long. This writer reported oncoming nurse to monitor if patient persist with pain to touch to notify MD. Review of LVN A's undated typed and signed statement on 07/02/24 reflected the following: To whom it may concern, Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed., At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3: 00 AM ] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to on coming nurse to monitor resident discomfort if worsens to report to NP/MD. Record review of LVN A's personnel file on 07/02/24 reflected the signature on LVN A's handwritten statement matched the signatures on her new hire paperwork. Interview on 07/02/24 at 2:25 PM LVN A stated she arrived to work around 6:00 PM on, 06/15/24, and Resident #1 was in her wheelchair and appeared to look tired, so she asked an aide to lay her down in bed. Later that evening, CNA B told her the resident was having some discomfort while she was trying to change her brief, so she went into Resident #1's room to assess the resident. LVN A denied trying to make the resident stand up and said Resident #1 indeed looked to have some discomfort, but it was not pain. LVN A described the discomfort as someone that was tired and did not want to be touched and again denied the discomfort as pain . LVN A said she continued to monitor the resident throughout the night and there were no concerns as Resident #1 has slept comfortably the whole night. LVN A was asked about her handwritten statement where she had documented facial grimacing when the resident's left leg was touched and LVN A denied writing a statement. LVN A further stated the only thing she wrote was her narrative in the progress notes of Resident #1's clinical record and again denied she wrote a statement of the incident. LVN A also said she did not contact the doctor because Resident #1 was not in pain and the resident had slept comfortably all night. Interview on 07/02/24 at 1:40 PM RN C stated when she arrived at the facility on, 06/16/24 at 6:00 AM, Resident #1 was in bed sleeping. She got report from the night nurse, LVN A, that Resident #1 was having pain to her left leg. RN C went in to assess the resident in her room and Resident #1 did not appear well, was not her normal self, and when she tried to move her left leg, the resident expressed pain through facial grimacing. RN C called the doctor and ordered an x-ray of the resident's leg, and the results came back positive for a hip fracture, so she was sent out to the hospital. Interview on 07/02/24 at 1:54 PM ADON stated she was not informed of all the details with Resident #1. The ADON said she only assisted in gathering a few statements from the staff and the Administrator had conducted the investigation with Resident #1's incident. Interview on 07/02/24 at 2:43 PM Administrator stated she had been made aware of Resident #1's hip fracture and she began an investigation of the incident. The Administrator was made aware LVN A denied writing a statement., and she was shown the handwritten statement that was part of the provider investigation report and shown the matching signatures. The Administrator said she had provided the wrong statement. The Administrator said had found LVN A's handwritten statement under her door and because corporate preferred their statements to be typed out, the [NAME] President of Clinical Operations had gotten LVN A's other statement. The Administrator further stated she would provide the LVN A's typed statement and that was the correct one. The Administrator could not explain why there were two statements where one addressed Resident #1 was having pain and the other statement did not. Interview on 07/02/24 at 3:19 PM with the [NAME] President of Clinical Operations revealed she was not aware LVN A had written a statement. and the facility did not have a DON at the time, so she called LVN A into the facility and had her type up a statement. The [NAME] President of Clinical Operations said LVN A further stated LVN A had been suspended and educated on pain management and resident assessment after the incident with Resident #1 because they felt like LVN A could have assessed the resident better and wanted to make sure she knew how to fully assess a resident and contact the doctor if needed. Record review of the facility's Change in Resident's Status or Condition policy, revised February 2021, reflected the following: Policy Statement: Our promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .b. discovery of injuries of an unknown source; .i. specific instruction to notify the physician of changes in the resident's condition. This was determined to be an Immediate Jeopardy (IJ) on 07/19/24 at 8:44 AM. The Administrator, the DON and ADON were notified. The Administrator was provided with the IJ template on 07/19/24 at 8:50 AM. The following Plan of Removal submitted by the facility was accepted on 07/19/24 at 2:37 PM: Problem: Facility failed to immediately consult with the resident's physician when there was a change in the resident's condition, when Resident #1 had a change of condition on 06/15/24 and did not receive timely treatment. - The following in-services were initiated by - started on 7/2/2024 and completed on 7/5/2024 COMPLIANCE NURSE DON: Any nursing staff member not present or in-service will not be allowed to assume their duties until in-serviced and expectations acknowledged. Licensed Nurses: - Promptly and accurately assessing a resident when change of condition has been identified / reported. Education started on 7/2/2024 and completed on 7/5/2024. - Assessing a resident's change in condition using SBAR, so that all necessary information is communicated to the physician or Nurse Practitioner. Education started on 7/2/2024 and completed on 7/5/2024. -Reporting changes of condition to the physician or nurse practitioner based on Change of Condition Form. Education started 7/2/2024 and completed on 7/5/2024. Non-licensed nursing staff: - Reporting changes in a resident's condition to a nurse immediately. Education started 6/16/2024 and completed on 7/5/2024. - If the nurse does not assess timely, the DON/Designee must be notified. Education started 6/16/2024 and completed 7/5/2024. The Administrator, DON and ADON were in-serviced .regarding .ensuring all staff applicable to the in-service receive the training, to use online resources and / or in person training, to ensure all trained staff have attested that they have received the training by a signed acknowledgement. An ADHOC QAPI meeting was conducted on 7/8/2024 regarding this plan and monitoring. The Medical Director .was notified of this plan and monitoring on 7/2/2024. Monitoring -The DON/Designee will monitor all kiosk (dashboard) alerts a minimum of 4 times per week to ensure any potential change of condition has been addressed timely. -The DON/Designee will randomly ask nurses per week what they would do if a resident had a change of condition, or it was report to them that a resident had a change of condition. -The QAPI committee will review the findings and make any needed changes. Monitoring of the facility's Plan of Removal included the following: Record review of the facility's Incident by Incident type reflected Resident #2, Resident #3, Resident #4, Resident #5 had unwitnessed falls and nursing staff documented, assessed the residents, and reported to the Interim DON, family, and physician. Record review of Admit/Discharge Report, from 06/16/24 through 07/19/24, reflected Resident #6, Resident #7, Resident #8, Resident #9 were discharged to the hospital due to change in condition. Residents were assessed and nursing staff documented change in condition using SBAR and notified the Interim DON, family, and physician. Record review of the facility's Change in Condition Evaluation - SBAR (Situation, Background, Assessment, and Recommendation), undated, reflected the form addressed signs and symptoms identified, start date, review findings and provider notifications, mental status evaluation, functional status evaluation, vital signs evaluation, provider notification and feedback, behavioral status evaluation, respiratory status evaluation, cardiovascular status evaluation, abdominal/GI status evaluation, genitourinary status evaluation, skin status evaluation, pain status evaluation, neurological status evaluation, general background evaluation and available laboratory test/diagnostic procedures and resident representative notification. Record review of the facility's Record of In-service Education, dated 06/16/24, reflected training for abuse, neglect policy - who was coordinator; resident rights; pain policy; and timely notification. In-services reflected all staff completed the trainings. The in-services were conducted and signed by nursing on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 06/25/24, reflected the training participant would be able to verbalize and demonstrate proper transfer techniques in order to safely provide patient care handling, transfers included sit to stand, stand - pivot, squat- pivot, slide board, and mechanical lift. The in-services were conducted and signed by CNAs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 06/26/24, reflected the Administrator, the Interim DON and ADON were in-serviced on all staff applicable to receive training to use online resources or in person training to ensure all trained staff have attested to receiving education. Record review of the facility's Record of In-service Education, dated 07/02/24, reflected training for what was change of condition, what to do when a change of condition happens, who to notify, orders to receive, full head to toe assessment, assess for pain, medicate as ordered and continue to assess and to follow through any new orders. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 07/03/24, reflected training regarding how to identify pain and what to do. The training record reflected: .pain may be late on set and resident may not be able to verbalize, job is to assess pain and treat timely, once treated - [you] have to assess for effectiveness, continue to monito if not effective new orders may be needed. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Monthly QA Meeting reflected the meeting was completed on 07/08/24. Interviews conducted on 07/19/24 from 2:40 PM through 5:45 PM with the Administrator, the Interim DON, ADON, LVN A, RN D, RN E, RN F, LVN G, LVN M, RN O, LVN Q, who worked the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM verbally revealed nurses were able to verify education was provided to them. Nursing staff were able to accurately summarize what was change of condition, what to do when a change of condition occurred, who to notify, orders to receive, completing a full head-to-toe assessment, assessing for pain, medicating as ordered and continuing to assess, following through any new orders, documenting, and completing the SBAR. The Interim DON and ADON stated they would be responsible for monitor all kiosk (dashboard) alert a minimum of 4 times per week to ensure any potential change of condition had been addressed timely and continue education on change of condition. Interviews conducted on 07/19/24 from 3:48 PM through 5:45 PM with CNA B, CNA H, CNA I, CNA J, CNA K, CNA L, CNA N, CNA P, CNA R, CNA S, and CNA T who work the shifts of 6:00 AM- 6:00 PM- 6:00 PM - 6:00 AM verbally revealed staff were able to verify education was provided to them, staff were able to accurately summarize what was change of condition, how to identify pain and who to notify. The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 07/19/2024 at 5:50 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. LVN A failed to ensure Resident #1 was provided with timely treatment when the resident had a changed of condition on 06/15/24. Resident #1 displayed signs and symptoms of pain when her left leg was touched on 06/15/24 at 7:45 PM. The physician was not notified the resident had a change of condition until the next morning 06/16/24 at approximately 6:00 AM and ordered x-rays, which revealed the resident had a left hip fracture, and she was sent to the hospital for evaluation and treatment. An Immediate Jeopardy (IJ) situation was identified on 0719/24. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delay in needed treatment and care. Findings included: Record review of Resident #1's MDS assessment, dated 06/24/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, arthritis, hip fracture, Alzheimer's disease, non-Alzheimer's dementia, vitamin D deficiency, hypocalcemia (calcium deficiency), and cognitive communication deficit. Resident #1 had long and short- term memory impairment and decision making was severely impaired. Resident #1 had unclear speech rarely understood/understands. The MDS further reflected the resident was in a manual wheelchair and dependent for all ADLs. Record review of Resident #1's care plan, revised 07/29/21, reflected she had a communication problem related to dementia. Interventions included to monitor and document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. Record review of Resident #1's progress notes, dated 06/15/24, documented by LVN A reflected: Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed. At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to oncoming nurse to monitor resident discomfort if worsens to report to NP/MD . Record review of Resident #1's x-ray report, dated 06/16/24, reflected: .EXAM: Pelvis and left hip HISTORY: Pain .FINDINGS: There is a fracture involving the proximal left femur centered within the intertrochanteric space. There does appear to be approximately a centimeter of shortening as well as a few degrees of varus angulation. There is no dislocations. A significant joint effusion is not seen. Mild symmetric osteoarthritis is seen . IMPRESSION: 1. Proximal left femur fracture . Record review of Resident #1's hospital records, dated 06/16/24, reflected Resident #1 had been diagnosed with an acute fracture of the left proximal femur (hip fracture). Record review of the facility's Provider Investigation Report, dated 06/17/24, reflected the following: .This resident is a 60 yo (year old) female who resides on the secured unit. The resident ambulates independently on the unit. This resident also ambulates in a wheelchair. This resident has dementia, osteoarthritis, and vitamin D deficiency. The weekend RN supervisor informed this admin that x-rays were ordered due to a resident possible leg fracture .On-coming aide notified charge nurse that during peri care resident was favoring her left leg. Charge nurse stated that resident is non-verbal and that she would monitor resident throughout her shift. Charge nurse indicated that resident slept through the night. Facility received x-rays, indicating possible fracture . Observation on 07/02/24 at 10:00 AM of Resident #1 revealed she was in a low bed with her eyes closed. After knocking, the resident's name was called out, but Resident #1 barely opened her eye, closed them right away and did not speak. Interview on 07/02/24 at 10:54 AM CNA B stated she was making her rounds on, 06/15/24, around 7:45 PM. She went in to change Resident #1 and when she started peri care, Resident #1 yelled out like she was in pain, so she went to get LVN A. At that time both the CNA B and LVN A tried to assist the resident to a standing position and Resident #1 yelled again. and They noted something was wrong, and it appeared like her left foot was hurting so she was put back in bed. Resident #1 was not able to speak therefore could not tell them what was wrong. CNA B said it was not normal for Resident #1 to yell out when she was being changed. CNA B further stated she worked from 7:00 PM to 7:00 AM and during the night she continued to monitor Resident #1. and during her brief change, the resident did not groan or appear to be in pain the remainder of her shift. Record review of LVN A's undated handwritten and signed statement reflected the following: To whom it may concern, Cc: [Resident #1] Upon my shift on June 15th, this writer [LVN A] noted patient sitting on w/c but seems sleepy (eyes closed). Notified nurse aide to lay patient in bed. During rounds for incontinent care with nurse aide, noted facial grimacing when touching pt on left leg but since patient is non-verbal, assessed pt left extremities no bruises noted, or any other skin issues. Layed [laid] pt comfortably in bed, while continuous monitoring, pt slept all night long. This writer reported oncoming nurse to monitor if patient persist with pain to touch to notify MD. Review of LVN A's undated typed and signed statement on 07/02/24 reflected the following: To whom it may concern Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed., At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to on coming nurse to monitor resident discomfort if worsens to report to NP/MD. Record review of LVN A's personnel file on 07/02/24 reflected the signature on LVN A's handwritten statement matched the signatures on her new hire paperwork. Interview on 07/02/24 at 2:25 PM LVN A stated she arrived to work around 6:00 PM on, 06/15/24, and Resident #1 was in her wheelchair and appeared to look tired, so she asked an aide to lay her down in bed. Later that evening, CNA B told her the resident was having some discomfort while she was trying to change her brief, so she went into Resident #1's room to assess the resident. LVN A denied trying to make the resident stand up and said Resident #1 indeed looked to have some discomfort, but it was not pain. LVN A described the discomfort as someone that was tired and did not want to be touched and again denied the discomfort as pain. LVN A said she continued to monitor the resident throughout the night and there were no concerns as Resident #1 has slept comfortably the whole night. LVN A was asked about her handwritten statement where she had documented facial grimacing when the resident's left leg was touched and LVN A denied writing a statement. LVN A further stated the only thing she wrote was her narrative in the progress notes of Resident #1's clinical record and again denied she wrote a statement of the incident. LVN A also said she did not contact the doctor because Resident #1 was not in pain and the resident had slept comfortably all night. Interview on 07/02/24 at 1:40 PM with RN C revealed when she arrived to the facility on , 06/16/24 at 6:00 AM, Resident #1 was in bed sleeping. She got report from the night nurse, LVN A, that Resident #1 was having pain to her left leg. RN C went in to assess the resident in her room and Resident #1 did not appear well, was not her normal self, and when she tried to move her left leg, the resident expressed pain through facial grimacing. RN C called the doctor and ordered an x-ray of the resident's leg, and the results came back positive for a hip fracture, so she was sent out to the hospital. Interview on 07/02/24 at 1:54 PM with the ADON revealed she was not informed of all the details with Resident #1. The ADON said she only assisted in gathering a few statements from the staff and the Administrator had conducted the investigation with Resident #1's incident. Interview on 07/02/24 at 2:43 PM with the Administrator revealed she had been made aware of Resident #1's hip fracture and she began an investigation of the incident. The Administrator was made aware LVN A denied writing a statement., and she was shown the handwritten statement that was part of the provider investigation report and shown the matching signatures. and The Administrator said she had provided the wrong statement. The Administrator said had found LVN A's handwritten statement under her door and because corporate preferred their statements to be typed out, the [NAME] President of Clinical Operations had gotten LVN A's other statement. The Administrator further stated she would provide LVN A's typed statement and that was the correct one. The Administrator could not explain why there were two statements where one addressed Resident #1 was having pain and the other statement did not. Interview on 07/02/24 at 3:19 PM with the [NAME] President of Clinical Operations revealed she was not aware LVN A had written a statement. and the facility did not have a DON at the time, so she called LVN A into the facility and had her type up a statement. The [NAME] President of Clinical Operations said LVN A further stated LVN A had been suspended and educated on pain management and resident assessment after the incident with Resident #1 because they felt like LVN A could have assessed the resident better and wanted to make sure she knew how to fully assess a resident and contact the doctor if needed. Record review of the facility's Change in Resident's Status or Condition policy, revised February 2021, reflected the following: Policy Statement: Our promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .b. discovery of injuries of an unknown source; .i. specific instruction to notify the physician of changes in the resident's condition. This was determined to be an Immediate Jeopardy (IJ) on 07/19/24 at 8:44 AM. The Administrator, the DON and ADON were notified. The Administrator was provided with the IJ template on 07/19/24 at 8:50 AM. The following Plan of Removal submitted by the facility was accepted on 07/19/24 at 2:37 PM: Problem: Facility failed to immediately consult with the resident's physician when there was a change in the resident's condition, when Resident #1 had a change of condition on 06/15/24 and did not receive timely treatment. - The following in-services were initiated by - started on 7/2/2024 and completed on 7/5/2024 COMPLIANCE NURSE DON: Any nursing staff member not present or in-service will not be allowed to assume their duties until in-serviced and expectations acknowledged. Licensed Nurses: - Promptly and accurately assessing a resident when change of condition has been identified / reported. Education started on 7/2/2024 and completed on 7/5/2024. - Assessing a resident's change in condition using SBAR, so that all necessary information is communicated to the physician or Nurse Practitioner. Education started on 7/2/2024 and completed on 7/5/2024. -Reporting changes of condition to the physician or nurse practitioner based on Change of Condition Form. Education started 7/2/2024 and completed on 7/5/2024. Non-licensed nursing staff: - Reporting changes in a resident's condition to a nurse immediately. Education started 6/16/2024 and completed on 7/5/2024. - If the nurse does not assess timely, the DON/Designee must be notified. Education started 6/16/2024 and completed 7/5/2024. The Administrator, DON and ADON were in-serviced .regarding .ensuring all staff applicable to the in-service receive the training, to use online resources and / or in person training, to ensure all trained staff have attested that they have received the training by a signed acknowledgement. An ADHOC QAPI meeting was conducted on 7/8/2024 regarding this plan and monitoring. The Medical Director .was notified of this plan and monitoring on 7/2/2024. Monitoring -The DON/Designee will monitor all kiosk (dashboard) alerts a minimum of 4 times per week to ensure any potential change of condition has been addressed timely. -The DON/Designee will randomly ask nurses per week what they would do if a resident had a change of condition, or it was report to them that a resident had a change of condition. -The QAPI committee will review the findings and make any needed changes. Monitoring of the facility's Plan of Removal included the following: Record review of the facility's Incident by Incident type reflected Resident #2, Resident #3, Resident #4, Resident #5 had unwitnessed falls and nursing staff documented, assessed the residents, and reported to the Interim DON, family, and physician. Record review of Admit/Discharge Report, from 06/16/24 through 07/19/24, reflected Resident #6, Resident #7, Resident #8, Resident #9 were discharged to the hospital due to change in condition. Residents were assessed and nursing staff documented change in condition using SBAR and notified the Interim DON, family, and physician. Record review of the facility's Change in Condition Evaluation - SBAR (Situation, Background, Assessment, and Recommendation), undated, reflected the form addressed signs and symptoms identified, start date, review findings and provider notifications, mental status evaluation, functional status evaluation, vital signs evaluation, provider notification and feedback, behavioral status evaluation, respiratory status evaluation, cardiovascular status evaluation, abdominal/GI status evaluation, genitourinary status evaluation, skin status evaluation, pain status evaluation, neurological status evaluation, general background evaluation and available laboratory test/diagnostic procedures and resident representative notification. Record review of the facility's Record of In-service Education, dated 06/16/24, reflected training for abuse, neglect policy - who is coordinator; resident rights; pain policy; and timely notification. In-services reflected all staff completed the trainings. The in-services were conducted and signed by nursing on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 06/25/24, reflected the training participant would be able to verbalize and demonstrate proper transfer techniques in order to safely provide patient care handling, transfers included sit to stand, stand - pivot, squat- pivot, slide board, and mechanical lift. The in-services were conducted and signed by CNAs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 06/26/24, reflected the Administrator, the Interim DON and ADON were in-serviced on all staff applicable to receive training to use online resources or in person training to ensure all trained staff have attested to receiving education. Record review of the facility's Record of In-service Education, dated 07/02/24, reflected training for what was change of condition, what to do when a change of condition happens, who to notify, orders to receive, full head to toe assessment, assess for pain, medicate as ordered and continue to assess and to follow through any new orders. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 07/03/24, reflected training regarding: how to identify pain and what to do. The training record reflected: .pain may be late on set and resident may not be able to verbalize, job is to assess pain and treat timely, once treated - [you] have to assess for effectiveness, continue to monito if not effective new orders may be needed. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Monthly QA Meeting reflected the meeting was completed on 07/08/24. Interviews conducted on 07/19/24 from 2:40 PM through 5:45 PM with the Administrator, the Interim DON, ADON, LVN A, RN D, RN E, RN F, LVN G, LVN M, RN O, LVN Q, who worked the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM revealed nurses were able to verify education was provided to them. Nursing staff were able to accurately summarize what was change of condition, what to do when a change of condition occurred, who to notify, orders to receive, completing a full head-to-toe assessment, assessing for pain, medicating as ordered and continuing to assess, following through any new orders, documenting, and completing the SBAR. The Interim DON and ADON stated they would be responsible for monitor all kiosk (dashboard) alert a minimum of 4 times per week to ensure any potential change of condition had been addressed timely and continue education on change of condition. Interviews conducted on 07/19/24 from 3:48 PM through 5:45 PM with CNA B, CNA H, CNA I, CNA J, CNA K, CNA L, CNA N, CNA P, CNA R, CNA S, and CNA T who work the shifts of 6:00 AM- 6:00 PM- 6:00 PM - 6:00 AM revealed staff were able to verify education was provided to them, staff were able to accurately summarize what was change of condition, how to identify pain and who to notify. The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 07/19/2024 at 5:50 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for 5 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1, who resided in the memory care unit, was provided a hazard free environment with adequate supervision when Resident #1 ingested body wash on 02/07/23, which was found while wandering in the room of Resident #2 and Resident #3. 2. The facility failed to provide a hazardous free environment in the memory care unit, even after Resident #1 ingested body wash on 02/07/23, when bottles of body wash and body lotion were left out in the room of Residents #4 and #5 on 02/15/23. These failures put memory care residents at risk of serious injury, hospitalization , or even death. An Immediate Jeopardy situation was identified on 02/15/23 at 3:54 PM. The Immediate Jeopardy was removed on 02/16/23 at 2:50 PM. The facility remained out of compliance at a scope of pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. Findings Included: Resident #1 Record review of Resident #1's electronic Facesheet, dated 02/15/23, revealed Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included senile degeneration of brain (the mental deterioration and loss of intellectual ability), neurocognitive disorder with Lewy bodies (affect chemicals in the brain whose changes, can lead to problems with thinking, movement, behavior, and mood), and schizoaffective disorder bipolar type. Record review of Resident #1's Quarterly MDS assessment, dated 01/21/23, revealed Resident #1's BIMS score was 00 which indicated severe cognitive impairment. Record review of Resident #1's care plan, initiated on 11/07/22, reflected Resident #1 had a communication problem due to dementia and the interventions included Ensure/provide a safe environment . avoid isolation. Further review revealed Resident #1 had behavior potentially causing harm, due to dementia, as evidenced by ingested non-food substance and the interventions included if wandering or pacing, initiate visual supervision during acute episode . staff will keep all potential non-food items out of view or accessibility. A record review of Resident #1's Progress Notes, dated 02/07/23, revealed LVN A documented Upon passing medication this am, resident was noted to be walking down hallway with red container in hand, this writer seen resident put container to mouth, resident was able to take one drink from container before I approached her. I noted that the container was a bottle of liquid hand soap from another resident's room. Assessed resident's oral cavity and rinsed mouth out. NP made aware, new order to monitor and obtain CBC, BMP. Poison control notified. Spoke with RN, stated push water as possible, monitor tolerance of water. Call back if further assistance needed. Case #75473317. RP, DON, Administrator Aware. Resident #2 Record review of Resident #2's electronic Facesheet, dated 02/15/23, revealed Resident #2 was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's diagnoses included unspecified dementia with behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities., agitation, anxiety, and psychosis), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs), wandering in disease classified elsewhere, and cognitive communication deficit. Record review of Resident #2's Quarterly MDS assessment, dated 01/12/23, revealed Resident #2's BIMS score was 5 which indicated severe cognitive impairment. Record review of Resident #2's care plan, initiated on 01/24/23, reflected Resident #2 had communication problem due to dementia with interventions that included Ensure/provide a safe environment. Further review revealed Resident #2 had complication due to impaired cognitive function/dementia and the interventions included cue, reorient, and supervise as needed. Record review of Resident #2's Progress Notes, dated 02/07/22, revealed Communication with Family this nurse spoke with RP and asked him not to bring anything such as soaps, colognes, spray bottles, any sort of chemicals. If there are any question regarding this to contact me. Cell phone number provided. Verbalized an understanding. Resident #3 Record review of Resident #3's electronic Facesheet, dated 02/15/23, revealed Resident #3 was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's diagnosis included unspecified dementia, unspecified severity, without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Record review of Resident #3's Quarterly MDS assessment, dated 12/14/23, revealed Resident #3's BIMS score was 3 which indicated severe cognitive impairment. Record review of Resident #3's care plan, initiated on 01/24/23, reflected Resident #3 had risk for complications due to impaired cognitive dementia or impaired though process with the interventions included monitor to MD any changes in cognitive function, specifically changes in decision making ability. Resident #4 Record review of Resident #4's electronic Facesheet, dated 02/15/23, revealed Resident #4 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #4's diagnoses included unspecified dementia with behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities., agitation, anxiety, and psychosis), schizoaffective & bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs), and restlessness and agitation. Record review of Resident #4's Comprehensive MDS assessment, dated 12/23/22, revealed Resident #4's BIMS score was 99 which indicated the resident was unable to complete the interview. Record review of Resident #4's care plan, initiated on 01/04/23, reflected Resident #4 was at risk for wandering with interventions that included identify pattern of wandering and was a resident looking for something. Resident #5 Record review of Resident #5's electronic Facesheet, dated 02/15/23, revealed Resident #5 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #5's diagnoses included unspecified dementia without behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities., agitation, anxiety, and psychosis) and Alzheimer's disease. Record review of Resident #5's Comprehensive MDS assessment, dated 02/03/23, revealed Resident #5's BIMS score was 0 which indicated severe cognitive impairment. Record review of Resident #5's care plan, initiated on 01/28/23, reflected Resident #5 had risk for complications due to impaired cognitive dementia or impaired though process with the interventions included monitor to MD any changes in cognitive function, specifically changes in decision making ability. In an interview on 02/15/23 at 9:45 AM, the ADMN stated LVN A noticed Resident #1 putting a red container to her mouth and immediately went to the resident and took the bottle. The ADMN stated it was a liquid soap bottle from Bath & Body works. She stated LVN A contacted poison control and was told to provide lots of water and monitor for change in condition. The ADMN stated LVN A was taking vitals and monitoring resident during mealtimes. She stated Resident #1 did not have a change in condition. The ADMN stated the liquid soap should not have been in a resident's room in memory care. She stated they did a sweep in memory care and removed any items that would have been harmful. The ADMN stated the nurses' completed weekly sweeps. She stated she in-serviced staff on abuse/neglect, chemicals, and prohibited items in memory care. An initial observation of the Memory Care Unit on 02/15/23 at 9:59 AM, revealed majority of the residents in the center dining area of the unit. There were two residents walking up and down the hall. Some of the resident's doors were open in the unit and there were not residents in the rooms. An observation on 02/15/23 at 10:01 AM revealed the door to Resident #4 and Resident #5's room, was open and bottles of body wash and body lotion were left out on the sink. The bottles had liquid in them. The bottle of body wash was observed to have the cap flipped up and ready to pour. Resident #4 was observed in her bed asleep, and Resident #5 was not in the room. An interview was attempted with Resident #1 on 02/15/23 at 10:03 AM. Resident #1 was not verbally responding to the questions being asked, nor was she responding non-verbally by gesturing with her head or hands to yes and no questions. An observation on 02/15/23 revealed Resident #1's room was on the hall near the entrance of the Memory Care Unit. Residents #4 and #5's room (#310) was located on a different hall from Resident #1 towards the beginning of the hall entrance. Residents #2 and #3's room (#327) was located on a different hall than Resident #1's and was at the very end of the hall next to the emergency exit door. In an interview on 02/15/23 at 10:25 AM, the DON stated she removed the bottles of body wash and body lotion from the room of Residents #4 and #5. She stated the CNAs must have left it out when they got Residents #4 and #5 up for the day. The DON stated the body wash and body lotion should not have been left out because one of the residents could have got them, which could be harmful. She stated those items were supposed to be in the shower room, which was secured. In an interview on 02/15/23 at 10:35 AM, LVN A stated on 02/07/23 she was in the hallway passing meds and saw Resident #1 with a red bottle. LVN A stated she immediately started walking towards Resident #1 and saw her put the bottle up to her mouth and drink from the bottle. LVN A stated it was a bottle of body wash from Bath & Body Works and had Resident #2's name on it. She stated Resident #1 must have wandered into Residents #2 and #3's room and picked it up. She stated she took the bottle away from Resident #1 and had her open her mouth. LVN A stated there was soap residue on her tongue, so she knew she ingested the body wash. She stated the bottle was not empty and she did not know how much Resident #1 ingested. LVN A stated she knew the soap had chemicals that should not be ingested, so she contacted poison control and the facility's physician. She stated both poison control and the physician told her to give Resident #1 lots of water, monitor her for change in conditions, or if she was to become lethargic, then to send Resident #1 out to the hospital. LVN A stated she took Resident #1's vitals every 1-2 hours and vitals were good. She stated she had Resident #1 drink about 4-5 large cups of water and monitored her during lunch. LVN A stated Resident #1 ate her lunch well and seemed like her normal self. LVN A stated Resident #1 was known to walk around and go into other resident's rooms and take things. She stated Resident #1 was known to pick things up and ingest them. LVN A stated there was a time she picked up a bottle of orange juice from the nurses' cart and drunk the bottle. She stated luckily it was edible, but after that incident they had to keep the orange juice locked on the carts. LVN A stated the body wash should not have been out in Residents #2's room because it was memory care, and the residents did not know they were not supposed to ingest the body wash. She stated body wash was supposed to be kept in shower rooms, which were locked. LVN A stated families come to visit and sometimes they leave the residents' things to use, and the staff were unaware. She stated the nurses were supposed to do weekly sweeps. She stated she had not worked in memory care this week, so she did not know if they had completed a sweep. She stated after the incident with Resident #1, staff was in-serviced, and they did a swept to remove any dangerous items. In an interview on 02/15/23 at 10:46 AM, CNA B stated she was responsible for Residents #4 and #5. She stated Resident #4 was not ready to get out of bed, but she did get Resident #5 up. CNA B stated she changed Resident #5's brief, got her out of bed, and on the way out of the room, Resident #5 stopped and washed her hands in the sink. She stated she did not notice the body wash or body lotion on the sink. CNA B stated she did not put the products there nor did she use the products on Residents #4 or #5. CNA B stated she did not know how long the bottles were sitting out. She stated those items are not supposed to be left out and are normally locked in the shower rooms because they could be dangerous for residents. She stated she did get an in-service on 02/07/23 regarding those items should not be left out. CNA B stated she should have been looking would have removed the products, but she just did not notice them on the sink. A record review of the MSDS for the bottle of body lotion that was found on 02/15/23 in Residents #4 and #5's room revealed Hazards Identification: Classification Acute Toxicity-Oral, Eye Damage/Irritation . Hazard Statements: Causes eye irritation, May be harmful if swallowed. A record review of the MSDS for the bottle of body wash that was found on 02/15/23 in Residents #4 and #5's room revealed Hazards Identification: Classification Eye Damage/Irritation . Hazard Statements: Causes eye irritation. In an interview on 02/15/23 at 3:45 PM, the ADMN stated the facility did not have a policy regarding prohibited items in memory care. She stated for in-services they used pages 33 and 34 of the facility's admissions packet, which listed items residents could not have in their rooms. A record review of pages 33 and 34 of facility's admission packets , not dated, did not reveal resident's in memory care could not have soaps, body wash, or lotion; however, there was a Note, which stated the following: A good rule of thumb has been established by the Food and Drug Administration whereby any products labeled keep out of reach of children or carries any type of caution label is merchandise that contains ingredients which are harmful if taken without supervision or used in a way not designated. Many of our residents, due to mental impairments or poor eyesight might inadvertently drink or eat some of the above items causing irreparable harm. The Administrator was notified on 02/15/23 at 4:10 PM, that an Immediate Jeopardy had been identified due to the above failure. The IJ Template was provided to the Administrator on 02/15/23 at 4:13 PM. The Plan of Removal (POR) was accepted on 02/16/23 at 12:28 PM. The Plan of Removal reflected the following: 1. The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome, with completion date of 02/15/23. The DON educated the nurse aide leaving bath wash and lotion in memory care resident's room unattended to ensure hazardous products are not left in reach of memory care residents. The employee was suspended pending investigation. All resident on the Memory Care unit have potential to be affected and were assessed for complications by charge nurse, none were noted. All resident rooms and areas on the Memory Care unit were inspected for presence of bath wash and lotion or hazardous products by Administrator, DON, ADONs, department heads, none were noted. Going forward inspections will be carried out by the Interdisciplinary Team. 2. The facility took the following actions to prevent an adverse outcome from reoccurring, with completion date 02/15/23. The DON/Nursing Administration staff provided education to all staff on ensuring hazardous products are not left in reach of memory care residents. Bathing and lotion products are to be securely stored when not in use. All PRN Staff, Agency staff and staff not currently working will be in-serviced prior to their next shift on ensuring hazardous products are not left in reach of memory care residents. Orientation and training for new hires will include education to staff related to ensuring hazardous products are not left in reach of memory care residents. Review of the products showed they did not include keep out of reach of children, staff were instructed to read precautions of product use and check with the charge nurse when there is a question about products that are safe to leave in a resident's room. The facility Interdisciplinary Team Leaders will audit resident rooms daily to ensure compliance with the facility policy. Findings will be reported in daily QA Meeting. The Administrator/Maintenance Director will audit resident rooms weekly to validate compliance with facility policy. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring of the facility's Plan of Removal included the following: A record review of the medical records for the 47 residents in the memory care unit revealed they were assessed for complications by the charge nurse and there were no issues. Further review of the 47 residents' medical records revealed there were progress notes indicated their families had been contacted and advised not to leave prohibited items in the resident's rooms. Observations on 02/16/23 from 2:00 PM to 2:05 PM revealed all rooms and areas in the memory care unit were free from hazardous products. Interviews were conducted on 02/16/23 from 1:25 PM to 2:40 PM with the Administrator, DON, Activity Director, Activity Assistant, Staff Coordinator, 1 RN, 7 LVNs, 10 CNAs, 2 housekeeping, and 3 therapy staff from multiple shifts. The staff all indicated they had been in-serviced on safety awareness, which included a list of prohibited items in memory care, how hazardous items should be stored, the procedures on storing prohibited items that family members might bring for resident use, and procedures in case they were not sure if an item is hazardous. A record review of the in-services dated 02/15/23 on Safety Awareness, No soaps, chemicals, colognes, shaving creams, cleaning supplies of any kind left in resident's rooms on Memory Care, and All staff to read the precautions of a product use and check with charge nurse when there is a question about products are safe to leave in a resident's room revealed 56 signatures from multiple shifts and multiple departments (RNs, LVNs, Therapy, Housekeeping, Laundry, Maintenance, and Administration) had received in-services which covered all aspects of the POR . A record review of document titled Facility: Room Sweep, dated 02/15/23 to 02/16/23, revealed the facility's Interdisciplinary Team Leaders had conducted room sweeps for all rooms in the memory care unit. Each room number (120-332) was listed on the form and the Interdisciplinary Team Leaders who inspected the room had provided their signatures on the document. The Administrator was informed the Immediate Jeopardy was removed on 02/16/22 at 2:50 PM; however, the facility remained out of compliance at a scope of pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.

Based on interviews and record reviews, the facility failed to provide basic life support, including CPR, to a resident requiring emergency care for one (Resident #1) of 31 residents reviewed for CPR. LVN A failed to immediately start and continuously provide CPR when she determined Resident #1 did not have a pulse or respirations on [DATE]. Due to confusion over Resident # 1 code status CPR was not started at least 50 minutes after Resident #1 was found without a pulse or respiration. Resident #1 expired at the facility on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal. These failures could affect residents by placing them at risk for not receiving CPR and further life-saving treatments as desired, which could result in death. Findings included: Review of Resident #1's Face Sheet, dated [DATE], revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed his BIMS (brief interview for mental status) was 13 indicating he was cognitively intact. Review of Resident #1's chart under the first tab labeled Condition Alert revealed he was a full code. The next tab was labeled Consent and had the OOHDNR paperwork with a physician order [REDACTED]. Review of Resident #1's progress notes, dated [DATE], revealed Resident #1 requested to be a code status of full code, he verbalized understanding an this note was entered by the social worker. Review of Resident #1's progress note revealed the EMT called the time of death at 4:39 AM on [DATE] by LVN A. Review of the care plan dated [DATE] did not indicate a code status change. Review of nurse station one's 24-hour report for [DATE] and [DATE] reflected no documentation change in code status for Resident #1. Interview on [DATE] at 2:57 PM with CNA B revealed she worked the 10 PM to 6 AM shift on [DATE]. CNA B stated she was doing rounds early the morning of [DATE] when she observed Resident #1's skin was pale. CNA B stated she called him and when he did not respond, she called LVN A. CNA B stated Resident #1 was holding his [MEDICAL CONDITION] mask in his hand. CNA B stated LVN A tried to arouse the resident at 2:58 AM but he did not respond. CNA B stated LVN A ran to the nurse's station to retrieve a blood pressure cuff and the first time she checked him it did not have a reading. CNA B stated she and CNA D changed the resident within minutes after LVN A exit the room and sat him up in bed. CNA B stated LVN A yelled and was running with the crash cart to his room at 3:50 AM. CNA B stated LVN A and LVN E began CPR and the EMTs arrived at 4:19 AM. Interview on [DATE] at 5:25 PM with CNA B revealed Resident #1 was snow whitish, looking from the door. Further stated Resident #1 did not make any noises or move when his brief and clothes were being changed. CNA B stated resident was not breathing and she witnessed LVN A check his pulse and oxygen. Interview on [DATE] at 10:22 PM with CNA D revealed at 2:58 AM on [DATE] she was in Resident #1's room when LVN A tried to arouse Resident #1 and checked his blood pressure. CNA D stated Resident #1's blood pressure was high but she was unable to remember the exact reading. CNA D stated LVN A tried to check Resident #1's oxygen but he did not have a reading. CNA D stated she and CNA B changed Resident #1 and sat him up in bed and she continued to work because they were told he was a DNR by LVN A. CNA D stated at 3:50 AM, LVN A came back to Resident #1's room with the crash cart yelling they had to do CPR. CNA D stated LVN E did compressions as LVN A gave breaths. CNA D stated she called 911 at 3:50 AM. Interview on [DATE] at 5:20 PM with CNA D revealed Resident #1 was not moving and did not appear to be breathing. CNA D stated when she and CNA B were changing him he did not move or make any noises. Interview on [DATE] at 2:31 PM with LVN A revealed she worked the 10:00 PM to 6:00 AM shift on [DATE] and she did not receive any change of condition information regarding Resident #1 from RN C, the previous shift nurse. She stated CNA B had checked on Resident #1 every couple of hours, and she spoke with him about wearing his [MEDICAL CONDITION] to bed. LVN A stated CNA D called 911 at 3:50 AM while she and LVN E grabbed the crash cart and did CPR until the ambulance arrived at 4:19 AM. LVN A stated Resident #1 was pronounced deceased at 4:39 AM on [DATE]. Interview on [DATE] at 5:41 PM with LVN A revealed resident was not responsive, not breathing and his eyes were open and glazed over and he was not blinking. LVN further stated she spoke loudly to the resident, did a sternum rub, and checked his pulse both radial and carotid and she could not get a reading. Review of LVN A's nurses note dated [DATE] at 7:39 AM revealed, It was reported by nurse aide at 3 AM that resident was not responding and needed to be assessed. I rushed to the room and found resident unresponsive. I checked his code status which was found to be DNR based on the chart. I called DON about finding resident unresponsive and that he was a DNR based on the findings in the chart and the OOHDNR form that was in the front with the physician order [REDACTED]. I immediately called Code Blue and started CPR. Other staff members present at that time which included station 1 nurse and station 2 CNA's. Both nurses started CPR and CNA called [DATE]. Paramedics arrived and took over from both of nurses. Dr. Uddin notified. Paramedic came to nurses station and stated their on board doctor pronounced resident at 4:39 AM. SN called doctor again and called Don again and left message for son to call back facility. son called back and given name of funeral home of their choice. Given report to ADON and she stated she would call funeral home. Interview on [DATE] at 5:41 PM with LVN E revealed she was alerted by LVN A that she needed help with CPR on Resident #1. LVN E stated at 3:50 AM she began chest compressions and LVN A gave breaths until EMT arrived and took over. LVN E stated when someone readmitted to the facility they were supposed to check the code status in case it changed. LVN E stated she did not know Resident #1 and was unfamiliar with his health. LVN E stated the resident's code status was found in the chart, computer, and if they did not know, they were to treat the resident like a full code. Interview on [DATE] at 1:50 PM with the SW revealed Resident #1 advised her on [DATE] he wanted to change his code status to full code. The SW stated Resident #1 expressed understanding of the decision. The SW stated she documented the conversation in the progress notes of the electronic medical record. The SW stated she told RN C on [DATE] during shift change of the resident's code status change. The SW stated RN C who was the 2:00 PM to 10:00 PM charge nurse, advised her she would chart on it . The SW stated she was unsure if RN C had updated the chart. Interview on [DATE] at 5:48 PM with RN C revealed she was told by the SW that Resident #1 was going to be a full code. RN C further stated the SW was supposed to take the DNR paperwork out of the chart and update the code status. RN C did not chart anything about the code status change. Interview on [DATE] at 12:00 PM with the ADON revealed she expected LVN A to start CPR when she realized Resident #1 had both full code and DNR statuses in his chart. The ADON stated all staff were trained on where to locate code statuses. The ADON stated code status was documented on the first page of the chart and was colored red or green. The ADON stated a red color indicated DNR and green for full code. The ADON stated the ultimate cause of the IJ involving Resident #1 was a system failure. The ADON stated the SW told nursing staff during shift change and the nurse staff failed to document the code status change. Interview on [DATE] at 1:14 PM with the MD revealed if there were both code statuses in a resident's chart, she would expect staff to treat the resident as a full code and do CPR. Interview on [DATE] at 1:10 PM, with the DON revealed she got a phone call in the early morning around 3:30 AM on [DATE] regarding Resident #1. The DON stated when she was told Resident #1 was found unresponsive with a DNR, she advised LVN A to check the nurse's notes on the computer for the code status because she believed Resident #1 code status had changed. The DON stated after clarifying Resident #1's code status LVN A called a code blue and CPR was conducted between 3:30 AM and 4:00 AM. When the DON arrived at the facility later that morning, she conducted a quality assurance and performances improvement (QAPI) meeting over code statuses. The DON stated the Social Worker and ADON did a chart audit on code statuses to ensure residents who had a DNR wanted to remain a DNR and were aware of it. She stated LVN A was suspended pending the investigation at 8:30 AM. The DON also stated the cause of Resident #1's death was due to a delay by 50 minutes or more in administering CPR and a chart discrepancy in code status. The DON stated LVN A did not document Resident #1's respiratory or pulse information when she first checked him at 3:00 AM. The DON stated the SW should have told them during a different time rather than at shift change. She stated the SW could have written it in the 24-hour report and removed the DNR form from the chart. Interview on [DATE] at 12:35 PM with the DON revealed she expected staff to perform CPR immediately if a resident's chart had discrepancies with both full code and DNR statuses. She stated the code status of the residents should have been the first page/tab of the chart that was color coded. The DON stated a red sheet indicated DNR and was accompanied by a physician order [REDACTED]. A green sheet indicated a full code status. The DON stated if a status changed, the Social Worker was to update the information in the chart, advise the charge nurse, and write it in the 24-hour report. If the resident or the family chose a DNR (Do Not Resuscitate) status for a resident, the physician still had to sign the DNR order for the status to be considered enacted. If the resident's status was undecided or the staff did not have a signed DNR document, the resident was automatically considered as a full code. She said the facility did provide CPR certification training for the staff members. Review of LVN A's CPR certification record reflected she was CPR certified through the American Heart Association on [DATE] and it was recommended for renewal on [DATE]. Review of a Corrective Action Form for LVN A, dated [DATE], revealed LVN A was suspended due to a delay in administering CPR after Resident #1 was found unresponsive on [DATE]. The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ and retrieved on [DATE] reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions. Review of the facility's Advanced Directives and Treatment Decisions Standard of Practice, dated [DATE] and revised [DATE] reflected, Standard of Practice: It is the resident's right to formulate an Advanced Directive, and accept or refuse medical or surgical treatment .Standard of Practice Explanation and Compliance Guidelines: On admission, the facility will determine if the resident has executed an Advanced Directive and if not, determine whether the resident would like to formulate an Advanced Directive Decisions regarding Advanced Directives and treatment will be addressed with any significant change or improvement. Review of the facility's Do not Resuscitate Order, revised [DATE], reflected, Policy Interpretation and Implementation 1. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's orders [REDACTED]. 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record. The Administrator was notified on [DATE] at 5:57 PM that an Immediate Jeopardy situation was identified, and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] and included: Nurse in question suspended pending investigation on [DATE] at 8:30 AM. Audit was initiated on [DATE] and completed by nursing administrators on [DATE]. Medical Director was notified of the incident on [DATE] at 5:15 AM. Medical Director was notified of the IJ at [DATE] at 6:30 PM. Root Cause of the Incident per Investigation Resident chart had both full code and DNR and the LVN waited approximately 3:00 AM to 3:50 AM 50 minutes before initiating CPR SW communication verbalized resident code status change but did not enter it in the 24 hour report. Steps Implemented beginning [DATE]: SW to audit all current residents' advanced directives and code status. DON, ADON, and ADM were in serviced by Regional Nurse on standard of practice on identifying code status DON and ADON in serviced nurse staff on CPR; No nurse will be allowed to work until the in-service is completed; IDT team members have been educated as well. Licensed Nurses were re-educated provided by ADON on the Cardiopulmonary Resuscitation Policy and process to include the following: 1. Abuse and Neglect 2. CPR Policy 3. Identifying code status changes 4. Code status identified for quick reference 5. If any conflict or discrepancies in code status start CPR 6. Document code status changes in 24-hour report The implementation of red sticker on the outside of the chart and a red sheet in the resident chart to readily identify a DNR resident beginning [DATE] was completed and the Social Worker will oversee the compliance of the system. The implementation of a green sticker and green sheet inside the chart identify a full code status and CPR is to begin. The updating of the residents' code status will be discussed in a clinical meeting for follow up and to validate implementation of the processes. All staff will be in-serviced by [DATE] 2:00 PM. An Ad Hoc Quality Assurance Committee meeting (QPI) was held on [DATE] at 9:30 PM The QAC is responsible for the plan of removal and its monitoring. The QAC and MD will do weekly for six weeks and then for three months. The QAC will oversee compliance of this plan. Interview on [DATE] at 12:50 PM, with the Administrator revealed she had started working at the facility 20 days ago and the facility had provided training on how to perform CPR for LVN A on [DATE] and what was expected when there was a discrepancy in code status determination. Individual interviews with facility staff representing multiple shifts (LVN A, CNA B, RN C, CNA D, LVN E, SW, ADS,BOM,RN F, LVN G, LVN I, CNA J, CNA K, MA L, CNA M, CNA N, CNA O, CNA P, LVN Q, LVN R, CNA S, MA T, CNA U, CNA V, LVN W, CNA X, CNA Y, CNA Z, CNA AA, MR) on [DATE] to [DATE] revealed they had received in-service training and understood to initiate CPR immediately on a full code resident when he or she had a chart discrepancy on code status. The staff had sufficient knowledge of their roles in a code blue (resident code) emergency situation. Staff revealed they were trained to not stop compressions until the paramedics were ready to take over. Staff were trained to identify the red and green stickers on the outside of the chart. No concerns were noted during the interviews. Record review of 30 resident charts revealed the code status did match the code status in the chart from monitoring conducted by the social worker and ADON. On [DATE], the DON was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual 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.

Based on observation, interview, and record review, the facility failed to consult with the resident's physician and notify the resident's representative when there was a significant change in the resident's physical and mental status for one (Resident #7) of eight residents reviewed for a change of condition. The facility failed to consult with Resident #7's physician and representative when she had a significant weight loss. This failure could affect residents by resulting in a delay of appropriate medical treatment and a worsening of a resident's condition Findings included: Resident #7's MDS assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her height was four feet, six inches and her weight was 116 pounds. The resident's weight was stable. She was at risk for pressure sores but did not have any. She had mild cognitive impairment with a BIMs score of 11 (a score of 8-12 indicated mild impairment). She required extensive assistance of two staff for bed mobility and transfers. She was not ambulatory. She had limited range of motion to both her lower extremities. She required limited assistance of one staff for eating. Resident #7's Care Plan dated 07/01/18 revealed the resident had a potential risk for alteration in nutrition related to her mechanical soft diet and nutritional [MEDICAL CONDITION]. The goals included for the resident to consume greater than or equal to 75% of her meals and to maintain and stabilize at her current weight of 119 pounds, plus or minus 3 pounds. The approaches included monthly weights and to notify the physician and responsible party of changes as needed. Resident #7's Weight Change History, dated 11/20/18 at 11:08 AM, revealed the following monthly weights: 09/24/18 117.80 pounds 10/09/18 115.80 pounds 11/06/18 107.40 pounds (a loss of 8.8% in one month and 13 days - 9/24/18 to 11/06/18). Resident #7's Departmental Note dated 11/19/18 revealed the resident's responsible party was notified the resident had pressure ulcers and a wound consult was ordered. Resident's #7's wound care Surgical Note dated 11/19/18 revealed a consult was received for wounds located at the sacrum and right buttock. Risk factors were listed as depression and limited mobility. There was no documentation related to the resident's weight loss. Resident #7's physician progress notes [REDACTED]. The Assessment/Plan included: 1. Continued wound care to the Stage III wound to her back/buttock, 2. Hypertension, continued medications, 3. [MEDICAL CONDITION], continued medication and 4. Debility, continued supportive care. The resident's weight loss was not addressed. Resident's #7's Departmental Notes from 11/03/18 to 11/27/18 revealed no documentation the resident's physician or responsible party were notified of the resident's weight loss. The resident's weight loss was not documented or addressed in the notes. There was no documentation from the Dietician addressing Resident #7's weight loss. Observation on 11/20/18 at 12:40 PM revealed Resident #7 was in her room, sitting in her Broda chair (a specialized rolling chair that can tilt back for better positioning), attempting to feed herself with some difficulty. In an interview on 11/27/18 at 2:58 PM the Wound Care Nurse said she was treating Resident #7's wounds. She said she was not aware of the resident's weight loss. In a telephone interview on 11/27/18 at 3:16 PM, Resident #7's physician said he was not familiar with the particulars of the resident's care and would have to review her chart and return the call; however, no return call was received. In an interview on 11/27/18 at 3:58 PM the DON said Resident #7's weight had been stable until 11/06/18. She said there was no documentation the resident's physician or responsible party were notified but they should have been. She said the resident received a multivitamin but no other dietary supplements. In a telephone interview on 11/27/18 at 4:33 PM, Resident #7's responsible party said no one told her about the resident's weight loss but she could tell the resident was losing weight. She said the facility had never offered the resident any dietary supplements, but prior to her admission to the facility, the resident's primary physician advised her to drink Ensure (a weight loss supplement) and the resident was drinking it at home. She said if the facility offered the resident a supplement, the resident would accept it. Resident #7's Departmental Notes dated 11/27/18 a 5:42 PM revealed the resident fed herself after tray set up and ate 50% of her meal; it was noted today that the resident had lost weight and the Nurse Practitioner was notified. Dietary supplement orders were received for Majic Cup with every meal, Prostat 30 cc TID and [MEDICATION NAME] packet twice a day. The resident would be re-weighed again after two weeks. The Nurse Practitioner would be notified of it. The resident's daughter was notified of the resident's weight loss and the new orders. The facility's Weight Standard of Practice policy dated (MONTH) (YEAR) revealed notification of any weight variances along with recommended interventions must be communicated with the physician and family according to regulatory requirement.

Based on observation, interview, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and ensure the residents did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable; and ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for one (Resident #7) of three residents reviewed for pressure ulcers. The facility failed to provide to repositioning or pressure relieving devices for Resident #7's chair and as a result, the resident developed facility-acquired, Stage III pressure ulcers. This failure placed residents at risk of developing facility-acquired pressure ulcers and delay the healing of pressure ulcers. Findings included: Resident #7's MDS assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her height was four feet six inches and her weight was 116 pounds. The resident's weight was stable. She was at risk for pressure sores but did not have any. She had mild cognitive impairment with a BIMs score of 11 (a score of 8-12 indicated mild impairment). She required extensive assistance of two staff for bed mobility and transfers. She was not ambulatory. She had limited range of motion to both her lower extremities. She required limited assistance of one staff for eating. Resident #7's Care Plan dated 07/01/18 revealed the resident had a potential for impaired skin integrity related to mobility. The goal was for the resident's skin to remain intact. Approaches included to use a draw sheet for mobility to prevent friction and sheering; skin checks completed with each incontinent episode; promote adequate nutrition and hygiene; therapy screen as needed for positioning concerns, pressure relief as needed; turn and reposition every two hours and as needed. Resident #7's Braden Risk Assessment Report dated 10/15/18 revealed the risk score was 15 which indicated a mild risk for the development of pressure ulcers. The assessment noted the resident's nutrition was adequate and her mobility was limited; she was unable to make frequent or significant changes in her position independently. Observation on 11/20/18 at 12:40 PM revealed Resident #7 was in her room, sitting in her Broda chair (a specialized rolling chair that can tilt back for better positioning), attempting to feed herself with some difficulty. No pressure relieving cushions were observed. Resident #7's Skin Inspection Report dated 11/13/18 reveled the resident's skin was intact. Resident #7's Comprehensive Plan of Care dated 11/15/18 revealed the resident had a Stage I pressure ulcer to her sacrum and barrier cream was being applied. The approaches included to provide pressure reduction, monitor labs as ordered (no labs were ordered), skin assessments weekly and as needed and provide wound care per physician's instructions and review progress. On 11/19/18 the care plan was updated to reflect the resident now had Stage III pressure ulcers to her sacrum and right buttock. The approaches included the above and a low air loss mattress. Resident #7's (MONTH) (YEAR) departmental notes did not reflect documentation regarding the Stage I pressure ulcer identified in the care plan. There was no documentation in the notes regarding the wound deterioration. Resident's #7's Departmental Note dated 11/19/18 at 6:40 PM revealed the resident's responsible party was notified about the skin nurse's finding and concerns on the resident's right buttock and sacral area. Consent was obtained for a wound care physician to evaluate and treat the resident. The responsible party was educated on the importance for the resident to reposition and all the staff to put her on her side with a pillow behind her back to relieve the pressure from her sacrum and right buttock to allow for adequate blood flow to the tissue so it could heal. Resident's #7's wound care Surgical Note dated 11/19/18 revealed a consult was received for wounds located at the sacrum and right buttock. The sacral wound measured 0.7 cm x 0.5 cm x .02 cm and the wound on her right buttock measured 0.3 cm x 1.0 cm x 0.1 cm. The wound care physician debrided the wounds. Risk factors were listed as depression and limited mobility. There was no documentation related to the resident's weight loss and nutrition. Resident #7's physician progress notes [REDACTED]. Continued wound care to the Stage III wounds to her back and buttock, 2. Hypertension, continued medications, 3. [MEDICAL CONDITION], continued medication and 4. Debility, continued supportive care. The resident's weight loss and nutrition was not addressed. Resident's #7's Departmental Note dated 11/21/18 at 10:15 AM revealed the resident voiced no complaint of pain. She was sitting up in her wheelchair (Broda chair) and repositioned for comfort when in chair, and turned every two hours and as needed in bed. The resident was educated on the importance of not sitting up in her wheelchair for consecutive hours, and while in the wheelchair to readjust herself to redistribute her weight. She was educated on the importance of calling for assistance when incontinent episodes occurred. She verbalized understanding. Resident #7's Wound Assessment Report dated 11/26/18 revealed the resident had a Stage III pressure ulcer to her right buttock that measured 0.30 cm x 0.80 cm x 0.20 cm. She had a Stage III to her sacrum/sacral area that measured 0.80 cm x 0.50 cm x 0.40. Her admit weight was 119.80 pounds and her current weight was 107.40. The resident's pain level from the wounds was documented as a 1 out of 10. Her weight loss was not addressed. The wounds were being treated with collagen and dry dressing changes everyday. Resident #7's Wound Assessment Report dated 11/26/18 revealed the resident had a new shear wound to her left buttock, no measurement was documented. Observation on 11/27/18 from 12:29 PM to 1:27 PM revealed Resident #7 was in her room sitting in her Broda chair. There was no specialized cushion in the chair. In an interview on 11/27/18 at 2:58 PM the Wound Care Nurse said she was treating Resident #7's wounds. She said she was not aware of the resident's weight loss. She said the wound areas started as just a red spot from excoriation on/or around 11/15/18 and barrier cream was being applied, but then on 11/19/18 the Stage III's were identified. She said the resident liked to sit up in her specialized chair, but the chair put pressure on the resident's bony prominences of her sacral area, and that was causing pressure. She said now staff were repositioning her more and an air loss mattress was placed on her bed. She said she was not sure if the resident had a pressure relieving cushion in her wheelchair but there had been discussion of getting one. Observation on 11/27/18 at 3:04 PM revealed Resident #7 was in bed, on her side, with the low air loss mattress. Her Broda chair had a store-bought, dining room chair pillow, and a round pillow on the back rest. There was no specialized cushion for the chair. In a telephone interview on 11/27/18 at 3:16 PM with Resident #7's physician, he said he was not familiar with the particulars of the resident's care and would have to review her chart and return the call; however, no return call was received. Observation and interview on 11/27/18 at 4:20 PM revealed Resident #7 was on her back in bed. She said she got the pressure ulcers from sitting up in her Broda chair too long. She said the cushions in her chair were bought by her daughter. She said she did not have any pain or discomfort from the wounds. In an interview on 11/27/18 at 4:14 PM, LVN A said the resident's pressure ulcer appeared as a red spot and then developed quickly into a Stage III. She said it happened very fast. In a telephone interview on 11/27/18 at 4:33 PM Resident #7's responsible party said she purchased the cushion in the resident's Broda chair. She said the resident was unable to turn or reposition herself. Observation and interview on 11/28/18 at 6:06 AM with the Wound Nurse stated revealed Resident #7 developed a shear on her buttocks area, discovered on 11/26/18 when she got back from holiday weekend. She stated the floor nurses provided wound care on the weekends. She stated the new shear was being treated with the same treatment as the other wounds. She said the resident was total care, except she could feed herself. She said the resident was not able to reposition herself in bed or the chair. She stated the resident liked to sit in the chair or up in bed most of the day. She stated the resident was afraid of falling so she would not allow the chair to be tilted back. Resident #7's bottom had a large area of pink under the skin with 3 areas; one wound and two areas of shearing (right of the wound and one below the wound over the coccyx area). The Wound Nurse stated the pressure ulcer was a Stage III. The pressure ulcer measured 0.5 x 0.7 x 0.1; shearing measured 0.3 x 0.7 x 0.1; and the right shearing measured 0.5 x 1.5 cm. Observation on 11/28/18 at 8:10 AM revealed Resident #7 was in her Broda chair with the cushion her daughter purchased in place. Interview on 11/28/18 at 8:17 AM with the PTA said revealed Resident #7 was no longer in therapy. He said the Broda chair seat was not pressure relieving, it was just a standard seat that came with the chair. In an interview on 11/28/18 at 8:41 AM, the Wound Nurse said Resident #7's pressure ulcers were facility acquired but not completely unavoidable because the resident liked to sit up in her Broda chair and did not like the chair to be leaned back. She said the resident was not able to move or turn herself. She said the resident did not have a specialized cushion in the chair, but the facility could get her a gel cushion. She said she had the forms but had not done the Pressure Ulcer Investigation or the Unavoidable Pressure sore assessment (per the facility's policy). She said the new shear was from the resident being transferred and positioned but it was not a pressure ulcer. Observation on 11/28/18 at 9:20 AM Resident #7 was sitting in her Broda chair in the dining room preparing for an activity. Observation on 11/28/18 at 9:45 AM Resident #7 was sitting in her Broda chair in the dining room getting her nails done. The facility's undated Skin System Policy and Procedure policy revealed the intent of the policy was to promote the prevention of pressure ulcer development and promote healing of pressure ulcers that are present. The Skin Committee will meet at least weekly to review the care of residents with pressure ulcers, to include nutritional status and wound healing. The Unavoidable Pressure Sore form will be used to determine when and if the pressure sore was indeed unavoidable as required in the Federal Regulations. The Pressure Ulcer Investigation tool will be completed for all facility acquired pressure ulcers.

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one (Resident #7) of eight residents reviewed for nutrition. The facility failed to address and provide interventions when Resident #7 experienced a significant weight loss. This failure placed residents at risk for weight loss and a decline in their physical condition. Findings included: Resident #7's MDS assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her height was four feet, six inches and her weight was 116 pounds. The resident's weight was stable. She was at risk for pressure sores but did not have any. She had mild cognitive impairment with a BIMs score of 11 (a score of 8-12 indicated mild impairment). She required extensive assistance of two staff for bed mobility and transfers. She was not ambulatory. She had limited range of motion to both her lower extremities. She required limited assistance of one staff for eating. Resident #7's Care Plan dated 07/01/18 revealed the resident had a potential risk for alteration in nutrition related to her mechanical soft diet and nutritional [MEDICAL CONDITION]. The goals included for the resident to consume greater than or equal to 75% of her meals and to maintain and stabilize at her current weight of 119 pounds, plus or minus 3 pounds. The approaches included monthly weights and to notify the physician and responsible party of changes as needed. Resident #7's Nutritional Data Set and Progress Note dated 09/24/18 revealed the resident was four feet six inches tall and weighed 117.8 pounds. Her ideal body weight was 90 pounds, plus or minus 10 pounds. There was no significant change in the resident's weight. The resident was on a regular diet with a mechanical soft texture. She was not on a nutritional supplement. She was assessed to be a low nutritional risk and her skin was intact. The resident was eating 76-100% of her meals. The was no significant nutritional change since her last assessment. Observation on 11/20/18 at 12:40 PM revealed Resident #7 was in her room sitting in her Broda chair (a specialized rolling chair that can tilt back for better positioning) attempting to feed herself with some difficulty. Resident #7's last Nutritional Data Set and Progress Note was dated 09/24/18, and it revealed the resident's weight was 117.8; there was no significant change in her weight. SINCE WHEN? The progress note defined a significant change as a 5% weight loss in 30 days, a 7.5% in 90 days and 10% in 180 days. The progress note documented the resident was an [AGE] year-old female on a mechanical soft diet with 76-100% oral intake. Her intake was adequate to meet her nutritional needs. She had no skin breakdown. The assessment goal revealed: 1. greater than 75% oral intake, 2. less than 5% unintended weight change in 30 days and 3. to maintain her skin integrity. Recommendations were to continue the current plan of care. Resident #7 was assessed to be at low risk for weight loss. No labs were ordered. Resident #7's Meals and Snack intake for (MONTH) (YEAR) revealed the resident was eating 50 to 100% of her meals. Resident #7's Weight Change History dated 11/20/18 at 11:08 AM revealed the following monthly weights: 09/24/18 117.80 pounds 10/09/18 115.80 pounds 11/06/18 107.40 pounds (a loss of 8.8% in one month and 13 days - 9/24/18 to 11/06/18). Resident #7's Skin Inspection Report dated 11/13/18 reveled the resident's skin was intact. Resident #7's Departmental Note dated 11/19/18 revealed the resident's responsible party was notified the resident had pressure ulcers and a wound consult was ordered. Resident's #7's wound care Surgical Note dated 11/19/18 revealed a consult was received for wounds located at the sacrum and right buttock. Risk factors were listed as depression and limited mobility. There was no documentation related to the resident's weight loss. Resident #7's physician progress notes [REDACTED]. Continued wound care to the Stage III wound to her back/buttock, 2. Hypertension, continued medications, 3. [MEDICAL CONDITION], continued medication and 4. Debility, continued supportive care. The resident's weight loss and nutrition was not addressed. Resident's #7's Departmental Notes from 11/03/18 to 11/27/18 revealed no documentation the resident's physician or responsible party were notified of the resident's weight loss. The resident's weight loss and nutrition was not documented or addressed in the notes. In an interview on 11/27/18 at 2:58 PM the Wound Care Nurse said she was treating Resident #7's wounds. She said she was not aware of the resident's weight loss. In a telephone interview on 11/27/18 at 3:16 PM with Resident #7's physician, he said he was not familiar with the particulars of the resident's care and would have to review her chart and return the call; however, no return call was received. In an interview on 11/27/18 at 3:58 PM the DON said Resident #7's weight had been stable until 11/06/18. She said there was no documentation the resident's physician or responsible party were notified. She said the resident received a multivitamin but no other dietary supplements. There was no documentation from the Dietician about the resident's weight loss. In an interview on 11/27/18 at 4:14 PM, LVN A said she just heard today (11/27/18) about Resident #7's weight loss. She said the resident's pressure ulcer appeared as a red spot and then developed quickly into a Stage III. She said it happened very fast. In a telephone interview on 11/27/18 at 4:33 PM, Resident #7's responsible party said no one told her about the resident's weight loss but she could tell the resident was losing weight. She said the facility had never offered the resident any dietary supplements, but prior to her admission to the facility, the resident's primary physician advised her to drink Ensure and the resident was drinking it at home. She said if the facility offered the resident a supplement, the resident would accept it. Resident #7's Departmental Notes dated 11/27/18 a 5:42 PM revealed the resident fed herself after tray set up and ate 50% of her meal; it was noted today that the resident had lost weight and the Nurse Practitioner was notified. Dietary supplement orders were received for Majic Cup with every meal, Prostat 30 cc TID and [MEDICATION NAME] packet twice a day. The resident would be re-weighed again after two weeks. The Nurse Practitioner would be notified of it. The resident's daughter was notified of the resident's weight loss and the new orders. No labs were ordered. The facility's Weight Standard of Practice policy dated (MONTH) (YEAR) revealed weights and nutritional status are monitored by the Standards of Care Committee and the Consultant Dietitian. The DON or designee is responsible to see that weights are obtained regularly for all residents and any weights reflecting possible medical condition changes should be brought to the attention of the supervisor immediately. Residents triggering a significant weight variance defined as 5% in one month, 7.5% in three months and/or 10% in six months will be addressed by the Weight Variance Committee and placed on weekly weight monitoring.

Based on observation, interview and record review, the facility failed to ensure the resident was free from neglect for two (Residents #1 and #2) of six residents reviewed for neglect. 1. The facility failed to ensure the necessary care and services to prevent and treat diabetic wounds on Resident #1's feet were provided and failed to identify and seek emergent treatment for [REDACTED].#1's toes on 07/14/17. As a result, Resident #1 developed wet gangrene, osteo[DIAGNOSES REDACTED], and amputation of his left first toe. 2. The facility failed to treat facility acquired wounds on the toes of VA Resident #2 according to facility policy and procedure and failed to consult with appropriate parties regarding the course of treatment for [REDACTED]. As a result, Resident #2 developed an infection of the toes and osteo[DIAGNOSES REDACTED]. Additionally, the tip of the resident's third left toe fell off. An Immediate Jeopardy was identified on 07/25/17. While the Immediate Jeopardy was removed on 07/27/17 at 12:45 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. These failure placed the ten residents, who were under VA contract, at risk of not receiving timely and appropriate treatment and services to prevent the development and/or worsening of wounds and infection. Findings included: 1. Resident #1's MDS assessment, dated 04/01/17, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's lifetime occupation was retired Navy. The resident's [DIAGNOSES REDACTED]. The resident was at risk for the development of pressure ulcers. The resident also had a skin tear requiring the application of non-surgical dressings, and application of ointments/medications. The resident had no ulcers or other identified skin problems. The resident's cognitive status was intact. Resident #1's Care plans, dated 03/24/17, reflected impaired skin integrity as evidenced by multiple wounds. The resident was seen by the VA doctors for wound management. The facility interventions included to report signs and symptoms of infection (odor, increased drainage, pain, or redness.) Resident #1's Nursing Departmental Notes entered by LVN A, dated 03/25/17 at 3:30 p.m., reflected Resident #1 was a new admission to the facility and was a VA patient. The note reflected Resident #1 had an open area on his right lower extremity and left toe. The note did not identify the affected toe and did not describe or indicate the size of the open areas. A Podiatrist progress note, dated 04/06/17, reflected the resident was seen by the facility's contracted Podiatrist on that date. The progress note reflected the following: .Assessment: 1. Symptomatic onychomycosis digital nail toes 1 through 5 bilateral 2. Peripheral angiopathy and [MEDICAL CONDITION]. 3. DM with [MEDICAL CONDITION] 4. Heloma dura (hard corn) (left) great toe painful 5. Superficial ulcers (right( 4th/5th toes -- guarded prognosis Plan: 1. The offending nail margins were mechanically and electrically debrided to the level of normal underlying nail bed with good relief. 2. Cleansed ulcers (right) 4th/5th toes with [MEDICATION NAME] solution, applied padded (dressing) wound specialist consult to eval(uate) and tx (treat) ulcers. shave/filed HD(s) (heloma dura) with good relief, applied paddings, Continue supportive footcare, shoegear, glucose control. Patient should be treated in 61 days for foot care due to systemic conditions or sooner if complications arise. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 04/20/17 at 2:51 p.m. reflected the following: Wound location: Right Foot 5th toe: 0.5 cm x 1.2 cm x 0.1 cm, Etiology Trauma, 100% granulation tissue (healing surface of a wound), scant exudate, no sign and symptom of infection, periwound (tissue surrounding a wound): callous forming, Cleaned with (normal saline), pat dry, apply collagen, Wound Location: Right foot 4th toe 0.5 cm x 0.6 cm x 0.1 cm, Etiology Trauma, 100% granulation tissue, scant exudate, no sign and symptom of infection, periwound: callous forming, Cleaned with (normal saline), pat dry, apply collagen, Applied dry gauze between two toe(s) for cushion Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 04/24/17 3:51 p.m. reflected the following: Wound location: Left great toe, suspected arterial ulcer, as the dorsalis pedis pulse is week (sic), resident has history of diabetes. 1 cm x 1 cm x UTD (unable to determine), 100% eschar, no sign and symptom of infection, no drainage, Wound location: left 5th toe, suspected arterial, 0.5 cm x 0.5 cm x UTD, 100% eschar, no sign and symptom of infection, no drainage, resident denied pain at the time of assessment .Clean the wounds with (normal saline), pat dry, applied [MEDICATION NAME] solution, cover with dry dressing. WCTM (will continue to monitor). Review of Resident #1's physician orders [REDACTED]. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 04/27/17 2:56 p.m. reflected Resident #1 was assessed, and his wounds treated by the Facility Wound Care Nurse. The Facility Wound Care Physician also assessed the traumatic wounds on the resident's right foot, fifth toe and right foot, fourth toe and the wounds on the left foot, first toe and left foot, fifth toe. The etiology of the wounds on the left foot was changed to vascular or shoe trauma. The Facility Wound Care Physician recommended better fitting shoes for both feet for the resident. The family was notified. There was no documentation to indicate the VA was notified. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 04/28/17 12:57 p.m. reflected the following: Informed VA Nurse .about resident's wound condition. Informed VA nurse that doctor recommended good fitted shoe for both feet and supported device with cushion for right leg. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 05/04/17 3:53 p.m. reflected the following: Wound location: Right Foot 5th toe: 0.7 cm x 1.4 cm x utd, Etiology Trauma, 60% slough (dead skin or tissue that has fallen off), 40% granulation tissue, mild serosanguinous exudate (drainage containing blood), no sign and symptom of infection, periwound: calloused edge, Cleaned with (normal saline), pat dry, applied [MEDICATION NAME] soaked gauze, as per TAR. Wound Location: Right foot 4th toe, 1 cm x 1 cm x UTD, Etiology Trauma, 100% slough, mild serosanguinous exudate, no sign and symptom of infection, periwound: calloused edge, Cleaned with (normal saline), pat dry, applied [MEDICATION NAME] soaked gauze. Applied dry gauze between two toe(s) for cushion. (Physician L/Medical Director) assessed the resident today. Doctor recommended better fitting shoe, leave open to air as much as possible. Wound location: Left great toe tip: 1.2 cm x 1.8 cm x UTD, 100% Eschar, Etiology: vascular or trauma from shoe. No exudate, no sign and symptom of infection, Wound location: Left 5th toe: 0.2 cm x 0.2 cm x UTD, 100% Eschar (dry, dark scab), Etiology: vascular or trauma from shoe. No exudate, no sign and symptom of infection, Cleaned with (normal saline), pat dry, applied [MEDICATION NAME] soaked gauze, cover with dry dressing, as per TAR Resident #1's Physician Orders, dated 05/05/17, reflected to clean the right foot-fourth and fifth toes with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze, and cover with a dry dressing daily. A Radiology Interpretation report, dated 05/08/17, reflected Resident #1 had an arterial and venous duplex scan (test to determine blood flow) of both lower extremities. The scan revealed severe [MEDICAL CONDITION] disease (disease that affects blood flow), mild to moderate stenosis/obstruction (condition that affects blood flow). The recommendation was for a vascular surgeon evaluation and a MRI (magnetic resonance image) angiogram (scan that could show how well the blood flowed.) Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 05/17/17 at 1:13 p.m. reflected the following: Wound location: Right 5th toe: trauma: 1 cm x 0.6 cm x UT, 20% slough, 80% granulation tissue, scant serosanguinous drainage, No sign or symptom of infection, Wound Location: right 4th toe, lateral side: Trauma: 1 cm x 0.8 cm x UTD, 20% slough, 80% granulation tissue, No sign and symptom of infection, Scant serosanguinous drainage, Wound Location: Right 4th toe medial side, Trauma: 0.6 cm x 0.3 cm x UTD, 20% slough, 80% granulation tissue, scant serosanguinous drainage, no sign and symptom of infection. Right 3rd toe: Trauma: 0.5 cm x 0.5 cm x UTD, 20% slough, 80% granulation tissue, scant serosanguinous drainage, No sign and symptom of infection. Wound Location: Tip of the great left toe: suspected DTI, 1.6 cm x 0.6 cm x UTD, 100% eschar, no drainage, no sign and symptom of infection. Wound location: Left tip of the 5th toe: 0.3 cm x 0.3 cm x UTD, 100% eschar, no drainage, no sign and symptom of infection. Cleaned the both feet wounds with NS, pat dried, applied [MEDICATION NAME] soaked gauze, placed gauze in between right 3rd, 4th, and 5th toe(s) for cushioning. Both legs skin shining and pale. Dorsalis pedis pulse (pulse felt on the top of the foot) is absent for both feet .Reported to family and VA nurse. WCTM. Resident #1's Nursing Departmental Noted entered by the Facility Wound Care Nurse on 05/30/17 at 3:38 p.m. reflected the following: Wound location: Right 5th toe: trauma: 0.5 cm x 1 cm x UTD, 100% slough, mild serosanguinous drainage, no sign and symptom of infection, Wound Location: right 4th toe, lateral side: Trauma: 0.9 cm x 1.7 cm x UTD, 100% slough, no sign and symptom of infection, mild serosanguinous drainage, Wound Location: Right 4th toe medial side: Trauma: 0.6 cm x 0.6 cm x UTD, 100% slough, mild serosanguinous drainage, no sign and symptom of infection. Right 3rd toe lateral side, Trauma: 0.5 cm x 0.7 cm x UTD, 100% slough, mild serosanguinous drainage, no sign and symptom of infection. Wound Location: Tip of the great left toe: suspected DTI, 3 cm x 3 cm x UTD, 100% eschar, no drainage, no sign and symptom of infection. Wound Location: Left tip of the 5th toe: 0.1 cm x 0.1 cm x UTD, 100% eschar, no drainage, no sign and symptom of infection. Cleaned the both feet wound with NS, pat dried, applied [MEDICATION NAME] soaked gauze, placed gauze in between right 3rd, 4th, and 5th toe(s) for cushioning. Both legs skin shining and pale. Dosalis pedis pulse is absent for both feet. (Physician L/Medical Director) assessed the resident today .Reported to family and VA nurse. WCTM. Resident #1's Physician Orders, dated 05/30/17, reflected to clean the third and fourth toes on the right foot with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze, and cover with a dry dressing daily. Resident #1's e-TAR dated 06/01/17-06/09/17 reflected to clean left foot-great toe tip, left foot-fifth toe tip, right foot-third and fourth toes with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze, and cover with a dry dressing daily. Resident #1's VA Wound Care Consult Result report, dated 06/08/17 at 2:09 p.m. reflected the following: Right medial 5th toe: 0.8 x 0.8 cm x ?? cm (wound bed covered with 50% slough) Right lateral 4th toe: 1.3 x 1.6 x ?? cm (wound bed covered with 80% slough) Right medial 4th toe: 1.1 x 1.3 x >> cm (very close to bone) (wound bed covered with 90% slough) Right lateral 3rd toe: 1 x 1 x ?? cm (wound bed covered with 80% slough) Left great toe: Entire end of toe open with eschar forming and bone present .Pulses: Left DP and PT pulse greatly diminished Right DP and PT pulse greatly diminished Wound Pain: 10/10 (patient states especially at night and he takes a pain pill that he states sometime works, remainder of time pain 6/10) WOUND TREATMENT/PLAN RECOMMENDATIONS: Twice a day right 3rd, 4th, 5th toe wounds, right lateral foot wounds, and left great toe wound care: - Cleanse and dry bilateral toes/feet, especially between the toes - Apply [MEDICATION NAME] ([MEDICATION NAME]/iodine) impregnated gauze between the 3rd/4th and 4th/5th toes - Paint right lateral foot wound with [MEDICATION NAME] - Cover left great toe with [MEDICATION NAME] impregnated gauze .Ensure patient has Prevalon boots on (were provided during VA Outpatient Wound Clinic visit/appointment) Nursing and Rehab center to perform above Will notify appropriate personnel to ensure orders are faxed . 06/09/2017 ADDENDUM STATUS: COMPLETED (Facility Wound Care Nurse) RN (treatment nurse) at Woodridge Nursing and Rehab was contacted. The recommendations were reviewed and a copy of the note was faxed to the facility. (Facility Wound Care Nurse) will contact the nursing home pharmacy to determine if the facility has the product or a comparable dressing. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 06/09/17 at 3:22 p.m. reflected the following: Got resident's wound care treatment plan order through fax from VA nurse .Right 3rd/4th toe and right 4th/5th toe: clean with (normal saline), pat dry, apply [MEDICATION NAME] impregnated gauze between toes, and cover with dry dressing everyday BID (twice a day). Right Lateral foot wound: Clean with (normal saline), pat dry, paint with [MEDICATION NAME] solution everyday BID. Left great toe wound: clean with (normal saline), pat dry, apply [MEDICATION NAME] impregnated gauze, cover dressing with gauze, secure with kerlix and tape everyday BID Resident needs to have Prevalon Boots on everyday provide by VA wound clinic. Resident #1's e-TAR dated 06/09/17-07/20/17 reflected to clean the left foot-first toe; right foot-third, fourth, and fifth toe with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze between toes and cover with a dry dressing twice daily. Resident #1's Physician Orders, dated 06/10/17, reflected to clean the resident's left great toe with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze, cover with gauze, and secure with Kerlix wrap twice daily; and the right third, fourth and fifth toes were to be cleaned with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze between toes, and cover with dry dressing twice daily. Resident #1's VA Podiatry Consult Result report, dated 06/15/17, reflected the following: .Presents from nursing facility in wheelchair with an assistant. Here for wounds both feet between toes right and the end of the left great toe. Left great toe started with a nail trim from podiatrist that came to nursing facility. Wound care regularly with [MEDICATION NAME] sol(ution) and dressings. Not on any antibiotics. Wearing bed boots but does had Dr C shoes. No xrays have been done no vascular consult either. .No pulses palpated sensory perception negative toes bil Skin dry shiney (sic) cool Left great toe gangrenous distal aspect with distal phalanx expose dry black maceration web soaces with ulcer toes 3, 4, 5 right with odor as follows: Medial aspect 5, lat(eral) and med(ial) aspect 4, and lateral aspect 3rd toe right hammer toe deformity rigid bil(ateral). .[MEDICAL CONDITIONS], multiple digit ulcerations (right), (left) great toe gangrene distally exposed distal phalanx .P(lan): X-rays, Vascular consult, wound care dressing change for now TX: [MEDICATION NAME] sol(ution) and DSD bil Order CRP, Sed R Order bil xrays Consult for vascular surgery entered Rx (prescription) [MEDICATION NAME] (antibiotic) to cover for now. Resident #1's Nursing Departmental Notes entered by LVN M on 06/18/17 at 12:15 a.m. reflected the following: Late Entry (dated) 6/17/17 @ 6PM. Res back from OOP (out on pass) .Res (family member) told this nurse he is concern(ed) about the left great toe wound. Checked the affected toe and noticed with dressing on it and noticed black colored area. No drainage noted, surrounding skin pink; with no odor. Will endorsed (sic) to oncoming nurse to continue to monitor and to communicate to wound nurse Resident #1's Nursing Departmental Notes entered by LVN N on 06/19/17 at 8:00 p.m. reflected the following: RP (Responsible Party) concerned about patient left toe. Stated nobody has informed him about the left toe, the left toe has black skin, skin dead & toe is falling out, someone has put dressing, I think the bone is pointing out. Patient stated the wound nurse wrapped the toe. Assessed the toe, dressing applied, no drainage nor foul odor. No c/o pain distress/discomfort voiced Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 06/20/17 at 2:00 p.m. reflected the following wound measurements for the wounds that had worsened: Right foot - fourth toe, lateral side, 1.0 cm x 1.0 cm x UTD Right foot - fourth toe, medial side, 0.8 cm x 0.5 cm x UTD Left foot - first toe, 1.0 cm x 3.0 cm x UTD depth, 100% soft eschar Resident #1's VA Consultation Sheet reflected the resident was seen on 06/22/17 for vascular surgeon consultation. The report reflected Resident #1 had gangrene of the left toe with wounds on the right foot. Resident #1's VA Podiatry Follow-up Progress Notes, dated 06/22/17 at 9:00 a.m. reflected the following: .[MEDICAL CONDITION], multiple digit ulcerations Rt, Lt great toe gangrene distally exposed distal phalanx .bone infection suspected order SPECT (Single-photon emission computed tomography) .Once SPECT done if confirms bone infection then perform bone biopsy with Infectious Dis(ease) consult ASAP (as soon as possible) .Continue [MEDICATION NAME]. There was no evidence in the resident's facility clinical record reflecting that Resident #1 had been receiving the antibiotic medication, [MEDICATION NAME]. Resident #1's Physician Orders, dated 06/27/17, reflected [MEDICATION NAME] 500 mg by mouth twice daily for 14 days. Resident #1's e-TAR for 06/27/17 reflected [MEDICATION NAME] 500 mg by mouth twice daily for 14 days with a stop date of 07/11/17. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 06/27/17 at 3:39 p.m. reflected a new order for [MEDICATION NAME] received to treat the resident's foot infection. VA Nurse notified with updated orders. There was no evidence to indicate the resident was already on [MEDICATION NAME] as ordered by the VA Podiatrist on 06/15/17. Resident #1's Nursing Departmental Notes entered by LVN N on 06/27/17 at 6:22 p.m. reflected: N.O. (New Order) for [MEDICATION NAME] 500/Clav K 125 mg tab, take 1 tablet po bid x 14 days for foot infection. There was no documentation to indicate why the antibiotic was changed from [MEDICATION NAME] to [MEDICATION NAME]. Resident #1's Nursing Departmental Notes entered by LVN N on 06/27/17 at 9:05 p.m. reflected: .[MEDICAL CONDITION] +1 noted bilaterally to lower legs. Left big toe black and foul odor from both legs when changing dressing. Kerlix dressing applied to both legs. No drainage noted. WCTM. Resident #1's Physician Orders, dated 06/29/17, reflected to clean the tip of fifth toe on the left foot with normal saline, pat dry, paint with [MEDICATION NAME] solution, and cover with dry dressing twice daily. Resident #1's e-TAR for 06/29/17-07/20/17 reflected to clean left foot-tip of fifth toe with normal saline, pat dry, paint with [MEDICATION NAME] solution, and cover with dry dressing twice daily. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 07/05/17 at 4:27 p.m. reflected the resident's wound were assessed and treated, and the following new wounds were identified: Right foot- third toe, medial side, 1.0 cm x 1.0 cm x UTD Right foot- second toe, 0.8 cm x 0.5 cm x UTD Resident #1's Nursing Departmental Notes entered by the DON on 07/05/17 at 7:03 p.m. reflected the DON contacted the resident's family regarding the resident's wound status and the facility plan to admit the resident to the VA hospital to figure out the next step of his treatment plan. Resident #1's Nursing Departmental Notes entered by LVN A on 07/06/17 at 1:37 p.m. reflected the VA Nurse was contacted regarding the resident's wounds not improving and a possible direct admit to the VA hospital. VA nurse reported the resident had an upcoming appointment for his feet and would see what the VA doctor recommended. Resident #1's Facility Wound Care Physician Note completed by the Wound Care Physician Assistant on 07/07/17 reflected the resident had a chronic wound that may or may not heal, continue [MEDICATION NAME], check with the VA to see if an x-ray has been ordered to evaluate for osteo[DIAGNOSES REDACTED], if not, will order x-ray. The note reflected there would be a follow-up in one week. There was no documentation to indicate the resident ever took [MEDICATION NAME]. Facility Nurse Note by the facility Wound Care Nurse. 07/07/17 3:17 p.m.: Resident's wounds assessed by the facility wound care physician: Left foot- first toe, 3.5 cm x 3.5 cm x unable to determine UTD depth, 100% eschar Left foot- fifth toe, 0.2 cm x 0.2 cm x UTD depth, 100% eschar Right foot- fifth toe, 0.8 cm x 1.5 cm x UTD depth Right foot- forth toe, lateral side, 1.5 cm x 2.0 cm x UTD depth Right foot- forth toe, medial side, 1.5 cm x 2.1 cm x UTD depth Right foot- third toe, lateral side, 1.4 cm x 2.8 cm x UTD depth Right foot- third toe, medial side, 1.1 cm x 1.0 cm x UTD depth Right foot- second toe, 0.8 cm x 1.0 cm x UTD depth. Left message for VA nurse. Resident #1's Physician Orders, dated 07/06/17, reflected to clean the right medial third toe and right lateral second toe with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze between toes, and cover with dry dressing twice daily; and to apply toe spacer between the toes. Resident #1's e-TAR for 07/01/17-07/20/17 reflected to clean the left foot-first toe with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze, cover with gauze, and secure with Kerlix twice daily; to clean the right foot-third, fourth, and fifth toes with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze between toes and cover with a dry dressing twice daily; and to clean the left foot-tip of fifth toe with normal saline, pat dry, paint with [MEDICATION NAME] solution, and cover with dry dressing twice daily. Resident #1's e-TAR for 07/06/17-07/20/17 reflected to clean the right medial third toe and right lateral second toe with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze between toes, and cover with dry dressing twice daily; and apply toe spacer between the toes. Resident #1's VA Podiatrist Note, dated 07/13/17 at 10:30 a.m., reflected the resident had osteo[DIAGNOSES REDACTED] (bone infection) left great toe, gangrene right fourth toe, [MEDICAL CONDITION]. New orders written for Iodosorb to be applied twice daily to the left great toe and right foot-fourth digit and PRAFO (Pressure Relief Ankle Foot Orthosis). Explained to patient that if he had an amputation, he might not heal from surgery which could lead to an above the knee amputation. The patient to discuss with his family. The nursing facility was to continue to use [MEDICATION NAME] and a dry, sterile dressing to the left great toe and right foot-forth toe. There was no documentation to indicate the facility ordered Iodosorb or the PRAFO (Pressure Relief Ankle Foot Orthosis). Resident #1's Nursing Departmental Notes entered by LVN O on 07/13/17 at 7:07 p.m. reflected Resident #1 returned from VA Podiatrist appointment with no new orders. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 07/14/17 at 1:59 p.m., reflected the resident was assessed and wounds treated by the facility Wound Care Nurse. The resident's right foot-fourth toe was noted to be turning totally black. Mushy and thin to touch. Foul odor from both feet. Right foot- second toe, third toe, and fifth toe macerated and black. The condition of both feet was worsening. Left message with VA nurse. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 07/14/17 reflected a new order was received from the Facility Wound Care Physician to obtain an x-ray of the resident's both feet to rule out osteo[DIAGNOSES REDACTED] (bone infection). Results were negative for fracture and the soft tissues were unremarkable. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 07/17/17 at 4:04 p.m. reflected the DON informed the Wound Care Nurse she notified the resident's family regarding the condition of his feet. The Wound Care Nurse could not find evidence of the conversation. Resident's family notified regarding the worsening condition of the resident's feet. Resident #1's Nursing Departmental Notes entered by ADON G on 07/19/17 at 2:40 p.m. reflected a call was received from the VA Wound Nurse with instructions to contact the resident's family regarding the resident's scheduled VA podiatry appointment in two weeks or to send the resident to the VA hospital on [DATE]. Resident #1's Nursing Departmental Notes entered by LVN P on 07/19/17 at 11:03 p.m. reflected a foul odor was noted from the resident's feet. Resident #1's Nursing Departmental Notes entered by LVN E on 07/20/17 at 1:47 p.m. reflected the resident's family at the facility and requested the facility send the resident to the VA hospital due to the wounds on his lower extremities worsening. Left foot- first toe with black tissue and displaying signs and symptoms of infection with a foul odor. The right foot with necrotic (dead) tissue sloughing off. Facility Medical Director assessed the resident. Resident #1's Physician Orders, dated 07/20/17, reflected to send to the resident to the VA Hospital. Resident #1's Nursing Departmental Note, dated 07/20/17 at 2:58 p.m., reflected the resident was transferred to the VA hospital. Resident #1's VA Hospital Notes, dated 07/20/17 at 9:07 p.m., reflected the resident was assessed in the VA Hospital emergency room and admitted with bilateral foot pain and discharge. Resident diagnosed with [REDACTED]. The toes on both feet had purulent drainage and exudate. The resident was started on IV antibiotics. The left great toe was amputated on 07/23/17 due to wet gangrene and osteo[DIAGNOSES REDACTED]. Interviews with the family of Resident #1 on 07/24/17 at 10:50 a.m., 07/25/17 at 2:05 p.m., and 07/26/17 at 4:50 p.m. revealed the resident had his left toe amputated due to the development of gangrene on 07/23/17 after being admitted through the VA HospitalER on [DATE]. The family member reported the resident's right foot- forth toe was gangrenous also. The family member reported the VA Surgeon told him the facility should have sent the resident to another facility for treatment if they could not arrange to get the resident evaluated sooner at the VA. The family reported the VA Surgeon's plan was for above the knee amputations in both legs once the VA was able to get the resident's infection under control. The family reported the facility told him about the wounds on the right foot, but did not tell him about the wounds on the left foot. The family member reported when he attended the resident's care conference and confronted the facility about the resident's wound issues, the facility became very defensive and said they were doing everything they should have been. Additionally the Facility Medical Director/Physician L, who was Resident #1's facility attending physician, told the family member the plan was to treat the resident conservatively and let the toes fall off. The family member reported the facility and VA nurse said the resident could go to the VA hospital emergency room if he would take him, or the resident could wait and be seen at his scheduled VA appointment. The family member reported he was not medical personnel and did not know what the best option was. He told the facility if the resident needed emergency treatment then the facility could take the resident to the VA hospital emergency room and he would meet them there. The family member reported he spoke with the VA Physician Assistant on 07/20/17 and he told him if the resident's toes were dark and mushy then the resident needed to be transferred to the emergency room immediately. The family member reported he notified the facility on 07/20/17 and instructed them they needed to take the resident to the VA emergency room immediately. An interview with the DON and Wound Care Nurse on 07/25/17 at 9:40 a.m. revealed Resident #1 routinely went to the VA Wound Care Clinic and VA Podiatrist and he was sent to the VA hospital for poor circulation and wounds that couldn't heal. They reported the Facility Wound Care Physician saw residents with wounds weekly on Fridays, but she would only see VA residents monthly because she did not get paid to see them. They reported VA residents visited the VA Wound Care Clinic as appointments were set up by the VA. The DON reported she asked the family to take Resident #1 to the VA Hospital so they would address his wound issues. An interview with the Facility Medical Director/Physician L, Resident #1's facility attending physician, on 07/25/17 at 9:50 a.m. revealed Resident #1 had a lot of medical problems and his vascular system was very affected. Resident #1 had a long history of diabetes, four [MEDICAL CONDITION], [MEDICAL TREATMENT], and he did not have pedal pulses. The Medical Director reported there was no chance that his wounds would heal. The Medical Director reported that diabetic wounds got infected often and many residents with diabetic wounds required amputation. The Medical Director reported Resident #1 would require amputation to improve his quality of life. He reported he spoke to the family, date unknown, and tried to explain the resident's situation. The Medical Director reported the facility had a contract with the VA, but the VA was not being reimbursed properly. The Medical Director revealed if the VA did not see the residents then he would see them as needed or once a month, and if emergent issues arose they could go to the private hospital. An interview with the VA Nurse on 07/25/17 at 12:50 p.m. revealed a VA resident could make an appointment with the VA Wound Care Clinic and be seen in about 30 days. The VA Nurse also reported the facility wound care physician could see the resident some. A subsequent interview with the DON on 07/25/17 at 2:25 p.m. revealed the facility relied on the VA to be the primary for when medical decisions needed to be made for VA residents. The VA residents could see a facility physician if needed, but the facility had to have permission from the VA for all appointments and any issues with the VA residents. The DON reported that in case of an emergency, the facility could transfer a VA resident to the VA hospital emergency room and leave a message to get permission. The DON was asked about the documentation regarding the change in condition for Resident #1 on 07/14/17. She reported he was not sent to the hospital immediately, but she had been trying to get him more aggressive treatment and had spoken with the resident's family regarding the wound issues. The DON reported if a non-VA resident had a similar change in condition they would go to the ER to get more emergent treatment. An interview with the Facility Medical Director and Facility Wound Care Physician Assistant on 07/26/17 at 10:05 a.m. revealed they did not think there was a facility failure and neither physician would have changed the treatment plan for Resident

Based on observation, interview and record review, the facility failed to develop and implement written policies that prohibited and prevented abuse, neglect, and exploitation of residents for two (Residents #1 and #2) of six residents reviewed for neglect. 1. The facility failed to ensure the necessary care and services to prevent and treat diabetic wounds on Resident #1's feet were provided and failed to identify and seek emergent treatment for [REDACTED].#1's toes on 07/14/17. As a result, Resident #1 developed wet gangrene, osteo[DIAGNOSES REDACTED], and amputation of his left first toe. 2. The facility failed to treat facility acquired wounds on the toes of VA Resident #2 according to facility policy and procedure and failed to consult with appropriate parties regarding the course of treatment for [REDACTED]. As a result, Resident #2 developed an infection of the toes and osteo[DIAGNOSES REDACTED]. Additionally, the tip of the resident's third left toe fell off. An Immediate Jeopardy was identified on 07/25/17. While the Immediate Jeopardy was removed on 07/27/17 at 12:45 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. These failure placed the ten residents, who were under VA contract, at risk of not receiving timely and appropriate treatment and services to prevent the development and/or worsening of wounds and infection. Findings included: 1. Resident #1's MDS assessment, dated 04/01/17, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's lifetime occupation was retired Navy. The resident's [DIAGNOSES REDACTED]. The resident was at risk for the development of pressure ulcers. The resident also had a skin tear requiring the application of non-surgical dressings, and application of ointments/medications. The resident had no ulcers or other identified skin problems. The resident's cognitive status was intact. Resident #1's Care plans, dated 03/24/17, reflected impaired skin integrity as evidenced by multiple wounds. The resident was seen by the VA doctors for wound management. The facility interventions included to report signs and symptoms of infection (odor, increased drainage, pain, or redness.) Resident #1's Nursing Departmental Notes entered by LVN A, dated 03/25/17 at 3:30 p.m., reflected Resident #1 was a new admission to the facility and was a VA patient. The note reflected Resident #1 had an open area on his right lower extremity and left toe. The note did not identify the affected toe and did not describe or indicate the size of the open areas. A Podiatrist progress note, dated 04/06/17, reflected the resident was seen by the facility's contracted Podiatrist on that date. The progress note reflected the following: .Assessment: 1. Symptomatic onychomycosis digital nail toes 1 through 5 bilateral 2. Peripheral angiopathy and [MEDICAL CONDITION]. 3. DM with [MEDICAL CONDITION] 4. Heloma dura (hard corn) (left) great toe painful 5. Superficial ulcers (right( 4th/5th toes -- guarded prognosis Plan: 1. The offending nail margins were mechanically and electrically debrided to the level of normal underlying nail bed with good relief. 2. Cleansed ulcers (right) 4th/5th toes with [MEDICATION NAME] solution, applied padded (dressing) wound specialist consult to eval(uate) and tx (treat) ulcers. shave/filed HD(s) (heloma dura) with good relief, applied paddings, Continue supportive footcare, shoegear, glucose control. Patient should be treated in 61 days for foot care due to systemic conditions or sooner if complications arise. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 04/20/17 at 2:51 p.m. reflected the following: Wound location: Right Foot 5th toe: 0.5 cm x 1.2 cm x 0.1 cm, Etiology Trauma, 100% granulation tissue (healing surface of a wound), scant exudate, no sign and symptom of infection, periwound (tissue surrounding a wound): callous forming, Cleaned with (normal saline), pat dry, apply collagen, Wound Location: Right foot 4th toe 0.5 cm x 0.6 cm x 0.1 cm, Etiology Trauma, 100% granulation tissue, scant exudate, no sign and symptom of infection, periwound: callous forming, Cleaned with (normal saline), pat dry, apply collagen, Applied dry gauze between two toe(s) for cushion Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 04/24/17 3:51 p.m. reflected the following: Wound location: Left great toe, suspected arterial ulcer, as the dorsalis pedis pulse is week (sic), resident has history of diabetes. 1 cm x 1 cm x UTD (unable to determine), 100% eschar, no sign and symptom of infection, no drainage, Wound location: left 5th toe, suspected arterial, 0.5 cm x 0.5 cm x UTD, 100% eschar, no sign and symptom of infection, no drainage, resident denied pain at the time of assessment .Clean the wounds with (normal saline), pat dry, applied [MEDICATION NAME] solution, cover with dry dressing. WCTM (will continue to monitor). Review of Resident #1's physician orders [REDACTED]. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 04/27/17 2:56 p.m. reflected Resident #1 was assessed, and his wounds treated by the Facility Wound Care Nurse. The Facility Wound Care Physician also assessed the traumatic wounds on the resident's right foot, fifth toe and right foot, fourth toe and the wounds on the left foot, first toe and left foot, fifth toe. The etiology of the wounds on the left foot was changed to vascular or shoe trauma. The Facility Wound Care Physician recommended better fitting shoes for both feet for the resident. The family was notified. There was no documentation to indicate the VA was notified. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 04/28/17 12:57 p.m. reflected the following: Informed VA Nurse .about resident's wound condition. Informed VA nurse that doctor recommended good fitted shoe for both feet and supported device with cushion for right leg. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 05/04/17 3:53 p.m. reflected the following: Wound location: Right Foot 5th toe: 0.7 cm x 1.4 cm x utd, Etiology Trauma, 60% slough (dead skin or tissue that has fallen off), 40% granulation tissue, mild serosanguinous exudate (drainage containing blood), no sign and symptom of infection, periwound: calloused edge, Cleaned with (normal saline), pat dry, applied [MEDICATION NAME] soaked gauze, as per TAR. Wound Location: Right foot 4th toe, 1 cm x 1 cm x UTD, Etiology Trauma, 100% slough, mild serosanguinous exudate, no sign and symptom of infection, periwound: calloused edge, Cleaned with (normal saline), pat dry, applied [MEDICATION NAME] soaked gauze. Applied dry gauze between two toe(s) for cushion. (Physician L/Medical Director) assessed the resident today. Doctor recommended better fitting shoe, leave open to air as much as possible. Wound location: Left great toe tip: 1.2 cm x 1.8 cm x UTD, 100% Eschar, Etiology: vascular or trauma from shoe. No exudate, no sign and symptom of infection, Wound location: Left 5th toe: 0.2 cm x 0.2 cm x UTD, 100% Eschar (dry, dark scab), Etiology: vascular or trauma from shoe. No exudate, no sign and symptom of infection, Cleaned with (normal saline), pat dry, applied [MEDICATION NAME] soaked gauze, cover with dry dressing, as per TAR Resident #1's Physician Orders, dated 05/05/17, reflected to clean the right foot-fourth and fifth toes with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze, and cover with a dry dressing daily. A Radiology Interpretation report, dated 05/08/17, reflected Resident #1 had an arterial and venous duplex scan (test to determine blood flow) of both lower extremities. The scan revealed severe [MEDICAL CONDITION] disease (disease that affects blood flow), mild to moderate stenosis/obstruction (condition that affects blood flow). The recommendation was for a vascular surgeon evaluation and a MRI (magnetic resonance image) angiogram (scan that could show how well the blood flowed.) Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 05/17/17 at 1:13 p.m. reflected the following: Wound location: Right 5th toe: trauma: 1 cm x 0.6 cm x UT, 20% slough, 80% granulation tissue, scant serosanguinous drainage, No sign or symptom of infection, Wound Location: right 4th toe, lateral side: Trauma: 1 cm x 0.8 cm x UTD, 20% slough, 80% granulation tissue, No sign and symptom of infection, Scant serosanguinous drainage, Wound Location: Right 4th toe medial side, Trauma: 0.6 cm x 0.3 cm x UTD, 20% slough, 80% granulation tissue, scant serosanguinous drainage, no sign and symptom of infection. Right 3rd toe: Trauma: 0.5 cm x 0.5 cm x UTD, 20% slough, 80% granulation tissue, scant serosanguinous drainage, No sign and symptom of infection. Wound Location: Tip of the great left toe: suspected DTI, 1.6 cm x 0.6 cm x UTD, 100% eschar, no drainage, no sign and symptom of infection. Wound location: Left tip of the 5th toe: 0.3 cm x 0.3 cm x UTD, 100% eschar, no drainage, no sign and symptom of infection. Cleaned the both feet wounds with NS, pat dried, applied [MEDICATION NAME] soaked gauze, placed gauze in between right 3rd, 4th, and 5th toe(s) for cushioning. Both legs skin shining and pale. Dorsalis pedis pulse (pulse felt on the top of the foot) is absent for both feet .Reported to family and VA nurse. WCTM. Resident #1's Nursing Departmental Noted entered by the Facility Wound Care Nurse on 05/30/17 at 3:38 p.m. reflected the following: Wound location: Right 5th toe: trauma: 0.5 cm x 1 cm x UTD, 100% slough, mild serosanguinous drainage, no sign and symptom of infection, Wound Location: right 4th toe, lateral side: Trauma: 0.9 cm x 1.7 cm x UTD, 100% slough, no sign and symptom of infection, mild serosanguinous drainage, Wound Location: Right 4th toe medial side: Trauma: 0.6 cm x 0.6 cm x UTD, 100% slough, mild serosanguinous drainage, no sign and symptom of infection. Right 3rd toe lateral side, Trauma: 0.5 cm x 0.7 cm x UTD, 100% slough, mild serosanguinous drainage, no sign and symptom of infection. Wound Location: Tip of the great left toe: suspected DTI, 3 cm x 3 cm x UTD, 100% eschar, no drainage, no sign and symptom of infection. Wound Location: Left tip of the 5th toe: 0.1 cm x 0.1 cm x UTD, 100% eschar, no drainage, no sign and symptom of infection. Cleaned the both feet wound with NS, pat dried, applied [MEDICATION NAME] soaked gauze, placed gauze in between right 3rd, 4th, and 5th toe(s) for cushioning. Both legs skin shining and pale. Dosalis pedis pulse is absent for both feet. (Physician L/Medical Director) assessed the resident today .Reported to family and VA nurse. WCTM. Resident #1's Physician Orders, dated 05/30/17, reflected to clean the third and fourth toes on the right foot with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze, and cover with a dry dressing daily. Resident #1's e-TAR dated 06/01/17-06/09/17 reflected to clean left foot-great toe tip, left foot-fifth toe tip, right foot-third and fourth toes with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze, and cover with a dry dressing daily. Resident #1's VA Wound Care Consult Result report, dated 06/08/17 at 2:09 p.m. reflected the following: Right medial 5th toe: 0.8 x 0.8 cm x ?? cm (wound bed covered with 50% slough) Right lateral 4th toe: 1.3 x 1.6 x ?? cm (wound bed covered with 80% slough) Right medial 4th toe: 1.1 x 1.3 x >> cm (very close to bone) (wound bed covered with 90% slough) Right lateral 3rd toe: 1 x 1 x ?? cm (wound bed covered with 80% slough) Left great toe: Entire end of toe open with eschar forming and bone present .Pulses: Left DP and PT pulse greatly diminished Right DP and PT pulse greatly diminished Wound Pain: 10/10 (patient states especially at night and he takes a pain pill that he states sometime works, remainder of time pain 6/10) WOUND TREATMENT/PLAN RECOMMENDATIONS: Twice a day right 3rd, 4th, 5th toe wounds, right lateral foot wounds, and left great toe wound care: - Cleanse and dry bilateral toes/feet, especially between the toes - Apply [MEDICATION NAME] ([MEDICATION NAME]/iodine) impregnated gauze between the 3rd/4th and 4th/5th toes - Paint right lateral foot wound with [MEDICATION NAME] - Cover left great toe with [MEDICATION NAME] impregnated gauze .Ensure patient has Prevalon boots on (were provided during VA Outpatient Wound Clinic visit/appointment) Nursing and Rehab center to perform above Will notify appropriate personnel to ensure orders are faxed . 06/09/2017 ADDENDUM STATUS: COMPLETED (Facility Wound Care Nurse) RN (treatment nurse) at Woodridge Nursing and Rehab was contacted. The recommendations were reviewed and a copy of the note was faxed to the facility. (Facility Wound Care Nurse) will contact the nursing home pharmacy to determine if the facility has the product or a comparable dressing. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 06/09/17 at 3:22 p.m. reflected the following: Got resident's wound care treatment plan order through fax from VA nurse .Right 3rd/4th toe and right 4th/5th toe: clean with (normal saline), pat dry, apply [MEDICATION NAME] impregnated gauze between toes, and cover with dry dressing everyday BID (twice a day). Right Lateral foot wound: Clean with (normal saline), pat dry, paint with [MEDICATION NAME] solution everyday BID. Left great toe wound: clean with (normal saline), pat dry, apply [MEDICATION NAME] impregnated gauze, cover dressing with gauze, secure with kerlix and tape everyday BID Resident needs to have Prevalon Boots on everyday provide by VA wound clinic. Resident #1's e-TAR dated 06/09/17-07/20/17 reflected to clean the left foot-first toe; right foot-third, fourth, and fifth toe with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze between toes and cover with a dry dressing twice daily. Resident #1's Physician Orders, dated 06/10/17, reflected to clean the resident's left great toe with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze, cover with gauze, and secure with Kerlix wrap twice daily; and the right third, fourth and fifth toes were to be cleaned with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze between toes, and cover with dry dressing twice daily. Resident #1's VA Podiatry Consult Result report, dated 06/15/17, reflected the following: .Presents from nursing facility in wheelchair with an assistant. Here for wounds both feet between toes right and the end of the left great toe. Left great toe started with a nail trim from podiatrist that came to nursing facility. Wound care regularly with [MEDICATION NAME] sol(ution) and dressings. Not on any antibiotics. Wearing bed boots but does had Dr C shoes. No xrays have been done no vascular consult either. .No pulses palpated sensory perception negative toes bil Skin dry shiney (sic) cool Left great toe gangrenous distal aspect with distal phalanx expose dry black maceration web soaces with ulcer toes 3, 4, 5 right with odor as follows: Medial aspect 5, lat(eral) and med(ial) aspect 4, and lateral aspect 3rd toe right hammer toe deformity rigid bil(ateral). .[MEDICAL CONDITIONS], multiple digit ulcerations (right), (left) great toe gangrene distally exposed distal phalanx .P(lan): X-rays, Vascular consult, wound care dressing change for now TX: [MEDICATION NAME] sol(ution) and DSD bil Order CRP, Sed R Order bil xrays Consult for vascular surgery entered Rx (prescription) [MEDICATION NAME] (antibiotic) to cover for now. Resident #1's Nursing Departmental Notes entered by LVN M on 06/18/17 at 12:15 a.m. reflected the following: Late Entry (dated) 6/17/17 @ 6PM. Res back from OOP (out on pass) .Res (family member) told this nurse he is concern(ed) about the left great toe wound. Checked the affected toe and noticed with dressing on it and noticed black colored area. No drainage noted, surrounding skin pink; with no odor. Will endorsed (sic) to oncoming nurse to continue to monitor and to communicate to wound nurse Resident #1's Nursing Departmental Notes entered by LVN N on 06/19/17 at 8:00 p.m. reflected the following: RP (Responsible Party) concerned about patient left toe. Stated nobody has informed him about the left toe, the left toe has black skin, skin dead & toe is falling out, someone has put dressing, I think the bone is pointing out. Patient stated the wound nurse wrapped the toe. Assessed the toe, dressing applied, no drainage nor foul odor. No c/o pain distress/discomfort voiced Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 06/20/17 at 2:00 p.m. reflected the following wound measurements for the wounds that had worsened: Right foot - fourth toe, lateral side, 1.0 cm x 1.0 cm x UTD Right foot - fourth toe, medial side, 0.8 cm x 0.5 cm x UTD Left foot - first toe, 1.0 cm x 3.0 cm x UTD depth, 100% soft eschar Resident #1's VA Consultation Sheet reflected the resident was seen on 06/22/17 for vascular surgeon consultation. The report reflected Resident #1 had gangrene of the left toe with wounds on the right foot. Resident #1's VA Podiatry Follow-up Progress Notes, dated 06/22/17 at 9:00 a.m. reflected the following: .[MEDICAL CONDITION], multiple digit ulcerations Rt, Lt great toe gangrene distally exposed distal phalanx .bone infection suspected order SPECT (Single-photon emission computed tomography) .Once SPECT done if confirms bone infection then perform bone biopsy with Infectious Dis(ease) consult ASAP (as soon as possible) .Continue [MEDICATION NAME]. There was no evidence in the resident's facility clinical record reflecting that Resident #1 had been receiving the antibiotic medication, [MEDICATION NAME]. Resident #1's Physician Orders, dated 06/27/17, reflected [MEDICATION NAME] 500 mg by mouth twice daily for 14 days. Resident #1's e-TAR for 06/27/17 reflected [MEDICATION NAME] 500 mg by mouth twice daily for 14 days with a stop date of 07/11/17. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 06/27/17 at 3:39 p.m. reflected a new order for [MEDICATION NAME] received to treat the resident's foot infection. VA Nurse notified with updated orders. There was no evidence to indicate the resident was already on [MEDICATION NAME] as ordered by the VA Podiatrist on 06/15/17. Resident #1's Nursing Departmental Notes entered by LVN N on 06/27/17 at 6:22 p.m. reflected: N.O. (New Order) for [MEDICATION NAME] 500/Clav K 125 mg tab, take 1 tablet po bid x 14 days for foot infection. There was no documentation to indicate why the antibiotic was changed from [MEDICATION NAME] to [MEDICATION NAME]. Resident #1's Nursing Departmental Notes entered by LVN N on 06/27/17 at 9:05 p.m. reflected: .[MEDICAL CONDITION] +1 noted bilaterally to lower legs. Left big toe black and foul odor from both legs when changing dressing. Kerlix dressing applied to both legs. No drainage noted. WCTM. Resident #1's Physician Orders, dated 06/29/17, reflected to clean the tip of fifth toe on the left foot with normal saline, pat dry, paint with [MEDICATION NAME] solution, and cover with dry dressing twice daily. Resident #1's e-TAR for 06/29/17-07/20/17 reflected to clean left foot-tip of fifth toe with normal saline, pat dry, paint with [MEDICATION NAME] solution, and cover with dry dressing twice daily. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 07/05/17 at 4:27 p.m. reflected the resident's wound were assessed and treated, and the following new wounds were identified: Right foot- third toe, medial side, 1.0 cm x 1.0 cm x UTD Right foot- second toe, 0.8 cm x 0.5 cm x UTD Resident #1's Nursing Departmental Notes entered by the DON on 07/05/17 at 7:03 p.m. reflected the DON contacted the resident's family regarding the resident's wound status and the facility plan to admit the resident to the VA hospital to figure out the next step of his treatment plan. Resident #1's Nursing Departmental Notes entered by LVN A on 07/06/17 at 1:37 p.m. reflected the VA Nurse was contacted regarding the resident's wounds not improving and a possible direct admit to the VA hospital. VA nurse reported the resident had an upcoming appointment for his feet and would see what the VA doctor recommended. Resident #1's Facility Wound Care Physician Note completed by the Wound Care Physician Assistant on 07/07/17 reflected the resident had a chronic wound that may or may not heal, continue [MEDICATION NAME], check with the VA to see if an x-ray has been ordered to evaluate for osteo[DIAGNOSES REDACTED], if not, will order x-ray. The note reflected there would be a follow-up in one week. There was no documentation to indicate the resident ever took [MEDICATION NAME]. Facility Nurse Note by the facility Wound Care Nurse. 07/07/17 3:17 p.m.: Resident's wounds assessed by the facility wound care physician: Left foot- first toe, 3.5 cm x 3.5 cm x unable to determine UTD depth, 100% eschar Left foot- fifth toe, 0.2 cm x 0.2 cm x UTD depth, 100% eschar Right foot- fifth toe, 0.8 cm x 1.5 cm x UTD depth Right foot- forth toe, lateral side, 1.5 cm x 2.0 cm x UTD depth Right foot- forth toe, medial side, 1.5 cm x 2.1 cm x UTD depth Right foot- third toe, lateral side, 1.4 cm x 2.8 cm x UTD depth Right foot- third toe, medial side, 1.1 cm x 1.0 cm x UTD depth Right foot- second toe, 0.8 cm x 1.0 cm x UTD depth. Left message for VA nurse. Resident #1's Physician Orders, dated 07/06/17, reflected to clean the right medial third toe and right lateral second toe with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze between toes, and cover with dry dressing twice daily; and to apply toe spacer between the toes. Resident #1's e-TAR for 07/01/17-07/20/17 reflected to clean the left foot-first toe with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze, cover with gauze, and secure with Kerlix twice daily; to clean the right foot-third, fourth, and fifth toes with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze between toes and cover with a dry dressing twice daily; and to clean the left foot-tip of fifth toe with normal saline, pat dry, paint with [MEDICATION NAME] solution, and cover with dry dressing twice daily. Resident #1's e-TAR for 07/06/17-07/20/17 reflected to clean the right medial third toe and right lateral second toe with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze between toes, and cover with dry dressing twice daily; and apply toe spacer between the toes. Resident #1's VA Podiatrist Note, dated 07/13/17 at 10:30 a.m., reflected the resident had osteo[DIAGNOSES REDACTED] (bone infection) left great toe, gangrene right fourth toe, [MEDICAL CONDITION]. New orders written for Iodosorb to be applied twice daily to the left great toe and right foot-fourth digit and PRAFO (Pressure Relief Ankle Foot Orthosis). Explained to patient that if he had an amputation, he might not heal from surgery which could lead to an above the knee amputation. The patient to discuss with his family. The nursing facility was to continue to use [MEDICATION NAME] and a dry, sterile dressing to the left great toe and right foot-forth toe. There was no documentation to indicate the facility ordered Iodosorb or the PRAFO (Pressure Relief Ankle Foot Orthosis). Resident #1's Nursing Departmental Notes entered by LVN O on 07/13/17 at 7:07 p.m. reflected Resident #1 returned from VA Podiatrist appointment with no new orders. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 07/14/17 at 1:59 p.m., reflected the resident was assessed and wounds treated by the facility Wound Care Nurse. The resident's right foot-fourth toe was noted to be turning totally black. Mushy and thin to touch. Foul odor from both feet. Right foot- second toe, third toe, and fifth toe macerated and black. The condition of both feet was worsening. Left message with VA nurse. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 07/14/17 reflected a new order was received from the Facility Wound Care Physician to obtain an x-ray of the resident's both feet to rule out osteo[DIAGNOSES REDACTED] (bone infection). Results were negative for fracture and the soft tissues were unremarkable. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 07/17/17 at 4:04 p.m. reflected the DON informed the Wound Care Nurse she notified the resident's family regarding the condition of his feet. The Wound Care Nurse could not find evidence of the conversation. Resident's family notified regarding the worsening condition of the resident's feet. Resident #1's Nursing Departmental Notes entered by ADON G on 07/19/17 at 2:40 p.m. reflected a call was received from the VA Wound Nurse with instructions to contact the resident's family regarding the resident's scheduled VA podiatry appointment in two weeks or to send the resident to the VA hospital on [DATE]. Resident #1's Nursing Departmental Notes entered by LVN P on 07/19/17 at 11:03 p.m. reflected a foul odor was noted from the resident's feet. Resident #1's Nursing Departmental Notes entered by LVN E on 07/20/17 at 1:47 p.m. reflected the resident's family at the facility and requested the facility send the resident to the VA hospital due to the wounds on his lower extremities worsening. Left foot- first toe with black tissue and displaying signs and symptoms of infection with a foul odor. The right foot with necrotic (dead) tissue sloughing off. Facility Medical Director assessed the resident. Resident #1's Physician Orders, dated 07/20/17, reflected to send to the resident to the VA Hospital. Resident #1's Nursing Departmental Note, dated 07/20/17 at 2:58 p.m., reflected the resident was transferred to the VA hospital. Resident #1's VA Hospital Notes, dated 07/20/17 at 9:07 p.m., reflected the resident was assessed in the VA Hospital emergency room and admitted with bilateral foot pain and discharge. Resident diagnosed with [REDACTED]. The toes on both feet had purulent drainage and exudate. The resident was started on IV antibiotics. The left great toe was amputated on 07/23/17 due to wet gangrene and osteo[DIAGNOSES REDACTED]. Interviews with the family of Resident #1 on 07/24/17 at 10:50 a.m., 07/25/17 at 2:05 p.m., and 07/26/17 at 4:50 p.m. revealed the resident had his left toe amputated due to the development of gangrene on 07/23/17 after being admitted through the VA HospitalER on [DATE]. The family member reported the resident's right foot- forth toe was gangrenous also. The family member reported the VA Surgeon told him the facility should have sent the resident to another facility for treatment if they could not arrange to get the resident evaluated sooner at the VA. The family reported the VA Surgeon's plan was for above the knee amputations in both legs once the VA was able to get the resident's infection under control. The family reported the facility told him about the wounds on the right foot, but did not tell him about the wounds on the left foot. The family member reported when he attended the resident's care conference and confronted the facility about the resident's wound issues, the facility became very defensive and said they were doing everything they should have been. Additionally the Facility Medical Director/Physician L, who was Resident #1's facility attending physician, told the family member the plan was to treat the resident conservatively and let the toes fall off. The family member reported the facility and VA nurse said the resident could go to the VA hospital emergency room if he would take him, or the resident could wait and be seen at his scheduled VA appointment. The family member reported he was not medical personnel and did not know what the best option was. He told the facility if the resident needed emergency treatment then the facility could take the resident to the VA hospital emergency room and he would meet them there. The family member reported he spoke with the VA Physician Assistant on 07/20/17 and he told him if the resident's toes were dark and mushy then the resident needed to be transferred to the emergency room immediately. The family member reported he notified the facility on 07/20/17 and instructed them they needed to take the resident to the VA emergency room immediately. An interview with the DON and Wound Care Nurse on 07/25/17 at 9:40 a.m. revealed Resident #1 routinely went to the VA Wound Care Clinic and VA Podiatrist and he was sent to the VA hospital for poor circulation and wounds that couldn't heal. They reported the Facility Wound Care Physician saw residents with wounds weekly on Fridays, but she would only see VA residents monthly because she did not get paid to see them. They reported VA residents visited the VA Wound Care Clinic as appointments were set up by the VA. The DON reported she asked the family to take Resident #1 to the VA Hospital so they would address his wound issues. An interview with the Facility Medical Director/Physician L, Resident #1's facility attending physician, on 07/25/17 at 9:50 a.m. revealed Resident #1 had a lot of medical problems and his vascular system was very affected. Resident #1 had a long history of diabetes, four [MEDICAL CONDITION], [MEDICAL TREATMENT], and he did not have pedal pulses. The Medical Director reported there was no chance that his wounds would heal. The Medical Director reported that diabetic wounds got infected often and many residents with diabetic wounds required amputation. The Medical Director reported Resident #1 would require amputation to improve his quality of life. He reported he spoke to the family, date unknown, and tried to explain the resident's situation. The Medical Director reported the facility had a contract with the VA, but the VA was not being reimbursed properly. The Medical Director revealed if the VA did not see the residents then he would see them as needed or once a month, and if emergent issues arose they could go to the private hospital. An interview with the VA Nurse on 07/25/17 at 12:50 p.m. revealed a VA resident could make an appointment with the VA Wound Care Clinic and be seen in about 30 days. The VA Nurse also reported the facility wound care physician could see the resident some. A subsequent interview with the DON on 07/25/17 at 2:25 p.m. revealed the facility relied on the VA to be the primary for when medical decisions needed to be made for VA residents. The VA residents could see a facility physician if needed, but the facility had to have permission from the VA for all appointments and any issues with the VA residents. The DON reported that in case of an emergency, the facility could transfer a VA resident to the VA hospital emergency room and leave a message to get permission. The DON was asked about the documentation regarding the change in condition for Resident #1 on 07/14/17. She reported he was not sent to the hospital immediately, but she had been trying to get him more aggressive treatment and had spoken with the resident's family regarding the wound issues. The DON reported if a non-VA resident had a similar change in condition they would go to the ER to get more emergent treatment. An interview with the Facility Medical Director and Facility Wound Care Physician Assistant on 07/26/17 at 10:05 a.m. revealed they did not think there was a facility failure

Based on the comprehensive assessment of a resident, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for two (Residents #1 and #2) of six residents reviewed for quality of care. 1. The facility failed to ensure the necessary care and services to prevent and treat diabetic wounds on Resident #1's feet were provided and failed to identify and seek emergent treatment for [REDACTED].#1's toes on 07/14/17. As a result, Resident #1 developed wet gangrene, osteo[DIAGNOSES REDACTED], and amputation of his left first toe. 2. The facility failed to treat facility acquired wounds on the toes of VA Resident #2 according to facility policy and procedure and failed to consult with appropriate parties regarding the course of treatment for [REDACTED]. As a result, Resident #2 developed an infection of the toes and osteo[DIAGNOSES REDACTED]. Additionally, the tip of the resident's third left toe fell off. An Immediate Jeopardy was identified on 07/25/17. While the Immediate Jeopardy was removed on 07/27/17 at 12:45 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. These failure placed the ten residents, who were under VA contract, at risk of not receiving timely and appropriate treatment and services to prevent the development and/or worsening of wounds and infection. Findings included: 1. Resident #1's MDS assessment, dated 04/01/17, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's lifetime occupation was retired Navy. The resident's [DIAGNOSES REDACTED]. The resident was at risk for the development of pressure ulcers. The resident also had a skin tear requiring the application of non-surgical dressings, and application of ointments/medications. The resident had no ulcers or other identified skin problems. The resident's cognitive status was intact. Resident #1's Care plans, dated 03/24/17, reflected impaired skin integrity as evidenced by multiple wounds. The resident was seen by the VA doctors for wound management. The facility interventions included to report signs and symptoms of infection (odor, increased drainage, pain, or redness.) Resident #1's Nursing Departmental Notes entered by LVN A, dated 03/25/17 at 3:30 p.m., reflected Resident #1 was a new admission to the facility and was a VA patient. The note reflected Resident #1 had an open area on his right lower extremity and left toe. The note did not identify the affected toe and did not describe or indicate the size of the open areas. A Podiatrist progress note, dated 04/06/17, reflected the resident was seen by the facility's contracted Podiatrist on that date. The progress note reflected the following: .Assessment: 1. Symptomatic onychomycosis digital nail toes 1 through 5 bilateral 2. Peripheral angiopathy and [MEDICAL CONDITION]. 3. DM with [MEDICAL CONDITION] 4. Heloma dura (hard corn) (left) great toe painful 5. Superficial ulcers (right( 4th/5th toes -- guarded prognosis Plan: 1. The offending nail margins were mechanically and electrically debrided to the level of normal underlying nail bed with good relief. 2. Cleansed ulcers (right) 4th/5th toes with [MEDICATION NAME] solution, applied padded (dressing) wound specialist consult to eval(uate) and tx (treat) ulcers. shave/filed HD(s) (heloma dura) with good relief, applied paddings, Continue supportive footcare, shoegear, glucose control. Patient should be treated in 61 days for foot care due to systemic conditions or sooner if complications arise. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 04/20/17 at 2:51 p.m. reflected the following: Wound location: Right Foot 5th toe: 0.5 cm x 1.2 cm x 0.1 cm, Etiology Trauma, 100% granulation tissue (healing surface of a wound), scant exudate, no sign and symptom of infection, periwound (tissue surrounding a wound): callous forming, Cleaned with (normal saline), pat dry, apply collagen, Wound Location: Right foot 4th toe 0.5 cm x 0.6 cm x 0.1 cm, Etiology Trauma, 100% granulation tissue, scant exudate, no sign and symptom of infection, periwound: callous forming, Cleaned with (normal saline), pat dry, apply collagen, Applied dry gauze between two toe(s) for cushion Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 04/24/17 3:51 p.m. reflected the following: Wound location: Left great toe, suspected arterial ulcer, as the dorsalis pedis pulse is week (sic), resident has history of diabetes. 1 cm x 1 cm x UTD (unable to determine), 100% eschar, no sign and symptom of infection, no drainage, Wound location: left 5th toe, suspected arterial, 0.5 cm x 0.5 cm x UTD, 100% eschar, no sign and symptom of infection, no drainage, resident denied pain at the time of assessment .Clean the wounds with (normal saline), pat dry, applied [MEDICATION NAME] solution, cover with dry dressing. WCTM (will continue to monitor). Review of Resident #1's physician orders [REDACTED]. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 04/27/17 2:56 p.m. reflected Resident #1 was assessed, and his wounds treated by the Facility Wound Care Nurse. The Facility Wound Care Physician also assessed the traumatic wounds on the resident's right foot, fifth toe and right foot, fourth toe and the wounds on the left foot, first toe and left foot, fifth toe. The etiology of the wounds on the left foot was changed to vascular or shoe trauma. The Facility Wound Care Physician recommended better fitting shoes for both feet for the resident. The family was notified. There was no documentation to indicate the VA was notified. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 04/28/17 12:57 p.m. reflected the following: Informed VA Nurse .about resident's wound condition. Informed VA nurse that doctor recommended good fitted shoe for both feet and supported device with cushion for right leg. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 05/04/17 3:53 p.m. reflected the following: Wound location: Right Foot 5th toe: 0.7 cm x 1.4 cm x utd, Etiology Trauma, 60% slough (dead skin or tissue that has fallen off), 40% granulation tissue, mild serosanguinous exudate (drainage containing blood), no sign and symptom of infection, periwound: calloused edge, Cleaned with (normal saline), pat dry, applied [MEDICATION NAME] soaked gauze, as per TAR. Wound Location: Right foot 4th toe, 1 cm x 1 cm x UTD, Etiology Trauma, 100% slough, mild serosanguinous exudate, no sign and symptom of infection, periwound: calloused edge, Cleaned with (normal saline), pat dry, applied [MEDICATION NAME] soaked gauze. Applied dry gauze between two toe(s) for cushion. (Physician L/Medical Director) assessed the resident today. Doctor recommended better fitting shoe, leave open to air as much as possible. Wound location: Left great toe tip: 1.2 cm x 1.8 cm x UTD, 100% Eschar, Etiology: vascular or trauma from shoe. No exudate, no sign and symptom of infection, Wound location: Left 5th toe: 0.2 cm x 0.2 cm x UTD, 100% Eschar (dry, dark scab), Etiology: vascular or trauma from shoe. No exudate, no sign and symptom of infection, Cleaned with (normal saline), pat dry, applied [MEDICATION NAME] soaked gauze, cover with dry dressing, as per TAR Resident #1's Physician Orders, dated 05/05/17, reflected to clean the right foot-fourth and fifth toes with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze, and cover with a dry dressing daily. A Radiology Interpretation report, dated 05/08/17, reflected Resident #1 had an arterial and venous duplex scan (test to determine blood flow) of both lower extremities. The scan revealed severe [MEDICAL CONDITION] disease (disease that affects blood flow), mild to moderate stenosis/obstruction (condition that affects blood flow). The recommendation was for a vascular surgeon evaluation and a MRI (magnetic resonance image) angiogram (scan that could show how well the blood flowed.) Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 05/17/17 at 1:13 p.m. reflected the following: Wound location: Right 5th toe: trauma: 1 cm x 0.6 cm x UT, 20% slough, 80% granulation tissue, scant serosanguinous drainage, No sign or symptom of infection, Wound Location: right 4th toe, lateral side: Trauma: 1 cm x 0.8 cm x UTD, 20% slough, 80% granulation tissue, No sign and symptom of infection, Scant serosanguinous drainage, Wound Location: Right 4th toe medial side, Trauma: 0.6 cm x 0.3 cm x UTD, 20% slough, 80% granulation tissue, scant serosanguinous drainage, no sign and symptom of infection. Right 3rd toe: Trauma: 0.5 cm x 0.5 cm x UTD, 20% slough, 80% granulation tissue, scant serosanguinous drainage, No sign and symptom of infection. Wound Location: Tip of the great left toe: suspected DTI, 1.6 cm x 0.6 cm x UTD, 100% eschar, no drainage, no sign and symptom of infection. Wound location: Left tip of the 5th toe: 0.3 cm x 0.3 cm x UTD, 100% eschar, no drainage, no sign and symptom of infection. Cleaned the both feet wounds with NS, pat dried, applied [MEDICATION NAME] soaked gauze, placed gauze in between right 3rd, 4th, and 5th toe(s) for cushioning. Both legs skin shining and pale. Dorsalis pedis pulse (pulse felt on the top of the foot) is absent for both feet .Reported to family and VA nurse. WCTM. Resident #1's Nursing Departmental Noted entered by the Facility Wound Care Nurse on 05/30/17 at 3:38 p.m. reflected the following: Wound location: Right 5th toe: trauma: 0.5 cm x 1 cm x UTD, 100% slough, mild serosanguinous drainage, no sign and symptom of infection, Wound Location: right 4th toe, lateral side: Trauma: 0.9 cm x 1.7 cm x UTD, 100% slough, no sign and symptom of infection, mild serosanguinous drainage, Wound Location: Right 4th toe medial side: Trauma: 0.6 cm x 0.6 cm x UTD, 100% slough, mild serosanguinous drainage, no sign and symptom of infection. Right 3rd toe lateral side, Trauma: 0.5 cm x 0.7 cm x UTD, 100% slough, mild serosanguinous drainage, no sign and symptom of infection. Wound Location: Tip of the great left toe: suspected DTI, 3 cm x 3 cm x UTD, 100% eschar, no drainage, no sign and symptom of infection. Wound Location: Left tip of the 5th toe: 0.1 cm x 0.1 cm x UTD, 100% eschar, no drainage, no sign and symptom of infection. Cleaned the both feet wound with NS, pat dried, applied [MEDICATION NAME] soaked gauze, placed gauze in between right 3rd, 4th, and 5th toe(s) for cushioning. Both legs skin shining and pale. Dosalis pedis pulse is absent for both feet. (Physician L/Medical Director) assessed the resident today .Reported to family and VA nurse. WCTM. Resident #1's Physician Orders, dated 05/30/17, reflected to clean the third and fourth toes on the right foot with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze, and cover with a dry dressing daily. Resident #1's e-TAR dated 06/01/17-06/09/17 reflected to clean left foot-great toe tip, left foot-fifth toe tip, right foot-third and fourth toes with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze, and cover with a dry dressing daily. Resident #1's VA Wound Care Consult Result report, dated 06/08/17 at 2:09 p.m. reflected the following: Right medial 5th toe: 0.8 x 0.8 cm x ?? cm (wound bed covered with 50% slough) Right lateral 4th toe: 1.3 x 1.6 x ?? cm (wound bed covered with 80% slough) Right medial 4th toe: 1.1 x 1.3 x >> cm (very close to bone) (wound bed covered with 90% slough) Right lateral 3rd toe: 1 x 1 x ?? cm (wound bed covered with 80% slough) Left great toe: Entire end of toe open with eschar forming and bone present .Pulses: Left DP and PT pulse greatly diminished Right DP and PT pulse greatly diminished Wound Pain: 10/10 (patient states especially at night and he takes a pain pill that he states sometime works, remainder of time pain 6/10) WOUND TREATMENT/PLAN RECOMMENDATIONS: Twice a day right 3rd, 4th, 5th toe wounds, right lateral foot wounds, and left great toe wound care: - Cleanse and dry bilateral toes/feet, especially between the toes - Apply [MEDICATION NAME] ([MEDICATION NAME]/iodine) impregnated gauze between the 3rd/4th and 4th/5th toes - Paint right lateral foot wound with [MEDICATION NAME] - Cover left great toe with [MEDICATION NAME] impregnated gauze .Ensure patient has Prevalon boots on (were provided during VA Outpatient Wound Clinic visit/appointment) Nursing and Rehab center to perform above Will notify appropriate personnel to ensure orders are faxed . 06/09/2017 ADDENDUM STATUS: COMPLETED (Facility Wound Care Nurse) RN (treatment nurse) at Woodridge Nursing and Rehab was contacted. The recommendations were reviewed and a copy of the note was faxed to the facility. (Facility Wound Care Nurse) will contact the nursing home pharmacy to determine if the facility has the product or a comparable dressing. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 06/09/17 at 3:22 p.m. reflected the following: Got resident's wound care treatment plan order through fax from VA nurse .Right 3rd/4th toe and right 4th/5th toe: clean with (normal saline), pat dry, apply [MEDICATION NAME] impregnated gauze between toes, and cover with dry dressing everyday BID (twice a day). Right Lateral foot wound: Clean with (normal saline), pat dry, paint with [MEDICATION NAME] solution everyday BID. Left great toe wound: clean with (normal saline), pat dry, apply [MEDICATION NAME] impregnated gauze, cover dressing with gauze, secure with kerlix and tape everyday BID Resident needs to have Prevalon Boots on everyday provide by VA wound clinic. Resident #1's e-TAR dated 06/09/17-07/20/17 reflected to clean the left foot-first toe; right foot-third, fourth, and fifth toe with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze between toes and cover with a dry dressing twice daily. Resident #1's Physician Orders, dated 06/10/17, reflected to clean the resident's left great toe with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze, cover with gauze, and secure with Kerlix wrap twice daily; and the right third, fourth and fifth toes were to be cleaned with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze between toes, and cover with dry dressing twice daily. Resident #1's VA Podiatry Consult Result report, dated 06/15/17, reflected the following: .Presents from nursing facility in wheelchair with an assistant. Here for wounds both feet between toes right and the end of the left great toe. Left great toe started with a nail trim from podiatrist that came to nursing facility. Wound care regularly with [MEDICATION NAME] sol(ution) and dressings. Not on any antibiotics. Wearing bed boots but does had Dr C shoes. No xrays have been done no vascular consult either. .No pulses palpated sensory perception negative toes bil Skin dry shiney (sic) cool Left great toe gangrenous distal aspect with distal phalanx expose dry black maceration web soaces with ulcer toes 3, 4, 5 right with odor as follows: Medial aspect 5, lat(eral) and med(ial) aspect 4, and lateral aspect 3rd toe right hammer toe deformity rigid bil(ateral). .[MEDICAL CONDITIONS], multiple digit ulcerations (right), (left) great toe gangrene distally exposed distal phalanx .P(lan): X-rays, Vascular consult, wound care dressing change for now TX: [MEDICATION NAME] sol(ution) and DSD bil Order CRP, Sed R Order bil xrays Consult for vascular surgery entered Rx (prescription) [MEDICATION NAME] (antibiotic) to cover for now. Resident #1's Nursing Departmental Notes entered by LVN M on 06/18/17 at 12:15 a.m. reflected the following: Late Entry (dated) 6/17/17 @ 6PM. Res back from OOP (out on pass) .Res (family member) told this nurse he is concern(ed) about the left great toe wound. Checked the affected toe and noticed with dressing on it and noticed black colored area. No drainage noted, surrounding skin pink; with no odor. Will endorsed (sic) to oncoming nurse to continue to monitor and to communicate to wound nurse Resident #1's Nursing Departmental Notes entered by LVN N on 06/19/17 at 8:00 p.m. reflected the following: RP (Responsible Party) concerned about patient left toe. Stated nobody has informed him about the left toe, the left toe has black skin, skin dead & toe is falling out, someone has put dressing, I think the bone is pointing out. Patient stated the wound nurse wrapped the toe. Assessed the toe, dressing applied, no drainage nor foul odor. No c/o pain distress/discomfort voiced Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 06/20/17 at 2:00 p.m. reflected the following wound measurements for the wounds that had worsened: Right foot - fourth toe, lateral side, 1.0 cm x 1.0 cm x UTD Right foot - fourth toe, medial side, 0.8 cm x 0.5 cm x UTD Left foot - first toe, 1.0 cm x 3.0 cm x UTD depth, 100% soft eschar Resident #1's VA Consultation Sheet reflected the resident was seen on 06/22/17 for vascular surgeon consultation. The report reflected Resident #1 had gangrene of the left toe with wounds on the right foot. Resident #1's VA Podiatry Follow-up Progress Notes, dated 06/22/17 at 9:00 a.m. reflected the following: .[MEDICAL CONDITION], multiple digit ulcerations Rt, Lt great toe gangrene distally exposed distal phalanx .bone infection suspected order SPECT (Single-photon emission computed tomography) .Once SPECT done if confirms bone infection then perform bone biopsy with Infectious Dis(ease) consult ASAP (as soon as possible) .Continue [MEDICATION NAME]. There was no evidence in the resident's facility clinical record reflecting that Resident #1 had been receiving the antibiotic medication, [MEDICATION NAME]. Resident #1's Physician Orders, dated 06/27/17, reflected [MEDICATION NAME] 500 mg by mouth twice daily for 14 days. Resident #1's e-TAR for 06/27/17 reflected [MEDICATION NAME] 500 mg by mouth twice daily for 14 days with a stop date of 07/11/17. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 06/27/17 at 3:39 p.m. reflected a new order for [MEDICATION NAME] received to treat the resident's foot infection. VA Nurse notified with updated orders. There was no evidence to indicate the resident was already on [MEDICATION NAME] as ordered by the VA Podiatrist on 06/15/17. Resident #1's Nursing Departmental Notes entered by LVN N on 06/27/17 at 6:22 p.m. reflected: N.O. (New Order) for [MEDICATION NAME] 500/Clav K 125 mg tab, take 1 tablet po bid x 14 days for foot infection. There was no documentation to indicate why the antibiotic was changed from [MEDICATION NAME] to [MEDICATION NAME]. Resident #1's Nursing Departmental Notes entered by LVN N on 06/27/17 at 9:05 p.m. reflected: .[MEDICAL CONDITION] +1 noted bilaterally to lower legs. Left big toe black and foul odor from both legs when changing dressing. Kerlix dressing applied to both legs. No drainage noted. WCTM. Resident #1's Physician Orders, dated 06/29/17, reflected to clean the tip of fifth toe on the left foot with normal saline, pat dry, paint with [MEDICATION NAME] solution, and cover with dry dressing twice daily. Resident #1's e-TAR for 06/29/17-07/20/17 reflected to clean left foot-tip of fifth toe with normal saline, pat dry, paint with [MEDICATION NAME] solution, and cover with dry dressing twice daily. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 07/05/17 at 4:27 p.m. reflected the resident's wound were assessed and treated, and the following new wounds were identified: Right foot- third toe, medial side, 1.0 cm x 1.0 cm x UTD Right foot- second toe, 0.8 cm x 0.5 cm x UTD Resident #1's Nursing Departmental Notes entered by the DON on 07/05/17 at 7:03 p.m. reflected the DON contacted the resident's family regarding the resident's wound status and the facility plan to admit the resident to the VA hospital to figure out the next step of his treatment plan. Resident #1's Nursing Departmental Notes entered by LVN A on 07/06/17 at 1:37 p.m. reflected the VA Nurse was contacted regarding the resident's wounds not improving and a possible direct admit to the VA hospital. VA nurse reported the resident had an upcoming appointment for his feet and would see what the VA doctor recommended. Resident #1's Facility Wound Care Physician Note completed by the Wound Care Physician Assistant on 07/07/17 reflected the resident had a chronic wound that may or may not heal, continue [MEDICATION NAME], check with the VA to see if an x-ray has been ordered to evaluate for osteo[DIAGNOSES REDACTED], if not, will order x-ray. The note reflected there would be a follow-up in one week. There was no documentation to indicate the resident ever took [MEDICATION NAME]. Facility Nurse Note by the facility Wound Care Nurse. 07/07/17 3:17 p.m.: Resident's wounds assessed by the facility wound care physician: Left foot- first toe, 3.5 cm x 3.5 cm x unable to determine UTD depth, 100% eschar Left foot- fifth toe, 0.2 cm x 0.2 cm x UTD depth, 100% eschar Right foot- fifth toe, 0.8 cm x 1.5 cm x UTD depth Right foot- forth toe, lateral side, 1.5 cm x 2.0 cm x UTD depth Right foot- forth toe, medial side, 1.5 cm x 2.1 cm x UTD depth Right foot- third toe, lateral side, 1.4 cm x 2.8 cm x UTD depth Right foot- third toe, medial side, 1.1 cm x 1.0 cm x UTD depth Right foot- second toe, 0.8 cm x 1.0 cm x UTD depth. Left message for VA nurse. Resident #1's Physician Orders, dated 07/06/17, reflected to clean the right medial third toe and right lateral second toe with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze between toes, and cover with dry dressing twice daily; and to apply toe spacer between the toes. Resident #1's e-TAR for 07/01/17-07/20/17 reflected to clean the left foot-first toe with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze, cover with gauze, and secure with Kerlix twice daily; to clean the right foot-third, fourth, and fifth toes with normal saline, pat dry, apply [MEDICATION NAME] impregnated gauze between toes and cover with a dry dressing twice daily; and to clean the left foot-tip of fifth toe with normal saline, pat dry, paint with [MEDICATION NAME] solution, and cover with dry dressing twice daily. Resident #1's e-TAR for 07/06/17-07/20/17 reflected to clean the right medial third toe and right lateral second toe with normal saline, pat dry, apply [MEDICATION NAME] soaked gauze between toes, and cover with dry dressing twice daily; and apply toe spacer between the toes. Resident #1's VA Podiatrist Note, dated 07/13/17 at 10:30 a.m., reflected the resident had osteo[DIAGNOSES REDACTED] (bone infection) left great toe, gangrene right fourth toe, [MEDICAL CONDITION]. New orders written for Iodosorb to be applied twice daily to the left great toe and right foot-fourth digit and PRAFO (Pressure Relief Ankle Foot Orthosis). Explained to patient that if he had an amputation, he might not heal from surgery which could lead to an above the knee amputation. The patient to discuss with his family. The nursing facility was to continue to use [MEDICATION NAME] and a dry, sterile dressing to the left great toe and right foot-forth toe. There was no documentation to indicate the facility ordered Iodosorb or the PRAFO (Pressure Relief Ankle Foot Orthosis). Resident #1's Nursing Departmental Notes entered by LVN O on 07/13/17 at 7:07 p.m. reflected Resident #1 returned from VA Podiatrist appointment with no new orders. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 07/14/17 at 1:59 p.m., reflected the resident was assessed and wounds treated by the facility Wound Care Nurse. The resident's right foot-fourth toe was noted to be turning totally black. Mushy and thin to touch. Foul odor from both feet. Right foot- second toe, third toe, and fifth toe macerated and black. The condition of both feet was worsening. Left message with VA nurse. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 07/14/17 reflected a new order was received from the Facility Wound Care Physician to obtain an x-ray of the resident's both feet to rule out osteo[DIAGNOSES REDACTED] (bone infection). Results were negative for fracture and the soft tissues were unremarkable. Resident #1's Nursing Departmental Notes entered by the Facility Wound Care Nurse on 07/17/17 at 4:04 p.m. reflected the DON informed the Wound Care Nurse she notified the resident's family regarding the condition of his feet. The Wound Care Nurse could not find evidence of the conversation. Resident's family notified regarding the worsening condition of the resident's feet. Resident #1's Nursing Departmental Notes entered by ADON G on 07/19/17 at 2:40 p.m. reflected a call was received from the VA Wound Nurse with instructions to contact the resident's family regarding the resident's scheduled VA podiatry appointment in two weeks or to send the resident to the VA hospital on [DATE]. Resident #1's Nursing Departmental Notes entered by LVN P on 07/19/17 at 11:03 p.m. reflected a foul odor was noted from the resident's feet. Resident #1's Nursing Departmental Notes entered by LVN E on 07/20/17 at 1:47 p.m. reflected the resident's family at the facility and requested the facility send the resident to the VA hospital due to the wounds on his lower extremities worsening. Left foot- first toe with black tissue and displaying signs and symptoms of infection with a foul odor. The right foot with necrotic (dead) tissue sloughing off. Facility Medical Director assessed the resident. Resident #1's Physician Orders, dated 07/20/17, reflected to send to the resident to the VA Hospital. Resident #1's Nursing Departmental Note, dated 07/20/17 at 2:58 p.m., reflected the resident was transferred to the VA hospital. Resident #1's VA Hospital Notes, dated 07/20/17 at 9:07 p.m., reflected the resident was assessed in the VA Hospital emergency room and admitted with bilateral foot pain and discharge. Resident diagnosed with [REDACTED]. The toes on both feet had purulent drainage and exudate. The resident was started on IV antibiotics. The left great toe was amputated on 07/23/17 due to wet gangrene and osteo[DIAGNOSES REDACTED]. Interviews with the family of Resident #1 on 07/24/17 at 10:50 a.m., 07/25/17 at 2:05 p.m., and 07/26/17 at 4:50 p.m. revealed the resident had his left toe amputated due to the development of gangrene on 07/23/17 after being admitted through the VA HospitalER on [DATE]. The family member reported the resident's right foot- forth toe was gangrenous also. The family member reported the VA Surgeon told him the facility should have sent the resident to another facility for treatment if they could not arrange to get the resident evaluated sooner at the VA. The family reported the VA Surgeon's plan was for above the knee amputations in both legs once the VA was able to get the resident's infection under control. The family reported the facility told him about the wounds on the right foot, but did not tell him about the wounds on the left foot. The family member reported when he attended the resident's care conference and confronted the facility about the resident's wound issues, the facility became very defensive and said they were doing everything they should have been. Additionally the Facility Medical Director/Physician L, who was Resident #1's facility attending physician, told the family member the plan was to treat the resident conservatively and let the toes fall off. The family member reported the facility and VA nurse said the resident could go to the VA hospital emergency room if he would take him, or the resident could wait and be seen at his scheduled VA appointment. The family member reported he was not medical personnel and did not know what the best option was. He told the facility if the resident needed emergency treatment then the facility could take the resident to the VA hospital emergency room and he would meet them there. The family member reported he spoke with the VA Physician Assistant on 07/20/17 and he told him if the resident's toes were dark and mushy then the resident needed to be transferred to the emergency room immediately. The family member reported he notified the facility on 07/20/17 and instructed them they needed to take the resident to the VA emergency room immediately. An interview with the DON and Wound Care Nurse on 07/25/17 at 9:40 a.m. revealed Resident #1 routinely went to the VA Wound Care Clinic and VA Podiatrist and he was sent to the VA hospital for poor circulation and wounds that couldn't heal. They reported the Facility Wound Care Physician saw residents with wounds weekly on Fridays, but she would only see VA residents monthly because she did not get paid to see them. They reported VA residents visited the VA Wound Care Clinic as appointments were set up by the VA. The DON reported she asked the family to take Resident #1 to the VA Hospital so they would address his wound issues. An interview with the Facility Medical Director/Physician L, Resident #1's facility attending physician, on 07/25/17 at 9:50 a.m. revealed Resident #1 had a lot of medical problems and his vascular system was very affected. Resident #1 had a long history of diabetes, four [MEDICAL CONDITION], [MEDICAL TREATMENT], and he did not have pedal pulses. The Medical Director reported there was no chance that his wounds would heal. The Medical Director reported that diabetic wounds got infected often and many residents with diabetic wounds required amputation. The Medical Director reported Resident #1 would require amputation to improve his quality of life. He reported he spoke to the family, date unknown, and tried to explain the resident's situation. The Medical Director reported the facility had a contract with the VA, but the VA was not being reimbursed properly. The Medical Director revealed if the VA did not see the residents then he would see them as needed or once a month, and if emergent issues arose they could go to the private hospital. An interview with the VA Nurse on 07/25/17 at 12:50 p.m. revealed a VA resident could make an appointment with the VA Wound Care Clinic and be seen in about 30 days. The VA Nurse also reported the facility wound care physician could see the resident some. A subsequent interview with the DON on 07/25/17 at 2:25 p.m. revealed the facility relied on the VA to be the primary for when medical decisions needed to be made for VA residents. The VA residents could see a facility physician if needed, but the facility had to have permission from the VA for all appointments and any issues with the VA residents. The DON reported that in case of an emergency, the facility could transfer a VA resident to the VA hospital emergency room and leave a message to get permission. The DON was asked about the documentation regarding the change in condition for Resident #1 on 07/14/17. She reported he was not sent to the hospital immediately, but she had been trying to get him more aggressive treatment and had spoken with the resident's family regarding the wound issues. The DON reported if a non-VA resident had a similar change in condition they would go to the ER to get more emergent treatment. An interview with the Facility Medical Director and Facility Wound Care Physician Assistant on 07/26/17

Based on observation, interview and record review, it was determined the facility failed to implement its policies and procedures to prohibit neglect for one(Resident #13) of 16 residents reviewed for neglect. The facility failed to assess Resident #13's pain and consult with his physician regarding the resident's pain as his Care Plans for ROM and Pressure Ulcers indicated. A physician's orders [REDACTED]. During the provision of wound care, incontinent care, and care/repositioning, Resident #13 was screaming out in pain, grimacing, grunting, grabbing a CNA's wrist, grabbing the CNAs' clothing and clenching his fist. An Immediate Jeopardy (IJ) was identified on 02/01/12 at 2:50 PM. While the IJ was removed on 02/02/12, the facility remained out of compliance at a scope of "pattern" and severity level of "actual harm that was not immediate jeopardy" because the facility was still implementing and monitoring the Plan of Removal. These failures caused Resident #13 to be in undue, extreme pain during care and delayed his wound care treatments, which could result in delayed healing and placed the resident at risk for depression and a poor quality of life. These failures could affect the 55 residents, who were on pain management, and placed them at risk for experiencing unnecessary pain, being administered ineffective pain medication and result in a decline in their overall well-being and quality of care. Findings included: Review of Resident #13's MDS assessment dated [DATE] revealed Resident #13 was an [AGE] year-old male, admitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted on [DATE]. The assessment reflected the resident had short and long-term memory problems, and his cognitive skills for daily decision-making were severely impaired. The MDS assessment also reflected he was incontinent of bowel and bladder, needed extensive assistance for toilet use and was totally dependent on staff for bathing. Resident #13's MDS assessment reflected [DIAGNOSES REDACTED]. Resident #13's Care Plan dated 11/23/11 reflected he had contractures and limited ROM in his left upper and lower extremities. The approaches on the care plan were ROM program five times a week by the RA, offer pain medication to assist in ROM exercises and ROM daily with care by the CNAs. Resident #13's Nurse's Notes dated 01/11/12 reflected the resident had a sore on his left great toe, a red, bloody blister on the lower side of the toe, and a Stage II and Stage III on his left fingers between his fingers. Review of Resident #13's Acute Care Plans/Skin Integrity Alteration dated 01/11/12 revealed he had a Stage I Pressure Ulcer between his thumb and pointer finger, had a blister on his left great toe, a Stage II Pressure Ulcer on his left great toe, and a Pressure Ulcer between his second and third finger. The approaches included in the Acute Care Plans were apply skin treatment to affected areas as ordered, assess resident for pain and discomfort related to skin alteration, medicate resident for pain as ordered for comfort, administer medications as ordered by the physician, notify the physician of treatment or medications ordered that were not effective, and caution with reposition and transfers. Resident #13's Restorative Program Flow Sheet dated 01/21/12 through 01/28/12 revealed, "Perform passive range of motion to left hand, soak hand in warm water, contracture will have more joint movement in next 30 days." During the initial tour on Station One, on 01/30/12 at 10:15 AM with the assistance of LVN B, Resident #13 was observed with a contracture to his leg, drawn up to his hip, and unable to extend and his left arm was contracted along with his fingers. The resident said hello, when he was addressed. The surveyor asked LVN B to check Resident #13 to see if he was dry. LVN B donned her gloves and asked Resident #13 if she could check to see if he was dry. Resident #13 said ok. LVN B turned Resident #13 to check his brief and Resident #13 screamed out and said, "Oh! Oh that hurts!" Resident #13 was grimacing and grunting. LVN B told the surveyor Resident #13 required two persons and she requested a CNA to assist. When the CNA and LVN B attempted to remove Resident #13's brief, he screamed out, "That hurts!" Resident #13 continued grimacing and grunting. His brief was wet and the LVN assisted the resident back into his original position. The surveyor asked LVN B if resident #13 had medication ordered for his pain. LVN B stated Resident #13 had routine [MEDICATION NAME] (narcotic) for pain and routine [MEDICATION NAME] for joint pain prior to his hospital visit. She stated he returned to the facility about two to three weeks ago and the physician did not re-order his [MEDICATION NAME] or [MEDICATION NAME]. LVN B further stated, "His doctor ordered Tylenol for his pain, and told the nurses to monitor Resident #13's pain." The surveyor told LVN B Resident #13 sounded like he was really in pain. LVN B told the surveyor she would get the CNAs to provide incontinent care to Resident #13. LVN B did not acknowledge Resident #13's grimacing, grunting or his yelling in pain. Review of Resident #13's physician's orders [REDACTED].#13 was routinely administered via [DEVICE] [MEDICATION NAME]/APAP ([MEDICATION NAME]) 7.5/325 mg tablet one tab per G/T every HS and administered via [DEVICE] [MEDICATION NAME] ([MEDICATION NAME]) 10 mg tablet one tablet per G/T TID. Review of Resident #13's re-admission physician's orders [REDACTED]. An observation on 01/31/12 at 10:30 AM revealed CNA E and CNA F providing incontinent care provided to Resident #13. Resident #13 was incontinent of bowel. CNA E stood on Resident #13's left side and CNA F stood on the resident's right side. The CNAs removed the resident's soiled brief and the soiled draw sheet by turning the resident to his right side and then to his left side. Resident #13 started screaming, "Oh! Oh! That hurt." The CNAs placed a clean draw sheet under Resident #13 and the resident stated, "Oh my leg hurt!" The CNAs continued with the incontinent care. The CNAs turned Resident #13 onto his back and the resident while grimacing started screaming "Oh! Oh! You are hurting me!" Resident #13 also grabbed CNA F's wrist and both CNAs had to stop and pry the resident's hand from around CNA F's wrist. The resident continued to tell the CNAs he was hurting. CNA F stated, "He has never been this upset." CNA F and CNA E rolled Resident #13 onto his right side, and the resident stop screaming. Resident #13 started grabbing CNA F's wrist, pulling at CNA E and CNA F's clothing and telling them they were hurting him. The CNAs then placed a clean brief under Resident #13 and told the resident they had completed his care. Resident #13 again told the CNAs he was hurting. The CNAs then took a tube of [MEDICATION NAME] from the table and applied it to his buttocks, and Resident #13 screamed out and hit at the CNAs saying, "That hurts! You told me you had finished! You lied! My right leg hurts!" The CNAs completed the care and left the room. CNA F stated she was going to tell the charge nurse Resident #13 needed something for pain and something to settle him down. Review of Resident #13's Nurse's Notes dated 01/31/12 revealed: "11:00 AM Notified by CNA F that Resident #13 was combative R/T (ADON interpreted this R-T as possible "related to") to pain while repositioning. Physician at facility notified received orders to continue with PRN Tylenol orders." The entry was signed by LVN B. Review of Resident #13's physician's orders [REDACTED]." Review of Resident #13's Nurses Notes for 01/31/12 and the MAR dated January 2012 revealed LVN B did not administer Resident #13's pain medication after calling the physician to report the resident's pain. There was not a pain assessment for Resident #13 regarding the pain he experienced on 01/31/12 during incontinent care in the resident's clinical record. An interview was conducted on 01/31/12 at 2:10 PM with RA G concerning pain medication for Resident #13 during ROM. The surveyor asked RA G if Resident #13 complained of pain when he provided the ROM to his left hand and left foot. RA G stated when he did Resident #13's exercises, the resident cried and said it hurt. The surveyor asked RA G if Resident #13 received anything for pain prior to the ROM exercises and the RA stated, "I do not know. Ask the nurse." The surveyor asked RA G if he reported to the nurse Resident #13's pain during the ROM and RA G did not answer. On 01/31/12 at 2:15 PM an interview was conducted with LVN J, Resident #13's Charge Nurse for the 2:00 PM to 10:00 PM shift, about Resident #13's ROM and his pain medication. The surveyor asked LVN J if she offered pain medication to Resident #13 prior to his ROM exercises. LVN J stated, "What ROM?" The surveyor explained to LVN J ROM was care planned for Resident #13. The surveyor told LVN J RA G stated he provided the ROM on the 2:00 PM to 10:00 PM shift. LVN J stated Resident #13's pain medication was PRN and not routine. The surveyor asked LVN J if she offered Resident #13 his pain medication before he was provided ROM. LVN J stated she did not provide Resident #13 pain medication for ROM because his Tylenol was "PRN" and Resident #13 had to ask for the medication. The surveyor asked LVN J did she assess the resident for pain to determine if he needed the PRN Tylenol prior to ROM. LVN J stated no, she was not aware Resident #13 had ROM ordered. On 01/31/12 at 3: 50 PM, an interview was conducted with Resident #13 concerning his care in the facility. The surveyor asked Resident #13 how felt, and the resident replied ok now. The Surveyor asked the resident if he wanted to get up in his chair. Resident #13 told the surveyor he did not like to get up because it hurt when they got him up. Resident #13 stated he hurt when the staff turned him from side to side and the staff did that a lot. The surveyor asked the resident if his left arm hurt, and he said a lot. On 02/01/12 at 8:30 AM, the surveyor asked LVN B if she had administered Resident #13 pain medication. LVN B stated she administered Resident #13's Tylenol for pain this morning about 8:00 AM. The surveyor reviewed the MAR with LVN B, there was no assessment for pain documented on the MAR for the Tylenol. The surveyor asked LVN B why she did not monitor or assess Resident #13 for pain. LVN B stated Resident #13 was assessed for pain the first week he returned from the hospital and the staff stopped the daily pain assessments. LVN B stated she was aware the physician asked the nurses to monitor Resident #13 for pain. LVN B stated, "I cannot tell you why we are not assessing or monitoring the resident for pain." The surveyor asked LVN B why she did not assess Resident #13 for pain on 01/30/12 during the initial tour, when he said he was in pain and was yelling and grimacing. LVN B stated the first day during observation rounds, she forgot by the time the rounds were completed. She stated she was nervous because the surveyors were in the building and she was trying to remember what she had to do and what not to do. The surveyor asked LVN B why she did not give Resident #13 something for pain when the CNAs completed his incontinent care and reported to her the resident was having pain. LVN B stated she did not give the Tylenol because she thought Resident #13 told the staff everyday he was in pain. The surveyor asked LVN B if she did not assess the resident for pain how would she know the resident did not need a stronger medication for pain and how would she know if the Tylenol was effective. LVN B stated there was no way for her to determine if the Tylenol was effective because she did not assess pain or document pain assessments on Resident #13. On 02/01/12 at 9:00 AM, an interview was conducted with CNA E about Resident #13's pain during care. The surveyor asked CNA E if Resident #13 had pain when she provided assistance with his care or when she provided care to Resident #13. CNA E stated, "Resident #13 always hurt when I assisted with his care him and he screamed out 'Stop!'" The surveyor asked CNA E if she reported Resident #13's pain to the charge nurse, and CNA E stated she was sure the other CNA who helped her reported the pain and the resident's combativeness to the charge nurse. On 02/01/12 at 9:23 AM, an interview was conducted with CNA F regarding Resident #13's pain. The surveyor asked CNA F if she reported Resident #13's pain and combativeness during care to the charge nurse. CNA F stated she told LVN B Resident #13 was screaming out in pain, hitting and grabbing her arms and hands each time she tried to reposition him. CNA F stated she told LVN B Resident #13 said to leave him alone and they were hurting him. CNA F stated Resident #13 had never hit her like that before. CNA F stated since the residents re-admission from the hospital, he complained during his care that he was hurting, I reported the pain, but he never became combative. On 02/01/12 at 10:10 AM, the surveyor and LVN B accompanied Physician M, the wound care physician, to observe Resident #13's wounds and dressing changes. This was the first visit by Physician M to evaluate Resident #13's wounds. Physician M and LVN B removed Resident #13's dressing, and Resident #13 started saying, "Oh! Oh! Oh! That hurt!" Resident #13 was grimacing and yelling when the dressing was removed from his contracted fingers using a forcep like instrument. The physician with LVN B's assistance continued to remove the dressings on Resident #13's Pressure Ulcers and Resident #13 stated, "It hurt! Oh! Oh! Oh!" Resident #13 then made a fist and drew his right hand back and said it hurt. Physician M stepped back and said Resident #13 was in too much pain to continue and he needed pain medication before his dressings were completed. LVN B stated she gave the resident some Tylenol that morning. Physician M then stated Resident #13 needed something stronger than Tylenol. Physician M stated she would document the visit in Resident #13's clinical record and order him something stronger for pain. Physician M stated, "Give him the medication at least 30 minutes before his dressing change." LVN B stated she would finish his dressings and the surveyor pointed out the physician said to get the stronger medication first and then complete the dressing change. Physician M's order dated 02/01/12, for Resident #13 reflected, "[MEDICATION NAME] 5 mg PEG TID, [MEDICATION NAME] 5/325 one PEG Q 4-6 hrs PRN, [MEDICATION NAME] 0.5 mg PEG 30 minutes before wound dressing." LVN A and the surveyor reviewed the dates Resident #13 was checked for pain according to the Daily Skilled Nursing Notes. On 01/12/12, 01/13/12, 01/14/12, and 01/15/12 pain management was checked off as done. LVN A and the surveyor continued the review of Resident #13's clinical record and MAR. LVN A was not able to locate any documentation of pain assessments or pain monitoring for dates 01/17/12 through 02/01/12, except for 01/23/12. LVN A confirmed Resident #13 was not assessed for pain or monitored for pain from 01/17/12 through 02/01/12, except for 01/23/12. LVN A stated the nurses were supposed to be using the flow sheet form on the MAR "PRN Flowsheet for [MEDICATION NAME] and Other Medications" to document pain assessments and monitoring of pain. LVN A removed the form from the MAR and showed the surveyor. LVN A confirmed Resident #13's "PRN Flowsheet for [MEDICATION NAME] and Other Medications" form was blank and their were no pain assessments documented for the above dates. On 02/01/12 at 12:20 PM an interview was conducted with LVN A, who identified herself as the ADON in charge of station one where Resident #13 resided. She stated the facility did not have a DON. LVN A was asked about pain assessments and the monitoring of Resident #13's pain. LVN A stated it was the responsibility of the nurses to assess and monitor Resident #13 for pain and it was the nurses' responsibility to document their findings in the medical record. LVN A stated the pain was not monitored or assessed daily therefore there was no way to determine if Resident #13 was in pain. On 02/01/12 at 12:25 PM an interview was conducted with LVN B regarding pain assessments and documented monitoring of pain for Resident #13. LVN B stated she had not assessed Resident #13 for pain, she had not been monitoring him for pain and she had not documented a pain assessment. LVN B stated when Resident #13 was readmitted to the facility on [DATE], Physician N told the nurses to monitor the resident for pain and call him if Resident #13 needed a change in medication orders. LVN B provided the surveyor Resident #13's January 2012 MAR. Review of the MAR by the surveyor and LVN B revealed Tylenol [MEDICATION NAME] 650 mg per Peg Q 4 Hrs PRN was not administered during the month of January 2012. On 02/01/12 at 1:30 PM, the surveyor asked LVN A and LVN B if Resident #13's pain medication ordered by the wound physician had arrived LVN B stated, "No." On 02/01/12 at 2:15 PM, CNA I was interviewed regarding Resident #13's pain. The surveyor asked CNA I if Resident #13 had pain when the CNA provided care. CNA I stated since the resident returned from the hospital, for the last week or so he had complained of pain when his bed or briefs were changed. CNA I stated the resident's joints were probably hurting because he had bad contractures. The facility's current, undated Abuse Prevention Policy and Procedure reflected, "(name) strives to keep its facility free from neglect...Staff members will identify and assess suspected or alleged reports of abuse or neglect...E. Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... Employees are educated that they must report any suspicious event that may constitute abuse or neglect...1. The facility's administrator and/or designee conducts an internal investigation...2. The facility investigates all alleged violations and, when indicated, takes appropriate actions...3. (name) analyzes all occurrences to determine what change or changes are needed, if any, to the facility's policies and procedures to prevent further occurrences. 4. (name) conducts self-audits of its own processes to ensure all requirements of policies and procedures are followed...WHAT IS NEGLECT: This is the failure or refusal to fulfill any part of a person's obligation or duties to a resident. Necessities such as food, water, and safety. This may also include situations in which residents are being left to lie in feces or urine or failure to answer call lights in a timely manner...Passive: Occurs when a person fails to fulfill their obligation unintentionally or unconsciously inflicting distress in (sic) a resident. A caregiver may not knowingly ignore a resident when care is needed, resulting in harm in the resident...SIGNS AND SYMPTOMS OF ABUSE AND NEGLECT ...Emotional upset or agitation Unattended health problems...." An IJ was identified on 02/01/12 at 2:50 PM in the area of Resident Behavior/Facility Practice and the Administrator was informed at that time. A Plan of Removal for the IJ was requested at that time. On 02/01/12 at 3:15 PM, the Physician N, Resident #13's attending physician, returned the surveyor's telephone call regarding Resident #13's pain medication. Physician N stated Resident #13's [MEDICATION NAME] was discontinued at the hospital because the physician at the hospital did not think Resident #13 needed [MEDICATION NAME]. Physician N stated he did not reorder [MEDICATION NAME] for Resident #13 when he was re-admitted to the facility on [DATE]. Physician N stated he approved the Tylenol PRN for pain. He also stated he told the nurses to monitor Resident #13 for pain and if the resident needed an increase in pain medication to call him and he would take care of the issue. The surveyor told Physician N that Physician M saw Resident #13 around 10:00 AM with LVN B, and the resident's dressings were removed. The surveyor also informed Physician N that Physician M told LVN B Resident #13 was in so much pain, she could not continue the dressing change. The surveyor informed Physician N that the wound care physician stated she would write an order for [REDACTED]. Physician N stated he was aware Physician M was going to visit the resident. Physician N was also informed by the surveyor the pain medication ordered by Physician M had not been delivered yet. Physician N told the surveyor the nurses should have called him if Resident #13 was in pain. He also stated the nurses should have called him if they could not get the medication and he would have taken care of it right away. Physician N stated, "I will write an order now and get the medication to the facility." On 02/01/12 at 3:10 PM, LVN A stated she heard the surveyor interviewing staff yesterday afternoon during the 2:00 PM to 10:00 PM shift regarding Resident #13's pain and pain medication. LVN A stated she immediately in-serviced the evening staff on pain management and Resident #13's pain medication. On 02/01/12 at 3:45 PM, LVN A told the surveyor, "I am developing a care plan to address Resident #13's pain." Review of the accepted Plan of Removal, dated 02/01/12, revealed: 1. Resident #13's new order for pain medications was obtained from a local pharmacy on 02/01/12 at 4:00 PM. The resident was administered his pain medication immediately and assessed later to determine the effectiveness of the medication. The resident would be monitored for pain each shift. 2. All residents would be assessed for pain every shift and the assessment would be documented on the MAR starting 02/01/12. The physician would be notified by the charge nurse if there were findings of pain on assessment and current pain modalities, ordered pain medication and non-medical interventions were not effective. The numerical and Wong-Baker Scale would be used as an assessment tool to aide in the pain management assessment. 3. Pain would be monitored daily on each shift, during weekly, quarterly, annual, new admission, readmission and change of condition assessments by the charge nurse. 4. Nursing Management and/or Designee would monitor this by checking each halls' medication book for pain assessments on Mondays, Wednesdays and Fridays to ensure proper documentation and follow-up from the nursing staff. 5. Nursing Management would report to the Quality Assurance Committee monthly to evaluate the plan's effectiveness and make recommendations to the Medical Director, Administrator/designee as needed. 6. Charge nurses would notify the doctor of any increased pain or unrelieved pain for dosage changes as needed. 7. If medication was not available STAT, staff would notify the Administrator, Medical Director, and nurse manager on call for further action. 8. Staff was in-serviced on January 27th and January 31st and the education director would continue in-servicing nursing staff regarding pain management. 9. Nursing Staff would be re-in-serviced beginning February 1, 2012. 10. Quality Assurance Committee would meet monthly to evaluate the plan's effectiveness. On 02/01/12 at 4:00 PM, LVN A approached the surveyor and told the surveyor Resident #13 was administered Tylenol for pain at 3:30 PM until the pain medication ordered by Physician M was obtained from the pharmacy. LVN A told the surveyor he was not hurting now. On 02/01/12 at 5:00 PM, the surveyor observed Resident #13 in his bed, quiet and asleep. The resident did not awaken when the surveyor called his name. An interview was conducted with LVN P on 02/02/12 at 9:30 AM concerning pain management for Resident #17. LVN P stated Resident #17's pain medication was changed to [MEDICATION NAME] Sodium by the physician. LVN P stated she noticed Resident #17's pattern of pain occurred around noon and she notified the physician to change the [MEDICATION NAME] Sodium administration times to 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. An interview was conducted with ADON Q on 02/02/2012 at approximately 10:00 AM. ADON Q revealed in the past she had reviewed the resident's pain assessments on a quarterly basis in order to acquire accurate information for the MDS pain assessments. ADON Q stated she would now be reviewing the resident's pain assessments on a weekly basis. ADON Q revealed if she noticed a resident was not having adequate pain relief, or if the resident's pain assessment reflected the resident was experiencing an increase in pain, she would confer with the LVN to determine whether medication or alternative methods of pain relief were more appropriate. ADON Q revealed she would assess the resident and inform his/her physician about the need for increased pain control. An interview was conducted with LVN R on 02/02/2012 at approximately 12:30 PM. LVN R showed the surveyor new entries on the residents ' medication records under the heading "Pain Assessment." The assessments, timed for each eight hour shift, reflected "Daily pain assessment per scale 1:10. Pain scale prior to Rx. Pain scale after RX. Start date 02/01/12." LVN R revealed the residents' pain assessments were to be completed on each shift. LVN R revealed the facility was in-servicing all licensed staff regarding pain assessment and pain control. Resident #20's 01/23/2012 MDS assessment reflected the resident was cognitively intact and had no behavioral issues. On 01/30/3012 at approximately 10:25 AM ADON Q revealed Resident #20 had a [MEDICAL CONDITION] which could not be surgically repaired. Interview with Resident #20 on 02/02/2012 at approximately 1:30 PM revealed the resident did not have any problems with pain control. Resident #20 stated his doctor had ordered pain medication to be given to him routinely. Resident #20 stated he had medicine ordered if he had pain in between his routine doses but said he rarely needed it. Resident #19 ' s 11/29/2011 MDS assessment reflected the resident was cognitively intact and had no behavioral issues. On 01/30/2012 at approximately 9:05 AM LVN S revealed Resident #19 was primarily bedbound and rarely got out of bed into her Geri-chair. Interview with Resident #19 on 02/02/2012 at approximately 1:45 PM revealed her pain was well controlled. Resident #19 stated she had scheduled pain medications and they relieved her pain most of the time. Resident #19 said if she had pain in between the times her pain medications were scheduled she used her call light and called the nurse. Resident #19 said the nurses were very good about answering her call light and bringing her pain medicine if it was time for her to have it. While the IJ was removed on 02/02/12, the facility remained out of compliance at a scope of "pattern" and severity level of "actual harm that is not immediate jeopardy," because the facility was still implementing and monitoring the Plan of Removal. The Administrator and the Regional Director of Operations were informed on 02/02/12 at 10:49 AM that the IJ was removed. The CMS form 672, Resident Census and Conditions of Residents, dated 01/30/12 and signed by the Medicare Specialist reflected 55 residents were on pain management.

Based on observation, interview and record review, it was determined the facility failed to implement its written policies and procedures to prohibit neglect for one(Resident #13) of 16 residents reviewed for neglect. The facility failed to assess Resident #13's pain and consult with his physician regarding the resident's pain as his Care Plans for ROM and Pressure Ulcers indicated. A physician's orders [REDACTED]. During the provision of wound care, incontinent care, and care/repositioning, Resident #13 was screaming out in pain, grimacing, grunting, grabbing a CNA's wrist, grabbing the CNAs' clothing and clenching his fist. An Immediate Jeopardy (IJ) was identified on 02/01/12 at 2:50 PM. While the IJ was removed on 02/02/12, the facility remained out of compliance at a scope of "pattern" and severity level of "actual harm that was not immediate jeopardy" because the facility was still implementing and monitoring the Plan of Removal. These failures caused Resident #13 to be in undue, extreme pain during care and delayed his wound care treatments, which could result in delayed healing and placed the resident at risk for depression and a poor quality of life. These failures could affect the 55 residents, who were on pain management, and placed them at risk for experiencing unnecessary pain, being administered ineffective pain medication and result in a decline in their overall well-being and quality of care. Findings included: The facility's current, undated Abuse Prevention Policy and Procedure reflected, "(name) strives to keep its facility free from neglect...Staff members will identify and assess suspected or alleged reports of abuse or neglect...E. Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... Employees are educated that they must report any suspicious event that may constitute abuse or neglect...1. The facility's administrator and/or designee conducts an internal investigation...2. The facility investigates all alleged violations and, when indicated, takes appropriate actions...3. (name) analyzes all occurrences to determine what change or changes are needed, if any, to the facility's policies and procedures to prevent further occurrences. 4. (name) conducts self-audits of its own processes to ensure all requirements of policies and procedures are followed...WHAT IS NEGLECT: This is the failure or refusal to fulfill any part of a person's obligation or duties to a resident. Necessities such as food, water, and safety. This may also include situations in which residents are being left to lie in feces or urine or failure to answer call lights in a timely manner...Passive: Occurs when a person fails to fulfill their obligation unintentionally or unconsciously inflicting distress in (sic) a resident. A caregiver may not knowingly ignore a resident when care is needed, resulting in harm in the resident...SIGNS AND SYMPTOMS OF ABUSE AND NEGLECT ...Emotional upset or agitation Unattended health problems...." Review of Resident #13's MDS assessment dated [DATE] revealed Resident #13 was an [AGE] year-old male, admitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted on [DATE]. The assessment reflected the resident had short and long-term memory problems, and his cognitive skills for daily decision-making were severely impaired. The MDS assessment also reflected he was incontinent of bowel and bladder, needed extensive assistance for toilet use and was totally dependent on staff for bathing. Resident #13's MDS assessment reflected [DIAGNOSES REDACTED]. Resident #13's Care Plan dated 11/23/11 reflected he had contractures and limited ROM in his left upper and lower extremities. The approaches on the care plan were ROM program five times a week by the RA, offer pain medication to assist in ROM exercises and ROM daily with care by the CNAs. Resident #13's Nurse's Notes dated 01/11/12 reflected the resident had a sore on his left great toe, a red, bloody blister on the lower side of the toe, and a Stage II and Stage III on his left fingers between his fingers. Review of Resident #13's Acute Care Plans/Skin Integrity Alteration dated 01/11/12 revealed he had a Stage I Pressure Ulcer between his thumb and pointer finger, had a blister on his left great toe, a Stage II Pressure Ulcer on his left great toe, and a Pressure Ulcer between his second and third finger. The approaches included in the Acute Care Plans were apply skin treatment to affected areas as ordered, assess resident for pain and discomfort related to skin alteration, medicate resident for pain as ordered for comfort, administer medications as ordered by the physician, notify the physician of treatment or medications ordered that were not effective, and caution with reposition and transfers. Resident #13's Restorative Program Flow Sheet dated 01/21/12 through 01/28/12 revealed, "Perform passive range of motion to left hand, soak hand in warm water, contracture will have more joint movement in next 30 days." During the initial tour on Station One, on 01/30/12 at 10:15 AM with the assistance of LVN B, Resident #13 was observed with a contracture to his leg, drawn up to his hip, and unable to extend and his left arm was contracted along with his fingers. The resident said hello, when he was addressed. The surveyor asked LVN B to check Resident #13 to see if he was dry. LVN B donned her gloves and asked Resident #13 if she could check to see if he was dry. Resident #13 said ok. LVN B turned Resident #13 to check his brief and Resident #13 screamed out and said, "Oh! Oh that hurts!" Resident #13 was grimacing and grunting. LVN B told the surveyor Resident #13 required two persons and she requested a CNA to assist. When the CNA and LVN B attempted to remove Resident #13's brief, he screamed out, "That hurts!" Resident #13 continued grimacing and grunting. His brief was wet and the LVN assisted the resident back into his original position. The surveyor asked LVN B if resident #13 had medication ordered for his pain. LVN B stated Resident #13 had routine [MEDICATION NAME] (narcotic) for pain and routine [MEDICATION NAME] for joint pain prior to his hospital visit. She stated he returned to the facility about two to three weeks ago and the physician did not re-order his [MEDICATION NAME] or [MEDICATION NAME]. LVN B further stated, "His doctor ordered Tylenol for his pain, and told the nurses to monitor Resident #13's pain." The surveyor told LVN B Resident #13 sounded like he was really in pain. LVN B told the surveyor she would get the CNAs to provide incontinent care to Resident #13. LVN B did not acknowledge Resident #13's grimacing, grunting or his yelling in pain. Review of Resident #13's physician's orders [REDACTED].#13 was routinely administered via [DEVICE] [MEDICATION NAME]/APAP ([MEDICATION NAME]) 7.5/325 mg tablet one tab per G/T every HS and administered via [DEVICE] [MEDICATION NAME] ([MEDICATION NAME]) 10 mg tablet one tablet per G/T TID. Review of Resident #13's re-admission physician's orders [REDACTED]. An observation on 01/31/12 at 10:30 AM revealed CNA E and CNA F providing incontinent care provided to Resident #13. Resident #13 was incontinent of bowel. CNA E stood on Resident #13's left side and CNA F stood on the resident's right side. The CNAs removed the resident's soiled brief and the soiled draw sheet by turning the resident to his right side and then to his left side. Resident #13 started screaming, "Oh! Oh! That hurt." The CNAs placed a clean draw sheet under Resident #13 and the resident stated, "Oh my leg hurt!" The CNAs continued with the incontinent care. The CNAs turned Resident #13 onto his back and the resident while grimacing started screaming "Oh! Oh! You are hurting me!" Resident #13 also grabbed CNA F's wrist and both CNAs had to stop and pry the resident's hand from around CNA F's wrist. The resident continued to tell the CNAs he was hurting. CNA F stated, "He has never been this upset." CNA F and CNA E rolled Resident #13 onto his right side, and the resident stop screaming. Resident #13 started grabbing CNA F's wrist, pulling at CNA E and CNA F's clothing and telling them they were hurting him. The CNAs then placed a clean brief under Resident #13 and told the resident they had completed his care. Resident #13 again told the CNAs he was hurting. The CNAs then took a tube of [MEDICATION NAME] from the table and applied it to his buttocks, and Resident #13 screamed out and hit at the CNAs saying, "That hurts! You told me you had finished! You lied! My right leg hurts!" The CNAs completed the care and left the room. CNA F stated she was going to tell the charge nurse Resident #13 needed something for pain and something to settle him down. Review of Resident #13's Nurse's Notes dated 01/31/12 revealed: "11:00 AM Notified by CNA F that Resident #13 was combative R/T (ADON interpreted this R-T as possible "related to") to pain while repositioning. Physician at facility notified received orders to continue with PRN Tylenol orders." The entry was signed by LVN B. Review of Resident #13's physician's orders [REDACTED]." Review of Resident #13's Nurses Notes for 01/31/12 and the MAR dated January 2012 revealed LVN B did not administer Resident #13's pain medication after calling the physician to report the resident's pain. There was not a pain assessment for Resident #13 regarding the pain he experienced on 01/31/12 during incontinent care in the resident's clinical record. An interview was conducted on 01/31/12 at 2:10 PM with RA G concerning pain medication for Resident #13 during ROM. The surveyor asked RA G if Resident #13 complained of pain when he provided the ROM to his left hand and left foot. RA G stated when he did Resident #13's exercises, the resident cried and said it hurt. The surveyor asked RA G if Resident #13 received anything for pain prior to the ROM exercises and the RA stated, "I do not know. Ask the nurse." The surveyor asked RA G if he reported to the nurse Resident #13's pain during the ROM and RA G did not answer. On 01/31/12 at 2:15 PM an interview was conducted with LVN J, Resident #13's Charge Nurse for the 2:00 PM to 10:00 PM shift, about Resident #13's ROM and his pain medication. The surveyor asked LVN J if she offered pain medication to Resident #13 prior to his ROM exercises. LVN J stated, "What ROM?" The surveyor explained to LVN J ROM was care planned for Resident #13. The surveyor told LVN J RA G stated he provided the ROM on the 2:00 PM to 10:00 PM shift. LVN J stated Resident #13's pain medication was PRN and not routine. The surveyor asked LVN J if she offered Resident #13 his pain medication before he was provided ROM. LVN J stated she did not provide Resident #13 pain medication for ROM because his Tylenol was "PRN" and Resident #13 had to ask for the medication. The surveyor asked LVN J did she assess the resident for pain to determine if he needed the PRN Tylenol prior to ROM. LVN J stated no, she was not aware Resident #13 had ROM ordered. On 01/31/12 at 3: 50 PM, an interview was conducted with Resident #13 concerning his care in the facility. The surveyor asked Resident #13 how felt, and the resident replied ok now. The Surveyor asked the resident if he wanted to get up in his chair. Resident #13 told the surveyor he did not like to get up because it hurt when they got him up. Resident #13 stated he hurt when the staff turned him from side to side and the staff did that a lot. The surveyor asked the resident if his left arm hurt, and he said a lot. On 02/01/12 at 8:30 AM, the surveyor asked LVN B if she had administered Resident #13 pain medication. LVN B stated she administered Resident #13's Tylenol for pain this morning about 8:00 AM. The surveyor reviewed the MAR with LVN B, there was no assessment for pain documented on the MAR for the Tylenol. The surveyor asked LVN B why she did not monitor or assess Resident #13 for pain. LVN B stated Resident #13 was assessed for pain the first week he returned from the hospital and the staff stopped the daily pain assessments. LVN B stated she was aware the physician asked the nurses to monitor Resident #13 for pain. LVN B stated, "I cannot tell you why we are not assessing or monitoring the resident for pain." The surveyor asked LVN B why she did not assess Resident #13 for pain on 01/30/12 during the initial tour, when he said he was in pain and was yelling and grimacing. LVN B stated the first day during observation rounds, she forgot by the time the rounds were completed. She stated she was nervous because the surveyors were in the building and she was trying to remember what she had to do and what not to do. The surveyor asked LVN B why she did not give Resident #13 something for pain when the CNAs completed his incontinent care and reported to her the resident was having pain. LVN B stated she did not give the Tylenol because she thought Resident #13 told the staff everyday he was in pain. The surveyor asked LVN B if she did not assess the resident for pain how would she know the resident did not need a stronger medication for pain and how would she know if the Tylenol was effective. LVN B stated there was no way for her to determine if the Tylenol was effective because she did not assess pain or document pain assessments on Resident #13. On 02/01/12 at 9:00 AM, an interview was conducted with CNA E about Resident #13's pain during care. The surveyor asked CNA E if Resident #13 had pain when she provided assistance with his care or when she provided care to Resident #13. CNA E stated, "Resident #13 always hurt when I assisted with his care him and he screamed out 'Stop!'" The surveyor asked CNA E if she reported Resident #13's pain to the charge nurse, and CNA E stated she was sure the other CNA who helped her reported the pain and the resident's combativeness to the charge nurse. On 02/01/12 at 9:23 AM, an interview was conducted with CNA F regarding Resident #13's pain. The surveyor asked CNA F if she reported Resident #13's pain and combativeness during care to the charge nurse. CNA F stated she told LVN B Resident #13 was screaming out in pain, hitting and grabbing her arms and hands each time she tried to reposition him. CNA F stated she told LVN B Resident #13 said to leave him alone and they were hurting him. CNA F stated Resident #13 had never hit her like that before. CNA F stated since the residents re-admission from the hospital, he complained during his care that he was hurting, I reported the pain, but he never became combative. On 02/01/12 at 10:10 AM, the surveyor and LVN B accompanied Physician M, the wound care physician, to observe Resident #13's wounds and dressing changes. This was the first visit by Physician M to evaluate Resident #13's wounds. Physician M and LVN B removed Resident #13's dressing, and Resident #13 started saying, "Oh! Oh! Oh! That hurt!" Resident #13 was grimacing and yelling when the dressing was removed from his contracted fingers using a forcep like instrument. The physician with LVN B's assistance continued to remove the dressings on Resident #13's Pressure Ulcers and Resident #13 stated, "It hurt! Oh! Oh! Oh!" Resident #13 then made a fist and drew his right hand back and said it hurt. Physician M stepped back and said Resident #13 was in too much pain to continue and he needed pain medication before his dressings were completed. LVN B stated she gave the resident some Tylenol that morning. Physician M then stated Resident #13 needed something stronger than Tylenol. Physician M stated she would document the visit in Resident #13's clinical record and order him something stronger for pain. Physician M stated, "Give him the medication at least 30 minutes before his dressing change." LVN B stated she would finish his dressings and the surveyor pointed out the physician said to get the stronger medication first and then complete the dressing change. Physician M's order dated 02/01/12, for Resident #13 reflected, "[MEDICATION NAME] 5 mg PEG TID, [MEDICATION NAME] 5/325 one PEG Q 4-6 hrs PRN, [MEDICATION NAME] 0.5 mg PEG 30 minutes before wound dressing." LVN A and the surveyor reviewed the dates Resident #13 was checked for pain according to the Daily Skilled Nursing Notes. On 01/12/12, 01/13/12, 01/14/12, and 01/15/12 pain management was checked off as done. LVN A and the surveyor continued the review of Resident #13's clinical record and MAR. LVN A was not able to locate any documentation of pain assessments or pain monitoring for dates 01/17/12 through 02/01/12, except for 01/23/12. LVN A confirmed Resident #13 was not assessed for pain or monitored for pain from 01/17/12 through 02/01/12, except for 01/23/12. LVN A stated the nurses were supposed to be using the flow sheet form on the MAR "PRN Flowsheet for [MEDICATION NAME] and Other Medications" to document pain assessments and monitoring of pain. LVN A removed the form from the MAR and showed the surveyor. LVN A confirmed Resident #13's "PRN Flowsheet for [MEDICATION NAME] and Other Medications" form was blank and their were no pain assessments documented for the above dates. On 02/01/12 at 12:20 PM an interview was conducted with LVN A, who identified herself as the ADON in charge of station one where Resident #13 resided. She stated the facility did not have a DON. LVN A was asked about pain assessments and the monitoring of Resident #13's pain. LVN A stated it was the responsibility of the nurses to assess and monitor Resident #13 for pain and it was the nurses' responsibility to document their findings in the medical record. LVN A stated the pain was not monitored or assessed daily therefore there was no way to determine if Resident #13 was in pain. On 02/01/12 at 12:25 PM an interview was conducted with LVN B regarding pain assessments and documented monitoring of pain for Resident #13. LVN B stated she had not assessed Resident #13 for pain, she had not been monitoring him for pain and she had not documented a pain assessment. LVN B stated when Resident #13 was readmitted to the facility on [DATE], Physician N told the nurses to monitor the resident for pain and call him if Resident #13 needed a change in medication orders. LVN B provided the surveyor Resident #13's January 2012 MAR. Review of the MAR by the surveyor and LVN B revealed Tylenol [MEDICATION NAME] 650 mg per Peg Q 4 Hrs PRN was not administered during the month of January 2012. On 02/01/12 at 1:30 PM, the surveyor asked LVN A and LVN B if Resident #13's pain medication ordered by the wound physician had arrived LVN B stated, "No." On 02/01/12 at 2:15 PM, CNA I was interviewed regarding Resident #13's pain. The surveyor asked CNA I if Resident #13 had pain when the CNA provided care. CNA I stated since the resident returned from the hospital, for the last week or so he had complained of pain when his bed or briefs were changed. CNA I stated the resident's joints were probably hurting because he had bad contractures. An IJ was identified on 02/01/12 at 2:50 PM in the area of Resident Behavior/Facility Practice and the Administrator was informed at that time. A Plan of Removal for the IJ was requested at that time. On 02/01/12 at 3:15 PM, the Physician N, Resident #13's attending physician, returned the surveyor's telephone call regarding Resident #13's pain medication. Physician N stated Resident #13's [MEDICATION NAME] was discontinued at the hospital because the physician at the hospital did not think Resident #13 needed [MEDICATION NAME]. Physician N stated he did not reorder [MEDICATION NAME] for Resident #13 when he was re-admitted to the facility on [DATE]. Physician N stated he approved the Tylenol PRN for pain. He also stated he told the nurses to monitor Resident #13 for pain and if the resident needed an increase in pain medication to call him and he would take care of the issue. The surveyor told Physician N that Physician M saw Resident #13 around 10:00 AM with LVN B, and the resident's dressings were removed. The surveyor also informed Physician N that Physician M told LVN B Resident #13 was in so much pain, she could not continue the dressing change. The surveyor informed Physician N that the wound care physician stated she would write an order for [REDACTED]. Physician N stated he was aware Physician M was going to visit the resident. Physician N was also informed by the surveyor the pain medication ordered by Physician M had not been delivered yet. Physician N told the surveyor the nurses should have called him if Resident #13 was in pain. He also stated the nurses should have called him if they could not get the medication and he would have taken care of it right away. Physician N stated, "I will write an order now and get the medication to the facility." On 02/01/12 at 3:10 PM, LVN A stated she heard the surveyor interviewing staff yesterday afternoon during the 2:00 PM to 10:00 PM shift regarding Resident #13's pain and pain medication. LVN A stated she immediately in-serviced the evening staff on pain management and Resident #13's pain medication. On 02/01/12 at 3:45 PM, LVN A told the surveyor, "I am developing a care plan to address Resident #13's pain." Review of the accepted Plan of Removal, dated 02/01/12, revealed: 1. Resident #13's new order for pain medications was obtained from a local pharmacy on 02/01/12 at 4:00 PM. The resident was administered his pain medication immediately and assessed later to determine the effectiveness of the medication. The resident would be monitored for pain each shift. 2. All residents would be assessed for pain every shift and the assessment would be documented on the MAR starting 02/01/12. The physician would be notified by the charge nurse if there were findings of pain on assessment and current pain modalities, ordered pain medication and non-medical interventions were not effective. The numerical and Wong-Baker Scale would be used as an assessment tool to aide in the pain management assessment. 3. Pain would be monitored daily on each shift, during weekly, quarterly, annual, new admission, readmission and change of condition assessments by the charge nurse. 4. Nursing Management and/or Designee would monitor this by checking each halls' medication book for pain assessments on Mondays, Wednesdays and Fridays to ensure proper documentation and follow-up from the nursing staff. 5. Nursing Management would report to the Quality Assurance Committee monthly to evaluate the plan's effectiveness and make recommendations to the Medical Director, Administrator/designee as needed. 6. Charge nurses would notify the doctor of any increased pain or unrelieved pain for dosage changes as needed. 7. If medication was not available STAT, staff would notify the Administrator, Medical Director, and nurse manager on call for further action. 8. Staff was in-serviced on January 27th and January 31st and the education director would continue in-servicing nursing staff regarding pain management. 9. Nursing Staff would be re-in-serviced beginning February 1, 2012. 10. Quality Assurance Committee would meet monthly to evaluate the plan's effectiveness. On 02/01/12 at 4:00 PM, LVN A approached the surveyor and told the surveyor Resident #13 was administered Tylenol for pain at 3:30 PM until the pain medication ordered by Physician M was obtained from the pharmacy. LVN A told the surveyor he was not hurting now. On 02/01/12 at 5:00 PM, the surveyor observed Resident #13 in his bed, quiet and asleep. The resident did not awaken when the surveyor called his name. An interview was conducted with LVN P on 02/02/12 at 9:30 AM concerning pain management for Resident #17. LVN P stated Resident #17's pain medication was changed to [MEDICATION NAME] Sodium by the physician. LVN P stated she noticed Resident #17's pattern of pain occurred around noon and she notified the physician to change the [MEDICATION NAME] Sodium administration times to 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. An interview was conducted with ADON Q on 02/02/2012 at approximately 10:00 AM. ADON Q revealed in the past she had reviewed the resident's pain assessments on a quarterly basis in order to acquire accurate information for the MDS pain assessments. ADON Q stated she would now be reviewing the resident's pain assessments on a weekly basis. ADON Q revealed if she noticed a resident was not having adequate pain relief, or if the resident's pain assessment reflected the resident was experiencing an increase in pain, she would confer with the LVN to determine whether medication or alternative methods of pain relief were more appropriate. ADON Q revealed she would assess the resident and inform his/her physician about the need for increased pain control. An interview was conducted with LVN R on 02/02/2012 at approximately 12:30 PM. LVN R showed the surveyor new entries on the residents ' medication records under the heading "Pain Assessment." The assessments, timed for each eight hour shift, reflected "Daily pain assessment per scale 1:10. Pain scale prior to Rx. Pain scale after RX. Start date 02/01/12." LVN R revealed the residents' pain assessments were to be completed on each shift. LVN R revealed the facility was in-servicing all licensed staff regarding pain assessment and pain control. Resident #20's 01/23/2012 MDS assessment reflected the resident was cognitively intact and had no behavioral issues. On 01/30/3012 at approximately 10:25 AM ADON Q revealed Resident #20 had a [MEDICAL CONDITION] which could not be surgically repaired. Interview with Resident #20 on 02/02/2012 at approximately 1:30 PM revealed the resident did not have any problems with pain control. Resident #20 stated his doctor had ordered pain medication to be given to him routinely. Resident #20 stated he had medicine ordered if he had pain in between his routine doses but said he rarely needed it. Resident #19 ' s 11/29/2011 MDS assessment reflected the resident was cognitively intact and had no behavioral issues. On 01/30/2012 at approximately 9:05 AM LVN S revealed Resident #19 was primarily bedbound and rarely got out of bed into her Geri-chair. Interview with Resident #19 on 02/02/2012 at approximately 1:45 PM revealed her pain was well controlled. Resident #19 stated she had scheduled pain medications and they relieved her pain most of the time. Resident #19 said if she had pain in between the times her pain medications were scheduled she used her call light and called the nurse. Resident #19 said the nurses were very good about answering her call light and bringing her pain medicine if it was time for her to have it. While the IJ was removed on 02/02/12, the facility remained out of compliance at a scope of "pattern" and severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. The Administrator and the Regional Director of Operations were informed on 02/02/12 at 10:49 AM that the IJ was removed. The CMS form 672, Resident Census and Conditions of Residents, dated 01/30/12 and signed by the Medicare Specialist reflected 55 residents were on pain management. Resident #13 returned to the facility from the hospital with multiple Pressure Ulcers and he had contractures on one side of his body. The nurses had a physician's orders [REDACTED]. Resident #13 was seen during the provision of wound care, incontinent care, and care/repositioning. During those times, Resident #13 was screaming out in pain, grimacing, grunting, grabbing a CNA's wrist, grabbing the CNAs clothing and clenching his fist. The nurses did not provide Resident #13 with pain medication (Tylenol), they did not assess the resident for pain during those times and they did not inform the physician of the intensity of the pain. Physician M stopped the resident's wound care due to the severity of his pain. An Immediate Jeopardy (IJ) was identified on 02/01/12 at 2:50 PM. While the IJ was removed on 02/02/12, the facility remained out of compliance at a scope of "pattern" and severity level of "actual harm that was not immediate jeopardy" because the facility was still monitoring the Plan of Removal. These failures caused Resident #13 to be in undue, extreme pain during care and delayed his wound care treatments. These failures could affect the 55 residents, who were on a pain medications at risk for unnecessary pain, not having effective pain medication and a decline in their overall well-being. Findings included: The facility's current, undated Abuse Prevention Policy and Procedure reflected, "(name) strives to keep its facility free from neglect...Staff members will identify and assess suspected or alleged reports of abuse or neglect...E. Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... Employees are educated that they must report any suspicious event that may constitute abuse or neglect...1. The facility's administrator and/or designee conducts an internal investigation...2. The facility investigates all alleged violations and, when indicated, takes appropriate actions...3. (name) analyzes all occurrences to determine what change or changes are needed, if any, to the facility's policies and procedures to prevent further occurrences. 4. (name) conducts self-audits of its own processes to ensure all requirements of policies and procedures are followed...WHAT IS NEGLECT: This is the failure or refusal to fulfill any part of a person's obligation or duties to a resident. Necessities such as food, water, and safety. This may also include situations in which residents are being left to lie in feces or urine or failure to answer call lights in a timely manner...Passive: Occurs when a person fails to fulfill their obligation unintentionally or unconsciously inflicting distress in (sic) a resident. A caregiver may not knowingly ignore a resident when care is needed, resulting in harm in the resident...SIGNS AND SYMPTOMS OF ABUSE AND NEGLECT ...Emotional upset or agitation Unattended health problems...." Review of Resident #13's MDS assessment dated [DATE] revealed Resident #13 was an [AGE] year-old male, admitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted on [DATE]. The assessment reflected the resident had short and long-term memory problems, and his cognitive skills for daily decision-making were severely impaired. The MDS assessment also reflected he was incontinent of bowel and bladder, needed extensive assistance for toilet use and was totally dependent on staff for bathing. Resident #13's MDS assessment reflected [DIAGNOSES REDACTED]. Resident #13's Care Plan dated 11/23/11 reflected he had contractures and limited ROM in his left upper and lower extremities. The approaches on the care plan were ROM program five times a week by the RA, offer pain medication to assist in ROM exercises and ROM daily with care by the CNAs. Resident #13's Nurse's Notes dated 01/11/12 reflected the resident had a sore on his left great toe, a red, bloody blister on the lower side of the toe, and a Stage II and Stage III on his left fingers between his fingers. Review of Resident #13's Acute Care Plans/Skin Integrity Alteration dated 01/11/12 revealed he had a Stage I Pressure Ulcer between his thumb and pointer finger, had a blister on his left great toe, a Stage II Pressure Ulcer on his left great toe, and a Pressure Ulcer between his second and third finger. The approaches included in the Acute Care Plans were apply skin treatment to affected areas as ordered, assess resident for

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being for one (Resident #13) of 17 residents reviewed for pain management. The facility failed to assess Resident #13's pain and consult with his physician regarding the resident's pain as his Care Plans for ROM and Pressure Ulcers indicated. A physician's orders [REDACTED]. During the provision of wound care, incontinent care, and care/repositioning, Resident #13 was screaming out in pain, grimacing, grunting, grabbing a CNA's wrist, grabbing the CNAs' clothing and clenching his fist. An Immediate Jeopardy (IJ) was identified on 02/01/12 at 2:50 PM. While the IJ was removed on 02/02/12, the facility remained out of compliance at a scope of "pattern" and severity level of "actual harm that was not immediate jeopardy" because the facility was still implementing and monitoring the Plan of Removal. These failures caused Resident #13 to be in undue, extreme pain during care and delayed his wound care treatments, which could result in delayed healing and placed the resident at risk for depression and a poor quality of life. These failures could affect the 55 residents, who were on pain management, and placed them at risk for experiencing unnecessary pain, being administered ineffective pain medication and result in a decline in their overall well-being and quality of care. Findings included: Review of Resident #13's MDS assessment dated [DATE] revealed Resident #13 was an [AGE] year-old male, admitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted on [DATE]. The assessment reflected the resident had short and long-term memory problems, and his cognitive skills for daily decision-making were severely impaired. The MDS assessment also reflected he was incontinent of bowel and bladder, needed extensive assistance for toilet use and was totally dependent on staff for bathing. Resident #13's MDS assessment reflected [DIAGNOSES REDACTED]. Resident #13's Care Plan dated 11/23/11 reflected he had contractures and limited ROM in his left upper and lower extremities. The approaches on the care plan were ROM program five times a week by the RA, offer pain medication to assist in ROM exercises and ROM daily with care by the CNAs. Resident #13's Nurse's Notes dated 01/11/12 reflected the resident had a sore on his left great toe, a red, bloody blister on the lower side of the toe, and a Stage II and Stage III on his left fingers between his fingers. Review of Resident #13's Acute Care Plans/Skin Integrity Alteration dated 01/11/12 revealed he had a Stage I Pressure Ulcer between his thumb and pointer finger, had a blister on his left great toe, a Stage II Pressure Ulcer on his left great toe, and a Pressure Ulcer between his second and third finger. The approaches included in the Acute Care Plans were apply skin treatment to affected areas as ordered, assess resident for pain and discomfort related to skin alteration, medicate resident for pain as ordered for comfort, administer medications as ordered by the physician, notify the physician of treatment or medications ordered that were not effective, and caution with reposition and transfers. Resident #13's Restorative Program Flow Sheet dated 01/21/12 through 01/28/12 revealed, "Perform passive range of motion to left hand, soak hand in warm water, contracture will have more joint movement in next 30 days." During the initial tour on Station One, on 01/30/12 at 10:15 AM with the assistance of LVN B, Resident #13 was observed with a contracture to his leg, drawn up to his hip, and unable to extend and his left arm was contracted along with his fingers. The resident said hello, when he was addressed. The surveyor asked LVN B to check Resident #13 to see if he was dry. LVN B donned her gloves and asked Resident #13 if she could check to see if he was dry. Resident #13 said ok. LVN B turned Resident #13 to check his brief and Resident #13 screamed out and said, "Oh! Oh that hurts!" Resident #13 was grimacing and grunting. LVN B told the surveyor Resident #13 required two persons and she requested a CNA to assist. When the CNA and LVN B attempted to remove Resident #13's brief, he screamed out, "That hurts!" Resident #13 continued grimacing and grunting. His brief was wet and the LVN assisted the resident back into his original position. The surveyor asked LVN B if resident #13 had medication ordered for his pain. LVN B stated Resident #13 had routine [MEDICATION NAME] (narcotic) for pain and routine [MEDICATION NAME] for joint pain prior to his hospital visit. She stated he returned to the facility about two to three weeks ago and the physician did not re-order his [MEDICATION NAME] or [MEDICATION NAME]. LVN B further stated, "His doctor ordered Tylenol for his pain, and told the nurses to monitor Resident #13's pain." The surveyor told LVN B Resident #13 sounded like he was really in pain. LVN B told the surveyor she would get the CNAs to provide incontinent care to Resident #13. LVN B did not acknowledge Resident #13's grimacing, grunting or his yelling in pain. Review of Resident #13's physician's orders [REDACTED].#13 was routinely administered via [DEVICE] [MEDICATION NAME]/APAP ([MEDICATION NAME]) 7.5/325 mg tablet one tab per G/T every HS and administered via [DEVICE] [MEDICATION NAME] ([MEDICATION NAME]) 10 mg tablet one tablet per G/T TID. Review of Resident #13's re-admission physician's orders [REDACTED]. An observation on 01/31/12 at 10:30 AM revealed CNA E and CNA F providing incontinent care provided to Resident #13. Resident #13 was incontinent of bowel. CNA E stood on Resident #13's left side and CNA F stood on the resident's right side. The CNAs removed the resident's soiled brief and the soiled draw sheet by turning the resident to his right side and then to his left side. Resident #13 started screaming, "Oh! Oh! That hurt." The CNAs placed a clean draw sheet under Resident #13 and the resident stated, "Oh my leg hurt!" The CNAs continued with the incontinent care. The CNAs turned Resident #13 onto his back and the resident while grimacing started screaming "Oh! Oh! You are hurting me!" Resident #13 also grabbed CNA F's wrist and both CNAs had to stop and pry the resident's hand from around CNA F's wrist. The resident continued to tell the CNAs he was hurting. CNA F stated, "He has never been this upset." CNA F and CNA E rolled Resident #13 onto his right side, and the resident stop screaming. Resident #13 started grabbing CNA F's wrist, pulling at CNA E and CNA F's clothing and telling them they were hurting him. The CNAs then placed a clean brief under Resident #13 and told the resident they had completed his care. Resident #13 again told the CNAs he was hurting. The CNAs then took a tube of [MEDICATION NAME] from the table and applied it to his buttocks, and Resident #13 screamed out and hit at the CNAs saying, "That hurts! You told me you had finished! You lied! My right leg hurts!" The CNAs completed the care and left the room. CNA F stated she was going to tell the charge nurse Resident #13 needed something for pain and something to settle him down. Review of Resident #13's Nurse's Notes dated 01/31/12 revealed: "11:00 AM Notified by CNA F that Resident #13 was combative R/T (ADON interpreted this R-T as possible "related to") to pain while repositioning. Physician at facility notified received orders to continue with PRN Tylenol orders." The entry was signed by LVN B. Review of Resident #13's physician's orders [REDACTED]." Review of Resident #13's Nurses Notes for 01/31/12 and the MAR dated January 2012 revealed LVN B did not administer Resident #13's pain medication after calling the physician to report the resident's pain. There was not a pain assessment for Resident #13 regarding the pain he experienced on 01/31/12 during incontinent care in the resident's clinical record. An interview was conducted on 01/31/12 at 2:10 PM with RA G concerning pain medication for Resident #13 during ROM. The surveyor asked RA G if Resident #13 complained of pain when he provided the ROM to his left hand and left foot. RA G stated when he did Resident #13's exercises, the resident cried and said it hurt. The surveyor asked RA G if Resident #13 received anything for pain prior to the ROM exercises and the RA stated, "I do not know. Ask the nurse." The surveyor asked RA G if he reported to the nurse Resident #13's pain during the ROM and RA G did not answer. On 01/31/12 at 2:15 PM an interview was conducted with LVN J, Resident #13's Charge Nurse for the 2:00 PM to 10:00 PM shift, about Resident #13's ROM and his pain medication. The surveyor asked LVN J if she offered pain medication to Resident #13 prior to his ROM exercises. LVN J stated, "What ROM?" The surveyor explained to LVN J ROM was care planned for Resident #13. The surveyor told LVN J RA G stated he provided the ROM on the 2:00 PM to 10:00 PM shift. LVN J stated Resident #13's pain medication was PRN and not routine. The surveyor asked LVN J if she offered Resident #13 his pain medication before he was provided ROM. LVN J stated she did not provide Resident #13 pain medication for ROM because his Tylenol was "PRN" and Resident #13 had to ask for the medication. The surveyor asked LVN J did she assess the resident for pain to determine if he needed the PRN Tylenol prior to ROM. LVN J stated no, she was not aware Resident #13 had ROM ordered. On 01/31/12 at 3: 50 PM, an interview was conducted with Resident #13 concerning his care in the facility. The surveyor asked Resident #13 how felt, and the resident replied ok now. The Surveyor asked the resident if he wanted to get up in his chair. Resident #13 told the surveyor he did not like to get up because it hurt when they got him up. Resident #13 stated he hurt when the staff turned him from side to side and the staff did that a lot. The surveyor asked the resident if his left arm hurt, and he said a lot. On 02/01/12 at 8:30 AM, the surveyor asked LVN B if she had administered Resident #13 pain medication. LVN B stated she administered Resident #13's Tylenol for pain this morning about 8:00 AM. The surveyor reviewed the MAR with LVN B, there was no assessment for pain documented on the MAR for the Tylenol. The surveyor asked LVN B why she did not monitor or assess Resident #13 for pain. LVN B stated Resident #13 was assessed for pain the first week he returned from the hospital and the staff stopped the daily pain assessments. LVN B stated she was aware the physician asked the nurses to monitor Resident #13 for pain. LVN B stated, "I cannot tell you why we are not assessing or monitoring the resident for pain." The surveyor asked LVN B why she did not assess Resident #13 for pain on 01/30/12 during the initial tour, when he said he was in pain and was yelling and grimacing. LVN B stated the first day during observation rounds, she forgot by the time the rounds were completed. She stated she was nervous because the surveyors were in the building and she was trying to remember what she had to do and what not to do. The surveyor asked LVN B why she did not give Resident #13 something for pain when the CNAs completed his incontinent care and reported to her the resident was having pain. LVN B stated she did not give the Tylenol because she thought Resident #13 told the staff everyday he was in pain. The surveyor asked LVN B if she did not assess the resident for pain how would she know the resident did not need a stronger medication for pain and how would she know if the Tylenol was effective. LVN B stated there was no way for her to determine if the Tylenol was effective because she did not assess pain or document pain assessments on Resident #13. On 02/01/12 at 9:00 AM, an interview was conducted with CNA E about Resident #13's pain during care. The surveyor asked CNA E if Resident #13 had pain when she provided assistance with his care or when she provided care to Resident #13. CNA E stated, "Resident #13 always hurt when I assisted with his care him and he screamed out 'Stop!'" The surveyor asked CNA E if she reported Resident #13's pain to the charge nurse, and CNA E stated she was sure the other CNA who helped her reported the pain and the resident's combativeness to the charge nurse. On 02/01/12 at 9:23 AM, an interview was conducted with CNA F regarding Resident #13's pain. The surveyor asked CNA F if she reported Resident #13's pain and combativeness during care to the charge nurse. CNA F stated she told LVN B Resident #13 was screaming out in pain, hitting and grabbing her arms and hands each time she tried to reposition him. CNA F stated she told LVN B Resident #13 said to leave him alone and they were hurting him. CNA F stated Resident #13 had never hit her like that before. CNA F stated since the residents re-admission from the hospital, he complained during his care that he was hurting, I reported the pain, but he never became combative. On 02/01/12 at 10:10 AM, the surveyor and LVN B accompanied Physician M, the wound care physician, to observe Resident #13's wounds and dressing changes. This was the first visit by Physician M to evaluate Resident #13's wounds. Physician M and LVN B removed Resident #13's dressing, and Resident #13 started saying, "Oh! Oh! Oh! That hurt!" Resident #13 was grimacing and yelling when the dressing was removed from his contracted fingers using a forcep like instrument. The physician with LVN B's assistance continued to remove the dressings on Resident #13's Pressure Ulcers and Resident #13 stated, "It hurt! Oh! Oh! Oh!" Resident #13 then made a fist and drew his right hand back and said it hurt. Physician M stepped back and said Resident #13 was in too much pain to continue and he needed pain medication before his dressings were completed. LVN B stated she gave the resident some Tylenol that morning. Physician M then stated Resident #13 needed something stronger than Tylenol. Physician M stated she would document the visit in Resident #13's clinical record and order him something stronger for pain. Physician M stated, "Give him the medication at least 30 minutes before his dressing change." LVN B stated she would finish his dressings and the surveyor pointed out the physician said to get the stronger medication first and then complete the dressing change. Physician M's order dated 02/01/12, for Resident #13 reflected, "[MEDICATION NAME] 5 mg PEG TID, [MEDICATION NAME] 5/325 one PEG Q 4-6 hrs PRN, [MEDICATION NAME] 0.5 mg PEG 30 minutes before wound dressing." LVN A and the surveyor reviewed the dates Resident #13 was checked for pain according to the Daily Skilled Nursing Notes. On 01/12/12, 01/13/12, 01/14/12, and 01/15/12 pain management was checked off as done. LVN A and the surveyor continued the review of Resident #13's clinical record and MAR. LVN A was not able to locate any documentation of pain assessments or pain monitoring for dates 01/17/12 through 02/01/12, except for 01/23/12. LVN A confirmed Resident #13 was not assessed for pain or monitored for pain from 01/17/12 through 02/01/12, except for 01/23/12. LVN A stated the nurses were supposed to be using the flow sheet form on the MAR "PRN Flowsheet for [MEDICATION NAME] and Other Medications" to document pain assessments and monitoring of pain. LVN A removed the form from the MAR and showed the surveyor. LVN A confirmed Resident #13's "PRN Flowsheet for [MEDICATION NAME] and Other Medications" form was blank and their were no pain assessments documented for the above dates. On 02/01/12 at 12:20 PM an interview was conducted with LVN A, who identified herself as the ADON in charge of station one where Resident #13 resided. She stated the facility did not have a DON. LVN A was asked about pain assessments and the monitoring of Resident #13's pain. LVN A stated it was the responsibility of the nurses to assess and monitor Resident #13 for pain and it was the nurses' responsibility to document their findings in the medical record. LVN A stated the pain was not monitored or assessed daily therefore there was no way to determine if Resident #13 was in pain. On 02/01/12 at 12:25 PM an interview was conducted with LVN B regarding pain assessments and documented monitoring of pain for Resident #13. LVN B stated she had not assessed Resident #13 for pain, she had not been monitoring him for pain and she had not documented a pain assessment. LVN B stated when Resident #13 was readmitted to the facility on [DATE], Physician N told the nurses to monitor the resident for pain and call him if Resident #13 needed a change in medication orders. LVN B provided the surveyor Resident #13's January 2012 MAR. Review of the MAR by the surveyor and LVN B revealed Tylenol [MEDICATION NAME] 650 mg per Peg Q 4 Hrs PRN was not administered during the month of January 2012. On 02/01/12 at 1:30 PM, the surveyor asked LVN A and LVN B if Resident #13's pain medication ordered by the wound physician had arrived LVN B stated, "No." On 02/01/12 at 2:15 PM, CNA I was interviewed regarding Resident #13's pain. The surveyor asked CNA I if Resident #13 had pain when the CNA provided care. CNA I stated since the resident returned from the hospital, for the last week or so he had complained of pain when his bed or briefs were changed. CNA I stated the resident's joints were probably hurting because he had bad contractures. The facility's current, undated Abuse Prevention Policy and Procedure reflected, "(name) strives to keep its facility free from neglect...Staff members will identify and assess suspected or alleged reports of abuse or neglect...E. Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... Employees are educated that they must report any suspicious event that may constitute abuse or neglect...1. The facility's administrator and/or designee conducts an internal investigation...2. The facility investigates all alleged violations and, when indicated, takes appropriate actions...3. (name) analyzes all occurrences to determine what change or changes are needed, if any, to the facility's policies and procedures to prevent further occurrences. 4. (name) conducts self-audits of its own processes to ensure all requirements of policies and procedures are followed...WHAT IS NEGLECT: This is the failure or refusal to fulfill any part of a person's obligation or duties to a resident. Necessities such as food, water, and safety. This may also include situations in which residents are being left to lie in feces or urine or failure to answer call lights in a timely manner...Passive: Occurs when a person fails to fulfill their obligation unintentionally or unconsciously inflicting distress in (sic) a resident. A caregiver may not knowingly ignore a resident when care is needed, resulting in harm in the resident...SIGNS AND SYMPTOMS OF ABUSE AND NEGLECT ...Emotional upset or agitation Unattended health problems...." An IJ was identified on 02/01/12 at 2:50 PM in the area of Quality of Care and the Administrator was informed at that time. A Plan of Removal for the IJ was requested at that time. On 02/01/12 at 3:15 PM, the Physician N, Resident #13's attending physician, returned the surveyor's telephone call regarding Resident #13's pain medication. Physician N stated Resident #13's [MEDICATION NAME] was discontinued at the hospital because the physician at the hospital did not think Resident #13 needed [MEDICATION NAME]. Physician N stated he did not reorder [MEDICATION NAME] for Resident #13 when he was re-admitted to the facility on [DATE]. Physician N stated he approved the Tylenol PRN for pain. He also stated he told the nurses to monitor Resident #13 for pain and if the resident needed an increase in pain medication to call him and he would take care of the issue. The surveyor told Physician N that Physician M saw Resident #13 around 10:00 AM with LVN B, and the resident's dressings were removed. The surveyor also informed Physician N that Physician M told LVN B Resident #13 was in so much pain, she could not continue the dressing change. The surveyor informed Physician N that the wound care physician stated she would write an order for [REDACTED]. Physician N stated he was aware Physician M was going to visit the resident. Physician N was also informed by the surveyor the pain medication ordered by Physician M had not been delivered yet. Physician N told the surveyor the nurses should have called him if Resident #13 was in pain. He also stated the nurses should have called him if they could not get the medication and he would have taken care of it right away. Physician N stated, "I will write an order now and get the medication to the facility." On 02/01/12 at 3:10 PM, LVN A stated she heard the surveyor interviewing staff yesterday afternoon during the 2:00 PM to 10:00 PM shift regarding Resident #13's pain and pain medication. LVN A stated she immediately in-serviced the evening staff on pain management and Resident #13's pain medication. On 02/01/12 at 3:45 PM, LVN A told the surveyor, "I am developing a care plan to address Resident #13's pain." Review of the accepted Plan of Removal, dated 02/01/12, revealed: 1. Resident #13's new order for pain medications was obtained from a local pharmacy on 02/01/12 at 4:00 PM. The resident was administered his pain medication immediately and assessed later to determine the effectiveness of the medication. The resident would be monitored for pain each shift. 2. All residents would be assessed for pain every shift and the assessment would be documented on the MAR starting 02/01/12. The physician would be notified by the charge nurse if there were findings of pain on assessment and current pain modalities, ordered pain medication and non-medical interventions were not effective. The numerical and Wong-Baker Scale would be used as an assessment tool to aide in the pain management assessment. 3. Pain would be monitored daily on each shift, during weekly, quarterly, annual, new admission, readmission and change of condition assessments by the charge nurse. 4. Nursing Management and/or Designee would monitor this by checking each halls' medication book for pain assessments on Mondays, Wednesdays and Fridays to ensure proper documentation and follow-up from the nursing staff. 5. Nursing Management would report to the Quality Assurance Committee monthly to evaluate the plan's effectiveness and make recommendations to the Medical Director, Administrator/designee as needed. 6. Charge nurses would notify the doctor of any increased pain or unrelieved pain for dosage changes as needed. 7. If medication was not available STAT, staff would notify the Administrator, Medical Director, and nurse manager on call for further action. 8. Staff was in-serviced on January 27th and January 31st and the education director would continue in-servicing nursing staff regarding pain management. 9. Nursing Staff would be re-in-serviced beginning February 1, 2012. 10. Quality Assurance Committee would meet monthly to evaluate the plan's effectiveness. On 02/01/12 at 4:00 PM, LVN A approached the surveyor and told the surveyor Resident #13 was administered Tylenol for pain at 3:30 PM until the pain medication ordered by Physician M was obtained from the pharmacy. LVN A told the surveyor he was not hurting now. On 02/01/12 at 5:00 PM, the surveyor observed Resident #13 in his bed, quiet and asleep. The resident did not awaken when the surveyor called his name. An interview was conducted with LVN P on 02/02/12 at 9:30 AM concerning pain management for Resident #17. LVN P stated Resident #17's pain medication was changed to [MEDICATION NAME] Sodium by the physician. LVN P stated she noticed Resident #17's pattern of pain occurred around noon and she notified the physician to change the [MEDICATION NAME] Sodium administration times to 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. An interview was conducted with ADON Q on 02/02/2012 at approximately 10:00 AM. ADON Q revealed in the past she had reviewed the resident's pain assessments on a quarterly basis in order to acquire accurate information for the MDS pain assessments. ADON Q stated she would now be reviewing the resident's pain assessments on a weekly basis. ADON Q revealed if she noticed a resident was not having adequate pain relief, or if the resident's pain assessment reflected the resident was experiencing an increase in pain, she would confer with the LVN to determine whether medication or alternative methods of pain relief were more appropriate. ADON Q revealed she would assess the resident and inform his/her physician about the need for increased pain control. An interview was conducted with LVN R on 02/02/2012 at approximately 12:30 PM. LVN R showed the surveyor new entries on the residents ' medication records under the heading "Pain Assessment." The assessments, timed for each eight hour shift, reflected "Daily pain assessment per scale 1:10. Pain scale prior to Rx. Pain scale after RX. Start date 02/01/12." LVN R revealed the residents' pain assessments were to be completed on each shift. LVN R revealed the facility was in-servicing all licensed staff regarding pain assessment and pain control. Resident #20's 01/23/2012 MDS assessment reflected the resident was cognitively intact and had no behavioral issues. On 01/30/3012 at approximately 10:25 AM ADON Q revealed Resident #20 had a [MEDICAL CONDITION] which could not be surgically repaired. Interview with Resident #20 on 02/02/2012 at approximately 1:30 PM revealed the resident did not have any problems with pain control. Resident #20 stated his doctor had ordered pain medication to be given to him routinely. Resident #20 stated he had medicine ordered if he had pain in between his routine doses but said he rarely needed it. Resident #19 ' s 11/29/2011 MDS assessment reflected the resident was cognitively intact and had no behavioral issues. On 01/30/2012 at approximately 9:05 AM LVN S revealed Resident #19 was primarily bedbound and rarely got out of bed into her Geri-chair. Interview with Resident #19 on 02/02/2012 at approximately 1:45 PM revealed her pain was well controlled. Resident #19 stated she had scheduled pain medications and they relieved her pain most of the time. Resident #19 said if she had pain in between the times her pain medications were scheduled she used her call light and called the nurse. Resident #19 said the nurses were very good about answering her call light and bringing her pain medicine if it was time for her to have it. While the IJ was removed on 02/02/12, the facility remained out of compliance at a scope of "pattern" and severity level of "actual harm that is not immediate jeopardy," because the facility was still implementing and monitoring the Plan of Removal. The Administrator and the Regional Director of Operations were informed on 02/02/12 at 10:49 AM the IJ was removed. The CMS form 672, Resident Census and Conditions of Residents, dated 01/30/12 and signed by the Medicare Specialist reflected 55 residents were on pain management.