Every finding on record at Avir at Houston

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #1, Resident#2, and Resident #3) and 1of 3 staff (MA B). MA B failed to wash or sanitize hands between administering medications to Resident #1, Resident #2, and Resident #3 on 7/9/26 during medication administration. These failures could place residents at risk for spread of infection, cross contamination, and decrease in quality of life. Findings Included:Resident #1Review of Resident #1's admission assessment dated [DATE] reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, cough, pain, essential (primary) hypertension ( high blood pressure), low potassium, Alzheimer's disease with early onset (a progressive brain disease that slowly destroys memory, thinking skills and the ability to carry out simple daily tasks) anorexia (an eating disorder and mental health condition characterized by severe food restriction an intense fear of gaining weight and a distorted body image), personal history of transient ischemic attack ( occurs when blood flow to a part of the brain, spinal cord, or retina temporarily stops, depriving the tissue of oxygen), and cerebral infarction ( the necrosis) of brain tissue caused by a prolonged lack of blood flow without residual deficits), (personal history of malignant neoplasm (cancerous tumor) of breast. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. She needed extensive help from 1 staff with ADLs, and limited assistance with eating. Resident #2Review of Resident #2's admission assessment 7/9/26 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, fatigue, gangrene (death of body tissue), aphasia (difficulty communicating), chest pain, shortness of breath, low potassium, and essential (primary) hypertension (high blood pressure). Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score that was blank indicating severe cognitive impairment. She needed extensive help from 1 staff with ADLs, and limited assistance with eating. Resident #3Review of Resident #3's admission assessment 7/9/26 reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, osteoarthritis, heart failure, constipation, gastro-esophageal reflux disease without esophagitis, and morbid (severe) obesity due to excess calories.Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score was of 10 indicating moderate cognitive impairment.Observation on 7/9/26 at 10:15 a.m. revealed Resident #1 was sitting up in bed in her room. At 10:20 a.m. MA B administered 3 medications and Med Pass supplement to Resident #1 by mouth, then moved medication cart to and did not wash or sanitizer her hands before administering medication to Resident #2. MA B did not wash or sanitize her hands before administering medications to Resident #3.Interview with MA B on 7/9/26 at 11:30AM, regarding hand washing and using hand sanitizer in-between residents, she said she was nervous and she forgot. MA B said she had in-services about hand washing to prevent infection every month at least bi-weekly.During an interview on 07/9/26 at 4:02 p.m., the DON said staff should wash or sanitize her hands before leaving the resident's room, to prevent cross contamination and spread of germs.Record review of the facility policy on handwashing/hand hygiene date MED-PASS, Inc Rrevised October 2023 read in part, .tThis facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections.administrative practices to promote hand hygiene #3.hand hygiene products and supplies (soap, towel. ).indication for hand hygiene 1 a. immediately before touching a resident, 1b. before performing an aseptic task. 1f. before moving from a soiled body site to a clean body site on the same resident, 1g. immediately after glove removal.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7%, based on 2 errors out of 26 opportunities, which involved 2 of 6 residents (Residents #1 and #2) and 1 of 2 staff (MA B) reviewed for medication errors, in that: -MA B failed to administer medication Potassium Chloride ER (Extended Release is a prescription mineral supplement used to treat or prevent low potassium levels in the blood, ER medications the tablet or capsule is designed to dissolve slowly releasing a steady, controlled amount of potassium over several hours. Potassium is an essential mineral that your body uses to keep your heart beating regularly, your muscles moving properly and your nerves communicating is a vital mineral and electrolyte that carries an electrical charge, allowing the body to function) to Resident #1 according to the physician's order and pharmacy recommendation on 7/9/26. - MA B failed to administer medication Potassium Chloride ER to Resident #2 according to the physician's order and pharmacy recommendation on 7/9/26.These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Resident #1 Review of Resident #1's admission assessment [VT19.1]7/9/26 reflected she was an [AGE] year old[AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, cough, pain, essential (primary) hypertension ( high blood pressure), low potassium, Alzheimer's disease with early onset (a progressive brain disease that slowly destroys memory, thinking skills and the ability to carry out simple daily tasks) anorexia ( an eating disorder and mental health condition characterized by severe food restriction an intense fear of gaining weight and a distorted body image),), [VT20.1]personal history of transient ischemic attack ( occurs when blood flow to a part of the brain, spinal cord, or retina temporarily stops, depriving the tissue of oxygen), and cerebral infarction ( the necrosis) of brain tissue caused by a prolonged lack of blood flow without residual deficits), (personal history of malignant neoplasm (cancerous tumor) of breast. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. She needed extensive help from 1 staff with ADLs, and limited assistance with eating. Record review of Resident #1's care plan on dated 5/27/26 read revealed in part: Extended Release (Potassium Chloride) . Intervention . give Potassium Chloride ER as ordered by physician . Record review of Resident #1's physician's orders for dated 12/22/24 read revealed in part: . Potassium Chloride Extended Release 20 MEQ. Give 1 tablet by mouth one time a day for MINERAL . Record review of Resident #1's Medication Administration Record (MAR) dated July 2026 had revealed Oral Tablet Extended Release 20 MEQ (Potassium Chloride) Give 1 tablet by mouth one time a day for MINERAL. Record review of facility's medication scheduled every day /once daily reflected, it should be administered at 9AM. Observation on 7/9/26 at 10:15 AM, during medication administration revealed. MA B picked up Potassium Chloride Extended Release 20 MEQ blister packet and punched it one tablet into medication cup. Blister packet had highlighted Swallow Whole Do not Chew Or Crush. MA B then added and other medications (Amlodipine and Calcium) and crushed all medications and mixed it them in yogurt and administered this to Resident #1 by mouth. Resident #2Review of Resident #2's admission assessment [VT21.1]7/9/26 reflected she was a [AGE] year old[AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, fatigue, gangrene (death of body tissue), aphasia (difficulty communicating), chest pain, shortness of breath, low potassium essential (primary) hypertension (high blood pressure).Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score was blank indicating severe cognitive impairment. She needed extensive help from 1 staff with ADLs, and limited assistance with eating. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score was blank indicating severe cognitive impairment.She needed extensive help from 1 staff with ADLs, and limited assistance with eating. Record review of Resident #2's care plan on dated 6/27/26 read revealed in part . diagnosis of low potassium . Intervention . give Potassium Chloride medications as ordered . Record review of Resident #2's physician's orders for dated 3/20/2026 read revealed in part: . Potassium Chloride ER 10 meq, Give 10 meq by mouth one time a day for low potassium . Record review of Resident #2's Medication Administration Record (MAR) dated July 2026 had revealed Potassium Chloride ER 10 meq by mouth every day. Observation and interview on 7/9/26 at 10:35 AM, during medication administration. revealed MA B picked up Potassium Chloride Extended Release 10 MEQ blister packet and punched it out one tablet into medication cup. Blister packet had highlighted Swallow Whole Do not Chew Or Crush . MA B then added and other medications (Eliquis and Metoprolol) and crushed all medications and mixed it them in yogurt. MA B stopped before administering the medication to Resident #2 to check Potassium blister packet after surveyor intervention to read the packet to see if the medication was to be crushed or not, MA B said Potassium 10 meq was given once daily. MA B was shown the highlighted sign on the blister pack which read Swallow Whole Do not Chew Or Crush MA B said [Resident #2] cannot swallow Potassium 10 meq whole, and MA B continued to administer the potassium to Resident #2 by mouth. Interview on 7/9/26 at 11:20 a.m. with MA B regarding not following pharmacy recommendation and notifying the charge nurse on changing Potassium tablet to liquid. MA B said she did not check the blister packet highlighted sign on the Potassium blister packet do not crush or chew, MA B said she will be careful. MA B said crushing Resident #1 and Resident #2's potassium would not work as it should in their blood. Interview with DON on 7/9/26 at 4:00 PM regarding Resident #1 and Resident #2's Potassium ER crushed. DON said she was not aware of it. DON said she was going notify the doctor for start Potassium blood level lab work to be done. DON said she would start in-services to all staff and call the doctor changed to change Potassium tablet to liquid. Record Review of facility's policy Medication Administration Procedures with revised date of April 2019 revealed .4. Medications are administered in accordance with prescriber orders, including any required time frame.5.Medication administration times are determined by resident need and benefit, not staff convenience. Factor that are considered include:a. enhancing optimal therapeutic effect of the medication,b. preventing potential medication or food interactions.10. The individual administering the medication checks the label THREE(3) times to verify right resident, of medication should always be adhered to which includes the right medication, right dosage, right time and right method (route) of administration before giving the medication and the right dose.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents were free of significant medication errors for 2 (Resident #1 and Resident #2) of 6 residents reviewed for pharmacy services.MA B failed to administer medication Potassium Chloride ER (Extended Release is a prescription mineral supplement used to treat or prevent low potassium levels in the blood, ER medications the tablet or capsule is designed to dissolve slowly releasing a steady, controlled amount of potassium over several hours. Potassium is an essential mineral that your body uses to keep your heart beating regularly, your muscles moving properly and your nerves communicating is a vital mineral and electrolyte that carries an electrical charge, allowing the body to function) to Resident #1 and Resident #2 according to the physician's order and pharmacy recommendation on 7/9/26 when she administered the Potassium crushed by mouth when the instructions on the blister packet said to Swallow Whole Do not Chew Or Crush.This failure could place residents at risk of adverse reaction related to taking medications.Findings Included:Review of Resident #1's admission assessment [VT19.1]7/9/26 reflected she was an [AGE] year old[AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, cough, pain, essential (primary) hypertension ( high blood pressure), low potassium, Alzheimer's disease with early onset (a progressive brain disease that slowly destroys memory, thinking skills and the ability to carry out simple daily tasks) anorexia ( an eating disorder and mental health condition characterized by severe food restriction an intense fear of gaining weight and a distorted body image),), [VT20.1]personal history of transient ischemic attack ( occurs when blood flow to a part of the brain, spinal cord, or retina temporarily stops, depriving the tissue of oxygen), and cerebral infarction ( the necrosis) of brain tissue caused by a prolonged lack of blood flow without residual deficits), (personal history of malignant neoplasm (cancerous tumor) of breast. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. She needed extensive help from 1 staff with ADLs, and limited assistance with eating. Record review of Resident #1's care plan on dated 5/27/26 read revealed in part: Extended Release (Potassium Chloride) . Intervention . give Potassium Chloride ER as ordered by physician . Record review of Resident #1's physician's orders for dated 12/22/24 read revealed in part: . Potassium Chloride Extended Release 20 MEQ. Give 1 tablet by mouth one time a day for MINERAL . Record review of Resident #1's Medication Administration Record (MAR) dated July 2026 had revealed Oral Tablet Extended Release 20 MEQ (Potassium Chloride) Give 1 tablet by mouth one time a day for MINERAL. Record review of facility's medication scheduled every day /once daily reflected, it should be administered at 9AM. Observation on 7/9/26 at 10:15 AM, during medication administration revealed. MA B picked up Potassium Chloride Extended Release 20 MEQ blister packet and punched it one tablet into medication cup. Blister packet had highlighted Swallow Whole Do not Chew Or Crush. MA B then added and other medications ( Amlodipine and Calcium ) and crushed all medications and mixed it them [NAME] yogurt and administered this to Resident #1 by mouth. Resident #2Review of Resident #2's admission assessment [VT21.1]7/9/26 reflected she was a [AGE] year old[AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, fatigue, gangrene (death of body tissue), aphasia (difficulty communicating), chest pain, shortness of breath, low potassium essential (primary) hypertension (high blood pressure).Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score was blank indicating severe cognitive impairment. She needed extensive help from 1 staff with ADLs, and limited assistance with eating. Record review of Resident #2's care plan on dated 6/27/26 read revealed in part . diagnosis of low potassium . Intervention . give Potassium Chloride medications as ordered . Record review of Resident #2's physician's orders for dated 3/20/2026 read revealed in part: . Potassium Chloride ER 10 meq, Give 10 meq by mouth one time a day for low potassium . Record review of Resident #2's Medication Administration Record (MAR) dated July 2026 had revealed Potassium Chloride ER 10 meq by mouth every day. Observation and interview on 7/9/26 at 10:35 AM, during medication administration. revealed MA B picked up Potassium Chloride Extended Release 10 MEQ blister packet and punched it out one tablet into medication cup. Blister packet had highlighted Swallow Whole Do not Chew Or Crush . MA B then added and other medications ( Eliquis and Metoprolol) and crushed all medications and mixed it them in yogurt. MA B stopped before administering the medication to Resident #2 to check Potassium blister packet after surveyor intervention to review the packet instructions, and MA B said Potassium 10 meq was given once daily. MA B was shown the highlighted sign on the blister pack Swallow Whole Do not Chew Or Crush .MA B said, Resident #2 cannot swallow Potassium 10 meq whole, and MA B continued to administer the potassium to Resident #2 by mouth. Interview on 7/9/26 at 11:20 a.m. with MA B regarding not following pharmacy recommendation and notifying the charge nurse on changing Potassium tablet to liquid. MA B said she did not check the blister packet highlighted sign on the Potassium blister packet do not crush or chew, MA B said she will be careful. MA B said crushing Resident #1 and Resident #2's potassium would not work as it should in their blood. Interview with DON on 7/9/26 at 4:00 PM regarding Resident #1 and Resident #2's Potassium ER crushed. DON said she was not aware of it. DON said she was going to notify the doctor for stat (immediate) Potassium blood level lab work to be done. DON said she would start in-services to all staff and call the doctor changed to change Potassium tablet to liquid. Record Review of facility's policy Medication Administration Procedures with revised date of April 2019 revealed .4. Medications are administered in accordance with prescriber orders, including any required time frame.5.Medication administration times are determined by resident need and benefit, not staff convenience. Factor that are considered include:a. enhancing optimal therapeutic effect of the medication,b. preventing potential medication or food interactions.10. The individual administering the medication checks the label THREE(3) times to verify right resident, of medication should always be adhered to which includes the right medication, right dosage, right time and right method (route) of administration before giving the medication and the right dose.

Based on observation, interview and record review, the facility failed to ensure services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (Resident #1) of one resident reviewed. On 7/9/26, MA B administered a larger amount of Med Pass 2.0 (a high-calorie, high-protein nutritional shake) than what was written in Resident #1's physician orders.These failures could place residents at risk for fluid overload, weight gain, aspiration pneumonia, and abdominal discomfort. Findings Included: Review of Resident #1's admission assessment on 7/9/26 reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, cough, pain, essential (primary) hypertension (high blood pressure), low potassium, Alzheimer's disease with early onset (a progressive brain disease that slowly destroys memory, thinking skills and the ability to carry out simple daily tasks) anorexia (an eating disorder and mental health condition characterized by severe food restriction an intense fear of gaining weight and a distorted body image), personal history of transient ischemic attack (occurs when blood flow to a part of the brain, spinal cord, or retina temporarily stops, depriving the tissue of oxygen), and cerebral infarction (the necrosis of brain tissue caused by a prolonged lack of blood flow without residual deficits), persona l history of malignant neoplasm (cancerous tumor) of breast.Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. She needed extensive help from 1 staff with ADLs, and limited assistance with eating. Record review of Resident #1's care plan on 5/27/26 read in part:Med Pass 2.0 (a high-calorie, high-protein nutritional shake) nutrition supplement . Intervention . give nutritional supplements as ordered by physician . Record review of Resident #1's Physician's orders on 1/1/25 read in part: . Med Pass 2.0 three times a day 60ml PO . Record review of Resident #1's Medication Administration Record (MAR) dated July 2026 revealed Med Pass 2.0 three times a day 60ml PO. Observation on 7/9/26 at 10:15 AM of MA B administering Resident #1's medications revealed MA B took Resident #1's Med Pass 2.0 Carton, MA B poured 240mls in a glass cup and administered other medications separately by mouth. Interview on 7/9/26 at 10:20AM regarding the amount of Med Pass given to Resident #1 during medication administration, MA B said Resident #1 loved to take a whole cup of Med Pass. In an interview on 7/9/25 at 5:21 p.m. the DON said she expected her Medication Aides to give medication as ordered by the doctor. She said she expected nurses to give medications and Med Pass supplement as ordered by the physician., If they had a question about an order, they needed to call the physician or the charge nurse for clarification. DON said MA B was hired about 3 months ago and she had skills orientation on medication administration. DON said not following physician's orders could cause Resident # 1's weight gain and abdominal discomfort. Review of the facility's policy Administering Medications last reviewed in 2019, reflected, Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and ImplementationOnly persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview and record review the facility failed ensure that the hospice services met professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services and to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs for 1 of 4 residents (Resident #2) reviewed for hospice and personal care. The facility failed in notifying Resident #2's Hospice that Resident #2's NP recommended he see a Podiatrist for his long toenails. This failure could place residents at risk of not receiving foot care treatment in a timely manner.Record review of Resident #2's face sheet, dated 06/26/2026, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #2 had medical diagnoses which included cerebral infarction due to thrombosis of right middle cerebral artery (stroke due to blood clot of right middle artery in the brain) and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (weakness and paralysis following stroke affecting left dominant side). Record review of Resident #2's baseline care plan, dated 06/13/2026, reflected he was totally dependent on staff for ADLs, including dressing, footwear, personal hygiene, and showering, along with bed mobility. Resident #2 had no pain nor skin risks documented.Record review of Resident #2's foot evaluation, dated 06/14/2026 at 10:01a.m., by WCN B, reflected Resident #2 was noted as having eschar (necrotic/dead tissue that can spread over severe wounds) noted to left big toe and present upon admission.Record review of Resident #2's BIMS evaluation, dated 06/23/2026, reflected he had a score of 11, which indicated moderate cognitive impairment related to thinking and memory. Record review of Resident #2's care plan, dated 06/26/2026, reflected he had the following area care-planned:-Date initiated: 06/26/2026: Resident #2 was admitted with left great toe arterial ulcer and then developed left 2nd toe arterial ulcer, with interventions including evaluating ulcer characteristics on weekly rounds with wound care MD and monitor for signs of progression or declination.Record review of Resident #2's Physician Order Summary, dated 06/26/2026, reflected he had the following:-Start date 06/15/2026: left big toe eschar: skin prep daily every day shift.-Start date 06/15/2026: May be seen by Podiatrist as needed.-Start date 06/26/2026: Wound care to left great toe and 2nd toe, apply betadine (liquid solution used to treat/prevent infections), leave open to air every day shift.Record review of Resident #2's progress notes reflected the following:-06/20/2026 at 12:18p.m. by NP K, he had edema (fluid buildup in tissue) of the left foot, dry skin, left lower extremities insensate (lacking sensation). It was an arterial ulcer with full thickness. Resident #2 was recommended for routine in house Podiatry evaluation for management of thickened nails. The staff and Resident #2 verbalized understanding regarding the patient's wound, dressing care, and general treatment recommendations. See treatment recommendations and preventative measures as written. Notified wound RN at bedside and facility staff during post wound rounds.Record review of Resident #2's skin observations, from 06/14/2026 to 06/26/2026, reflected staff documented no skin concerns and no issues with scratched, redness, discoloration, skin tears or open areas on the resident.-06/25/2026 at 10:27 p.m., RN C wrote Resident #2 had a skin issue on his left dorsum (upper part of a surface) 1st digit (Hallux [big toe]), arterial, wound present on admission. Unknown how long the wound had been present.-06/26/2026 at 5:48 p.m., the SW wrote she spoke with hospice regarding toenail care concerns and the hospice nurse would be onsite on 06/29/2026 to provide services. Observation and interview with WCN B on 06/26/2026 at 12:34 p.m., revealed WCN B observed Resident #2's toenails. Resident #2's three middle toes on both feet had thick nails that were around 3mm length each. WCN B said he did not know if Resident #2's toenails needed to be trimmed but nursing staff should have contacted the SW so she could make a podiatry appointment for Resident #2 . Resident #2 said he had been at the facility for two weeks and someone cut one toenail but not the rest. Resident #2's family member said he visited the previous week and Resident #2's toenails were already long at that time. In a later observation and interview with Resident #2 on 06/26/2026 at 5:20p.m, Resident #2 said he did not think he needed to tell someone about his long toenails because he thought it was part of the facility's responsibility to ensure he received care. Resident #2 said he would like them trimmed for his personal hygiene and his long toenails were not causing pain. Resident #2 was observed with dirt under his fingernails and he said he would like them cleaned and trimmed down.Observation and interview with WCN A on 06/26/2026 at 1:04 p.m., WCN A went into Resident #2's room and observed Resident #2's toenails on both feet and said the toenails on both feet needed trimming. WCN A said someone would come daily to check on his wound on his feet and said she focused on the feet and not the nails but said if a resident's nails were long, nursing staff would tell the SW who would call the podiatrist and put the resident on a list. WCN A said if toenails were not clipped, they could curl up and break the skin. The SW said she will call the podiatrist to schedule an appointment for Resident #2 at the next visit.Interview with the SW on 06/26/2026 at 4:02 p.m., she said Resident #2 was not on her podiatry list at that moment and the MDs would usually reach out to her about any orders for podiatry. The SW said Resident #2's NP or MD should have reached out to her so she could have added Resident #2 on the list for podiatry to see on their next visit to the facility. The SW said the facility had podiatry rounds for newly admitted residents and Resident #2 would have been seen anyway. The SW said podiatry visited every two to three months. The SW said Resident #2's insurance would have only allowed a podiatry visit every two months and they would not come before that time. Attempted interview with CNA M on 06/26/2026 at 4:53p.m., she was Resident #2's aide from 6 a.m. to 2 p.m. Voicemail message left and no returned communications as of exit.Attempted interview with CNA G on 06/26/2026 at 4:56p.m., she was an aide on Resident #2's unit from 6 a.m. to 2 p.m. Voicemail message left and no returned communications as of exit.Attempted interview with LVN B on 06/26/2026 at 4:59 p.m., she was Resident #2's nurse from 6 a.m. to 2 p.m. Voicemail message left and no returned communications as of exit.Interview with the DON on 06/26/2026 at 5:15 p.m., she said she would check on when the last time the podiatry group came and when their next visit would be. If the next visit was too far out, the DON would find another podiatry group to come see Resident #2. The DON said Resident #2 had long nails upon admission. The DON said she would look for communication between the facility and the podiatry group and Resident #2's hospice. In a later interview on 06/26/2026 at 6:50 p.m., the DON said the residents who were on hospice could been seen by their podiatrist sooner. The DON said the facility's nursing staff could have taken care of the dirt under Resident #2's fingernails. The DON said she did not know why staff did not inform the SW about Resident #2's nails. The DON said she did not see any negative outcome if hospice was not contacted. The DON said she now remembered Resident #2's NP put his long toenails into the wound report that the DON and her team received, and she thought she noticed it and was going to have him put on the podiatry list but did not get to complete that task. The DON said typically if she knew about long toenails she would have her nurses come in to assess the residents and put them on the podiatry list. Interview with the HRN on 06/26/2026 at 5:44 p.m., she was resident #2's hospice nurse said there were no records of the facility calling hospice regarding Resident #2's long toenails before 06/26/2026 at 5:30 p.m. The HRN said typically the facility would communicate any changes or updates with hospice to ensure records reflected each other, including requests for services. The HRN said their hospice group could have done those things like clip toenails if they knew the facility wanted hospice to address them for the residents and the facility should have let hospice know and put the NP's request in the documentation and reflect it in the resident's care plan . The HRN did not see any orders for Resident #2 to see a podiatrist. The HRN said hospice was supportive and not primary. Record review of the facility's policy titled Hospice Program last revised July 2017, it read in part, .10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities include the following:.b.Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care;c.Notifying the hospice about the following:(1)A significant change in the resident's physical, mental, social, or emotional status .d.Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day.

Based on observation, interview and record review the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health and provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 1 of 5 (Resident #2) residents reviewed for foot care .1.The facility failed to ensure Resident #2 did not have long toenails around 3 mm on the three middle bilateral toes, observed on 06/26/2026.2. The facility failed to ensure the NP recommendations made for Resident #2 to see a Podiatrist on 06/20/2026 were followed and no attempts to make a podiatry appointment were made until 06/26/2026 after State Surveyor intervention .These failures could place residents at risk of developing foot problems such as infection and hinder recovery from existing disease processes . Record review of Resident #2's face sheet, dated 06/26/2026, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #2 had medical diagnoses which included cerebral infarction due to thrombosis of right middle cerebral artery (stroke due to blood clot of right middle artery in the brain) and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (weakness and paralysis following stroke affecting left dominant side). Record review of Resident #2's baseline care plan, dated 06/13/2026, reflected he was totally dependent on staff for ADLs, including dressing, footwear, personal hygiene, and showering, along with bed mobility. Resident #2 had no pain nor skin risks documented.Record review of Resident #2's foot evaluation, dated 06/14/2026 at 10:01a.m., by WCN B, reflected Resident #2 was noted as having eschar (necrotic/dead tissue that can spread over severe wounds) noted to left big toe and present upon admission.Record review of Resident #2's BIMS evaluation, dated 06/23/2026, reflected he had a score of 11, which indicated moderate cognitive impairment related to thinking and memory. Record review of Resident #2's care plan, dated 06/26/2026, reflected he had the following area care-planned:-Date initiated: 06/26/2026: Resident #2 was admitted with left great toe arterial ulcer and then developed left 2nd toe arterial ulcer, with interventions including evaluating ulcer characteristics on weekly rounds with wound care MD and monitor for signs of progression or declination.Record review of Resident #2's Physician Order Summary, dated 06/26/2026, reflected he had the following:-Start date 06/15/2026: left big toe eschar: skin prep daily every day shift.-Start date 06/15/2026: May be seen by Podiatrist as needed.-Start date 06/26/2026: Wound care to left great toe and 2nd toe, apply betadine (liquid solution used to treat/prevent infections), leave open to air every day shift.Record review of Resident #2's progress notes reflected the following:-06/20/2026 at 12:18p.m. by NP K, he had edema (fluid buildup in tissue) of the left foot, dry skin, left lower extremities insensate (lacking sensation). It was an arterial ulcer with full thickness. Resident #2 was recommended for routine in house Podiatry evaluation for management of thickened nails. The staff and Resident #2 verbalized understanding regarding the patient's wound, dressing care, and general treatment recommendations. See treatment recommendations and preventative measures as written. Notified wound RN at bedside and facility staff during post wound rounds.Record review of Resident #2's skin observations, from 06/14/2026 to 06/26/2026, reflected staff documented no skin concerns and no issues with scratched, redness, discoloration, skin tears or open areas on the resident.-06/25/2026 at 10:27 p.m., RN C wrote Resident #2 had a skin issue on his left dorsum (upper part of a surface) 1st digit (Hallux [big toe]), arterial, wound present on admission. Unknown how long the wound had been present.-06/26/2026 at 5:48 p.m., the SW wrote she spoke with hospice regarding toenail care concerns and the hospice nurse would be onsite on 06/29/2026 to provide services. Observation and interview with WCN B on 06/26/2026 at 12:34 p.m., revealed WCN B observed Resident #2's toenails. Resident #2's three middle toes on both feet had thick nails that were around 3mm length each. WCN B said he did not know if Resident #2's toenails needed to be trimmed but nursing staff should have contacted the SW so she could make a podiatry appointment for Resident #2 . Resident #2 said he had been at the facility for two weeks and someone cut one toenail but not the rest. Resident #2's family member said he visited the previous week and Resident #2's toenails were already long at that time. In a later observation and interview with Resident #2 on 06/26/2026 at 5:20p.m, Resident #2 said he did not think he needed to tell someone about his long toenails because he thought it was part of the facility's responsibility to ensure he received care. Resident #2 said he would like them trimmed for his personal hygiene and his long toenails were not causing pain. Resident #2 was observed with dirt under his fingernails and he said he would like them cleaned and trimmed down.Observation and interview with WCN A on 06/26/2026 at 1:04 p.m., WCN A went into Resident #2's room and observed Resident #2's toenails on both feet and said the toenails on both feet needed trimming. WCN A said someone would come daily to check on his wound on his feet and said she focused on the feet and not the nails but said if a resident's nails were long, nursing staff would tell the SW who would call the podiatrist and put the resident on a list. WCN A said if toenails were not clipped, they could curl up and break the skin. The SW said she will call the podiatrist to schedule an appointment for Resident #2 at the next visit.Interview with the SW on 06/26/2026 at 4:02 p.m., she said Resident #2 was not on her podiatry list at that moment and the MDs would usually reach out to her about any orders for podiatry. The SW said Resident #2's NP or MD should have reached out to her so she could have added Resident #2 on the list for podiatry to see on their next visit to the facility. The SW said the facility had podiatry rounds for newly admitted residents and Resident #2 would have been seen anyway. The SW said podiatry visited every two to three months. The SW said Resident #2's insurance would have only allowed a podiatry visit every two months and they would not come before that time. Attempted interview with CNA M on 06/26/2026 at 4:53p.m., she was Resident #2's aide from 6 a.m. to 2 p.m. Voicemail message left and no returned communications as of exit.Attempted interview with CNA G on 06/26/2026 at 4:56p.m., she was an aide on Resident #2's unit from 6 a.m. to 2 p.m. Voicemail message left and no returned communications as of exit.Attempted interview with LVN B on 06/26/2026 at 4:59 p.m., she was Resident #2's nurse from 6 a.m. to 2 p.m. Voicemail message left and no returned communications as of exit.Interview with the DON on 06/26/2026 at 5:15 p.m., she said she would check on when the last time the podiatry group came and when their next visit would be. If the next visit was too far out, the DON would find another podiatry group to come see Resident #2. The DON said Resident #2 had long nails upon admission. The DON said she would look for communication between the facility and the podiatry group and Resident #2's hospice. In a later interview on 06/26/2026 at 6:50 p.m., the DON said the residents who were on hospice could been seen by their podiatrist sooner. The DON said the facility's nursing staff could have taken care of the dirt under Resident #2's fingernails. The DON said she did not know why staff did not inform the SW about Resident #2's nails. The DON said she did not see any negative outcome if hospice was not contacted. The DON said she now remembered Resident #2's NP put his long toenails into the wound report that the DON and her team received, and she thought she noticed it and was going to have him put on the podiatry list but did not get to complete that task. The DON said typically if she knew about long toenails she would have her nurses come in to assess the residents and put them on the podiatry list. Interview with the HRN on 06/26/2026 at 5:44 p.m., she was resident #2's hospice nurse said there were no records of the facility calling hospice regarding Resident #2's long toenails before 06/26/2026 at 5:30 p.m. The HRN said typically the facility would communicate any changes or updates with hospice to ensure records reflected each other. The HRN said their hospice group could have done those things like clip toenails if they knew the facility wanted hospice to address them for the residents and the facility should have let hospice know and put the NP's request in the documentation and reflect it in the resident's care plan . The HRN did not see any orders for Resident #2 to see a podiatrist. The HRN said hospice was supportive and not primary. Record review of the facility's policy titled Hospice Program last revised July 2017, it read in part, .10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities include the following:.b.Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care;c.Notifying the hospice about the following:(1)A significant change in the resident's physical, mental, social, or emotional status.(2)Clinical complications that suggest a need to alter the plan of care.(3)A need to transfer the resident from the facility for any condition.(4)The resident's death.d.Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. Record review of the facility's policy titled Supporting Activities of Daily Living last updated February 2025, it read in part, 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.2. 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: a. hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care including initial goals based on admission orders and physician orders for 2 of 4 residents (Resident #18 and Resident #2) reviewed for comprehensive care plans. 1.The facility failed to develop a care plan and interventions to address Resident #18's two diabetic ulcers and a pressure injury in a timely manner.2.The facility failed to develop a care plan and interventions to address Resident #2's great big toe ulcer in a timely manner.These failures could place residents at risk of not having their individual, medical and functional needs identified and cause a physical decline in health.1. Record review of Resident #18's face sheet, dated 06/26/2026, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE]. She had medical diagnoses which included end stage renal disease , amputation of left leg below the knee, morbid obesity with alveolar hypoventilation (when breathing is too shallow or slow to meet the body's needs), type 2 diabetes mellitus with foot ulcer (high blood sugar with foot wound) and non-pressure chronic ulcer of right heel and midfoot with other specified severity. Resident #18 was discharged on 06/25/2026 due to uncontrollable skin pain.Record review of Resident #18's Comprehensive MDS, dated [DATE], reflected she had a BIMS of 15, which indicated she was cognitively intact related to memory and thinking. She required supervision with ADLs like personal hygiene and upper body dressing. She required total assistance with showering, lower body dressing and footwear. Resident #18 was coded for diabetic foot ulcers and surgical wounds. Record review of Resident #18's baseline care plan, dated 06/01/2026, reflected Resident #18 required IV medications while at the facility and was marked as not being at risk of any skin concerns. Record review of Resident #18's progress notes reflected the following:-06/04/2026: [Resident #18] was hospitalized on [DATE] from MRSA bacteremia and required IV vancomycin. She was seen by infectious disease and wound care specialties. Wound history during hospitalization: chronic right heel and foot wounds, including diabetic ulcers and prior surgical sites with dressings maintained clean, dry, and intact . with etiology consistent with diabetic neuropathy (damaged nerves), pressure, and impaired perfusion compounded by ESRD and obesity. Additional risk factors impacting wound healing included immobility, poor nutritional status, glycemic variability, dialysis dependence, and recurrent infection risk related to vascular access.Record review of Resident #18's infection screening, dated 06/04/2026, reflected she had a current infection. She was admitted with and no signs or symptoms of infection.Record review of Resident #18's skin assessments, conducted by WCN A reflected the following:-06/05/2026 at 10:19 a.m.: Resident #18 had a right plantar (sole or bottom of the foot) wound and right heel wound present on admission. Right plantar wound was nearly completely epithelized (when the protective skin layer covers and starts to close the open wound) and had a dry wound bed and the right heel ulcer had granulation tissue (new tissue that covers wound and is the beginning of healing process) covering the bed.Record review of Resident #18's care plan, last captured 06/25/2026, reflected she had the following care areas:-Date Initiated: 06/22/2026. Resident #18 had potential for pressure ulcer and development of other types of skin injury r/t impaired mobility, disease process diabetes. She had diabetic ulcers to her right foot and a laceration/DTI to her right upper posterior thigh and was at risk for complications/delayed healing .Wound care to right buttocks due to excoriation. Interventions included administering treatments as ordered and monitor for effectiveness, and to obtain and monitor lab/diagnostic work as ordered.-Date Initiated: 06/22/2026. Resident #18 had diabetic ulcers to her right foot, right heel, right plantar with interventions including monitoring pressure areas for color, sensation, temperature and monitor wound for size, depth, necrosis (dead tissue), granulation and infection including green drainage, foul odor, redness and swelling.Record review of Resident #18's Order Summary Report, dated 06/26/2026, reflected she had the following orders:-Start date: 05/30/2026: wound care group to consult for skin and wound conditions/prevention.-Start date: 06/02/2026: Vancomycin HCl in NaCl Intravenous Solution 1.75-0.9 GM/500ML - % - use 1750 mg intravenously one time a day every Monday, Wednesday, Friday for bacteria infection until 06/07/2026.-Start date: 06/02/2026: wound care to right heel, cleanse with wound cleanser, apply collagen sheet to wound, cover with ABD (type of dressing to manage heavy drainage from large wounds), rolled gauze and wrap every day shift on Tuesday, Thursday and Saturday.-Start date: 06/06/2026: wound care to right plantar, cleanse with wound cleanser, apply collagen sheet and gel to wound, cover with bordered gauze and wrap every day shift every Tuesday, Thursday and Saturday. -Start date: 06/17/2026: wound care to right buttocks, cleanse with soap and water, pat dry, apply triad paste, cover with bordered dressing (foam dressing with border, like a bandage).Resident #18's orders did not include any orders for assessing for infection in the right foot . Interview with MDS A on 06/26/2026 at 5:27 p.m., she was the MDS Coordinator for three months. MDS A said she worked with another MDS staff, but she was not in the facility due to a medical procedure . MDS A said nurses gave reports to aides about resident care but Resident #18's interventions on infection and diabetic ulcers should have been in the care plan so staff could provide individualized care to Resident #18. If Resident #18's conditions were not documented in the care plan then that could affect her recovery and the way care was provided to her. MDS A stated that Resident #18's diabetic ulcers were not documented in her baseline care plan. 2. Record review of Resident #2's face sheet, dated 06/26/2026, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #2 had medical diagnoses which included cerebral infarction due to thrombosis of right middle cerebral artery (stroke due to blood clot of right middle artery in the brain) and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (weakness and paralysis following stroke affecting left dominant side). Record review of Resident #2's baseline care plan, dated 06/13/2026, reflected he was totally dependent on staff for ADLs, which included dressing, footwear, personal hygiene, and showering, along with bed mobility. Resident #2 had no pain nor skin risks documented.Record review of Resident #2's foot evaluation, dated 06/14/2026 at 10:01a.m. by WCN B, reflected Resident #2 was noted as having eschar (necrotic/dead tissue that can spread over severe wounds) noted to left big toe and present upon admission.Record review of Resident #2's progress notes reflected the following:-06/20/2026 at 12:18p.m. by NP K, He had edema (fluid buildup in tissue) of the left foot, dry skin, left lower extremities insensate (lacking sensation). It was an arterial ulcer with full thickness. Resident #2 was recommended for routine in house Podiatry evaluation for management of thickened nails. The staff and Resident #2 verbalized understanding regarding the patient's wound, dressing care, and general treatment recommendations. See treatment recommendations and preventative measures as written. Notified wound RN at bedside and facility staff during post wound rounds.Record review of Resident #2's BIMS evaluation, dated 06/23/2026, reflected he had a score of 11, which indicated moderate cognitive impairment related to thinking and memory. Record review of Resident #2's care plan, dated 06/26/2026, reflected he had the following area care-planned:-Date initiated: 06/26/2026: Resident #2 was admitted with left great toe arterial ulcer and then developed left 2nd toe arterial ulcer, with interventions which included evaluating ulcer characteristics on weekly rounds with wound care MD and monitor for signs of progression or declination.Record review of Resident #2's Physician Order Summary, dated 06/26/2026, reflected he had the following:-Start date 06/15/2026: left big toe eschar: skin prep daily every day shift.-Start date 06/15/2026: May be seen by Podiatrist as needed.-Start date 06/26/2026: Wound care to left great toe and 2nd toe, apply betadine (liquid solution used to treat/prevent infections), leave open to air every day shift.Record review of Resident #2's skin observations, from 06/14/2026 to 06/26/2026, reflected staff documented no skin concerns and no issues with scratched, redness, discoloration, skin tears or open areas on the resident.-06/25/2026 at 10:27 p.m., RN C wrote Resident #2 had a skin issue on his left dorsum (upper part of a surface) 1st digit (Hallux [big toe]), arterial, wound present on admission. RN C also wrote it was unknown how long the wound had been present.-06/26/2026 at 5:48 p.m., the SW wrote she spoke with hospice regarding toenail care concerns and the hospice nurse would be onsite on 06/29/2026 to provide services. Observation and interview with WCN B on 06/26/2026 at 12:34 p.m., Resident #2's left big toenail was blackened about one inch from the top. WCN B said that was Resident #2's ulcer and it was being treated at the facilityAttempted interview with CNA M on 06/26/2026 at 4:53 p.m., she was Resident #2's aide from 6a.m. to 2 p.m. Voicemail message left and no returned communications as of exit.Attempted interview with CNA G on 06/26/2026 at 4:56p.m., she was an aide on Resident #2's unit from 6 a.m. to 2 p.m. Voicemail message left and no returned communications as of exit.Attempted interview with LVN B on 06/26/2026 at 4:59 p.m., she was Resident #2's nurse from 6 a.m. to 2 p.m. Voicemail message left and no returned communications as of exit.Interview with the DON on 06/26/2026 at 6:50 p.m., she said care plans should be completed immediately and the MDS nurses and the DON were responsible for ensuring resident care and interventions were added to the care plan. Care plans should be done as soon as it is noticed. The DON said Resident #18's diabetic ulcers were not caught until 06/22/2026 .Record review of the facility's policy titled Comprehensive Person-Centered Care Plans, last revised March 2022, it read in part, 7.The comprehensive, person-centered care plan:a.includes measurable objectives and timeframes;b.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:(1)services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;(2)any specialized services to be provided as a result of PASARR recommendations; and(3)which professional services are responsible for each element of care;c.includes the resident's stated goals upon admission and desired outcomes;d.builds on the resident's strengths; ande.reflects currently recognized standards of practice for problem areas and conditions.9.Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.10.When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.11.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to ensure that each resident receives adequate supervision for 1 (Resident #1) of 1 reviewed for supervision.The facility failed to provide supervision for Resident #1 when he eloped from the facility on 6/7/2026 between the hours of 9:15 a.m. and 9:40 a.m., when Resident #1 was found by law enforcement outside the perimeter of the facility in the grass. This failure could place all residents at risk of experiencing pain, physical, emotional distress, and possible death. Record Review of Resident #1's chart reveals he was a [AGE] year-old male with a BIMS score of 6, admitted to the facility on [DATE]. Resident #1's primary diagnosis was dehydration. He was also diagnosed with unspecified mood disorder, bipolar, major depression, hyperlipidemia, post traumatic stress disorder, and unspecified dementia. He uses a wheelchair for mobility. He was impaired on both sides, lower extremity ([NAME], knee, ankle, foot) to have functional limitation in range of motion. He requires partial/moderate assistance to walk 10 feet. Record Review of Resident #1's Discharge summary dated [DATE] revealed he was admitted due to being found down with hypotensive (abnormally low blood pressure). Record Review of local temperature website revealed on 06/7/2026 the temperature was from 79 degrees to 84 degrees.Record Review of Resident #1's progress notes dated 6/7/2026 at 12:40 pm reveals Resident #1 was observed outside the back gate lying on the grass by a patrol police, who saw him, pulled over, and called 911. Record Review of Resident #1's progress notes dated 6/7/2026 at 4:35 p.m., Resident #1 returned to the facility, via stretcher by city ambulance. He was alert and oriented x 3. It also reveals the EMS staff stated that he is very alert and ok. Record Review of Resident #1's progress notes dated 6/8/2026 revealed Resident #1 had a BIM's evaluation and an elopement evaluation. Resident #1's BIM was 10. Resident #1's elopement evaluation revealed Resident #1 had low calcium identified per hospital evaluation over the weekend; calcium 8.5 on 6/6 BMP (8.4 on 6/2/ CMP), started calcium carbonate 1 hypocalcemia (low calcium levels in the blood), and continue calcium carbonate indefinitely. Record Review of, In-Service/Training Record of Attendance Sign In-Sheet, dated 06/8/2026 revealed the ADON educated the staff across all disciplines and shifts on topic of: Identification of Residents at risk of elopement, including those with dementia, confusion or wandering behaviors. Reviewing the importance of frequency monitoring, following care plans, maintaining door security measures and immediately reporting unaccounted Residents.Interviews were conducted on 6/18/2026 between 5:35 p.m. and 6:13 p.m. with multiple staff to verify the in-service had been conducted and to validate the staff understanding of the information presented to them. Members of staff was asked what was covered during their in-service. No concerns were found regarding their understanding of requirements, training materials, and expectations. Record Review of Resident #1 care plan dated 6/8/2026 reveals Resident #1 safety will be maintained throughout the next review date, he will not leave the facility unattended through the next review period, and for the facility to identity if there is a certain time of day wandering/elopement attempts occur. Record Review of Resident #1's medication list reveals he was complaint with his medications for the last 30 days. He was prescribed the following medications: Aspirin Oral Tablet Chewable 81 MG (Aspirin), Given 1 tablet by mouth one time a day for supplementMultivitamin Oral Tablet (Multiple Vitamin), Given 1 tablet by mouth one time a day for SupplementTamsulosin HCl Oral, Capsule 0.4 MG (Tamsulosin HCl), Given 1 capsule by mouth one time a day for ProstateVenlafaxine HCl Oral, Tablet 75 MG (Venlafaxine HCl), Given 1 tablet by mouth one time a day for Depression Vitamin B Complex OralTablet (B-Complex Vitamins, Given 1 tablet by mouth one time a day for SupplementamLODIPine Besylate Oral Tablet 5 MG (Amlodipine Besylate), Given 1 tablet by mouth two times a day for HTNamLODIPine Besylate Oral Tablet 5 MG (Amlodipine Besylate), Given 1 tablet by mouth two times a day for HTNBacitracin to skin tear with non-adherent dressing. Change 2x daily two times a dayLactulose Oral Solution 20 GM/30ML (Lactulose), Given 30 ml by mouth two times a day for hyperammonemia (dangerously high levels of ammonia in the blood)Memantine HCl Oral Tablet 10 MG (Memantine HCl), Given 1 tablet by mouth two times a day for Alzheimer's In an interview on 6/8/2026 at 9:57 a.m. with CMA A, she states she has been working at the facility for two years. She stated CNA A stated Resident #1 went to therapy around 10 a.m. on 6/7/2026. She stated the Receptionist informed her that the police was outside of the facility and the Resident was outside. She stated prior to the Resident being missing, she last seen Resident #1 around 8:30 a.m. or 9:00 a.m. when she went to give him his medication, in his room. She stated she did not know Resident #1 was outside because therapy never brought Resident #1 back to his room like they usually do. She stated she checks on the Residents about every 30 minutes. She states the facility ensure that all Resident was accounted for by checking on them often. She stated during an elopement, staff will first alert all staff, alert the Administration, looking inside and out of the facility, and call the police. She stated she will follow the next steps from the Administrator or the DON. She stated neglect was when a Resident call for help and staff do not help them, she stated she will report neglect to the Abuse Coordinator, the Administrator. In an attempted interview on 6/8/2026 with CNA A, she was contacted numerous times, but no contact was made. In an interview on 6/8/2026 at 10:07 a.m. with the Nurse Practitioner, he stated he has been the Nurse Practitioner for the facility for at least 3 years. When asked what was the safety concerns associated with Resident #1 being on his own, in the community with his diagnoses, medications and history, he stated the Resident does have pretty advanced dementia, has period of lucidity fluctuates. He stated most of the time the Resident is confused. In an interview on 6/8/2026 at 10:22 a.m. with Human Resource Coordinator/Receptionist, she stated she has been working at the facility for eleven years. She stated on 6/7/2026 she was covering the front desk due to the Receptionist being out. She stated she noticed Resident #1 was coming from the back way of the building around 7:45 a.m. and she chatted with him for a while. She stated they were standing in the front foyer and he stated he wanted some fresh air so Resident #1 sit in front of the build, and she was watching him at 7:50 a.m. She stated around 8:45 a.m. PT A transported Resident #1 to therapy. She stated at first Resident #1 did not want to go to therapy, but she offered to give him a popsicle up his return. She stated at around 9:40 a.m., HPD arrived and asked her about a Resident being outside. She stated the HPD officer was describing the Resident #1 and she knew who he was. She stated by the time she arrived to Resident #1, EMS had already arrived and Resident #1 was lying on the ground with his wheelchair. She stated she started talking to him and asking him how did he get out on the curb. She stated Resident #1 told her that he had come from around the building, through the back. She stated she called for the LVN A and the PT A that had him. She stated EMS wanted to take him to the hospital because of a low blood pressure. She stated she then called PT A and LVN A to come outside and speak with the EMS and HPD. She stated she then came back inside the facility. She stated the staff should check on the Residents every two hours. She stated the facility ensure all Residents are accounted for and none or missing when the nurses perform their rounding to know where the Residents are at all times. She states she understands the risk to the Residents if a Residents elopes, he could possibly endanger himself. She states if a Resident elopes, staff search the inside and outside of building, she will notify the Admin, DON, and call 911. She states an example of neglect was when a staff does not change a Resident. She stated she will report neglect to her Administrator. In an interview on 6/7/2026 at 10:44 a.m. with LVN A, states she has been working at the facility for three months. She stated on 6/7/2026 at 9:55 a.m. the Receptionist came to her and asked her where was Resident #1. She stated she informed her that she did assist Resident #1 with his breakfast around 7:00 a.m. She stated she told her the last time she had seen Resident #1 was about 8:00 a.m., when he was walking without his wheelchair and she took him to his room. She stated she placed Resident #1 in his wheelchair and went to another room where her attention was needed. She stated the DON asked her before 10 a.m., where was Resident #1, she told her the last time she seen him was when she placed him in his wheelchair. She stated the DON told her he was outside with the Resident with the police. She stated the DON asked her how did Resident #1 get outside. She stated she went to the therapist office, asked PT A, to show her where exactly he put the Resident #1 after therapy. She stated PT A took her to the back of court where another Resident was sitting. She stated she looked around the facility looking for his wheelchair tracks because she found mud on his wheelchair. She then printed the face sheet for HPD and he was transporting the Resident to the hospital. She stated she notified the DON. She stated the Resident wife was already at the facility to visit Resident #1. She stated she informed Resident #1's wife of her findings and the wife went to the hospital. She stated she checks on the Residents every two hours, continuous all shift. She stated the facility ensure all Residents are accounted for and none or missing by doing her rounds. She stated the procedure for elopement was to search the inside and out of the building, brown code, notify the DON, Administrator, and follow their instructions. She stated neglect is when you don't care for your patient or know where they are. She stated she would report neglect to the Administrator. In an interview on 6/8/2026 at 11:29 a.m. with PT A he stated he has been working at the facility for three year, only on the weekends. He stated on 6/7/2026 at 8:45 a.m. he took the Resident #1 for therapy. He stated when he got to the Resident #1 he was sitting outside, in the front. He stated when he was taking the Resident back from therapy around 9:15 a.m. and 9:30 a.m. the Resident asked to go back outside. He stated he informed Resident #1 he could not put him in the front of the facility, he stated he would put him in the back covered patio. He stated it was normal practice to put the Residents on the back patio; there was another Resident also outside. He stated when he was doing a treatment with another Resident around 10 a.m., another therapist told him a Resident fell outside and a staff member asked for him. He stated when he arrived outside the EMS was loading Resident #1 into the EMS vehicle and he was found outside the gated area. He stated HPD got Resident #1's face sheet. He stated the protocol for elopement was every staff search inside and outside for the missing Resident and he does not know the administrative part of the procedure. He stated neglect was not providing the Resident with the necessary care to meet the Resident's needs. He stated he will report neglect to the administrator or the DON. In an interview on 6/8/2026 at 12:23 p.m. with Resident #1, he stated he does get enough food to eat, receives his medications, and was not being abused. He stated he could not breathe the other day and went down. He stated he was ok now. He was dressed, groomed, in lobby. In an interview on 6/8/2026 at 12:45 p.m. with the DON, she stated she has been working at the facility for two months. She stated on 6/7/2026 around 9:45 a.m. she was informed that the Resident was headed to the hospital for having low bp and was found outside the perimeter. She stated she came to the facility at 10:40 a.m. on 6/7/2026 and spoke with the Receptionist, she informed her that Resident #1 had walked to the reception desk wanting to go outside to get some fresh air. She stated the Receptionist allowed him outside in front but positioned his chair where she was able to see him from the desk. She stated before Resident #1 went to therapy he did refuse at first, but the Receptionist told him he was going to get him a popsicle and he decided to go. She stated therapy got a wheelchair and Resident #1 went to therapy. She stated after therapy, 911 comes into the facility to inform the staff that a Resident was outside. She stated the 911 told her that a Resident had fell outside with his wheelchair. She stated the nurse was informed and Resident #1 was taken to the hospital for low bp and a little shortness of breath for further evaluation. She stated when she arrived at 10:40 a.m. she talked with the nurse and the Receptionist. She stated she talked with the nurse which stated she had talked to the Resident wife. She stated she talked to all the staff and began an investigation. She stated she was in communication with the nurse all day. She stated she informed the nurse to do the change in condition. She stated the Resident arrived back at the facility around 4:00 p.m. on 6/7/2026. She stated she asked the Receptionist and the physical therapy guy to write a statement. She states the staff checks on the Residents at least every two hours but could be more. She stated the nurse and CNA's do their rounds to ensure all Residents are accounted for and none or missing. She stated the protocol for elopement was to notify all staff to search inside and outside in multiple directions, call the local authority, family members and doctors. She stated an example of neglect was when Resident is incontinent and needs to be changed, develop bed sore. She states she reports neglect to the Administrator. She stated she does not think this resident has a history of elopement. She stated the interventions that are put into place to prevent future occurrences of elopement was to keep a closer eye and to ensure the other departments put the Resident back into nursing and not on the patio. When asked why Resident #1 was not supervised, she stated the Resident was not supervised, she stated she cannot answer it, she was asking the same question. She stated it was everyone responsibility, every member of staff which works with a Resident, to ensure that the Residents are supervised. She stated she understands the risk to the Resident if he was not supervised. She stated the risk to the Residents not being supervise was harm or hurting themselves. In an interview on 6/9/2026 at 8:42 a.m. with Patrol Officer with HPD, he stated he has been working with the agency for three and a half years. He stated on 6/7/2025 he was driving around in the morning and seen this older gentleman on the grass. He stated he stopped to ensure the gentlemen did not need any medical assistance. He stated Resident #1 informed him he was walking, got tired, and was just resting. He stated as he was speaking to him, he saw the Resident wheelchair laying a few feet away. He stated he asked Resident #1 if he lived at the facility behind him, he stated yes but was trying to move out. He stated he asked Resident #1 how he was feeling and he stated he was having a hard time breathing. He stated he asked Resident #1 if he could get up he stated he was a little weak, as he was laying on the ground. He stated he stayed with Resident #1 until medical arrived. He stated he asked EMS to get his vitals. He stated when medial arrived, he went inside to ask if Resident #1 lives at the facility. He stated the Receptionist identified that Resident #1 did live at the facility. He stated one of the gates at the facility was broken and it was probably how Resident #1 got out. He stated he talked to PT A which stated he left Resident #1 in the backyard and was the last time he had seen him. He stated PT A did not know he had gotten outside of the facility. He stated he advised the Receptionist that the gate needed to be fixed to prevent other Residents from getting outside of the facility. He stated Resident #1 was transported to the hospital. In an interview on 6/17/2026 at 4:27 pm with Maintenance Director, he states he has been working at the facility off and on for six years. He stated he was aware the gate was broken and had been waiting on the parts for four or five months. He stated the facility is looking for the parts. He stated the board and motors need repair and two boards need to be replace. He stated on 6/7/2026, after the Resident eloped, he went to the gate and closed it, because the Resident eloped out of an open gate. He states he does understand the risk to the Resident if the gate is not fixed or is open without being fixed. He stated the Risk is elopement or accident can occur. He states the facility is monitor the Residents leaving in and out of the building. He stated it is not protocol for Residents to be left alone outside on the back patio unsupervised. In an observation with DON, on 6/18/2026 at 2:40 p.m., the front gate was observed to be closed unable to open. The surveyor strongly shook the gate, it did not open. In an interview on 6/18/2026 at 5:05 p.m. with the DON, she stated the gate was closed on 6/7 and it is not able to be open. She stated she has educated her staff on the importance of bring Resident's back to the nurse after treatments, the elopement process, how to review the importance of frequency monitoring, following care plans, maintaining door security measures, and immediately reporting unaccounted Residents. Record Review of facility policy, Resident Rights, revised February 2021, read in part, revealed, 'be free from abuse, neglect, misappropriation of property, and exploitation.' Record Review of facility policy, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, read in part, revealed 'Residents have the rights to be free from abuse, neglect, misappropriation of resident property and exploration. '

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 3 residents reviewed for infection control. - The facility failed to ensure CNA A washed or sanitized her hands and performed glove changes appropriately while providing incontinence care to Resident #1 on 06/16/26. This deficient practice placed residents at risk for cross contamination and the spread of infection. Finding included: Review of Resident #1's face sheet dated 6/16/26 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: cognitive communication deficit, essential primary hypertension, ( high blood pressure), hyperlipidemia ( high fat in the blood), major depression disorder ( causes ongoing sadness, hopelessness and loss of interest that lasts at least two weeks, it can affect sleep, energy and relationships) and anxiety( a feeling of fear, dread and uneasiness) and cerebral infarction( ischemic stroke)and left hemiplegia( a form of paralysis that affects one side of the body, usually due to a brain or spinal cord injury). Review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1's BIMS score was 3 indicating impaired cognition. Resident #1 was assessed to require dependent assistance for all ADLs. Resident #1 was further assessed to have functional limitations in range of motion for unilateral upper and lower extremities. Further review revealed Resident #1 required ssistance with ADL care with one to two staff assist.Record review of Resident #1's care plan dated 03/13/26 revealed Resident #1 was incontinent of bowel and bladder. Interventions: perform routine rounding to include incontinence care and brief changes. Observation during incontinent care on 6/16/26 at 11:45 AM, CNA A brought clean linen, wipes, and a brief in a plastic bag. CNA A donned clean gloves without using hand sanitizer or washing hands. CNA A did not change gloves, used the same gloves throughout the procedures and left the room with the soiled trash without washing hands to the soiled linen room.Interview on 6/16/26 at 11:55 AM, CNA A said she was very nervous, she stated if she did not wash or sanitize her hands when going from a dirty to clean surface, it could cause cross contamination and a risk of transferring infection.Interview on 6/16/26 at 1:50 PM, the DON said it was the facility's policy for staff to wash or sanitize hands when going from a dirty to clean surface. She stated staff had been in-serviced on infection control and hand hygiene. She stated if hand hygiene or sanitizing was not performed when going from a dirty to clean surface, it could cause an infection.Record review of the facility policy revision date October 2023 updated 1/2025 titled Hand Hygiene, revealed the following: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Policy Interpretation and ImplementationAdministrative Practices to Promote Hand Hygiene1.All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2.All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility.Indications for Hand Hygiene1.Hand hygiene is indicated:a.immediately before touching a resident;b.before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device);c.after contact with blood, body fluids, or contaminated surfaces;d.after touching a resident;e.after touching the resident's environment;f.before moving from work on a soiled body site to a clean body site on the same resident; andg.immediately after glove removal.2.Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations.3.Wash hands with soap and water:a.when hands are visibly soiled; andb.after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile.4.Single-use disposable gloves should be used:a.before aseptic procedures;b.when anticipating contact with blood or body fluids; andc.when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions.5.The use of gloves does not replace hand washing/hand hygiene.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinent care. The facility failed to ensure CNA A properly cleaned Resident #1 during incontinent care when CNA A did not around Resident #1's buttocks on 06/16/2026.This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included:Review of Resident #1's face sheet dated 6/16/26 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: cognitive communication deficit, essential primary hypertension ( high blood pressure), hyperlipidemia ( high fat in the blood), major depression disorder (causes ongoing sadness, hopelessness and loss of interest that lasts at least two weeks, it can affect sleep, energy and relationships) and anxiety (a feeling of fear, dread and uneasiness) and cerebral infarction (ischemic stroke) and left hemiplegia (a form of paralysis that affects one side of the body, usually due to a brain or spinal cord injury). Review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1's BIMS score was 3 indicated impaired cognition. Resident #1 was assessed to require dependent assistance for all ADLs. Resident #1 was further assessed to have functional limitations in range of motion for unilateral upper and lower extremities. Further review revealed Resident #1 requiredassistance with ADL care with one to two staff assist.Record review of Resident #1's care plan dated 03/13/26 revealed she was incontinent of bowel and bladder. Interventions: perform routine rounding to include incontinence care and brief changes. Observation during incontinent care on 6/16/26 at 11:45 AM, CNA A brought clean linen, wipes, and brief in a plastic bag. CNA A donned clean gloves without using hand sanitizer or washing hands. CNA A unfastened and remove the soiled brief, CNA A said Resident #1 was on her monthly flow, using the wet wipes cleaned her perineal area, without changing gloves she repositioned resident to her left side and wiped in-between the buttocks, CNA A did not clean around the buttocks A removed the clean brief from the plastic bag and placed it under the Resident #1. Interview with CNA A on 6/16/26 at 11:55 AM, she said she started working at the facility about 3 months ago. CNA A said she was very nervous and she forget to clean around the buttocks. CNA A said she had 3 days of orientation with returned demonstration for incontinent care and hand washing with the former DON. CNA A said she knew not cleaning the buttocks could cause more skin breakdown and odors.Interview on 6/16/25 at 1:50 PM, the DON said CNA A was supposed to perform incontinent care in a manner to keep residents clean without any odors. The DON stated her expectation was for the CNAs to clean around resident buttocks and perineal area. She said the aides should have a skilled check-off before working on the floor. They also had in-services on ADL rounding and incontinent care. She stated not performing incontinent care properly could potentially cause resident's skin breakdown and infections. She would have in-service and monitor the staff.Review of the facility's Policies and Procedures Revised August 22 titled: Urinary Continence and Incontinence - Assessment and ManagementPolicy Statement1.The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence.2.Management of incontinence will follow relevant clinical guidelines.3.The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.18.As indicated, and if the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan.4.Incontinence care should be individualized at night in order to maintain comfort and skin integrity, and minimize sleep disruption

Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #93) of five residents reviewed for discharges. The facility failed to safely discharge Resident #93 when she was:1. discharged home on [DATE] by EMS via stretcher, incontinent of bowel and bladder, and unable to ambulate, with no support services from home health.2. discharged without an AMA (This occurs when a patient chooses to leave a hospital or healthcare facility before the treating physician recommends discharge), discharge notice, or notice to the Ombudsman per facility policy. During less than 24 hours after Resident #93 was discharged home she urinated and defecated on herself and was unable to change her clothing and clean her body. Resident #93 was subsequently hospitalized due to CHF exacerbation (a chronic condition where the heart does not pump blood as effectively as it should, causing fluid to back up in the lungs or body) and fluid overload less than 24 hours after discharge from the nursing facility.An IJ was identified on 05/05/2026. The IJ template was provided to the facility on [DATE] at 5:51 PM. While the IJ was removed on 05/08/2026, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.This failure could place residents at risk for serious injury, harm, and/or death due to lack of appropriate supervision.Findings included: Review of Resident #93's face sheet dated 05/05/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included acute on chronic diastolic (congestive) heart failure (a serious, often irreversible condition characterized by a stiff left ventricle failing to relax between beats), acute pulmonary edema (a life-threatening, sudden buildup of fluid in the lung's air sacs (alveoli), causing severe breathing difficulty, air hunger, rapid respiratory failure), other obesity due to excess calories (abnormal or excessive fat accumulation that risks health, caused by an imbalance between calorie intake and expenditure), and non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin(a skin-level chronic wound). Review of Resident #93's admission MDS assessment, dated 03/10/2026, reflected a BIMS score of 15, indicating no cognitive impairment. Section GG Functional abilities admission reflected: 1. Roll left and rights, the ability to roll lying on back left and right side and return to lying on back on the bed - substantial/maximal assistance - helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort2. Sit to lying, the ability to move from sitting on side of bed to lying flat on the bed - dependent- helper does all of the effort, resident does none of the effort to complete the activity or, the assistance of two or more helpers is required for the resident to complete the activity.3. Lying to sitting on side of bed- the ability to move from lying on the back to sitting on the side of the bed with no back support- dependent- helper does all of the effort, resident does none of the effort to complete the activity or, this distance of two or more helpers is required for the resident to complete the activity.4. Set to stand - the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed - Not attempted due to medical condition or safety concerns5. Chair bed to chair transfer: the ability to transfer to and from a bed to a chair (or wheelchair) - not attempted due to medical condition or safety concerns.6. Toilet transfer - the ability to get on and off a toilet or commode - not attempted due to medical condition or safety concerns.7. Tub/shower transfer - the ability to Get in and out of a tower/tub - not attempted due to medical condition or safety concern8. Walk 10 feet: once standing - the ability to walk 10 feet in a room, corridor, or similar space - Not attempted due to medical condition or safety concerns. Urinary continence - always incontinent Bowel continence - always incontinent Height and Weight - 67 inches 396 pounds Number of venous and arterial ulcers (chronic, often painful, lower extremity wounds requiring distinct treatments based on the underlying circulation issue) - oneHigh Risk Drug Classes - diuretic (medications that help the kidneys remove excess salt (sodium) and water from the body through urine. They are primarily used to treat high blood pressure, heart failure, and swelling (edema) by reducing fluid volume in blood vessels)Special Treatments, procedures, and programs - oxygen therapy (a medical treatment providing supplemental oxygen to individuals with low blood oxygen levels (hypoxemia), enabling better organ function, reduced fatigue, and easier breathing)Therapy services - speech-language pathology and audiology services (provide comprehensive assessment, diagnosis, and treatment for communication, hearing, and swallowing disorders), occupational therapy (a healthcare profession that helps people across the lifespan participate in daily activities-or occupations-they want and need to do, especially after injury, illness, or disability), and physical therapy (focused on promoting, maintaining, or restoring health through physical interventions, such as exercise, massage, and education).Discharge planning - no active planning already occurring for resident to return to the community Review of Resident #93's care plan focus dated 03/24/2026 reflected Resident #93 had an ADL self-care performance deficit of Resident #93 was bedfast (confined to bed, typically due to illness, injury, or extreme age, often functioning as a synonym for bedridden) all or most of the time. Resident #93 had a care plan focus dated 03/24/2026 she wished to discharge home after rehabilitation. Resident #93 had a focus dated 03/24/2026 risk for falls related to incontinence, balance issues during transition, impaired range of motion bilaterial lower extremities, diuretic/antihypertensive (class of medications used to treat high blood pressure (hypertension) by reducing vascular resistance, slowing the heart rate, or reducing blood volume) and sleep-aid medications. Resident #93 had a focus dated 03/24/2026 of bowel and bladder incontinence. Resident #93 had a focus of venous/statis ulcer (slow-healing, shallow wounds-often on the lower leg or ankle-caused by poor circulation where blood pools due to damaged vein valves). Resident #93 had a focus dated 03/24/2026 of potential for altered respiratory status/difficulty breathing related to pulmonary edema and respiratory failure. Resident #93 had a focus dated 04/20/2026 of COPD (a progressive, treatable lung disease that causes obstructed airflow, making it hard to breathe). Record review of Physical Therapy Evaluation and Plan of Treatment dated 03/04/2026 reflected frequency 5 times/week 60 days daily certification period 04/04/2026 through 05/02/2026. Objective progress short-term goals:1. Resident #93 will increase bed mobility to CGA (level of assistance where the therapist maintains physical contact (usually light hands or holding a gait belt) with the patient during mobility activities to ensure safety and balance. It indicates a high fall risk, requiring more support than supervision but less than minimal assistance) using bedrail. 2. Resident #93 will increase BLE strength 2+/5 (a muscle is performing slightly above a poor level, but it is still quite weak) in order to return to prior level of functioning abilities and decrease level of assistance from caregivers 3. Resident #93 will increase dynamic level of sitting balance to fair in order to participate in EOB activities 4. Resident #93 will perform standing transfers with substantial/maximal assistance in order to return to prior level functioning abilities Bed Mobility = Dependent; Transfers = not attempted due to medical conditions or safety concerns (recommended [mechanical] lift for safety.); assistive device during transfers = Wheelchair. Review of Resident #93's orders reflected an MD order dated 03/25/2026 for weekly weights: Monday, Wednesday, and Friday. Record review of Resident #93's weights reflected two weights taken by mechanical lift. One on Wednesday 03/04/2026: 396 pounds and one on Saturday 04/04/2026: 379 pounds. Record review of MD progress note dated 04/14/2026 reflected Hospital Course - Resident #93 was recently hospitalized for worsening lower-extremity swelling and shortness of breath and diagnosed with acute pulmonary edema and CHF exacerbation; weight was -400 pounds at admission (baseline 350s). Resident #1 admitted to the facility from hospital for worsening lower-extremity swelling, shortness of breath, and diagnosed with acute pulmonary edema and CHF exacerbation - weight was -400 pounds at admission (baseline 350s). Today's basic metabolic panel was reviewed, revealing continued unfavorable renal trends with creatinine (a waste product produced by muscles from the breakdown of a compound called creatine, blood test measures how well the kidneys are functioning, with high levels typically indicating kidney damage, dysfunction, or diseases) now 1.11, rising from baseline of 0.66 to 0.92 and then 1.06 on 04/14.2026. Other malaise (a general, often vague, feeling of being unwell, uncomfortable, or off without a specific, localized cause) persistent debility continues to limit functional progress. During today's encounter, patient remains insistent on discharge home despite ongoing counseling regarding safety concerns, high fall risk, and current functional limitations (supervision for bed mobility, partial/moderate assistance for transfers). Social work consultation recommended to initiate discharge planning and address safe disposition. Patient insistent on unsafe home discharge despite persistent debility and high fall risk; counseled on safety concerns. Record review of MD order dated 04/23/2026 reflected Furosemide Oral Tablet 40 MG (Furosemide) (a prescription loop diuretic (water pill) used to treat fluid retention (edema) caused by heart failure, kidney disease, or liver disease, and to treat high blood pressure) Give 1.5 tablet by mouth two times a day for edema. Record review of MD progress note dated 04/28/2026 reflected the patient has submitted an appeal contesting the proposed discharge plan. Facility nursing staff expressed concerns regarding dietary adherence reporting that the patient had been consuming fast food in violation of recommended nutritional guidelines. This pattern of non-compliance poses particular challenges given Resident #93's underlying volume-sensitive cardiac condition and recent weight trajectory. Record review of NP progress note dated 04/30/2026 reflected patient on chronic supplemental oxygen (baseline), resting in bed. NOMNC (Notice of Medicare Non-Coverage) was issued, patient lost appeal. Anticipating discharge soon. Long-term care/custodial care was offered but patient declined. Functional baseline unchanged: supervision for bed mobility, partial/moderate assistance for transfers, rolling walker for ambulation, high fall risk. Discussion with nursing and CNA staff indicates the patient has been noncompliant with diet and fluid restriction. The patient has been found eating fried chicken from outside the facility, which is likely contributing to exacerbation. A detailed discussion was held with the patient regarding diet and fluid management, with instructions to avoid outside food and foods with high sodium content, as well as to restrict fluid intake to 1.2 L daily. Record review of Resident #93's Physical Therapy Treatment Encounter Note(s) dated 04/30/2026 reflected Functional Status as a Result of Skilled Interventions - Bed Mobility = Partial/moderate assistance; Transfers = Substantial/maximal assistance; Assistive Device During Transfers = Wheelchair Record review discharge summary by NP for Resident #93 dated 05/01/2026 reflected Resident #93 seen for discharge summary. Resident was overall stable breathing had improved compared to earlier in the week, lungs were clean, lower extremity edema was 1+ ankles (indicated mild pitting edema, where a slight indentation appears upon pressure and disappears rapidly, often caused by fluid retention from prolonged sitting/standing, high salt intake, or minor vein issues). Spoke with SW Resident #1 will be discharging home tomorrow. DME was due to be delivered and follow up with cardiology for heart failure management. Record review of facility Discharge Summary not signed by Resident #93 or the facility dated 05/01/2026 reflected resident will discharge home by ambulance by a stretcher, home care services were arranged by HH agency for physical therapy, occupational therapy, nursing care, medical equipment ordered (wheelchair, hospital bed, and 3 in 1 (a versatile, adjustable toileting aid designed for seniors, post-surgery recovery, or those with limited mobility). No therapy recommendations listed. Record review social services progress note dated 05/01/2026 by SWA reflected patient will be discharging tomorrow between 2:30 PM and 3:00 PM. Record review nursing progress note dated 05/02/2026 by LVN D reflected Resident discharged home via stretcher, left alert and oriented X4 (patient is fully alert and aware of four key spheres: person (who they are), place (where they are), time (date/time), and situation (why they are there, no respiratory distress noted, medication provided and left with all belongings. Record review of HH Patient Information Sheet for Resident #93 reflected Coordination Notes dated 04/30/2026 please notify facility of decline of HH referral due to insurance denial and 05/01/2026 called facility for social worker informing them of decline of referral for HH at this time. During an interview on 05/05/2026 at 9:15 AM with Resident #93's FM #1 she said Resident #93 told her Resident #93 was going home and FM #1 said she was concerned about Resident #93 being able to take care of herself at home. FM #1 said Resident #93 could not walk. FM #1 said FM #2 was not a care giver for Resident #93. FM #1 said she attempted several times to speak to a social worker at the facility, and no one answered the phone. FM #1 said she finally spoke with the facility receptionist and left a message for the SW to call FM #1, but FM #1 did not receive a return call from a SW. FM #1 said she kept asking Resident #93 who was going to take care of her and Resident #93 said she did not know. FM #1 asked Resident #93 why they were sending her home and Resident #93 said she no longer had any insurance and was free to go home at any time. FM #1 said she heard from FM #2 that Resident #93 arrived home at approximately midnight on Saturday 05/02/2026 and the following morning, on Sunday 05/03/2026, Resident #93 was wearing the same clothing had on when she left the facility and had urinated and defecated and was unable to clean herself. FM #1 said Resident #93 had a friend come to her home and remove Resident #93's soiled clothing and clean her. FM #1 said her friends told Resident #93 she needed to call EMS. During an interview on 05/05/2026 at 10:27 AM with Resident #93's FM #2 he said Resident #93 had been in the hospital since Sunday, 05/03/2026. FM #2 said the facility wanted Resident #93 to leave but he was not sure why they wanted her to leave. He said Resident #93 did not challenge leaving because there was nothing else Resident #93 could do. FM #2 thought the person who wanted her to leave was the SWA. FM #2 said that Resident #93 said she did not feel like she was physically able to take care of herself. FM #2 said Resident #93 could not walk and could not get to the bathroom by herself. FM #2 said she came home then went back to the hospital the next day. FM #2 said Resident #93 was swelling up due to cardiac issues. On 05/05/2026 at 10:45 AM surveyor attempted to contact NP by phone and received a message that NP was out of the office until 05/10/2026. During an interview on 05/05/2026 at 11:26 AM the PTA said he worked with Resident #93, and she had trouble breathing and was a mechanical lift only resident. PTA said SOB was her main issue. PTA said on a good day, using a walker, Resident #93 could take a few steps forward and a few steps backward. PTA A said even rolling Resident #93 on her side was hard and Resident #93 had SOP because of fluid related to CHF. PTA said Resident #93 was not involved in her discharge process, but she was safe to go home with help. PTA said Resident #93 would need some kind of assistance throughout the day to clean her up. PTA said she could sit on the side of the bed. PTA said Resident #93 wanted to go home. During an interview on 05/05/2026 at 12:15 PM with a HH representative from the HH agency listed on Resident #93's 05/01/2026 discharge summary said Resident #93 was not approved by them for HH services. The HH representative said Resident #93's payment for HH was declined because of lack of insurance coverage. During an interview on 05/05/2026 at 12:31 PM with the ADM she said she began working at the facility on 04/17/2026. The ADM said Resident #93 was discharged from the facility on 05/02/2026 and there was no discharge notice and no notice to the ombudsman. During an interview on 05/05/2026 at 1:08 PM with LVN UM she said Resident #93 was discharged from the facility because her insurance was rejected. LVN UM said Resident #93 was she was incontinent and left on a stretcher. LVN UM said she assumed Resident #93 had family to take care of her. During an interview on 05/05/2026 at 1:15 PM with the BOM she said Resident #93 was private insurance and the facility did not follow Medicaid guidelines because Resident #93 had private insurance. She said the facility cannot discharge residents unless they have a safe discharge. The BOM said they did not assist Resident #93 with applying for Medicare because Resident #93 did not request Medicaid and Resident #93 was planning to go home. During an interview on 05/05/2026 at 1:26 PM with the SWA he said Resident #93 received a notice of Medicare non-coverage and Resident #93 lost her appeal and he asked Resident #93 if she wanted to go home or go to another facility. Resident #93 said she wanted to go home. The SWA said Resident #93 wanted to appeal the denial of her coverage because she wanted to walk but when her appeal was denied, she had a hospital bed, a wheelchair, and a combination toilet and shower chair for her home. The SWA said he had conversations with Resident #93 stating a skilled nursing home was highly recommended and Resident #93 said she did not want to go to skilled nursing. He said if you cannot walk, a skilled nursing home was recommended. Resident #93 said she had a family member who did not live too far away and he could come check on her and her. The SWA said that between family and HH that would be enough care for Resident #93. The SWA said if Resident #93 did not want to go to a skilled nursing facility, he could not force her. The SWA said he was of course concerned about her falling or hurting herself. The SWA said there was a HH representative whom he touched base with prior to Resident #93 leaving who said Resident #93 would get HH services. The SWA said the representative with HH said everything was fine. The SWA said he did contact Adult Protective Service to make a visit to Resident #93's home. He said Resident #93 was not discharged until her hospital bed, wheelchair, and combination shower chair and bedside toilet were delivered. The SWA said Resident #93 told him she had oxygen at her home already and if Resident #93 needed additional oxygen, the HH agency would provide it. The SWA said the beginning of her being discharged started with Resident #93's insurance company declining her medical coverage for her stay at the facility. The SWA said he did not offer her a Medicaid application. The SWA said Resident #93 paid for her hospital bed, her wheelchair, and combination toilet and shower chair herself. The SWA said as far as he was concerned Resident #93 was fine because she had all her equipment and HH. The SWA said the facility did not have her sign the AMA because the discharge was insurance driven. He said he could have offered her a Medicaid application, but it was too late and bill would have added up for her to have private pay. The SWA said he was the person who handled Resident #93's discharge. The SWA said the insurance company made Resident #93 leave because the insurance company did not approve Resident #93's appeal. During an interview on 05/05/2026 at 1:46 PM the MD said Resident #93 was quite challenging because Resident #93 had issues with CHF and she did not watch her diet. She said her CHF was affecting her breathing and her fluid levels. The MD said Resident #93 was not getting much better and was not making huge strides in therapy. The MD said she recommended long term care. The MD said Resident #93 was taking care of a family member and was insistent on going home. The MD said in no way did she recommend that Resident #93 going home was safe given Resident #93's health issues. The MD said the SW said he would discuss with Resident #93 not going home. The MD said the facility did not have Resident #93 sign an AMA because they have had trouble with getting HH services for residents after a resident has signed an AMA. During an interview on 05/05/2026 at 2:01 PM with Resident #93's FM #2 he said it was very hard to reach the SW when he called the facility. He said the facility had a high turnover of employees and there were 2 or 3 SWs. FM#2 said he left several messages for a SW to call him back and he did not receive a return call. FM #2 said Resident #93 told him she did not want to leave the facility because she wanted to be able to walk before she left. FM #2 said when Resident #93 went home, she had a bed, a walker, and a commode. FM #2 said to his knowledge she had no oxygen at her home. FM #2 said the oxygen that she did receive was given to her from the EMS personnel. FM #2 said he was not going to take care of Resident #93. FM #2 said he was at Resident #93's home when Resident #93 came home. FM #2 said Resident #93 was supposed to have someone in place to give her wound care and change her brief. FM #2 said to his knowledge, nothing was in place and Resident #93 did not have a nebulizer for breathing treatments. FM #2 said he had a full-time job and was not a caregiver for Resident #93. FM #2 said he came over to Resident #93's home on Sunday, 05/03/2026 about 9:30 AM and Resident #93 had urinated and pooped on herself. FM #2 said Resident #93 could not walk to the restroom. FM #2 said Resident #93 had some friends come over and change Resident #93 and get her cleaned up. FM #2 said Resident #93 could not walk one step when she came home from the facility. FM #2 said EMS carried her into the house and transferred her into her hospital bed. FM #2 said he absolutely did not feel like it was safe for Resident #93 to be at home. FM #2 said he could not believe that the facility let her come home and he thought that they discharged Resident #93 because her insurance expired. During an interview on 05/5/2026 at 3:40 PM with NP in hospital IMU (a step-down unit for patients requiring closer monitoring than a general ward but less than intensive care) she said Resident #93 was admitted to the hospital on [DATE] for CHF exacerbation and fluid overload. During an interview on 05/05/2026 when she was at the hospital at 3:46 PM with Resident #93 she said she was not informed about going to a skilled nursing facility. She said she did not need to go home to take care of a family member. Resident #93 said the NP at the facility told Resident #93 her time was up and she needed to go home. She said she was unable to walk. During an interview on 05/05/2026 at 4:00 PM with LVN D she said she was the nurse who discharged Resident #93 home. LVN D said Resident #93 was excited to go home and Resident #93 had no respiratory issues when she was discharged . LVN D said Resident #93 was on continuous oxygen when she was discharged and she was bedbound. LVN D said Resident #93 could not walk. LVN D was told by a nurse at the facility, she did not remember the nurse's name, that Resident #93 was going to have HH. LVN D said Resident #93 probably would not have done well at home without HH. LVN D said she did not believe Resident #93 would have a safe discharge without HH. During an interview on 05/08/2026 at 8:51 AM with the ADM said different people were responsible for resident discharges. The ADM said an IDT (approach in healthcare, where nurses, physicians, therapists, and social workers collaborate closely to create a unified, patient-centered care plan) meeting was part of the discharge process. The ADM said the SW had the responsibility for a resident HH referral. The ADM said the discharge process happens upon admission. The ADM said the discharge policy should be followed to the letter. The ADM said the best thing to do about HH was for the SW to call the HH provider and confirm HH was in-place. During an interview on 05/08/2026 at 10:04 AM with the SWA he said he had his only telephone extension, separate from the SW extension, and was not aware that the HH called the facility and reported that they would not be providing HH to Resident #93. The SWA said he spoke with an HH representative who did not tell him there were problems with obtaining HH for Resident #93. The SWA said he felt HH should have communicated better within their agency. He said he would not have called Adult Protective Services for a well check call for Resident #93; he said that a SW would have done this and he was an assistant to the SW. The SWA said the SW stopped working for the facility on Thursday, April 28, 2026, before Resident #93 was discharged . During an interview on 05/08/2026 at 10:21 AM with EMT said when Resident #93 went home she was in stable condition. EMT said Resident #93 was morbidly obese and there was no way she could walk. EMT said she has bilateral stage 4 pitted edema (severe condition characterized by very deep pits (approximately 8 millimeters or more) that last for 2-5 minutes or longer, causing gross distortion of both legs that indicates severe fluid retention, often caused by systemic issues like [congestive heart failure], [kidney disease], or [severe liver dysfunction)). The EMT said they had a struggle getting her inside the house. The EMT said he did not know what care she was going to have while she was at home. During an interview on 05/08/2026 at 11:20 with the former SW she said when she stopped working for the facility, Resident #93 was still a resident. She said Resident #93 always said she wanted to go home and her discharge plan was always for Resident #93 to return home. The former SW was not aware that HH had declined services to Resident #93. The SW said there was no formal meeting about Resident #93's discharge. During an interview on 05/08/2026 at 1:50 PM with the VPC she said an AMA would be applicable if the MD did not feel the resident was ready for discharge, but the resident said that they were leaving. The VPC said she was not familiar with the situation with Resident #93 and did not know if a notice of discharge or if an AMA was necessary because she had not been with the company long enough to know a lot of the policies and procedures. During an interview on 05/08/2026 at 2:23 PM with the RNC she said an AMA would be necessary if the patient acknowledged and were informed by the facility that it was not safe for them to discharge from the facility. The RNC said if a resident just wanted to leave and the patient did not have a medical release that would be going against medical advice. Record review of facility Transfer or Discharge, Facility-Initiated dated October 2022 reflected once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy.Policy Interpretation and Implementation1. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless:1. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility. 2. the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at this facility. 1. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. 2. For a resident who becomes eligible for Medicaid after admission to a facility, the facility will charge a resident only allowable charge under Medicaid. Facility-Initiated Transfer or Discharge Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences.In some cases, residents are admitted for short-term, skilled rehabilitation under Medicare, but, following completion of the rehabilitation program, they communicate that they are not ready to leave the facility. In these situations, if the facility proceeds with discharge, it is considered a facility-initiated discharge.Non-Payment as a Basis for DischargeNon-payment for a stay in the facility occurs when the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility and also may apply:1. when the resident has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or2. after the third-party payer (including Medicare or Medicaid) denied the claim and the resident refused to pay for his/her stay.2. The facility will notify the resident of their change in payment status, and ensure the resident has the necessary assistance to submit any third-party paperwork.3. If the resident continues to need long-term care services, the facility, under the requirements above, will offer the resident the ability to remain, which may include:1. offering the resident the option to remain in the facility by paying privately for a bed;2. providing the Medicaid-eligible resident with necessary assistance to apply for Medicaid coverage in accordance with S483.10(g)(13), F579, with an explanation that:1. if denied Medicaid coverage, the resident would be responsible for payment for all days after Medicare payment ended; and2. if found eligible, and no Medicaid bed became available in the facility or the facility participated only in Medicare (SNF only), the resident would be discharged to another facility with available Medicaid beds if the resident wants to have the stay paid by Medicaid.4. If a resident's initial Medicaid application is denied but appealed, this suspends non-payment status while the appeal is pending. An Immediate Jeopardy was identified on 05/05/2026 and the Administrator was notified of the Immediate Jeopardy on 05/05/2026 at 5:51 PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The facility's POR for Immediate Jeopardy was accepted on 05/07/2026 at 8:30 AM and reflected the following: PLAN OF REMOVAL: Facility Name:Date: 5/5/26The facility failed to ensure a safe discharge for Resident #93 on 05/02/26, which resulted in Resident #1 requiring hospitalization due to CHF exacerbation on 05/03/26. Resident #1 was not discharged with home health in place and confirmed to have all necessary DME's in place prior to discharge. Immediate Action: -The facility immediately contacted resident #1 to inform her that the facility will accept the readmission immediately, or as soon as the hospital deems them ready for transport. Attempted to leave a VM for this resident to return facility's call. Text message sent to resident's personal cell

Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 15 residents (Resident #20, Resident #59, Resident #64 and Resident #102) reviewed for resident rights. The facility failed to ensure CNA B knocked on Resident #20, and Resident #59 and Resident #64's doors when going into the residents' rooms. The facility failed to ensure Resident #102's catheter had privacy cover on it. These failures could place residents at risk of poor self-esteem and feeling like their privacy was being invaded.Findings include: 1. Record review of Resident #20's face sheet, dated 05/05/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included metabolic encephalopathy (brain disease), hypertensive chronic kidney disease (damage to kidneys due to chronic high blood pressure), hyperlipidemia (high cholesterol), hypertension (high blood pressure), weakness, and unsteadiness on feet. Record review of Resident #20's admission MDS assessment, dated 02/23/2026, revealed Resident #20 had a BIMS score of 08, which indicated moderate impairment. Record review of Resident #20's care plan dated 04/17/2026 did not reflect anything about privacy or knocking on the resident's door. During an interview with Resident #20 on 05/05/2026 at 8:09a.m., she said the staff never knocked on the door. She said she would prefer for the staff to knock on the door, especially if the door was closed. 2. Record review of Resident #59's admission sheet, dated 05/05/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #59 had diagnoses which included heart failure, respiratory failure, muscle weakness, gastroesophageal reflux disease without esophagitis (reflux), hypertension (high blood pressure), and sepsis (a life-threatening complication of an infection). Record review of Resident #59's admission MDS assessment, dated 05/06/2026, revealed Resident #59 had a BIMS score of 10, which indicated moderate impairment. Record review of Resident #59's care plan dated 04/17/2026 did not reflect anything about privacy or knocking on the resident's door. During an interview with Resident #59 on 05/05/2026 at 7:49a.m., she said staff do not knock on the door. She said staff were supposed to knock on the door. She said it would be nice if the staff knocked on the door. She said if she was being changed staff would just walk inShe said staff just were not thinking before they entered the room. 3. Record review of Resident #64's face sheet, dated 05/05/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #64 had diagnoses which included protein-calorie malnutrition (inadequate intake of both protein and calories), sepsis (a life-threatening complication of an infection), hypertension (high blood pressure), kidney failure, and alcohol abuse. Record review of Resident #64's admission MDS assessment, dated 04/20/2026, revealed Resident #64 had a BIMS score of 09, which indicated moderate impairment. Record review of Resident #64's care plan dated 04/17/2026 did not reflect anything about privacy or knocking on the resident's door. During an interview with Resident #64 on 05/05/2026 at 8:02a.m., he said staff just walk into his room all the time. He said he would like for staff to knock all the time. He said he got irritated when staff just walked into his room. 4. Record review of Resident #102's face sheet, dated 05/05/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #102 had diagnoses which included hearing loss, pain, hypertension (high blood pressure), hypertension (high blood pressure), cognitive communication deficit (problems with communication), fracture of on rib and pain. Record review of Resident #102's admission MDS assessment, dated 05/06/2026, revealed Resident #102 had a BIMS score of 99, which indicated unable to complete the interview. Record review of Resident #102's care plan dated 05/01/2026 did not reflect anything about the catheter. Observation of Breakfast Hall meal tray's being passed on 05/05/2026 at 7:17a.m., revealed CNA B did not knock on Resident #59's door before entering the room. Observation of Breakfast Hall meal tray's being passed on 05/05/2026 at 7:25a.m., revealed CNA B did not knock on Resident #64's door before entering the room. Observation of Breakfast Hall meal tray's being passed on 05/05/2026 at 7:28a.m., revealed CNA B did not knock on Resident #20's door before entering the room.Observations on 05/05/26 at 08:53 AM and 12:48p.m., revealed Resident #102 in bed, asleep and not available for interview. A urinary bag hanging from the side, bottom of Resident #102's bed that had no privacy cover. Urine was exposed and the bag contained urine that was dark orange in color. The urine could be seen from the hallway. During an interview with CNA B on 05/05/2026 at 11:32 a.m., revealed she had been trained on resident rights. She said the policy was staff were to knock on the door before entering. She said knocking was for the resident's privacy. She said all staff were responsible for knocking. She said residents may get upset if staff do not knock. She said the nurses monitored to ensure staff are knocking. She said the nurses monitored by observation. She said she was nervous because the surveyor was there watching her. During an interview with MA F on 05/05/26 at 12:52 p.m., she stated urinary bags were supposed to be hung with a clean privacy bag to cover that was dated. She stated exposed urine affected residents' self-worth and dignity. She stated she did not notice Resident #102's bag as she was a new admit. She stated policy, at any facility, was for a privacy bag to be utilized. She stated she believed the DON would be ultimately responsible for ensuring privacy bags were available and used.During an interview with CNA A on 05/05/26 at 12:58 p.m., he stated privacy bags were supposed to be cleaned and covered, according to facility policy. He stated was over supplies and had to responsibility of making sure they were utilized. He stated the nurse was to be notified in the event the privacy bags were lacking. He stated he had just peeked in Resident #102's room and did not actually go inside because she was asleep. He stated he did not realize she had a urinary bag. He stated the lack of privacy could cause residents shame.During an interview with Central Supply on 05/05/26 at 02:25 p.m., she stated she was responsible for resident supplies. She stated privacy bags came with urinary bags she stated she was unaware Resident #102 did not have a privacy bag. She stated staff were supposed to on into the supply closet and get one if they noticed an exposed urinary bag. She stated when Resident #102 was admitted on [DATE] she had a privacy bag with her urinary bag. She stated facility policy stated privacy covers were a requirement for all urinary bags. She stated the lack of privacy on the urinary bag could have a negative effect on residents in that could be a dignity issue. During an interview with the DON on 05/07/2026 at 5:08p.m., revealed she had been trained on resident right. She said the policy was staff were to knock and wait for the resident to tell them to enter. She said all staff should knock on the resident's door. She said a resident may feel disrespected if staff did not knock. She said the management and charge nurses should be monitoring. She said managementRecord review of the Dignity Policy dated 02/2021 revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

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 diseases and infections for 4 (Resident #7, Resident #32, Resident #95 and Resident #101) of 7 residents reviewed for infection control. The facility failed to ensure CNA A wore PPE as required for Resident # 32, who was on enhanced barrier precautions. The facility failed to ensure Central Supply wore PPE as required for Resident # 95, who was on enhanced barrier precautions. The facility failed to ensure LVN D followed infection control and prevention by not cleaning the glucometer prior to and after checking Resident #101's blood sugar, and by not cleaning the insulin vial prior to withdrawing a dose. The facility failed to ensure LVN D followed the hand hygiene policy by not properly performing hand hygiene while administering insulin to Resident #101. The facility failed to ensure RN A followed infection control and prevention by not cleaning the glucometer and basket, in which she stored the glucometer supplies, after checking Resident #7's blood sugar and prior to putting it into the medication cart. These failures could place residents at risk for cross contamination and the spread of infection.Findings included: 1. Review of Resident #7's face sheet dated 05/06/2026 revealed a [AGE] year-old female initially admitted to the facility on [DATE]. She re-entered the facility on 04/04/2026 with the following diagnoses: Type 2 diabetes mellitus with hyperglycemia;.Review of Resident #7's MDS assessment dated [DATE] revealed she had a BIMS score of 4 which indicated severely impaired cognition. During an Observation on 05/07/2026 at 11:15a.m., reflected RN A used a small amount of hand sanitizer and rubbed it on the palms of her hands for a few seconds. She checked Resident #7's blood sugar, she failed to clean the glucometer prior to putting it in the medication cart. She used a purple basket to store the glucometer supplies when she entered Resident #7's room and placed it on Resident #7's bedside table. She failed to clean the purple basket prior to putting it in the medication cart.During an interview on 05/07/2026 at 11:17a.m., RN A reported they do sanitize the glucometer before and after each use. She stated, I don't have my sanitizer on the medication cart. She reported not cleaning the glucometer before and after each use can put the resident at risk of getting an infection. She reported she should sanitize her hands with hand sanitizer for at least 20 seconds since she did not wash her hands with soap and water. She reported not sanitizing her hands for 20 seconds could transmit infection. 2. Record review of Resident #32's face sheet, dated 05/07/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #32 had diagnoses which included nontraumatic intracerebral hemorrhage (a severe stroke involving bleeding directly into the brain), person injured in a motor-vehicle accident, nontraumatic subarachnoid hemorrhage (spontaneous bleeding in the fluid filled space between the brain and the skull), fractured rib, fractured lower leg, and fractured spine. Record review of Resident #32's admission MDS assessment, dated 04/21/2026, revealed Resident #32 had a BIMS score of 01, which indicated severe cognitive impairment. Record review of Resident #32's care plan dated 05/04/2026 [Resident #32] has actual impairment to skin integrity related to: Right hip closed surgical wound, Trauma to left lower abdominal quadrant, closed midline abdominal surgical wound, trauma to right lower abdominal quadrant. Interventions were use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Further review revealed the care plan did address enhanced barrier precautions. During an observation with Resident #32 on 05/05/2026 at 9:14a.m., Resident #32's room door had an enhanced barrier precautions sign on it. The PPE station right outside Resident #32's door was equipped with only 1 glove and 1 gown. CNA A assisted with removing a brace from her right arm. CNA A did not utilize PPE of any type. During an interview with CNA A on 05/05/2026 at 9:18a.m., he said he had been with the facility nearly 14 years. He said any time there was a PPE station, staff was supposed to utilize the PPE. He said the PPE equipment was set up for residents who had a catheter or IV and was not necessarily for conditions. He said the expectation was to put the PPE on any time there was PPE outside the resident's door. He said nurses would usually tell the CNAs which resident had what condition. He said if he did not adequately utilize PPE he could transfer something to another resident, he said he did not know if there was a policy in place. He said his most recent in-service training on infection control was about a couple of weeks ago. He said the DON was responsible for ensuring infection control policies were adhered to 3. Record review of Resident #95's admission sheet, dated 05/07/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #95 had diagnoses which included breast cancer, Asperger's syndrome (a neurodevelopment condition), protein-calorie malnutrition (inadequate intake of both protein and calories), anxiety (feeling of uneasiness or worry), and hypokalemia (low potassium). Record review of Resident #95's admission MDS assessment, dated 03/21/2026, revealed Resident #95 had a BIMS score of 99, which indicated unable to complete interview. Record review of Resident #95's care plan dated 04/06/2026 revealed Staff must use gown and glovesduring high-contact resident care activities that could possibly result in transfer of MDROs (multidrug-resistant organism) to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO. During an observation and interview on 05/05/2026 at 8:00a.m., Resident #95 was yelling from the hall yelling in his room. Enhanced barrier precaution sign was on Resident #95's door. Staff were observed entering the room with no PPE. Central Supply stated Resident #95 had a small wound. She said she was just assisting with pulling Resident #95 up in the bed. She said PPE was required any time patient care was provided to the resident. 4. Review of Resident #101's face sheet dated 05/07/2026 revealed was a [AGE] year-old male admitted to the facility on [DATE]. He had the following diagnosis: Type 2 diabetes mellitus (a chronic condition where the body develops insulin resistance, which is a condition where body cells fail to respond effectively to insulin eventually leading to high blood sugar or type 2 diabetes). Review of Resident #101's physician orders with a start date of 05/01/2026 revealed the following insulin order: Insulin Lispro inject 5 units subcutaneously before meals for high blood sugars. Hold Lispro if BS under 200.During an observation on 05/07/2026 at 11:38a.m., reflected LVN D placed the glucometer supplies in a gray tray. She failed to perform hand hygiene prior to putting gloves on. She failed to clean the glucometer prior to checking Resident #101's blood sugar. She failed to clean the top of the insulin vial prior to withdrawing a dose for Resident #101. She sanitized the palms of her hands for less than 5 seconds, and she failed to spread the hand sanitizer on the back of her hands prior to administering Resident #101's insulin. Resident #101 asked her to empty his urinal, and LVN D failed to properly perform hand hygiene after emptying his urinal. She sanitized the palms of her hands for less than 5 seconds, and she failed to spread the hand sanitizer on the back of her hands. She failed to clean the glucometer or gray tray prior to putting it in the medication cart.During an interview on 05/07/2026 at 12:00 p.m., LVN D reported not cleaning the glucometer prior to and after each use on a resident could cause biohazard transmission due to intermingling with fluids. She reported staff should wipe the insulin vial prior to puncturing it to ensure a clean surface. She reported that staff should sanitize their hands for 15-20 seconds by covering their hands with sanitizer and allowing them to dry. She reported they can also wash for 20 seconds with hot water. During an interview with the DON on 05/07/2026 5:11p.m., she said she had been trained on infection control. She said the policy for PPE was for enhanced barrier precautions meant the staff needed to gown up and glove up and wash hands. She said everyone was responsible to wear PPE if they were going into the resident's room. She said if staff did not wear PPE the facility could have cross contamination and spread different things to other residents. She said the nurse and management team monitored to ensure staff wore PPE. She said the management team and nurses monitored through in-services and observation rounds. She said she did not know why staff were going in rooms without wearing PPE. She said they know they should be wearing the PPE. She reported that staff should clean the glucometer before and after each use with a resident. She reported that staff should perform hand hygiene or wash their hands prior to entering and after exiting a resident's room. She reported hand hygiene should also be performed in between administering medications to one resident, and prior to administering medications to another resident. She stated, staff should perform hand hygiene for at least 20 seconds to ensure their hands are properly cleaned. She reported the management team and charge nurses were responsible for monitoring hand hygiene by staff. During an interview with the ADM on 05/08/2026 at 9:11a.m., she said she had been trained on infection control she said she had been trained on infection control. she said the policy was that the staff wear PPE special when it was indicated on the resident's door. She said if the resident has a sign on their door for PPE, staff should wear PPE. She said if staff did not wear PPE with those residents staff could spread diseases or other communitive diseases. She said the IP monitored to ensure staff were wearing PPE. She said the IP and management monitored through observation round. She said she did not know why staff were not wearing PPE. In an interview on 05/08/2026 at 2:13 pm, ADM reported the glucometer should have been sanitized prior and after use with a resident. Record review of the Handwashing/Hand Hygiene Policy date 10/2023 revealed The facility considered hand hygiene the primary means to prevent the spread of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for hand hygiene included: a. immediately before touching a resident; b. before performing an aseptic task; c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; and e. after touching the resident's environment. Their procedure for applying alcohol-based hand rubs was 1. Apply generous amount of product to palm of hand and rub hands together. 2. Cover all surfaces of hands and fingers until hands are dry. 3. Rub hands together for a minimum of 15 seconds.

Based on observation, interview, and record review the facility failed to serve food and drink that was palatable, attractive, and a safe and appetizing temperature for residents for one (1) of one (1) kitchen reviewed for food and nutrition services. The facility failed to serve warm food to residents. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life.Findings included: During an interview on 05/05/2026 at 7:01 a.m. Resident #63 stated the food was always cold when he ate in his room. Resident #63 stated that he had to ask staff to warm up his food and bring it back because he could not eat cold food because it did not taste good. During an interview on 05/05/2026 at 7:32 a.m. Resident #91 stated the food was not good and it was served cold. During an observation and interview on 05/05/2026 at 7:35 a.m. and 8:28 a.m. Resident #75 was overhead yelling from her room, where is my breakfast? Can someone bring me my breakfast? My plate is cold. Staff reheated plate and returned it. Resident #75 stated every time her food was brought to her room, the food was cold. Resident #75 stated that staff reheated her plate, and the food came back hard. During an interview on 05/05/2026 at 8:19 a.m. Resident #103 stated that his food usually arrived cold. During an interview on 05/06/2026 at 10:18 a.m. Resident #19 stated the food was always cold. In an observation on 05/06/2026 at 12:18 p.m., the State Survey Team participated in the sampling of the Lunch Meal which included one regular test tray. The lunch tray consisted of beans, spinach, and a meat patty that appeared to be turkey with a gravy on top. When tasted by two state surveyors, all the food on test tray was cold. In an observation on 05/07/2026 at 12:30 p.m., the State Survey Team participated in the sampling of the Lunch Meal which included one regular test tray. The lunch tray consisted of a Philly cheesesteak sandwich, mashed potatoes, red potatoes, green beans and mixed vegetables, a tossed salad, and cheesecake. When tasted by two state surveyors, the green beans and mixed vegetable on the test tray were cold. During an interview on 05/07/2026 at 1:15 p.m., the DA stated she was responsible for putting meal trays on the carts to go to the floors and the food was hot when it came out of the kitchen. The DA had heard from some staff that the food was cold. During an interview on 05/07/2026 at 1:22 p.m., the RD stated that she came to the facility once a week. The RD was aware of some complaints about the food being cold, it had not been often enough for her to do any type of in-service training. The RD stated her expectation would be that hot foods would be served to the residents according to standardized guidelines of 120 . If food was served cold, residents were less likely to eat and then input would be down, which could lead to unexpected weight loss. During an interview on 05/07/2026 at 1:40 p.m. the dietary cook stated he was aware of residents complaining that their food was cold. When that happens, it usually depended on which staff members were working on the floor because some C.N.A work faster than others. His expectation would be that hot food was served hot around 165 degrees, otherwise, it could make residents sick. During confidential resident interviews, nine residents stated that the food was not warm when they received it. During an interview on 05/07/2026 at 6:16 p.m. the ADM stated that her expectation was food would be delivered to residents at a safe and warm temperature according to policy to decrease the risk of infection, bacteria, or contamination. The ADM was unaware of any residents complaining about cold food. Record review of the facility policy titled, Food and Nutrition Services revised October 2017, reflected, Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. Record review of the facility policy titled, Food Preparation and Service revised November 2022, reflected, The danger zone for food temperatures is above 41 F and below 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Proper hot and cold temperatures are maintained during food distribution and service.

Based on observation and interview, the facility failed to ensure storage of drugs and biologicals used in the facility for 2 of 8 medication carts observed for medication storage and labeling. The facility failed to ensure loose medications were removed from the medication carts. This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medication. This failure could lead to unsafe and unsecure storage of all medication to reduce, minimize loss, or diversions for all medications.Findings included: Observation on 05/07/2026 at 11:07 a.m., reflected RN B had five loose pills in her medication cart. In an interview on 05/07/2026 at 11:08 a.m., RN B reported the nurses, unit managers, DON, and pharmacy check the medication carts. She reported that the pharmacy checks the medication carts every month. She reported she notified DON and disposed of the loose medications in the sharp's container [specialized, puncture-resistant receptacle used to safely dispose of medical instruments that can cut or puncture the skin, such as needles and syringes]. Observation on 05/07/2026 at 11:30 a.m., reflected RN A had one loose pill in her medication cart. She disposed of the loose pill in the trash can. In an interview on 05/07/2026 at RN A stated, loose pills in the medication cart could cause confusion. She reported that managers and RNs check the medication carts every week for loose medications. Observation on 05/07/2026 at 11:56 a.m., reflected LVN D's medication cart had 1 small, round, blue pill which was loose in her medication cart. There was a bottle of Active Liquid Protein that did not have an open date written on it. In an interview on 05/07/2026 at 12:00 pm, LVN D reported staff will not be able to identify a medication if it is loose in the medication cart. She reported she disposed of loose pills in the pill incinerator. She denied they dispose of loose pills in the sharps container. In an interview on 05/07/2026 at 5:15 pm, DON stated nurses should always clean their medication cart after each shift. She stated, everybody should be responsible for their carts. She reported management checks the medication carts 3-4 times a week. She stated, it is an infection control issue to have loose pills in the medication carts. She reported they expect staff to write the open date on medications. She stated, I am not sure if [Active Liquid protein] is good for 2 weeks. She stated, there is a rationale for writing the open date on medications, but I don't know what the rationale is for writing the open date on Active Liquid protein. In an interview on 05/08/2026 at 2:13 pm, ADM reported staff should check their medication carts to ensure there are not loose pills in their medication carts. She stated, the nurse manager is responsible for rounding and making sure that happens. Review of the facility's administering medications policy with a revision date of 04/2019 revealed medications are administered in a safe and timely manner, and as prescribed. 12. The expiration/beyond use date on the medication label is checked prior to administering [sic]. When opening a multi-dose container, the date opened is recorded on the container.

Based on interview and record review, the facility failed to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 of 3 residents (Resident #27, Resident #73, and #85) reviewed for activities. The facility failed to provide Resident #27 with activities he was able to do, failed to offer Resident #73 activities, and failed to provide Resident #85 activities that interested him. This failure could place residents at risk for boredom, depression, and diminished quality of life. Findings include: 1.Review of Resident #27's face sheet dated 05/07/2026 reflected an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included blindness right eye category 5 (total, irreversible blindness, often defined as no light perception) and blindness left eye category 4 (represents a severe visual impairment where the best corrected visual acuity in the eye is worse than 20/200, defined as having only ability to see light rathethan form). Review of Resident #27's Resident Assessment and Care Screening MDS assessment, dated 04/07/2026, reflected a BIMS score of 6, indicating severe cognitive impairment. Section B - Hearing, Speech, and Vision reflected vision highly impaired - sees large print, but not regular print in newspaper/books. Section F - preferences for customary routine activities - F0500 how important is it to you to have books, newspapers, and magazines to read - very important. Review of Resident #27's care plan focus dated 04/16/2026 reflected visual impairment/legally bind related to glaucoma (a group of eye diseases that damage the optic nerve-often due to high eye pressure-leading to permanent, irreversible vision loss or blindness) and eye infection/eye pressure and no focus on Resident #27's care plan for activities. During an interview on 05/08/2026 at 11:49 AM with Resident #27 he said he got bored on the weekends because the facility did not have enough activities especially because they did not have activities to accommodate the blind. Resident #27 said a staff member did take him to play bingo, but he was not provided with a large print bingo card, so he was unable to participate. 2.Review of Resident #73's face sheet dated 05/08/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included displaced comminuted fracture of shaft of right femur (a severe injury where the thighbone is broken into three or more pieces and has shifted out of alignment), atrial fibrillation (the most common treated heart arrhythmia, characterized by a rapid, chaotic, and irregular heartbeat originating in the heart's upper chambers (atria)), and morbid obesity due to excess calories (occurs when calorie consumption consistently exceeds energy expenditure). Review of Resident #73's Resident Assessment and Care Screening MDS assessment, dated 04/30/2026, reflected a BIMS score of 15 indicating no cognitive impairment. Review of Resident #73's baseline care plan dated 04/23/2026 reflected no focus care plan for activities. During an interview on 05/08/2026 12:22 pm with Resident #73 she said she was not asked about activities she would like to do when she was admitted to the facility. She said the first time she received an activity calendar was on 05/08/2026. Resident #73 said no one had come to her room and offered her any activities, like coloring materials or puzzles, she could do in her room. Resident #73 said she was bored. She said when someone came to her room, she talked their ear off because she was so bored. 3.Review of Resident #85's face sheet dated 05/08/2026 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included central cord syndrome at C3 level of cervical spinal cord (a severe, incomplete cervical spinal cord injury characterized by disproportionately greater motor impairment in the arms/hands than in the legs, often caused by hyperextension injuries in individuals with pre-existing cervical spondylosis), occlusion and stenosis of unspecified meddle cerebral artery (narrowing (stenosis) or blockage (occlusion) of the brain's largest vessel, often due to atherosclerosis or blood clots), and cerebral aneurysm, no ruptured (a weak, bulging spot in a brain artery that has not yet leaked or burst). Review of Resident #85's quarterly MDS assessment, dated 03/22/2026, reflected a BIMS score of 9 indicating moderate cognitive impairment. Review of Resident #85's care plan reflected a focus dated 06/19/2024 Resident #85 was dependent on staff for activities. Cognitive stimulation, social interaction related to physical limitations. During an interview on 05/08/2026 at 1:42 PM with Resident #85 he said the facility had asked him what activities he would like. He said they used to play a toss game outside, but they cannot currently locate the game. Resident #85 said they used to have popcorn during movies but have been told they can no longer have popcorn and he does not know why. He said he was currently bored. During an interview on 05/07/2026 at 10:27 AM with the acting AD she said she had been doing the activities at the facility for about two weeks after the previous activity coordinator left. The acting AD stated activities do not start on time which was why the 10:00 AM scheduled activity for aromatherapy and manicures did not occur at that time. She said at 10:00 AM she was going to the residents' room and handed out the amended activities calendar. The acting AD said there was not a lot of involvement in activities because a lot of residents did not have the physical ability to come to the activities. The acting AD said the same 4 or 5 people show up to all the activities. The acting AD said she felt like there were enough activities for the residents. She said she did not have any training in being an activities director and she was not offered any direction from anyone at the facility with the activities. She said she got a lot of help from HR. She said the activities might start on time or might not start on time it just depended, but she had an activity every day. She felt like there were not enough people who were able to participate in activities because of their physical issues or might not have stamina. She said she had a lot of residents who said they were not up to it. During an interview on 05/08/2026 at 10:50 AM with the ADM she said residents should be asked about their activity preferences. She said the AD should be the person to obtain that information from the residents somewhere during the initial phase of the resident's admission. The ADM said the AD should meet with the residents to discuss activities the resident might like. She said she was not sure what the negative effect would be if residents were not offered activities they liked. During an interview on 05/08/2026 at 1:50 PM with the VPC she said she thought it was important to offer residents activities. The VPC said activities were important because they helped with residents' social wellbeing and maybe kept them from being bored. Record review of the facility Activity Programs policy dated June 2018 reflected Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Policy Interpretation and Implementation - 1. The activities program is provided to support the well-being of residents and to encourage both independence and community interaction.2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.3. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities.4. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive, or emotional health.5. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs.6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs.7. Our activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident. Activity programs include activities that promote - self-esteem; comfort; pleasure; education; creativity; success; and independence.8. Activities are not necessarily limited to formal activities being provided only by activities staff. Other facility staff, volunteers, visitors, residents, and family members may also provide the activities.9. All activities are documented in the resident's medical record.10. Activities participation for each resident is approved by the attending physician based on information in the resident's comprehensive assessment.11. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g., bed bound or visually impaired residents).

Based on interview and record review, the facility failed to ensure a new resident was not admitted with mental illness unless the state mental health authority determined, based on independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission for 2 of 12 residents (Resident #35 and Resident #65) reviewed for PASRR services. The facility failed to ensure a PASRR screening was completed correctly for Resident #35 and for Resident #65. This failure could place residents at risk for not obtaining the services needed to treat their mental health diagnoses. The findings include: 1. Record review of Resident #35's face sheet, dated 05/06/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included bipolar (extreme mood swings), shortness of breath, dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), hypertension (high blood pressure), cerebral infraction (stroke), and need for assistance with personal care. Record review of Resident #35's admission MDS assessment, dated 03/23/2026, revealed Resident #35 had a BIMS score of 99, which indicated unable to complete the interview. The MDS also documented bipolar disorder (extreme mood swings) as active diagnoses. Record review of Resident #35's care plan, dated on 04/07/2026, noted [Resident #35] used psychotropic medications related to behavior management - bipolar and psychosis. The interventions were Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness every- shift. Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Record review revealed of Resident #35's PASRR dated 03/13/2026 revealed mental illness was marked no. During an interview with Resident #35 on 05/05/2026 at 11:12 a.m., Resident #35 would not answer questions about his mental illness. Resident #35 said his care was good. 2. Record review of Resident #65's face sheet, dated 05/06/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #65 had diagnoses which included bipolar (extreme mood swings), major depressive disorder (mental health disorder characterized by persistent depressed mood), schizophrenia (mental health condition that affects everything from how you think, how you feel and how you behave), dysphagia (inability to empty from the throat to the esophagus), hypertension (high blood pressure), and cerebral infraction (stroke). Record review of Resident #65's admission MDS assessment, dated 04/15/2026, revealed Resident #65 had a BIMS score of 13, which indicated intact cognitive response. The MDS also documented bipolar disorder (extreme mood swings), schizophrenia (mental health condition that affects everything from how you think, how you feel and how you behave), anxiety disorder (feeling of uneasiness or worry), and depression as active diagnoses. Record review of Resident #65's care plan, dated on 04/12/2026, noted [Resident #65] uses psychotropic.medications r/t Schizophrenia/Bipolar Disorder The interventions were Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness every- shift. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. Discuss with MD, family re ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of (SPECIFY: psychotropic medication drugs being given). Record review revealed of Resident #65's PASRR dated 04/09/2026 revealed mental illness was marked no. Interview attempted with Resident #65 on 05/05/2026 at 9:11a.m., was unsuccessful. During an interview with the MDS Coordinator on 05/07/2026 at 3:55p.m., she said she had been trained on PASRR. She said the policy for PASRR was all residents had to have a PASRR when they were admitted to the facility. She said she was responsible for ensuring the resident had a PASRR. She said they get the PASRR from where the resident admits from. She said the MDS Nurse was responsible for reviewing the PASRR and ensuring it was correct. She said the MDS Nurse was also responsible for submitting all the PASRR in simple (the PASRR system). She said some diagnoses that would trigger a resident as a positive PASRR was mental retardation, Intellectual disabilities, schizophrenia, major depressive disorder and bipolar. She said if a resident had a new qualifying diagnosis the facility would discuss the resident and the new diagnosis in the morning meeting, check the progress notes, and pull a report. She said she was responsible for sending the referral in to the state agency. She said if a PASRR was not marked correctly the facility would not be able to care for the resident or give them the proper treatment they need. She said the DON and ADM monitored to ensure the PASRR was correct. She said the DON did an audit and the team discussed the audit in the morning meeting. She said the Regional Reimbursement Consultant monitored competency. She said the Regional Reimbursement Consultant did a competency check list to ensure everyone was on same processes. She said that Resident #35 and Resident #65 both should have been PASRR positive. She said both residents should have been marked as yes for mental illness. She said she did not know why Resident #35 and Resident #65 were not marked correctly. During an interview with the ADM on 05/08/2026 at 9:20a.m., revealed she had been trained on PASRR. She said the MDS Nurse was responsible for ensuring the resident had a PASRR. She said the PASRR should be done before admission. She said the MDS Nurse should ensure the PASRR was correct. She said residents were screened for PASRR by their medical records and it was determined by the information in their record. She said some diagnoses that would make a resident PASRR positive was schizophrenia, Intellectual disability, and some psychosis. She said the MDS Nurse was responsible for sending the referral to the state designated authority. She said if a resident had a new diagnosis something triggered in the computer system. She said the Regional Reimbursement Nurse monitored to ensure the PASRRs were done correctly. She said the Regional Reimbursement Nurse pulled a report and audits so many PASRRs per week to ensure they were accurate. She said the Regional Reimbursement Nurse monitored competency in PASRR. She said the Regional Reimbursement Nurse did a competency checklist and training. She said if the resident was PASRR positive and was marked incorrectly the resident would not get the resources that they qualified for. She said she did not know why Resident #35 and Resident #65's PASRR was marked incorrectly. Record review of the PASRR Policy dated 01/20/2026 revealed The aim of the PASRR program is to identify residents with Mental Illness, Intellectual Disability or Developmental Disability and to ensure they are properly placed, whether in community or in a Nursing Facility and to ensure they receive the services they require for their Mental Illness, Intellectual Disability or Developmental Disability. When it is determined that a PL 1 was filled out incorrectly, the MDS Coordinator, Social Worker or designee will reach out to the hospital/responsible case worker and ask them to correct the form. If the referring case worker is unwilling/unable to correct the PL 1 that contains a potential error, the social worker or designee will complete and submit a form 1012 or new PL 1. A subsequent positive PL 1 will be entered according to 1012 findings. When it is determined that an individual's diagnosis was changed and/or a state surveyor determines the PL 1 was incorrect, the social worker or designee will complete and submit a form 1012 or new PL 1. A subsequent positive PL 1 will be entered according to 1012 findings.

Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #27) of one residents reviewed for vision impairment. The facility failed to ensure Resident #27 1. Was told what food he was having for breakfast and where it was located on his tray and it was free from cellophane 2. Received large print reading materials This failure could place residents at risk of needs and accommodation being unmFindings Include: Review of Resident #27's face sheet dated 05/07/2026 reflected an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included blindness right eye category 5 (total, irreversible blindness, often defined as no light perception) and blindness left eye category 4 (represents a severe visual impairment where the best corrected visual acuity in the eye is worse than 20/200, defined as having only ability to see light rather than form). Review of Resident #27's Resident Assessment and Care Screening MDS assessment, dated 04/07/2026, reflected the following: *a BIMS score of 6, indicating severe cognitive impairment. *Section B - Hearing, Speech, and Vision reflected vision highly impaired - sees large print, but not regular print in newspaper/books.* Section F - preferences for customary routine activities - F0500 how important is it to you to have books, newspapers, and magazines to read - very important. Review of Resident #27's care plan focus dated 04/16/2026 reflected visual impairment/legally bind related to glaucoma (a group of eye diseases that damage the optic nerve-often due to high eye pressure-leading to permanent, irreversible vision loss or blindness) and eye infection/eye pressure. Further review revealed there was no focus area addressing activities. Observation on 05/05/2026 at 8:30 AM of Resident #27 alone in his room sitting on the edge of his bed with a bedside table in front of him with a meal tray on the bedside table. The meal tray had a bowl of grits mostly empty and spilled on the outside of the bowl, scrambled eggs, a piece of toast, a plastic cup of juice (unknown flavor) covered in cellophane, and a closed plastic container of grape jelly. Observation on 05/08/2026 at 3:50 PM of facility activity calendar attached to a bulletin board in Resident #27's room reflected the calendar was not in large print and Resident #27 was unable to read it. During an interview on 05/05/2026 at 8:30 am with Resident #27 he said when he was served breakfast in the morning and staff bring him his tray, they put it on his bedside table, and leave the room. Resident #27 said staff did not tell him what food was on his plate or where it was on the breakfast tray. Resident #27 said he was trying to eat because he did not want to lose any more weight. He said he was blind and asked the surveyor to tell him where his food was on the tray. When asked if he wanted his juice, he said he did not know he had juice. Resident #27 requested assistance to remove the plastic. Resident #27 said this aggravated him because he was blind. Resident #27 said he tried to be as independent as he could be, and he was the only blind resident in the facility. Resident #27 said that he used a cane and learned after a while how to get to the nurses' station without using a cane. He said when he wanted something and he did not have assistance; he would walk to the nurses' station and ask for help. During a Resident Council meeting held on 05/07/2026 at 1:00 PM Resident #27 said he was told about the resident council meeting, and he asked that a staff member come to his room and take him to the meeting because he did not know where the meeting was going to take place. Resident #27 said a staff member did not come to his room to take him to the meeting and he walked to the nurses' station and asked someone to take him to the meeting. Resident #27 said they dropped off papers for him, but they were not large print and he could not read them. Resident #27 said the facility did not do anything to facilitate blind people. During an interview on 05/07/2026 at 3:18 pm with an OT she said about two months ago Resident #27 told her the aides were dropping off his food and leaving without telling him what food was on his plate, where the food was, or removing the cellophane wrapping. The OT said she spoke to a nurse about it, and it was supposed to be addressed. The OT said she could not remember the name of the nurse she spoke with. The OT said the staff was in a hurry and did not take the time to orientate him to his food. The OT said she would get frustrated if she could not see, there was no one to ask, and she was not told where food was on her plate. The OT said Resident #27 went to the dining room for lunch and dinner and there were staff in the dining room to tell him what was on his plate. During an interview on 05/07/2026 at 3:48 pm with LVN UM she said she supervised the nurses. She said Resident #27 had a disorder and saw shadows and things that were not there. LVN UM said staff brought Resident #27 breakfast, they uncovered his food, removed any cellophane, and told him where his food was. LVN UM said he needed this accommodation because of his vision. LVN UM said it would be disheartening to have food placed in front of you and not knowing what it was or where it was. LVN UM said if she were Resident #27 this would be frustrating. During an interview on 05/07/2026 at 4:03 PM with CNA C she said Resident #27 always had breakfast in his room and she told him what he had on his breakfast plate and she told him where his food was. She said he did not need any additional assistance. CNA C said if you did not do something for Resident #27, he would ask you to do it. During an interview on 05/08/2026 at 8:51 AM with the ADM she said Resident #27 was visually impaired. She said she was not sure if Resident #27 received large print reading materials. The ADM said it would be good for Resident #27 to know what was on his plate when he received meals. During an interview on 05/08/2026 at 12:27 PM with LVN F she said the CNAs usually took Resident #27 his breakfast. LVN F said the CNAs told him where his drink was and where the food was on his plate. During an interview on 05/08/2026 with the VPC she said Resident #27's activity calendar should be in large print so he could read it. During an interview on 05/08/2026 at 2:13 PM the RNC said if a resident was visually impaired, they should receive accommodation. The RNC said everyone was responsible for accommodating Resident #27's needs. The RNC said if he could not see his food, it would be frustrating and if someone just presented the food to him and left, she would be frustrated. Record review of facility Accommodation of Needs policy dated March of 2023 reflected Policy Statement our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. Policy Interpretation and Implementation - The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Examples of such adaptations may include:In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the residents' wishes. For example:1. interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity;2. arranging toiletries and personal items so that they are in easy reach of the resident; and3. maintaining hearing aids, glasses, and other adaptive devices for residents.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 6 of 10 residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for pharmacy services.The facility failed to administer Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7's medications greater than one hour after the scheduled administration time.This failure placed residents at risk for receiving less than therapeutic benefits from medicationsFindings included:Record review of Resident #2's face sheet, dated 04/15/26, reflected Resident #2 was admitted to the facility on [DATE]. She was a [AGE] year-old female diagnosed with type 2 diabetes, orthostatic hypotension (low blood pressure when standing), peripheral vascular disease(slow peripheral blood circulation) , anxiety disorder, muscle weakness and hypertension.Record review of Resident #2's initial MDS dated [DATE] reflected a BIMS score of 13 indicating her cognition was intact.Record review of Resident #2's care plan dated 04/14/26 reflected that she was on medication for anxiety, depression , anemia , pain from hip fracture and hypertension (high blood pressure). The intervention indicated administering medications as ordered by physician and monitor for side effects . Record review of Resident #2's physicians' orders reflected her medications scheduled at 8a.m were amlodipine Besylate oral tablet 10 MG, linagliptin oral tablet 5 MG, Multivitamin oral tablet, Ferrous Sulfate oral Table oral tablet Delayed Release , Metoprolol Tartrate oral tablet 25 MG and Acetaminophen oral tablet 500 MG.Record review of Resident #2's April 2026 MAR reflected that on 04/15/26 Resident#2's medications scheduled at 8:00am were administered at 11:03am.During an interview on 04/15/26 at 11:30am the RP of Resident #2 stated Resident #2 received medications later than 9 a.m. every now and then. He stated it was not a big issue as none of her medications were time sensitive and no harm occurred because of it. He stated however he preferred the medications administered with time consistency.Record review of Resident #3's face sheet, dated 04/15/26, reflected Resident #3 was admitted to the facility on [DATE]. She was a [AGE] year-old female diagnosed with fracture of unspecified part of neck of left femur (thigh bone), type 2 diabetes, syncope (fainting) and collapse, cardiomyopathies (inability to pump blood by heart muscles) , acute embolism(blockage of lung artery) and thrombosis(formation of blood clots in blood vessels) and pain.Record review of Resident #3's initial MDS dated [DATE] reflected a BIMS score of 14 indicating her cognition was intact.Record review of Resident #3's care plan dated 11/25/25 reflected that she had hypertension, cardiomyopathy, embolism, pain and relevant intervention was giving medications as ordered and monitoring /documenting side effects and effectivenessRecord review of Resident #3's physicians' orders revealed her medications scheduled at 8 a.m. included Aspirin 81 mg oral tablet, Carvedilol 3.125 mg oral tablet, Furosemide 40 mg oral tablet, Liquid Protein 30 ml (once a day), Lisinopril 2.5 mg oral tablet, Pantoprazole Sodium 40 mg delayed-release oral tablet, Calcium 500 + D oral tablet (500 mg calcium - 5 mcg vitamin D), and Acetaminophen 500 mg oral capsule.Record review of Resident #3's April 2026 MAR reflected that on 04/15/26 Resident#3's medications scheduled at 8:00am were administered at 11:20am.During an interview on 04/15/26 at 12:15pm Resident #3 stated Resident #3 received medications later than 9 a.m. She stated she was okay even though they were late, however, preferred to receive them as scheduled. She stated the delay occurred occasionally .Record review of Resident #4's face sheet dated 04/15/26 reflected, Resident #4 was admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with cerebral infarction(stroke), obesity, dizziness and giddiness, epilepsy, nausea with vomiting, anxiety disorder, hypertension and , abdominal painRecord review of Resident #4's quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating his cognition was intact.Record review of Resident #4's physicians' orders reflected that his medications scheduled at 8 a.m. and 9 a.m. included Docusate Sodium 100 mg oral tablet, Losartan Potassium 100 mg oral tablet, Isosorbide Mononitrate Extended Release 24-Hour 120 mg oral tablet, Nifedipine Extended Release 24-Hour 90 mg oral tablet, Pantoprazole Sodium 20 mg delayed-release oral tablet, Sertraline HCl 50 mg oral tablet, Spironolactone 25 mg oral tablet, Carvedilol 25 mg oral tablet, Levetiracetam 1000 mg oral tablet, and Hydralazine HCl 50 mg oral tablet. Record review of Resident #4's April 2026 MAR reflected that on 04/15/26 Resident#4's medications scheduled at 8:00am and 9:00am were administered at 10:20am.During an interview on 04/15/26 at 12:15pm Resident #4 stated he received medications everyday and had not noticed what time he received them. He stated, if medications were provided everyday, he was least concerned about the time. He stated the nurses were doing a good job with administering medications.Record review of Resident #5's face sheet dated 04/15/26 reflected Resident #5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female diagnosed with Parkinson's disease, type 2 diabetes, anxiety disorder, hypertension and pain.Record review of Resident #5's quarterly MDS dated [DATE] reflected a BIMS score of 03 indicating her cognition was severely impaired.Record review of Resident #5's care plan dated 02/14/24 reflected that she was taking medications for Depression, Anxiety, seizures, Parkinson's, Diabetes Mellitus, hypertension, Dementia and the relevant intervention was administering medications as ordered and monitoring/documenting for side effects and effectiveness.Record review of Resident #5's physicians' orders reflected that her medications scheduled at 8 a.m. included Amlodipine Besylate 5 mg oral tablet, Cholecalciferol 25 mcg tablet, Lisinopril 10 mg oral tablet, Multivitamin-Minerals oral tablet, Pantoprazole Sodium 40 mg delayed-release oral tablet, Amantadine HCl 100 mg oral capsule, Docusate Sodium 100 mg tablet, Ferrous Sulfate 325 mg oral tablet, Memantine HCl 10 mg oral tablet, Metoprolol Tartrate 25 mg oral tablet, MiraLAX 17 g packet, Risperidone 0.5 mg oral tablet, Valproic Acid oral solution, Venlafaxine HCl 75 mg (250 mg/5 ml), Vitamin C 500 mg oral tablet, and Clonazepam 1 mg disintegrating oral tablet.Record review of Resident #5's April 2026 MAR reflected that on 04/15/26 Resident#5's medications scheduled at 8:00am were administered at 11:07am.Resident #5 was unable to participate in an interview due to her cognitive capacity.Record review of Resident #6's face sheet, dated 04/15/26, reflected Resident #6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female diagnosed with cauda equina syndrome(compressed nerve roots at the bottom of the base of spine), malignant neoplasm (cancerous cell growth) , COPD (breathing difficulty), chronic pain syndrome, anxiety disorders, major depressive disorder.Record review of Resident #6's quarterly MDS dated [DATE] reflected a BIMS score of 06 indicating her cognition was severely impaired.Record review of Resident #6's care plan dated 03/26/26 reflected that resident had pain r/t disease process cauda equina syndrome , chronic pain and she was on anticoagulant, hyperlipidemia(high cholesterol) meds, antidepressant , also medications for dizziness, dementia, hypertension. She was also potential for Respiratory infections/distress, Hypoxia (low oxygen level), SOB, and cough related to DX of COPD. The relevant intervention was administering medication/puffers as ordered and monitoring for effectiveness and side effects.During a record review on 04/15/26 of Resident #6's physicians' orders as of 04/15/26, it was reflected that her medications scheduled at 8 a.m. included Amlodipine Besylate 10 mg oral tablet, Baclofen 10 mg oral tablet, Lidocaine 4% external patch, MiraLAX 17gram powder (per scoop), Sertraline HCl 50 mg oral tablet, Vitamin B12 100 mcg oral tablet, Vitamin D3 50 mcg oral capsule, Apixaban 5 mg oral tablet, Caltrate with D3, Docusate Sodium 100 mg oral tablet, Gabapentin 300 mg oral capsule, Hydrocodone-Acetaminophen 10-325 mg oral tablet, and Pepcid 20 mg oral tablet. Record review of Resident #6's April 2026 MAR reflected that on 04/15/26 Resident#6's medications scheduled at 8:00am were administered at 10:35am.Resident #6 was unable to participate in an interview due to her cognitive capacity.Record review of Resident #7's face sheet, dated 04/15/26, reflected Resident #7 was admitted to the facility on [DATE] . He was a [AGE] year-old male diagnosed with end stage renal disease, shortness of breath, hypertension, bipolar disorder, diseases of liver, chronic kidney disease, restlessness and agitation, COPD and dementia.Record review of Resident #7's initial MDS dated [DATE] reflected a BIMS score of 06 indicating his cognition was severely impaired.Record review of Resident #7's care plan dated 10/18/25 reflected he had performance deficit r/t end stage renal disease, COPD, major Depressive and bipolar Disorder disorders, Respiratory infections/distress, Hypoxia, SOB, and cough related to COPD and Dementia. The relevant intervention was administering medications and monitoring effects and side effects.During a record review on 04/15/26 of Resident #7's physicians' orders as of 04/15/26, it was reflected that his medications scheduled at 8 a.m. included Amlodipine Besylate 5 mg oral tablet, Benztropine Mesylate 1 mg oral tablet, Divalproex Sodium 500 mg delayed-release oral tablet, Memantine HCl 5 mg oral tablet, and Olanzapine 10 mg oral tablet. Record review of Resident #7's April 2026 MAR reflected that on 04/15/26 Resident#7's medications scheduled at 8:00am were administered at 11:35am.Resident #7 was unable to participate in an interview due to his cognitive capacity.Observation and record review on 04/15/26 at 12:20pm, it was revealed that the morning medications of Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7 were administered by MA C.During an interview on 04/15/26 at 12:25 p.m., MA C stated that she worked at the facility as a PRN and started her shift at 6 a.m. on this day. She explained that she knew medications scheduled for 8 a.m. could be administered anytime between 7 a.m. and 9 a.m. She added, nevertheless there were quite a few residents who received their medications after 9 a.m., as she had other commitments and began administering medications later than expected. MA C said that administering medications at the correct time was a fundamental principle of medication administration and was essential to ensure the optimal therapeutic benefit.During an interview on 04/15/26 at 12:30 p.m., LVN A stated that she was the nurse in charge and that MA C was under her supervision. She explained that the hall was often short-staffed, which sometimes led to MAs and LVNs being assigned tasks other than medication administration. She added that this negatively affects the timely administration of medications. LVN A stated she was aware that medication administration should be completed within one hour of the scheduled time. She mentioned that, like on this day and many other days in the past, medications were not always administered on time due to the triaging of nursing tasks shared among LVNs and MAs .LVN A stated she had reported this issue to the previous DON and no actions taken. She added, hopefully the issue would be resolved as the facility had a new DON and administrator and they were aware of the situation.During an interview on 04/15/26 at 12:45 p.m., RN D stated that she worked in a different hall than MA C and was responsible for administering medications in her hall. She reported that residents with 8 a.m. medication schedules had their medications administered well before 9 a.m. RN D said that administering medications on time was important to maximize their benefits. She also noted that some medications were highly sensitive to timing, and it was the responsibility of the medication administrator to ensure they were given promptly.During an interview on 04/15/26 at 1:02 p.m., the NP stated that he did not have any comments regarding medication administration, as it was not part of his responsibilities. When asked whether a delay in administering medications could adversely affect residents, he responded that it depends on the medication and various other factors, and it was not necessarily an issue for all medications. He explained that medication scheduling was not managed by him, so he was unable to comment further. The NP emphasized that ensuring medications were administered on time was the facility's responsibility, and he did not play a role in that process.During an interview on 04/15/26 at 1:45 p.m., the AP stated that she was the primary attending physician for the residents at the facility. She said that some medications were time-sensitive, such as seizure and pain medications, and must be administered as scheduled without delay. She noted that currently, there were no residents on such medications at the facility, so delayed medication administration was not an immediate concern. The AP clarified that the NP works at the facility under her licensure, and both she and the NP were responsible for prescribing medications and determining doses and frequencies. She stated she visited the residents at the facility regularly and observed and verified that none of the residents were negatively impacted with the delay in medication administered if it was happened.During an interview on 04/15/26 at 2:20 p.m., the MD stated that he had heard about the issue regarding the delay in administering morning medications on this day. He emphasized that administering medications on time was very important, regardless of the medication, as residents have different physical conditions and respond differently to treatments. He added that some medications were particularly sensitive and required careful timing. The MD stated that staff at the facility needed additional training and education in this area and affirmed his commitment in ensuring all residents receive quality care.During an interview on 04/15/26 at 12:55 p.m., the DON stated that she had started working at the facility one week prior and getting to know the issues and concerns in the nursing area. She explained that medication administration should follow the physician's orders and that administering medications at the correct time was a key aspect of medication administration principles. She noted that delays could result in next doses being given too early or too late, which might prevent residents from achieving the intended therapeutic effects. She further stated that, in some cases, delayed or mistimed medication administration could cause more harm than benefit. The DON mentioned that some medications were time-sensitive for certain residents and conditions, and the best practice was to follow the facility policy of administering medications within one hour before or after the scheduled time.Record review of the facility policy Administering Medications revised in April 2019 reflected : Medications are administered in a safe and timely manner and as prescribed .Medication administration times are determined by resident need and benefit , not staff convenience .Factors that are considered include:Enhancing optimal therapeutic effect of medication.Medications are administered within one hour of the prescribed time unless otherwise specified ( for example , before and after meal orders).

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #1) reviewed for respiratory care.The facility failed to ensure Resident #1's O2 nasal cannula and water bottle changed every week as ordered by the physician.This failure placed residents at risk for respiratory infections through contamination. Findings included:Record review of Resident #1's face sheet, dated 04/14/26, reflected Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female diagnosed with COPD (difficulty to breath due to restricted airflow) , obstructive sleep apnea (breathing stop and start during sleep) , acute bronchiolitis (lower respiratory infection) , chronic kidney disease, dementia, major depressive disorder and dysphagia (difficulty to swallow).Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 01 indicating her cognition was severely impaired. Further review revealed he was on oxygen therapy for respiratory issues.Record review of Resident #1's care plan dated 11/26/25 reflected that she was on oxygen therapy via nasal cannula continuously and/or PRN for SOB and the relevant intervention was providing oxygen as ordered by physician.Record review of Resident #1's physician's order reflected : O2: O2 sats every shift and PRN: every night shift. -Start Date-11/23/2025. O2: Change and label water humidification and nasal cannula tubing weekly on Sunday on night shift. -Start Date-11/23/2025During an observation and interview on 04/14/26 at 1:10p.m. of the labels on Resident #1's nasal cannula and the water humidification bottle connected to oxygen tank revealed that they were last changed on 02/23/26.The resident was in bed and stated she did not know or remembered anything related to the oxygen nasal cannula.During an observation and interview on 04/14/26 at 1:35 PM, LVN A removed Resident #1's oxygen nasal cannula and humidifying container. She stated that, as per the physician's order, it was the responsibility of the Sunday night shift nurses to change them every week. She explained that if they were not changed regularly, there was a possibility of microorganism colonization, which could cause serious respiratory and other infections. She also mentioned that it was a mistake by other staff members, as no one verified whether the cannula and water container had been changed by the Sunday night shift nurses, according to the order. She added, it was evident that they had not changed in the past month, even though the order was to change them every Sunday.During an interview on 04/14/26 at 2:30 p.m., RN B stated that she worked in a different hall than Resident #1's . She stated that she had only one resident on oxygen therapy and confirmed that her oxygen nasal cannula tubing was changed on 04/10/26. RN B stated that, as per protocol, the cannula needs to be changed every week or when it was found soiled or nonfunctional. She added that changing the cannula, mask, and humidifier bottle was important to minimize the risk of respiratory infections.During an interview on 04/15/26 at 11:00 a.m. with the DON, she stated that she started working at the facility as the DON one week ago and committed to addressing concerns related to nursing. She said that the oxygen humidifier bottle, nasal cannula, and humidifier mask should be dated and changed weekly, as well as PRN if they were found empty or soiled. She explained that, although according to the physician's order, it was the responsibility of the night nurses on Sundays, everyone was responsible for ensuring they were changed as per the order. She stated that her plan was for the ADON and DON to make rounds as often as possible to ensure that physician's orders were carried out and that other nursing tasks were up to date. She also mentioned she was not happy that the physician's order was not followed for over a month , as this increased the risk of respiratory infections from soiled equipment.Review of the facility policy Oxygen Administration revised in October 2010 reflected the following: Verify that there is a physician's order for this procedure . Review the physician's orders , facility protocol for oxygen administration .Oxygen /nebulizer tubing/masks to be changed by nursing department weekly and documented in the electronic record.

Based on interview and record review the facility failed to ensure a resident with pressure ulcer (injury/bedsore) is skin and tissue damage from prolonged pressure, friction, or shear) receives necessary treatment services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers from developing for 1 of 4 closed record (CR) #1 reviewed for pressure ulcers in that: 1. The facility failed to prevent the development of a pressure ulcers to CR #1's 1-left foot measuring (Length x Width x Depth) 2x2x0 centimeters (cm).2. The facility failed to prevent the development of a pressure ulcers to CR #1's right lateral ankle measuring 1x1x1 cm.3. The facility failed to prevent the development of a pressure ulcers to CR #1's 1-left hip measuring 4x4x0 cm.4. The facility failed to prevent the development of a pressure ulcers to CR #1's-sacrum/sacral (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) measuring 10x15.5x0 resulting in CR #1 being transferred to a local acute care hospital 10/30/2025. 5. The facility failed to provide CR #1 with a pressure reducing mattress on 10/15/2025 resulting in CR #1 being without the mattress for 15-days resulting in the development of sacrum pressure wound. 6. The facility failed to provide CR #1 with pressure reducing heel boots for 11-days from 10/15/2025 to 10/26/2025 resulting in the resident acquiring. On 11/13/2025 at 02:41 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/15/2025 at 06:01 p.m., The facility remained out of compliance with the scope of pattern that was not actual harm with potential for more than the minimal harm that was not an immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed residents at risk for further skin breakdown, infections, and pain. Findings included: Record review of CR #1's facesheet dated 11/11/2025 reflected a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 10/30/2025 with medical diagnoses including but not limited to fracture of fourth lumbar vertebra (supporting the upper body and connecting to the pelvis), injury to fourth lumbar (L4): vertebra in the lower back) level of lumbar spinal cord (refers to the nerve roots), traumatic subdural hemorrhage (excessive bleeding from a damaged blood vessel) without loss of consciousness, abrasion of right forearm, abrasion, left lower leg, lumbago with sciatica (a condition characterized by lower back pain that radiates down the buttocks and into one or both legs), and edema (swelling caused by fluid buildup in the body's tissues). Record review of CR #1's undated care plan reflected CR #1 required total assistance for all assistance of daily living (ADLs): (specify) mobility, transfers, dressing, eating, toileting, hygiene/grooming, bathing related to (r/t) clinical diagnosis (as listed above) initiated and revised on 08/17/2025. Goal: CR #1 will have all ADLs met by staff as evidenced by turning and repositioning and safe transfer initiated and revised on 08/17/2025. Interventions/Tasks: CR #1 required assistance with meals initiated on 08/17/2025 and revision on 09/01/2025. Have two-person transfer or mechanical lift as needed initiated on 08/17/2025. Record review of CR #1's hospital discharge records dated 08/04/2025 reflected that CR #1 discharged to the facility for recovery from a fall, head injury subdural hygroma (a collection of cerebrospinal fluid in the brain), fracture injury L4 superior endplate (the top surface of the vertebrate bones) compression fracture with 27 percent (%) loss of vertebral height and 2 millimeters retropulsion (disorder where a person tends to fall backward). Moderate spinal canal stenosis (narrows and puts pressure on the spinal cord) at this level after repeated falls withing a 3-day period beginning on 07/25/2025 while in CR #1's personal residence. Record review of CR #1's Comprehensive Minimum Data Set, dated [DATE] reflected the resident had a Brief Interview for Mental Status (BIMS) score of 03 indicating that the CR #1 had severe cognitive impairment. Section M0100: Determination of the Pressure Ulcer/Injury Risk indicated that a formal assessment instrument/tool and clinical assessment were performed. Section M0150: Risk of Pressure Ulcers/Injuries indicated that the CR #1 was at risk for developing pressure ulcers/injuries. Section M0210: Unhealed Pressure Ulcers/Injuries indicated that the resident had not had one or more unhealed pressure ulcers/injuries. And had not had one or more unhealed pressure ulcers/injuries. Other Ulcers, Wounds and Skin Problems, none were present. M1040: Other Ulcers, Wounds and Skin Problems, none present. Foot problems. None were present. Section M - Skin Conditions M1200: Skin and Ulcer/Injury Treatments: Pressure reducing device for bed. Record review of CR #1's Predicting Pressure Sore Risk Scale assessment effective date: 08/15/2025 at 06:36 p.m. CR #1 was a Low Risk, sensory perception. Ability to respond meaningfully to pressure-related discomfort: No Impairment/Responds to verbal commands. Had no sensory deficit which would limit ability to feel or voice pain or discomfort. Moisture degree to which skin is exposed to moisture: Very Moist/Skin is often, but not always moist. Linen/bedsheets must be changed at least once a shift. Activity degree of physical activity: Chairfast/Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. Had no limitation or mobility/ability to change and control body position/ability to make major and frequent changes in position. Record review of CR #1's Clinical Record Progress Notes dated 8/15/2025 06:08 p.m. CR #1 was admitted into the facility from an acute care hospital for a fall with subdural hygroma and L4 compression fracture (spinal surgery for fractures) managed conservatively; urinary tract infection treated. Head to toe skin check done, redness noted to his buttock, bruise to his left side of his stomach, skin tear to his right upper arm. Record review of CR #1's Weekly Skin assessment dated : 08/16/2025 07:30 p.m. reflected MD A noted old trauma wounds, and old bruising. CR #1's skin color was normal, and temperature warm, equal, and dry. Integrity of skin intact. Further noted: Old bruising to right abdomen (Abd), old bruising to right arm, and old trauma wound to right arm. Record review of CR #1's Clinical Record Progress Notes dated 8/16/2025 at 01:13 p.m. reflected Licensed Vocational Nurse (LVN) A performed an observed CR #1 in room with on and off confusion noted and bed placed to lowest position. Further revealed noted during a head-to-toe skin assessed: Redness noted to sacral area/perineal the area of skin and tissue between the anus and the genitals) area. Applied barrier cream and will continue/encourage application. Record review of CR #1's Weekly Skin assessment dated [DATE]at 01:31 p.m. reflected MD A instructed LVN B to complete CR #1's weekly skin assessments. CR #1's skin color: Normal, with temperature equal, skin dry, and integrity of skin intact. Noted surgical wounds with old bruised, and no new wounds. Record review of CR #1's Orders dated 08/18/2025 at 08:22 a.m. reflected: MD A ordered Enhanced Barrier Precautions/barrier cream to bed added to CR #1's wounds. Record review of CR #1's Weekly Skin assessment dated [DATE] at 05:38 p.m. reflected MD A ordered LVN B to complete this weekly skin assessment. Full Assessment found that CR #1's skin color to be normal, with normal temperature warm, equal, and dry. Integrity of skin intact. Further assessment found old bruise to right Abd, old trauma scar to right arm. Record review of CR #1's Weekly Skin assessment dated [DATE] at 09:58 p.m. reflected MD A ordered LVN A to complete this weekly skin assessment. Full Assessment: Color normal, temperature warm, and integrity of skin intact. Record review of CR #1's Weekly Skin assessment dated [DATE] at 10:22 p.m. reflected MD A ordered LVN A to complete this weekly skin assessment. Full Assessment: Color normal, temperature warm, and integrity of skin intact.: Record review of CR #1's Weekly Skin assessment dated [DATE] at 06:13 p.m. reflected MD A complete this weekly skin assessment. Skin color normal, temperature warm, and integrity of skin intact. Record review of CR #1's Weekly Skin assessment dated [DATE] at 06:13 p.m. reflected MD A complete this weekly skin assessment. Skin color normal, temperature warm, and integrity of skin intact. Record review of CR #1's Weekly Skin assessment dated [DATE] at 08:50 p.m. reflected MD A instructed LVN A to perform a full skin assessment. LVN A noted skin coloring normal and temperature warm. Record review of CR #1's Skin assessment dated [DATE] at 10:13 p.m. reflected MD A instructed LVN A to complete this weekly Skin Assessment. Skin Assessment found no alterations in skin integrity noted. Record review of CR #1's Communication Form/Situation, Background, Assessment, Recommendation (SBAR) dated 10/14/2025 at 12:00 a.m. The change in condition, symptoms, or signs observed and evaluated is/are: Skin wound or ulcer, change in skin color or condition This started on: 10/14/2025. This condition, symptom, or sign has occurred before: unknown. Background: CR #1 in the facility for: Long-Term Care. Skin evaluation found discoloration to wound. Review and Notify: to Primary Care Clinician Notified. Recommendations of Primary Clinicians (if any): Wound doctor to eval/see and treat wound discoloration as indicated. Record review of CR #1's Orders dated 10/14/2025 at 09:32 p.m. reflected MD A Ordered: Wound doctor to evaluate and treat sacrum wound and left foot wound. Order Type/Treatment Orders were: Evaluate and treat wounds one time a day for wounds for 2 days. Record review of CR #1's Skin assessment dated [DATE] at 09:33 p.m. reflected MD A instructed LVN A to complete this weekly Skin Assessment. Assessment finding blister to left (outer) ankle and blister to sacrum. Record review of CR #1's Clinical Record Progress Notes dated 10/14/2025 at 09:35 p.m. created by LVN B reflected, a change in condition/s reported: During CR #1's incontinent care an open wound to CR #1's sacrum, with redness, and swelling was discovered and blister likeness on his left foot. No signs/symptoms (s/s) of pain or any discomfort noticed or reported. Medical Doctor (MD) Recommended/Ordered for Wound Doctor (WD) consult. Record review of CR #1's Wound assessment dated [DATE] at 02:37 p.m. reflected WC received instructions from MD A to complete weekly wound assessments and complete wound assessment to be completed for each wound. Type of wound: Pressure ulcer, sacrum with date of onset 10/15/2025. Wound acquired within facility. Contributing factors: Pressure. Drainage - Character, serosanguinous (fluid that contains both blood and serum (the liquid part of blood), appearing as thin, watery, pinkish-red or light red drainage from a wound). Drainage amount light, with no odor, and wound edges pink. Support devices: Apply Positioning devices. Skin turgor (elasticity, its ability to change shape and snap back, tested by pinching it) fair. Current treatment: Cleanse with wound cleanser and apply wound gel (moist healing environment, control bacteria), and cover with bordered gauze (a sterile, multi-layer wound dressing with an adhesive border that secures it to the skin) daily and prescribed as needed (PRN). Record review of CR #1's Wound assessment dated [DATE] at 02:48 p.m. reflected MD A instructed WC to complete this weekly Skin Assessment for each of CR #1's wounds. Assessment: Pressure ulcer, site left foot, date of onset 10/14/2025, and acquired within the facility. Describe contributing factors: Pressure. Wound stage: deep tissue injury (DTI) Current treatment prepare skin by leaving open to air. Record review of CR #1's Orders dated: 10/15/2025 at 02:53 p.m. reflected MD A Ordered/Treatment Monitoring: Left foot one time a day. Monitor the treatment site for surrounding skin condition and pain status. If changes are observed, document signs with a progress note for further review. Record review of CR #1's Orders dated: 10/15/2025 at 02:57 p.m. reflected MD A Ordered/Treatment Order: provide skin care to left foot every shift. Record review of CR #1's Orders dated 10/15/2025 at 02:58 p.m. reflected MD A ordered description: Sacrum: Cleanse with wound cleanser/normal saline (NS) apply Wound gel and cover with bordered gauze daily and PRN. Order Type: Treatment Orders. Pharmacy Order Summary: Sacrum: Cleanse with wound cleanser/NS apply Wound gel and cover with bordered gauze daily and PRN/one time a day. Record review of CR #1's Skin assessment dated [DATE] at 04:52 p.m. MD A instructed WC to complete this weekly Skin Assessment for each of CR #1's wounds. Assessment found a pressure wound to sacrum area and a DTI blister to left lower extremity. Record review of CR #1's Clinical Record Progress Notes dated 10/15/2025 at 05:15 p.m. Nurse Practitioner (NP) A reflected facility requested a follow up visit to evaluate CR #1's wound. Assessment performed with WC noting a new onset of a sacral ulcer, approximately the size of a baseball with mild redness to surrounding tissue and eschar (a thick, black, leathery layer of dead tissue (necrosis) that forms on the skin after a pressure sore to center of area). Also, noted a DTI to CR #1's left medial foot (the inner edge, running from the heel to the big toe, forming the high part of the arch (medial longitudinal arch) with bones like the talus, navicular, cuneiforms, first metatarsal, and big toe). The medial heel and medial foot (below greater/big toe) had ulcers approximately half dollar size. Further findings noted 2-other ulcers to medial foot are approximately the same size. Spoke with certified nursing aid (CNA) A who confirmed those ulcers were new. Review of CR #1's intake log indicates he does eat over 50% of most of his meals. NP A ordered Complete Blood Count (CBC) blood test (checks the proportion of red blood cells in your blood to help diagnose and monitor conditions like anemia, infections, and blood disorders), Basic Metabolic Panel (BMP) blood test (checks for fluid balance, metabolism, and kidney function, and to help diagnose and monitor various other conditions), and pre-albumin (blood test for measuring and assessing nutritional status. Low prealbumin levels can indicate malnutrition, liver disease, or inflammation), tomorrow. Also ordering air mattress and Prevalon (pressure-relieving heel protectors) boots to offload pressure. Consults to Dietitian and Wound Care MD have been placed. Record review of CR #1's Clinical Record Progress Notes dated 10/17/2025 at 10:00 a.m. reflected NP A's follow up visit with CR #1 noted pressure ulcers to sacrum and foot were examined and found to be relatively unchanged from earlier in the week. The sacral ulcer showed some improvement with approximately 10% granulation (new healthy) tissue now present. The wounds did not appear infected upon examination 10/17/2025. Laboratory studies from 10/16/2025 revealed white blood count (WBC) of 5.5 (normal), hemoglobin 9.2 (low, with a possible indication of anemia, which results from causes such as iron, B12, or folate deficiencies, chronic diseases, or blood loss), sodium 140 (normal range), potassium 4.5 (normal range), Blood Urea Nitrogen (BUN) 12 (normal range), creatinine 0.82 (normal range), and albumin (the most abundant protein in the blood, produced by the liver and essential for maintaining blood pressure and volume) 2.8 (low range). The low albumin level was consistent with protein calorie malnutrition. I discussed with the LVN E about ordering an air mattress and boots to offload pressure on the affected areas. Additionally, I am ordering nutritional supplements (boost shakes) twice a day and placing a consultation to the dietitian for further nutritional assessment and recommendations. Will continue to monitor wound healing progress. Record review of CR #1's Clinical Record Progress Notes dated 10/20/2025 at 01:36 p.m. reflected: NP B seen CR for Skin and Wound. Presents for initial evaluation and management of a non-healing open wound on the sacrum and bilateral lower extremities (BLE). CR #1's LVN A reports that the wound has been present for unknown amount of time as he was admitted to the facility with multiple pressure ulcers. They are currently using - dry dressing for the sacral wound care dressing and skin prep to the BLE ulcers. Offloading techniques in use included leg elevation on pillows. Pressure relief included frequent turning and repositioning. Counseled CR #1's nurse on wound care, diet/nutrition, and pressure relief. Risk factors that may contribute to wound formation and/or delay or poor wound healing: Impaired Functional Mobility, Risk of Malnutrition. Risk factors, diagnoses, and associated interventions have been noted in the CR #1's medical record and are managed by the facility care team. Wound: 3 Location: Sacrum Primary Etiology: Pressure Ulcer/Injury Stage/Severity: Unstageable procedures: A sharp debridement (the medical procedure of removing dead, damaged, or infected skin tissue) was not performed today due to consent for procedure unable to be obtained. Pressure ulcer of sacral region, unstageable. Treatment Recommendations: 1. Cleanse with 0.125% Dakins solution. 2. apply Wound gel to base of the wound. 3. secure with bordered foam. 4. change daily, PRN. Assessment/Plan: The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. Consider arterial doppler if wounds worsen or new wounds develop. CR #1 is incontinent of bowel and bladder. Use appropriate moisture barrier creams per formulary to provide thorough skin care with each incontinent episode. Use formulary briefs when indicated to manage moisture and assess often. Continue with turning and repositioning schedule per protocol for pressure prevention. Position CR #1 side to side as tolerated. Float heels while in bed with use of pillows. Follow up with MD A weekly. Record review of CR #1's Orders dated 10/21/2025 at 10:15 a.m. reflected MD A Ordered Standard Medication: SilverMed External Gel (Silver). Medication Class: Dermatological. Route of Administration: Topically order summary: Apply to sacrum topically one time a day for Wound Care. Record review of CR #1's Clinical Record Progress Notes dated 10/21/2025 at 12:15 p.m. reflected: MD A follow up for evaluation of CR #1's worsening pressure ulcers. MD A noted after discussion with the WC, it was noted that CR #1 has developed a new DTI to his right heel. This represents a concerning progression of CR #1's pressure-related wounds, which now affect both heels and his sacral region. To address these worsening wounds, MD A requested the staff to order an air mattress to reduce pressure on the sacral area and heel boots to protect both feet from further tissue damage. These interventions are essential to prevent further deterioration of the existing wounds and to promote healing. ***Medications*** Wound gel to be applied to sacrum one time a day for wound care. Record review of CR #1's Wound Assessment date: 10/22/2025 at 02:47 p.m. reflected MD A instructed WC to complete this weekly Skin Assessment for each of CR #1's wounds Assessment: Pressure ulcer skin tear, site sacrum, date of onset 10/20/2025, acquired within facility. Describe contributing factors: Pressure. Wound stage: unstageable. 10.5x7x0.5. 10.5 length by (x), 7 width x 0.5 depth (Length x Width x Depth). Drainage - Serosanguinous, moderate amount. Wound edges red. Granulation 100%, and skin turgor fair. Current treatment: Wound gel, cover with dry dressing. Record review of CR #1's Wound Assessment 10/22/2025 at 02:50 p.m. reflected MD A instructed WC to complete this weekly Skin Assessment for each of CR #1's wounds. Assessment: Pressure ulcer, site left foot scattered, date of onset 10/20/2025. Acquired within the facility. Describe contributing factors: Pressure. Suspected DTI. 10x16x0. Drainage, none, odor, none, and edges of wound red in color (usually a normal sign of the body's healing inflammation). Record review of CR #1's Wound assessment dated [DATE] at 02:52 p.m. reflected MD A instructed WC to complete this weekly Skin Assessment for each of CR #1's wounds. Assessment: Pressure ulcer, site right lateral ankle - date of onset 10/20/2025, acquired within the facility, unstageable. 2x2x0. Drainage, none. Support devices - positioning devices. Skin turgor fair. Record review of CR #1's Skin assessment dated [DATE] at 02:55 p.m. reflected MD A instructed WC to complete this weekly Skin Assessment for each of CR #1's wounds. Right ankle (inner) - pressure, sacrum pressure, and pressure left foot. Comments: open area to sacrum. DTI to right ankle and left foot. Record review of CR #1's Clinical Record Progress Notes dated 10/26/2025 at 09:38 p.m. created by LVN C reflected: CR #1 received heel boots for pressure ulcers at lower extremities/foot/heel. Record review of facility's delivery order summary for CR #1's air mattress dated 10/28/2025. Ordered On 10/28/2025 at 08:43 a.m. Received by the delivery company on 10/29/2025 at 3:02 p.m. Priority Next Business Day Fulfill Dated 10/29/2025. Record review of CR #1's Clinical Record Progress Notes dated 10/29/2025 at 02:30 p.m. reflected Skin and Wound evaluation and management of a non-healing open wound on the sacrum and BLE on 10/28/2205 by NP B. Wound deterioration noted, advised hospitalization due to sacral necrosis (dead skin tissue in the sacral area). NP B noted if CR #1 does not go to the hospital he should receive x-rays, labs, wound culture (post debridement), wound healing supplements, low air loss (LAL) mattress, heel relief boots are advised. NP B to follow up weekly. Recommended sending CR #1 to the emergency room (ER). Record review of CR #1's Communication Form SBAR Situation dated 10/29/2025 at 3:00 p.m. reflected NP A noted change in condition of skin wound or ulcer started on 10/29/2025 and stayed the same. Recommendations: Wound Doctor consult order given. Record review of CR #1's Skin Assessment date 10/29/2025 at 03:10 p.m. reflected MD A instructed WC to complete this weekly Skin Assessment for each of CR #1's wounds. Assessment indicated alterations in skin integrity: Right ankle (outer) pressure, sacrum - pressure, and pressure left foot cluster. Record review of CR #1's Wound assessment dated [DATE] at 03:15 p.m. reflected MD A instructed WC to complete this weekly wound assessment and complete separate wound assessment each wound. Skin Prep/Assessment: Pressure ulcer, right lateral ankle. Date of onset 08/15/2025, wound acquired within the facility. Describe contributing factors pressure: 1x1x1 cm. No drainage, no odor, wound edges red, and skin turgor poor. Support devices: Heel protectors. Record review of CR #1's Skin assessment dated [DATE] at 04:42 p.m. reflected MD A instructed LVN A to complete CR #1's weekly skin assessments on each of CR #1's wounds. Left trochanter (hip), left pressure wound, right heel blister, and sacrum pressure comments: Treatment continues on this wound. No alterations in skin integrity noted. Record review of CR #1's Clinical Record Progress Notes dated 10/30/2025 at 02:45 p.m. reflected NP A noted: Discharge Summary. discharge date : [DATE]. CR #1 transfer out to acute care hospital - Leave. ***Chief Complaint*** Sacral ulcer requiring debridement ***Hospital Course*** CR #1 laying in bed, awake and alert. His multiple pressure ulcers remain unchanged compared to the 10/29/2025 examination. NP A spoke with the facility administrator (ADM) regarding CR #1's wound care. WC NP had attempted debridement earlier in the week but was unable to reach Family A to obtain consent. Given that the sacral ulcer will likely require surgical debridement, NP A recommended transferring CR #1 for this procedure. The nursing staff made two attempts to contact Family, unsuccessful. NP noted after discussion with the staff, will transfer CR #1 to acute care hospital for surgical debridement of his sacral ulcer. Patients were wearing Prevalon boots for pressure offloading. Record review of CR #1's Clinical Record Progress Notes dated 10/30/2025 reflected Pain. No pain other than this note: ***Vital Signs*** blood pressure (bp), 131/75, oxygen (O2) 96, Pain level 2 (0: none and 10 worse), Temp 97.5, Respiratory Rate 18, Heart Rate 69. Record review of CR #1's October 2025 (10/16/2025 - 10/30/2025) TAR reflected: Apply skin prep to left foot every shift. One time a day. Start Date 10/16/2025 08:00 a.m. Hold Date from 10/31/2025 09:51 a.m. to 11/01/2025 1200 a.m. D/C Date 11/10/2025 05:02 p.m. All treatments indicated as being received. Record review of CR #1's October 2025 (10/16/2025 - 10/30/2025) TAR reflected: Monitor dressing to sacrum site every shift. One time a day. Start Date 10/16/2025 08:00 a.m. Hold Date from 10/31/2025 09:51 a.m. to 11/01/2025 12:00 a.m. D/C Date 11/10/2025 05:02 p.m. All treatments indicated as being received. Record review of CR #1's October 2025 (10/21/2025 - 10/30/2025) TAR reflected: Right Lateral ankle skin prep daily. One time a day. Start Date 10/21/2025 08:00 a.m. Hold Date from 10/31/2025 09:51 a.m. to 11/01/2025 12:00 a.m. D/C Date 11/10/2025 05:02 p.m. All treatments indicated as being received. Record review of CR #1's October 2025 (10/16/2025 - 10/30/2025) TAR reflected: Sacrum: Clean with wound cleaner/NS apply Wound gel and cover with border gauze daily and PRN. One time a day. Start Date 10/16/2025 08:00 a.m. Hold Date from 10/31/2025 09:51 a.m. to 11/01/2025 12:00 a.m. D/C Date 11/10/2025 05:02 p.m. All treatments indicated as being received. Record review of CR #1's October 2025 (10/16/2025 - 10/30/2025) TAR reflected: Wound doctor to evaluate and treat as indicated. Sacrum wound and left foot wound. One time day for wound for 2 days. Start Date 10/15/2025 08:00 a.m. D/C Date 11/16/2025 12:30 p.m. All treatments indicated as being received. Record review of CR #1's hospital records dated 11/02/2025 reflected CR #1's current diagnosis, medical condition and poor overall outcome if surgical intervention will be done. Family A had been made aware of the unstageable infected nature of themultiple sacral wounds of CR, and surgery is not recommended. Any intervention due to CR #1's end stage dementia, poorquality of life and possible non healing large post operation wounds that may develop, and CR#1 was entirely bed bound. Family A understands the need for hospice placement as of this time and is looking at new long-term facility. Record review of CR #1's hospital records dated 11/05/2025 reflected CR #1 admitted with chief Complaint: infected sacral decubitus. Inpatient Diagnoses: open wound - primary - Onset: 10/30/2025. At some point, CR #1 developed a sacral ulcer which got infected leading to this admission. Assessment and Recommendations: [AGE] year-old man with immobility and failure to thrive who has a large sacral pressure ulcer that is infected. Traditionally one would recommend excisional debridement but in this case this would be futile. CR #1 has expressed to Family A that he does not want life-prolonging interventions. Risk was discussed with Family A of the infection becoming systemic and leading to sepsis/death. Suggestion was to use a palliative approach / hospice and Family A is willing to pursue this. Goals of care will be pain control and odor control if it becomes an isolating factor that would keep Family A from spending time with CR. Local antiseptics will not be of benefit as the odor comes from the necrotic (dead skin) tissue under the skin level. Should odor become very problematic then palliative debridement could be re-considered. Foot DTI and unstageable pressure ulcers are dry and can be left alone. He has also lesioned on feet and wrists. Exam/General: wasted-looking man in no distress. Skin/Wound Exam: Sacral ulcer with fully necrotic wound bed, boggy (skin texture abnormality characterized principally by a palpable sense of sponginess resulting from increased fluid content) and with foul odor. Peri-ulcer skin without signs of cellulitis. Right heel with dark discoloration, no skin breakdown. Right ankle with necrotic ulcers, dry, no drainage or signs of infection. Left heel intact. Left lateral hip ulcer with necrotic base and anasarca (severe, generalized swelling throughout the entire body caused by extensive fluid accumulation in tissues). Moderate-to-large sacral decubitus ulceration (skin injury from prolonged pressure) with no evidence osteomyelitis (painful bone infection/bacteria) involving the underlying sacrum or coccyx (small triangular bone at the base of the spinal column). In an interview on 11/11/2025 at 12:12 p.m. WC stated that she had begun working for the facility full time approximately two months ago Monday - Friday from 8 a.m. - 5 p.m. She stated she previously worked PRN weekends. She stated that she had not been familiar with CR #1 at the time of his admission, but mid to end of October 2025 received an order from the NP C to begin new wound treatment to his sacrum. She stated NP C ordered labs and put into place the following interventions: air mattress, heel protector, nutritional supplements, and increase repositioning as CR #1 had begun laying on one side more than the other. She stated CR #1 was incontinent, had what the facility called a regular mattress. She stated that CR #1 sat on his bottom around the clock making and believed that it made it difficult for the sacrum wound to improve. She stated that she educated the floor nurses and CNAs after each wound care treatment to ensure that they were performing frequent repositioning to assist with worsening wounds. She stated a short time later (week or so) pressure wounds developed on both of CR #1's heels. She stated that the CR #1 had not yet received his air mattress due to a backorder issue as indicated by Director of Nurse (DON) who was responsible for insuring were ordered and put into place. She stated that at some point the heel protectors were received and put into place. She stated at times, during skin assessments, and would care CR #1 would grunt and/or grimace when repositioned. She stated that CR #1 only communicated with a hello and a smile, but no full sentences and had not outright expressed pain during assessments. She stated on 10/28/2025 CR #1 was discharged to the hospital by the NP C for a gangrene (death of body tissue caused by a loss of blood supply) diagnosis to his sacrum wound. In an interview on 11/11/2025 at 12:41 p.m. DON stated that CR #1 was a confused patient who ate very little. She stated that CR #1 had a couple pressure wounds that NP A alluded to had progressed quickly. She stated that the progression could have contributed to the CR #1's low protein intake. She stated NP A placed an order for an air mattress for offloading weight pressure and boot for CR #1's heels. She stated that CR #1 discharged to the hospital recently for debridement to a sacrum wound. She stated that CR #1 was on the air mattress at the time he discharged . She stated LVN E and CNA A were most familiar with CR #1's care. In an interview on 11/11/2025 at 12:57 p.m. CNA E stated that he had worked for the facility for 5 plus years from 6 a.m. to 2p.m. He stated he had been responsible for CR #1's ADLs. He stated that CR #1 was verbal, lively, and often joked around. He stated that Family A would ask for assistance getting CR #1 dressed and into a chair for lunch during visits. He stated that Family A had expressed concerns of CR #1's wounds worsening and requested CR #1 receive an air mattress. He stated he informed LVN E who was unsuccessful locating an air mattress but found CR #1's boot protectors and placed them on his feet. He stated he placed pillows under the resident's legs to assist with offloading CR #1's weight. He stated that he was aware of CR #1's sacrum wound and t

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident goals and preference for 1 (Resident #81) of 1 reviewed for tracheostomy care. -LVN A failed to reconnect Resident #81's trach to oxygen after removing it to gather trach supplies. -LVN A failed to properly secure Resident #81's trach when removing the trach tie. -LVN A failed to clean Resident #81's trach stoma to prevent infection. An IJ was identified on 02/16/2024. The IJ template was provided to the facility on [DATE] at 5:44PM. While the IJ was removed on 02/19/2024 at 10:55AM, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not an immediate jeopardy because all staff had not been trained on tracheostomy care. The failures has the potential to place resident(s) with tracheostomies at risk of not receiving the necessary care and services needed to meet their medical goals resulting in a decline in health or harm. Findings included : Record review of Resident #81's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses that included: intracranial hemorrhage (bleeding on the brain), respiratory failure (serious condition making it difficult to breathe), encephalopathy (brain disease that alters the way the brain function), tracheostomy (procedure to help air and oxygen reach the lungs by creating a surgical opening in the neck), dysphagia (difficulty swallowing), narcolepsy (condition that cause one to fall asleep suddenly without warning), hypertension (elevated blood pressure), epilepsy (temporary uncontrolled stiffening and jerking of arms and legs or loss of awareness), and dependence on supplemental oxygen ( oxygen therapy that provides one with extra oxygen to breathe). Record review of Resident #81's physician's orders for the month of February 2024 revealed the following orders: -Dated 02/14/2024 Ambu bag (device used to provide respiratory support to an individual), extra trach tube and O2 tank at the bedside. -Dated 02/14/2024 Change disposable inner cannula daily and PRN. -Dated 02/14/2024 Change trach tubing collar weekly and PRN, date all pieces of tubing. -Dated 02/14/2024 Oxygen via tracheostomy collar at 35% (4L) every shift. -Dated 02/14/2024 Suction tracheostomy q shift and PRN. -Dated 02/14/2024 Trach care every shift and PRN -Dated 02/15/2024 Tracheostomy cuff Shiley size 6 in place. Record review of Resident #81's Baseline Care Plan dated 02/14/2024 revealed special treatment that included oxygen therapy and tracheostomy care. Observation on 02/16/24 at 10:35 AM revealed Resident #81 was resting in bed with the head of bed elevated, receiving continuous feedings via a gastrostomy tube (insertion of a surgical tube in the stomach to provide nutrition). The resident's tracheostomy was connected to oxygen at 4 liters per minute. The resident had a fenestrated (having one or more openings) gauze around the trach site that appeared clean and dry. Resident trach was secured with a trach tie. Further observation was made of the resident having respiratory/trach supplies in the room at the bed side that included suctioning kits, inner cannulas, an Ambu bag, etc. Further observation was done with LVN A preparing to provide trach care for the resident. LVN A disinfected the resident's bedside table and placed the trach supplies on the bedside table and washed her hands. LVN A told the surveyor that Resident #81 had already been suctioned and did not need to be suctioned at this time. The surveyor told the nurse that she could proceed with care. LVN A proceeded to check the resident's pulse oximetry that was at 96%. At 10:36AM LVN A proceeded with care by removing the oxygen from the resident's trach and placing the oxygen mask on the resident's chest. LVN A then completely removed the trach tie from around the resident's neck along with the dressing to the trach site, disposing of materials in a trash can at the resident's' bedside. At this time the resident coughed with the trach moving. LVN A placed her fingers at the trach site to prevent the trach from dislodging while proceeding to clean around the resident's trach site, not starting at the stoma (surgery to create an opening from an area inside the body to the outside) site and moving away from the stoma, instead using the same wipe to clean more than one time near the stoma site. Further observation was made of the resident beginning to move her left hand toward the trach site. Resident oxygen was still resting on her chest. The surveyor asked LVN A at 10:39AM to check the resident's oxygen saturation. Resident oxygen saturation was 90%. The surveyor asked the nurse to place the resident back on her oxygen and secure the trach with trach tie to prevent further decrease in resident oxygen level . Resident oxygen saturation had increase to 94%. Resident call light was alarmed by LVN A for the ADON to come to room. Further observation was made of the resident's physician entering the resident room with a student. The physician began to assess the resident and observed that the resident was not wearing a trach tie and told the nurse to put a trach tie on Resident #81. LVN A proceeded to place a trach tie on the resident but did not secure the right side of resident the trach tie. LVN A applied a 4 x 4 gauze that was not fenestrated gauze to the resident's stoma site. The 4 x 4 gauze was not neatly placed around the trach stoma site. Observation was made of Resident #81 beginning to cough. The surveyor asked LVN A to secure the right side of the resident's trach tie and if she could place a fenestrated gauze (gauze with an opening through which secretions can drain). After LVN A placed a fenestrated gauze around the resident's stoma site, and secured the trach tie, the resident stopped coughing. Interview on 02/16/24 at 11:00AM LVN A said the last time she had worked at facility with residents that had tracheostomies was about 7-8 years ago. LVN A said she had been a nurse for [AGE] years and had been working at the facility for 2 years. LVN A said she had not been in-serviced on trach care while working at the facility. Interview on 02/16/24 at 11:08AM the ADON and DON said the last training that the facility had done on trach care was about 6 months ago but would have to check to be certain. The ADON and DON said Resident #81 had arrive at the NF about 2 days ago. Further interview, with the DON and ADON said they were not at the facility when Resident #81 arrived at the facility because Resident #81 was admitted to the facility on the night shift. The ADON said the facility had not admitted any residents (s) with a tracheostomy in a long time. The ADON said Resident #81 should have never been admitted to the facility because the facility had not admitted a resident with a trach in a long time. Interview on 02/16/2024 at 4:00PM the DON said he and the ADON had not in-serviced the staff on trach care and that the facility Respiratory Therapist would be coming to the facility on [DATE] to in-service the staff on tracheostomy care. The DON said he had given the nursing staff the facility policy on tracheostomy care after Resident #81 was admitted to the facility. Further interview the DON said he had asked LVN A after Resident #81 was admitted to the facility if she was comfortable in providing trach care. The DON said LVN A said she was comfortable with caring for residents with a trach. The DON said he gave a trach training last year sometime and that LVA A should have received the training. The DON was not able to produce documentation that an in-service was done with the nursing staff on tracheostomy care in 2022. Interview on 02/19/2024 at 1:03PM the Respiratory Therapist said the last time she had come to the facility was sometime in 2023. The Respiratory Therapist said when she came to the facility in 2023, she was following up with the facility to see if she could be of service and at that time, the facility did not have any residents with tracheostomies. The Respiratory Therapist said she was contracted with the facility and came to the facility on an as needed basis. The Respiratory Therapist said she preferred to be called in advance prior to a new admission so that she could educate the staff and provide guidance for the facility. The Respiratory Therapist said the reason staff should be using a spilt gauze to place around the trach stoma after cleaning was to help absorb any secretions around the stoma. Interview on 02/22/2024 at 2:00PM the Administrator said the last time the NF had admitted a resident with a tracheostomy was in 2022. The Administrator said he started working at the facility in August of 2022 and the DON began working at the facility in September of 2022. The Administrator said whenever a resident was considered for admission to the facility, the marketing team would send the referral to the facility that included the business office as well as the DON and ADON. The Administratorion said the DON and ADON reviewed the residents' medical records and acknowledged they receive the referral. The Administrator said no one in administration was caught off guard on any new admission. The Administrator said the facility knew that Resident #81 was going to be admitted to the facility but did not know the exact day that resident was going to be admitted . Record review of the facility last in-service on tracheostomy care revealed it was done in 2022 . Record review of the facility policy on Tracheostomy Care revised October 2023 revealed in part: .With moistened gauze starting at the 12 o'clock position of the stoma, wipe toward the 3 o'clock position. Begin again with a new gauze square at 12 o'clock and clean toward 9 o'clock. To clean the lower half of the site, start at the 3 o'clock position and clean toward 6 o'clock; then wipe from 9 o'clock to 6 o'clock, using a clean moistened square for each wipe. Continue this pattern on the surrounding skin and tube flange (projecting flat rim, collar that maintain position) .Apply fenestrated gauze pad around the insertion skite, touching only outer edges .Replace neck ties: A two person technique is recommended, with one person holding the tracheostomy tube in place while the other secures the ties .If resident's condition is unstable, or if the stoma is less than two weeks old, apply new ties before removing old ties . The Administrator and DON were notified on 02/16/23 at 5:44 PM that an IJ situation had been identified due to the above failures. The IJ template was provided. The following plan of removal was submitted by the facility on 02/17/2024 and accepted on 02/17/2023 at 11:08AM. PLAN OF REMOVAL Date: 2/16/2024 The facility failed to ensure that Resident #81 who required respiratory care, including tracheostomy care was provided such care consistent with professional standards of practice when the facility failed to provide adequate care and in service staff on tracheostomy care prior to and after resident was admitted to the facility on [DATE]. Immediate action: LVN A was removed from providing care to Resident #1 on 2/16/2024 and would not be permitted to work until trained and return demonstration is complete. On 2/16/2024 an AdHoc QAPI meeting was held with the Director of Nursing, Executive Director, Medical Director, and Co-Medical Director. Reviewed: IJ Template, Resident #1's chart, and plan of removal. The policy on tracheostomy care in-service was initiated by the DON and will run concurrent with training provided by Respiratory Therapist. Respiratory Therapist initiated training on 2/16/2024 on Respiratory Assessments, O2 Therapy, Nebulizer Therapy, Suctioning, Tracheotomy Training & Emergency Procedures. Nursing staff caring for Resident #1 will be trained prior to next working shift. New hires (licensed nurses) will receive education before working. Licensed Nurses will not be able to work until training is completed. Training and competency checks will be completed by 2/18/2024. No other residents are affected as this is the only resident admitted to the facility . Assessment was completed on Resident #1 by an RN with no adverse findings on 2/16/2024. The DON/Designee will make random rounds on all patients requiring tracheostomy care to ensure staff competency initiated on 2/17/2024. The DON/Designee will ensure that staff is trained prior to the admission of any patients that require tracheostomy care by reviewing referrals prior to admission. The DON or designee will review clinicals for new admissions to identify any specialized needs initiated on 2/16/2024. The Admissions Director was educated on process of reviewing referrals by the DON or designee prior to admissions on 2/17/2024. The Administrator will review education records of staff to ensure they are properly trained in specialized areas to be implemented on 2/16/2024. ________________________________________________________________________ The surveyor confirmed the plan of removal had been implemented sufficiently to remove IJ by the following: Interview on 02/17/2024 at 11:48AM LVN C said she worked at the facility PRN on all shifts. LVN C said she had been in- serviced on tracheostomy care and that the skill was a sterile procedure when performing trach suctioning and cleaning around the stoma site. LVN C said the trach had to always be secured when providing care. LVN C said prior to suctioning the resident she was supposed to assess the resident's lung sounds and check the resident's oxygen saturation by placing the pulse oximetry on the resident's finger and to not remove the pulse oximetry until trach suction had been completed. LVN C said when cleaning the trach stoma site, she had to clean starting at the site moving away from the stoma, one wipe at a time. Interview on 02/17/2024 at 1:06PM LVN D said she worked on the weekends double shift from 6AM-10PM full time. LVN D said she had been in-serviced on tracheotomy care to assess the lung sounds prior to and after suctioning along with checking the resident's pulse oximetry. LVN D said she was also in-serviced to always ensure that the trach was secured. LVN D said when cleaning around the stoma she was supposed to clean starting near the stoma site, moving away from the stoma and being careful to not introduce bacteria to the stoma site, one wipe at time. LVN D said she was in-serviced that when she had to replace or change the tie around the trach to untie one string at a time to prevent the trach from dislodging. LVN D said she was to apply a split gauze to the stoma site after cleaning around the stoma site to better absorb any moisture. LVN D said she was in-serviced that when suctioning the resident or cleaning the stoma, it was a sterile technique. Interview on 02/17/2024 at 1:12PM LVN E said she worked the weekend shift form 6AM-10PM full time. LVN E said she had been in-serviced on trach care regarding suctioning, cleaning of the stoma site, assessing the resident's lung sounds prior to and after suctioning, checking the oxygen saturation before, during, and after suctioning the resident. LVN E said if the resident's trach dislodged, she was in-serviced to place a new trach immediately and if met with resistance to down size with a smaller trach reassessing the resident and informing the physician what took place. LVN E said when cleaning the stoma to clean at the stoma, moving away one wipe at a time, going in a clock motion to prevent infection. LVN E said she was in-service to always make sure resident trach was secure during care and afterwards and only loosen one tie at a time when changing or having to clean the stoma site. Interview on 02/18/2024 at 1:30PM LVN F said she worked at the facility full time from 6:00AM to 10PM and had been in- serviced on the following regarding tracheostomy care: trach suctioning and stoma care was a sterile procedure, assessing the resident prior, during, and after trach suctioning by observing respirations, oxygen saturation, and lung sounds, cleaning of the stoma, how to remove the trach tie without dislodging the trach, what to do if a trach dislodged (replace immediately with the same size trach, if meet resistance to downsize to a small trach size), assess the resident for any distress, notify the physician of happenings, and how to dispose of soiled material placing in a red biohazard bag. Interview on 02/18/2024 at 1:38PM RN G said he worked at the facility PRN on various shifts. RN G said he had been in-serviced on how to care for a resident with a tracheostomy. RN G said when performing trach suctioning and cleaning the stoma was a sterile technique. RN G said before performing suctioning, the lung sounds, and oxygen saturation should be assessed prior leaving the pulse oximeter on the resident to monitor the oxygen saturation throughout the procedure. RN G said before starting the procedure, the workspace should be disinfected. RN G said once he placed on his sterile gloves, the dominant hand should be establish being careful not to break sterile procedure. RN G said when cleaning the stoma, he was in-serviced to clean the stoma site one wipe at a time moving away from the stoma. RN G said when cleaning the stoma, the trach did not have to be removed but loosened enough to clean around the site and that the nurse should use a split gauze to apply around the stoma site. RN G said when changing the trach tie. oOne tie should be removed at a time to prevent the trach from dislodging. RN G said if the trach dislodged, he would replace with a new trach same size and if he could not get the trach back in, he would get a smaller size to reinsert. RN G said the same size trach should always be kept at the bedside along with a smaller one size down. Interview on 02/18/2024 at 2:12PM LVN H said she worked at the facility on the weekends from 2PM-6AM. LVN H said she had been in-serviced on trach care, that it was a sterile procedure to prevent infections. LVN H said before suctioning the resident, she was in-serviced to disinfect her workspace, wash her hands prior to the procedure, and then assess the resident's lung sounds and oxygen saturation. LVN H said when not suctioning the resident, the oxygen needed to be connected to the resident. LVN H said the pulse oximeter needed to be kept on the resident's finger so the nurse could monitor the resident's oxygen saturation throughout the procedure. LVN H said she was also in-service that the resident head of bed was elevated when suctioning the resident and to always know what hand her dominant hand was to suction the resident, so she did not contaminate the procedure. LVN H said when cleaning the resident's stoma, she had to make sure that resident's trach tie was secured enough in case the resident coughed to prevent the trach from dislodging. LVN H said when cleaning the trach stoma, she would start clockwise at the 12:00 o'clock position cleaning the stoma moving outward one wipe at a time to avoid reintroducing bacteria to the stoma site and when done would apply a split gauze to the stoma site. LVN H said when changing the trach tie she would remove one tie at a time always keeping one tie in place. LVN H said if the trach came out and she could not insert a new trach the same size, she would insert the next trach size down from the original size. LVN H said she would also provide the resident with oxygen if needed and call the doctor. Interview on 02/18/2024 at 7:00PMvia phone RN I said he was working the 2PM-10AM and had been in-serviced on tracheostomy care on how to perform sterile technique when suctioning, changing the inner cannula, and cleaning the stoma. RN I said he had to check the resident oxygen saturation and listen to the lung sounds before suctioning, oxygenate the resident in between suction, when changing the trach tie, untie one side at a time to prevent the risk of the trach coming out. RN I said if the trach dislodged, he would reinsert immediately and if he had to would insert a smaller size trach if met resistance. RN I said he would then assess the resident and oxygenate as needed. RN I said he would send the resident out if unstable and call the physician. Interview on 02/18/2024 at 7:27PM via phone LVN B said she worked every weekend shift from 2PM-6AM. LVN B said she had received an in-service on how to care for a resident with a tracheostomy. LVN B said trach suctioning was a sterile technique to prevent resident from getting an infection. LVN B said resident oxygen level had to be taken before suctioning incase the resident needed to be oxygenated as well as assessing the lung sounds. LVN B said when changing resident trach tie, only remove one tie at a time to prevent the trach from coming out. LVN B said if the resident's trach came out, she would try and insert the trach immediately or get a smaller size if could not reinsert the original size trach. LVN B said she would continue to assess the resident and if the resident was unstable, she would call 911 right away, notify the doctor, continue to observe the resident and administer further care, one being oxygen, if needed. Observation on 02/19/2024 at 9:56AM revealed tracheostomy care on Resident #81 (who was resting in bed with head of bed elevated receiving continuous gastrostomy feedings) by LVN J. LVN J washed his hands, disinfected his workspace/bedside table, and placed the trach supplies (normal saline, suction kit with sterile gloves) on his workspace/bedside table. LVN J paused the resident's continuous gastrostomy feedings, washed his hands again, listened to the resident's lung sounds and checked the resident's oxygen saturation which was 98% and left the pulse oximetry on the resident's finger. LVN J then put on a pair of clean gloves after sanitizing his hands and began to open the suction kit and normal saline container without contaminating his sterile field. LVN J placed on his sterile gloves confirming that his right hand would be his dominant hand and suctioned the resident intermittently pulling the suction catheter out of the trach with no concerns identified. Resident #81 tolerated the procedure with minimum reaction or distress noted. Interview on 02/19/2024 at 10:15AM LVN J said he had been in-serviced that when he provide trach suctioning, or changing out the inner cannula the procedure was invasive, and therefore was a sterile procedure to prevent infections. LVN J said he was also in-serviced that if the trach came out, he was to get a new trach the same size and put it back in. LVN J said if he was unable to get the same size trach back in, he would get the next size down to insert. LVN J said he was in-serviced to the keep trach supplies at the bedside including a smaller trach size for emergency purposes. LVN J said if he had to change the trach ties, he was in-serviced to change one tie at time to keep the trach from coming out. On 2/19/2024 at 10:55AM the Administrator was informed the IJ was removed, however, the facility remained out of compliance at a scope of isolation and severity of harm that is not an immediate jeopardy 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 ensure that the nursing staff were able to demonstrate competency in skills and techniques necessary to provide tracheostomy care for 1 (Resident #81) of 1 resident reviewed for tracheostomy care. -LVN A failed to reconnect Resident #81's trach to oxygen after removing to gather trach supplies. -LVN A failed to properly secure Resident #81's trach when removing the trach tie. -LVN A failed to clean Resident #81's trach stoma to prevent introducing micro-organism (bacteria) inside of tracheostomy. An IJ was identified on 02/16/2024. The IJ template was provided to the facility on [DATE] at 5:44PM. While the IJ was removed on 02/19/2024 at 10:55AM, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not an immediate jeopardy because all staff had not been trained on tracheostomy care. This failure has the potential to place resident(s) with tracheostomies at risk of not receiving the necessary care and services needed to meet their medical goals resulting in a decline in health or harm. Findings included: Record review of Resident #81 face sheet revealed a 77year old female admitted to the facility on [DATE] with the following diagnoses that included: intracranial hemorrhage (bleeding on the brain), respiratory failure (serious condition making it difficult to breathe), encephalopathy (brain disease that alters the way the brain function), tracheostomy (procedure to help air and oxygen reach the lungs by creating a surgical opening in the neck), dysphagia (difficulty swallowing), narcolepsy (condition that cause one to fall asleep suddenly without warning), hypertension (elevated blood pressure), epilepsy (temporary uncontrolled stiffening and jerking of arms and legs or loss of awareness), and dependence on supplemental oxygen ( oxygen therapy that provides one with extra oxygen to breathe). Record review of Resident #81's physician orders for the month of February 2024 revealed the following orders: -Dated 02/14/2024 Ambu bag (device used to provide respiratory support to an individual), extra trach tube and O2 tank at the bedside -Dated 02/14/2024 Change disposable inner cannula daily and PRN -Dated 02/14/2024 Change trach tubing collar weekly and PRN date all pieces of tubing -Dated 02/14/2024 oxygen via tracheostomy collar at 35% (4L) every shift -Dated 02/14/2024 Suction tracheostomy q shift and PRN -Dated 02/14/2024 trach care every shift and PRN -Dated 02/15/2024 tracheostomy cuff Shiley size 6 in place Record review of Resident #81's Baseline Care Plan dated 02/14/2024 revealed special treatment that included oxygen therapy and tracheostomy care. Observation on 02/16/24 at 10:35 AM Resident #81 was resting in bed with head of bed elevated receiving continuous feedings via gastrostomy tube. Resident tracheostomy was connected to oxygen at 4 liters. Resident had a fenestrated gauze around trach site that appeared clean and dry. Resident trach was secured with a trach tie. Further observation was made of resident having respiratory/trach supplies in room at the bed side that included suctioning kits, inner cannulas, Ambu bag, etc. Further observation was done with LVN A preparing to provide trach care for resident. LVN A disinfected resident bedside table and placed trach supplies on the bedside table and washed her hands. LVN A told the surveyor that Resident #81 had already been suctioned and did not need to be suctioned at this time. The surveyor told the nurse that she could proceed with care. LVN A proceeded to check resident pulse oximetry that was at 96%. At 10:36AM LVN A proceeded with care by removing the oxygen from resident trach and placing on resident's chest. LVN A then completely removed the trach tie from around resident neck along with the dressing to trach site disposing of materials in a trash can at residents' bedside. At this time resident coughed with the trach moving. LVN A placed her fingers at the trach site to prevent the trach from dislodging while proceeding to clean around resident trach site, not starting at the stoma site and moving away from the stoma, instead using the same wipe to clean more than one time near the stoma site. Further Observation was made of resident beginning to move her left hand toward trach site. Resident oxygen was still resting on her chest. The surveyor asked LVN A at 10:39AM to check resident oxygen saturation. Resident oxygen saturation was 90%. The surveyor asked the nurse to place resident back on her oxygen and secure trach with trach tie. Resident oxygen saturation had increase to 94%. Resident call light was alarmed for the ADON to come to room. Further observation was made of resident physician entering resident room with a student. The physician began to assess resident and observed that resident was not wearing a trach tie and told the nurse to put a trach tie on Resident #81. LVN A proceeded to place a trach tie on resident but did not secure the right side of resident trach tie and applied a 4 x 4 gauze and not fenestrated gauze to resident stoma site. The 4 x 4 gauze was not neatly gathered around the trach stoma site with observations made of resident appearing to be comfortable beginning to cough. The surveyor asked LVN A to secure the right side of resident trach tie and if she could place a fenestrated gauze (gauze with an opening through which secretions can drain). After LVN A placed a fenestrated gauze around resident stoma site, and secured the trach tie, resident stopped coughing and appeared comfortable. Interview on 02/16/24 at 11:00AM LVN A said the last time she had worked at facility with residents that had tracheostomies was about 7-8 years ago. LVN A said she had been working at the facility for 2 years and had never received in-service on tracheostomy care. Interview on 02/16/24 at 11:08AM the ADON and DON said the last training that the facility had done on trach care was about 6 months ago but would have to check to be certain. The DON and ADON said they were unaware that Resident #81 was being admitted to the facility and that resident was admitted after they had left the faciity on the night shift. Further interview on 02/16/2024 at 4:00PM the DON said he and the ADON had not in-serviced the staff on trach care and that the facility Respiratory Therapist would be coming to the facility on [DATE] to in-service the staff on tracheostomy care. The DON said he had given the nursing staff the facility policy on tracheostomy care. Further interview with the DON said LVN A said she was comfortable with caring for residents with a trach. The DON said he gave a trach training last year sometime and that LVA A should have received the training. The DON was not able to produce documentation that in-service was done with the nursing staff on tracheostomy care in 2022. Record review on 02/16/2024 of the facility last in-service on tracheostomy care was in 2022. 02/19/2024 at 12:30PM Interview with the Administrator said he did not know if the facility had a skills competency check list for the nurses and would have to ask the DON. The Administrator said he did know that the facility gave a 3-day orientation for all new hires. The Administrator said he did not know in detail what was done in the 3-day orientation with new employees. Interview on 02/19/2024 at 1:03PM the Respiratory Therapist said the last time she had come to the facility was sometime in 2023. The Respiratory Therapist said when she came to the facility in 2023, she was following up with the facility to see if she could be of service and at that time, the facility did not have any resident (s) with tracheostomies. The Respiratory Therapist said she was contracted with the facility and came to the facility on an as needed basis. The Respiratory Therapist said she preferred to be called in advance prior to a new admission so that she could educate the staff and provide guidance for the facility. The Respiratory Therapist said the reason staff should be using a spilt gauze to place around the trach stoma after cleaning was to help absorb any secretions around the stoma. The Respiratory Therapist said she assessed Resident #81, and the resident was stable, not having in copious secretions from her tracheostomy. The Respiratory Therapist said she had also assessed the facility respiratory/tracheostomy supplies and that the facility had adequate supplies. The Respiratory Therapist said after assessing the nursing staff skills in trach care, the in-service was much needed. The Respiratory Therapist said because the facility had a resident at the facility with a tracheostomy, she would be coming to the facility on a weekly basis. Interview on 02/19/2024 at 1:30PM the DON said new nurses got at least a 3-day orientation that consisted of going over the facility's policy and procedures, medication pass, electronic medical record/PCC. The DON said the facility did not have a written skills competency check off list that he was aware of and if they did, the facility was not utilizing the competency check off list. The DON said when the facility hired a nurse, they just asked if the nurse was competent in doing certain skills . The DON said since the facility had incurred an IJ in the area of trach care, the facility was discussing on potentially setting up a skills area for new hires to demonstrate their skills or pairing them with a chosen preceptor. 02/19/2024 at 2:00PM Interview with the Administrator said he just learned on 02/18/2024 that the NF did have a Nursing Competency Skills Checklist, but the facility was just not using the form and could not provide a reason why the facility was not using the form. The Administrator said moving forward the facility would be utilizing the Nursing Competency Skills Checklist. The Administratorion said the DON and ADON reviewed each resident admission referral and must acknowledge they receive the referral and therefore no one in administration was caught off guard on any new admission. The Administrator said the facility knew that Resident #81 was going to be admitted to the facility just did not know the exact day that resident was going to be admitted . The Administrator said the facility did not have a specific policy on staff training. Record review of the facility policy for the Director of Nursing Job Description revealed in part: .The DON is a registered nurse who oversees and supervises the care of the residents. The DON also provides direct resident/patient care .Develop and conduct in-services for the clinical staff . The Administrator and DON were notified on 02/16/23 at 5:44 PM that an IJ situation had been identified due to the above failures. The IJ template was provided. The following plan of removal was submitted by the facility on 02/17/2024 and accepted on 02/17/2023 at 11:08AM. PLAN OF REMOVAL Date: 2/16/2024 The facility failed to ensure that Resident #81 who required respiratory care, including tracheostomy care was provided such care consistent with professional standards of practice when the facility failed to provide adequate care and in service staff on tracheostomy care prior to and after resident was admitted to the facility on [DATE]. Immediate action: LVN A was removed from providing care to Resident #1 on 2/16/2024 and would not be permitted to work until trained and return demonstration is complete. On 2/16/2024 an AdHoc QAPI meeting was held with the Director of Nursing, Executive Director, Medical Director, and Co-Medical Director. Reviewed: IJ Template, Resident #1's chart, and plan of removal. The policy on tracheostomy care in-service was initiated by the DON and will run concurrent with training provided by Respiratory Therapist. Respiratory Therapist initiated training on 2/16/2024 on Respiratory Assessments, O2 Therapy, Nebulizer Therapy, Suctioning, Tracheotomy Training & Emergency Procedures. Nursing staff caring for Resident #1 will be trained prior to next working shift. New hires (licensed nurses) will receive education before working. Licensed Nurses will not be able to work until training is completed. Training and competency checks will be completed by 2/18/2024. No other residents are affected as this is the only resident admitted to the facility . Assessment was completed on Resident #1 by an RN with no adverse findings on 2/16/2024. The DON/Designee will make random rounds on all patients requiring tracheostomy care to ensure staff competency initiated on 2/17/2024. The DON/Designee will ensure that staff is trained prior to the admission of any patients that require tracheostomy care by reviewing referrals prior to admission. The DON or designee will review clinicals for new admissions to identify any specialized needs initiated on 2/16/2024. The Admissions Director was educated on process of reviewing referrals by the DON or designee prior to admissions on 2/17/2024. The Administrator will review education records of staff to ensure they are properly trained in specialized areas to be implemented on 2/16/2024. ________________________________________________________________________ The surveyor confirmed the plan of removal had been implemented sufficiently to remove IJ by the following: Interview on 02/17/2024 at 11:48AM LVN C said she worked at the facility PRN on all shifts. LVN C said she had been in- serviced on tracheostomy care and that the skill was a sterile procedure when performing trach suctioning and cleaning around the stoma site. LVN C said the trach had to always be secured when providing care. LVN C said prior to suctioning the resident she was supposed to assess the resident's lung sounds and check the resident's oxygen saturation by placing the pulse oximetry on the resident's finger and to not remove the pulse oximetry until trach suction had been completed. LVN C said when cleaning the trach stoma site, she had to clean starting at the site moving away from the stoma, one wipe at a time. Interview on 02/17/2024 at 1:06PM LVN D said she worked on the weekends double shift from 6AM-10PM full time. LVN D said she had been in-serviced on tracheotomy care to assess the lung sounds prior to and after suctioning along with checking the resident's pulse oximetry. LVN D said she was also in-serviced to always ensure that the trach was secured. LVN D said when cleaning around the stoma she was supposed to clean starting near the stoma site, moving away from the stoma and being careful to not introduce bacteria to the stoma site, one wipe at time. LVN D said she was in-serviced that when she had to replace or change the tie around the trach to untie one string at a time to prevent the trach from dislodging. LVN D said she was to apply a split gauze to the stoma site after cleaning around the stoma site to better absorb any moisture. LVN D said she was in-serviced that when suctioning the resident or cleaning the stoma, it was a sterile technique. Interview on 02/17/2024 at 1:12PM LVN E said she worked the weekend shift form 6AM-10PM full time. LVN E said she had been in-serviced on trach care regarding suctioning, cleaning of the stoma site, assessing the resident's lung sounds prior to and after suctioning, checking the oxygen saturation before, during, and after suctioning the resident. LVN E said if the resident's trach dislodged, she was in-serviced to place a new trach immediately and if met with resistance to down size with a smaller trach reassessing the resident and informing the physician what took place. LVN E said when cleaning the stoma to clean at the stoma, moving away one wipe at a time, going in a clock motion to prevent infection. LVN E said she was in-service to always make sure resident trach was secure during care and afterwards and only loosen one tie at a time when changing or having to clean the stoma site. Interview on 02/18/2024 at 1:30PM LVN F said she worked at the facility full time from 6:00AM to 10PM and had been in- serviced on the following regarding tracheostomy care: trach suctioning and stoma care was a sterile procedure, assessing the resident prior, during, and after trach suctioning by observing respirations, oxygen saturation, and lung sounds, cleaning of the stoma, how to remove the trach tie without dislodging the trach, what to do if a trach dislodged (replace immediately with the same size trach, if meet resistance to downsize to a small trach size), assess the resident for any distress, notify the physician of happenings, and how to dispose of soiled material placing in a red biohazard bag. Interview on 02/18/2024 at 1:38PM RN G said he worked at the facility PRN on various shifts. RN G said he had been in-serviced on how to care for a resident with a tracheostomy. RN G said when performing trach suctioning and cleaning the stoma was a sterile technique. RN G said before performing suctioning, the lung sounds, and oxygen saturation should be assessed prior leaving the pulse oximeter on the resident to monitor the oxygen saturation throughout the procedure. RN G said before starting the procedure, the workspace should be disinfected. RN G said once he placed on his sterile gloves, the dominant hand should be establish being careful not to break sterile procedure. RN G said when cleaning the stoma, he was in-serviced to clean the stoma site one wipe at a time moving away from the stoma. RN G said when cleaning the stoma, the trach did not have to be removed but loosened enough to clean around the site and that the nurse should use a split gauze to apply around the stoma site. RN G said when changing the trach tie. oOne tie should be removed at a time to prevent the trach from dislodging. RN G said if the trach dislodged, he would replace with a new trach same size and if he could not get the trach back in, he would get a smaller size to reinsert. RN G said the same size trach should always be kept at the bedside along with a smaller one size down. Interview on 02/18/2024 at 2:12PM LVN H said she worked at the facility on the weekends from 2PM-6AM. LVN H said she had been in-serviced on trach care, that it was a sterile procedure to prevent infections. LVN H said before suctioning the resident, she was in-serviced to disinfect her workspace, wash her hands prior to the procedure, and then assess the resident's lung sounds and oxygen saturation. LVN H said when not suctioning the resident, the oxygen needed to be connected to the resident. LVN H said the pulse oximeter needed to be kept on the resident's finger so the nurse could monitor the resident's oxygen saturation throughout the procedure. LVN H said she was also in-service that the resident head of bed was elevated when suctioning the resident and to always know what hand her dominant hand was to suction the resident, so she did not contaminate the procedure. LVN H said when cleaning the resident's stoma, she had to make sure that resident's trach tie was secured enough in case the resident coughed to prevent the trach from dislodging. LVN H said when cleaning the trach stoma, she would start clockwise at the 12:00 o'clock position cleaning the stoma moving outward one wipe at a time to avoid reintroducing bacteria to the stoma site and when done would apply a split gauze to the stoma site. LVN H said when changing the trach tie she would remove one tie at a time always keeping one tie in place. LVN H said if the trach came out and she could not insert a new trach the same size, she would insert the next trach size down from the original size. LVN H said she would also provide the resident with oxygen if needed and call the doctor. Interview on 02/18/2024 at 7:00PMvia phone RN I said he was working the 2PM-10AM and had been in-serviced on tracheostomy care on how to perform sterile technique when suctioning, changing the inner cannula, and cleaning the stoma. RN I said he had to check the resident oxygen saturation and listen to the lung sounds before suctioning, oxygenate the resident in between suction, when changing the trach tie, untie one side at a time to prevent the risk of the trach coming out. RN I said if the trach dislodged, he would reinsert immediately and if he had to would insert a smaller size trach if met resistance. RN I said he would then assess the resident and oxygenate as needed. RN I said he would send the resident out if unstable and call the physician. Interview on 02/18/2024 at 7:27PM via phone LVN B said she worked every weekend shift from 2PM-6AM. LVN B said she had received an in-service on how to care for a resident with a tracheostomy. LVN B said trach suctioning was a sterile technique to prevent resident from getting an infection. LVN B said resident oxygen level had to be taken before suctioning incase the resident needed to be oxygenated as well as assessing the lung sounds. LVN B said when changing resident trach tie, only remove one tie at a time to prevent the trach from coming out. LVN B said if the resident's trach came out, she would try and insert the trach immediately or get a smaller size if could not reinsert the original size trach. LVN B said she would continue to assess the resident and if the resident was unstable, she would call 911 right away, notify the doctor, continue to observe the resident and administer further care, one being oxygen, if needed. Observation on 02/19/2024 at 9:56AM revealed tracheostomy care on Resident #81 (who was resting in bed with head of bed elevated receiving continuous gastrostomy feedings) by LVN J. LVN J washed his hands, disinfected his workspace/bedside table, and placed the trach supplies (normal saline, suction kit with sterile gloves) on his workspace/bedside table. LVN J paused the resident's continuous gastrostomy feedings, washed his hands again, listened to the resident's lung sounds and checked the resident's oxygen saturation which was 98% and left the pulse oximetry on the resident's finger. LVN J then put on a pair of clean gloves after sanitizing his hands and began to open the suction kit and normal saline container without contaminating his sterile field. LVN J placed on his sterile gloves confirming that his right hand would be his dominant hand and suctioned the resident intermittently pulling the suction catheter out of the trach with no concerns identified. Resident #81 tolerated the procedure with minimum reaction or distress noted. Interview on 02/19/2024 at 10:15AM LVN J said he had been in-serviced that when he provide trach suctioning, or changing out the inner cannula the procedure was invasive, and therefore was a sterile procedure to prevent infections. LVN J said he was also in-serviced that if the trach came out, he was to get a new trach the same size and put it back in. LVN J said if he was unable to get the same size trach back in, he would get the next size down to insert. LVN J said he was in-serviced to the keep trach supplies at the bedside including a smaller trach size for emergency purposes. LVN J said if he had to change the trach ties, he was in-serviced to change one tie at time to keep the trach from coming out. On 2/19/2024 at 10:55AM the Administrator was informed the IJ was removed, however, the facility remained out of compliance at a scope of isolation and severity of harm that is not an immediate jeopardy the facility was continuing to monitor the implementation and effectiveness of their plan of removal. 48923

Based on observation, interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for 1of 5 residents (CR#1) reviewed for physician notification. The facility failed to notify the physician of Resident #1's continued change in condition, including low blood pressure and high pulse rate, for approximately 12 hours. After approximately 12 hours Resident #1 was sent to the hospital via emergency transport and was admitted with Pneumonia, Acute Kidney Failure, and Septic Shock and was placed on life-support. An IJ was identified on 11/6/2023. The IJ template was provided to the facility on [DATE] at 4:13pm. While the IJ was removed on 11/8/2023, the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan. This failure could affect residents by placing them at risk of delayed treatment that has the propensity to lead to death. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year-old female admitted to the NF on 10/26/2023. CR#1 diagnoses included the following: chronic respiratory failure with hypercapnia (occurs when the respiratory system cannot adequately remove carbon dioxide), candida esophagitis (weakened immune system), sickle-cell trait (inherited blood disorder), demyelinating disease of central nervous system (central nervous system disorder), chronic inflammatory demyelinating polyneuritis (Progressive weakness and reduced senses in the arms and legs), Congestive heart failure (A chronic condition that prevent the heart from pumping blood as well as it should). Record review of CR#1's MDS dated [DATE] did not reveal a BIMS score. Record review of CR#1's baseline care plan dated 10/26/23 and revised on 10/30/23 revealed allowing residents to make decision regarding treatment, care and provide opportunities for resident to make choices. Record review of CR#1's Physician Orders revealed the following orders: - Start Date-10/26/23 2200-D/C Date 11/2/23 1639 HydrAlazine HCI Oral Tablet 50 MG (Hydralazine)-Give 1 tablet by mouth every 8 hours for High blood Pressure Hold for BP<110/60 or HR <60 - Start Date-11/01/2023 1400-D/C Date-11/01/2023 1907 revealed an order for NS via IV Perlpheral (3L) at 75cc r/t dehydration every shift for fluids - Start Date-11/01/23 2200-D/C Date 11/02/2023 1639-NS via Clysis (introducing large amount of fluids into the body) (3L) at 75cc r/t dehydration every shifter for fluids - Start Date-11/01/2023 2200 - D/C Date-11/02/2023-Sodium Chloride Intravenous 0.9% (Sodium Chloride)- Use 75 ml/hr ml/hr Intravenously every shift for dehydration until 11/3/23 23:59 3L via Clysis Record Review of CR#1's Progress Notes revealed the following: Record review of vitals revealed blood pressure completed on 11/1/2023 at 5:34am - blood pressure 90/68 Pulse 74 Record review of vitals revealed blood pressure completed on 11/1/2023 at 1:54pm- blood pressure 86/56 Pulse 65 Record review of vitals revealed blood pressure completed on 11/1/2023 at 5:28pm -blood pressure 75/55 Pulse 120 Record review of vitals revealed blood pressure completed on 11/2/2023 at 5:20am - blood pressure 102/57 Pulse 130 Record review of vitals revealed blood pressure completed on 11/2/2023 at 7:00am - blood pressure 63/48 Pulse 136 Record review of the SBAR summary Late Entry, created by LVN A on 11/2/23 at 10:23pm effective 11/1/23 at 7:20pm on 11/1/2023 at 12:02 revealed a change in condition: Temp: T 97.9 - 11/1/2023 3:54 Route: Forehead (non-contact) Weight: W 176.8 lb - 11/2/2023 10:52 Scale: Mechanical Lift Pulse Oximetry: O2 92.0% - 11/1/2023 13:54 Method: Room Air Blood Glucose: BS 113.0 - 11/1/2023 11:23 In an interview with FM A on 11/2/2023 at 12:25pm revealed a concern with CR#1 vitals since the early morning of 11/1/2023. The concerns were based on her level of care and her current health condition. FM A stated CR#1 had not eaten or had any fluids by mouth in 4 days and was severely dehydrated. There was a concern by the RP that nursing personnel showed no urgency in attending to CR#1's medical needs. FM A was informed on 11/1/2023 at or close to 10:00am, by the SW, that the nursing staff had ordered a doppler from the pharmacy due to nursing staff having a difficult time locating a vein. It would take at least 4 hours for the doppler to arrive to the facility. After 8 hours without follow up from the social worker or nursing staff, RP A asked RN A what was the status of the doppler. RN A informed RP A that they were changing directions because the doppler had not arrived. Interview with LVN A on 11/2/23 at 1:55pm revealed received information from LVN B about 6:30am on 11/2/23. was that CR# 1 was trending low blood pressure. LVN A was given an order to do a straight catheter (tube inserted through a narrow opening into a body cavity)and start resident on 3 liters saline 75cc hourly until her scheduled transportation arrived between 7:00 AM and 9:00 AM this morning. However, CNA A checked CR#1's vitals on her initial rounds and immediately reported blood pressure 55 / 44 and pulse was high as it was between 136 and 140. LVN A confirmed what she was told by CNA A by taking CR#1's vitals again. This time the resident bp was 63/48 and showed signs of Tachycardia (elevated heart rate). The DON contacted and permission given to send CR#1 out 911. Interview on 11/2/23 at 3:54pm with CNA A revealed she took CR#1 vitals at the beginning of her shift 6a-2p). She stated she took CR#1 blood pressure, and it was low, but her pulse was high and breathing through her mouth appearing to need oxygen, which none was in the vicinity. She stated she immediately reported this to LVN A. CNA A was informed, by LVN A to get CR#1 ready because she (CR#1) was going out 911. Telephone interview with LVN B on 11/2/23 at 4:14pm revealed on 11/1/23 at approximately 10:00pm they met with RN A for shift change briefing. LVN B was informed by RN A that there was a lot going on with CR#1and FM. FM's has requested a pain pump and RN A informed FM that is not a procedure they did at the facility. LVN B informed him the family wanted CR#1 transferred to a pnotes/dx?referred hospital for a G-Tube (tube placed in stomach). LVN B stated there was no clear instructions and was unsure what was really going on. LVN B was getting ready to administer CR#1's blood pressure medication. The blood pressure as 88/61 blood pressure, which was too low. No medication was given based on the orders to hold if bp was less than 110/60. Instead, he propped her legs up because she had an IV running sodium chloride at about 0.9% running at 75 milliliters' an hour. LVN B stated RN A directed him to follow-up with transportation that was reserved for CR#1 to be picked-up between 7am-9am and taken to the hospital of choice for the FM. LVN B spoke with FM around 11:00pm on 11/1/2023 with the confirmation. Also, LNV B stated he took CR#1's vitals around 5:00am on 11/2/2023. Prior to administering CR#1's blood pressure medication, the blood pressure read 106/54 and heart rate was around 120. Because the blood pressure was out of parameters of the doctors' orders, he did not administer. LVN B also stated CR#1 responded to him calling her name. Observation of CR#1 on 11/3/23 at 9:00am at hospital revealedCR#1 was highly sedated; eyes closed no distress noted and non-interviewable. Her RP was at her bedside. RP stated she was waiting on her siblings to get to the hospital as the doctor(s) wanted to have a consultation with all of the family members. Interview with ER physician on 11/3/2023 at 9:30am revealed CR#1 arrived yesterday (11/2/2023), via, ambulance and had to be placed immediately on ventilator (Breathing machine). He stated, CR#1 is in critical condition and is not going to make it. In fact, is dying. Further stated, CR#1's current diagnosis is Pneumonia, Acute Kidney Failure and Septic Shock. In a telephone interview with Facility Physician on 11/3/23 at 1:29pm- He stated he completed his rounds on 11/1/23 at 5:00am. During his assessment of CR#1 the blood pressure was 90/68 and pulse 74. An IV for fluids was ordered at that time. Later in the afternoon toward evening hours, Physician A received a telephone call and was informed that CR#1 was dehydrated, and access needed changing (change the entrance of fluid in the body). An order was completed to change access and start clysis to LLA, d/t DVT in bilateral upper extremities. NS %0.9 running at 75 cc/hr via gravity. Further interview with the Facility Physician stated neither he or his NP were ever notified of the changes in CR#1's vitals. Also Stated, based on CR#1's medical history when admitted into the facility, if he had known of the low blood pressure, he would have ordered CR#1 transferred to the hospital via EMS 911. In a telephone interview with the NP on 11/3/23 at 2:04pm. it was revealed she was notified by RN A on 11/1/23 at 9:39pm that CR#1's condition had changed, and the FM had requested CR#1 be transferred, via, transportation back to the hospital. The NP stated if the FM wanted CR#1 to go to hospital then send her out. On 11/2/23 NP received a text message from LVN A that CR#1 went to the hospital, via, 911 ambulance. NP stated at no time was she informed by the nursing staff of the decrease in vitals or the increase in pulse rate. During a telephone interview with RN A on 11/3/23 at 2:39PM- revealed CR#1 was a little responsive with yes or no questions asked throughout the evening of 11/1/2023. When touched or moved CR#1 would groan as if she was in a lot of pain. During this time, RN A stated she did not call the doctor to tell of the declining blood pressure because she felt the doctor already had been notified of the low blood pressure and she was waiting for IV rehydration that was ordered from the pharmacy. RN A stated she took CR#1's blood pressure earlier in the afternoon, stated it was low, but did not notate it nor can she remember what it was. RN A took the blood pressure again and it was 75/55 and pulse 120. CR#1 was not responding verbally at this time. When asked, why she didn't call the doctor when the vitals were 75/55 and pulse 120, RN A stated she is not sure what she was wondering at the time. RN A stated the doctor should have been called. An interview with the DON on 11/3/23 at 3:37pm - revealed he was notified on 11/2/2023 by LVN A of CR#1's declining vitals and S-Bar and that they RP wanted to wait for transportation to a hospital of choice. The DON informed LVN A to use her nursing skills and if the CR#1 needed to go 911 then call 911. The DON was not notified that CR#1's vitals were declining; but notified the resident was having a change in condition on 11/1/23 at 1:00pm. Based on the CR#1 blood pressure going from 102/57 (130) to 63/48 (136) the call to 911 should have been made. During a telephone interview with the pharmacist on 11/7/2023 at 11:16am it was revealed a verbal order for CR#1 and was called in on 11/1/23 at or around 6:22pm. The prescription was filled and went out during the 8:00pm delivery. There were no other orders. Received an email from the pharmacist on 11/7/2023 at 11:45am - that revealed an email of the fax that was sent to the pharmacy for an order of Sodium Chloride Hydration (3bags). The order was called in on 11/1/23 at 1816 (6:16pm) by RN A. A Policy Review of the Significant Change in Condition revised February 2021, The nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition. The following Plan of Removal submitted by the facility was accepted on 11/7/2023 at 9:31am., after multiple revisions. FACILITY'S PLAN OF REMOVAL DATED 11/06/23. Immediate action: CR # 1 was sent to the emergency roiagnom on [DATE] via 911 services. On 11/6/2023 an ADHOC QAPI meeting was held with the Director of Nursing, Executive Director, Medical Director and Co-Medical Director. Reviewed: IJ Template, CR #1's chart, and Plan of Removal. Director of Nursing initiated in-service on 11/6/2023 with all nursing staff changes of condition. Topics included: assessing resident blood pressure, respirations, and pulse, reporting abnormal vital signs to the physician upon identification of the abnormality, reporting abnormal vital sign trends to the Physician upon identification of the abnormality, notify the Physician of delays in care to include: unable to obtain iv access and delays in pharmacy delivery, and ensuring residents are sent to the emergency room for emergent conditions (such as severe hypotension) upon identification of the emergent condition. All nursing staff will be trained before working their next shift. New hires (licensed nurses) will receive education in orientation. Licensed Nurses will not be able to work until training is completed. Training will be completed by 11/7/2023. The Director of Nursing initiated in-service with CNAs on 11/6/23 regarding vital signs. Topics included assessing the resident's blood pressure and reporting abnormal vital signs to the charge nurse immediately. All CNAs will be trained before working their next shift. New hires (CNAs) will receive education in orientation. CNAs will not be able to work until training is completed. Training will be completed by 11/7/2023. On 11/6/23 the Director of Nursing completed a 100% audit of residents' vital signs and physician orders from 11/1/23 to present. The audit included reviewing residents' vital signs for abnormalities or abnormal trends and ensuring these were communicated with the physician timely. The audit also included reviewing new physician orders from 11/1/23 to current to ensure implementation and no delays of care. No adverse findings were noted. The DON/Designee will review Point Click Care vitals report daily to audit abnormalities in residents' vitals to include blood pressure, pulse and respirations to ensure that at the sign of abnormalities physician is promptly notified. Monitoring Review of the Plan of Removal revealed each medical staff member (RN's, LVN's and CNA's) were in-serviced, between 11/6/2023 and 11/8/2023 on Urgency in the notifications when resident vitals are abnormal, any changes in resident conditions, if blood pressure and heart rate are out of the normal parameters an immediate notification to nursing and physician is required and documentation of date, time of the occurrence. Monitoring interviews on 11/7/2023 through 11/8/2023 with 39 staff across three shifts to include 6AM-2PM, 2PM-10PM & 10PM-6AM (RN's, LVN's, CNA's) indicated they had been in-serviced on Urgency, Changes in Conditions, assessing blood pressure parameters and how to identify and who to immediately report changes to and the importance of documentation in the system immediately. During the interviews each staff member were asked to provide an example of what they felt was urgency and what they would do. All CNA's interviewed indicated they would immediately contact the RN or LVN if the vitals are too low, or the resident has a change in condition. They also indicated if necessary and they are unable to contact the RN/LVN/DON or anyone else and the need occurs they would call 911 then complete the appropriate documentation afterwards. The RN and LVN indicated the same. They also indicated that it was imperative for them not to wait to document, but to document all occurrences. The DON will closely monitor changes in conditions with patients by completing an audit daily and reviewing all new physician orders from 11/1/23 to present and foregoing. He stated prior to the IJ he was auditing bi-weekly; however, feels it is more important to complete the audits daily. The Executive Director was notified the IJ lowered on 11/8/2023 at 11:05am and the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan.

Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 5 residents (CR# 1) reviewed for quality of care. The facility failed to ensure that CR #1 received treatment and care in accordance with professional standards of practice. The facility failed to call 911 services to transport CR#1 to a higher level of care, instead, attempted to use their non-emergency transportation to send resident to the hospital when CR #1 ' s blood pressure was extremely low and pulse extremely high. The facility failed to transfer CR #1 to the hospital in a timely manner when resident ' s vitals began to decline. The facility initially became aware of CR#1 ' s declining vitals 11/1/23 at 5:34am and 911 was called 11/2/23 at 7:00am, 24 hours after the facility was made aware of CR#1 ' s condition. An IJ was identified on 11/6/2023. The IJ template was provided to the facility on [DATE] at 4:13pm. While the IJ was removed on 11/8/2023, the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan. This failure could affect residents by placing them at risk of delayed treatment that has the propensity to lead to death. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year-old female admitted to the NF on 10/26/2023. CR#1 diagnoses included the following: chronic respiratory failure with hypercapnia (occurs when the respiratory system cannot adequately remove carbon dioxide), candida esophagitis (weakened immune system), sickle-cell trait (inherited blood disorder), demyelinating disease of central nervous system (central nervous system disorder), chronic inflammatory demyelinating polyneuritis (Progressive weakness and reduced senses in the arms and legs), Congestive heart failure (A chronic condition that prevent the heart from pumping blood as well as it should). Record review of CR#1's MDS dated [DATE] did not reveal a BIMS score. Record review of CR#1's baseline care plan dated 10/26/23 and revised on 10/30/23 revealed allowing residents to make decision regarding treatment, care and provide opportunities for resident to make choices. Record review of CR#1's Physician Orders revealed the following orders: - Start Date-10/26/23 2200-D/C Date 11/2/23 1639 HydrAlazine HCI Oral Tablet 50 MG (Hydralazine)-Give 1 tablet by mouth every 8 hours for High blood Pressure Hold for BP<110/60 or HR <60 - Start Date-11/01/2023 1400-D/C Date-11/01/2023 1907 revealed an order for NS via IV Perlpheral (3L) at 75cc r/t dehydration every shift for fluids - Start Date-11/01/23 2200-D/C Date 11/02/2023 1639-NS via Clysis (introducing large amount of fluids into the body) (3L) at 75cc r/t dehydration every shifter for fluids - Start Date-11/01/2023 2200 - D/C Date-11/02/2023-Sodium Chloride Intravenous 0.9% (Sodium Chloride)- Use 75 ml/hr ml/hr Intravenously every shift for dehydration until 11/3/23 23:59 3L via Clysis Record Review of CR#1's Progress Notes revealed the following: Record review of vitals revealed blood pressure completed on 11/1/2023 at 5:34am - blood pressure 90/68 Pulse 74 Record review of vitals revealed blood pressure completed on 11/1/2023 at 1:54pm- blood pressure 86/56 Pulse 65 Record review of vitals revealed blood pressure completed on 11/1/2023 at 5:28pm -blood pressure 75/55 Pulse 120 Record review of vitals revealed blood pressure completed on 11/2/2023 at 5:20am - blood pressure 102/57 Pulse 130 Record review of vitals revealed blood pressure completed on 11/2/2023 at 7:00am - blood pressure 63/48 Pulse 136 Record review of the SBAR summary Late Entry, created by LVN A on 11/2/23 at 10:23pm effective 11/1/23 at 7:20pm on 11/1/2023 at 12:02 revealed a change in condition: Temp: T 97.9 - 11/1/2023 3:54 Route: Forehead (non-contact) Weight: W 176.8 lb - 11/2/2023 10:52 Scale: Mechanical Lift Pulse Oximetry: O2 92.0% - 11/1/2023 13:54 Method: Room Air Blood Glucose: BS 113.0 - 11/1/2023 11:23 In an interview with FM A on 11/2/2023 at 12:25pm revealed a concern with CR#1 vitals since the early morning of 11/1/2023. The concerns were based on her level of care and her current health condition. FM A stated CR#1 had not eaten or had any fluids by mouth in 4 days and was severely dehydrated. There was a concern by the RP that nursing personnel showed no urgency in attending to CR#1's medical needs. FM A was informed on 11/1/2023 at or close to 10:00am, by the SW, that the nursing staff had ordered a doppler from the pharmacy due to nursing staff having a difficult time locating a vein. It would take at least 4 hours for the doppler to arrive to the facility. After 8 hours without follow up from the social worker or nursing staff, RP A asked RN A what was the status of the doppler. RN A informed RP A that they were changing directions because the doppler had not arrived. Interview with LVN A on 11/2/23 at 1:55pm revealed received information from LVN B about 6:30am on 11/2/23. was that CR# 1 was trending low blood pressure. LVN A was given an order to do a straight catheter (tube inserted through a narrow opening into a body cavity)and start resident on 3 liters saline 75cc hourly until her scheduled transportation arrived between 7:00 AM and 9:00 AM this morning. However, CNA A checked CR#1's vitals on her initial rounds and immediately reported blood pressure 55 / 44 and pulse was high as it was between 136 and 140. LVN A confirmed what she was told by CNA A by taking CR#1's vitals again. This time the resident bp was 63/48 and showed signs of Tachycardia (elevated heart rate). The DON contacted and permission given to send CR#1 out 911. Interview on 11/2/23 at 3:54pm with CNA A revealed she took CR#1 vitals at the beginning of her shift 6a-2p). She stated she took CR#1 blood pressure, and it was low, but her pulse was high and breathing through her mouth appearing to need oxygen, which none was in the vicinity. She stated she immediately reported this to LVN A. CNA A was informed, by LVN A to get CR#1 ready because she (CR#1) was going out 911. Telephone interview with LVN B on 11/2/23 at 4:14pm revealed on 11/1/23 at approximately 10:00pm they met with RN A for shift change briefing. LVN B was informed by RN A that there was a lot going on with CR#1and FM. FM's has requested a pain pump and RN A informed FM that is not a procedure they did at the facility. LVN B informed him the family wanted CR#1 transferred to a pnotes/dx?referred hospital for a G-Tube (tube placed in stomach). LVN B stated there was no clear instructions and was unsure what was really going on. LVN B was getting ready to administer CR#1's blood pressure medication. The blood pressure as 88/61 blood pressure, which was too low. No medication was given based on the orders to hold if bp was less than 110/60. Instead, he propped her legs up because she had an IV running sodium chloride at about 0.9% running at 75 milliliters' an hour. LVN B stated RN A directed him to follow-up with transportation that was reserved for CR#1 to be picked-up between 7am-9am and taken to the hospital of choice for the FM. LVN B spoke with FM around 11:00pm on 11/1/2023 with the confirmation. Also, LNV B stated he took CR#1's vitals around 5:00am on 11/2/2023. Prior to administering CR#1's blood pressure medication, the blood pressure read 106/54 and heart rate was around 120. Because the blood pressure was out of parameters of the doctors' orders, he did not administer. LVN B also stated CR#1 responded to him calling her name. Observation of CR#1 on 11/3/23 at 9:00am at hospital revealedCR#1 was highly sedated; eyes closed no distress noted and non-interviewable. Her RP was at her bedside. RP stated she was waiting on her siblings to get to the hospital as the doctor(s) wanted to have a consultation with all of the family members. Interview with ER physician on 11/3/2023 at 9:30am revealed CR#1 arrived yesterday (11/2/2023), via, ambulance and had to be placed immediately on ventilator (Breathing machine). He stated, CR#1 is in critical condition and is not going to make it. In fact, is dying. Further stated, CR#1's current diagnosis is Pneumonia, Acute Kidney Failure and Septic Shock. In a telephone interview with Facility Physician on 11/3/23 at 1:29pm- He stated he completed his rounds on 11/1/23 at 5:00am. During his assessment of CR#1 the blood pressure was 90/68 and pulse 74. An IV for fluids was ordered at that time. Later in the afternoon toward evening hours, Physician A received a telephone call and was informed that CR#1 was dehydrated, and access needed changing (change the entrance of fluid in the body). An order was completed to change access and start clysis to LLA, d/t DVT in bilateral upper extremities. NS %0.9 running at 75 cc/hr via gravity. Further interview with the Facility Physician stated neither he or his NP were ever notified of the changes in CR#1's vitals. Also Stated, based on CR#1's medical history when admitted into the facility, if he had known of the low blood pressure, he would have ordered CR#1 transferred to the hospital via EMS 911. In a telephone interview with the NP on 11/3/23 at 2:04pm. it was revealed she was notified by RN A on 11/1/23 at 9:39pm that CR#1's condition had changed, and the FM had requested CR#1 be transferred, via, transportation back to the hospital. The NP stated if the FM wanted CR#1 to go to hospital then send her out. On 11/2/23 NP received a text message from LVN A that CR#1 went to the hospital, via, 911 ambulance. NP stated at no time was she informed by the nursing staff of the decrease in vitals or the increase in pulse rate. During a telephone interview with RN A on 11/3/23 at 2:39PM- revealed CR#1 was a little responsive with yes or no questions asked throughout the evening of 11/1/2023. When touched or moved CR#1 would groan as if she was in a lot of pain. During this time, RN A stated she did not call the doctor to tell of the declining blood pressure because she felt the doctor already had been notified of the low blood pressure and she was waiting for IV rehydration that was ordered from the pharmacy. RN A stated she took CR#1's blood pressure earlier in the afternoon, stated it was low, but did not notate it nor can she remember what it was. RN A took the blood pressure again and it was 75/55 and pulse 120. CR#1 was not responding verbally at this time. When asked, why she didn't call the doctor when the vitals were 75/55 and pulse 120, RN A stated she is not sure what she was wondering at the time. RN A stated the doctor should have been called. An interview with the DON on 11/3/23 at 3:37pm - revealed he was notified on 11/2/2023 by LVN A of CR#1's declining vitals and S-Bar and that they RP wanted to wait for transportation to a hospital of choice. The DON informed LVN A to use her nursing skills and if the CR#1 needed to go 911 then call 911. The DON was not notified that CR#1's vitals were declining; but notified the resident was having a change in condition on 11/1/23 at 1:00pm. Based on the CR#1 blood pressure going from 102/57 (130) to 63/48 (136) the call to 911 should have been made. During a telephone interview with the pharmacist on 11/7/2023 at 11:16am it was revealed a verbal order for CR#1 and was called in on 11/1/23 at or around 6:22pm. The prescription was filled and went out during the 8:00pm delivery. There were no other orders. Received an email from the pharmacist on 11/7/2023 at 11:45am - that revealed an email of the fax that was sent to the pharmacy for an order of Sodium Chloride Hydration (3bags). The order was called in on 11/1/23 at 1816 (6:16pm) by RN A. A Policy Review of the Significant Change in Condition revised February 2021, The nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition. The following Plan of Removal submitted by the facility was accepted on 11/7/2023 at 9:31am., after multiple revisions. FACILITY'S PLAN OF REMOVAL DATED 11/06/23. Immediate action: CR # 1 was sent to the emergency roiagnom on [DATE] via 911 services. On 11/6/2023 an ADHOC QAPI meeting was held with the Director of Nursing, Executive Director, Medical Director and Co-Medical Director. Reviewed: IJ Template, CR #1's chart, and Plan of Removal. Director of Nursing initiated in-service on 11/6/2023 with all nursing staff changes of condition. Topics included: assessing resident blood pressure, respirations, and pulse, reporting abnormal vital signs to the physician upon identification of the abnormality, reporting abnormal vital sign trends to the Physician upon identification of the abnormality, notify the Physician of delays in care to include: unable to obtain iv access and delays in pharmacy delivery, and ensuring residents are sent to the emergency room for emergent conditions (such as severe hypotension) upon identification of the emergent condition. All nursing staff will be trained before working their next shift. New hires (licensed nurses) will receive education in orientation. Licensed Nurses will not be able to work until training is completed. Training will be completed by 11/7/2023. The Director of Nursing initiated in-service with CNAs on 11/6/23 regarding vital signs. Topics included assessing the resident's blood pressure and reporting abnormal vital signs to the charge nurse immediately. All CNAs will be trained before working their next shift. New hires (CNAs) will receive education in orientation. CNAs will not be able to work until training is completed. Training will be completed by 11/7/2023. On 11/6/23 the Director of Nursing completed a 100% audit of residents' vital signs and physician orders from 11/1/23 to present. The audit included reviewing residents' vital signs for abnormalities or abnormal trends and ensuring these were communicated with the physician timely. The audit also included reviewing new physician orders from 11/1/23 to current to ensure implementation and no delays of care. No adverse findings were noted. The DON/Designee will review Point Click Care vitals report daily to audit abnormalities in residents' vitals to include blood pressure, pulse and respirations to ensure that at the sign of abnormalities physician is promptly notified. Monitoring Review of the Plan of Removal revealed each medical staff member (RN's, LVN's and CNA's) were in-serviced, between 11/6/2023 and 11/8/2023 on Urgency in the notifications when resident vitals are abnormal, any changes in resident conditions, if blood pressure and heart rate are out of the normal parameters an immediate notification to nursing and physician is required and documentation of date, time of the occurrence. Monitoring interviews on 11/7/2023 through 11/8/2023 with 39 staff across three shifts to include 6AM-2PM, 2PM-10PM & 10PM-6AM (RN's, LVN's, CNA's) indicated they had been in-serviced on Urgency, Changes in Conditions, assessing blood pressure parameters and how to identify and who to immediately report changes to and the importance of documentation in the system immediately. During the interviews each staff member were asked to provide an example of what they felt was urgency and what they would do. All CNA's interviewed indicated they would immediately contact the RN or LVN if the vitals are too low, or the resident has a change in condition. They also indicated if necessary and they are unable to contact the RN/LVN/DON or anyone else and the need occurs they would call 911 then complete the appropriate documentation afterwards. The RN and LVN indicated the same. They also indicated that it was imperative for them not to wait to document, but to document all occurrences. The DON will closely monitor changes in conditions with patients by completing an audit daily and reviewing all new physician orders from 11/1/23 to present and foregoing. He stated prior to the IJ he was auditing bi-weekly; however, feels it is more important to complete the audits daily. The Executive Director was notified the IJ lowered on 11/8/2023 at 11:05am and the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan.

Based on observation, interview, and record review, the facility failed to establish and maintain infection control procedures that provided a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 14 of 14 residents ( Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 , #13 and CR#1) and 6 of 6 staff (PT A, RN Z, CNA A, CNA B, CNA C, LVN P) reviewed for infection control. The facility failed to ensure a system was in place to immediately notify staff of their positive test results and prohibit them from working. The facility failed to ensure staff were screened prior to beginning their shift. The facility failed to report 6 COVID positive staff and 12 positive residents to HHSC. An Immediate Jeopardy (IJ) was identified on 07/23/20. While the IJ was lowered on 07/29/20 the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures place all facility residents, staff, and visitors at risk of infection or outbreak due to COVID-19. Findings include: Record review of staff COVID19 test results dated 6/24/20 revealed Housekeeping Aide C and LVN W tested positive. Record review of facility's fax to the health department dated 7/8/20 revealed PT A worked on 7/3 and got tested following her shift for COVID19. The test result was negative. She was admitted to the emergency roiagnom on ,[DATE] and tested positive for COVID19 on 7/7. The facility included contact tracing. Further review revealed she had contact with CR #1 on 7/3. A phone call was placed on 7/29/20 at 3:07 pm to PT A. A voicemail was left. The phone call was not returned. Record review of facility's fax to the health department dated 7/10/20 revealed CR #1 began having breathing problems. She was transferred to the emergency room where she was diagnosed to have COVID19. During an interview on 7/22/20 at 10:33 am, the Administrator said they tested all residents and staff in June and two staff members were positive. He said PT A called on 7/7 and said she tested positive. CR #1, who had been in close contact with PT A began having shortness of breath on 7/8. She was transferred to the emergency room where she tested positive for COVID. He said due to that COVID outbreak they tested all residents on 7/10 and received the results yesterday. He said he had been reporting all the positive cases to the local health department. Record review of staff COVID test results collected on 7/15 and reported on 7/17 revealed CNA K, CNA S, CNA C, and LVN P tested positive. Record review of staff COVID test results collected on 7/15 and reported on 7/18 revealed CNA A and CNA B tested positive. Record review of CNA A's timesheet revealed she worked on 7/18 and 7/19 from 6 am - 2 pm. Record review of the facility's screening questionnaire log dated 7/19/20 revealed CNA A had no symptoms. Record review of the staff sign in sheet dated 7/19/20 revealed CNA A worked on the Laurel wing and was responsible for caring for the residents in rooms 25 - 36. Record review of the facility's census dated 7/28/20 revealed 10 residents in rooms 25-36. 4 of the residents were COVID positive and the other 6 were COVID negative. During an interview on 7/28/20 at 4:24 pm when asked if any staff worked with a positive test result the DON said if staff were in the building when results were received they were immediately sent home. When asked if there were any staff who worked after being identified as positive she said no. When asked about the positive results received on 7/18, she said 7/18 was a Saturday and the results were faxed to the facility. She said she was responsible for test results and did not have a designee for the weekend. She said when she got to work that Monday the positive staff were called and informed they were positive. When asked if she was aware positive staff worked over the weekend she said not to her knowledge. When informed results faxed on 7/18 identified two staff members who were positive who worked over the weekend staff worked over the weekend who tested positive she said she would not have let them work if she knew they were positive. When asked where CNA A and CNA B worked last she said they both worked on Laurel. When asked how they would handle test results received over the weekend in the future she said they switched labs and results could be viewed online. She said she currently did not have access to the online system but was working on regaining access. She said they were receiving results via fax. During an interview on 7/23/20 at 1:27 pm, the Administrator said the contact tracing for the 6 identified positive staff members was a work in progress. He said he started the contact tracing, but it was not completed. The contact tracing was requested but not received prior to exit. Record review of resident COVID test results collected on 7/10 and reported on 7/20 revealed Residents #1 - #12 tested positive. Record review of facility's self-reported intakes in Tulip reviewed on 7/22/20 revealed there were no intakes regarding COVID positive staff or residents. Record review of the nursing facility COVID-19 Response dated August 2020 read in part (j) A nursing facility must report COVID-19 activity as required by §19.1601(d)(2) and 42 CFR §483.80(g)(1)-(2). COVID-19 activity must be reported to HHSC Complaint and Incident Intake as described below:(1) Report the first confirmed case of COVID-19 in staff or residents, and the first confirmed case of COVID-19 after a facility has been without cases for 14 days or more, to HHSC Complaint and Incident Intake through TULIP or by calling [PHONE NUMBER] within 24 hours of the positive. (2) Submit a Form 3613-A Provider Investigation Report to HHSC Complaint and Incident Intake through TULIP or by calling [PHONE NUMBER] within five days from the day a confirmed case is reported. (k) If an executive order or other direction is issued by the Governor of Texas, the President of the United States, or another applicable authority, that is more restrictive than this rule or any minimum standard relating to a nursing facility, the nursing facility must comply with the executive order or other direction. During an interview on 7/22/20 at 10:33 am, the Administrator was asked if any positive COVID results were reported to HHSC. He said the regulations said results had to be reported to the local health department or HHSC and he had been reporting them to the local health department. Screening Record review of CDC.gov website read in part, screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Fever is either measured temperature >100.0oF or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., NSAIDs). Clinical judgement should be used to guide testing of individuals in such situations. Record review of the screening form dated 7/24/20 revealed RN Z was not screened. During an interview on 7/24/20 at 5:38 pm, when asked if RN Z filled out the screening today she said no. She said she was rushing, but she knew better and would go do the screening now. During an interview on 7/27/20 at 7:25 am, the DON said staff were to be screened at the beginning of their shift and receive a colored wrist band. She said they do spot checks and ensure everyone has a band. Record review of RN A's personnel file revealed she was hired on 1/28/20. Further review revealed on 4/6/20 she filled out a questionnaire indicating she worked at another healthcare facility. She listed two nursing homes in which she worked part-time and as needed. During an interview on 7/24/20 at 5:20 pm the Administrator and DON were present. When asked if there were any staff who worked at other facilities the Administrator said, Not to our knowledge. He was informed RN Z worked at another facility and previously tested positive for COVID. They said they were unaware she tested positive and worked at another facility. Record review of RN A's timesheet dated January 2020 - July 2020 revealed she worked between 26 and 40 hours every week from January to April. The last day she worked was April 16th and she returned on June 22nd. During an interview on 7/24/20 at 5:38 pm, RN Z said she worked at two facilities full-time and the DON was aware. She said back in April she began having symptoms she thought were allergy related and tested herself for COVID. She said when she tested positive she called both facilities and informed them of her positive test result. She said she spoke with the DON who took her off of the schedule and only recently just got put back on. During a follow-up interview on 7/24/20 at 5:45 pm the Administrator and DON were present. When informed RN Z said the DON was aware she worked at another facility and had informed her directly of the positive COVID test, the DON again said she was not aware of either. When asked why RN Z had not worked for months she said she was part-time. Record review of the facility's COVID-19 mitigation plan revealed the designated COVID unit was located on the Oak wing. Further review revealed Residents with active COVID-19 infection confirmed by testing or those residents who are recovering from COVID-19 infection are cohorted together in a designated unit. Residents exposed to COVID-19 would be quarantined for 14 days. The plan indicated the facility was to report any positive tests to the local health department. It did not indicate HHSC needed to be informed. Record review of the nursing facility COVID-19 Response dated August 2020 read in part (c) A nursing facility must screen all residents, staff and people who come to the facility in accordance with the following criteria of this subchapter: (1) Fever defined as a temperature of 100.4 Fahrenheit and above, or signs or symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat; (2) Signs or symptoms of COVID-19 including, but not limited to, fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea; (3) Additional signs and symptoms as outlined by the CDC: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html; (4) Contact in the last 14 days, unless to provide or receive critical assistance, with someone who has a confirmed [DIAGNOSES REDACTED]. For updated information on affected countries visit: https://www.cdc.gov/coronavirus/2019-ncov/[MEDICATION NAME]/map-and-travel-notices.html. (d) A nursing facility must screen according to the following timeframes: (1) each resident at least three times a day, occurring at least once each shift; and (2) each employee or contractor before entering the facility at the start of their shift. (e) A nursing facility must cohort residents based on the residents' COVID-19 status. (f) A resident with unknown COVID-19 status must be quarantined and monitored for fever and symptoms of COVID-19 per CDC guidance. (g) A COVID-19 positive resident must be isolated until they meet CDC guidelines for the discontinuation of transmission-based precautions. (h) A nursing facility must implement a staffing policy requiring the following: (1) The facility must designate staff to work with each cohort and staff should not change designation from one day to another, unless required in order to maintain adequate staffing for a cohort. (2) Staff may not work with more than one cohort. (3) Staff must wear appropriate PPE as described in subsection (a)(6) of this section based on the cohort with which they work. (4) Staff must report to the facility via phone prior to reporting for work if they have known exposure or symptoms. (5) Staff must perform self-monitoring on days they do not work. (6) A policy regarding staff working with other long-term care (LTC) providers that includes the following: (A) Limits the sharing of staff with other LTC providers and facilities, unless required in order to maintain adequate staffing at a facility. (B) Maintains a list of staff who work for other LTC providers or facilities that includes the names and addresses of the other employers. (C) Requires all staff to report to the facility immediately if there are COVID-19 positive cases at the staff's other place of employment. (D) Requires the facility to notify the staff's other place of employment if the staff member is diagnosed with [REDACTED]. (i) All NF staff must wear a facemask while in the facility. Staff who are caring for COVID-19 positive residents and those caring for residents with unknown COVID-19 status must wear an N95 mask, gown, gloves, and goggles or a face shield. All facemasks and N95 masks must be in good functional condition as described in the COVID-19 Response for Nursing Facilities, and worn appropriately, completely covering the nose and mouth, at all times. Record review of the facility's policy on infection control dated October 2018 revealed Outbreak management is a process that consists of determining the presence of an outbreak; managing the affected residents; preventing the spread to other residents; documenting information about the outbreak; reporting the information to appropriate public health authorities; educating the staff and the public; monitoring for recurrences; reviewing the care after the outbreak has subsided; and recommending new or revised policies to handle similar events in the future. The facility Administrator and DON were notified on 7/23/20 at 1:45 pm that immediate jeopardy was identified due to the above failures. A copy of the IJ template was provided at this time and a plan of removal was requested. The final plan of removal was accepted on 7/26/20 at 11:54 am after several revisions were made. IJ plan of removal includes: Pandemic Response Plan has been reviewed and implemented and implementation validated by Administrator and DON on 7/23/2020. The Oak Wing will be identified as an isolation hall/unit. All residents who are COVID+ were isolated on 7/23/2020 and are being monitored Q shift for worsening signs and symptoms of COVID-19. Residents will be removed from isolation once negative results are received. Biohazard waste containers have been placed in each isolation room. Staff has been educated and in-service to place biohazard waste containers in each isolation room. Red biohazard bags for waste and yellow biohazard bags for laundry and to remain in place until isolation complete. DON and Administrator completed in -service on 7/23/2020. Staff and residents tested for COVID-19. Completed by ADON and DON, on 7/23/2020. Ten of the residents were transferred to the COVID-19 unit and isolated and two were isolated in their current rooms due to refusal to transfer to the COVID unit and staff received instructions to wear N95 mask, disposable gowns, face shields and goggles. HHSC was notified on 7/22/2020 of previous and existing COVID+ staff and residents by the Administrator on 7/22/2020. Contact tracing of residents and staff who are exposed to COVID-19 will be completed by Administrator and DON. Administrator initiated contact tracing inservicing to staff on 7/23/2020. Following contact tracing immediate measures will be taken to inform all who interact or may have recently interacted with NF of the positive result so that further limitations can be enacted to control the spread of infection to family or other service providers. Update Tracking Line List as needed by Administrator. Implement enhanced cleaning and disinfection techniques. Supply appropriate PPE, activate isolation/cohort plan. Report COVID+ cases to LHD and HHSC/DSHS. Test all staff and residents for COVID-19. Residents and staff will be educated and in-serviced following outcome of contact tracing. Contact tracing results to be discussed in QA. QA meeting was held with Dr Nguyen, Medical Director on 7/24/2020 with issues identified and response removal plan. The following training and in-servicing were initiated for staff on duty on 7/23/2020 by ADON, DON, Unit Manager and Administrator. Inservice topics included: Isolated residents to have a notification sign posted at door. Completed by ADON on 07/23/2020.Isolated resident's doors are to remain closed. Completed by ADON on 07/23/2020. Residents who test positive for COVID-19 will be transferred to COVID+ wing and isolated. Completed by Unit Manager on 07/23/2020. Staff in-service on using biohazard waste containers in rooms for doffing by ADON on 7/23/2020. Biohazard waste containers have been placed in each isolation room for doffing. Waste will be placed in red biohazard bags and sealed inside biohazard box for safe transport. Linens and resident's clothing will be placed in yellow biohazard bags with a biodegradable bag inside and sealed for safe transport to respective places. Laundry has been educated and in-service completed on 7/23/2020 by the Administrator with returning demonstration for washing contaminated linen/clothing to prevent cross contamination. In-serviced staff on proper usage of PPE and availability of disposable gowns. Completed by ADON on 07/23/2020. In-serviced laundry, housekeeping, plant, nursing and administrative staff on how to identify COVID+ residents, handle contaminated waste and disinfect contaminated rooms. Completed by Administrator & Director of Nursing on 07/23/2020. In-serviced and trained staff on how to identify COVID+ residents and the immediate actions to take once residents are identified. Completed by: ADON on 07/23/2020. All staff will be trained/educated on these new processes by 7/25/2020. Competency check performed on current staff by DON and Unit Manager for donning and doffing PPE on 7/23/2020. Staff in-service on the need to change PPE between positive and negative residents on 7/23/2020 by ADON. All donning stations and isolation carts have been provided with disposable gowns for the purpose of isolation or quarantine residents on 7/23/2020 by Unit Manager and ADON. Training initiated 7/23/2020 by ADON on donning, doffing and changing of PPE between positive and negative residents. All remaining staff will be trained by ADON, Unit Manager by 7/25/2020 on donning, doffing and changing PPE between positive and negative residents before allowing staff to care for patients. The COVID unit will be staffed with employees who are independent from the non-COVID unit. Inservice initiated with staff on Signs & Symptoms of COVID-19 and reporting s/s to employer on 7/24/2020 by DON. Updated Signs & Symptoms Monitoring Log to include updated s/s per CDC by Administrator on 7/24/2020. Signs and Symptoms posters posted throughout the facility. Inservice provided to staff, if s/s experienced staff is to quarantine at home, test and provide updates to the employer on progress of testing and results, completed by MDS and Unit Manager on 7/25/2020. Facilities Plan to ensure compliance quickly: New hire competency checks will be completed for Donning & Doffing. Random competency checks will be completed by Sharon Odom, RN, DON. Random compliance rounds will be made on COVID+ resident rooms to ensure infection control compliance by Sharon Odom, RN, DON. All lab results for COVID-19 testing will be monitored by Toyin Ibrahim, RN, ADON. Lab changed to Baylor Genetics for more timely COVID-19 test results. Working with Texas HHSC/DSHS to ensure that test kits are available to test staff and residents quickly and efficiently. Mitigation Plan will be updated to include: CDC's Return to Work for HCP revision. Isolation of COVID+ residents. Require facility staff to only work in one facility at a time. Implement On Shift app for employee notification of COVID+ results. Administrator will be responsible for ensuring completion of plan of removal. Monitoring Record review of the facility's plan of removal binder on 7/26/20 revealed in-services including COVID positive residents, closed doors and signs indicating residents on isolation, biohazard waste containers, PPE usage, and signs/symptoms of COVID. Further review revealed the facility's mitigation plan was updated as specified in the plan of removal. Observations made on 7/26/20 revealed all but two positive COVID residents were removed from their rooms and placed on the COVID wing. Resident #5 and Resident #7 remained in their rooms. They had signs on their doors indicating they were on isolation and isolation carts outside of their rooms stocked with PPE including disposable gowns. Their rooms had two biohazard boxes for linen and PPE. Interviews conducted on 7/26/20 with 1 LVN, the Medical Records Director, 1 CNA, and 1 housekeeper on the 2nd shift revealed they had a comprehensive understanding of the trainings and in-services received. Interviews conducted on 7/27/20 with 1 RN, 1 LVN, 2 CNAs, on the 3rd and 1st shifts revealed they had a comprehensive understanding of the trainings and in-services received. Record review of the facility's plan of removal binder on 7/26/20 revealed competency checks for donning and doffing standard precautions and transmission-based precautions form dated 7/23/20 revealed gloves were the first item removed first and hand hygiene performed after all PPE has been removed. There was no competency check for CNA L. Observation and interview on 7/27/20 at 6:24 am revealed, CNA L exiting a resident's room with gloves on holding a blood pressure cuff. She headed over to the nursing station where she handed off the cuff and threw away the gloves. She did not perform hand hygiene. She walked near the entrance of the unit where an isolation cart was stocked with PPE. She retrieved a disposable gown and pulled it over her head touching her face shield. She said the resident's room she just left was under 14-day quarantine and she was checking the vitals. When asked about expectations on hand hygiene she said it should be performed before and after putting on gloves. When asked why she did not perform hand hygiene when she removed her gloves she said because the surveyor requested an interview. When asked if she was trained on donning/doffing she said when doffing you take the gown off first and then the gloves in the resident's room. She said she did take off the gloves, but she put on new gloves to bring the blood pressure cuff. During an interview on 7/27/20 at 7:25 am, the DON said they did a return demonstration over donning/doffing with all staff. She said when taking off PPE the gloves were to be removed first. She said hand hygiene should be performed before putting gloves on and after taking them off and they should be disposed of in the resident's room prior to exiting. When asked the proper way to put on a gown that goes over the head she said she would have to see that gown. When informed of the observation with CNA L, the DON said she would re-Inservice staff. CNA L's competency sheet was requested but not provided prior to exit. During an interview on 7/27/20 at 7:25 am, the DON said Resident #13 (who resided on Willow) tested positive from the 7/23 test date. She said two other staff members that worked on Willow also tested positive so everyone on that wing was put on isolation and droplet precautions. She said there were biohazard boxes in all rooms and all doors should be closed. Observations on 7/27/20 at 7:28 am revealed an isolation cart at the entrance of Willow. Staff were observed in proper PPE and all doors were closed. Observations on 7/28/20 at 3:55 pm revealed two residents on Willow, who were on isolation, had their doors opened. During an interview on 7/28/20 at 4:15 pm, RN B said all resident room doors should be closed. When informed of the two residents with their doors opened he said one resident liked to keep it open because she feels claustrophobic and the other needed redirection. Observations on 7/29/20 at 1:45 pm revealed all residents on isolation's doors were closed and Isolation carts were stocked with PPE. Staff were observed wearing the bands indicating they were screened prior to their shift and observed donning/doffing properly. On 07/29/20 at 1:10 pm, the facility Administrator and DON were notified the IJ was lowered. However, the facility remained out of compliance at a severity level of no actual harm with potential for minimal harm that is not immediate jeopardy and a scope of pattern because the facility continuing to educate their staff and monitor the effectiveness of the Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for one of six residents (Resident #1) reviewed for quality of care. The facility failed to timely answer Resident #1's call light for help with going to the bathroom. Resident #1 sustained a fall with a right [MEDICAL CONDITION] with attempting to go to the bathroom herself. Resident #1 was not properly assessed by RN #1 before being picked off the floor after a fall and complaint of pain. The facility staff (RN #1) failed to seek prompt medical intervention and waited five hours when Resident #1 complained of hip pain after a fall and had a blood pressure of [AGE]/47. RN #1 also failed to administer Resident #1 pain medication after she complained of right hip pain after a fall. As a result , the resident was transferred to the hospital where she underwent a hip surgery. These failures affected one resident and placed her at risk for experiencing prolonged pain from delayed intervention and decline in health. Findings include: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female who was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. She was diagnosed with [REDACTED]. Record review of Resident #1's admission MDS, dated , 10/15/19 revealed she was usually able to make herself understood and usually understood others, had a BI[CONDITION] score of 9 indicating moderately impaired cognition, required extensive staff assistance with bed mobility, transfers, locomotion, dressing, dressing, toilet use, bathing and personal hygiene, used a wheelchair or walker for ambulation, was always incontinent of bowel and bladder, received or was offered and declined PRN pain medication within the previous five days of the assessment, and had not had any falls in the month prior to admission. Record review of Resident #1's care plan, updated 11/4/19 revealed the resident was dependent on staff for activities, cognitive stimulation, and social interaction. She had forgetfulness, impaired memory, impaired cognition, required close monitoring and re-orientation, she was at risk for falls due to impaired cognition, weakness, and body balance concerns. Goal included: monitor every two hours and as needed for minimal falls. Interventions for this focus area included monitor resident every two hours, monitor resident and ensure the ADL needs are all met such as toileting, thirst, hunger, anxiety, or signs and symptoms of pain. Record review of Resident #1's care plan, updated 11/4/19 revealed the resident had an actual fall with injury on [DATE] and indicated all unwitnessed falls required neuro checks for monitoring signs and symptoms of head injury. The resident used a wheelchair for locomotion, and required extensive one-person assistance with transfers, toilet use, bathing, dressing, personal hygiene, and grooming. Record review of Provider Investigation Report, dated [DATE] revealed on [DATE], at 6:05 a.m., Resident #1 was observed laying on the floor in her room by the side of her bed. RN #1 assessed the resident who was noted to have right hip pain. The attending doctor was notified of the incident and the complaint of pain and ordered a stat x-ray and [MED] for pain. The resident was sent to the hospital for further evaluation and was diagnosed with [REDACTED]. The resident returned to the facility on [DATE]. Record review of a written witness statement from CNA B, dated [DATE] revealed , I got to the unit around 6:00 a.m. I started my rounds.I was coming around the corner and heard someone calling out help me. This was around 6:05 a.m. and I found Resident #1 on the floor. She said she was trying to go to the restroom. I went and got RN #1 and he check her, and we put her in the chair. Record review of Resident #1's incident report dated [DATE] revealed it was completed by RN #1 . The document read in part, .CNA (CNA B) reported to this writer at 6:05 a.m. that patient is on the floor. This writer went immediately to patient's room and found patient on the floor at bed side. Patient stated, I fell down trying to get to the toilet, my right hip hurts. Immediate Action Taken, Description: Patient was placed in bed with assist by CNA (CNA B). This writer performed head to toe assessment on patient. Vital signs as follows: Blood pressure [AGE]/47, Pulse 69, Resp 18, BS 199, Oxygen Saturation 95%. Patient complained of pain to right hip rated 7 on a pain scale of 0 to 10. Doctor notified. New order given for [MEDICATION NAME] 650 mg by mouth every eight hours as needed; one now for pain, X-ray to right hip performed at 11:30 a.m. per doctor order. DON notified. Family member notified. Family member arrived at 6:45 a.m. and remained at bedside with patient. Patient insisted she want to be taken to the hospital now. Doctor notified and instructed for patient to be transferred to the hospital per her request. Patient was transferred to local hospital on a stretcher via local ambulance company at 11:40 a.m. Mental Status: Oriented to Place, Time, Person, and Situation. Record review of Resident #1's monthly physician order [REDACTED]. [MEDICATION NAME] Gel 1% - Apply 1 applicator [MEDICATION NAME] three times a day for pain apply to right shoulder . Medication had order date of 10/29/19. [MEDICATION NAME] Tablet - Give 650 mg by mouth every 8 hours as needed for pain. Medication was ordered [DATE] . Record review of Resident #1's MAR for November 2019 revealed the following: [MEDICATION NAME] Gel 1% - Apply 1 applicator [MEDICATION NAME] three times a day for pain apply to right shoulder (Administered on [DATE] at 8:00 a.m.) [ENTITY]t date 10/29/19. [MEDICATION NAME] Tablet - Give 650 mg by mouth every 8 hours as needed for pain (None administered) [ENTITY]t date/time : [DATE] & 10:00 p.m. Record review of Resident #1's hospital record Final Radiology Report, dated [DATE] revealed Resident #1 had an x-ray of her right hip. The report read, .Questionable subcapital right [MEDICAL CONDITION] noted. Additional subtle fracture seen involving the right inferior pubic ramus. No dislocation. No bony destructive lesion. Record review of facility 's Individual Inservice Form, dated 11/4/19 revealed RN #1 was personally in-serviced on Assessment after a fall incident, documentation, and medication administration. The plan of action included: Assess resident after each fall incident, Document all assessments that were done, and Sign MAR after each medication administration. Record review of a letter written by the facility's DON, dated 11/4/19 revealed On Monday 11/4/19, I received a report that Resident #1 who had a fall incident on 11/2 had a hip x-ray done and the result was positive for fracture. RN #1 was the nurse in charge and was called in to the DON's office regarding the incident. Nurse was asked what the procedure is when a resident is observed lying on the floor and the incident is un-witnessed. Nurse response was, assist resident back to bed and assess. Response is not correct as the procedure was to assess resident for injury before moving the resident. An individual in-service was done on the proper procedure when a resident is observed on the floor and an incident is not witnessed.On assessment patient verbalized to nurse having pain, nurse notified the attending doctor and received order for [MED]. Order was entered to computer by Nurse and according to him [MED] was given but MAR was not signed. Nurse was asked if pain medication was actually given since MAR was not signed, Nurse said that he documented in progress notes. Review of progress notes did not show pain medication being given either. Record review of Resident #1's progress note, dated [DATE] at 1:18 p.m. revealed it read in part, CNA reported patient was on the floor. This writer went in patient's room and found patient on floor by bedside. CNA helped put patient back in bed. Patient complained of right hip pain rated 7 on pain scale of 0 to 10. Head to toe assessment performed. vital signs as follows Blood pressure [AGE]/47; Pulse 63; Resp 18; BS 199; Oxygen Saturation 95%. Resident #1's family member notified. MD notified. New order for [MEDICATION NAME] 650 mg by mouths every 8 hours as needed, one now. Stat x-ray to right hip done at 11:30 a.m. DON notified. Patient requested to be sent to the hospital. MD notified of request and instructed to grant patient's request. Patient transferred to local hospital on stretcher by ambulance company. Note was written by RN#1 In a telephone interview with RN #1 on [DATE], at 10:45 a.m., he stated when he arrived for his shift at 5:50am on [DATE], a couple of call lights were on, including Resident #1's. The CNA (CNA B) stated she had just come out of Resident #1's room and she was ok. He went to the restroom and when he came out, the CNA said Resident #1 was on the floor. He went into the room and saw the resident on the floor. The resident said she was ok and tried to go to the restroom by herself because nobody had answered the call light, and nobody had been in her room since the night before. The resident told RN #1 her right hip pain level was seven. He said he did vitals. He said there was water and ice all over the floor from the resident's water pitcher. Another nurse came to help, and they put the resident back in bed and continued the assessment. The resident's blood pressure was low. The nurse called the doctor and received an order for [REDACTED]. He called the resident's family member, who came right over. He gave the resident [MED] and a pain cream which she already had at 6:20 - 6:30 a.m. He called the x-ray company at 7:45 a.m. and a colleague called again at 9:45 a.m. and there was no answer. By 11:20 a.m., the resident requested to go to the hospital, but the family member wanted her to wait until the pain medication take effect. The x-ray company arrived at 11:30 a.m. and the E[CONDITION] arrived about the same time. He stated he did not send the resident out sooner because the family member wanted to wait to see if the pain went down after the medication. He said he was concerned for the resident and the resident insisted again to be sent out. The family member agreed at that time. RN#1 said he did not notify any one of the resident's low blood pressure. Observation and interview of Resident #1 on [DATE], at 11:50 a.m. revealed she was sitting in a wheelchair in her room. She was alert and oriented but complained of pain to her shoulder. Resident #1 stated on that morning, she got up to go to the restroom and the bedside table was by the bed. She tried to catch the table getting up and knocked over the cup of ice-water. She and the cup fell to the floor. She had pushed her call button and thought she had waited about an hour. The staff previously asked her to wait for help so she tried to wait. Resident #1 said she could not remember how long she waited for help. She could not recall if she got any pain medication that morning after she fell . The resident said she was in so much pain that day and it took so long for the ambulance to get there. She said her family member never asked the staff to wait before taking her to the hospital. In an interview with the DON on [DATE], at 1:15 p.m., she stated RN #1 documented he gave Resident #1 [MED] on a nurse's note but did not sign the MAR. She said he should have signed the MAR and he told her he forgot. When asked why the resident was not sent out to a hospital sooner and why 911 was not called to transport, she stated 911 was not called and a regular ambulance transport was called because it was not an emergency situation. She was sent out after five hours, but she was not bleeding so it was not an emergency. If the [MEDICAL CONDITION] was known at that time, it would have been an emergency and 911 would have been called. She said hip pain was not an emergency because the hip could be stabilized. They did not have the x-ray results at that time and stat x-ray is about 4 hours. The DON said no neuro checks were documented but the nurse should have done them to ensure there were no changes. He called her that day around 10-11 a.m. He called her again and said he was sending her out. She stated a pain level of seven could have been a change of condition, but her level of consciousness was high so a pain level of 10 would not have been a change. She stated low blood pressure would have been a change in condition. When informed Resident #1's blood pressure was low that morning, the DON stated the nurse did not inform her of the low blood pressure and low blood pressure would have been a reason to send her out emergency. The DON said there was no policy regarding changes of condition. In a later telephone interview with RN #1 on [DATE], at 2:05 p.m. he stated when he assessed Resident #1, he asked about pain and did a head to toe assessment. Her leg was hurting too much to assess her range of motion. He said the resident's light was on at 5:50 a.m. when he arrived. He stated he only gave Resident #1 [MED] at 6 something. No other pain medicine was given throughout the day. He said her pain level decreased to a 2-3 . RN #1 said he documented the [MED] given on the progress note. He could not recall if he had documented the MAR, but he believed so. He said he conducted neuro checks but he could not remember if he documented the neuro checks . Record review of Resident #1's progress notes and clinical record revealed no documentation to show Resident #1's pain level was assessed after the initial response of seven out of 10 pain rating. There were also no documented neurological checks following Resident#1's unwitnessed fall. In an interview with the ADON on [DATE], at 2:30 p.m. she said a pain level of seven was high and [MED] 650 mg would not be suitable for that level. The nurse should have pushed further and called the doctor right back for a stronger medication. She stated she would have assessed the resident's range of motion, but she did not know if RN #1 did that. She said stat x-ray was four hours because they had to call contractors. When informed Resident #1's blood pressure was [AGE]/47, the ADON said, Wow! She stated that was an emergency and 911 should have been called especially with a fall and pain. An attempt was made to contact CNA B by telephone on [DATE], at 2:52 p.m. A voicemail message was left but it was never returned. An attempt was made to contact Resident #1's family member by telephone on [DATE], at 3:00 p.m. The call was returned on 11/19/19, at 1:20 p.m. She stated she arrived at the facility after they called her at about 8:00 a.m. Resident #1 was in a lot of pain and she was in bed. The staff said she was getting a stat x-ray to see if the resident was ok. The nurse kept calling the x-ray people and they arrived about 11:00 a.m. The resident was screaming in pain when they were doing the x-ray. She said the staff waited from 6:00 a.m. until 11:00 a.m. She never saw anybody give the resident pain medication and nobody said they had. She said she never told anybody to wait before sending the resident out and did not know anything about pain medication. Resident #1 had already asked to be sent out and said her whole side was hurting from her waist down. The resident kept telling her how much pain she was in while they waited. She tried to get them to take action before, but she finally said she did not want to wait anymore for the x-ray because they would have to take another one at the hospital anyway. Resident #1 had surgery the next day because the doctor said the fracture could have gotten worse. The family member said watching the resident in pain while just waiting for an x-ray was very upsetting and it took too long. Record review of facility policy, Assessing Falls and Their Causes, dated March 2018, revealed it read in part, .After a Fall; 1. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Obtain an record vital signs as soon as it is safe to do so. 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details.6. Observe for delayed complications of a fall for approximately forty-eight hours after observed or suspected fall and will document findings in the medical record. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings.Documentation When a resident falls, the following information should be recorded in the resident's medical record.3. Interventions, first aid, or treatment administered.

Based on interview, and record review, the facility failed to consult with the physician when a change of condition occurred for one of eight residents (CR #2) reviewed for physician consultation. The facility failed to assess, intervene and consult with the physician when CR #2 had a change in condition and died six hours later. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. This failure affected one resident and placed 34 other residents in the facility at risk of not having their physicians consulted when they experienced a change in condition and required their medical care. Findings include: Intake # 1 CR #2 Record review of CR #2's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of CR #2's quarterly assessment MDS dated [DATE] revealed the following Diagnoses: [REDACTED]. Further review of this MDS assessment revealed CR #2 had a BIMS score of 11, indicating her cognition was moderately impaired, required limited assistance with all ADLs except eating, was continent of bowel and bladder and did not require respiratory treatments. Record review of CR #2 's care plan, which was not dated, revealed resident had impaired gas exchange related to respiratory concerns such as [MEDICAL CONDITION] evidenced by shortness of breath upon exertion; use of oxygen, rapid irregular, labored breathing, pale related to respiratory disease. Goals: the resident will function at the highest practicable level within limitations of disease. Approaches included: follow MD orders and administer oxygen via nasal cannula, and breathing treatment as ordered. Monitor vital signs am oxygen saturation as scheduled and as needed, report significant changes, assess and monitor for symptoms of respiratory distress, increased anxiety, cyanosis and shortness of breath. Maintain calm and quiet environment, monitor lab as ordered, monitor oxygen saturation level as ordered. Record review of CR #2's Nurse notes dated [DATE] at 4:00 a.m. and written by LVN #3 revealed resident observed sitting up in wheelchair, head slumped down, took a closer look and noted resident's eye fixed and appears to have passed out/fainted, assisted resident into bed and made her comfortable with head of bed elevated, vital signs taken: blood pressure 144, blood pressure ,[DATE], 62, respiration 22. Oxygen continues at 2 liters. No distress noted but it does appear breathing is rapid, called Physician on call number, awaiting response. Record review of CR #2's Nurse Notes written by LVN #4, dated [DATE] revealed the following: 6:00 a.m. - received patient in bed call light within reach, patient awake, a.m. care provided, accu check done result 131, patient ate 15% of breakfast. 8:00 a.m. - oxygen saturation was 96%, respiration was non-labored at 18 cycles per minute. 10:05 a.m. - resident requested a bowl of cereal, offered to patient, and consumed 75% and coffee. 11:05 a.m. - patient requested to use the bathroom, assisted by assigned CNA, who helped patient back in bed, patient remained onside of bed gasping for air, 911 initiated by writer. 11:25 a.m. - on arrival patient had stopped breathing, CPR not initiated due to DNR status. Interview on [DATE] at 12:08 p.m., the DON said she recalled CR #2 passed away a couple of day ago. She said it was expected because the resident had [MEDICAL CONDITION] and had a DNR status. She recalled the resident used oxygen. Interview on [DATE] at 1:02 p.m., LVN #4 said she took care of CR #2 on the morning of [DATE]. She said she took report from the night shift nurse LVN #3 on the morning of [DATE] and LVN #3 did not inform her that CR #2 had a change in condition during the night shift. LVN #4 said CR #2 had severe [MEDICAL CONDITION] and began experiencing respiratory distress around 11:00 a.m. after she got up to use the bathroom. LVN #4 said she placed a non-rebreather mask on CR #2 and increased her oxygen liters, then called 911. She said CR #2 had stopped breathing when 911 arrived. She said she did not initiate CPR because CR #2 had a DNR status. Interview on [DATE] at 1:12 p.m., the RN Weekend Supervisor said she was not informed about CR #2's change in condition upon duty assumption on [DATE]. The RN Weekend Supervisor said she was called to the resident's room and when she got there the 911 crew arrived at the same time. She said CR#2 had stopped breathing at that time. Interview on [DATE] at 1:58p.m., LVN #5 said CR #2 had severe [MEDICAL CONDITION] and required oxygen at all times. She was told the resident passed away on the weekend which surprised everyone. LVN #5 explained it was unexpected. Interview via phone on [DATE] at 5:00p.m., CNA #2 said on the morning of [DATE], she saw CR #2 ' s call light on and went into her room to help. CNA #2 said she was not CR #2 ' s assigned aide, but assisted the resident to the restroom. CNA #2 said CR #2 had respiratory problems and had to use oxygen all the time. CNA #2 said CR #2 had her oxygen on as she took her to the bathroom in her wheelchair. She said CR #2 returned to her bedside and held CNA #2 and said don ' t leave me and then began having rapid respiration. CNA #2 said it all happened very quickly. She called the nurse, but CR #2 passed away. CNA #2 said all the aides knew CR #2 had severe respiratory problems. Interview on [DATE] at 7:10 a.m., the DON said staff were trained to care for CR #2 who experienced a significant change in condition. She said the staff were provided training upon hire and on an on-going basis. The DON said on the job in-services were provided to staff frequently, as well as skill check offs with feedback to staff following incidents. The DON said the facility had protocol in place for use when a resident had a change in condition. She further said staff were trained to use the SBAR and interact tools, as well as to seek help from internal resources like supervisors in the facility. Interview via phone on [DATE] at 1:46 p.m., LVN #3 said during the night shift on [DATE] she saw CR #2 hanging between the toilet seat and her wheelchair, holding the arm of her wheel chair. She quickly assisted the resident to her wheelchair, put her oxygen on because she did not have it on, then helped her to bed and made her comfortable. She said CR #2's respiration was normal and she had no distress during this incident. LVN #3 said she called the physician and spoke to someone who was to notify the physician. She explained the facility protocol was to call the physician on call number and they would return the call by the next morning. She agreed she should have called again before her shift ended. She further said she told the morning nurse LVN #4 to follow-up and to monitor CR #2 closely when she gave her report. She said she would have called 911 if CR#2 was not a DNR and that it would have been a problem if she called 911 for a DNR. LVN#3 was asked why her account was different from her documentation on the resident's nurse notes. She said she thought CR #2 was just struggling to sit up in her wheelchair. LVN #3 said after CR #2 was put in bed, she became alert and responsive again and was talking. LVN #3 said she was shocked when the DON told her CR #2 passed away a couple of hours later that day. Record review of facility's 24 hour report for the night shift on [DATE] did not reveal any documentation of CR #2's change in condition. CR #2's incident was not reported on the 24 hours report. Interview on [DATE] at 7:05 a.m., the DON said based on the incident account documented on CR #2's nurse notes for the night shift on [DATE] at 4:00 a.m., CR#2 should have been sent to the hospital via 911. She further said LVN #3 was terminated for not promptly intervening and communicating the incident to other nurses to follow-up. Record review of the facility's policy on notification of physicians dated February 2016 revealed the facility shall promote a two way system of communication between the facility and physician. Staff will notify the physician at various times during a resident's stay in order to ensure all appropriate information has been made available to allow the physician to provide the highest level of care to the residents. Licensed nurses shall notify the physician upon a change in condition of a resident, and to make them aware that a resident's condition is worsening etc. The facility Administrator and DON were notified on [DATE] at 11:30 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted [DATE]. After several revisions, a plan was accepted on [DATE] at 3:30 p.m. Interview on [DATE] at 6:02 p.m., the Administrator said he was surprised about the immediate jeopardy identified in the facility. When the Administrator was asked what procedures were available to ensure the nursing needs of the residents were met, he stated the residents' care was based on implementing the physician's orders [REDACTED]. He said the facility had an interdisciplinary morning meeting every day in which incidents that had occurred were discussed. The Administrator also said the facility hired qualified staff who are screened and verified as required. The facility had a nurse consultant who was responsible for hiring and training of staff as well as ensuring their competencies in nursing skills. Interview on [DATE] at 7:07 a.m., the DON said staff were trained to care CR #2 who experienced a significant change in condition. She said the staff were provided training upon hire and on an on-going basis. The DON said on the job in-services were provided to staff frequently, as well as skill check offs with feedback to staff following incidents. The DON said the facility had protocol in place for use when a resident had a change in condition. She further said staff were trained to use the SBAR and interact tools, as well as to seek help from internal resources like supervisors in the facility. Immediate Jeopardy Plan of Removal 1. Accurate assessment of patients: A. Licensed nursing staff and Certified Nurse Aides (CNA's) were in-serviced on [DATE] and [DATE] on: a. Assessing and evaluating change in conditions of patients b. Recognizing life threatening situations and seeking emergency medical service (call 911). c. Providing interventions to stabilize patient's condition. d. Performing accurate and adequate documentation. B. Assessment process to include head to toe assessment. C. Assessing of GI bleeding, respiratory distress, analyze findings and provide and providing immediate action. D. Case study - Mrs. T. (this case study illustrates how a CNA making morning rounds tells her charge nurse that Mrs. T is not herself today. The nurse assesses the resident and discovers the patient is afebrile, but pale, and is orthostatic .there is bloody stool.) Discussion follows. 2. Emergency transfer patient: A. Licensed nursing staff were in-serviced on [DATE] and [DATE] on: a. Emergency transfer patient policy and procedure. b. Notification of physician. In summary and reference to above the in-services/training provided emphasized: A. Accuracy of assessment of: 1. GI Bleeding/Hemorrhage and 2. Respiratory Distress B. Analyzing the assessment findings to provide care and services appropriately. C. Notification of physician (Immediate versus Non-Immediate) D. Emergency Transfer (In all life-threatening situations call 911 for immediate transfer to the hospital emergency room .) E. Early identification of a change in condition (utilize the Stop and Watch Form.) 3. The DON, ADON, and charge nurses completely audited 100% of all charts on [DATE] to ensure patients who had experienced a change in condition were provided assessment, evaluation, and appropriate interventions. 4. The DON and ADON physically assessed 100% of the residents on [DATE] and no additional changes in condition were found. 5. No licensed nursing staff will be allowed to work their shift until they have attended the mandatory in-service on resident assessment and emergency transfer procedures. 6. All certified nurse aides (CNA's) will not be allowed to work their shift until they have attended the mandatory in-service on Stop and Watch. 7. The two licensed nurses involved with the incidents were evaluated by the administration. One will be terminated and the other will be placed on 90 day probation with retraining in accuracy of assessment, utilizing findings to manage patient care and emergency transfer situations. The surveyor monitored the Plan of Removal on [DATE] and [DATE] during all three shifts including licensed and registered nurses worked from 6am to 2pm, 2pm to 10pm, and 10pm- 6am as follows: Facility protocols concerning proper assessment to identify changes of condition, emergency transfer and when to call 911 were reviewed. In-services on procedures concerning proper assessment and analysis of abnormal vital signs, changes of condition, and documentation, were conducted on [DATE], [DATE] and [DATE]. In-services were conducted on all three shifts with over 70% of the nursing staff attending. 90% of the nursing staff covering three shifts were interviewed on [DATE] and [DATE], and all staff were able to express up to date knowledge on the facility's procedures for a resident's change in condition, emergency transfer and when to notify physicians of changes. Interviews with nursing staff on all three shifts revealed no changes in condition had been identified since the immediate jeopardy was identified. Observations of residents in the facility revealed no changes in condition that required emergency transfer. After monitoring the implementation of the plan, the IJ was removed. The Administrator and the DON were informed the IJ was removed on [DATE] at 7:00 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of Actual Harm that is not immediate jeopardy with a scope identified as a pattern. The facility was continuing to monitor and evaluate the effectiveness of their plan to ensure residents' physicians were promptly consulted following changes in condition, proper assessment, and emergency transfer to the hospital. The facility provided a census dated [DATE] which revealed 34 residents.

Based on interview, and record review, the facility failed to implement their policy and procedure that prohibited neglect of two of eight residents (CR #1 and CR #2) reviewed for neglect. The facility failed to identify CR #1's change in condition required a prompt emergency transfer to the hospital. CR #1 had large blood clots coming from his rectum and abnormal vital signs. CR #1 arrived at the ER approximately 2 hours and 45 minutes after the NP ordered the transfer. CR #1 was diagnosed with [REDACTED]. The facility failed to assess, intervene and consult with the physician when CR #2 had a change in condition and died six hours later. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. These failures affected two residents and placed 34 other residents at risk of not having prompt interventions when a change in condition occurred which would cause a delay in the residents receiving treatment and care which could cause increased suffering, or death. Findings include: Intake # 1 CR #1 Record review of CR #1's face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. CR #1's [DIAGNOSES REDACTED]. Record review of CR #1 ' s admission assessment notes dated [DATE] at 9:00p.m., revealed the resident arrived at the facility via EMS with the [DIAGNOSES REDACTED].#1 was alert and oriented x 4, able to verbalize his needs and denied pain, no shortness of breath, respiration was even and unlabored, no distress noted, heart rate regular, and distal pulse present. Abdomen soft and non-tender, bowel sounds present in all quadrants, continent of both bowel and bladder, urine dark and concentrated and no foul odor noted. Drainage bag from upper abdomen outer quadrant notes drained 360 cc of green watery drainage. Bilateral upper extremity [MEDICAL CONDITION] X 2 and ted hose on. Patient education on fall prevention protocol, use of call light, room orientation. Record review of CR#1 ' s clinical record revealed no interim care plan. Record review of CR #1's vital signs and weight flow sheet revealed the following; [DATE] - blood pressure ,[DATE], temperature 98.9, pulse 89, respiration 18 and oximetry 97% room air. [DATE] - blood pressure ,[DATE], temperature 97.8, pulse 81, respiration 18 and oximetry 97. [DATE] - blood pressure ,[DATE], temperature 97.6, pulse 78, respiration 18 and oximetry 98. Record review of CR #1's SBAR communication form dated [DATE] with no time, revealed the changes in condition identified were weakness, unstable vital signs, bleeding from the rectum (blood clots). Things that made this condition or symptom worse: very large blood clots. Vital signs: blood pressure - ,[DATE], heart rate - 102, temperature- 96.8, oximetry - 34% to 90 % on two liters of oxygen via nasal cannula. Further review revealed additional notes which read .patient noted lying in bed, complaint of weakness, assessment noted patient skin cool, clammy to touch with patient diaphoretic, glucose test was 162 mg/dl, blood pressure was ,[DATE]. Patient skin color pale. Patient alert and oriented and talking, denied having any pains, oxygen saturation 34% - 93% and fluctuating, oxygen started at 2 liters via nasal cannula. Bilateral lower extremity elevated. Pulled patients' pants off and noticed large amount of clotted blood. Nurse practitioner called, responsible party/wife called, new order received to send the patient to the hospital for GI bleeding. EMS was called for transportation; expected time of arrival was 30 minutes. Time NP was notified was 6:47pm. Record review of CR #1's nursing notes dated [DATE] revealed the following documentation written by LVN #2 who was CR #1's charge nurse: 5:40 p.m. - patient awake, alert and oriented x 3, resting in bed watching television. Patient stated that he is not hungry yet will eat the food delivered for supper in a little bit. 6:07 p.m. - went on to check patient for the percentage of meal eaten, found patient lying in bed with eyes closed, even non-labored breathing, skin cold to touch, clammy and pale. Patient diaphoretic, noted soaked t-shirt and pants. Patient seem lethargic, called patients' name twice and did a light chest rub, patient opened his eyes, responding to stimulation answering yes. 6:10 p.m. - LVN #1 called into the room, patient more alert and awake. Patient was asked how are you feeling? What happened? Patient stated I had weakness all day. Vitals checked: blood glucose - 162 mg/dl, blood pressure - ,[DATE] mmHg, Pulse - 109 beats per minute, oxygen saturation - 34% to 98% (fluctuating) respiratory rate - 18, patient repositioned in bed due to [MEDICAL CONDITION] by having the bilateral lower extremities higher than the head of the bed. Patient was given oxygen delivered via nasal cannula, patient awake, alert and oriented X 3, responds to stimuli and questions, denies pain and shortness of breath. Patient's shoes, socks and pants removed to get patient off from wet clothing, found large clumps of brown congealed (coagulated/clotted) blood coming from patients rectum. Patient stated I feel like I am having a bowel movement, towels used to wipe patient's legs. 6:15 p.m. - Nurse practitioner was notified of the event, the assessment and the interventions. New order to send the patient to the hospital at the medical center. 6:25 p.m. - trying to contact responsible party via home phone (only phone listed in the chart), no response. 6:30 p.m. - received responsible party's cell phone number through patient, calls forwarding to voice mail. 6:35 p.m. - Nurse and aide at the patient's bedside, assessing patient checking patients vitals every 15 minutes and attending to patient's needs. Patient still awake, alert and oriented x 3, responds to questions, denies pain and shortness of breath. Patient percutaneous biliary drain intact to the right side. Bag emptied with 200 ml. Record review of CR #1's nursing notes dated [DATE] at 8:10 p.m. revealed the following documentation written by LVN # 1: At 6:10 p.m. writer was called to (CR #1's) room, patient noted lying in bed eyes closed, respiration even and unlabored, skin cool, clammy to touch, patient diaphoretic, patient complained of weakness all day, blood sugar was checked - 162 mg/dl, patient alert and oriented x 3. Patient was repositioned in bed, bilateral lower extremities elevated and head of bed lowered to increase blood pressure ,[DATE]. Patient's oxygen saturation at 34% to 93%, oxygen at 2 liters started. 6:15 p.m. - Nurse Practitioner returned call and was informed of the above action, patient's pants was pulled down for removal and noted very large brown (congealed) blood - source of blood noted from rectum, NP was notified, new order to send the patient to hospital. DON was notified. 6:23 p.m. - (CR #1's) spouse was called at home, without answer. Message was left to call facility, patient's spouse cell phone number was received from patient and called, message left to call the facility. 6:45 p.m. - patient's spouse returned call and was informed of patient's change in condition, NP order to send him to the hospital for GI bleed. Patient spouse stated that the patient should be sent to the hospital and she would call the ER Doctor to meet her and the patient there. 6:50 p.m. - Patient's spouse called the nurses' station with a raised loud tone yelling I am calling the doctor now; I want to talk to my husband. 6:55 p.m. - first EMS was called expected time of arrival (ETA) was 2 hours, second EMS called and ETA was one and one half hours, third EMS called had ETA of 30 minutes and was given ok to transport the patient to hospital. Patient in bed and LVN #2 was at bed side to monitor his condition. 7:15 p.m. - patient's spouse called to station and started yelling where is the ambulance?, how long does it take to get there?, she was informed of dispatch time report of 30 minutes ETA and would call as soon as the phone call ended. Third EMS was called and dispatch said ETA was 5 - 10 minutes. Family member at the facility stated the patient should be sent to the hospital at the medical center. 7:45 p.m.- patient's spouse called to the station angrily demanding in a loud tone to call 911 to transfer the patient, 911 was called per spouse's request, third EMS was called to inform of spouse's decision. 8:00 p.m. - 911 here to transfer patient, family member accompanied patient, medical records sent with 911. Record review of CR #1's transfer form dated [DATE] with no time, revealed the reason for transfer to ER was GI (gastrointestinal) bleeding (large clots from rectum). CR #1's vital signs were: heart rate 102, respiration 26 and blood pressure ,[DATE]. Record review of CR #1's ER record dated [DATE] revealed the resident had [DIAGNOSES REDACTED]. Further review revealed CR #1's heart rate was 131 and he was transfused with two units of blood STAT. Interview on [DATE] at 12:14 p.m., the DON said she reviewed CR #1's incident on [DATE]. When asked what she thought of it, she said the staff responded appropriately. She said the staff called her and she was aware the resident was to be sent to the hospital. The DON said nothing could have been done differently. She further said she did not think intervention for CR #1, who had GI bleeding with low blood pressure, was delayed. Observation and interview on [DATE] at 4:30 p.m. revealed CR #1 in the hospital in ICU. He was alert and oriented. CR #1 said he was ok and hoped to get better. When asked about his stay at the facility before his transfer, he said the staff at the facility said his blood pressure was low and gave him salt. The staff told him it would help to get his blood pressure back up. CR #1 said the salt was burning his tongue but staff continued to give him the salt. Interview on [DATE] at 4:40 p.m., CR#1's spouse said she was notified of CR #1's change in condition about 6:40 p.m. on [DATE]. She told staff to transfer CR #1 to the downtown hospital because all of his doctors were at that hospital. She said she was shocked when she called the facility back and the ambulance to transfer CR #1 to the hospital still had not arrived. She said she did not know it took hours to get an ambulance. She expressed that she was scared when the staff did not think they needed to call 911 for someone bleeding, since they did not know how long he had been bleeding and how much blood he had lost. She also said she had a family member go to the facility to see what was going on. She said CR #1 was very pale when he got to the hospital because he had lost so much blood from a [DIAGNOSES REDACTED] ulcer that was found in the ER. CR #1's blood pressure was so low, ,[DATE], that they immediately transfused him with blood. CR #1's spouse said the resident told her the facility gave him salt that burned his mouth. She said she did not understand why the nurses gave him salt. She further said when she called the facility; she did not even know that the staff did not call 911 immediately. She said staff left CR #1 in the facility bleeding for 4 hours because CR #1 did not arrive at the hospital until 9:00 p.m. that evening. Interview on [DATE] at 11:10 a.m., CNA #1 said she was with CR #1 and the nurse (LVN #2) on [DATE] prior to his transfer to the hospital. She said she was in the room helping LVN #2 clean up CR #1. CNA #1 said CR #1 was losing a lot of blood, and his oxygen saturation and blood pressure were going up and down. She said CR #1 was lying down in bed the whole time, quiet and not talking as much as he used to. Interview on [DATE] at 2:40 p.m., LVN #1 gave an account of the events that took place with CR #1 on [DATE] that matched what was documented in CR #1's nurses note. LVN #1 said on [DATE] around 6:15 p.m. she left LVN #2 with CR #1 while she went to call the NP, spouse and EMS. She said she did not call 911 because the resident was not in any distress and the NP did not tell her to call 911. She said she called two different EMS companies and was told the ETA was 2 hours, so she called the DON to get permission to call another EMS that was not one of the facility's preferred ambulance services. She said the resident's spouse called the facility from the hospital and requested that 911 be called. She said she was unsure when the resident left the facility. Interview on [DATE] at 2:49 p.m., LVN #2 said she had been a nurse for about 4 months and this was her first nursing job. She stated on [DATE] when she saw CR #1 in bed he looked sweaty and tired and he had not eaten his dinner. She took his vitals and blood sugar and his blood sugar was 162, heart rate was about a 100 and blood pressure was low. She said she called LVN #1 to ask for assistance and when they took CR #1's pants down, they saw coagulated blood coming out of his rectum with feces. She said his spouse and NP were notified and transportation was called. LVN #2 said CR #1 was stable, he was talking the whole time they were waiting for transportation, denied pain, and did not appear to be in any distress. She said CR #1's oxygen saturation was fluctuating between 34% - 98% and he was on 2 liters of oxygen. She said she did not think the resident was in distress that required 911 to be called. Interview on [DATE] at 4:40p.m., the Nurse Consultant said she expected staff to call 911 when a resident had an oxygen saturation as low as 34%. She agreed the staff did not utilize their assessment results properly. She agreed CR #1 should have been sent to the hospital via 911 as soon as the bleeding was identified. CR #2 Record review of CR #2's face sheet revealed [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #2's quarterly assessment MDS dated [DATE] revealed the following Diagnoses: [REDACTED]. Further review of this MDS assessment revealed CR #2 had a BIMS score of 11, indicating her cognition was moderately impaired, required limited assistance with all ADLs except eating, was continent of bowel and bladder and did not require respiratory treatments. Record review of CR#2 ' s care plan, which was not dated, revealed resident had impaired gas exchange related to respiratory concerns such as [MEDICAL CONDITION] evidenced by shortness of breath upon exertion; use of oxygen, rapid irregular, labored breathing, pale related to respiratory disease. Goals: the resident will function at the highest practicable level within limitations of disease. Approaches included: follow MD orders and administer oxygen via nasal cannula, and breathing treatment as ordered. Monitor vital signs am oxygen saturation as scheduled and as needed, report significant changes, assess and monitor for symptoms of respiratory distress, increased anxiety, cyanosis and shortness of breath. Maintain calm and quiet environment, monitor lab as ordered, monitor oxygen saturation level as ordered . Record review of CR #2's Nurse notes dated [DATE] at 4:00 a.m. written by LVN #3 revealed resident observed sitting up in wheelchair, head slumped down, took a closer look and noted resident's eye fixed and appears to have passed out/fainted, assisted resident into bed and made her comfortable with head of bed elevated, vital signs taken: blood pressure 144, blood pressure ,[DATE], 62, respiration 22. Oxygen continues at 2 liters. No distress noted but it does appear breathing is rapid, called Physician on call number, awaiting response. Record review of CR #2's Nurse Notes written by LVN #4, dated [DATE] revealed the following: 6:00 a.m. - received patient in bed call light within reach, patient awake, a.m. care provided, accu check done result 131, patient ate 15% of breakfast. 8:00 a.m. - oxygen saturation was 96%, respiration was non-labored at 18 cycles per minute. 10:05 a.m. - resident requested a bowl of cereal, offered to patient, and consumed 75% and coffee. 11:05 a.m. - patient requested to use the bathroom, assisted by assigned CNA, who helped patient back in bed, patient remained on side of bed gasping for air, 911 initiated by writer. 11:25 a.m. - on arrival patient had stopped breathing, CPR not initiated due to DNR status. Interview on [DATE] at 12:08 p.m., the DON said she recalled CR #2 passed away a couple of day ago. She said it was expected because the resident had [MEDICAL CONDITION] and had a DNR status. She recalled the resident used oxygen. Interview on [DATE] at 1:02 p.m., LVN #4 said she took care of CR #2 on the morning of [DATE]. She said she took report from the night shift nurse LVN #3 on the morning of [DATE] and LVN #3 did not inform her that CR #2 had a change in condition during the night shift. LVN #4 said CR #2 had severe [MEDICAL CONDITION] and began experiencing respiratory distress around 11:00 a.m. after she got up to use the bathroom. LVN #4 said she placed a non-rebreather mask on CR #2 and increased her oxygen liters, then called 911. She said CR #2 had stopped breathing when 911 arrived. She said she did not initiate CPR because CR #2 had a DNR status. Interview on [DATE] at 1:12 p.m., the RN Weekend Supervisor said she was not informed about CR #2's change in condition upon duty assumption on [DATE]. The RN Weekend Supervisor said she was called to the resident's room and when she got there the 911 crew arrived at the same time. She said CR#2 had stopped breathing at that time. Interview via phone on [DATE] at 1:46 p.m., LVN #3 said during the night shift on [DATE] she saw CR #2 hanging between the toilet seat and her wheelchair, holding the arm of her wheel chair. She quickly assisted the resident to her wheelchair, put her oxygen on because she did not have it on, then helped her to bed and made her comfortable. She said CR #2's respiration was normal and she had no distress during this incident. LVN #3 said she called the physician and spoke to someone who was to notify the physician. She explained the facility protocol was to call the physician on call number and they would return the call by the next morning. She agreed she should have called again before her shift ended. She further said she told the morning nurse LVN #4 to follow-up and to monitor CR #2 closely when she gave her report. She said she would have called 911 if CR#2 was not a DNR and that it would have been a problem if she called 911 for a DNR. LVN#3 was asked why her account was different from her documentation on the resident's nurse notes. She said she thought CR #2 was just struggling to sit up in her wheelchair. LVN #3 said after CR #2 was put in bed, she became alert and responsive again and was talking. LVN #3 said she was shocked when the DON told her CR #2 passed away a couple of hours later that day. Record review of facility's 24 hour report for the night shift on [DATE] did not reveal any documentation of CR #2's change in condition. CR#2's incident was not reported on the 24 hours report. Interview on [DATE] at 1:58p.m., LVN #5 said CR #2 had severe [MEDICAL CONDITION] and required oxygen at all times. She was told the resident passed away on the weekend which surprised everyone. LVN #5 explained it was unexpected. Interview via phone on [DATE] at 5:00p.m., CNA #2 said on the morning of [DATE], she saw CR #2 ' s call light on and went into her room to help. CNA #2 said she was not CR #2 ' s assigned aide, but assisted the resident to the restroom. CNA #2 said CR #2 had respiratory problems and had to use oxygen all the time. CNA #2 said CR #2 had her oxygen on as she took her to the bathroom in her wheelchair. She said CR #2 returned to her bedside and held CNA #2 and said don ' t leave me and then began having rapid respiration. CNA #2 said it all happened very quickly. She called the nurse, but CR #2 passed away. CNA #2 said all the aides knew CR #2 had severe respiratory problems. Interview on [DATE] at 7:05 a.m., the DON said based on the incident account documented on CR #2's nurse notes for the night shift on [DATE] at 4:00 a.m., CR#2 should have been sent to the hospital via 911. She further said LVN #3 was terminated for not promptly intervening and communicating the incident to other nurses to follow-up. Record review of the facility's policy on emergency transfer dated ,[DATE] revealed the facility shall provide for health and safety of all residents, the facility shall initiate an immediate transfer of a resident when appropriate. The charge nurses shall assess the resident and determine if they require emergency transfer, they will assess the resident for the following: oxygen saturation less than 90% (unless it is the resident's normal with [MEDICAL CONDITION]), respiration rate greater than 30 per minute or less than 10 per minute, finger stick glucose less than 45 and non-responsive or greater than 400, chest pain not relieved with Nitro [MEDICATION NAME] X 3, excessive bleeding, a change in a resident's behavior that would indicate that an emergency condition exist, other cardiac or respiratory distress issues which the licensed staff believed require an emergency transfer. Record review of the facility's policy on abuse and neglect prohibition dated ,[DATE] revealed each resident had the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. Record review of the facility's policy on notification of physicians dated February 2016 revealed the facility shall promote a two way system of communication between the facility and physician. Staff will notify the physician at various times during a resident's stay in order to ensure all appropriate information has been made available to allow the physician to provide the highest level of care to the residents. Licensed nurses shall notify the physician upon a change in condition of a resident, and to make them aware that a resident's condition is worsening etc. The facility Administrator and DON were notified on [DATE] at 11:30 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted [DATE]. After several revisions, a plan was accepted on [DATE] at 3:30 p.m. Interview on [DATE] at 6:02 p.m., the Administrator, who was also the abuse and neglect coordinator, said he was surprised about the immediate jeopardy identified in the facility. He said he knew CR #1 was sent to the hospital but was unsure why. He said he did not know the full details of what happened. He recalled the resident was fine and had a couple of appointments that day and there were no identified problems. When the Administrator was asked what procedures were available to ensure the nursing needs of the residents were met, he stated the residents ' care was based on implementing the physician's order [REDACTED]. He said the facility had an interdisciplinary morning meeting every day in which incidents that had occurred were discussed. The Administrator also said the facility hired qualified staff who are screened and verified as required. The facility had a nurse consultant who was responsible for hiring and training of staff as well as ensuring their competencies in nursing skills. Interview on [DATE] at 7:07 a.m., the DON said LVN #2 who was CR #1's charge nurse was a new nurse and did not properly assess the resident's condition. She believed this contributed to the immediate jeopardy identified. When asked what she would have expected the staff to do, she said the resident should have been sent out to the ER immediately. The DON agreed the resident had significant signs that staff failed to identified or analyze. The DON further said LVN #1 was the more experienced nurse of the two and she also failed to think critically and provide emergent assistance. The DON said staff were trained to care for CR #1 and CR #2 who both experienced significant changes in condition. She said the staff were provided training upon hire and on an on-going basis. The DON said on the job in-services were provided to staff frequently, as well as skill check offs with feedback to staff following incidents. The DON said the facility had protocol in place for use when a resident had a change in condition. She further said staff were trained to use the SBAR and interact tools, as well as to seek help from internal resources like supervisors in the facility. Immediate Jeopardy Plan of Removal 1. Accurate assessment of patients: A. Licensed nursing staff and Certified Nurse Aides (CNA ' s) were in-serviced on [DATE] and [DATE] on: a. Assessing and evaluating change in conditions of patients b. Recognizing life threatening situations and seeking emergency medical service (call 911). c. Providing interventions to stabilize patient's condition. d. Performing accurate and adequate documentation. B. Assessment process to include head to toe assessment. C. Assessing of GI bleeding, respiratory distress, analyze findings and provide and providing immediate action. D. Case study - Mrs. T. (this case study illustrates how a CNA making morning rounds tells her charge nurse that Mrs. T is not herself today. The nurse assesses the resident and discovers the patient is afebrile, but pale, and is orthostatic .there is bloody stool.) Discussion follows. 2. Emergency transfer patient: A. Licensed nursing staff were in-serviced on [DATE] and [DATE] on: a. Emergency transfer patient policy and procedure. b. Notification of physician. In summary and reference to above the in-services/training provided emphasized: A. Accuracy of assessment of: 1. GI Bleeding/Hemorrhage and 2. Respiratory Distress B. Analyzing the assessment findings to provide care and services appropriately. C. Notification of physician (Immediate versus Non-Immediate) D. Emergency Transfer (In all life-threatening situations call 911 for immediate transfer to the hospital emergency room .) E. Early identification of a change in condition (utilize the Stop and Watch Form.) 3. The DON, ADON, and charge nurses completely audited 100% of all charts on [DATE] to ensure patients who had experienced a change in condition were provided assessment, evaluation, and appropriate interventions. 4. The DON and ADON physically assessed 100% of the residents on [DATE] and no additional changes in condition were found. 5. No licensed nursing staff will be allowed to work their shift until they have attended the mandatory in-service on resident assessment and emergency transfer procedures. 6. All certified nurse aides (CNA ' s) will not be allowed to work their shift until they have attended the mandatory in-service on Stop and Watch. 7. The two licensed nurses involved with the incidents were evaluated by the administration. One will be terminated and the other will be placed on 90 day probation with retraining in accuracy of assessment, utilizing findings to manage patient care and emergency transfer situations. The surveyor monitored the Plan of Removal on [DATE] and [DATE] during all three shifts including licensed and registered nurses worked from 6am to 2pm, 2pm to 10pm, and 10pm- 6am as follows: Facility protocols concerning proper assessment to identify changes of condition, emergency transfer and when to call 911 were reviewed. In-services on procedures concerning proper assessment and analysis of abnormal vital signs, changes of condition, and documentation, were conducted on [DATE], [DATE] and [DATE]. In-services were conducted on all three shifts with over 70% of the nursing staff attending. 90% of the nursing staff covering three shifts were interviewed on [DATE] and [DATE], and all staff were able to express up to date knowledge on the facility's procedures for a resident's change in condition, emergency transfer and when to notify physicians of changes. Interviews with nursing staff on all three shifts revealed no changes in condition had been identified since the immediate jeopardy was identified. Observations of residents in the facility revealed no changes in condition that required emergency transfer. After monitoring the implementation of the plan, the IJ was removed. The Administrator and the DON were informed the IJ was removed on [DATE] at 7:00 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of Actual Harm that is not immediate jeopardy with a scope identified as a pattern. The facility was continuing to monitor and evaluate the effectiveness of their plan to ensure residents' physicians were promptly consulted following changes in condition, proper assessment, and emergency transfer to the hospital. The facility provided a census dated [DATE] which revealed 34 residents.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable mental, physical and psychosocial well-being in accordance with the comprehensive assessment for two of eight residents (CR #1 and CR #2) reviewed for quality of care. The facility failed to identify CR #1's change in condition required a prompt emergency transfer to the hospital. CR #1 had large blood clots coming from his rectum and abnormal vital signs. CR #1 arrived at the ER approximately 2 hours and 45 minutes after the NP ordered the transfer. CR #1 was diagnosed with [REDACTED]. The facility failed to assess, intervene and consult with the physician when CR #2 had a change in condition and died six hours later. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. These failures affected two residents and placed 34 other residents at risk of not having prompt interventions when a change in condition occurred which would cause a delay in the residents receiving treatment and care which could cause increased suffering, or death. Findings include: Intake # 1 CR #1 Record review of CR #1's face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. CR #1's [DIAGNOSES REDACTED]. Record review of CR #1 ' s admission assessment notes dated [DATE] at 9:00p.m., revealed the resident arrived at the facility via EMS with the [DIAGNOSES REDACTED].#1 was alert and oriented x 4, able to verbalize his needs and denied pain, no shortness of breath, respiration was even and unlabored, no distress noted, heart rate regular, and distal pulse present. Abdomen soft and non-tender, bowel sounds present in all quadrants, continent of both bowel and bladder, urine dark and concentrated and no foul odor noted. Drainage bag from upper abdomen outer quadrant notes drained 360 cc of green watery drainage. Bilateral upper extremity [MEDICAL CONDITION] X 2 and ted hose on. Patient education on fall prevention protocol, use of call light, room orientation. Record review of CR#1's clinical record revealed no interim care plan. Record review of CR #1's vital signs and weight flow sheet revealed the following; [DATE] - blood pressure ,[DATE], temperature 98.9, pulse 89, respiration 18 and oximetry 97% room air. [DATE] - blood pressure ,[DATE], temperature 97.8, pulse 81, respiration 18 and oximetry 97. [DATE] - blood pressure ,[DATE], temperature 97.6, pulse 78, respiration 18 and oximetry 98. Record review of CR #1's SBAR communication form dated [DATE] with no time, revealed the changes in condition identified were weakness, unstable vital signs, bleeding from the rectum (blood clots). Things that made this condition or symptom worse: very large blood clots. Vital signs: blood pressure - ,[DATE], heart rate - 102, temperature- 96.8, oximetry - 34% to 90 % on two liters of oxygen via nasal cannula. Further review revealed additional notes which read .patient noted lying in bed, complaint of weakness, assessment noted patient skin cool, clammy to touch with patient diaphoretic, glucose test was 162 mg/dl, blood pressure was ,[DATE]. Patient skin color pale. Patient alert and oriented and talking, denied having any pains, oxygen saturation 34% - 93% and fluctuating, oxygen started at 2 liters via nasal cannula. Bilateral lower extremity elevated. Pulled patients' pants off and noticed large amount of clotted blood. Nurse practitioner called, responsible party/wife called, new order received to send the patient to the hospital for GI bleeding. EMS was called for transportation; expected time of arrival was 30 minutes. Time NP was notified was 6:47pm. Record review of CR #1's nursing notes dated [DATE] revealed the following documentation written by LVN #2 who was CR #1's charge nurse: 5:40 p.m. - patient awake, alert and oriented x 3, resting in bed watching television. Patient stated that he is not hungry yet will eat the food delivered for supper in a little bit. 6:07 p.m. - went on to check patient for the percentage of meal eaten, found patient lying in bed with eyes closed, even non-labored breathing, skin cold to touch, clammy and pale. Patient diaphoretic, noted soaked t-shirt and pants. Patient seem lethargic, called patients' name twice and did a light chest rub, patient opened his eyes, responding to stimulation answering yes. 6:10 p.m. - LVN #1 called into the room, patient more alert and awake. Patient was asked how are you feeling? What happened? Patient stated I had weakness all day. Vitals checked: blood glucose - 162 mg/dl, blood pressure - ,[DATE] mmHg, Pulse - 109 beats per minute, oxygen saturation - 34% to 98% (fluctuating) respiratory rate - 18, patient repositioned in bed due to [MEDICAL CONDITION] by having the bilateral lower extremities higher than the head of the bed. Patient was given oxygen delivered via nasal cannula, patient awake, alert and oriented X 3, responds to stimuli and questions, denies pain and shortness of breath. Patient's shoes, socks and pants removed to get patient off from wet clothing, found large clumps of brown congealed (coagulated/clotted) blood coming from patients rectum. Patient stated I feel like I am having a bowel movement, towels used to wipe patient's legs. 6:15 p.m. - Nurse practitioner was notified of the event, the assessment and the interventions. New order to send the patient to the hospital at the medical center. 6:25 p.m. - trying to contact responsible party via home phone (only phone listed in the chart), no response. 6:30 p.m. - received responsible party's cell phone number through patient, calls forwarding to voice mail. 6:35 p.m. - Nurse and aide at the patient's bedside, assessing patient checking patients vitals every 15 minutes and attending to patient's needs. Patient still awake, alert and oriented x 3, responds to questions, denies pain and shortness of breath. Patient percutaneous biliary drain intact to the right side. Bag emptied with 200 ml. Record review of CR #1's nursing notes dated [DATE] at 8:10 p.m. revealed the following documentation written by LVN # 1: At 6:10 p.m. writer was called to (CR #1's) room, patient noted lying in bed eyes closed, respiration even and unlabored, skin cool, clammy to touch, patient diaphoretic, patient complained of weakness all day, blood sugar was checked - 162 mg/dl, patient alert and oriented x 3. Patient was repositioned in bed, bilateral lower extremities elevated and head of bed lowered to increase blood pressure ,[DATE]. Patient's oxygen saturation at 34% to 93%, oxygen at 2 liters started. 6:15 p.m. - Nurse Practitioner returned call and was informed of the above action, patient's pants was pulled down for removal and noted very large brown (congealed) blood - source of blood noted from rectum, NP was notified, new order to send the patient to hospital. DON was notified. 6:23 p.m. - (CR #1's) spouse was called at home, without answer. Message was left to call facility, patient's spouse cell phone number was received from patient and called, message left to call the facility. 6:45 p.m. - patient's spouse returned call and was informed of patient's change in condition, NP order to send him to the hospital for GI bleed. Patient spouse stated that the patient should be sent to the hospital and she would call the ER Doctor to meet her and the patient there. 6:50 p.m. - Patient's spouse called the nurses' station with a raised loud tone yelling I am calling the doctor now; I want to talk to my husband. 6:55 p.m. - first EMS was called expected time of arrival (ETA) was 2 hours, second EMS called and ETA was one and one half hours, third EMS called had ETA of 30 minutes and was given ok to transport the patient to hospital. Patient in bed and LVN #2 was at bed side to monitor his condition. 7:15 p.m. - patient's spouse called to station and started yelling where is the ambulance?, how long does it take to get there?, she was informed of dispatch time report of 30 minutes ETA and would call as soon as the phone call ended. Third EMS was called and dispatch said ETA was 5 - 10 minutes. Family member at the facility stated the patient should be sent to the hospital at the medical center. 7:45 p.m.- patient's spouse called to the station angrily demanding in a loud tone to call 911 to transfer the patient, 911 was called per spouse's request, third EMS was called to inform of spouse's decision. 8:00 p.m. - 911 here to transfer patient, family member accompanied patient, medical records sent with 911. Record review of CR #1's transfer form dated [DATE] with no time, revealed the reason for transfer to ER was GI (gastrointestinal) bleeding (large clots from rectum). CR #1's vital signs were: heart rate 102, respiration 26 and blood pressure ,[DATE]. Record review of CR #1's ER record dated [DATE] revealed the resident had [DIAGNOSES REDACTED]. Further review revealed CR #1's heart rate was 131 and he was transfused with two units of blood STAT. Interview on [DATE] at 12:14 p.m., the DON said she reviewed CR #1's incident on [DATE]. When asked what she thought of it, she said the staff responded appropriately. She said the staff called her and she was aware the resident was to be sent to the hospital. The DON said nothing could have been done differently. She further said she did not think intervention for CR #1, who had GI bleeding with low blood pressure, was delayed. Observation and interview on [DATE] at 4:30 p.m. revealed CR #1 in the hospital in ICU. He was alert and oriented. CR #1 said he was ok and hoped to get better. When asked about his stay at the facility before his transfer, he said the staff at the facility said his blood pressure was low and gave him salt. The staff told him it would help to get his blood pressure back up. CR #1 said the salt was burning his tongue but staff continued to give him the salt. Interview on [DATE] at 4:40 p.m., CR#1's spouse said she was notified of CR #1's change in condition about 6:40 p.m. on [DATE]. She told staff to transfer CR #1 to the downtown hospital because all of his doctors were at that hospital. She said she was shocked when she called the facility back and the ambulance to transfer CR #1 to the hospital still had not arrived. She said she did not know it took hours to get an ambulance. She expressed that she was scared when the staff did not think they needed to call 911 for someone bleeding, since they did not know how long he had been bleeding and how much blood he had lost. She also said she had a family member go to the facility to see what was going on. She said CR #1 was very pale when he got to the hospital because he had lost so much blood from a [DIAGNOSES REDACTED] ulcer that was found in the ER. CR #1's blood pressure was so low, ,[DATE], that they immediately transfused him with blood. CR #1's spouse said the resident told her the facility gave him salt that burned his mouth. She said she did not understand why the nurses gave him salt. She further said when she called the facility; she did not even know that the staff did not call 911 immediately. She said staff left CR #1 in the facility bleeding for 4 hours because CR #1 did not arrive at the hospital until 9:00 p.m. that evening. Interview on [DATE] at 11:10 a.m., CNA #1 said she was with CR #1 and the nurse (LVN #2) on [DATE] prior to his transfer to the hospital. She said she was in the room helping LVN #2 clean up CR #1. CNA #1 said CR #1 was losing a lot of blood, and his oxygen saturation and blood pressure were going up and down. She said CR #1 was lying down in bed the whole time, quiet and not talking as much as he used to. Interview on [DATE] at 2:40 p.m., LVN #1 gave an account of the events that took place with CR #1 on [DATE] that matched what was documented in CR #1's nurses note. LVN #1 said on [DATE] around 6:15 p.m. she left LVN #2 with CR #1 while she went to call the NP, spouse and EMS. She said she did not call 911 because the resident was not in any distress and the NP did not tell her to call 911. She said she called two different EMS companies and was told the ETA was 2 hours, so she called the DON to get permission to call another EMS that was not one of the facility's preferred ambulance services. She said the resident's spouse called the facility from the hospital and requested that 911 be called. She said she was unsure when the resident left the facility. Interview on [DATE] at 2:49 p.m., LVN #2 said she had been a nurse for about 4 months and this was her first nursing job. She stated on [DATE] when she saw CR #1 in bed he looked sweaty and tired and he had not eaten his dinner. She took his vitals and blood sugar and his blood sugar was 162, heart rate was about a 100 and blood pressure was low. She said she called LVN #1 to ask for assistance and when they took CR #1's pants down, they saw coagulated blood coming out of his rectum with feces. She said his spouse and NP were notified and transportation was called. LVN #2 said CR #1 was stable, he was talking the whole time they were waiting for transportation, denied pain, and did not appear to be in any distress. She said CR #1's oxygen saturation was fluctuating between 34% - 98% and he was on 2 liters of oxygen. She said she did not think the resident was in distress that required 911 to be called. Interview on [DATE] at 4:40p.m., the Nurse Consultant said she expected staff to call 911 when a resident had an oxygen saturation as low as 34%. She agreed the staff did not utilize their assessment results properly. She agreed CR #1 should have been sent to the hospital via 911 as soon as the bleeding was identified. CR #2 Record review of CR #2's face sheet revealed [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #2's quarterly assessment MDS dated [DATE] revealed the following Diagnoses: [REDACTED]. Further review of this MDS assessment revealed CR #2 had a BIMS score of 11, indicating her cognition was moderately impaired, required limited assistance with all ADLs except eating, was continent of bowel and bladder and did not require respiratory treatments. Record review of CR#2 ' s care plan, which was not dated, revealed resident had impaired gas exchange related to respiratory concerns such as [MEDICAL CONDITION] evidenced by shortness of breath upon exertion; use of oxygen, rapid irregular, labored breathing, pale related to respiratory disease. Goals: the resident will function at the highest practicable level within limitations of disease. Approaches included: follow MD orders and administer oxygen via nasal cannula, and breathing treatment as ordered. Monitor vital signs am oxygen saturation as scheduled and as needed, report significant changes, assess and monitor for symptoms of respiratory distress, increased anxiety, cyanosis and shortness of breath. Maintain calm and quiet environment, monitor lab as ordered, monitor oxygen saturation level as ordered . Record review of CR #2's Nurse notes dated [DATE] at 4:00 a.m. written by LVN #3 revealed resident observed sitting up in wheelchair, head slumped down, took a closer look and noted resident's eye fixed and appears to have passed out/fainted, assisted resident into bed and made her comfortable with head of bed elevated, vital signs taken: blood pressure 144, blood pressure ,[DATE], 62, respiration 22. Oxygen continues at 2 liters. No distress noted but it does appear breathing is rapid, called Physician on call number, awaiting response. Record review of CR #2's Nurse Notes written by LVN #4, dated [DATE] revealed the following: 6:00 a.m. - received patient in bed call light within reach, patient awake, a.m. care provided, accu check done result 131, patient ate 15% of breakfast. 8:00 a.m. - oxygen saturation was 96%, respiration was non-labored at 18 cycles per minute. 10:05 a.m. - resident requested a bowl of cereal, offered to patient, and consumed 75% and coffee. 11:05 a.m. - patient requested to use the bathroom, assisted by assigned CNA, who helped patient back in bed, patient remained on side of bed gasping for air, 911 initiated by writer. 11:25 a.m. - on arrival patient had stopped breathing, CPR not initiated due to DNR status. Interview on [DATE] at 12:08 p.m., the DON said she recalled CR #2 passed away a couple of day ago. She said it was expected because the resident had [MEDICAL CONDITION] and had a DNR status. She recalled the resident used oxygen. Interview on [DATE] at 1:02 p.m., LVN #4 said she took care of CR #2 on the morning of [DATE]. She said she took report from the night shift nurse LVN #3 on the morning of [DATE] and LVN #3 did not inform her that CR #2 had a change in condition during the night shift. LVN #4 said CR #2 had severe [MEDICAL CONDITION] and began experiencing respiratory distress around 11:00 a.m. after she got up to use the bathroom. LVN #4 said she placed a non-rebreather mask on CR #2 and increased her oxygen liters, then called 911. She said CR #2 had stopped breathing when 911 arrived. She said she did not initiate CPR because CR #2 had a DNR status. Interview on [DATE] at 1:12 p.m., the RN Weekend Supervisor said she was not informed about CR #2's change in condition upon duty assumption on [DATE]. The RN Weekend Supervisor said she was called to the resident's room and when she got there the 911 crew arrived at the same time. She said CR#2 had stopped breathing at that time. Interview via phone on [DATE] at 1:46 p.m., LVN #3 said during the night shift on [DATE] she saw CR #2 hanging between the toilet seat and her wheelchair, holding the arm of her wheel chair. She quickly assisted the resident to her wheelchair, put her oxygen on because she did not have it on, then helped her to bed and made her comfortable. She said CR #2's respiration was normal and she had no distress during this incident. LVN #3 said she called the physician and spoke to someone who was to notify the physician. She explained the facility protocol was to call the physician on call number and they would return the call by the next morning. She agreed she should have called again before her shift ended. She further said she told the morning nurse LVN #4 to follow-up and to monitor CR #2 closely when she gave her report. She said she would have called 911 if CR#2 was not a DNR and that it would have been a problem if she called 911 for a DNR. LVN#3 was asked why her account was different from her documentation on the resident's nurse notes. She said she thought CR #2 was just struggling to sit up in her wheelchair. LVN #3 said after CR #2 was put in bed, she became alert and responsive again and was talking. LVN #3 said she was shocked when the DON told her CR #2 passed away a couple of hours later that day. Record review of facility's 24 hour report for the night shift on [DATE] did not reveal any documentation of CR #2's change in condition. CR#2's incident was not reported on the 24 hours report. Interview on [DATE] at 1:58p.m., LVN #5 said CR #2 had severe [MEDICAL CONDITION] and required oxygen at all times. She was told the resident passed away on the weekend which surprised everyone. LVN #5 explained it was unexpected. Interview via phone on [DATE] at 5:00p.m., CNA #2 said on the morning of [DATE], she saw CR #2 ' s call light on and went into her room to help. CNA #2 said she was not CR #2 ' s assigned aide, but assisted the resident to the restroom. CNA #2 said CR #2 had respiratory problems and had to use oxygen all the time. CNA #2 said CR #2 had her oxygen on as she took her to the bathroom in her wheelchair. She said CR #2 returned to her bedside and held CNA #2 and said don ' t leave me and then began having rapid respiration. CNA #2 said it all happened very quickly. She called the nurse, but CR #2 passed away. CNA #2 said all the aides knew CR #2 had severe respiratory problems. Interview on [DATE] at 7:05 a.m., the DON said based on the incident account documented on CR #2's nurse notes for the night shift on [DATE] at 4:00 a.m., CR#2 should have been sent to the hospital via 911. She further said LVN #3 was terminated for not promptly intervening and communicating the incident to other nurses to follow-up. Record review of the facility's policy on emergency transfer dated ,[DATE] revealed the facility shall provide for health and safety of all residents, the facility shall initiate an immediate transfer of a resident when appropriate. The charge nurses shall assess the resident and determine if they require emergency transfer, they will assess the resident for the following: oxygen saturation less than 90% (unless it is the resident's normal with [MEDICAL CONDITION]), respiration rate greater than 30 per minute or less than 10 per minute, finger stick glucose less than 45 and non-responsive or greater than 400, chest pain not relieved with Nitro [MEDICATION NAME] X 3, excessive bleeding, a change in a resident's behavior that would indicate that an emergency condition exist, other cardiac or respiratory distress issues which the licensed staff believed require an emergency transfer. Record review of the facility's policy on notification of physicians dated February 2016 revealed the facility shall promote a two way system of communication between the facility and physician. Staff will notify the physician at various times during a resident's stay in order to ensure all appropriate information has been made available to allow the physician to provide the highest level of care to the residents. Licensed nurses shall notify the physician upon a change in condition of a resident, and to make them aware that a resident's condition is worsening etc. The facility Administrator and DON were notified on [DATE] at 11:30 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted [DATE]. After several revisions, a plan was accepted on [DATE] at 3:30 p.m. Interview on [DATE] at 6:02 p.m., the Administrator said he was surprised about the immediate jeopardy identified in the facility. He said he knew CR #1 was sent to the hospital but was unsure why. He said he did not know the full details of what happened. He recalled the resident was fine and had a couple of appointments that day and there were no identified problems. When the Administrator was asked what procedures were available to ensure the nursing needs of the residents were met, he stated the residents ' care was based on implementing the physician's order [REDACTED]. He said the facility had an interdisciplinary morning meeting every day in which incidents that had occurred were discussed. The Administrator also said the facility hired qualified staff who are screened and verified as required. The facility had a nurse consultant who was responsible for hiring and training of staff as well as ensuring their competencies in nursing skills. Interview on [DATE] at 7:07 a.m., the DON said LVN #2 who was CR #1's charge nurse was a new nurse and did not properly assess the resident's condition. She believed this contributed to the immediate jeopardy identified. When asked what she would have expected the staff to do, she said the resident should have been sent out to the ER immediately. The DON agreed the resident had significant signs that staff failed to identified or analyze. The DON further said LVN #1 was the more experienced nurse of the two and she also failed to think critically and provide emergent assistance. The DON said staff were trained to care for CR #1 and CR #2 who both experienced significant changes in condition. She said the staff were provided training upon hire and on an on-going basis. The DON said on the job in-services were provided to staff frequently, as well as skill check offs with feedback to staff following incidents. The DON said the facility had protocol in place for use when a resident had a change in condition. She further said staff were trained to use the SBAR and interact tools, as well as to seek help from internal resources like supervisors in the facility. Immediate Jeopardy Plan of Removal 1. Accurate assessment of patients: A. Licensed nursing staff and Certified Nurse Aides (CNA ' s) were in-serviced on [DATE] and [DATE] on: a. Assessing and evaluating change in conditions of patients b. Recognizing life threatening situations and seeking emergency medical service (call 911). c. Providing interventions to stabilize patient's condition. d. Performing accurate and adequate documentation. B. Assessment process to include head to toe assessment. C. Assessing of GI bleeding, respiratory distress, analyze findings and provide and providing immediate action. D. Case study - Mrs. T. (this case study illustrates how a CNA making morning rounds tells her charge nurse that Mrs. T is not herself today. The nurse assesses the resident and discovers the patient is afebrile, but pale, and is orthostatic .there is bloody stool.) Discussion follows. 2. Emergency transfer patient: A. Licensed nursing staff were in-serviced on [DATE] and [DATE] on: a. Emergency transfer patient policy and procedure. b. Notification of physician. In summary and reference to above the in-services/training provided emphasized: A. Accuracy of assessment of: 1. GI Bleeding/Hemorrhage and 2. Respiratory Distress B. Analyzing the assessment findings to provide care and services appropriately. C. Notification of physician (Immediate versus Non-Immediate) D. Emergency Transfer (In all life-threatening situations call 911 for immediate transfer to the hospital emergency room .) E. Early identification of a change in condition (utilize the Stop and Watch Form.) 3. The DON, ADON, and charge nurses completely audited 100% of all charts on [DATE] to ensure patients who had experienced a change in condition were provided assessment, evaluation, and appropriate interventions. 4. The DON and ADON physically assessed 100% of the residents on [DATE] and no additional changes in condition were found. 5. No licensed nursing staff will be allowed to work their shift until they have attended the mandatory in-service on resident assessment and emergency transfer procedures. 6. All certified nurse aides (CNA ' s) will not be allowed to work their shift until they have attended the mandatory in-service on Stop and Watch. 7. The two licensed nurses involved with the incidents were evaluated by the administration. One will be terminated and the other will be placed on 90 day probation with retraining in accuracy of assessment, utilizing findings to manage patient care and emergency transfer situations. The surveyor monitored the Plan of Removal on [DATE] and [DATE] during all three shifts including licensed and registered nurses worked from 6am to 2pm, 2pm to 10pm, and 10pm- 6am as follows: Facility protocols concerning proper assessment to identify changes of condition, emergency transfer and when to call 911 were reviewed. In-services on procedures concerning proper assessment and analysis of abnormal vital signs, changes of condition, and documentation, were conducted on [DATE], [DATE] and [DATE]. In-services were conducted on all three shifts with over 70% of the nursing staff attending. 90% of the nursing staff covering three shifts were interviewed on [DATE] and [DATE], and all staff were able to express up to date knowledge on the facility's procedures for a resident's change in condition, emergency transfer and when to notify physicians of changes. Interviews with nursing staff on all three shifts revealed no changes in condition had been identified since the immediate jeopardy was identified. Observations of residents in the facility revealed no changes in condition that required emergency transfer. After monitoring the implementation of the plan, the IJ was removed. The Administrator and the DON were informed the IJ was removed on [DATE] at 7:00 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of Actual Harm that is not immediate jeopardy with a scope identified as a pattern. The facility was continuing to monitor and evaluate the effectiveness of their plan to ensure residents' physicians were promptly consulted following changes in condition, proper assessment, and emergency transfer to the hospital. The facility provided a census dated [DATE] which revealed 34 residents.

Based on observation, record review, and interview, the administration failed to administer the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical well-being for two of eight residents (CR #1 and CR #2) reviewed for quality of care. The Administrator failed to implement the facility's abuse and neglect policy and procedure. The Administrator failed to supervise the DON on training and monitoring the nursing staff to assess, monitor, promptly consult physicians concerning a change of condition in residents and initiate emergency medical transfers as the resident's condition requires. The DON failed to train staff to monitor, assess, provide care and consult physicians timely concerning residents with changes in condition. The DON failed to train staff to assess, and identify changes requiring the need of emergency medical services for prompt intervention. An immediate jeopardy (IJ) identified on [DATE] at 11:30 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. These failures affected two residents; CR #1 who was in hypovolemic shock upon arrival to ER and had two units of blood transfused STAT and CR #2 who passed away six hours later in the facility without any interventions and placed 34 other residents at risk of not having prompt interventions when a change in condition occurred which would cause a delay in the residents receiving treatment and care which could cause increased suffering, or death. Findings include: Intake # 1 CR #1 Record review of CR #1's face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. CR #1's [DIAGNOSES REDACTED]. Record review of CR #1's admission assessment notes dated [DATE] at 9:00p.m., revealed the resident arrived at the facility via EMS with the [DIAGNOSES REDACTED].#1 was alert and oriented x 4, able to verbalize his needs and denied pain, no shortness of breath, respiration was even and unlabored, no distress noted, heart rate regular, and distal pulse present. Abdomen soft and non-tender, bowel sounds present in all quadrants, continent of both bowel and bladder, urine dark and concentrated and no foul odor noted. Drainage bag from upper abdomen outer quadrant notes drained 360 cc of green watery drainage. Bilateral upper extremity [MEDICAL CONDITION] X 2 and ted hose on. Patient education on fall prevention protocol, use of call light, room orientation. Record review of CR #1's clinical record revealed no interim care plan. Record review of CR #1's vital signs and weight flow sheet revealed the following; [DATE] - blood pressure ,[DATE], temperature 98.9, pulse 89, respiration 18 and oximetry 97% room air. [DATE] - blood pressure ,[DATE], temperature 97.8, pulse 81, respiration 18 and oximetry 97. [DATE] - blood pressure ,[DATE], temperature 97.6, pulse 78, respiration 18 and oximetry 98. Record review of CR #1's SBAR communication form dated [DATE] with no time, revealed the changes in condition identified were weakness, unstable vital signs, bleeding from the rectum (blood clots). Things that made this condition or symptom worse: very large blood clots. Vital signs: blood pressure - ,[DATE], heart rate - 102, temperature- 96.8, oximetry - 34% to 90 % on two liters of oxygen via nasal cannula. Further review revealed additional notes which read .patient noted lying in bed, complaint of weakness, assessment noted patient skin cool, clammy to touch with patient diaphoretic, glucose test was 162 mg/dl, blood pressure was ,[DATE]. Patient skin color pale. Patient alert and oriented and talking, denied having any pains, oxygen saturation 34% - 93% and fluctuating, oxygen started at 2 liters via nasal cannula. Bilateral lower extremity elevated. Pulled patients' pants off and noticed large amount of clotted blood. Nurse practitioner called, responsible party/wife called, new order received to send the patient to the hospital for GI bleeding. EMS was called for transportation; expected time of arrival was 30 minutes. Time NP was notified was 6:47pm. Record review of CR #1's nursing notes dated [DATE] revealed the following documentation written by LVN #2 who was CR #1's charge nurse: 5:40 p.m. - patient awake, alert and oriented x 3, resting in bed watching television. Patient stated that he is not hungry yet will eat the food delivered for supper in a little bit. 6:07 p.m. - went on to check patient for the percentage of meal eaten, found patient lying in bed with eyes closed, even non-labored breathing, skin cold to touch, clammy and pale. Patient diaphoretic, noted soaked t-shirt and pants. Patient seem lethargic, called patients' name twice and did a light chest rub, patient opened his eyes, responding to stimulation answering yes. 6:10 p.m. - LVN #1 called into the room, patient more alert and awake. Patient was asked how are you feeling? What happened? Patient stated I had weakness all day. Vitals checked: blood glucose - 162 mg/dl, blood pressure - ,[DATE] mmHg, Pulse - 109 beats per minute, oxygen saturation - 34% to 98% (fluctuating) respiratory rate - 18, patient repositioned in bed due to [MEDICAL CONDITION] by having the bilateral lower extremities higher than the head of the bed. Patient was given oxygen delivered via nasal cannula, patient awake, alert and oriented X 3, responds to stimuli and questions, denies pain and shortness of breath. Patient's shoes, socks and pants removed to get patient off from wet clothing, found large clumps of brown congealed (coagulated/clotted) blood coming from patients rectum. Patient stated I feel like I am having a bowel movement, towels used to wipe patient's legs. 6:15 p.m. - Nurse practitioner was notified of the event, the assessment and the interventions. New order to send the patient to the hospital at the medical center. 6:25 p.m. - trying to contact responsible party via home phone (only phone listed in the chart), no response. 6:30 p.m. - received responsible party's cell phone number through patient, calls forwarding to voice mail. 6:35 p.m. - Nurse and aide at the patient's bedside, assessing patient checking patients vitals every 15 minutes and attending to patient's needs. Patient still awake, alert and oriented x 3, responds to questions, denies pain and shortness of breath. Patient percutaneous biliary drain intact to the right side. Bag emptied with 200 ml. Record review of CR #1's nursing notes dated [DATE] at 8:10 p.m. revealed the following documentation written by LVN # 1: At 6:10 p.m. writer was called to (CR #1's) room, patient noted lying in bed eyes closed, respiration even and unlabored, skin cool, clammy to touch, patient diaphoretic, patient complained of weakness all day, blood sugar was checked - 162 mg/dl, patient alert and oriented x 3. Patient was repositioned in bed, bilateral lower extremities elevated and head of bed lowered to increase blood pressure ,[DATE]. Patient's oxygen saturation at 34% to 93%, oxygen at 2 liters started. 6:15 p.m. - Nurse Practitioner returned call and was informed of the above action, patient's pants was pulled down for removal and noted very large brown (congealed) blood - source of blood noted from rectum, NP was notified, new order to send the patient to hospital. DON was notified. 6:23 p.m. - (CR #1's) spouse was called at home, without answer. Message was left to call facility, patient's spouse cell phone number was received from patient and called, message left to call the facility. 6:45 p.m. - patient's spouse returned call and was informed of patient's change in condition, NP order to send him to the hospital for GI bleed. Patient spouse stated that the patient should be sent to the hospital and she would call the ER Doctor to meet her and the patient there. 6:50 p.m. - Patient's spouse called the nurses' station with a raised loud tone yelling I am calling the doctor now; I want to talk to my husband. 6:55 p.m. - first EMS was called expected time of arrival (ETA) was 2 hours, second EMS called and ETA was one and one half hours, third EMS called had ETA of 30 minutes and was given ok to transport the patient to hospital. Patient in bed and LVN #2 was at bed side to monitor his condition. 7:15 p.m. - patient's spouse called to station and started yelling where is the ambulance?, how long does it take to get there?, she was informed of dispatch time report of 30 minutes ETA and would call as soon as the phone call ended. Third EMS was called and dispatch said ETA was 5 - 10 minutes. Family member at the facility stated the patient should be sent to the hospital at the medical center. 7:45 p.m.- patient's spouse called to the station angrily demanding in a loud tone to call 911 to transfer the patient, 911 was called per spouse's request, third EMS was called to inform of spouse's decision. 8:00 p.m. - 911 here to transfer patient, family member accompanied patient, medical records sent with 911. Record review of CR #1's transfer form dated [DATE] with no time, revealed the reason for transfer to ER was GI (gastrointestinal) bleeding (large clots from rectum). CR #1's vital signs were: heart rate 102, respiration 26 and blood pressure ,[DATE]. Record review of CR #1's ER record dated [DATE] revealed the resident had [DIAGNOSES REDACTED]. Further review revealed CR #1's heart rate was 131 and he was transfused with two units of blood STAT. Interview on [DATE] at 12:14 p.m., the DON said she reviewed CR #1's incident on [DATE]. When asked what she thought of it, she said the staff responded appropriately. She said the staff called her and she was aware the resident was to be sent to the hospital. The DON said nothing could have been done differently. She further said she did not think intervention for CR #1, who had GI bleeding with low blood pressure, was delayed. Observation and interview on [DATE] at 4:30 p.m. revealed CR #1 in the hospital in ICU. He was alert and oriented. CR #1 said he was ok and hoped to get better. When asked about his stay at the facility before his transfer, he said the staff at the facility said his blood pressure was low and gave him salt. The staff told him it would help to get his blood pressure back up. CR #1 said the salt was burning his tongue but staff continued to give him the salt. Interview on [DATE] at 4:40 p.m., CR#1's spouse said she was notified of CR #1's change in condition about 6:40 p.m. on [DATE]. She told staff to transfer CR #1 to the downtown hospital because all of his doctors were at that hospital. She said she was shocked when she called the facility back and the ambulance to transfer CR #1 to the hospital still had not arrived. She said she did not know it took hours to get an ambulance. She expressed that she was scared when the staff did not think they needed to call 911 for someone bleeding, since they did not know how long he had been bleeding and how much blood he had lost. She also said she had a family member go to the facility to see what was going on. She said CR #1 was very pale when he got to the hospital because he had lost so much blood from a [DIAGNOSES REDACTED] ulcer that was found in the ER. CR #1's blood pressure was so low, ,[DATE], that they immediately transfused him with blood. CR #1's spouse said the resident told her the facility gave him salt that burned his mouth. She said she did not understand why the nurses gave him salt. She further said when she called the facility; she did not even know that the staff did not call 911 immediately. She said staff left CR #1 in the facility bleeding for 4 hours because CR #1 did not arrive at the hospital until 9:00 p.m. that evening. Interview on [DATE] at 11:10 a.m., CNA #1 said she was with CR #1 and the nurse (LVN #2) on [DATE] prior to his transfer to the hospital. She said she was in the room helping LVN #2 clean up CR #1. CNA #1 said CR #1 was losing a lot of blood, and his oxygen saturation and blood pressure were going up and down. She said CR #1 was lying down in bed the whole time, quiet and not talking as much as he used to. Interview on [DATE] at 2:40 p.m., LVN #1 gave an account of the events that took place with CR #1 on [DATE] that matched what was documented in CR #1's nurses note. LVN #1 said on [DATE] around 6:15 p.m. she left LVN #2 with CR #1 while she went to call the NP, spouse and EMS. She said she did not call 911 because the resident was not in any distress and the NP did not tell her to call 911. She said she called two different EMS companies and was told the ETA was 2 hours, so she called the DON to get permission to call another EMS that was not one of the facility's preferred ambulance services. She said the resident's spouse called the facility from the hospital and requested that 911 be called. She said she was unsure when the resident left the facility. Interview on [DATE] at 2:49 p.m., LVN #2 said she had been a nurse for about 4 months and this was her first nursing job. She stated on [DATE] when she saw CR #1 in bed he looked sweaty and tired and he had not eaten his dinner. She took his vitals and blood sugar and his blood sugar was 162, heart rate was about a 100 and blood pressure was low. She said she called LVN #1 to ask for assistance and when they took CR #1's pants down, they saw coagulated blood coming out of his rectum with feces. She said his spouse and NP were notified and transportation was called. LVN #2 said CR #1 was stable, he was talking the whole time they were waiting for transportation, denied pain, and did not appear to be in any distress. She said CR #1's oxygen saturation was fluctuating between 34% - 98% and he was on 2 liters of oxygen. She said she did not think the resident was in distress that required 911 to be called. Interview on [DATE] at 4:40p.m., the Nurse Consultant said she expected staff to call 911 when a resident had an oxygen saturation as low as 34%. She agreed the staff did not utilize their assessment results properly. She agreed CR #1 should have been sent to the hospital via 911 as soon as the bleeding was identified. CR #2 Record review of CR #2's face sheet revealed [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #2's quarterly assessment MDS dated [DATE] revealed the following Diagnoses: [REDACTED]. Further review of this MDS assessment revealed CR #2 had a BIMS score of 11, indicating her cognition was moderately impaired, required limited assistance with all ADLs except eating, was continent of bowel and bladder and did not require respiratory treatments. Record review of CR#2 ' s care plan, which was not dated, revealed resident had impaired gas exchange related to respiratory concerns such as [MEDICAL CONDITION] evidenced by shortness of breath upon exertion; use of oxygen, rapid irregular, labored breathing, pale related to respiratory disease. Goals: the resident will function at the highest practicable level within limitations of disease. Approaches included: follow MD orders and administer oxygen via nasal cannula, and breathing treatment as ordered. Monitor vital signs am oxygen saturation as scheduled and as needed, report significant changes, assess and monitor for symptoms of respiratory distress, increased anxiety, cyanosis and shortness of breath. Maintain calm and quiet environment, monitor lab as ordered, monitor oxygen saturation level as ordered . Record review of CR #2's Nurse notes dated [DATE] at 4:00 a.m. written by LVN #3 revealed resident observed sitting up in wheelchair, head slumped down, took a closer look and noted resident's eye fixed and appears to have passed out/fainted, assisted resident into bed and made her comfortable with head of bed elevated, vital signs taken: blood pressure 144, blood pressure ,[DATE], 62, respiration 22. Oxygen continues at 2 liters. No distress noted but it does appear breathing is rapid, called Physician on call number, awaiting response. Record review of CR #2's Nurse Notes written by LVN #4, dated [DATE] revealed the following: 6:00 a.m. - received patient in bed call light within reach, patient awake, a.m. care provided, accu check done result 131, patient ate 15% of breakfast. 8:00 a.m. - oxygen saturation was 96%, respiration was non-labored at 18 cycles per minute. 10:05 a.m. - resident requested a bowl of cereal, offered to patient, and consumed 75% and coffee. 11:05 a.m. - patient requested to use the bathroom, assisted by assigned CNA, who helped patient back in bed, patient remained on side of bed gasping for air, 911 initiated by writer. 11:25 a.m. - on arrival patient had stopped breathing, CPR not initiated due to DNR status. Interview on [DATE] at 12:08 p.m., the DON said she recalled CR #2 passed away a couple of day ago. She said it was expected because the resident had [MEDICAL CONDITION] and had a DNR status. She recalled the resident used oxygen. Interview on [DATE] at 1:02 p.m., LVN #4 said she took care of CR #2 on the morning of [DATE]. She said she took report from the night shift nurse LVN #3 on the morning of [DATE] and LVN #3 did not inform her that CR #2 had a change in condition during the night shift. LVN #4 said CR #2 had severe [MEDICAL CONDITION] and began experiencing respiratory distress around 11:00 a.m. after she got up to use the bathroom. LVN #4 said she placed a non-rebreather mask on CR #2 and increased her oxygen liters, then called 911. She said CR #2 had stopped breathing when 911 arrived. She said she did not initiate CPR because CR #2 had a DNR status. Interview on [DATE] at 1:12 p.m., the RN Weekend Supervisor said she was not informed about CR #2's change in condition upon duty assumption on [DATE]. The RN Weekend Supervisor said she was called to the resident's room and when she got there the 911 crew arrived at the same time. She said CR#2 had stopped breathing at that time. Interview via phone on [DATE] at 1:46 p.m., LVN #3 said during the night shift on [DATE] she saw CR #2 hanging between the toilet seat and her wheelchair, holding the arm of her wheel chair. She quickly assisted the resident to her wheelchair, put her oxygen on because she did not have it on, then helped her to bed and made her comfortable. She said CR #2's respiration was normal and she had no distress during this incident. LVN #3 said she called the physician and spoke to someone who was to notify the physician. She explained the facility protocol was to call the physician on call number and they would return the call by the next morning. She agreed she should have called again before her shift ended. She further said she told the morning nurse LVN #4 to follow-up and to monitor CR #2 closely when she gave her report. She said she would have called 911 if CR#2 was not a DNR and that it would have been a problem if she called 911 for a DNR. LVN#3 was asked why her account was different from her documentation on the resident's nurse notes. She said she thought CR #2 was just struggling to sit up in her wheelchair. LVN #3 said after CR #2 was put in bed, she became alert and responsive again and was talking. LVN #3 said she was shocked when the DON told her CR #2 passed away a couple of hours later that day. Record review of facility's 24 hour report for the night shift on [DATE] did not reveal any documentation of CR #2's change in condition. CR#2's incident was not reported on the 24 hours report. Interview on [DATE] at 1:58p.m., LVN #5 said CR #2 had severe [MEDICAL CONDITION] and required oxygen at all times. She was told the resident passed away on the weekend which surprised everyone. LVN #5 explained it was unexpected. Interview via phone on [DATE] at 5:00p.m., CNA #2 said on the morning of [DATE], she saw CR #2 ' s call light on and went into her room to help. CNA #2 said she was not CR #2 ' s assigned aide, but assisted the resident to the restroom. CNA #2 said CR #2 had respiratory problems and had to use oxygen all the time. CNA #2 said CR #2 had her oxygen on as she took her to the bathroom in her wheelchair. She said CR #2 returned to her bedside and held CNA #2 and said don ' t leave me and then began having rapid respiration. CNA #2 said it all happened very quickly. She called the nurse, but CR #2 passed away. CNA #2 said all the aides knew CR #2 had severe respiratory problems. Interview on [DATE] at 7:05 a.m., the DON said based on the incident account documented on CR #2's nurse notes for the night shift on [DATE] at 4:00 a.m., CR#2 should have been sent to the hospital via 911. She further said LVN #3 was terminated for not promptly intervening and communicating the incident to other nurses to follow-up. Record review of the facility's policy on emergency transfer dated ,[DATE] revealed the facility shall provide for health and safety of all residents, the facility shall initiate an immediate transfer of a resident when appropriate. The charge nurses shall assess the resident and determine if they require emergency transfer, they will assess the resident for the following: oxygen saturation less than 90% (unless it is the resident's normal with [MEDICAL CONDITION]), respiration rate greater than 30 per minute or less than 10 per minute, finger stick glucose less than 45 and non-responsive or greater than 400, chest pain not relieved with Nitro [MEDICATION NAME] X 3, excessive bleeding, a change in a resident's behavior that would indicate that an emergency condition exist, other cardiac or respiratory distress issues which the licensed staff believed require an emergency transfer. Record review of the facility's policy on abuse and neglect prohibition dated ,[DATE] revealed each resident had the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. Record review of the facility's policy on notification of physicians dated February 2016 revealed the facility shall promote a two way system of communication between the facility and physician. Staff will notify the physician at various times during a resident's stay in order to ensure all appropriate information has been made available to allow the physician to provide the highest level of care to the residents. Licensed nurses shall notify the physician upon a change in condition of a resident, and to make them aware that a resident's condition is worsening etc. The facility Administrator and DON were notified on [DATE] at 11:30 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted [DATE]. After several revisions, a plan was accepted on [DATE] at 3:30 p.m. Interview on [DATE] at 6:02 p.m., the Administrator said he was surprised about the immediate jeopardy identified in the facility. He said he knew CR #1 was sent to the hospital but was unsure why. He said he did not know the full details of what happened. He recalled the resident was fine and had a couple of appointments that day and there were no identified problems. When the Administrator was asked what procedures were available to ensure the nursing needs of the residents were met, he stated the residents ' care was based on implementing the physician's order [REDACTED]. He said the facility had an interdisciplinary morning meeting every day in which incidents that had occurred were discussed. The Administrator also said the facility hired qualified staff who are screened and verified as required. The facility had a nurse consultant who was responsible for hiring and training of staff as well as ensuring their competencies in nursing skills. Interview on [DATE] at 7:07 a.m., the DON said LVN #2 who was CR #1's charge nurse was a new nurse and did not properly assess the resident's condition. She believed this contributed to the immediate jeopardy identified. When asked what she would have expected the staff to do, she said the resident should have been sent out to the ER immediately. The DON agreed the resident had significant signs that staff failed to identified or analyze. The DON further said LVN #1 was the more experienced nurse of the two and she also failed to think critically and provide emergent assistance. The DON said staff were trained to care for CR #1 and CR #2 who both experienced significant changes in condition. She said the staff were provided training upon hire and on an on-going basis. The DON said on the job in-services were provided to staff frequently, as well as skill check offs with feedback to staff following incidents. The DON said the facility had protocol in place for use when a resident had a change in condition. She further said staff were trained to use the SBAR and interact tools, as well as to seek help from internal resources like supervisors in the facility. Immediate Jeopardy Plan of Removal 1. Accurate assessment of patients: A. Licensed nursing staff and Certified Nurse Aides (CNA ' s) were in-serviced on [DATE] and [DATE] on: a. Assessing and evaluating change in conditions of patients b. Recognizing life threatening situations and seeking emergency medical service (call 911). c. Providing interventions to stabilize patient's condition. d. Performing accurate and adequate documentation. B. Assessment process to include head to toe assessment. C. Assessing of GI bleeding, respiratory distress, analyze findings and provide and providing immediate action. D. Case study - Mrs. T. (this case study illustrates how a CNA making morning rounds tells her charge nurse that Mrs. T is not herself today. The nurse assesses the resident and discovers the patient is afebrile, but pale, and is orthostatic .there is bloody stool.) Discussion follows. 2. Emergency transfer patient: A. Licensed nursing staff were in-serviced on [DATE] and [DATE] on: a. Emergency transfer patient policy and procedure. b. Notification of physician. In summary and reference to above the in-services/training provided emphasized: A. Accuracy of assessment of: 1. GI Bleeding/Hemorrhage and 2. Respiratory Distress B. Analyzing the assessment findings to provide care and services appropriately. C. Notification of physician (Immediate versus Non-Immediate) D. Emergency Transfer (In all life-threatening situations call 911 for immediate transfer to the hospital emergency room .) E. Early identification of a change in condition (utilize the Stop and Watch Form.) 3. The DON, ADON, and charge nurses completely audited 100% of all charts on [DATE] to ensure patients who had experienced a change in condition were provided assessment, evaluation, and appropriate interventions. 4. The DON and ADON physically assessed 100% of the residents on [DATE] and no additional changes in condition were found. 5. No licensed nursing staff will be allowed to work their shift until they have attended the mandatory in-service on resident assessment and emergency transfer procedures. 6. All certified nurse aides (CNA ' s) will not be allowed to work their shift until they have attended the mandatory in-service on Stop and Watch. 7. The two licensed nurses involved with the incidents were evaluated by the administration. One will be terminated and the other will be placed on 90 day probation with retraining in accuracy of assessment, utilizing findings to manage patient care and emergency transfer situations. The surveyor monitored the Plan of Removal on [DATE] and [DATE] during all three shifts including licensed and registered nurses worked from 6am to 2pm, 2pm to 10pm, and 10pm- 6am as follows: Facility protocols concerning proper assessment to identify changes of condition, emergency transfer and when to call 911 were reviewed. In-services on procedures concerning proper assessment and analysis of abnormal vital signs, changes of condition, and documentation, were conducted on [DATE], [DATE] and [DATE]. In-services were conducted on all three shifts with over 70% of the nursing staff attending. 90% of the nursing staff covering three shifts were interviewed on [DATE] and [DATE], and all staff were able to express up to date knowledge on the facility's procedures for a resident's change in condition, emergency transfer and when to notify physicians of changes. Interviews with nursing staff on all three shifts revealed no changes in condition had been identified since the immediate jeopardy was identified. Observations of residents in the facility revealed no changes in condition that required emergency transfer. After monitoring the implementation of the plan, the IJ was removed. The Administrator and the DON were informed the IJ was removed on [DATE] at 7:00 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of Actual Harm that is not immediate jeopardy with a scope identified as a pattern. The facility was continuing to monitor and evaluate the effectiveness of their plan to ensure residents' physicians were promptly consulted following changes in condition, proper assessment, and emergency transfer to the hospital. The facility provided a census dated [DATE] which revealed 34 residents.

Based on interview and record review, the facility failed to follow their written policies and procedures concerning the reporting and investigation of neglect for one of 12 residents (Resident #30) reviewed for care provided after change of condition was identified. The facility failed to provide services for Resident #30 concerning her 357 mg/dL critical level blood glucose level and her continued refusal of insulin and for blood glucose monitoring. Resident #30's physician was not consulted nor was medical care provided which resulted in the resident ' s transfer to the hospital with a blood glucose over 600 three days later. This was determined to be a past noncompliance immediate Jeopardy (IJ) due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure affected one resident who required acute care at a hospital due to an untreated elevated blood sugar and placed 17 residents with diabetes at risk of harm of deterioration of health due to not receiving medical services. Findings include: Record review of the facility's Reportable Incident Protocol dated January 2015, revealed " ... External Reportable Incidents: The criteria for reporting to the Department of Aging and Disability Services (DADS) for reportable incidents is ...Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... Upon the occurrence of an accident/incident that the facility staff has reason to believe meets the criteria for being reportable, staff must immediately contact the Executive Director or the Director of Nurse. The Executive Director or Director of Nursing must immediately contact DADS..." Record review of the facility's Acknowledgement of Abuse Policy and Reporting Requirements dated January 2015 revealed each staff must sign as part of their training. The form reads the facility "...does not tolerate conduct that may be considered abuse or neglect of its patients." Record review of the facility's Patient Abuse Investigation Questionnaire dated January 2015 revealed "Instructions: Interview several patients and or family members to determine their awareness of abuse that may have occurred inside the facility using the questions below as a guide. Select interviewable patients for your sample..." Record review of the Patient Abuse Investigation form dated January 2015 revealed "...This document has been prepared for review and evaluation by the Quality Assessment and Assurance Committee ..." The form reveals details of the incident to be recorded along with witness statements, summary of interviews and reviews of medical records. The form goes on to findings, conclusions and recommendations/corrective action. Resident #30 Record review of Resident #30 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The resident ' s admission [DIAGNOSES REDACTED]. Record review of Resident #30 ' s MDS assessment dated [DATE], revealed a BIMS score of 13 out of 15 indicating the resident was cognitively intact. She required extensive assistance for transfers and mobility, dressing and hygiene. The MDS also identified that Resident #30 exhibited rejection of care behavior one to three days of the 7 day assessment period. Record review of the resident ' s care plans title " Potential for fluctuation of blood sugar related to [DIAGNOSES REDACTED]. Continued review revealed the following interventions: notify physician and family, accucheck before meals and bedtime as ordered, administer sliding scale insulin as ordered and if blood glucose is greater than 350 give 9 units of insulin and notify physician, administer standing bedtime insulin as ordered. Observation on 1/26/15 at 8:55 A.M. during initial tour revealed Resident #30 in bed awake and eating breakfast. The resident would not engage in communication at that time. Record review of Laboratory results revealed the speciman was collected on 12/15/14 at 8:10 (no A.M. or P.M. noted) dated 12/16/14 at 2:01 (no A.M. or P.M. noted) revealed Resident #30's glucose was 357mg/dL with the expected normal range of 70-110. "...Critical value called to (LVN #14) at 1:26 A.M." Record review of Resident #30's medication administration record (MAR) and physician's orders [REDACTED].M.) every day. The MAR also revealed the resident was to receive a routine dose of [MEDICATION NAME] 25 units at bedtime. Continued review revealed the resident had an accucheck completed on 12/3/14, 12/5/14 at 11:30 A.M. and 12/18/14 at 8:00 P.M. and the resident refused all other accuchecks scheduled from 12/1/14 to 12/18/14. Record review of the 12/2014 MAR revealed the resident allowed blood glucose monitoring three times in December 2014. On 12/3/2014 Resident #30 ' s blood sugar per the accucheck was 128. Resident #30 ' s blood sugar on 12/5/2014 per the accucheck was 104. Resident #30's blood sugar documented on the MAR for 12/18/2014 revealed a blood sugar over 600. Record review of Resident #30 ' s nurse ' s notes dated 12/16/14 at 1:50 A.M. revealed " Reviewed call from lab stating res (resident) glucose is 357, critical lab called in to (Dr. #1), awaiting call back. Res usually refuses B/S (blood sugar) check/insulin. Will continue to monitor " (LVN # 22). Record review of the Resident #30 ' s nurse ' s notes dated 12/16/14 at 4:30 A.M. revealed " paged (Dr #1) earlier on, regarding critical lab for res, but no call back. Spoke to on call services and promised to relay the message. Glucose from lab is 357, res is stable and has a history of refusing B/S check and insulin " (LVN #22). Record review of the Resident #30 ' s nurse ' s notes dated 12/16/14 at 6:00 A.M. revealed " Received report abn (abnormal) lab result. Pending Dr. return call. Blood glucose lab is 357. Resident has been refusing blood glucose check daily. Family has been notified previously and physician aware " ... (LVN #1). Record review of the nurse ' s notes dated 12/16/14 at 6:38 A.M. revealed the Resident #30 refused to have her blood sugar tested . The record did not reveal the physician was notified. Record review of Resident #30's nurse ' s notes dated 12/16/14 at 7:45 A.M. revealed the resident refused her blood sugar test. The record did not reveal the physician was notified. Record review of Resident #30 ' s nurse ' s notes written by LVN #1 dated 12/16/14 at 8:30 A.M. revealed " (family member) in room visiting pt (resident). Approached Res (resident) to offer medications and request to do accucheck at this time. This LVN asked resident May we do your blood sugar check? (family member) responded we don ' t do that. She doesn ' t have to do that. " I asked if he was aware that she has to have BS (blood sugar) checked in order to give the sliding scale insulin. (family member) responded " yes but if she doesn ' t want it, she doesn ' t have to. " Record review of Resident #30 ' s nurse ' s note written by LVN #1 dated 12/16/2014 at 9:15 A.M. " Call to Dr (#1) regarding panic level glucose for 12/16/14 and abnormal U/A (urine analysis) pending culture and sensitivity. Call resident ' s (family member) to inform of critical lab results of 12/15/14. Responded he was not aware of those results. Updated him that critical lab results revealed BS of 357. (Family member) responded " well, now give her insulin according to those results " Explained to (family member) that BS can change and her BS may not be at 357 but resident is refusing her BS at this time and I would be notifying Physician and would continue to encourage resident to allow us to monitor her BS and would greatly appreciate him also encouraging resident to cooperate with BS monitoring during his visits and was communicating and updating him on her condition. (Family member) verbally acknowledged and thanked this LVN." Record review of Resident #30's nurse ' s notes dated 12/17/14, not timed, revealed the resident refused her blood glucose monitoring. Continued review revealed a call was placed to Dr #1 for confirmation of receipt of laboratory results received in the office and pending physician review. Record review of the resident ' s MAR dated 12/1/14 to 12/31/14 revealed the resident ' s routine bedtime [MEDICATION NAME] 25 units every night at bedtime (8:00 P.M.) was refused by the resident on 12/6/14 and 12/17/14. Record review of Resident #30's nurse ' s notes dated 12/18/14, not timed, revealed the resident continued to refuse her blood sugar and insulin. Continued review revealed a call was placed to Dr#1's offices and LVN #1 spoke with an office staff who informed the nurse that Dr #1 would call back after reviewing the abnormal labs. Continued review of the nurse ' s notes revealed a message was also left that the resident continued to refuse her blood glucose monitoring and insulin. Record review of Resident #30's clinical record revealed no other nurse ' s notes regarding the resident ' s blood sugar or physician notification until the transfer form on 12/18/2014 was completed. Record review of Resident #30 ' s clinical record Resident Transfer Form dated 12/18/14, untimed, revealed Resident #30 was transferred to a local community hospital with a blood glucose greater than 600. Record review of Resident #30's History and Physical from the local community hospital dated 12/19/14 revealed Resident #30's history and present illness "...Her blood glucose was in the 600 prior to EMS arrival. The patient has had similar problems with her blood sugar previously, reportedly the patient is very noncompliant..." The assessment and plan portion of the form revealed "Uncontrolled [MEDICAL CONDITION]. We will check hemoglobin A1c level...the patient is currently not in diabetic ketoacidosis. Blood glucose is now better controlled." Record review of Resident #30 ' s physician's order [REDACTED]. Blood sugar 150-199 1 unit Blood sugar 200-249 3 units Blood sugar 250 - 299 5 units Blood sugar 300-349 7 units Blood sugar 350 and over give 9 units and call medical doctor. Observation on 1/27/15 at 4:50 P.M revealed Resident #30 asleep with her blanket over her head. The resident was on her right side with the head of the bed slightly elevated. Interview on 1/28/15 at 4:35 P.M. LVN #9 stated she was working with the Resident #30 and sent her to the hospital on [DATE] .LVN #9 continued and stated the resident allowed her to do the evening accuchecks ( a finger stick test done at the bedside to monitor blood glucose quickly). The result did not come as a number result it displayed too high to read which indicated her blood sugar result was greater than 600. LVN #9 stated she called the on-call physician and sent the resident to the hospital. Interview on 1/28/15 at 4:55 P.M. LVN # 22 stated she did not call the physician back more frequently after she received the laboratory glucose result because the resident was asleep and was stable. She stated she should have called back more frequently than she did and she should have called the medical director when the doctor did not respond timely. Interview on 1/28/2015 at 11:00 A.M. the DON, after reviewing Resident #30's medical record acknowledge that staff should have notified someone when the doctor did not respond. He acknowledged the new systems and trainings had been put into place to prevent these types of incidents. It was determined that these failures place Resident #30 in an immediately Jeopardy (IJ) situation from 12/16/14 through 12/18/14. The facility took the following action to correct the non-compliance on 1/7/15: 1. The DON and Administrator identified a system problem in the notification and recognizing a change in condition in a resident and presented the problem to the QA committee on 1/7/2015 where the SBAR (Situation, Background, Assessment and Request system) was introduced. Policies and procedures were developed concerning the SBAR and the notification of physicians. 2. DON and Administrator met with the facility physicians on 1/20/15 to discuss improving communication for resident changes in condition. 3. New hired nurse orientation on 1/22/15 included procedures for calling a physician when a resident has a change in condition. The attending physician was to be called every 15 minutes for three times and if no response they were to call the medical director. 4. Facility Nursing staff RN ' s, LVN ' s and CNA ' s were in serviced on 1/23/15 on the SBAR form/system and the calling of the physician/medical director if no response. Identification: Interview on 1/29/15 at 11:54 A.M., the DON explained there was problem communicating with physicians identified immediately after his hire (1/5/2015) by himself and the Administrator and was discussed in the weekly QA meeting. He stated they saw an increase in the number of repeat hospitalization s that may have been prevented if the physician was contacted and notified the resident had a problem and the physician could have intervened to prevent the re-hospitalization . He stated they had a meeting with the physicians and a new communication tool known as the Situation, background, assessment or appearance and request (SBAR) was implemented. The DON stated we began to in-service the staff on 1/22/15 at the new hire orientation and on 1/23/15 to the existing nursing staff regarding the procedure to notify the physician for changes, notify the medical director if they were not able to contact the residents attending physician and the SBAR. The DON stated when he started to work on 1/5/15 there were no systems in place, no in-services were done, and there were no policies for standard of care or for communication of resident changes to the physician. The procedure we use now for notifying the physician is best practice. Interview on 1/29/15 at 12:03 P.M., the Administrator stated she was hired on 12/22/14, but did not begin working at the facility for three weeks after her hire date due to attending training. She stated during her first week at the facility a weekly QA meeting was held on 01/07/15 she and the DON identified a problem with the communication with physicians. She stated they saw a lot of residents going to the hospital repeatedly and identified resident's conditions that should have been assessed by staff and the doctor notified to treat the residents and maybe prevent them from going to the hospital again. She stated she and the DON invited all Residents ' physicians to a meeting to get their input regarding the situation on 01/20/15 and seven doctors, including the two Medical Directors, attended and gave input on remedying this situation. One suggestion, which the DON had already recommended, was using the SBAR as a communication tool between the nurses and the physicians. The Administrator stated this was immediately put in place and all staff were in-serviced on using the SBAR on 1/23/15. The training included the procedure to notify the physician for changes and notifying the medical director if they were not able to contact the resident ' s attending physician. The Administrator stated when she began working in the facility she realized there was no documentation, policies and procedures, or systems in place to address many issues and she and the DON had been creating them and in-servicing staff since this realization. Monitoring by surveyor revealed: 1. Record review of the facility Standards of Care #12 dated January 2015 revealed: The stop and watch early warning tool when the resident first presents with a change of condition. A SBAR communication tool and progress note must be completed upon a change in condition and prior to contacting the physician. A Quality Improvement Tool should be completed for each acute care transfer. The Quality Assurance meeting must include a review of appropriate and timely completion of the Early Warning Report, the SBAR communication tool, transfer form, Quality Improvement Tool and the overall effectiveness based upon readmission rates. 2. Record review of the Early Warning Tool dated January 2015 revealed if a change was identified in a resident the form must be completed and given to a nurse. 3. Record review of the facility SBAR Communication Form and progress notes revealed: Evaluate the resident Check vital signs (blood pressure, heart rate, temperature, respiratory rate, oxygen level in the blood with use of the oximetry and finger stick glucose Review the record (recent progress notes, labs, orders). Have all relevant information available when reporting. 4. Record review of an additional 13 residents for appropriate and timely consultations and the implementation of changes in medical care revealed resident ' s laboratory results and glucose levels . The laboratory result records were initialed as the physician being notified. The glucose levels were below the level of when a physician was to be notified but all were recorded as ordered by the physician and proper amounts of insulin were administered. 5. Interviews with six nursing staff over two shifts on two days concerning effectiveness with recent training's revealed the staff were very knowledgeable concerning when to call the attending physician and to call every 15 minutes up to one hour and if no response to call the medical director. 6. Record review of the new hire orientation conducted on 1/22/15 with nursing staff RNs and LVNs on the SBAR system, notification of the physician in a timely manner and what to do if the attending does not respond revealed 100% of the January 2015 new hires were in serviced. Interview on 1/28/15 between 2:00 PM and 3:00 P.M. new hire nurses # ' s 9 and 16 revealed they received training during their orientation on 1/22/15 regarding calling the physician for changes every 15 minutes up to an hour and if no response call the medical director and the use of the SBAR as a communication tool when calling. 7. Record review of the nursing in-service conducted on 1/23/15 with nursing staff including RNs, LVNs and CNAs (15) regarding calling the physician for changes every 15 minutes up to an hour and if no response call the medical director, the use of the SBAR as a communication tool when calling. 38% of the nursing staff were in serviced on 1/23/15. In-services continued to be conducted during the annual service. No staff interviewed throughout the survey had not been inserviced. Interview on 1/29/15 at 1:45 P.M. DON revealed he monitored compliance by doing the following: Chart checks, 24 hour nursing report, rounds on each nurses station and he received report on every resident who had any change of condition. There was also a stand up meeting at 8:00 A.M. with all department heads for clinical monitoring. He stated he would meet with each 6-2 shift nurse and get a report on all residents, then conducted a stand down meeting at 4:00 P.M. with each 2-10 P.M. shift nurse to do a follow up from the day shift. An informal weekly quality assurance meeting with the department heads weekly and a formal quality assurance meeting including the physicians was done monthly. All monitoring was to be reported during the quality assurance meetings for any recommendations. The DON reported there were 18 residents with diabetes in the facility.

Based on observation, interview and record review, the facility failed to implement policies and procedures that would have prohibited the neglect of one of 12 residents (Resident # 30) reviewed for care provided for a critical level blood glucose. The facility failed to provide services for Resident #30 concerning her 357 mg/dL critical level blood glucose level, her continued refusal of insulin and for blood glucose monitoring. Resident #30's physician was not consulted nor was medical care provided which resulted in the resident ' s transfer to the hospital with a blood glucose over 600 three days later. This was determined to be a past noncompliance immediate Jeopardy (IJ) due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure affected one resident who required acute care at a hospital due to an untreated elevated blood sugar and placed 17 residents who had diabetes at risk of harm of deterioration of health due to not receiving medical services. Findings include: Resident #30 Record review of Resident #30 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The resident ' s admission [DIAGNOSES REDACTED]. Record review of Resident #30 ' s MDS assessment dated [DATE], revealed a BIMS score of 13 out of 15 indicating the resident was cognitively intact. She required extensive assistance for transfers and mobility, dressing and hygiene. The MDS also identified that Resident #30 exhibited rejection of care behavior one to three days of the 7 day assessment period. Record review of the resident ' s care plans title " Potential for fluctuation of blood sugar related to [DIAGNOSES REDACTED]. Continued review revealed the following interventions: notify physician and family, accucheck before meals and bedtime as ordered, administer sliding scale insulin as ordered and if blood glucose is greater than 350 give 9 units of insulin and notify physician, administer standing bedtime insulin as ordered. Observation on 1/26/15 at 8:55 A.M. during initial tour revealed Resident #30 in bed awake and eating breakfast. The resident would not engage in communication at that time. Record review of Resident #30's medication administration record (MAR) and physician's orders [REDACTED].M.) every day. The resident was also to receive [MEDICATION NAME] 25 units at bedtime. Continued review revealed the resident had an accucheck completed on 12/3/14, 12/5/14 at 11:30 A.M. and 12/18/14 at 8:00 P.M. and the resident refused all other accuchecks scheduled from 12/1/14 to 12/18/14. On 12/18/14 resident was discharged to hospital. Record review of the 12/2014 MAR revealed the resident allowed blood glucose monitoring three times in December 2014. On 12/3/2014 Resident #30 ' s blood sugar per the accucheck was 128. Resident #30 ' s blood sugar on 12/5/2014 per the accucheck was 104. Resident #30's blood sugar documented on the MAR for 12/18/2014 revealed a blood sugar over 600. Record review of the resident ' s MAR dated 12/1/14 to 12/31/14 revealed Insulin was to be given before meals and at bedtime based on a sliding scale ( the amount of insulin administered is based on the blood glucose level). Review of the MAR revealed 9 units of insulin should be given and the physician notified if the resident ' s blood glucose level is greater than 350. Record review of Laboratory results revealed the speciman was collected on 12/15/14 at 8:10 (no A.M. or P.M. noted) dated 12/16/14 at 2:01 (no A.M. or P.M. noted) revealed Resident #30's glucose was 357mg/dL with the expected normal range of 70-110. "...Critical value called to (LVN #14) at 1:26 A.M." Record review of Resident #30 ' s nurse ' s notes dated 12/16/14 at 1:50 A.M. revealed " Reviewed call from lab stating res (resident) glucose is 357, critical lab called in to (Dr. #1), awaiting call back. Res usually refuses B/S (blood sugar) check/insulin. Will continue to monitor " (LVN # 22). Record review of the Resident #30 ' s nurse ' s notes dated 12/16/14 at 4:30 A.M. revealed " paged (Dr #1) earlier on, regarding critical lab for res, but no call back. Spoke to on call services and promised to relay the message. Glucose from lab is 357, res is stable and has a history of refusing B/S check and insulin " (LVN #22). Record review of the Resident #30 ' s nurse ' s notes dated 12/16/14 at 6:00 A.M. revealed " Received report abn (abnormal) lab result. Pending Dr. return call. Blood glucose lab is 357. Resident has been refusing blood glucose check daily. Family has been notified previously and physician aware " ... (LVN #1). Record review of the nurse ' s notes dated 12/16/14 at 6:38 A.M. revealed the Resident #30 refused to have her blood sugar tested . The record did not reveal the physician was notified. Record review of Resident #30's nurse ' s notes dated 12/16/14 at 7:45 A.M. revealed the resident refused her blood sugar test. The record did not reveal the physician was notified. Record review of Resident #30 ' s nurse ' s notes written by LVN #1 dated 12/16/14 at 8:30 A.M. revealed " (family member) in room visiting pt (resident). Approached Res (resident) to offer medications and request to do accucheck at this time. This LVN asked resident May we do your blood sugar check? (family member) responded we don ' t do that. She doesn ' t have to do that. " I asked if he was aware that she has to have BS (blood sugar) checked in order to give the sliding scale insulin. (family member) responded " yes but if she doesn ' t want it, she doesn ' t have to. " Record review of Resident #30 ' s nurse ' s note written by LVN #1 dated 12/16/2014 at 9:15 A.M. " Call to Dr (#1) regarding panic level glucose for 12/16/14 (from speciman collected 12/15/2014)and abnormal U/A (urine analysis) pending culture and sensitivity. Call resident ' s (family member) to inform of critical lab results of 12/15/14 (called to the facility on [DATE]). Responded he was not aware of those results. Updated him that critical lab results revealed BS of 357. (Family member) responded " well, now give her insulin according to those results " Explained to (family member) that BS can change and her BS may not be at 357 but resident is refusing her BS at this time and I would be notifying Physician and would continue to encourage resident to allow us to monitor her BS and would greatly appreciate him also encouraging resident to cooperate with BS monitoring during his visits and was communicating and updating him on her condition. (Family member) verbally acknowledged and thanked this LVN." Continued review revealed no return call from the physician. Record review of Resident #30's nurse ' s notes dated 12/17/14, not timed, revealed the resident refused her blood glucose monitoring. Continued review revealed a call was placed to Dr #1 for confirmation of receipt of laboratory results received in the office and pending physician review. Record review of the resident ' s MAR dated 12/1/14 to 12/31/14 revealed the resident ' s routine bedtime [MEDICATION NAME] 25 units was to be given every night at bedtime (8:00 P.M.) the resident refused her insulin from 12/6/14 and 12/17/14. Record review of Resident #30's nurse ' s notes dated 12/18/14, not timed, revealed the resident continued to refuse her blood sugar and insulin. Continued review revealed a call was placed to Dr#1's offices and LVN #1 spoke with an office staff who informed the nurse that Dr #1 would call back after reviewing the abnormal labs. Continued review of the nurse ' s notes revealed a message was also left that the resident continued to refuse her blood glucose monitoring and insulin. Record review of Resident #30's clinical record revealed no other nurse ' s notes regarding the resident ' s blood sugar or physician notification until the transfer form on 12/18/2014 was completed. Record review of Resident #30 ' s clinical record Resident Transfer Form dated 12/18/14, untimed, revealed Resident #30 was transferred to a local community hospital with a blood glucose greater than 600. Record review of Resident #30's History and Physical from the local community hospital dated 12/19/14 revealed Resident #30's history and present illness "...Her blood glucose was in the 600 prior to EMS arrival. The patient has had similar problems with her blood sugar previously, reportedly the patient is very noncompliant..." The assessment and plan portion of the form revealed "Uncontrolled [MEDICAL CONDITION]. We will check hemoglobin A1c level...the patient is currently not in diabetic ketoacidosis. Blood glucose is now better controlled." Record review of Resident #30 ' s physician's order [REDACTED]. Blood sugar 150-199 1 unit Blood sugar 200-249 3 units Blood sugar 250 - 299 5 units Blood sugar 300-349 7 units Blood sugar 350 and over give 9 units and call medical doctor. Observation on 1/27/15 at 4:50 P.M revealed Resident #30 asleep with her blanket over her head. The resident was on her right side with the head of the bed slightly elevated. Interview on 1/28/15 at 4:35 P.M. LVN #9 stated she was working with the Resident #30 and sent her to the hospital on [DATE] .LVN #9 continued and stated the resident allowed her to do the evening accuchecks ( a finger stick test done at the bedside to monitor blood glucose quickly). The result did not come as a number result it displayed too high to read which indicated her blood sugar result was greater than 600. LVN #9 stated she called the on-call physician and sent the resident to the hospital. Interview on 1/28/15 at 4:55 P.M. LVN # 22 stated she did not call the physician back more frequently after she received the laboratory glucose result because the resident was asleep and was stable. She stated she should have called back more frequently than she did and she should have called the medical director when the doctor did not respond timely. Interview on 1/28/2015 at 11:00 A.M. the DON, after reviewing Resident #30's medical record acknowledge that staff should have notified someone when the doctor did not respond. He acknowledged the new systems and trainings had been put into place to prevent these types of incidents. It was determined that these failures place Resident #30 in an immediately Jeopardy (IJ) situation from 12/16/14 through 12/18/14. The facility took the following action to correct the non-compliance on 1/7/15: 1. The DON and Administrator identified a system problem in the notification and recognizing a change in condition in a resident and presented the problem to the QA committee on 1/7/2015 where the SBAR (Situation, Background, Assessment and Request system) was introduced. Policies and procedures were developed concerning the SBAR and the notification of physicians. 2. DON and Administrator met with the facility physicians on 1/20/15 to discuss improving communication for resident changes in condition. 3. New hired nurse orientation on 1/22/15 included procedures for calling a physician when a resident has a change in condition. The attending physician was to be called every 15 minutes for three times and if no response they were to call the medical director. 4. Facility Nursing staff RN ' s, LVN ' s and CNA ' s were in serviced on 1/23/15 on the SBAR form/system and the calling of the physician/medical director if no response. Identification: Interview on 1/29/15 at 11:54 A.M., the DON explained there was problem with communication to physicians identified immediately after his hire (1/5/2015) by himself and the Administrator and was discussed in the weekly QA meeting. He stated they saw an increase in the number of repeat hospitalization s that may have been prevented if the physician was contacted and notified the resident had a problem and the physician could have intervened to prevent the re-hospitalization . He stated they had a meeting with the physicians and a new communication tool known as the Situation, background, assessment or appearance and request (SBAR) was implemented. The DON stated we began to in-service the staff on 1/22/15 at the new hire orientation and on 1/23/15 to the existing nursing staff regarding the procedure to notify the physician for changes, notify the medical director if they were not able to contact the residents attending physician and the SBAR. The DON stated when he started to work on 1/5/15 there were no systems in place, no in-services were done, and there were no policies for standard of care or for communication of resident changes to the physician. The procedure we use now for notifying the physician is best practice. Interview on 1/29/15 at 12:03 P.M., the Administrator stated she was hired on 12/22/14, but did not begin working at the facility for three weeks after her hire date due to attending training. She stated during her first week at the facility a weekly QA meeting was held on 01/07/15 she and the DON identified a problem with the communication with physicians. She stated they saw a lot of residents going to the hospital repeatedly and identified resident's conditions that should have been assessed by staff and the doctor notified to treat the residents and maybe prevent them from going to the hospital again. She stated she and the DON invited all Residents ' physicians to a meeting to get their input regarding the situation on 01/20/15 and seven doctors, including the two Medical Directors, attended and gave input on remedying this situation. One suggestion, which the DON had already recommended, was using the SBAR as a communication tool between the nurses and the physicians. The Administrator stated this was immediately put in place and all staff were in-serviced on using the SBAR on 1/23/15. The training included the procedure to notify the physician for changes and notifying the medical director if they were not able to contact the resident ' s attending physician. The Administrator stated when she began working in the facility she realized there was no documentation, policies and procedures, or systems in place to address many issues and she and the DON had been creating them and in-servicing staff since this realization. Monitoring by surveyor revealed: 1. Record review of the facility Standards of Care #12 dated January 2015 revealed: The stop and watch early warning tool when the resident first presents with a change of condition. A SBAR communication tool and progress note must be completed upon a change in condition and prior to contacting the physician. A Quality Improvement Tool should be completed for each acute care transfer. The Quality Assurance meeting must include a review of appropriate and timely completion of the Early Warning Report, the SBAR communication tool, transfer form, Quality Improvement Tool and the overall effectiveness based upon readmission rates. 2. Record review of the Early Warning Tool dated January 2015 revealed if a change was identified in a resident the form must be completed and given to a nurse. 3. Record review of the facility SBAR Communication Form and progress notes revealed: Evaluate the resident Check vital signs (blood pressure, heart rate, temperature, respiratory rate, oxygen level in the blood with use of the oximetry and finger stick glucose Review the record (recent progress notes, labs, orders). Have all relevant information available when reporting. 4. Record review of an additional 13 residents for appropriate and timely consultations and the implementation of changes in medical care revealed resident ' s laboratory results and glucose levels . The laboratory result records were initialed as the physician being notified. The glucose levels were below the level of when a physician was to be notified but all were recorded as ordered by the physician and proper amounts of insulin were administered. 5. Interviews with six nursing staff over two shifts on two days concerning effectiveness with recent training's revealed the staff were very knowledgeable concerning when to call the attending physician and to call every 15 minutes up to one hour and if no response to call the medical director. 6. Record review of the new hire orientation conducted on 1/22/15 with nursing staff RNs and LVNs on the SBAR system, notification of the physician in a timely manner and what to do if the attending does not respond revealed 100% of the January 2015 new hires were in serviced. Interview on 1/28/15 between 2:00 PM and 3:00 P.M. new hire nurses # ' s 9 and 16 revealed they received training during their orientation on 1/22/15 regarding calling the physician for changes every 15 minutes up to an hour and if no response call the medical director and the use of the SBAR as a communication tool when calling. 7. Record review of the nursing in-service conducted on 1/23/15 with nursing staff including RNs, LVNs and CNAs (15) regarding calling the physician for changes every 15 minutes up to an hour and if no response call the medical director, the use of the SBAR as a communication tool when calling. 38% of the nursing staff were in serviced on 1/23/15. In-services continued to be conducted during the annual service. No staff interviewed throughout the survey had not been inserviced. Interview on 1/29/15 at 1:45 P.M. DON revealed he monitored compliance by doing the following: Chart checks, 24 hour nursing report, rounds on each nurses station and he received report on every resident who had any change of condition. There was also a stand up meeting at 8:00 A.M. with all department heads for clinical monitoring. He stated he would meet with each 6-2 shift nurse and get a report on all residents, then conducted a stand down meeting at 4:00 P.M. with each 2-10 P.M. shift nurse to do a follow up from the day shift. An informal weekly quality assurance meeting with the department heads weekly and a formal quality assurance meeting including the physicians was done monthly. All monitoring was to be reported during the quality assurance meetings for any recommendations. Record review of the facility's Reportable Incident Protocol dated January 2015, revealed "...Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." The DON reported there were 18 residents with diabetes in the facility.

Based on observation, interview and record review, the facility failed to provide the necessary care and services, in accordance with the comprehensive assessment and plan of care, to attain the highest practicable mental and physical well-being for one of 12 residents ( Residents # ' s 30 ) reviewed for receiving timely medical care after a change in condition. Resident # 30 ' s physician was not provided necessary medical care concerning her 357 milligrams per deciliter (mg/dL) critical level blood glucose. Resident #30's physician was not consulted concerning the blood level, the resident's consistent refusal for blood glucose monitoring and insulin. The resident was transferred to the hospital with blood glucose over 600 three days later after not receiving any care. This was determined to be a past noncompliance immediate Jeopardy (IJ) due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure affected one resident who required acute care at a hospital due to untreated elevated blood sugar, and placed 17 additional residents with diabetes at risk of harm of deterioration of health due to medical care not being provided and their physicians not being consulted. Findings include: Resident #30 Record review of Resident #30 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The resident ' s admission [DIAGNOSES REDACTED]. Record review of Resident #30 ' s MDS assessment dated [DATE], revealed a BIMS score of 13 out of 15 indicating the resident was cognitively intact. She required extensive assistance for transfers and mobility, dressing and hygiene. The MDS also identified that Resident #30 exhibited rejection of care behavior one to three days of the 7 day assessment period. Record review of the resident ' s care plans title " Potential for fluctuation of blood sugar related to [DIAGNOSES REDACTED]. Continued review revealed the following interventions: notify physician and family, accucheck before meals and bedtime as ordered, administer sliding scale insulin as ordered and if blood glucose is greater than 350 give 9 units of insulin and notify physician, administer standing bedtime insulin as ordered. Observation on 1/26/15 at 8:55 A.M. during initial tour revealed Resident #30 in bed awake and eating breakfast. The resident would not engage in communication at that time. Record review of Laboratory results revealed the speciman was collected on 12/15/14 at 8:10 (no A.M. or P.M. noted) dated 12/16/14 at 2:01 (no A.M. or P.M. noted) revealed Resident #30's glucose was 357mg/dL with the expected normal range of 70-110. "...Critical value called to (LVN #14) at 1:26 A.M." Record review of Resident #30's medication administration record (MAR) dated 12/1/2014 - 12/31/2014 revealed accuchecks were to be done before meals and at bed time (8:00 P.M.) every day. Insulin was to be administered per the accucheck results. Continued review revealed the resident had an accucheck completed on 12/3/14, 12/5/14 at 11:30 A.M. and 12/18/14 at 8:00 P.M. and the resident refused all other accuchecks scheduled from 12/1/14 to 12/18/14. Continued review of the MAR revealed on 12/3/2014 Resident #30 ' s blood sugar per the accucheck was 128. Resident #30 ' s blood sugar on 12/5/2014 per the accucheck was 104. Resident #30's blood sugar documented on the MAR for 12/18/2014 revealed a blood sugar over 600. Record review of the resident ' s MAR and physician's orders [REDACTED]. The orders were Blood sugar 150-199 1 unit, Blood sugar 200-249 3 units, Blood sugar 250 - 299 5 units, Blood sugar 300-349 7 units. Review of the same MAR revealed that 9 units of insulin should be given and the physician notified if the resident ' s blood glucose level is greater than 350. Record review of Resident #30 ' s nurse ' s notes dated 12/16/14 at 1:50 A.M. revealed " Reviewed call from lab stating res (resident) glucose is 357, critical lab called in to (Dr. #1), awaiting call back. Res usually refuses B/S (blood sugar) check/insulin. Will continue to monitor " (LVN # 22). Record review of the Resident #30 ' s nurse ' s notes dated 12/16/14 at 4:30 A.M. revealed " paged (Dr #1) earlier on, regarding critical lab for res, but no call back. Spoke to on call services and promised to relay the message. Glucose from lab is 357, res is stable and has a history of refusing B/S check and insulin " (LVN #22). Record review of the Resident #30 ' s nurse ' s notes dated 12/16/14 at 6:00 A.M. revealed " Received report abn (abnormal) lab result. Pending Dr. return call. Blood glucose lab is 357. Resident has been refusing blood glucose check daily. Family has been notified previously and physician aware " ... (LVN #1). Record review of the nurse ' s notes dated 12/16/14 at 6:38 A.M. revealed the Resident #30 refused to have her blood sugar tested . The record did not reveal the physician was notified. Record review of Resident #30's nurse ' s notes dated 12/16/14 at 7:45 A.M. revealed the resident refused her blood sugar test. The record did not reveal the physician was notified. Record review of Resident #30 ' s nurse ' s notes written by LVN #1 dated 12/16/14 at 8:30 A.M. revealed " (family member) in room visiting pt (resident). Approached Res (resident) to offer medications and request to do accucheck at this time. This LVN asked resident May we do your blood sugar check? (family member) responded we don ' t do that. She doesn ' t have to do that. " I asked if he was aware that she has to have BS (blood sugar) checked in order to give the sliding scale insulin. (family member) responded " yes but if she doesn ' t want it, she doesn ' t have to. " Record review of Resident #30 ' s nurse ' s note written by LVN #1 dated 12/16/2014 at 9:15 A.M. " Call to Dr (#1) regarding panic level glucose for 12/16/14 (from speciman collected on 12/15/2014) and abnormal U/A (urine analysis) pending culture and sensitivity. Call resident ' s (family member) to inform of critical lab results of 12/15/14 (results called to facility on 12/16/2014). Responded he was not aware of those results. Updated him that critical lab results revealed BS of 357. (Family member) responded " well, now give her insulin according to those results " Explained to (family member) that BS can change and her BS may not be at 357 but resident is refusing her BS at this time and I would be notifying Physician and would continue to encourage resident to allow us to monitor her BS and would greatly appreciate him also encouraging resident to cooperate with BS monitoring during his visits and was communicating and updating him on her condition. (Family member) verbally acknowledged and thanked this LVN." Continued review revealed no verbal confirmation from the physician that information had been received. Record review of Resident #30's nurse ' s notes dated 12/17/14, not timed, revealed the resident refused her blood glucose monitoring. Continued review revealed a call was placed to Dr #1 for confirmation of receipt of laboratory results received in the office and pending physician review. Record review of the resident ' s MAR dated 12/1/14 to 12/31/14 revealed the resident ' s bedtime routine [MEDICATION NAME] 25 units was to be given every night at bedtime (8:00 P.M.) and the resident refused her insulin on 12/6/14 and 12/17/14. Record review of Resident #30's nurse ' s notes dated 12/18/14, not timed, revealed the resident continued to refuse her blood sugar and insulin. Continued review revealed a call was placed to Dr#1's offices and LVN #1 spoke with an office staff who informed the nurse that Dr #1 would call back after reviewing the abnormal labs. Continued review of the nurse ' s notes revealed a message was also left that the resident continued to refuse her blood glucose monitoring and insulin. Record review of Resident #30's clinical record revealed no other nurse ' s notes regarding the resident ' s blood sugar or physician notification until the transfer form on 12/18/2014 was completed. Record review of Resident #30 ' s clinical record Resident Transfer Form dated 12/18/14, untimed, revealed Resident #30 was transferred to a local community hospital with a blood glucose greater than 600. Record review of Resident #30's History and Physical from the local community hospital dated 12/19/14 revealed Resident #30's history and present illness "...Her blood glucose was in the 600 prior to EMS arrival. The patient has had similar problems with her blood sugar previously, reportedly the patient is very noncompliant..." The assessment and plan portion of the form revealed "Uncontrolled [MEDICAL CONDITION]. We will check hemoglobin A1c level...the patient is currently not in diabetic ketoacidosis. Blood glucose is now better controlled." Record review of Resident #30 ' s physician's order [REDACTED]. Blood sugar 150-199 1 unit Blood sugar 200-249 3 units Blood sugar 250 - 299 5 units Blood sugar 300-349 7 units Blood sugar 350 and over give 9 units and call medical doctor. Observation on 1/27/15 at 4:50 P.M revealed Resident #30 asleep with her blanket over her head. The resident was on her right side with the head of the bed slightly elevated. Interview on 1/28/15 at 4:35 P.M. LVN #9 stated she was working with the Resident #30 and sent her to the hospital on [DATE] . LVN #9 continued and stated the resident allowed her to do the evening accuchecks ( a finger stick test done at the bedside to monitor blood glucose quickly). The result did not come as a number result it displayed too high to read which indicated her blood sugar result was greater than 600. LVN #9 stated she called the on-call physician and sent the resident to the hospital. Interview on 1/28/15 at 4:55 P.M. LVN # 22 stated she did not call the physician back more frequently after she received the laboratory glucose result because the resident was asleep and was stable. She stated she should have called back more frequently than she did and she should have called the medical director when the doctor did not respond timely. Interview on 1/28/2015 at 11:00 A.M. the DON, after reviewing Resident #30's medical record acknowledge that staff should have notified someone when the doctor did not respond. He acknowledged the new systems and trainings had been put into place to prevent reoccurrence of this type of incident. It was determined that these failures place Resident #30 in an immediately Jeopardy (IJ) situation from 12/16/14 through 12/18/14. The facility took the following action to correct the non-compliance on 1/7/15: 1. The DON and Administrator identified a system problem in the notification and recognizing a change in condition in a resident and presented the problem to the QA committee on 1/7/2015 where the SBAR (Situation, Background, Assessment and Request system) was introduced. Policies and procedures were developed concerning the SBAR and the notification of physicians. 2. DON and Administrator met with the facility physicians on 1/20/15 to discuss improving communication for resident changes in condition. 3. New hired nurse orientation on 1/22/15 included procedures for calling a physician when a resident has a change in condition. The attending physician was to be called every 15 minutes for three times and if no response they were to call the medical director. 4. Facility Nursing staff RN ' s, LVN ' s and CNA ' s were in serviced on 1/23/15 on the SBAR form/system and the calling of the physician/medical director if no response. Identification: Interview on 1/29/15 at 11:54 A.M., the DON explained there was problem communicating with physicians identified immediately after his hire (1/5/2015) by himself and the Administrator and was discussed in the weekly QA meeting. He stated they saw an increase in the number of repeat hospitalization s that may have been prevented if the physician was contacted and notified the resident had a problem and the physician could have intervened to prevent the re-hospitalization . He stated they had a meeting with the physicians and a new communication tool known as the Situation, background, assessment or appearance and request (SBAR) was implemented. The DON stated we began to in-service the staff on 1/22/15 at the new hire orientation and on 1/23/15 to the existing nursing staff regarding the procedure to notify the physician for changes, notify the medical director if they were not able to contact the residents attending physician and the SBAR. The DON stated when he started to work on 1/5/15 there were no systems in place, no in-services were done, and there were no policies for standard of care or for communication of resident changes to the physician. The procedure we use now for notifying the physician is best practice. Interview on 1/29/15 at 12:03 P.M., the Administrator stated she was hired on 12/22/14, but did not begin working at the facility for three weeks after her hire date due to attending training. She stated during her first week at the facility a weekly QA meeting was held on 01/07/15 she and the DON identified a problem with the communication with physicians. She stated they saw a lot of residents going to the hospital repeatedly and identified resident's conditions that should have been assessed by staff and the doctor notified to treat the residents and maybe prevent them from going to the hospital again. She stated she and the DON invited all Residents ' physicians to a meeting to get their input regarding the situation on 01/20/15 and seven doctors, including the two Medical Directors, attended and gave input on remedying this situation. One suggestion, which the DON had already recommended, was using the SBAR as a communication tool between the nurses and the physicians. The Administrator stated this was immediately put in place and all staff were in-serviced on using the SBAR on 1/23/15. The training included the procedure to notify the physician for changes and notifying the medical director if they were not able to contact the resident ' s attending physician. The Administrator stated when she began working in the facility she realized there was no documentation, policies and procedures, or systems in place to address many issues and she and the DON had been creating them and in-servicing staff since this realization. Monitoring by surveyor revealed: 1. Record review of the facility Standards of Care #12 dated January 2015 revealed: The stop and watch early warning tool when the resident first presents with a change of condition. A SBAR communication tool and progress note must be completed upon a change in condition and prior to contacting the physician. A Quality Improvement Tool should be completed for each acute care transfer. The Quality Assurance meeting must include a review of appropriate and timely completion of the Early Warning Report, the SBAR communication tool, transfer form, Quality Improvement Tool and the overall effectiveness based upon readmission rates. 2. Record review of the Early Warning Tool dated January 2015 revealed if a change was identified in a resident the form must be completed and given to a nurse. 3. Record review of the facility SBAR Communication Form and progress notes revealed: Evaluate the resident Check vital signs (blood pressure, heart rate, temperature, respiratory rate, oxygen level in the blood with use of the oximetry and finger stick glucose Review the record (recent progress notes, labs, orders). Have all relevant information available when reporting. 4. Record review of an additional 13 residents for appropriate and timely consultations and the implementation of changes in medical care revealed resident ' s laboratory results and glucose levels . The laboratory result records were initialed as the physician being notified. The glucose levels were below the level of when a physician was to be notified but all were recorded as ordered by the physician and proper amounts of insulin were administered. 5. Interviews with six nursing staff over two shifts on two days concerning effectiveness with recent training's revealed the staff were very knowledgeable concerning when to call the attending physician and to call every 15 minutes up to one hour and if no response to call the medical director. 6. Record review of the new hire orientation conducted on 1/22/15 with nursing staff RNs and LVNs on the SBAR system, notification of the physician in a timely manner and what to do if the attending does not respond revealed 100% of the January 2015 new hires were in serviced. Interview on 1/28/15 between 2:00 PM and 3:00 P.M. new hire nurses # ' s 9 and 16 revealed they received training during their orientation on 1/22/15 regarding calling the physician for changes every 15 minutes up to an hour and if no response call the medical director and the use of the SBAR as a communication tool when calling. 7. Record review of the nursing in-service conducted on 1/23/15 with nursing staff including RNs, LVNs and CNAs (15) regarding calling the physician for changes every 15 minutes up to an hour and if no response call the medical director, the use of the SBAR as a communication tool when calling. 38% of the nursing staff were in serviced on 1/23/15. In-services continued to be conducted during the annual service. No staff interviewed throughout the survey had not been inserviced. Interview on 1/29/15 at 1:45 P.M. DON revealed he monitored compliance by doing the following: Chart checks, 24 hour nursing report, rounds on each nurses station and he received report on every resident who had any change of condition. There was also a stand up meeting at 8:00 A.M. with all department heads for clinical monitoring. He stated he would meet with each 6-2 shift nurse and get a report on all residents, then conducted a stand down meeting at 4:00 P.M. with each 2-10 P.M. shift nurse to do a follow up from the day shift. An informal weekly quality assurance meeting with the department heads weekly and a formal quality assurance meeting including the physicians was done monthly. All monitoring was to be reported during the quality assurance meetings for any recommendations. The DON reported there were 18 residents with diabetes in the facility.

Based on observation, interview and record review, the facility failed to consult with the resident's physician when a change in condition occurred for one of 12 residents (Residents # ' s 30 ) reviewed for residents ' physicians being consulted concerning the resident's care when a change in condition has occurred. Resident # 30 ' s physician was not immediately consulted concerning her 357 milligrams per deciliter (mg/dL) critical level blood glucose results which was reported from the laboratory to LVN #14 on 12/16/14, the residents consistent refusal for blood sugars to be monitored and the administration of insulin. The resident was transferred to the hospital with a blood glucose over 600 two days later on 12/18/14. This was determined to be a past noncompliance immediate Jeopardy (IJ) due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure affected one resident who required acute care treatment at a hospital due to an untreated elevated blood sugar, and placed 17 residents with diabetes at risk of harm of deterioration of health due to their physician not being consulted. Findings include: Resident #30 Record review of Resident #30 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The resident ' s admission [DIAGNOSES REDACTED]. Record review of Resident #30 ' s MDS assessment dated [DATE], revealed a BIMS score of 13 out of 15 indicating the resident was cognitively intact. She required extensive assistance for transfers and mobility, dressing and hygiene. The MDS also identified that Resident #30 exhibited rejection of care behavior one to three days of the 7 day assessment period. Record review of the resident ' s care plans title " Potential for fluctuation of blood sugar related to [DIAGNOSES REDACTED]. Continued review revealed the following interventions: notify physician and family, accucheck before meals and bedtime as ordered, administer sliding scale insulin as ordered and if blood glucose is greater than 350 give 9 units of insulin and notify physician, administer standing bedtime insulin as ordered. Observation on 1/26/15 at 8:55 A.M. during initial tour revealed Resident #30 in bed awake and eating breakfast. The resident would not engage in communication at that time. Record review of the resident ' s MAR and physician's orders [REDACTED]. The orders were Blood sugar 150-199 1 unit, Blood sugar 200-249 3 units, Blood sugar 250 - 299 5 units, Blood sugar 300-349 7 units. Review of the same MAR revealed that 9 units of insulin should be given and the physician notified if the resident ' s blood glucose level is greater than 350. Continued review revealed the resident had an accucheck completed on 12/3/14, 12/5/14 at 11:30 A.M. and 12/18/14 at 8:00 P.M. and the resident refused all other accuchecks scheduled from 12/1/14 to 12/18/14. On 12/18/14 resident was discharged to hospital. Record review of the MAR revealed on 12/3/2014 Resident #30 ' s blood sugar per the accucheck was 128. Resident #30 ' s blood sugar on 12/5/2014 per the accucheck was 104. Resident #30's blood sugar documented on the MAR for 12/18/2014 revealed a blood sugar over 600. Record review of Laboratory results revealed the specimen was collected on 12/15/14 at 8:10 (no A.M. or P.M. noted) dated 12/16/14 at 2:01 (no A.M. or P.M. noted) revealed Resident #30's glucose was 357mg/dL with the expected normal range of 70-110. "...Critical value called to (LVN #14) at 1:26 A.M." Record review of Resident #30 ' s nurse ' s notes dated 12/16/14 at 1:50 A.M. revealed " Reviewed call from lab stating res (resident) glucose is 357, critical lab called in to (Dr. #1), awaiting call back. Res usually refuses B/S (blood sugar) check/insulin. Will continue to monitor " (LVN # 22). Record review of the Resident #30 ' s nurse ' s notes dated 12/16/14 at 4:30 A.M. revealed " paged (Dr #1) earlier on, regarding critical lab for res, but no call back. Spoke to on call services and promised to relay the message. Glucose from lab is 357, res is stable and has a history of refusing B/S check and insulin " (LVN #22). Record review of the Resident #30 ' s nurse ' s notes dated 12/16/14 at 6:00 A.M. revealed " Received report abn (abnormal) lab result. Pending Dr. return call. Blood glucose lab is 357. Resident has been refusing blood glucose check daily. Family has been notified previously and physician aware " ... (LVN #1). Record review of the nurse ' s notes dated 12/16/14 at 6:38 A.M. revealed the Resident #30 refused to have her blood sugar tested . Continued review revealed no return call from the physician. (LVN #1) Record review of Resident #30's nurse ' s notes documented by LVN #1 dated 12/16/14 at 7:45 A.M. revealed the resident refused her blood sugar test. The record did not reveal the physician was notified. Record review of Resident #30 ' s nurse ' s notes written by LVN #1 dated 12/16/14 at 8:30 A.M. revealed " (family member) in room visiting pt (resident). Approached Res (resident) to offer medications and request to do accucheck at this time. This LVN asked resident May we do your blood sugar check? (family member) responded we don ' t do that. She doesn ' t have to do that. " I asked if he was aware that she has to have BS (blood sugar) checked in order to give the sliding scale insulin. (family member) responded " yes but if she doesn ' t want it, she doesn ' t have to. " Record review of Resident #30 ' s nurse ' s note written by LVN #1 dated 12/16/2014 at 9:15 A.M. " Call to Dr (#1) regarding panic level glucose for 12/16/14 ( from speciman collected 12/15/2014) and abnormal U/A (urine analysis) pending culture and sensitivity. Call resident ' s (family member) to inform of critical lab results of 12/15/14 (called to facility on 12/16/2014). Responded he was not aware of those results. Updated him that critical lab results revealed BS of 357. (Family member) responded " well, now give her insulin according to those results " Explained to (family member) that BS can change and her BS may not be at 357 but resident is refusing her BS at this time and I would be notifying Physician and would continue to encourage resident to allow us to monitor her BS and would greatly appreciate him also encouraging resident to cooperate with BS monitoring during his visits and was communicating and updating him on her condition. (Family member) verbally acknowledged and thanked this LVN." Continued review did not reveal the physician returned the call. Record review of Resident #30's nurse ' s notes dated 12/17/14, not timed, revealed the resident refused her blood glucose monitoring. Continued review revealed a call was placed to Dr #1 for confirmation of receipt of laboratory results received in the office and pending physician review. (LVN #1) Record review of the resident ' s MAR dated 12/1/14 to 12/31/14 revealed the resident ' s bedtime [MEDICATION NAME] 25 units was to be given every night at bedtime (8:00 P.M.)and the resident refused this insulin on 12/6/14 and 12/17/14. Record review of Resident #30's nurse ' s notes dated 12/18/14, not timed, revealed the resident continued to refuse her blood sugar and insulin. Continued review revealed a call was placed to Dr#1's offices and LVN #1 spoke with an office staff who informed the nurse that Dr #1 would call back after reviewing the abnormal labs. Continued review of the nurse ' s notes revealed a message was also left that the resident continued to refuse her blood glucose monitoring and insulin. Record review of Resident #30's clinical record revealed no other nurse ' s notes regarding the resident ' s blood sugar or physician notification until the transfer form on 12/18/2014 was completed. Record review of Resident #30 ' s clinical record Resident Transfer Form dated 12/18/14, untimed, revealed Resident #30 was transferred to a local community hospital with a blood glucose greater than 600. Record review of Resident #30's History and Physical from the local community hospital dated 12/19/14 revealed Resident #30's history and present illness "...Her blood glucose was in the 600 prior to EMS arrival. The patient has had similar problems with her blood sugar previously, reportedly the patient is very noncompliant..." The assessment and plan portion of the form revealed "Uncontrolled [MEDICAL CONDITION]. We will check hemoglobin A1c level...the patient is currently not in diabetic ketoacidosis. Blood glucose is now better controlled." Record review of Resident #30 ' s physician's order [REDACTED]. Blood sugar 150-199 1 unit Blood sugar 200-249 3 units Blood sugar 250 - 299 5 units Blood sugar 300-349 7 units Blood sugar 350 and over give 9 units and call medical doctor. Observation on 1/27/15 at 4:50 P.M revealed Resident #30 asleep with her blanket over her head. The resident was on her right side with the head of the bed slightly elevated. Interview on 1/28/15 at 11:00 A.M. DON stated the nurses should contact the Medical Director if they do not get a response from the resident ' s attending. He stated we have two Medical Directors. After the DON reviewed the laboratory glucose results and the nurse ' s notes he stated Nurse #22 should have called the Medical Director. He stated the new system should prevent this problem from going forward. Interview on 1/28/15 at 4:35 P.M. LVN #9 stated she was working with the Resident #30 and sent her to the hospital on [DATE] .LVN #9 continued and stated the resident allowed her to do the evening accuchecks ( a finger stick test done at the bedside to monitor blood glucose quickly). The result did not come as a number result it displayed too high to read which indicated her blood sugar result was greater than 600. LVN #9 stated she called the on-call physician and sent the resident to the hospital. Interview on 1/28/15 at 4:55 P.M. LVN # 22 stated she did not call the physician back more frequently after she received the laboratory glucose result because the resident was asleep and was stable. She stated she should have called back more frequently than she did and she should have called the medical director when the doctor did not respond timely. It was determined that these failures place Resident #30 in an immediately Jeopardy (IJ) situation from 12/16/14 through 12/18/14. The facility took the following action to correct the non-compliance on 1/7/15: 1. The DON and Administrator identified a system problem in the notification and recognizing a change in condition in a resident and presented the problem to the QA committee on 1/7/2015 where the SBAR (Situation, Background, Assessment and Request system) was introduced. Policies and procedures were developed concerning the SBAR and the notification of physicians. 2. DON and Administrator met with the facility physicians on 1/20/15 to discuss improving communication for resident changes in condition. 3. New hired nurse orientation on 1/22/15 included procedures for calling a physician when a resident has a change in condition. The attending physician was to be called every 15 minutes for three times and if no response they were to call the medical director. 4. Facility Nursing staff RN ' s, LVN ' s and CNA ' s were in serviced on 1/23/15 on the SBAR form/system and the calling of the physician/medical director if no response. Identification: Interview on 1/29/15 at 11:54 A.M., the DON explained there was problem with communicating with physicians identified immediately after his hire (1/5/2015) by himself and the Administrator and was discussed in the weekly QA meeting. He stated they saw an increase in the number of repeat hospitalization s that may have been prevented if the physician was contacted and notified the resident had a problem and the physician could have intervened to prevent the re-hospitalization . He stated they had a meeting with the physicians and a new communication tool known as the Situation, background, assessment or appearance and request (SBAR) was implemented. The DON continued we began to in-service the staff on 1/22/15 at the new hire orientation and on 1/23/15 to the existing nursing staff regarding the procedure to notify the physician for changes, notify the medical director if they were not able to contact the residents attending physician and the SBAR. The DON stated when he started to work on 1/5/15 there were no systems in place, no in-services were done, and there were no policies for standard of care or for communication of resident changes to the physician. The procedure we use now for notifying the physician is best practice. Interview on 1/29/15 at 12:03 P.M., the Administrator stated she was hired on 12/22/14, but did not begin working at the facility for three weeks after her hire date due to attending training. She stated during her first week at the facility a weekly QA meeting was held on 01/07/15 she and the DON identified a problem with the communication with physicians. She stated they saw a lot of residents going to the hospital repeatedly and identified resident's conditions that should have been assessed by staff and the doctor notified to treat the residents and maybe prevent them from going to the hospital again. She stated she and the DON invited all Residents ' physicians to a meeting to get their input regarding the situation on 01/20/15 and seven doctors, including the two Medical Directors, attended and gave input on remedying this situation. One suggestion, which the DON had already recommended, was using the SBAR as a communication tool between the nurses and the physicians. The Administrator stated this was immediately put in place and all staff were in-serviced on using the SBAR on 1/23/15. The training included the procedure to notify the physician for changes and notifying the medical director if they were not able to contact the resident ' s attending physician. The Administrator stated when she began working in the facility she realized there was no documentation, policies and procedures, or systems in place to address many issues and she and the DON had been creating them and in-servicing staff since this realization. Monitoring by surveyor revealed: 1. Record review of the facility Standards of Care #12 dated January 2015 revealed: The stop and watch early warning tool when the resident first presents with a change of condition. A SBAR communication tool and progress note must be completed upon a change in condition and prior to contacting the physician. A Quality Improvement Tool should be completed for each acute care transfer. The Quality Assurance meeting must include a review of appropriate and timely completion of the Early Warning Report, the SBAR communication tool, transfer form, Quality Improvement Tool and the overall effectiveness based upon readmission rates. 2. Record review of the Early Warning Tool dated January 2015 revealed if a change was identified in a resident the form must be completed and given to a nurse. 3. Record review of the facility SBAR Communication Form and progress notes revealed: Evaluate the resident Check vital signs (blood pressure, heart rate, temperature, respiratory rate, oxygen level in the blood with use of the oximetry and finger stick glucose Review the record (recent progress notes, labs, orders). Have all relevant information available when reporting. 4. Record review of an additional 13 residents for appropriate and timely consultations and the implementation of changes in medical care revealed resident ' s laboratory results and glucose levels . The laboratory result records were initialed as the physician being notified. The glucose levels were below the level of when a physician was to be notified but all were recorded as ordered by the physician and proper amounts of insulin were administered. 5. Interviews with six nursing staff over two shifts on two days concerning effectiveness with recent training's revealed the staff were very knowledgeable concerning when to call the attending physician and to call every 15 minutes up to one hour and if no response to call the medical director. 6. Record review of the new hire orientation conducted on 1/22/15 with nursing staff RNs and LVNs on the SBAR system, notification of the physician in a timely manner and what to do if the attending does not respond revealed 100% of the January 2015 new hires were in serviced. Interview on 1/28/15 between 2:00 PM and 3:00 P.M. new hire nurses # ' s 9 and 16 revealed they received training during their orientation on 1/22/15 regarding calling the physician for changes every 15 minutes up to an hour and if no response call the medical director and the use of the SBAR as a communication tool when calling. Interview with the Staffing Educator on 01/28/15 at 2:15 P.M. revealed she gave an in-service training on using the SBAR and notifying physicians of a Resident's change in condition on 01/23/15. She stated staff were trained to notify the physician immediately for any changes in condition and if the physician did not call back within 30 minutes, they were to call the physician again. If the physician did not return that call within 15 minutes, the staff were to call one of the two Medical Directors. The Staffing Educator stated staff should not wait any longer than 1 hour to notify a Medical Director of a change in condition. 7. Record review of the nursing in-service conducted on 1/23/15 with nursing staff including RNs, LVNs and CNAs (15) regarding calling the physician for changes every 15 minutes up to an hour and if no response call the medical director, the use of the SBAR as a communication tool when calling. 38% of the nursing staff were in serviced on 1/23/15. In-services continued to be conducted during the annual service. No staff interviewed throughout the survey had not been inserviced. Interview on 1/29/15 at 1:45 P.M. DON revealed he monitored compliance by doing the following: Chart checks, 24 hour nursing report, rounds on each nurses station and he received report on every resident who had any change of condition. There was also a stand up meeting at 8:00 A.M. with all department heads for clinical monitoring. He stated he would meet with each 6-2 shift nurse and get a report on all residents, then conducted a stand down meeting at 4:00 P.M. with each 2-10 P.M. shift nurse to do a follow up from the day shift. An informal weekly quality assurance meeting with the department heads weekly and a formal quality assurance meeting including the physicians was done monthly. All monitoring was to be reported during the quality assurance meetings for any recommendations. The DON reported there were 18 residents with diabetes in the facility.