Every finding on record at Avir at Orem

Based on interview and record review the facility to ensure each resident was free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 6 residents (CR #1 and CR #2) reviewed for abuse. The facility failed to protect CR #1 from sexual abuse by CR #2 on 8/15/2026. CR #2 entered CR #1's room while she was sleeping, touched her vaginal area, and placed her hand on his genitals. CR #1 was subsequently transferred to the hospital for a sexual assault assessment. The noncompliance was identified as Past Non-Compliance. The IJ began on 08/15/2026 and ended on 08/16/2026. The facility corrected the non-compliance before the survey began. This failure placed the resident at risk for physical and psychological harm, emotional distress, and trauma. Findings included: Record review of CR #1's face sheet dated 8/18/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged to the hospital on 8/16/2026. Her diagnoses included: Alzheimer's disease (a progressive brain disorder and the most common cause of dementia), legal blindness, and hearing loss, polyneuropathy (a medical condition where multiple peripheral nerves throughout the body malfunction at the same time), epilepsy (a long-term brain disorder that causes repeated, sudden seizures), lack of coordination, and muscle weakness. Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. Further review of the MDS revealed she required max assist with all ADLs and was dependent on staff. Record review of CR #1's care plan initiated on 8/15/2026 and revised on 8/17/2026 revealed a focus area of a Resident noted standing over CR #1 while in bed holding her hand with pants hanging down. Further review of care plan revealed interventions to move resident found in room to different area from other residents and send CR #1 out to ER for evaluation. Record review of CR #1's progress notes dated 8/15/2026 at 10:30pm by RN A revealed, This writer was notified by a CNA that another resident was in resident's room. RP was notified about the incident. RP later called back and said she was coming over to the facility. RP arrived and said she was calling 911 and police to report sexual assault. This writer called DON and Administrator/abuse coordinator to notify them of incident. 911 crew came and picked up resident to hospital, resident was alert and oriented at baseline and in no distress at the time of transfer, she was accompanied by her RP. MD notified. Record review of CR #2's face sheet dated 8/18/2026 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged to the hospital on 8/16/2026. His diagnoses included: Parkinson's disease (a movement disorder of the nervous system that worsens over time), acute kidney failure (the sudden loss of kidney function), lack of coordination, and cognitive communication deficit (a breakdown in communication caused by disrupted thinking skills rather than a problem with the physical ability to speak or basic language knowledge). Record review of CR #2's quarterly MDS dated [DATE] revealed a BIMS score of 11 out of 15 indicating moderate cognitive impairment. Further review of the MDS revealed no behaviors present and he could ambulate with a walker. Record review of CR #2's care plan initiated on 8/15/2026 and revised on 8/17/2026 revealed a focus area of, CR #2 has a behavior problem related to inappropriate sexually behavior. The care plan interventions included: Move resident to different area with all males and send resident out to psych hospital for evaluation. Record review of CR #2's progress notes dated 8/15/2026 at 10:32pm by RN A revealed, Per CNA assigned, at 10:18pm, he was found in room [ROOM NUMBER], with his pants down and holding the left hand of the resident in the room. Resident was redirected out and asked what he was doing there? He was unable to explain. Resident redirected to his room, assisted back to bed at this time, will continue to monitor. Record review of CR #2's SBAR dated 8/16/2026 at 4:08am by RN A revealed the nursing observations, evaluation, and recommendations were, Resident was Sexually inappropriate with a fellow resident, and the Primary Care Provider feedback was to send out for evaluation. Interview on 8/17/2026 at 1:13pm, CR #1's RP said the night of 8/15/2026 she received a call from the facility nurse around 10:30pm stating another resident was found in CR #1's room and the staff were not sure what happened. The RP said the footage from CR #1's room camera was checked, and it showed another male resident come into her room and sexually assault her. The RP said CR #1 was sleeping and after the male resident began touching on her, it caused her to awaken. The RP said the video showed her trying to fight him off and was calling out for a doctor. The RP said the male resident opened CR #1's brief and he could be seen touching on her vaginal area and putting his fingers inside her. The RP said at some point the male resident got on top of CR #1 and raped her. The RP said they could not tell for sure on the video if when he was on top of CR #1, he was able to actually penetrate her but said she could be seen trying to push him away. The RP said after seeing this footage she immediately went up to the facility and called the police. She said when she got to the facility she was so upset over what she had seen and told the staff when she arrived she was pressing charged because the male resident who went into her room and sexually assaulted her. The RP said the police and EMS arrived to the facility shortly after she did where she gave a statement to the police and CR #1 was taken to the hospital to have a sexual assault assessment completed. The RP said both she and CR #1 were traumatized from the situation. The RP said CR #1 was cognitively impaired and would not be able to say what happened the night of 8/15/2026 but said it was evident that she would not want to be wakened up out of her sleep, and sexually assaulted. The RP became tearful expressing that CR #1 was blind and very hard of hearing and felt in the moment CR #1 knew she was being sexually assaulted and was frightened. The RP said the video showed the male resident enter CR #1's room at 10:07pm and showed the CNA open the door and come into the room at 10:23pm. The RP said the hospital had completed a sexual assault assessment on CR #1 but the results were still pending, however, in the meantime the hospital started her on antibiotics in case she was exposed to any sexual transmitted infections during the assault. The RP said they were looking for a different facility placement for CR #1 because they did not want her to return to the facility. The RP felt the male resident had been watching and planning to assault CR #1 because CR #1 usually had a roommate but had been without one for almost a month when the assault happened. The RP denied finding any other concerning footage and felt this was the first occurrence of the assault. Record review of CR #1's room camera footage provided by RP on 8/17/2026 at 5:15pm from the night of 8/15/2026 revealed CR #2 walking into CR #1's room while she was sleeping in bed. CR #2 proceeded to stand over CR #1 while she was sleeping in bed. CR #2 then picked up CR #1's hand and placed it inside his shorts and moved her hand back and forth over his genitals. The room camera footage also showed CR #2 pulling CR #1's bed covers off of her while she appeared to be still sleeping and touching on her vaginal area outside of her brief and then eventually opening her brief up and sticking his fingers in her vaginal area. At this time in the video, CR #1 awakens and attempts to push his hands away, tries to pull her covers back up and hits him on the shoulder. CR #1 could be heard yelling out and said, what are you doing in here. CR #2 grabbed her wrist and moved her hands back towards his genitals and proceeded to hold her hand there why he continued to touch her vaginal area with his other hand. Interview on 8/17/2026 at 1:50pm, CNA A said she came in to work the night shift on 8/15/2026 around 10:00pm. She said she was not the assigned CNA to the hall where CR #1 and CR #2 resided (600 hall) but she went down that hall to answer a call light that was on to help out CNA B who was assigned to the 600 hall. CNA A said while walking down the hall she noticed CR #1's door was closed which she felt was odd because they always kept it open to keep an eye on her for fall risk. CNA A said she knocked on the door and opened it, she found CR #2 standing next to CR 1's bed holding her hand with his pants hanging down. CNA A said she immediately said, why are you in here to CR #2 but he did not respond and quickly walked out the room past her and into his room across the hall. CNA A said when she opened the door CR #1 was laying in bed on her side and appeared to have her covers pulled up. She said she was awake and heard her mumbling words to CR #2 when she opened the door but could not make out what she said. CNA A said she immediately went to the nurse's station and told RN A what she saw and went back to CR #2's room where she observed him go into the bathroom in his room. CNA A said RN A and LVN A immediately went down to CR #1's room to check on her but she did not go in with them and stayed by CR #2's room. CNA A said CR #2 was Spanish speaking but he also understood and spoke some English. CNA A said CR #2 never did voice what he was doing in the room and would not answer her when she asked. CNA A denied ever observing any type of behaviors from CR #2 and said he usually stayed to himself and would walk around the facility using his walker but denied him ever going into other residents' rooms. CNA A said CNA B eventually showed up and she took over watching over CR #2. CNA A said she knew that CR #1's RP showed up to the facility later that night but said she was taking care of the residents she was assigned to on another hall, so she was not sure what transpired when the RP showed up. CNA A said she did know that the police ended up showing up and CR #1 was brought to the hospital. Phone interview on 8/17/2026 at 2:27pm, RN A said she worked the 6pm - 6am shift of 8/15/2026 and CR #1 and CR #2 were her assigned residents. RN A said she recalled providing care to a resident next door to CR #1 around 9:30pm and when she left out the next door residents room, she saw both CR #1 and CR #2 in their rooms laying in bed. RN A said the CNAs had shift change at 10:00pm and shortly after she recalled CNA A coming to tell her and LVN A that she had just found CR #2 in CR #1's room holding her hand with his pants down. RN A said she and LVN A immediately went down to CR #1's room and found her sleeping in bed with her covers pulled up over her. RN A said they pulled her covers back and found that one side of her brief was undone. RN A said she pulled back her brief to look inside and noticed there was a small amount of feces in the brief so she closed the brief back. RN A said she noticed a small blood smear on the side of the bed but it was not near CR #1. RN A said she presumed that the blood spot came from CR #2's leg because he had multiple lesions on his legs that would sometimes bleed and had he leaned on the side of her bed, it would have left a blood spot where they found it. RN A said CR #1 continued to sleep when they checked on her, so they left the room and went across the hall to CR #2's room where they found him washing his hands in the bathroom. RN A said they questioned him about what he was doing in CR #1's room but he acted like he did not understand and laid down in his bed. RN A said she then called CR #1's RP to inform her of what happened. RN A said the RP asked her what CR #2 was doing in the room and she responded that she did not know and what they saw was all the information they knew. RN A said the RP hung up and said she was going to check the room camera to see what happened. RN A said shortly after they talked on the phone the RP showed up to the facility upset stating she was pressing charges and had called the police because CR #1 was sexually assaulted. RN A said she immediately called the Administrator and the DON to let them know what the RP reported she saw on the room camera. RN A said at some point the RP showed her one short clip of the room camera that showed CR #2 standing over CR #1 in bed and he had his hand in her brief touching her vaginal area. RN A said CR #2 stayed in his room when the RP showed up and it was not until CR #1 was taken by EMS to the hospital that CR #2 came out of his room and the CNAs had to follow him around and redirect him back to his room. RN A said CR #2 became combative with the staff about not letting him walk around the facility and the police had to intervene and put him in hand cuffs. RN A said the police remained at the facility for several hours and brought in a translator to question CR #2. RN A said the police ultimately decided not to take CR #2 into custody and he remained in the facility for a few more hours with one-on-one supervision until he was able to be transported to the hospital to be evaluated. RN A said CR #2 would sometimes become frustrated when trying to redirect him because there was a language barrier but denied him ever having aggressive or sexual behaviors. RN A said CR #2 often walked with his walker around the facility in the halls, but they never had issues with him going into other residents' rooms. Phone interview on 8/17/2026 at 3:10pm, CNA B said she got to work around 10:20pm on 8/15/2026 and shortly after her arrival she went straight into doing rounds. CNA B said as she was going down 600 hall, she saw staff redirecting CR #2 to his room, but she did not know what had happened with him and CR #1 yet. CNA B said she went in to check on CR #1 and said she could smell she had a bowel movement. CNA B said she left the room to get supplies and came back to CR #1's room to change her. CNA B said she did not notice anything out of the ordinary while changing her such as her vaginal area having any signs of irritation. CNA B said she did notice the blood stain on the side of her sheets and was not sure where it came from. CNA B said she also changed the bed linen. CNA B said when she came out of the CR #1's room, CNA A was there in front of CR #2's room and told her what she had observed regarding finding CR #2 in CR #1's room. CNA B said she was told the nurses were aware and was contacting CR #1's RP to check the room camera to see what happened. CNA B said shortly after CR #1's RP showed up to the facility upset yelling that she was pressing charges and she was calling the police. CNA B denied speaking with the RP but said the cops did show up to the facility and the RP requested CR #1 be taken to the hospital for evaluation. CNA B said CR #1 was taken to the hospital via EMS and the police stayed at the facility for a long time gathering statements and asked her to bag the brief and sheets she had removed from CR #1's room which she provided. CNA B said after CR #1 left with EMS and the RP left, CR #2 attempted to come out of his room and walk around. She said she and CNA A had to follow him around and redirect him back to his room. CNA B said CR #2 became combative and tried pushing her and swinging at her so he could leave the room which made the police intervene and eventually resulted in them placing him in handcuffs. CNA B said after a while another CNA showed up to sit with CR #2 one on one until he was eventually transferred to the hospital. CNA B said this behavior was unusual for CR #2 and denied him ever being combative with her or having a hard time redirecting him. CNA B said she never saw or heard of CR #2 having sexual behaviors and stated he usually walked around the facility and stayed to himself in his room. Phone interview on 8/17/2026 at 4:17pm, LVN A said she worked 6pm - 6am on 8/15/2026 but she was not assigned to CR #1 or CR #2. LVN A said she recalled CNA A coming up to her and RN A stating she found CR #2 in CR #1's room. LVN A said she went with RN A down to CR #1's room and observed her in bed sleeping. LVN A said the covers were pulled up over CR #1's body when they went in the room so they had to pull back her covers to look at her body. LVN A said CR #1's brief was open on one side and she had a bowel movement inside her brief. LVN A said she heard RN A observed blood on the CR #1's sheets but she did not see it. LVN A said they went to CR #2's room to check on him and she saw him washing his hands in the bathroom. LVN A said RN A tried asking him what he was doing in CR #1's room but he would not answer. LVN A said RN A called CR #1's RP so she could check the room camera. LVN A recalled that the RP showed up to the facility upset and called the police saying CR #1 was sexually assaulted. LVN A said she only saw one video clip the RP had that showed CR #2 grabbing CR #1's hands and putting it down his pants. LVN A said after CR #1 left to go out to hospital and the RP left CR #2 began trying to wander around the facility and became combative trying to kick the CNA. LVN A said she knew the police had to intervene and had him in hand cuffs. LVN A said she was surprised by CR #2's actions because he usually slept through the night and did not get up once it got late. LVN A said she had never witnessed CR #2 be aggressive before or have any type of behaviors. Phone interview on 8/17/2026 at 4:38pm, CR #2's MD said he was surprised to hear what had happened between CR #1 and CR #2 because CR #2 had no history of any type of behaviors or being sexually inappropriate. The MD said CR #2 had Parkinson's disease but had no mental health diagnoses or mental health medications to manage behaviors. The MD said he had talked to the hospital where CR #2 was sent to and they reported they only found that he may have been a little dehydrated but had not found anything else clinically going on with him. Interview on 8/17/2026 at 6:06pm, the Administrator and DON said they were notified the night of 8/15/2026 regarding CR #2 being found in CR #1's room and the RP alleging CR #1 was sexually assaulted. They stated both of them came up to the facility that night, but the DON had arrived first. They stated the police stayed in the facility several hours investigating and had CR #2 in handcuffs. The Administrator said it was unclear throughout that time the police were there if they were going to take CR #2 into custody but said after a few hours of waiting the police told them they were not going to take him. The Administrator said the police almost insisted that CR #2 was not being arrested but they could not let him remain in the facility. The Administrator said they had to explain to the police that they would try to get him out of the building, but they were still responsible for his safety and were not able to just put him out of the building. The Administrator and the DON explained that EMS refused to take CR #2 to the hospital because he stated he did not want to go and they said they would not take him since he voiced not wanting to go and left. The DON said they had to call another medical transport company to come out that agreed to transport him to the hospital. The DON said while they waited for the transport to arrive CR #2 was moved to another side of the facility and a CNA stayed with him one on one. Both the Administrator and the DON said they had requested to see the room camera footage, but the police stated they were not able to show them and the RP had not provided them with the video footage. The DON and Administrator stated both CR #1 and CR #2 had been residents at the facility for several years and was upset this had happened. They stated the two residents never had interactions before and CR #2 had no prior behaviors that would indicate he would do something like that. The DON said during their investigation they looked for any signs or reasoning of why CR #2 would suddenly behave that way he did but had not come up with any answers. The DON said the same night of the incident they gathered statements from the staff and began in-services of abuse and neglect, inappropriate sexual behaviors, resident rights, resident to resident altercations, and sexual abuse. The Administrator added they completed safe surveys with residents in the facility with no negative findings and also completed abuse and neglect quizzes with the staff. The Administrator said he had been in contact with the RP since the incident and he did not feel they wanted CR #1 to return to the facility. The Administrator also said CR #2 was still in the hospital and they were not going to admit him back into the facility. The Administrator said their Social Worker was working with the hospital and CR #2's RP to find him a different placement. Interview on 8/18/2026 at 10:07pm, CR #2's psychiatrist said he had heard a little about what happened with CR #2. The psychiatrist said this was surprising behavior because CR #2 had no prior behaviors that he knew of. The psychiatrist said CR #2 had Parkinson's disease and said when Parkinson's reaches the most advanced stage, patients could develop what was called Parkinson's psychosis in which the disease begins to affect their behavior. The psychiatrist said this was usually not something that suddenly happened but said it was possible. The Psychiatrist said he does not know if this is why CR #2's behavior suddenly changed but said since he was at the hospital they would hopefully be able to evaluate him and determine if his Parkison's had advanced to Parkinson's psychosis. Record review of the facility Resident to Resident Altercation policy (Revised September 2022) revealed in part, .All altercations including those that may represent resident to resident abuse, are investigated and reported to the nursing supervisor, the director of nursing service and to the administrator. 1. Facility staff monitor residents for aggressive /inappropriate behaviors towards other residents, family members, visitors, or to the staff. Record review of the facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy (Revised April 2021) revealed in part, .Resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat residents symptoms. Record review of the facility Recognizing Signs and Symptoms of Abuse/Neglect policy (Revised April 2021) revealed in part, .All types of resident abuse, neglect, exploitation or misappropriation of resident property are strictly prohibited. Sexual Abuse is defined as non-consensual sexual contact of any type with a resident. c. Signs of sexual abuse. (4) Torn, stained or bloody underclothing. The noncompliance was identified as Past Non-Compliance. The IJ began on 08/15/2026 and ended on 08/16/2026. The facility corrected the non-compliance by: Separated both residents involved and both were sent to hospital for medical evaluation on 8/15/2026 RP of both residents were notified and physicians were notified on 8/15/2026 Gathered statements from all staff members involved in the incident on 8/15/2026 Held a QAPI meeting regarding the abuse of CR #1 on 8/16/2026 Conducted safe surveys with residents on 8/16/2026 Started in-services with all staff over: abuse and neglect, inappropriate sexual behaviors, resident rights, resident to resident altercations, and sexual abuse on 8/16/2026 Conducted abuse/neglect quizzes with staff on 8/16/2026 Record review revealed the above interventions were completed from 8/15/2026 - 8/16/2026. Interviews on 8/17/2026 and 8/18/2026 with night shift staff RN A, CNA A, CNA B, LVN A and day shift staff LVN B, CNA C, CNA D and a Restorative Aide revealed they were knowledgeable over in-service topic noted above. On 08/18/2026 at 2:31pm, the facility Administrator was notified of past noncompliance IJ. An IJ template was provided to the Administrator via email.

Based on record review and interview, the facility failed to transmit accurate, encoded, complete MDS assessments to the CMS system within 13 days for 4 of 18 residents records reviewed for MDS transmission (Residents # 2, 6, 13). -The facility failed to ensure that Resident #2's, annual MDS assessment dated [DATE] was transmitted within 14 days -The facility failed to ensure that Resident #6's, annual MDS assessment dated [DATE] was transmitted within 14 days -The facility failed to ensure that Resident #13's, annual MDS assessment dated [DATE] was transmitted within 14 days These failures put residents at risk of not having their assessments completed timely which could result in denial of services or denial of payment for services. Findings included: Record review of Resident #2's face sheet dated 06/02/26 revealed Resident # 2 was admitted to the facility on [DATE]. His diagnoses included the End stage renal diseases (Organs lose ability to filter waste), type 2 diabetes body inability to process glucose), essential hypertension (high blood pressure), muscle weakness and unsteady feet . Record review of Resident #6's annual MDS with ARD date of 04/14/26 was signed as completed on 05/05/26 which was 25 days after the ARD date. -Review of Resident #6's face sheet, dated 06/03/26, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included Demetia (a group of symptoms affecting memory, thinking and social abilities), psychotic disturbance, mood disturbance, depression, and essential hypertension (primary). Record review of Resident # 6's MDS assessment dated [DATE] revealed the MDS was completed on 05/17/26 which was 21 days after the ARD date. -Record review of Resident #13's Record review of Resident #13's face sheet, dated 06/03/26 revealed Resident #13 was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included post-traumatic stress disorder (witness to a traumatic or threatening event), developmental disability, muscle wasting, abnormal gait and mobility, anxiety disorder and communicative deficit (lack of communication). Record review of Record review of Resident # 13's MDS assessment dated [DATE] revealed the MDS was completed on 10/15/25 which was 20 days after the ARD date. Record review of Resident #13's annual MDS with ARD date of 04/14/26 was signed as completed on 05/05/26 which was 25 days after the ARD date. Interview with the MDS Coordinator on 6/4/26 at 3:00PM, he said He was new to the position and had been trying to work on all the late MDS. He said he had just got a helper that would assist him in completing the MDS. HE said the facility followed the RAI manual. Record review of the facility policy on resident assessment, revised March 2022, referring to the RAI manual, revealed, in part: .a comprehensive assessment of every resident's needs is made at intervals designated by OBRA requirements.OBRA required assessments are federally mandated and must be performed on all residents of Medicare and/or Medicaid certified nursing homes.

Based on observations, interviews, and record review, the facility failed to store, prepare and distribute food in accordance with professional standards for food safety in that - The facility failed to ensure that the vVent hood above the stove was free of grease build up. The facility failed to ensure that frozen meat was properly thaw under running These failures placed residents at risk of foodborne illness and accident. Findings included: Kitchen observation, and interview with the Dietary Manager on 06/02/26 at 8:30am, revealed Dietary Aide K washing her hands in one side of 2 compartment sink and on the other side were 2-10lbs of frozen grand ground beef was in a pan of standing water. During an interview theThe Dietary Manager said the staff was supposed to wash her hands in one of the handing washing sink in the kitchen and not in the food preparation sink. She said all frozen food was are supposed to be thawed in a bowl under running water to prevent bacteria growth. Observation of the vent hood above the stove and interview with the Dietary Manager, revealed the vent hood was coated with grease build up. Review of the cleaning schedule that was posted on the side of the vent hood, revealed the last time the vent hood was clean was in December of 2025 and was scheduled to be clean in March of 2026. The Dietary Manager said the cleaning company did not show up as scheduled. She said the Administrator was aware of the grease built up. She said the grease build up was a fire hazard. During an interview with the Administrator on 06/02/26 at 4:00PM, he said the vent hood was supposed to be clean in March, but the company did not show up for the cleaning, and he had tried to contact them but no show. He said he was aware of the situation, and he hopes hoped they would come this weekend 06/05/26 to do the cleaning Record review of facility's policy dated 2001 and revised 11/2022- revealed :policy statement: Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices Food Preparation Area. 4. Appropriate measures are used to prevent cross contamination. These include:d. cleaning and sanitizing work surfaces (including cutting boards) and food-contact equipment between uses, following food code guidelines.5. Handwashing sinks are located near food preparation and clean dish areas and are separate from ware washing sinks. Thawing Frozen Food1. Foods are not thawed at room temperature. Appropriate thawing procedures include:a. thawing in the refrigerator in a drip-proof container.b. completely submerging the item in cold running water (70 F or below) that is running fast enough to agitate and remove loose ice particles.c. thawing in a microwave oven and then cooking and serving immediately; ord. thawing as part of a continuous cooking process

Based on interviews and record review, the facility failed did not implement policies and procedures to ensure the resident's medical record includes documentation of receiving or refusal of influenza or pneumococcal immunization for 5 of 6 residents reviewed for immunizations (Resident#2, Resident #3, Resident #11, Resident #60, and Resident #84). The facility failed to implement their influenza and pneumococcal immunization policies to document evidence in the electronic medical record the offering or the refusal of the influenza and pneumococcal immunization status for Resident #2, Resident #3, and Resident #11. The facility failed to implement their pneumococcal immunization policy to document evidence in the electronic medical record the offering or the refusal of the pneumococcal immunization status for Resident #60 and Resident #84. The failures could place residents at risk of contracting viral illness, influenza or pneumococcal disease, or of not being informed of the benefits and risk which could cause respiratory complications and lead to potential adverse health outcomes.Record review of Resident #2's face sheet dated 6/4/2026 revealed a [AGE] year-old male admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included Unspecified cerebral infarction(a condition where a blood clot blocks a blood vessel in the brain), Type 2 diabetes mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), end stage renal disease (a condition in which the kidneys no longer function normally). Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. Section O of Resident #2's quarterly MDS dated [DATE] indicated that he was offered both influenza and pneumococcal vaccinations and had declined the offer of both the influenza and pneumococcal vaccines. Record review of Resident #2's electronic record revealed no documented evidence of the facility offering or the refusal of influenza or pneumococcal vaccines. Record review of Resident #3's face sheet dated 6/4/2026 revealed a [AGE] year-old female was originally admitted into the facility on 8/21/2023 and readmitted on [DATE] with diagnoses that included hypokalemia (low potassium level in the blood), muscle weakness and Essential Hypertension (a type of high blood pressure that does not have a known cause).Record review of Resident #3's quarterly MDS dated 4/1602026 revealed a BIMS score of 10 which indicated moderate cognitive impairment. Section O of Resident #3's quarterly MDS indicated that Resident #3 was offered both influenza and pneumococcal vaccinations and had declined the offer of both the influenza and pneumococcal vaccines. Record review of Resident #3's electronic record did not reveal documented evidence of Resident #3's refusal of the influenza and pneumococcal vaccine. Record review of Resident #11's face sheet dated 6/4/2026 revealed a [AGE] year-old male originally admitted into the facility on 8/31/2023 and readmitted on [DATE] with diagnoses that included cerebral atherosclerosis (a condition where fatty deposits build up inside the arteries that supply blood to the brain), Type 2 Diabetes Mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), and hemiplegia (a condition where one side of the body becomes completely or almost paralyzed). Record review of Resident #11's quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated moderately cognitive impairment. Section O of Resident #11's quarterly MDS dated [DATE] indicated Resident #11 was not up to date on his influenza and pneumococcal vaccination and had declined the offer of both the influenza and pneumococcal vaccines. Record review of Resident #11's electronic record did not reveal documented evidence of Resident #11's refusal of the influenza and pneumococcal vaccine. Record review of Resident #60's face sheet dated 6/4/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Nontraumatic intracerebral hemorrhage in hemisphere subcortical (a sudden, unexplained bleed inside the brain that is not caused by an injury, and happening in a deep part of the brain within one of the brain's lobe), anxiety disorder (is a type of mental health where you feel intense, persistent, and often uncontrollable fear or worry that goes beyond normal nervousness), and Chronic Obstructive Pulmonary Disease (a group of diseases affecting the lungs). Record review of Resident #60's quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. Section O of Resident #60's quarterly MDS dated [DATE] indicated that she was offered both influenza and pneumococcal vaccinations and had declined the offer of both the influenza and pneumococcal vaccines. Record review of Resident #60's electronic record revealed no documented evidence of pneumococcal vaccine offering, administration, or refusal. Record review of Resident #84's face sheet dated 6/4/2026 revealed a [AGE] year-old female originally admitted into the facility on 3/20/2025 and readmitted on [DATE] with diagnoses that included senile degeneration of brain (a slow, progressive decline in brain function that happens with age, often leading to memory loss, confusion, and trouble with everyday tasks), Type 2 diabetes mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), and Essential Hypertension (a type of high blood pressure that does not have a known cause). Record review of Resident #84's quarterly MDS dated [DATE] revealed a BIMS score of zero which indicated severe cognitive impairment. Section O of Resident #84's quarterly MDS dated [DATE] indicated that she was offered both influenza and pneumococcal vaccinations and she had declined the offer of both the influenza and pneumococcal vaccines.Record review of Resident #84's electronic record revealed no documented evidence of pneumococcal vaccine offering, administration, or refusal. Interview with the DON on 6/4/2026 at 12:22 pm revealed the DON stated that the ADON was responsible for coordinating and administering resident vaccinations, including influenza, COVID-19, and pneumococcal vaccines. The DON reported that she had personally observed the ADON administering vaccines. The DON stated that the ADON was currently on leave and was responsible for overseeing the facility's vaccination program for both residents and staff, including vaccine education, administration, tracking, and documentation. The DON was asked to provide documentation of offering, administration or refusal of the influenza and pneumococcal vaccines for Resident #2, Resident #3, Resident #11, Resident #60, and Resident #84, but she stated the refusal documentations were expected to be in the ADON's office, however, the binder could not be found. The DON stated the refusal documentation was an area that she was aware of that needed attention and would be working on getting the refusal documentation uploaded and updated in PCC (Point click care). The DON stated the risk of not having up to date immunization records for residents could possibly lead to preventable illness, or unnecessary vaccinations. Interview with the ADON on 6/4/2026 at 1:22 p.m., revealed she was the infection preventionist for the facility and was responsible for immunization compliance. The ADON stated that a resident's immunization status should be listed in the immunization tab of the electronic record but sometimes it was in the notes section. The ADON stated that all residents were offered influenza and pneumococcal immunizations. She stated that the facility conducted an annual influenza vaccination clinic for residents. The ADON stated that refusals were entered into PCC (Point Click Care) and that signed refusal forms and Vaccine Information Statements (VIS) were maintained in binders located in her office. The ADON was asked to provide documentation of offering, administration or refusal of the influenza and pneumococcal vaccines for Resident #2, Resident #3, Resident #11, Resident #60, and Resident #84. She stated she had been away from the facility for approximately one month and was unsure whether the records remained in the office, but she did not know why the binder could not be found. When asked how she monitored immunization compliance for the residents, the ADON did not have an answer. When asked what the risk was associated with not assessing immunization compliance, the ADON stated the residents could be vaccinated twice for the same illness, the residents could get sick with a preventable disease, or the resident could receive vaccinations that were contraindicated. Record review of facility policy statement, undated and titled Influenza vaccine revealed in part. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. Record review of facility policy titled Pneumococcal Vaccine revealed in part. Residents/representative have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the of the refusal of the pneumococcal vaccination.

Based on interview and record reviews, the facility failed to develop and implement policy and procedures to ensure residents were offered, received, or refused the Covid-19 immunization, for 5 of 6 residents (Resident #2, Resident #3, Resident #11, Resident #60 and Resident #84) who were reviewed for immunization compliance. The facility failed to develop a Covid-19 immunization policy that addressed the documentation in Resident #2, Resident #3, Resident #11, Resident #60 and Resident #84's electronic medical records for having received or not receiving the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Record review of Resident #2's face sheet dated 6/4/2026 revealed a [AGE] year-old male admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included Unspecified cerebral infarction(a condition where a blood clot blocks a blood vessel in the brain), Type 2 diabetes mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), end stage renal disease (a condition in which the kidneys no longer function normally). Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. Section O of Resident #2's quarterly MDS dated [DATE] indicated Resident #2's COVID - 19 vaccination was not up to date. Record review of Resident #2's electronic record revealed no documented evidence that revealed his immunization status for Covid-19. Record review of Resident #3's face sheet dated 6/4/2026 revealed a [AGE] year-old female was originally admitted into the facility on 8/21/2023 and readmitted on [DATE] with diagnoses that included hypokalemia (low potassium level in the blood), muscle weakness and Essential Hypertension (a type of high blood pressure that does not have a known cause). Record review of Resident #3's quarterly MDS dated 4/1602026 revealed a BIMS score of 10 which indicated moderate cognitive impairment. Section O of Resident #3's quarterly MDS indicated that Resident #3's COVID - 19 vaccination was not up to date. Record review of Resident #3's electronic record did not reveal documented evidence of Resident #3's refusal of the COVID - 19 vaccinations. Record review of Resident #11's face sheet dated 6/4/2026 revealed a [AGE] year-old male originally admitted into the facility on 8/31/2023 and readmitted on [DATE] with diagnoses that included cerebral atherosclerosis (a condition where fatty deposits build up inside the arteries that supply blood to the brain),Type 2 Diabetes Mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), and hemiplegia (a condition where one side of the body becomes completely or almost paralyzed).Record review of Resident #11's quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated moderately cognitive impairment. Section O of Resident #11's quarterly MDS dated [DATE] indicated Resident #11's COVID - 19 vaccination was not up to date. Record review of Resident #11's electronic record did not reveal documented evidence of Resident #11's refusal of the COVID - 19 vaccinations. Record review of Resident #60's face sheet dated 6/4/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Nontraumatic intracerebral hemorrhage in hemisphere subcortical (a sudden, unexplained bleed inside the brain that is not caused by an injury, and happening in a deep part of the brain within one of the brain's lobe), anxiety disorder (is a type of mental health where you feel intense, persistent, and often uncontrollable fear or worry that goes beyond normal nervousness), and Chronic Obstructive Pulmonary Disease (a group of diseases affecting the lungs). Record review of Resident #60's quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. Section O of Resident #60's quarterly MDS dated [DATE] indicated Resident #60's COVID - 19 vaccination was not up to date. Record review of Resident #60's electronic record revealed no documented evidence that revealed his immunization status for Covid-19. Record review of Resident #84's face sheet dated 6/4/2026 revealed a [AGE] year-old female originally admitted into the facility on 3/20/2025 and readmitted on [DATE] with diagnoses that included senile degeneration of brain (a slow, progressive decline in brain function that happens with age, often leading to memory loss, confusion, and trouble with everyday tasks), Type 2 diabetes mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), and Essential Hypertension (a type of high blood pressure that does not have a known cause). Record review of Resident #84's quarterly MDS dated [DATE] revealed a BIMS score of zero which indicated severe cognitive impairment. Section O of Resident #84's quarterly MDS dated [DATE] indicated Section O of Resident #84's quarterly MDS dated [DATE] indicated Resident #84's COVID - 19 vaccination was not up to date. Interview with the DON on 6/4/2026 at 12:22 p.m., revealed that the ADON is responsible for coordinating and overseeing the facility's immunization program, including COVID-19 vaccinations. The DON stated the ADON was on leave and maintained immunization tracking and documentation. When requested to provide documentation of COVID - 19 vaccines offering, administration or refusal of covid -19 vaccine for Resident #2, Resident #3, Resident #11, Resident #60, and Resident #84 the DON was unable to locate the refusal records and stated the documentation was expected to be in the ADON's office. The DON stated the refusal documentation was an area that she was aware of that needed attention and would be working on getting the refusal documentation uploaded and updated in PCC (Point Click Care - facility's system of electronic documentation). The DON stated the risk of not having up to date immunization records for residents could possibly lead to preventable illness, or unnecessary vaccinations. Interview with ADON on 6/4/2026 at 1:22 p.m., revealed she was the infection preventionist for the facility and was responsible for immunization compliance. The ADON stated that a resident's immunization status should be listed in the immunization tab of the electronic record but sometimes it was in the notes section. The ADON stated that all residents were offered COVID - 19 on admission. The ADON stated that refusals were entered into PCC (Point Click Care) and that signed refusal forms and Vaccine Information Statements (VIS) were maintained in binders located in her office. The ADON was asked to provide documentation of offering, administration or refusal of the COVID - 19 vaccines for Resident #2, Resident #3, Resident #11, Resident #60, and Resident #84, but she stated she had been away from the facility for approximately one month and was unsure whether the records remained in the office but could not be found. When asked how she monitored immunization compliance for the residents, the ADON did not have an answer. When asked what the risk was associated with not assessing immunization compliance for COVID - 19, the ADON stated the residents could be vaccinated twice for the same illness, or the resident could receive vaccinations that were contraindicated. Record review of facility policy statement titled Coronavirus Disease (COVID - 19) - Infection Prevention and Control Measures revealed in part. This facility follows infection prevention and control (IPC) practices recommended by the Center for Disease Control and Prevention to prevent the transmission of COVID - 19 within the facility. The facility's policy did not address did not address this failure.

Based on observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan with measurable objectives and timetable to meet the resident's medical, nursing, and psychosocial needs that were identified in the comprehensive assessment for 1 of 18 residents reviewed for care plans (Resident # 105). --Resident # 105 did not have a care plan for ADLs. This failure placed residents at risk of not having their needs identified and addressed. Reord review of Resident # 105's admission record revealed admission date 10/4/24 with diagnoses including dementia (loss of cognitive functioning), major depressive disorder (persistent feeling of sadness and loss of interest), chronic kidney disease (inability of kidneys to filter waste from the body), heart disease (condition affecting heart structure, function, vessels), heart failure (inability of heart muscle to pump blood), Diabetes (imbalance of glucose in the blood), embolism and thrombosis of deep veins of lower extremities (restriction of blood flow to lower extremities), hypertension (high blood pressure). Record review of Resident #105's Quarterly MDS dated [DATE] revealed always understood and always understands, BIMS of 14, indicating independent cognitive skills; moderate staff assistance required for hygiene, and dressing of upper body, with maximum staff assistance required for toileting, bathing/showering, and lower body dressing; occasional bladder incontinence, continent of bowel, and therapeutic (diabetic) diet. Observation of Resident 105 on 6/2/26 at 9:30am revealed she was in bed and said she was waiting for the CNA to come back and help her get cleaned up and out of bed. She said she could do most things on her own and was ok once she was in her wheelchair but needed assistance with changing briefs and dressing. Observation of Resident #105 on 6/3/26 at 10:00am revealed she was in her wheelchair, dressed, and participating in the resident council meeting. She said she did have assistance with toileting and dressing this morning. Record review of Resident # 105's care plan dated 9/2/25 revealed no care plan for ADLs, which would include appropriate interventions. Interview with MDS coordinator on 6/4/26 at 10:30am revealed he did not see a care plan for ADLs for Resident #105. He searched through all of the care plans with the surveyor and could not find a care plan for ADLs. He said it was an omission and the care plan should have been updated to include ADLs for Resident # 105. He said he receives input from the different departments for the resident's condition and needs, and he completes the care plan for all residents. He said the risk to the residents of having an incomplete care plan would be the resident would not get what they need. Interview with the DON on 6/4/26 at 10:55am revealed the care plan should be complete and reflect the resident's condition. She said all the departments contribute to the care plans and the MDS coordinator completes it, and the risk to the residents if it was not accurate would be the residents would not receive the care they needed. Record review of the facility care plan policy, revised March 2022, revealed, in part: .comprehensive resident-centered care plans are developed within 7 days of the MDS assessment .includes measurable timeframes and objectives .describes services to be furnished .assessments of residents are ongoing and care plans are revised if information about a resident or resident's condition change.

Based on interview and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 2 residents (Resident #2) reviewed for mental illness, disability, or developmental disability.The facility failed to ensure Resident #2, who had a positive PL1, had a PL2 completed.This failure could place residents at risk of mental health needs not being met. Record review of Resident #2's face sheet, dated 5/6/2026, revealed a [AGE] year-old male who was admitted to the facility originally on 11/18/2020 and readmitted on [DATE]. Resident #2 had diagnoses which included Cerebral infarction (the most common type of stroke; occurs when a blood vessel in the brain becomes blocked, cutting off oxygen supply to brain tissue), ESRD (a condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), Type 2 Diabetes Mellitus (a type of nerve damage that occurs as a complication of diabetes, primarily due to prolonged high blood sugar levels most commonly affecting the legs and feet, leading to symptoms such as pain, numbness, or tingling) , and Major Depressive Disorder (a formal diagnosis in the DSM-5, requiring at least five specific symptoms [like persistent sadness, loss of interest, sleep or appetite changes, fatigue, or thoughts of death] lasting at least two weeks and causing significant daily problems). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognition.Record review of Resident #2's care plan revealed a focus, initiated on 5/2/2026 and revised on 5/4/2026, that read Resident #2 has a history of trauma related to PTSD from the Army and the potential for increase in behaviors.Record review of Resident #2's PASARR Level 1 Screening, dated 8/1/2025, completed by MDS Nurse A, revealed in Section C 0100, an answer of yes which indicated Resident #2 had evidence or an indicator of mental illness.During an interview on 5/6/2026 at 2:28 p.m., MDS Nurse A stated he had worked at the facility for two years. MDS Nurse A stated he was responsible for MDS assessments and PASSAR related issues and was involved in creating care plans. MDS Nurse A stated he completed a PL1 for Resident #2 on 8/1/2025 due to a CHOW and noticed Resident #2 had a diagnosis of Major Depressive Disorder which resulted in a positive PL1 for Resident #2. MDS Nurse A stated Major Depressive Disorder was a qualifying condition for mental illness. MDS Nurse A stated he was not aware Resident #2 had a diagnosis of PTSD. MDS Nurse A stated he had not seen a diagnosis of PTSD in Resident #2's medical record and was unclear why it was noted as a focus in Resident #1's most recent care plan. MDS Nurse A stated he was unable to submit the PL1 that was created on 8/1/2025 because the facility did not have an NPI number. MDS Nurse A stated without an NPI number he was unable to submit the PL1 1 to the Simple LTC Portal which would have triggered a need for a PL2. MDS Nurse A stated his resource, and mentor was MDS Nurse B who served as a regional MDS nurse. MDS Nurse A stated the risks to residents who had a positive PL1 and was not submitted to Simple LTC Portal, included residents not receiving services that could have been offered to them. During an interview on 5/6/2026 at 3:22 p.m., the DON stated she was not responsible for PASARR screenings and knew very little about PASARR regulations. The DON stated she assumed Resident #2 had PTSD but realized that assumption was not true. The DON stated Resident #2 did not have an official diagnosis of PTSD. During an interview on 5/6/2026 at 3:57 p.m., MDS Nurse B stated she had worked at the facility since October 2025. MDS Nurse B stated she was the regional MDS nurse and acted as a resource to MDS nurse A. MDS Nurse B stated the facility had undergone a CHOW on August 1, 2025. MDS Nurse B stated anytime a CHOW occurred, the facility needed to wait for the Simple LTC Portal to update NPI and Medicaid numbers. MDS Nurse B stated once the facility received their new numbers, the facility would then upload the positive PL1's into Simple LTC. MDS Nurse B stated there was not a way to upload positive PL1's at that time. MDS Nurse B stated the risks to residents who had a positive PL1 and had not received a PL2 included residents not receiving services if they were not forthcoming with how they felt. MDS Nurse B stated the facility was contracted in-house psychiatric services, and residents with mental illness could be provided with services in the community or could be transported to an outpatient setting if their insurance allowed. MDS Nurse B stated the facility also conducted mood screenings quarterly, and behavior monitoring for those residents on medication for mental health. MDS Nurse B stated residents were constantly monitored, and the facility could provide in-house psychiatric services in the event it was needed. During an interview on 5/6/2026 at 4:20 p.m., the Administrator stated he had worked for the facility since October 2024. The Administrator stated MDS Nurse A was responsible for PASARR related issues. The Administrator stated the facility ownership changed in August of 2025, and he had still been waiting for the CHOW to be completed through the State. Record review of the facility's, undated, policy titled PASSR, read in part, the MDS Coordinator or designee will input all PL1's into the online portal on admission.In the event of positive PL1 that indicates the individual may have ID/DD/ or MI, the MDS Coordinator, Social Worker or designee will.notify LIDDA within 2 calendar days of admission to schedule the IDT and initiate the PE process.2. Monitor the Simple portal daily for the PE.

Based on interviews and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 24 residents (Resident #51) reviewed for significant medication errors. The facility failed to ensure Metoprolol (a blood pressure (BP) medication given to lower high blood pressure) was administered six times in March 2025 to Resident #51 as ordered on 02/26/2025 by the physician and Resident #51 was administered Metoprolol 12.5 mg outside of physician set parameter of the residents SBP (the top BP number) less than 100 hold. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health. Findings included: Record review of Resident #51's admission face sheet, undated, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included: Atrial Fibrillation (irregular often rapid heart rate resulted in poor blood flow), Hypertension (high blood pressure), cardiac pacemaker (small Implanted electronic device to help the hearts rhythm with electric impulses). Record review of Resident #51's quarterly Minimum Data Set (MDS) dated [DATE] reflected the resident's Brief Interview for Mental Status (BIMS (a score used to assess cognitive function) was 15 which indicted his cognition was intact. The MDS indicated Resident #51's speech was clear. He was able to make himself understood and he was able to understand others. The resident required supervision only for eating and oral hygiene. He required maximum assistance for toileting, showers/baths. Partial assistance was needed for personal hygiene. Resident #51 was always frequently incontinent of bowel and bladder. Record review of Resident #51's care plan initiated 02/24/2025 reflected the following: Problem: The resident received hypertensive medications. Goal: The resident would receive hypertensive medications without any complications. Interventions: Provide Metoprolol as ordered Staff would check blood pressure before medications were given. Record review of Resident #51's order summary report, active orders dated as of 04/03/2025, revealed, Metoprolol Tartrate Tablet. Give 12.5 mg by mouth two times a day related to hypertension. Hold for a systolic blood pressure (SBP) less than 100. Order dated 02/26/2025. Record review of Resident #51's March 2025 Medication Administration Record (MAR) dated 03/01/2025 -03/31/2025 reflected, the resident was administered Metoprolol 12.5 mg outside of physician set parameter of SBP (The top BP reading) less than 100 on: 03/02/2025 at 9:00AM with BP 88/61 by MA A 03/03/2025 at 9:00AM with BP 97/64 by MA A 03/04/2025 at 5:00 PM with BP 95/60 by MA B 03/05/2025 at 5:00 PM with BP 97/62 by MA B 03/09/2025 at 9:00 AM with BP 97/65 by MA A 03/20/2025 at 9:00 AM with BP 90/61 by MA A In an interview and record review of Resident #51's MAR on 04/02/2025 at 10:10 AM MA A stated the initials documented on 03/02/2025, 03/03/2025, 03/09/2025, 03/20/2025 were her initials. The MA A stated the check mark documented the medication was given. MA A stated when the blood pressure was outside the ordered parameters it should not have been given. MA A stated if a medication was not administered it would be documented it was not given due to outside parameters. MA A stated the medication should not have been given on the dates. MA A stated she knew better than to give it. She stated it must have been incorrect documentation. MA A stated the pharmacist trained the staff on medication administration which included observed administration of medications. To prevent this again she would slow down, read the order and document correctly. In a phone interview on 04/02/2025 at 11:24 AM the facility pharmacist stated the physician ordered parameter was to help hold the resident's BP above a certain level. It was to prevent the BP from dropping too low. The pharmacist stated the expectation was the physician's hold order was followed. The risk was the BP could go too low. The pharmacist stated she did routine staff in-service and monitored medication administration. In a phone interview on 04/02/2025 at 12:40 PM Resident #51's NP stated she saw the resident's BP ran low. She stated the reason for the parameter hold order was a guide to keep the resident's BP at a safe level. The NP stated the medication was to lower BP. The risk was the BP would drop too low. The NP stated Resident #51's BP did run low. The NP continued and stated the resident needed the medication for his heart. In a phone interview on 04/02/2025 at 12:58 PM MA B stated she checked the BP. MA B stated she checked the parameter to make sure it was alright to give. The MA stated the parameter was to hold for the resident's SBP less than 100 the medication should not have been given. The Medication was to lower the BP. The risk was the BP would go too low. Next time she would double check before she gave any medication. In an interview on 04/03/2025 at 9:13 AM ADON stated the risk of the medication administered under the ordered parameter was low BP, fainting, hospitalization . The ADON stated the pharmacist regularly in-serviced the staff on medication administration. The ADON stated the MARs were reviewed daily in the morning meeting to monitor administration of medications. The ADON stated regular monitoring included administration, omission and availability of medications. In an interview on 04/03/2025 at 11:39 AM DON stated the risk of the medication being administered below the ordered hold value was the BP dropping. The DON stated she did not know why it was administered to Resident #51. The DON stated she thought it may have been a documentation error. The DON stated reeducation for following the physician's orders would be done to prevent this again. In an interview on 04/03/2025 at 2:45 PM the Administrator stated he understood a resident received a BP medication when the BP was under the ordered hold parameter. He stated he was not clinical, and he did not know all the risks and effects. The Administrator stated he expected medication to be administered as ordered without medication errors. In a follow up interview on 04/03/2025 at 3:11 pm The DON stated medication administration was monitored daily during the stand-up morning meetings the MARs were reviewed. Record review of the facility policy titled Administering Medications Revised dated April 2019 read in part . Policy Statement Medication are administered in a safe and timely manner, .and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescribed orders, including any time frame .

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 24 residents (Resident #40) reviewed for infection control practices. The facility failed to ensure CNA C followed proper infection control, glove changes and hand hygiene for Resident #40 during incontinent care. CNA C failed to use a clean wipe, change gloves and perform hand hygiene during incontinent care. This failure could place residents at risk of infection or a decline in health. The findings included: Record review of Resident #40's admission face sheet undated revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #40 was readmitted on [DATE]. Resident #40's diagnoses included: hemiplegia /hemiparesis ( muscles weakness or partial paralysis to one side of the body), diabetes mellitus (body did not produce enough insulin or use it properly), nontraumatic intracerebral hemorrhage (bleeding within the brain not caused by an injury), epilepsy (nerve cell activity in the brain was not working correctly resulted in seizures), Cerebrovascular disease (condition affected the brain's blood vessels and blood flow). Record review of Resident #40's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40's speech clarity identified he had no speech. Resident #40 rarely/never made himself understood. The resident rarely/never understood others. Brief Interview for Mental Status (BIMS (a score used to assess cognitive function) was unable to be scored. Resident #40's cognitive skills for daily decision making was moderately impaired. Continued review of the MDS revealed Resident #40 was dependent on staff for eating, oral hygiene, toileting hygiene shower/bathe, personal hygiene. Resident# 40 was always incontinent of his bowel and bladder. Record review of Resident # 40's care plan updated on 02/14/2025 revealed: Problem: Resident was incontinent of bowel and bladder related to stoke, hemiplegia. Goal: The resident would remain free from skin breakdown due to incontinence. Interventions: Clean perineum (area of skin between anus and scrotum) with each incontinent episode. Record review of Resident #40's order summary report dated 04/03/2025 revealed Zinc oxide ointment 10% apply to scrotum two times a day for skin condition. Order dated 12/07/2024. Observation on 04/03/2025 at 9:28 AM during incontinent care revealed Resident #40 in bed on his back with the head of the bed elevated. Resident #40 was nonverbal. CNA C was positioned on the left side of the resident's bed. CNA D was positioned on the right side of the resident's bed. Resident #40 was turned to his right side. The resident's brief was rolled under the resident. CNA C used one incontinent wipe cleaned down the resident's right buttock, cleaned down the resident's left buttock, and cleaned the resident's anal area. Continued observation revealed Resident #40 was positioned on his back. Without a glove change or hand hygiene, CNA C obtained one new wipe. CNA C wiped down the resident's right groin, down the residents left groin, down his penis with the same wipe. In an interview on 04/03/2025 at 9:43 AM CNA C stated she did clean the resident's back first before she moved to the front. CNA C stated the resident should have been cleaned from front to back. CNA C stated she did use the same wipe to clean. She did not get a new wipe each time. CNA C stated gloves were to be changed and hand hygiene should have been done. CNA C stated she started with his buttock because he was on his side already. CNA C stated she was nervous. CNA C stated she was not thinking that was why she did not change the wipes, her gloves or do hand hygiene. CNA C stated the risk was an infection. The CNA stated she would slow down to prevent this again. In an interview on 04/03/2025 at 11:04 AM CNA D stated each wipe should have been discarded after one wipe and not reused. CNA D stated the resident's front should have been cleaned before the back. The CNA should have changed her gloves and washed her hands. CNA D stated she did not know why this occurred. She stated the risk was infection because of contamination. In an interview on 04/03/2025 at 11:39 AM the DON stated the staff reported to her the incontinent care was not done correctly. The DON stated CNA C was reminded the disposable wipes should be discarded after one use. The CNA was reminded when she cleaned from one area to another, gloves were to be changed. Hand hygiene was to be done with glove changes and care was to be done from front to back. The resident's care should not have started at the buttocks. The DON stated this was an experience CNA. The DON stated she did not know why this happened. The DON stated she expected proper infection control to be followed. The DON stated the risk was infection and to prevent this again the staff would be retrained. In an interview on 04/03/2025 at 2:45 PM the Administrator stated he was notified proper procedure was not followed during the resident's care. The Administrator stated he expected infection control protocols were followed to prevent infection. He stated the risk was infection. The Administrator stated to prevent this again the staff would be reeducated on infection control. In a follow up interview on 04/03/2025 at 3:11 PM the DON stated we monitored infections during the morning stand up meetings. The DON stated trainings were done annually and as needed during the year. Record review of the facility policy titled Perineal Care Revised dated February 2018 read in part . Purpose The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infection an skin irritation and to observe the resident's skin condition . Record review of the facility policy titled .Infection Control Revised dated October 2018 read in part . Policy Statement this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections .Policy Interpretation and Implementation 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility; b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors and the general public .

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 (Resident #1) of 7 residents reviewed for abuse. CNA A failed to immediately notify the Administrator on 09/03/24 Resident #1 had bruising on the right arm of unknown origin. This failure could place residents at risk for abuse and neglect. Findings Included: Record review of admission record dated 02/27/25 revealed Resident #1 was an [AGE] year-old woman admitted to the facility on [DATE] with diagnoses which included unspecified visual loss, unspecified osteoarthritis, anxiety disorder, muscle wasting and atrophy (the wasting away or shrinking of an organ, tissue, or muscle), other lack of coordination, unspecified lack of coordination, hypertension, and long term (current) use of anticoagulants ( blood thinners). A record review of Resident 1's admission MDS assessment dated [DATE] revealed Resident #1 was assessed to have the ability to usually understand others and could make herself understood. Further review revealed a Brief Interview for Mental Status was not conducted due to a code zero entered which indicated, resident is rarely/never understood. Resident #1 had clear speech and adequate hearing and severely impair vision. Record review of Resident #1's care plan, dated 10/11/22, reflected, [Resident #1] is receiving anticoagulant therapy r/t Atrial fibrillation .Goal . [Resident #1] will be free from discomfort or adverse reactions related to anticoagulant use through the review date.Interventions . Daily skin inspection. Report abnormalities to the nurse. Record review of a Skin Only Evaluation completed by RN B, dated 09/04/24, reflected new issue: right upper arm bruise noted. Location: right forearm. Skin issue: bruising. Record review of an undated statement by CNA A reflected, I noticed a dark discoloration on Resident #1's arm. I reported it to [ LVN 1], but I'm unsure if he had heard me as I spoke in a lower tone than normal. Record review of a statement by LVN C dated 09/10/24 revealed, was notified of resident bruise from previous shift nurse-bruise on right upper arm assessed by me. In an interview on 02/25/2025 at 10:18am with Family Member D revealed she visited Resident #1 on 08/29/2024 and there were no concerns. Family Member D stated when she visited Resident #1 on 09/03/24, Resident #1 had a large deep purple bruise on her right arm. Family Member D stated she asked LVN E to look at the bruise. Family Member D stated LVN E stated the DON would be informed and Family Member D would be contacted. Family Member D stated CNA A came into the room and stated the bruise was noticed a few days ago and it was reported to LVN C. Family Member D stated she contacted the DON on 09/05/24, due to not receiving a call 09/04/24, and the DON stated she did not know anything about the issues and was not informed by any facility staff members. An attempted interview with Resident #1 on 02/25/25 at 11:05am revealed Resident #1 responded to questions with rambling speech. Resident #1's rambling speech continued on-going during the interview. Resident #1 was observed sitting up in bed and the call light within reach. No visible injuries observed. An interview with CNA A on 02/25/25 at 2:28pm revealed he has worked at the facility for 7 years. CNA A revealed he noticed a bruise on Resident #1's forearm and LVN 1 was informed immediately. CNA A stated he has worked at the facility for 7 years. CNA A stated abuse should be reported as soon as it happens to the DON or Administrator. CNA A stated he probably should have informed the Administrator but informed the charge nurse instead. Telephone interview with LVN C on 02/27/25 at 8:05am revealed CNA A did not inform him of the bruise. LVN C stated had he been informed; he would have followed protocol. LVN C stated the protocol included notifying the family, the DON, completing a skin assessment and incident report. LVN C stated abuse was reported immediately to the DON and Administrator. An interview with the DON on 02/27/25 at 3:58pm revealed she spoke with Family Member D but was unsure when. The DON stated CNA A stated LVN C was informed of the bruise but was unsure if LVN C heard him. The DON stated the interim Administrator was informed of the bruise on 09/05/24. The DON stated the protocol for injury of unknown origin was the CNA reported to the nurse, who assessed the resident, an incident report was completed, and the physician and family members were notified. The DON stated Resident #1 was on blood thinners and she flails her arms, and the assumption was Resident #1 may have hit the side rail of the bed. The DON stated the risk of staff failure to report an injury of unknow origin was delayed time with resolution of injury/treatment. An interview with the Administrator, the Abuse Coordinator, on 02/25/25 at 4:18pm, revealed his employment and training started the end of September with the interim Administrator. The Administrator stated he was unaware of Resident #1's bruise and unsure if the interim Administrator was aware. The Administrator stated the expectation was notification of a bruise that is out of the ordinary, what it is and where the bruise is located to find the root cause of the bruise. The Administrator stated the lack of notification was concerning and it is an opportunity for education for the staff on reporting abuse. Record review of the facility's policy titled, Investigating Resident Injuries, revised April 2021, reflected all resident injuries are investigated. The director of nursing services or a designee assesses all resident injuries and documents findings in the medical record. If the nursing and medical assessment determines an injury of unknown source the investigation will follow the protocols set forth in our facility's established abuse investigation guidelines.

Based on observation, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene to a resident who is unable to carry out activities of daily living for one of five residents (Resident #2) reviewed for ADL care. The facility failed to provide Resident #2, who required extensive assistance, with timely incontinence care on 02/25/25 from 6:30 a.m. to 11:30 a.m. This failure could place residents at risk of skin breakdown, urinary tract infections and loss of dignity. Findings included: Record review of Resident #2's Admission Record, dated 02/27/25, reflected a [AGE] year-old male with an admitted [DATE]. Resident #2 diagnoses included Paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), Flaccid Hemiplegia affection left nondominant side (loss of muscle tone on one side of the body), need for assistance with personal care, and muscle wasting and atrophy (causes muscles to lose mass and strength). Record review of Resident #2's MDS assessment dated [DATE] reflected frequent urinary and bowel incontinence. Resident #2 reflected toilet transfer was not applicable and dependent regarding toileting hygiene. Resident #2 had a BIMS of 15, which indicated he was cognitively intact. Record review of Resident #2's care plan, revised 12/28/21, reflected, Resident #2 has an alteration in elimination r/t bowel/bladder incontinence .Goal . [Resident #2] will remain free from skin breakdown due to incontinence and brief use .Interventions .Check [Resident #2] during care rounds for incontinence .Toilet use: [Resident #2] requires x1 extensive to use toilet. An interview with Resident #2 on 02/25/25 at 11:28am revealed he had not had a diaper change since 6:30am. Resident #2 revealed he had no wound issues because he took care of the area below his waist. No stains on Resident #2's bedsheet was observed nor odor in the room. An interview with CNA F on 02/25/25 at 11:44am revealed Resident #2 had not been changed since his shift began at 6am. CNA F stated he had to get residents in their wheelchairs on another hall. An interview with CNA G on 02/26/25 at 8:15am revealed incontinent residents were checked every 2 hours and more often depending on their condition. CNA G stated she worked on a different hall than Resident #2 and was very busy. CNA G stated she was assigned to Resident #2 but asked CNA F to check on Resident #2, to ensure incontinent care was provided, and charted before she left. CNA G stated the risk for delayed incontinent care to the resident could be skin breakdown, infections, wounds, or bed sores. Second interview with CNA F on 02/26/25 at 10:00am revealed Resident #2 was not his assigned room. CNA F stated Resident #2's call light was the reason why he entered Resident #2's room on 02/25/25 to change him. CNA F stated Resident #2 was assigned to CNA G on 02/25/25. An interview with the ADON on 02/27/25 at 1:43pm revealed the expectations for incontinent residents were for CNAs to check incontinent residents when rounds were conducted and as needed. The ADON stated the risk for incontinence delay could result in skin breakdown or risk of UTIs ( urinary tract infections). An interview with the DON on 02/27/25 at 3:58pm revealed the expectation regarding incontinent care was for residents to get checked every two hours. The DON stated the risk for incontinence delay was potential infection and breakdown. Record review of the facility's policy titled, Urinary Continence and Incontinence-Assessment and Management revised August 2022, reflected Management of incontinence will follow relevant clinical guidelines . 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.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for care plans. -The facility failed to ensure Resident #1's treatment orders for Right Heel Unstageable DTI were followed as ordered by the physician on 12/18/24 . -Wound Care Nurse documented administering a treatment to Resident #1's Right Heel Unstageable DTI that she did not provide on 12/18/24 . These deficient practice could affect residents with comprehensive care plans and could result in missed or delayed continuity of care. Findings included: Record review of the admission sheet for Resident #1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included pressure ulcer of right ankle, stage 4 (a severe, deep wound on the right ankle where the skin damage extends beyond the subcutaneous tissue, potentially exposing muscle, tendon, or bone), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #1's comprehensive MDS assessment dated [DATE] revealed a BIMS of 08 out of 15 indicating moderately impaired cognition. She required substantial/maximal assistance from staff for toilet hygiene, personal hygiene, upper/lower body dressing. Resident #1 had indwelling catheter. Resident#1 was always incontinent of bowel. Further review of Section M0150. Risk of Pressure Ulcers/injuries. Is the resident at risk of developing pressure ulcers/injuries? Coded: Yes. G. Unstageable - Deep tissue injury: coded: 0 Record review of Resident #1's Care plan dated 01/09/2021 and revised on 12/18/2024 revealed the following care plan: Problem: [Resident#1] has DTI to Right heel Goal: [Resident#1] will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #1's physician's order dated 12/06/2024 revealed an order for Right Heel Unstageable DTI: Cleanse with normal saline or wound cleanser, pat dry apply Skin Prep 3 times a week, PRN. Every day shift every Mon, Wed, Fri. Record review of Resident #1's TAR for the month of December 2024 revealed an order for Right Heel Unstageable DTI: Cleanse with normal saline or wound cleanser, pat dry apply Skin Prep 3 times a week, PRN. Every day shift every Mon, Wed, Fri was signed off 6am-6pm on 12/18/24 by the Wound Care Nurse. Observation and attempted interview on 12/18/24 at 10:16 a.m., with Resident#1 revealed she was resting on an air mattress. Resident mumbled for about 5 minutes while being interviewed and could not respond appropriately to the questions asked about her wounds. Resident had wounds on the sacrum, Right leg/foot/shin lateral/anterior that were without the dressing. Observation on 12/18/24 at 10:31a.m., revealed Wound Care Nurse providing wound care for Resident #1. Wound Care Nurse gathered the supplies at the treatment cart in the hallway before bringing them into Resident #1's room. Continued observation revealed right heel unstageable DTI with intact skin approximately 2.0 centimeters in diameter. Wound Care Nurse failed to provide treatment to right heel as ordered. In an interview and record review on 12/18/24 at 1:13p.m., with the Wound Care Nurse, she said she provided treatment to Resident#1's right lateral shin, sacrum, right lateral foot, and right anterior shin. This Surveyor reviewed Resident #1's TAR with the Wound Care Nurse. Wound Care Nurse said she signed off on the order for unstageable DTI of the right heel but forgot to provide the treatment. When asked why she signed off on the order if she did not provide the treatment. WCN said she forgot because the right heel did not need a dressing just a skin prep. WCN said skin prep helped dry up the wound. Wound Care Nurse said it was important to follow physician order to promote wound healing. In an interview on 12/18/24 at 1:45p.m., with the DON, when asked how does staff know what treatment to provide to residents. What is the risk to the resident due to this failure? The DON said it was important to follow physician orders to facilitate wound healing. To ensure accuracy, treatment should be administered by referencing the computer orders rather than relying on memory. The DON said it was important to sign off on each order once the corresponding treatment has been completed. Record review of the facility's Wound Care policy dated (Revised October 2010) revealed read in part: .Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 3 residents (Resident #1) reviewed for infection. -The facility failed to ensure Wound Care Nurse performed hand hygiene after removing soiled gloves and before applying new gloves while providing Resident #1's wound care on 12/18/24. -The facility failed to ensure Resident#1's wounds were covered after evaluation from the wound care physician on 12/18/24. These failures could place residents at risk for the spread of infection. Findings included: Record review of the admission sheet for Resident #1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included pressure ulcer of right ankle, stage 4 (a severe, deep wound on the right ankle where the skin damage extends beyond the subcutaneous tissue, potentially exposing muscle, tendon, or bone), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #1's comprehensive MDS assessment dated [DATE] revealed a BIMS of 08 out of 15 indicating moderately impaired cognition. She required substantial/maximal assistance from staff for toilet hygiene, personal hygiene, upper/lower body dressing. Resident #1 had indwelling catheter. Resident#1 was always incontinent of bowel. Further review of Section M0150. Risk of Pressure Ulcers/injuries. Is the resident at risk of developing pressure ulcers/injuries? Coded: Yes. G. Unstageable - Deep tissue injury: coded: 0 Record review of Resident #1's Care plan dated 01/09/2021 and revised on 12/18/2024 revealed the following care plan: Problem: [Resident#1] has DTI to Right heel Goal: [Resident#1] will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Observation and attempted interview on 12/18/24 at 10:13 a.m., with Resident#1 and the Wound Care Doctor. The Wound Care Doctor said he had evaluated Resident#1's wounds and had to run to other facility. Wound Care Doctor left Resident#1's wounds uncovered. Further observation revealed old/soiled dressings had been removed and were left on the resident's bed rather than being properly disposed of. Observation and attempted interview on 12/18/24 at 10:16 a.m., with Resident#1 revealed she was resting on an air mattress. Resident mumbled for about 5 minutes while being interviewed and could not respond appropriately to the questions asked about her wounds. Resident had wounds on the sacrum, Right leg/foot/shin lateral/anterior that were without the dressing. Old/soiled dressings had been removed and were left on the resident's bed rather than being properly disposed of. Observation on 12/18/24 at 10:31a.m., revealed Wound Care Nurse providing wound care for Resident #1. Wound Care Nurse gathered the supplies at the treatment cart in the hallway before bringing them into Resident #1's room. There was no dressing on the sacrum wound. Continued observation revealed an open area of approximately 5.0 centimeters in diameter. WCN cleansed the wound with normal saline, removed her soiled gloves, and without sanitizing/washing her hands donned clean gloves and continued the treatment. In an interview on 12/18/24 at 1:13p.m., with the Wound Care Nurse, she said the wound care doctor did not cover the wounds, and she was rushed in dressing them and forgot to sanitize her gloves between gloves change. She said this failure placed risk for infection. She said she received in-serviced on infection control 3 to 4 weeks ago at this facility. Could not recall the exact date. She said the DON spot checked her once a month. In an interview on 12/18/24 at 1:45p.m., with the DON, she said the WCN should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing wound care. The DON said the Wound Care Doctor should have covered the wounds and disposed of soiled dressing properly. She said these failures were risk for infection control. She said staff received in-service on infection control every 2 to 3 months. Record review of facility's COVID-19 Prevention & infection Control in-service (not dated) conducted by the ADON revealed Wound Care Nurse did not sign the in-service. Record review of the facility's Infection Control policy dated (Revised October 2018) revealed read in part: . Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Record review of the facility's Handwashing/Hand Hygiene policy dated (Revised August 2019) revealed read in part: .Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: m. After removing gloves. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .

Based on interview and record review the facility failed to ensure the resident has the right to access personal and medical records pertaining to himself and allow the resident to obtain a copy of the records upon request and upon two working days advance notice to the facility for 1 of 2 residents (CR#1) whose records were reviewed in that: - The facility failed to provide CR#1's Responsible party copies of medical records after a request was submitted to the facility on [DATE]. This failure could place residents at risk of violation of their rights by not receiving copies of their medical records. Findings included: Record review of the admission sheet (undated) for CR #1 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. His diagnoses included type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), hypertension (a condition in which the force of the blood against the artery walls is too high) and bed confinement (unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair). Family member was listed as Responsible Party. Resident was transferred to the hospital on 09/29/2023. Record review of CR #1's Quarterly MDS assessment, dated 09/25/2023, revealed the BIMS score 07 out of 15 indicating severely impaired cognition. He required extensive assistance from staff physical assist for personal hygiene, toilet, dressing and bed mobility. Resident was always incontinent of bowel and bladder. Record review of CR #1's care plan initiated 3/17/2023 and revised on 10/06/2023 revealed the following: Focus: The resident has potential fluid deficit r/t feeding tube as a nutritional approach Goal: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor/document/report PRN any s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Record review of the facility's Record Request for CR#1 revealed the form was signed by RP on 10/06/2023. In a telephone interview on 11/19/2024 at 8:55a.m., with CR #1's family member, she stated she was the responsible party for CR #1. The Family member stated she submitted a record request in October 2023, but the facility has not yet provided the requested records as of today (11/19/2024). In an interview on 11/19/2024 at 11:02a.m., with the Medical records/central supply, she stated she began in medical records role on May 28, 2024. She stated the process for requesting medical records involved the family/ resident filling out the record request form. The form was then sent to the corporate office where once approved she would print the records and process their request within 24 hours. She stated that once the records were mailed corporate would then be notified that the request had been fulfilled. She stated the copy of the records that were mailed was retained for three years as part of their records. She stated that she was not aware if previous requests had been made by CR#1's family member requesting copies of the medical record. In an interview on 11/19/24 at 1:02 p.m., with the Administrator, he stated he found the records request made by the family member for CR#1 on 10/06/2023. The Administrator stated with CR#1 discharged the facility was unable to locate his binder to check if the record request was possibly mailed. He stated when a request was made, it should be fulfilled within 24 hours. Record review of facility's Release of Information policy (revised November 2009) revealed in part: .Policy statement: Our facility maintains the confidentiality of each resident's personal and protected health information. Policy Interpretation and Implementation: 3. All information contained in the resident's medical record is confidential and may only be released by the written consent of the resident or his/her legal representative (sponsor), consistent with state laws and regulations. 8.The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative (sponsor). 9. A resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident's written or oral request .

Based on observation, interview and record reviews the facility failed to ensure a resident that was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 4 (Resident #1) reviewed for Activities of Daily Living. The facility failed to ensure Resident #1's adult brief was checked and changed when needed. This failure could affect all residents that required staff assistance with activities of daily living and could result in poor hygiene and skin breakdown. Findings Included: Record review of Resident #1's undated face sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with blood vessel supply), atrial fibrillation(an irregular, often rapid heartbeat commonly caused by poor blood flow), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), vascular dementia (brain damaged from multiple strokes), unsteadiness on feet (when gait and balance issues makes it difficult to stand and walk). Record review of Resident #1's annual MDS dated [DATE] revealed Section C0500- Brief interview of mental status as coded as 05 (severe cognitive impairment). Section GG 0130- Functional Abilities and goals revealed C. Toileting hygiene- The ability to maintain perineal hygiene was coded as 3, which represented Partial/moderate assistance in which the helper does half of the effort. Section GG0170- revealed F. Toilet transfer was coded as 3, which represented partial/moderate assistance in which helper does half the effort. Section H0300- Urinary Continence was coded as 2 for frequently incontinent. H0400. Bowel incontinent was coded as 2 for frequently incontinent. Record review of Resident #1's care plan dated 10/05/2022 and revised on 10/18/2023 revealed Resident #2 had an ADL self-care performance deficit r/t dementia, impaired balance and late effects of CVA. Interventions: Bed mobility: Limited assist X1 staff. Toileting: Extensive assist X 1-2 staff and Transfer: Limited X2 staff. Resident has bladder/bowel incontinence r/t dementia and requires assistance with toileting hygiene. Interventions: Check [NAME] as indicated and as required for incontinence. Wash, rinse and dry perineum. Observations of Resident #1 revealed: 3/28/2024 at 3:07pm- Strong urine odor in Resident #1's bedroom. He was asleep. 4/4/2024 at 4:02am- revealed Resident #1 was sitting in his wheelchair bent over wiping his bed sheets with paper towels. His bed sheets were wet with urine. He was not interview able. Observation on 4/4/2024 at 4:00 a.m., revealed two CNA's coming out of an office located on station 1 near the 700 Hall. They were observed to be stretching and yawning. An interview with RNA on 4/4/2024 at 4:14am, revealed her expectation of her overnight staff is to ensure residents are clean and diapers briefs are changed as needed. She denied that the two CNA's seen coming out of the office were asleep . She stated that they round every two hours and that she believed Resident #1 was just a heavy wetter. She was informed Resident #1 was wet as well as his bed. She said he must have just wet his bed because she is pretty sure the CNA staff checked on him about 2 hours ago. An interview with CNA A on 4/4/2024 at 4:22am, revealed she was responsible for Hall 500 . She stated she conducted 2-hour checks on the residents although most were asleep. She was asked if any of the residents had requested not to be awaken in the middle of the night and she responded, No, she checked on all of her residents and would change their briefs, if needed. An interview with CNA B on 4/4/2024 at 4:31am, revealed she was responsible for rounding every 2 hours and said she had checked on Resident #1 just a couple of hours ago and his brief did not need changing. She said she changed the residents as needed throughout the night. She said she was responsible for Hall 700 where Resident #1's room was located. She stated he sometimes got into his wheelchair unassisted although he is supposed to get assistance. She said she did not help him get into his wheelchair this morning(4/4/24). She said Resident #1 was asleep when she last checked on him. An interview with CNA C on 4/4/2024 at 4:37am, revealed her to deny that she was asleep as she was observed yawning and stretching as she walked out of an office located on Station 2. She said she was responsible for Hall 800 but usually worked 500. She said it is her job to check on all residents throughout the night. She said she changed residents' adult diapers as needed. She said some of the residents does not like to be disturbed and she make sure they are dry before they go to sleep. An interview with the DON on 4/4/2024 at 5:22am, she was informed Resident #1 was wet and was observed wiping his bed sheet with paper towels. She said she told and had the CNA give him a shower and changed his sheets. She said it is her expectation all residents are clean, dry, and safe in the facility. She said incontinent care is important in preventing skin breakdown and infections. An interview with the Administrator on 4/5/2024 at 2:30pm, she stated she was aware of the situation with Resident #1. She said she expect all of the nursing staff to ensure residents are clean and dry. She said she they are rounding every 2 hours. She said there are a few residents that are heavy wetters and should be checked on more often . She said she believed Resident #1 was a heavy wetter if she was not mistaken. She said all staff should be attentive to the needs of the residents. Record review of the facility's ADL policy revised on 3/2018 reflected #2 to state 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.

Based on observation, interview, and record review the facility failed to ensure that residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 residents (CR #1) reviewed for dialysis. The facility failed to ensure CR #1 received hemodialysis since she admitted to the facility on [DATE]. CR #1 missed dialysis on Saturday 2/10/24 and Tuesday 2/13/24. CR #1 was sent to the hospital on 2/14/24 with signs of altered mental status, increased confusion, and lethargy. The facility failed to document monitoring of CR #1's dialysis port (access site used when blood is transported from the body for cleaning) The facility failed to obtain a signed contract with CR #1's dialysis center. An immediate jeopardy (IJ) was identified on 2/16/24 at 12:26 p.m. While the IJ was removed on 2/17/24 at 12:43 p.m., 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 isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of missing vital treatments and experiencing worsening kidney damage, serious health side effects, and hospitalization . Findings include: Record review of CR#1's face sheet dated 2/15/24 revealed a [AGE] year-old female admitted on [DATE] and discharged to an acute care hospital on 2/14/24. Her diagnoses included end stage renal disease, unspecified kidney failure, heart failure, and mild cognitive impairment. Record review of CR #1's 5-day MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. She required supervision to maximal assistance with ADLs. Record review of CR #1's baseline care plan dated 2/14/24 revealed she was alert, cognitively intact, and required dialysis. Record review of CR #1's Hospital record dated 2/1/24 revealed Hemodialysis was completed on 2/3/24 and 2/6/24. She had a right upper arm arteriovenous graft (a synthetic access point into the body's circulatory system to perform dialysis) present on admission to the hospital (on 2/1/24). She had a tunneled hemodialysis catheter in the left internal jugular vein (a thin, plastic tube inserted under the skin for dialysis) placed on 11/29/23. Record review of CR #1's Hospital Progress Note dated 2/6/24 revealed CR #1 was a [AGE] year-old with known history of ESRD on Tuesday, Thursday, Saturday hemodialysis schedule. Assessment and Plan: 5. ESRD on hemodialysis - TTS schedule. Record review of Email Correspondence dated 2/8/24 at 4:14 p.m. from CR #1's dialysis center to the Admission Coordinator read in part, .I am needing the following information to request a contract between our facilities from our legal department . Once I receive this, I can request a contract draft from my legal department. Once they send it to me, I will send back to you for review and if everything is good your Administrator can sign and once returned to me, I will need my RVP to sign and then I will send you a completed signed copy . Record review of Email Correspondence dated 2/8/24 at 4:22 p.m. from the Admissions Coordinator to CR #1's dialysis center revealed the requested information for the contract was completed and returned. The email read, . Can you include me in the email when you send it please. And can (CR #1) start dialysis or until contract has been signed? . There were no further emails. Record review of CR #1's Clinical admitted d 2/9/24 revealed hemodialysis was not selected. There was no documentation regarding her dialysis port. Record review of the facility's 24-Hour Summary Report dated 2/9/24 - 2/10/24 and 2/10/24 - 2/11/24 revealed handwritten notes that CR #1 had hemodialysis on T-Th-S. The note was written by LVN B. Record review of CR #1's History and Physical dated 2/10/24 by NP A read in part, .initial assessment status post hospitalization for pneumonia, respiratory failure, acute on chronic HF, ESRD . Diagnosis, Assessment and Plan: End stage renal disease: HD per nephro . Dependence on renal dialysis: continue with HD per nephro . Record review of CR #1's skilled evaluation dated 2/11/24 by LVN M revealed hemodialysis was selected. There was no documentation about her dialysis port. Record review of CR #1's skilled evaluation dated 2/12/24 by LVN Z revealed hemodialysis was selected. There was no documentation about her dialysis port. Record review of CR #1's Progress Note dated 2/12/24 by MD B read in part, .Patient seen today - she is stable and not in distress . She is also tolerating dialysis . diagnosis, assessment, and plan: . dependence on renal dialysis: continue with HD . Record review of the facility's 24-Hour Summary dated 2/12/24 - 2/13/24 revealed handwritten notes that CR #1 had hemodialysis on T-Th-S. The note also read, Monitor . (family member) concerned about her being asleep all the time. Record review of CR #'1's Progress Note dated 2/13/24 by NP B read in part, .patient in bed alert, awake, talking . Chest: dialysis port . Diagnosis, Assessment, and Plan . End stage renal disease: HD three times per week t/th/sat . Record review of CR #1's Physician Orders for February 2024 revealed: 1.Dialysis days T-Th-Sat do not arrive later than 6:45 a.m. by w/c, order date 2/14/24. 2.Dialysis address: . chair time 6:30 a.m. please do not arrive any later than 6:45 a.m., order date 2/14/24. 3.Dialysis - left subclavian port notify MD/NP for any unusual/unexpected findings every shift, order date 2/14/24. Record review of CR #1's Medication Administration Record for February 2024 revealed there was no documentation of dialysis or port monitoring between 2/9/24 - 2/14/24. In an observation and interview on 2/13/24 at 11:58 a.m., CR #1 was lying in her bed in the facility. She said she felt fine, but the staff were not very good and rushed her care. CR #1 coughed multiple times but said she felt fine. Record review of CR #1's nursing note dated 2/13/24 at 10:01 a.m. (Late Entry Date: 2/14/24 at 4:23 p.m.) by LVN Z read, .This writer to ask resident's name. Resident response was (correct name). This writer to ask resident's name 10 seconds later, resident responded (incorrect name). ADON to inform MD, New order in place to send resident to hospital for further evaluation. Record review of CR #1's nursing note dated 2/14/24 at 9:35 a.m. by ADON A read in part, Late entry, resident didn't want to go to dialysis on yesterday. (Name) NP aware will be in the building to assess. Record review of CR #1's nursing note dated 2/14/24 at 9:51 a.m. by ADON A read, This nurse assess resident and informed NP of my findings of confusion and lethargy, ordered to send to hospital. Record review of CR #1's nursing note dated 2/14/24 at 11:45 a.m. by LVN Z read, Two EMS in facility to transport resident to hospital . resident in stable condition at time of discharge. Record review of CR #1's SBAR Communication Form dated 2/14/24 by ADON A revealed the change in condition, symptoms, or signs observed and evaluated was: altered mental status. The condition, symptom, or sign had not occurred before. The Mental Status Evaluation was: an altered level of consciousness. The Function Status Evaluation was: needs more assistance with ADLs. The recommendation was to send to hospital. In an interview on 2/14/24 at 4:02 p.m. LVN Z said CR #1 was sent to the hospital for altered mental status. She said this morning (2/14/24) she asked CR #1 for her name and CR#1 responded incorrectly. She said yesterday (2/13/24) she was able to make her needs known when she hit the call light but this morning (2/14/24) she could not remember why she hit the light. She said the resident was on dialysis and she monitored the shunt for bleeding. She said the dialysis orders were put in today. She said CR #1 refused to go to dialysis on Tuesday 2/13/24 but said the resident did not tell the refusal to her. In an observation and interview on 2/14/24 at 4:15 p.m. with ADON A, she said CR #1 was more lethargic and confused today. She said she had altered mental status and could be getting toxic. She said she notified the NP and the NP said to send her out to the hospital to be dialyzed. She said CR #1 did not go to dialysis on Saturday (2/10/24). She said her ejection fraction (the amount of blood pumped out of your heart's lower chambers each time it contracts) was 26 (ejection fraction in a healthy heart is 50% to 70%) and they were discussing CR #1 going on hospice. She said CR #1 told her she was not going to dialysis on Saturday because her family member said they were not going to do dialysis. She said at that time CR #1 was alert but had some confusion. ADON A said yesterday (Tuesday, 2/13/24) she asked CR #1 if she was going to dialysis and CR #1 said no because she did not feel good. She said she entered CR #1's dialysis orders into the system today (2/14/24) because she was scrubbing her medical charts. She said the orders were in CR #1's hospital history and physical and she had not followed up on the resident's chart prior to today. She said CR #1's dialysis orders should have been in the system so everyone would know about the orders. She said she did not know why they were not put in the system on admission. She said she could not say if nurses were monitoring the dialysis port. She said the port should be monitored for bleeding because a resident could bleed out and die quickly. She said if a resident refused dialysis, staff should notify the MD. Observation of ADON A's cell phone revealed a new admission alert text message. The message included CR #1's name, dialysis days T-Th-Sat, chair time: 6:30 a.m., and dialysis address. In an interview on 2/14/24 at 4:47 p.m. with LVN Z, she said she was supposed to document the assessment of CR #1's dialysis port in her chart. In an interview on 2/15/24 at 9:04 a.m. with CR #1's family member, she said she was not aware CR #1 was sent to the hospital and was not notified about her missing dialysis on Saturday and Tuesday. She said CR #1 had been a dialysis resident for over [AGE] years and would never refuse dialysis because she knew what happened if she missed even one treatment. She said she was at the facility on Monday and Tuesday (2/12/24 and 2/13/24) of this week and CR #1 was heavily sedated. She said she reported the information to LVN M. She said CR #1's dialysis days were Tuesday, Thursday, and Saturday. She said no one got the resident up on Tuesday for dialysis and she missed it. She said she also missed dialysis on Saturday 2/10/24. She said it would be bad if CR #1 missed dialysis. She said the family never had a conversation with the facility about CR #1 not going to dialysis and said the family chose this facility because the facility had a contract with CR #1's dialysis center. She said the facility informed her how she would get to dialysis, were aware of the chair time, would assist her with getting ready and would send her to dialysis. In an interview on 2/15/24 at 9:43 a.m. CNA A said she worked with CR #1 on Saturday and Tuesday. She said she did not know CR #1 was a dialysis resident until she was sent to the hospital yesterday (2/14/24) for dialysis. She said CR #1 did not go to dialysis on Saturday. She said no one told her (CNA A) that she needed to go. She said on Tuesday (2/13/24) CR #1 asked her if she was going to dialysis today (Tuesday) and said she was supposed to go to dialysis. She said CR #1 wanted to get in her chair and said she should be getting ready for dialysis today. CNA said she told CR #1 she was not sure and would ask the nurse. CNA said the nurse told her no. She said CR #1 was a new resident and she (CNA) did not know her dialysis days. She said she did not ask the resident and the nurse did not say anything about her being a dialysis resident. In an interview on 2/15/24 at 10:00 a.m. with NP B, she said she saw CR #1 in the facility on Tuesday 2/13/24 and she was alert and oriented at the time. She said she looked at CR #1's dialysis port and nothing was going on. She said CR #1 told her during the visit that her dialysis days were Tuesday, Thursday, and Saturday. She said CR #1 did not say anything about refusing to go. She said ADON A reported to her on Wednesday 2/14/24 that CR #1 was more confused and missed dialysis on Saturday and Tuesday because she refused. The NP said she was not aware prior to Wednesday of the resident refusals. She said the facility usually notified the MD/NPs of dialysis refusals and would normally contact her. She said for the first dialysis refusal, if the resident was stable, the facility should call the dialysis center and reschedule dialysis for the next day. She said for the second dialysis refusal, or if symptomatic, the resident must go to the hospital. She said symptoms could include edema (swelling caused due to excess fluid accumulation in the body tissues), shortness of breath, and not feeling well. She said she ordered to send CR #1 to the hospital because she missed dialysis and had symptoms. She said dialysis was needed and she did not want the resident to miss it. She said the facility told her the resident was dialyzed on Friday 2/9/24 prior to admitting to the facility. She said CR #1 should have gone to dialysis on Saturday. In an interview on 2/15/24 at 10:46 a.m. with CR #1's family member, she said when CR #1 did not get dialysis it caused a major impact on her functioning. In an interview on 2/15/24 at 11:05 a.m. with ADON A (with CR #1's family members present), ADON A said CR #1 went to the hospital and ADON A was informed CR #1 would not let the hospital dialyze her last night (2/14/24). In an interview on 2/15/24 at 11:32 a.m. with CR #1's dialysis center, the representative said CR #1's first day missed at the dialysis center was on 2/3/24 and she had not been back since. She said the nursing facility called the dialysis center on 2/8/24 (one day prior to admission) to obtain a nursing home contract. She said the dialysis center sent an email to the facility to obtain information, but they never received a response back. She said they never had a contract with the facility. In an interview on 2/15/24 at 12:19 p.m. with LVN S she said she helped with CR #1's admission and put her orders into the system. She said she did not recall entering dialysis orders for CR #1. She said she medication orders came from the hospital discharge paperwork. She said if the dialysis orders were not on the paper with the medications, she was not sure where to find it. She said CR #1 did not mention dialysis to her that day and she did not see any dialysis ports on the resident. LVN S said she was not trained on admitting residents but there was a packet available at the nurses station with admission instructions that she did not have to refer to. She said if she saw an order for dialysis, she would have put it in. She said she did not have to arrange anything for CR #1. In an interview on 2/15/24 at 12:39 p.m. with the Admissions Coordinator, she said she was working on obtaining the contract with the dialysis center. She said she sent the information for the contract to the dialysis center on 2/8/24 but did not get a response. She said she called the center the next day to speak with the clinical manager, but she was not there. She said she was informed by the dialysis center that they were working on the contract. She said it was required for them to have dialysis contract but if the contract is in progress, they would still accept the resident. She said the facility did not receive a signed contract and she did not follow up with the dialysis center this week, but it was on her follow up list. She said she did not set up transportation for CR #1 because she was a wheelchair transport and the facility transferred residents in wheelchairs. She said she sent out a new admission alert text to the department heads on 2/9/24 with CR #1's dialysis information. She said she did not receive a text back. She said Van Driver A was not on the group text. In an interview on 2/15/24 at 1:34 p.m. with the DON, she said she was not aware of CR #1's admission until she returned to work on Tuesday 2/13/24. She said she did not learn of the dialysis refusal until Wednesday (2/14/24) and said she was unsure about CR #1's dialysis on Saturday. She said if a resident refuses dialysis nurses should talk to the doctor to see what they want to do, educate the resident, and document in the chart for communication purposes. She said CR #1's dialysis orders were not put in on admission and they should have been because it was a part of her admission. She said there was no legitimate way to know if the dialysis orders were carried out or not and said there was a phrase that said if it was not documented it did not happen. She said ADON A should have reviewed the orders by Monday but did not know why they were not verified. In an interview on 2/15/24 at 2:08 p.m. ADON A said CR #1 refused dialysis. She said CR #1 was confused on Saturday and it was progressive. She said if a resident refused dialysis the nurse should call the MD and get instructions. She said she did not call the MD. She said the facility should have notified the MD. She said CR #1 refused with the night nurse and she did not find out about it until Tuesday. She said she called NP B and told her she did not go to dialysis. In an interview on 2/15/24 at 2:20 p.m. with the Administrator, she said ADON A informed her on Wednesday (2/14/24) that CR #1 refused dialysis on Tuesday (2/13/24). She said ADON A did not say anything about Saturday. She said she did not know if CR #1's dialysis orders were put into the system on admission. She said the orders should be put in because they had to follow MD orders and communicate what the plan is. She said she could not say if the van drivers were made aware of CR #1's need for dialysis transportation. She said she expected for residents to be transported to and from dialysis. She said resident families and the NP should be contacted on refusals and the protocol for dialysis refusals was to encourage the resident. She said the NP should be contacted at the initial refusal because dialysis is serious, and the facility had to ensure the resident received care and services. She said she and the Admissions Coordinator were responsible for dialysis contracts and said they did not typically admit residents if there was no contract to ensure they are on the same page. In an interview on 2/15/24 at 2:48 p.m. with the Hospital Charge Nurse, she said per CR #1's admission note, CR #1 was admitted from the nursing home due to missing dialysis for 1 week. She said there were no notes of CR #1 refusing dialysis and she had it today in the hospital. In an interview on 2/15/24 at 3:06 p.m. with CR #1 in the local hospital. She said she kept telling the nurses and aides at the nursing facility that she needed to go to dialysis and her dialysis days were T, Th, and Sat. She said staff kept telling her she would go tomorrow but she never did. She said she sat her clothes out on Monday afternoon in anticipation of going to dialysis on Tuesday morning and staff asked her Why are you setting clothes out when dialysis is not until tomorrow? You do not need to set clothes out today. She said she never refused dialysis because she knew what it would do to her body. She said she first started to feel bad on Monday 2/12/24. She said she felt confused/disoriented and started calling a lot. She said she started having jerky movements with her hands and she knew it was from missing dialysis. She said she was tired and slept all day. She said they kept ignoring her and then all of a sudden, they rushed her to the hospital for dialysis (on 2/14/24). She said she still had some jerky movements and could not hear out of her left ear when she could before. In an interview on 2/15/24 at 3:41 p.m. with the Hospital RN, she said the nursing facility called her this morning to get an update on CR #1. She said since CR #1 was admitted to the hospital for missing dialysis, she asked the facility why CR #1 missed dialysis. The facility told her that CR #1 refused. The Hospital RN said she never told the facility that CR #1 refused dialysis at the hospital. She said CR #1 never refused dialysis at the hospital and she had it early this morning. In an interview on 2/15/24 at 5:36 p.m. with LVN K she said when she came to work on Saturday 2/10/24 she received report from the night nurse LVN B that CR #1 was stable. She said LVN B did not say anything to her about dialysis or refusals for CR #1. She said there may have been something on the paper shift report about dialysis, but she could not remember. She said she was not aware CR #1 was a dialysis resident and did not find out until yesterday (2/14/24). She said CR #1 did not say anything to her about dialysis. She said she was not aware of a dialysis port and there were no skin assessments done. She said she normally found out about dialysis through the resident's admission packet and through report. In an interview on 2/15/24 at 6:07 p.m. with LVN B she said she knew CR #1 went to dialysis on T, Th, Sat but said she was unaware of her chair time and did not think she would be sent out on her shift, the night shift. She said she saw CR #1 dialysis days on her hospital paperwork and wrote the days down on the 24-hour report. She said CR #1 did not refuse anything with her and she did not have to notify the physician. She said CR #1's admitting nurse put her orders in and passed the information onto LVN B's partner nurse, LVN C. She said CR #1's dialysis orders should have been in the system. She said if her chair time was at 6:45 a.m. she would have been sent out on her shift, the night shift. She said no one told her CR #1 would be going out on her shift and there was no report given to her about dialysis. She said the nurse to relieve her was LVN K. She said when she came back to work the next night during shift report there was nothing to report and no changes. She said she asked the nurse if everyone went to dialysis and the nurse said yes. She said she did not specifically ask if CR #1 went to dialysis. She said she was not trained on new admissions but said there was a paper that told them what to do. In an interview on 2/15/24 at 6:44 p.m. with LVN C she said she assisted LVN S by completing the last portion of CR #1's admission assessment - the ADL and transfer portion. She said she did not remember if CR #1 said anything to her about dialysis. She said she did not recall seeing information on CR #1's dialysis. In an interview on 2/15/24 at 7:00 p.m. with CR #1's family member, she said CR #1 received dialysis at the hospital today. She said the hospital had no recollection of CR #1 refusing dialysis at the hospital as said by ADON A earlier. She said CR #1 made an outcry that she wanted to go to dialysis while at the nursing facility but could not. In an interview on 2/16/24 at 1:51 p.m. with Van Driver A, she said she provided transportation for residents in wheelchairs to dialysis and doctors appointments. She said she did not know who CR #1 was and only had one new resident since October 2023 that the Administrator notified her of, Resident #3. She said on Tuesdays she arrived at the facility between 6:30 a.m. and 6:50 a.m. and transported Resident #3, Resident #49, and Resident #23 to dialysis. She said since she started as the van driver she was only notified of one dialysis refusal one time and that was with Resident #23 around the time of the Christmas party. In an interview on 2/16/24 at 7:46 p.m. with LVN M she said she knew CR #1 was on dialysis but did not know her chair time and thought she would be leaving on the morning shift. She said she did not have to get CR #1's dialysis paperwork ready. This Surveyor told LVN M that CR #1's chair time was no later than 6:45 a.m. LVN M said if it was at that time CR #1 would have left on her shift between 5 and 6 a.m. She said she reported to the day shift verbally and maybe on the 24 hour summary report that everyone on 100, 300, and 400 were on the T ,Th, Sat dialysis schedule. She said CR #1 was a new admission and the information was not passed on. She said on Tuesday night (2/13/24) CR #1's family member came to the facility. She said she (LVN M) looked for CR #1's dialysis communication paper and it was not there. In an interview on 2/17/24 at 5:21 p.m. LVN M said on Tuesday night 2/13/24 CR #1's family member was in the facility and was concerned about CR #1 being so tired. She said CR #1's family member told her she was supposed to go to dialysis. She said she checked to see if she went but saw she did not. She said CR #1 did not refuse dialysis with her but maybe did that morning. She said she never sent the resident out to dialysis. Record review of email correspondence between this Surveyor and the Administrator revealed the dialysis contract for CR #1's dialysis center and the nursing facility was requested on 2/16/24 at 6:30 p.m., 2/17/24 at 7:57 a.m., and 2/17/24 at 12:57 p.m. The contract was not provided. Record review of email correspondence between this Surveyor and the Administrator dated 2/17/24 at 1:12 p.m. revealed the Administrator said she would reach out to the dialysis center on Monday (2/19/24). Record review of the facility's policy End-Stage Renal Disease, Care of a Resident with dated September 2010 read in part, .Residents with end-stage renal disease will be cared for according to currently recognized standards of care. Policy Interpretation and Implementation: .4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed . Record review of the facility's policy Hemodialysis Catheters - Access and Care of dated February 2023 read in part, .Care of Central Dialysis Catheters 1. The central catheter site must be kept clean and dry at all times . Documentation: the nurse should document in the resident's medical record every shift as follows: 1. Location of catheter, 2. Condition of dressing . 3. If dialysis was done during shift. 4. Any part of report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis . Record review of the facility's policy Requesting, Refusing and/or Discontinuing Care or Treatment dated February 2021 read in part, .1. Residents/representatives are informed (in advance) of: a. the care that will be furnished or made available to the resident based on his or her assessment and plan of care; b. the risks and benefits of the proposed care, treatment, treatment alternatives or treatment options . 5. If a resident/representative requests, discontinues or refuses care or treatment, an appropriate member of the IDT will meet with the resident/representative to: a. determine why he or she is requesting, refusing or discontinuing care or treatment; b. try to address his or her concerns and discuss alternative options; and c. discuss the potential outcomes or consequences (positive and negative) of the decision . On 2/16/24 at 12:26 p.m. the Administrator was notified of the Immediate Jeopardy due to the above failures. The IJ template was provided to the Administrator and a plan of removal was requested at that time. The following Plan of Removal (POR) was submitted by the facility and accepted on 2/17/24 at 9:12 a.m.: IMMEDIATE JEOPARDY PLAN OF REMOVAL February 16, 2024 IMMEDIATE ACTION: Please accept this as a Plan of Removal to remove the IJ Identified in area of Quality of Care Systematic Approach: 1. CR #1 was transferred to on 2/14/24 at 11:45 am for further evaluation and treatment. 2. The Medical Director was immediately notified by the Administrator on 2/16/24 at 1:41pm and the Chief Operating Officer at 12:32 pm of Immediate Jeopardy. 3. Administrator reviewed facility's policy on Care of a Resident with End-Stage Renal Disease, Care of Residents on Hemodialysis, Charting Guidelines, Change in Condition and Refusal of Treatment and CMS Dialysis Critical Element Pathway on 2/16/24. Charting Guidelines were modified on 2/16/24 to specifically include hemodialysis care. 4. All current Dialysis Appointments will be entered on the Resident Event calendar in PCC, facility's EHR system on 2/16/24 which is viewable by all clinical users. License Nurses, Dept. Managers and Van Drivers will be in-service on this process 2/16/24-2/17/24 by the Administrator. All future dialysis appointments will be added upon admission. New nurses, department managers and van drivers will be trained on this process during orientation. 5. All current Dialysis Residents (including name of Dialysis Center and day/time of chair appointment) will be entered on the PCC Dashboard on 2/16/24 to ensure all users are aware. New admissions requiring hemodialysis services will be added upon admission. 6. Order template for dialysis orders was reviewed by the regional nurse consultant on 2/16/24; these order templates will be queued in PCC by the DON, nurse manager. 7. and/or weekend RN supervisor for all residents requiring hemodialysis prior to admission to facility. 8. 100% of Charge nurses (RN/LVN), Nurse Managers and Weekend Supervisor will be educated per the DON by 2/17/2024 on the following topics. Any nurse who has (sic) completed the training will be removed from the schedule until their training is completed. A. Admission/Readmission Process, which will emphasis (sic) the importance of reviewing transferring clinicals to determine the Plan of care, required Medical Equipment or Specialty Supplies is warranted. Emphasis placed on required care and documentation of residents requiring hemodialysis B. Notification of Change in Condition of physician and responsible party C. Entering and following Physician Orders in a timely manner D. Resident Assessment related to residents' receiving hemodialysis E. Care of Residents with End Stage Renal Disease F. Hemodialysis Access Care and documentation G. Dialysis Communication Form H. Charting Guidelines I. Refusal of Care and Treatment J. Resident Rights and how to address residents' concerns The topics above will be included in the New Hire Training for nurses hired after 2/16/2024. 9. The facility DON conducted an audit on 2/15/24 on all 7 residents receiving dialysis services to ensure orders are entered and are carried out according to MD Order. The audit findings revealed that all orders were accurate and complete. A clinical assessment will be performed on current Dialysis Residents on 2/16/24 by the nurse managers. 10. Monitoring a. The DON will conduct weekly randomized audits for a period of 4 weeks ensuring Nursing Staff Members demonstrate knowledge of Policies and Procedures for residents receiving Dialysis. b. New/Readmissions' charts will be reviewed daily by the DON, ADON and/or Weekend RN Supervision to ensure completeness and compliance with corrective actions within the first 24 hours of admission beginning 2/17/24. c. A new Admission Checklist will be implemented on 2/16/24 for all residents to ensure the completion of each system. Nurses will be in-serviced on this process on 2/16/24-2/17/24. 11. Root Cause Analysis was conducted on 2/16/24 and identified issues related to transcribing of orders, assessment of residents and effective shift reporting. Director of Nursing will conduct training with 100% of [NAME] [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure the environment remained as free of accident hazards as is possible for 3 of 7 residents' rooms (Resident #84, Resident #80, and Resident #33) reviewed for accidents. -The facility failed to maintain water temperatures at a safe temperature level in Resident #84, Resident #80, and Resident #33's bathrooms. This failure could place residents at risk of injuries and burns. Findings include: Resident #84 Record review of Resident #84's face sheet revealed a [AGE] year-old male admitted on [DATE]. His diagnosis included convulsions (a medical event in which nerve cell activity in the brain is disrupted, causing muscles to involuntarily contract and spasm), Wernicke's encephalopathy (a disorder that primarily affects the memory system in the brain), heart disease, and depression. Record review of Resident #84's admission MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. He required supervision with toileting hygiene. In an observation and interview on 2/13/24 at 9:43 a.m. with Resident #84, his bathroom sink water was hot to touch and this Surveyor removed fingers from the water after approximately 2 seconds. Resident #84 said he used the restroom and sink. He said it was hard to find the warm water and it was either cold or really hot. In an observation and interview on 2/13/24 at 2:08 p.m. of Resident #84's bathroom, the Maintenance Director took the sink water's temperature using his thermometer and the temperature ranged from 128 F to 130.4 F. The Maintenance Director said the water was hot and said it was not like that last week. Resident #84 said the window between the hot and cold water was very narrow. Resident #80 Record review of Resident #80's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnosis included heart failure, syncope (fainting or passing out) and collapse, lack of coordination, and need for assistance with personal care. Record review of Resident #80's quarterly MDS assessment dated [DATE] revealed a BIMS score was 5 out of 15 which indicated severe cognitive impairment. She required partial to moderate assistance with toileting hygiene. In an observation and interview on 2/13/24 at 1:38 p.m. with Resident #80, her bathroom sink water was hot to touch. Resident #80 said she used the restroom and sink, and said the water was ok. In an observation on 2/13/24 at 2:11 p.m. of Resident #80's bathroom, the Maintenance Director took the sink water's temperature with his thermometer and the temperature was 128.1 F. Resident #33 Record review of Resident #33's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnosis included hemiplegia (paralysis on one side) and hemiparesis (partial paralysis on one side) following cerebral infarction (stroke), need for personal care, anemia (low number of red blood cells), depression, and diabetes. Record review of Resident #33's admission MDS assessment dated [DATE] revealed a BIMS score was 15 out of 15 which indicated no cognitive impairment. She required substantial to maximal assistance with toileting hygiene. In an observation and interview on 2/13/24 at 9:23 a.m. with Resident #33, her bathroom sink water was hot to touch and this Surveyor removed fingers from the water after approximately 2 seconds. Resident #33 said she could not walk and did not use her restroom. Interview on 2/13/24 at 2:01 p.m. with the Maintenance Director, he said he started working at the facility 2 weeks ago. He said he tested water temperatures on each hall once per week. He said he conducted one week of testing since starting. He said water temperatures should be between 102 F - 110 F. In an observation on 2/13/24 at 2:12 p.m. of Resident #33's bathroom, the Maintenance Director took the sink water's temperature with his thermometer and the temperature was 128 F. Interview on 2/13/24 at 2:20 p.m. the Maintenance Director said he was responsible for checking water temperatures. He said he checked the temperatures one week and they were good. He said he was unsure how the water temperatures rose. He said he liked to keep the water temperatures between 102 F and 120 F and if the water was too hot the residents could burn their hands. He said he would adjust the hot water heater. In an observation on 2/13/24 at 2:38 p.m. of the hot water heaters revealed Tank #1's temperature was 124 F and operating set point was 120 F. Tank #2's temperature was 133 F and operating set point was 133 F. In an observation and interview on 2/13/24 at 2:43 p.m. with CNA G, she said the resident bathroom water did not get too hot. She entered Resident #33's bathroom and turned the hot water on. CNA G touched the water and said it was hot, hot, too hot. She said she had to pull her hand back a little from the water. She said the water temperature had not been like that. Interview on 2/13/24 at 3:59 p.m. with the Administrator, she said the upper water limit was 120 F. She said she did not know how the temperature got out of range and she had not given her key to the hot water tank room to anyone. She said the Maintenance Director monitored the water temperatures and was responsible for ensuring the temperatures were in range. She said the Maintenance Director had temperature logs and checked hot water heaters if the water was beyond the temperature. She said there were no complaints from staff or residents regarding hot water temperatures and no residents were affected. She said some residents had fragile skin and may not be able to handle the temperature. She said she did not want anyone to get injured and it could be a safety risk. Interview on 2/14/24 at 11:08 a.m. with the Maintenance Director, he said he adjusted the hot water tanks to an operating temperature of 111 F yesterday 2/13/24. In an observation on 2/14/24 at 11:10 a.m. of Resident #33's bathroom sink revealed the hot water was warm and no longer hot to touch. Record review of the facility's Logbook Documentation dated 2/13/24 revealed the water temperatures were marked done on time by the Maintenance Director on 2/9/24. Water temperatures were tested on each hallway and resulted the following on 2/9/24: 100 hall -107 F, 200 hall - 108 F, 300 hall - 106 F, 400 hall - 109 F, 500 hall - 107 F, 600 hall - 105 F, 700 hall - 109 F, and 800 hall - 105 F. Record review of the facility's policy Water Temperatures, Safety of dated December 2009 read in part, .Tap water in the facility shall be kept within a temperature range to prevent scalding of residents . 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 F or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log .

Based on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for 2 (Resident #35 and Resident #30) out of 18 residents reviewed for care plan accuracy. -The facility failed to update Resident #35's comprehensive care plan to include an updated BIMS score and removal of the left hand posey (something to grip to help prevent contractures) and the right-hand carrot (something to grip with a severe hand contracture). -The facility failed to update Resident #30's comprehensive care plan to include the oxygen she was using and remove the finger extension brace (splint worn for contracture management in the fingers) and the hand splints (splint worn to protect joints by positioning correctly) which were not being used. These failures could place residents at risk of their medical, physical, and psychosocial needs not being met. Findings include: Resident #35 Record review of Resident #35's undated face sheet revealed she was a [AGE] year-old female readmitted on [DATE], with an original admitted [DATE]. She had diagnoses of acute respiratory failure (lungs cannot release enough oxygen into the blood), pneumonia (infection of the lungs), chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe), encephalopathy (condition that causes brain dysfunction), gastrostomy (tube into stomach for nutrition), muscle wasting and atrophy, joint contracture (tightening or shortening causing deformity), hemiplegia affecting right side (paralysis), quadriplegia (paralysis of upper and lower extremities), and bed confinement. Record review of Resident #35's Quarterly MDS dated [DATE] revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. The MDS revealed she had impairment on one side of her upper extremities and lower extremities and used a wheelchair. She was dependent with personal hygiene, putting on/taking off footwear, lower/upper body dressing, shower/bath, toileting hygiene, oral hygiene, and eating. She was also dependent with rolling left and right, chair/bed-to-chair transfer, and tub/shower transfer. According to the MDS, Resident #35 was receiving OT, but she was not on the Restorative Nursing program (nursing interventions that promotere resident's ability to adapt/adjust to living indepedently). Record review of Resident #35's care plan dated 12/18/23, revealed a Focus: Restorative: Resident #35 has Right hand carrot [something to grip with a severe hand contracture] and left hand posey [something to grip to help prevent contractures] (Initiated: 8/18/23, Revised 8/18/23). Goal: Individualized assistance with right hand carrot [something to grip with a severe hand contracture] and left posey [something to grip to help prevent contractures] will be provided (Initiated: 8/18/23, Revised: 8/18/23, Target: 12/3/23). Interventions: Dependent upon trained staff with the application and/or removal of prosthetic device, brace or splint x 5 per week x2 hrs (Initiated: 8/18/23, Revised: 9/13/23). Requires assistance from trained staff with the application and/or removal of a prosthetic device, brace or splint 5 per week x2 hrs (Initiated: 8/18/23, Revised: 9/13/23). Focus: Resident #35 has a cognitive deficit r/t late effects of CVA (stroke), long/short term memory deficit, BIMS 00 (Initiated: 9/19/16, Revised: 6/21/23). Goal: Resident #35 will improve current level of cognitive function through the review date (Initiated: 9/19/16, Revised: 3/24/23, Target: 12/3/23). Interventions: Communicate with Resident #35's caregivers regarding my capabilities and needs (Initiated: 9/19/16, Revised: 9/22/17). Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status (Initiated: 9/19/16). Record review of Resident #35's Physician Orders revealed the following order from MD A: -R hand carrot [something to grip with a severe hand contracture] and left hand posey daily [something to grip to help prevent contractures], one time a day for contracture management. Remove per schedule. Ordered on 8/18/23 at 8:00am and discontinued on 12/6/23 at 9:13am. Record review of Resident #35's Restorative Nursing Program flow sheet from January 2024 revealed Goal: Pt to wear R hand posey (something to grip to help prevent contractures) 2-4hrs x5 times a week, signed by the Rehab Director and the DON. In an observation and interview on 2/13/24 at 8:44am with Resident #35 she was lying on her back in bed. She had aphasia (unable to speak) and was unable to communicate. She did not have any splints or braces on her hands. In an observation on 2/14/24 at 10:03am with Resident #35, she was asleep on her back in bed. She had prevalon boots (heel protection boots) on and was on an air mattress, but no splints/braces were seen on her hands. Resident #30 Record review of Resident #30's undated face sheet revealed she was an [AGE] year-old female readmitted on [DATE] with an original admitted [DATE]. She had diagnoses of Alzheimer's disease, contracture of left hand, contracture of joint, muscle wasting and atrophy, contracture of right hand (tightening or shortening causing deformity), encephalopathy (condition that causes brain dysfunction), palliative care, dementia, need for assistance with personal care, dysphagia (trouble swallowing), cardiac arrest (heart stopped), history of falling, and speech and language deficits following cerebrovascular disease (conditions that affect blood flow and blood vessels in the brain). Record review of Resident #30's Quarterly MDS dated [DATE], revealed a BIMS was unable to be performed due to her condition. The MDS revealed she had impairment on one side of her upper and lower extremities, and she did not use a mobility device due to being bedbound. According to the MDS, she was dependent with all self-care activities, and with rolling left to right in bed, chair/bed to chair transfer, tub/shower transfers, and all other mobility activities were unable to be performed due to her condition. The MDS revealed the resident was on oxygen, received ST, OT, PT, but did not mention Restorative Nursing (nursing interventions that promotere resident's ability to adapt/adjust to living indepedently). Record review of Resident #30's care plan dated 12/20/23, revealed a Focus: Resident #30 has ADL self-care performance deficits r/t cognitive and mobility impairment (Initiated: 12/31/17, Revised: 4/12/23). Goal: Restorative: Resident #30 will maintain or increase to max assistance with feed finger foods while seated in wheelchair in feeder dining room through the review date (Initiated: 9/30/20, Revised: 11/10/23, Target: 1/10/24). Interventions: Personal hygiene/oral care: Place hand splints [splint worn to protect joints by positioning correctly] on both hands every morning, remove at bedtime (Initiated: 8/14/21). Focus: The resident has an alteration in musculoskeletal status right hand contracture in all fingers. Finger extension brace [splint worn for contracture management in the fingers] given to decrease contracture. To be worn 16 hours of the day (Initiated: 9/30/20, Revised: 1/12/24). Goal: The resident will be free of complications r/t contracture management through review date (Initiated: 9/30/20, Revised: 11/10/23, Target: 1/10/24). Interventions: Follow facility protocol, PT treatment plan, MD orders, for contracture management, report abnormalities to care team (Initiated: 9/30/20, Revised: 5/5/21). The care plan did not mention the continuous oxygen she was on. Record review of Resident #30's medical record revealed the following Physician Orders from MD B: -O2 @ 2L/min via NC continuous to maintain O2 sats > 92%, every shift. Ordered on 8/9/23 at 6:00pm. -Apply right and left hand posey [something to grip to help prevent contractures], one time a day for contracture management. Apply at 8:00am and remove at 8:00pm. Ordered 8/18/23 at 7:29am. Record review of Resident #30's Physician Orders revealed there were no orders for the hand splints or the finger extension brace. Record review of Resident #30's January and February 2024 MAR/TAR's revealed no record of the hand splints or finger extension brace. However, it did reveal documentation of the resident using O2 @ 2L via NC. In an observation on 2/14/24 at 10:09am, Resident #30 was asleep on her back in bed. She had oxygen via NC and left and right hand posey's on. A finger extension was not observed, neither were the hand splints. Interview with the MDS Coordinator on 2/16/24 at 2:10pm, she said she had only been working at the facility for 2 weeks. She said the IDT met once a week and they would update the care plans at that time. She said it was a team effort to update the care plans and not one person specifically was responsible for updating them. Interview with the DON on 2/16/24 at 2:15pm, she said the IDT met once a week and it was a team effort to update the care plans at that time. She said they discuss the residents at the meeting and update the care plan accordingly. She said the Director of Rehab and herself were responsible for updating the care plans relating to the Restorative Therapy. Interview with the Director of Rehab on 2/16/24 at 2:50pm, she said she started in October 2023 and when she first started, she walked the building with the OT and evaluated the residents to see who were on Restorative Therapy and who needed it. She said she wrote orders for the Restorative Therapy devices and the DON reviewed them and signed off on them. She said she also gave a copy to the ADON, and she would update the computer. She was unsure if the ADON was creating an order for it or not. She also said she attended the IDT meeting and discussed which residents were on Restorative Therapy and then the ADON would update the care plans accordingly, she never touched the care plans. She would re-evaluate residents every 3mths for therapy. Record review of the facility's policy and procedure on Care Plans, Comprehensive Person-Centered (revised March 2022) read in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is delivered within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes, b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .c. includes the resident's stated goals upon admission and desired outcomes, d. builds on the resident's strengths, and e. reflects currently recognized standards of practice for problem areas and conditions .10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition, b. when the desired outcome is not met, c. when the resident has been readmitted to the facility from a hospital stay, and d. at least quarterly, in conjunction with the required quarterly MDS assessment .

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 1 Resident (#56) reviewed for oxygen in that: -Resident #56's oxygen was administered at 3 Liters Per Minute instead of 2 Liters Per Minute via nasal cannula as ordered by the physician. This deficient practice could affect Resident #56 who received oxygen continuously and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. Findings include: Record review of Resident #56's face sheet revealed that Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Pneumonia (an infection of the lungs that may be caused by bacteria, viruses, or fungi)-unspecified Organism; Acute respiratory Failure with hypoxia; and Emphysema (a lung condition that causes shortness of breath)-unspecified, pleural effusion in other conditions classified elsewhere. Record review of Resident #56's December 2023 Consolidated Physician's Orders revealed an order for oxygen continuous at 2 Liters Per Minute (LPM) per nasal cannula with a start date of 12/16/2023. Observation on 02/13/24 at 09:21 AM revealed Resident #56's O2 rate was at 3 liters. Observation on 02/13/2024 at 4:01 PM revealed Resident #56's O2 rate was at 3 liters. Interview on 02/13/2024 at 4:02 PM with the ADON B, she said the nurse in charge should check the Oxygen level on every shift. The ADON looked at the oxygen and confirmed the oxygen tank was set at 3 LPM instead of 2 LPM as ordered by the physician. In a phone interview on 02/15/24 at 08:41 AM, LVN H said that she should check the Oxygen level before signing off on it as administered, but she misread it or did not pay closer attention and signed off for 2 liters. She said that the nurses had to check the O2 every shift. She said she was aware of the consequences of administering more Oxygen than required to a resident. She said the resident could become dependent on more Oxygen than needed. A review of Resident #56's Care plan dated 12/16/2023 read, The resident has oxygen therapy as ordered and PRN r/t CHF H. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Review of the undated facility oxygen administration procedures stated, Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute.

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 on one of two medication carts (the 100/300/400 nurse cart) reviewed for pharmacy services. -The facility failed to account for 53 of CR #1's Oxycodone-Acetaminophen tablets. - Staff failed to document the administration of narcotic medications in a correct manner for CR #1. This failure could place residents at risk for drug diversion and delay in medication administration. Findings include: Record review of CR#1's face sheet revealed a [AGE] year-old female admitted on [DATE] and discharged to an acute care hospital on 2/14/24. Her diagnoses included spondylosis without myelopathy or radiculopathy, lumbar region (a small crack between two vertebrae without spinal cord compression or nerve root compression), polyneuropathy (damage to multiple peripheral nerves), end stage renal disease, unspecified kidney failure, heart failure, and mild cognitive impairment. Record review of CR #1's 5-day MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. Record review of CR #1's baseline care plan dated 2/14/24 revealed she was alert, cognitively intact, and did not have pain. Record review of CR #1's Pain assessment dated [DATE] by LVN C revealed she did not have pain or was hurting at any time in the last 5 days. Record review of CR #1's History and Physical dated 2/10/24 by NP A revealed she complained of chronic back pain. Diagnosis, Assessment, and Plan: Back pain, continue with Percocet (oxycodone/APAP), lidocaine patch, Flexeril, gabapentin; continue to monitor pain level; discussed with staff to administer pain medication and to reassess. Record review of Resident CR #1's Physician's order dated 02/09/24 revealed an order for oxycodone-Acetaminophen oral tablet 10-325 mg (oxycodone w/Acetaminophen) give 325 mg (1 tablet) by mouth every 4 hours as needed for pain. Record review of CR #1's Medication Administration Record for the month of February 2024 revealed Oxycodone-Acetaminophen oral tablet 10-325 mg was not documented as administered on 02/09/24, 02/10/24, 02/11/24, 02/12/24, 02/13/24 and 02/14/24. Record review of CR #1's Narcotic Record for Oxycodone-Acetaminophen 10 mg - 325 mg dated 2/9/24 revealed 60 tablets were received on 2/9/24. The next entry revealed a corrected count with 59 tablets remaining. The following entries indicated there were 52 tablets documented as administered/removed from the blister pack between 2/10/24 and 2/14/24. One portion of the record did not account for 1 tablet when the documentation skipped from 41 tablets remaining to 39 tablets remaining. The handwriting was the same for those 52 entries and the dates, times, and signatures were illegible. There were 20 entries that did not have a nurse signature. There were 6 tablets remaining on the Narcotic Record. In an observation on 2/15/24 at 10:50 a.m. of CR #1's Oxycodone/APAP 10 mg - 325 mg tablet blister pack which was removed from the 100/300/400 nurse cart revealed there were 6 tablets remaining out of 60. In an interview on 2/15/24 at 9:04 a.m. with CR #1's family member, she said she visited the facility on 2/13/24 and CR #1 was heavily sedated. She said she told LVN M to take her off the pain medicine. In an interview on 2/15/24 at 12:19 p.m. with LVN S. She said she put CR #1's orders in during admission. She said CR #1 was not in pain at that time. In an interview on 2/15/24 at 3:06 p.m. with CR #1 in the local hospital, she said she never asked for any pain medication or Oxycodone while at the Nursing Home. She said she was taking it at the hospital before the nursing home, but never needed it at the facility. She said nursing staff asked her about pain only a couple times and she said she did not have any pain. She said she told staff when she first came to the facility that she did not want any pain medication. She said staff never told her that they were giving her pain medication or Oxycodone. In an interview on 2/15/24 at 5:36 p.m. with LVN F, she said CR #1 did not have any complaints of pain. She said she did not give her any Oxycodone. In an interview on 2/15/24 at 6:07 p.m. with LVN B, she said CR #1 did not complain of pain. She said she never had to administer Oxycodone to the resident. She said when she did narcotic count during shift change, she and the next nurse would compare the number of pills on the narcotic record with the number of pills in the blister pack. She said the focus was on if the numbers matched. She said when a prn narcotic was given, the nurse would document the time, amount given, amount remaining, and their signature. She said if a signature was missing, she would notify the ADON. In an interview on 2/16/24 at 9:20 a.m., LVN D said she was the nurse for hall 100, 300 and 400. She said she followed the facility's protocol to sign off any resident's medication given/refused on their MAR. She said if a resident received, refused, or did not receive scheduled or PRN medication she would always sign it off on their MAR. LVN D was not able to say what negative outcomes on Residents if their narcotics were not signed off on the MAR. In an interview on 2/16/24 at 9:43 a.m., LVN F said she knew she was to sign-out on the narcotic count sheet after administration and on the medication administration record. She said the failure to do that would cause the narcotic count to show less on the next count and it could lead to a narcotics diversion. She said she had done in-service on medication administration. In an interview on 2/16/24 at 12:23 p.m., with the Administrator, she said oxycodone-Acetaminophen was signed out during the shift of LVN Z from 2/9/24 to 2/14/24. DON reviewed the medications during a family complaint. It was revealed that medications had been signed out for during the time CR #1 was hospitalized . LVN Z was suspended pending investigation. She was asked to submit to a drug screen. LVN Z submitted to a drug screen at the facility that showed a positive result. LVN Z stated that it was an incorrect reading, so she was outsourced for a drug screening and the ADON followed the LVN Z to the location. In an interview on 2/16/24 at 3:30 p.m. with LVN Z, she said CR #1 was not in pain and she was not familiar with and did not administer Oxycodone-APAP to the resident. She said she arrived at the facility (on 2/16/24) and took a drug screen. She said her test had faint lines and was told she tested positive for benzodiazepines and two other things. She said she was offered to go to an outside vendor but when she got there, she was unable to produce enough urine. She said the outside vendor offered her water, but she decided she did not trust the facility. In an interview on 02/16/24 at 4:20p.m., with the DON and the Administrator. The DON said her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the MAR and to sign on the narcotic log to prevent discrepancies and to have proof the medications were administered. DON said the risk of not logging after administering the medication resident could be administered overdose or miss the dose. She said it was a standard practice for nurses to log off narcotics as they administer. She said she did random audits by comparing the narcotic sheets and by counting the medication. She said she did not check the MARs during those audits. The DON identified the staff member who failed to sign off the oxycodone-Acetaminophen for CR #1's MAR as LVN Z. In an interview on 2/16/24 at 7:46 p.m. with LVN M, she said CR #1 never asked her for pain medicine. She said on Tuesday night (2/13/24) CR #1's family member came in and asked if the Oxycodone and other medications could be discontinued. She said there were 59 Oxycodone tablets remaining at that time. She said she passed the cart on to LVN Z during shift change Wednesday morning (2/14/24) and there was only 1 of CR #1's Oxycodone/APAP pill (out of 60) missing that time. Record review of facility's Administering Medications policy (Revised April 2019) revealed read in part: .Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug . Record review of facility's Controlled Substances (Revised April 2019) revealed read in part: .Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation: 10. Upon Administration: a. The nurse administering the medication is responsible for recording: (1) Name of the resident receiving the medication; (2) Name, strength and dose of the medication; (3) Time of administration; (4) Method of administration; (5) Quantity of the medication remaining; and (6) Signature of nurse administering medication . 40249

Based on interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents 1 of 15 residents (CR #1) reviewed for accidents hazards/supervision/devices, in that: -The facility failed to ensure that CR#1 received adequate supervision. CR#1 eloped from the facility on [DATE]. CR #1 was located hours later and transferred to the hospital where he died from heat stroke. --The facility failed to identify CR #1 who had diagnosis of dementia and history of wandering, as an elopement risk. CR #1 was allowed to exit the facility freely without any supervision on ,d+[DATE]. CR #1 was found several hours later lying on the ground. CR #1 was transferred to the hospital where he died from exposure from the heat. --The facility failed to train staff on researching resident's history when assessing residents for wandering or triggering on being an elopement risk. This failure could place all 14 residents with a history of wandering at risk for injury. On [DATE] at 5:00 p.m. an Immediate Jeopardy (IJ) was identified. the I.J. was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could affect residents and place them at risk of wandering, elopement, and other dangers that could result in injury or death. The findings were: Record review of CR #1's face sheet dated [DATE] revealed he was a [AGE] year-old male that was admitted to the nursing facility on [DATE] with a diagnosis of unspecified dementia with behaviors; Record review of CR #1's Admission MDS assessment dated [DATE] revealed that Section I: Active diagnoses was blank. The BIMS) was a 4 indicating CR #1 was severe impairment for mental status. Section E revealed: behavior present was disorganized thinking. CR #1 was capable of walking in room, walking in corridor, walking on and off unit with supervision requiring no assistive devices. Record review of CR #1's care plan initiated [DATE] did not indicate he was an elopement risk or wanderer. Record review of CR # 1's Admission Wandering assessment dated [DATE] revealed CR #1 was independent with no assist with mobility, diagnoses and history of wandering were incomplete. CR #1 scored a 2 on the assessment which indicated he was low risk for wandering. Record review of the facility 24-hour summary report dated [DATE] and to [DATE] revealed CR #1 was noted to not be in his room for lunch, staff alerted, search initiated found in neighborhood. No wander-guard. Hospital. Record review of the facility reported incident investigation for CR #1 revealed the incident date was [DATE] at 10:30 a.m Incident Type reflected Missing Resident/Individual. Level of Supervision revealed no special supervision and independently ambulatory. The report reflected CR #1's capacity to make informed decisions indicated no. Description of the allegation reflected CNA S assigned to CR #1 delivered his lunch tray around 12 p.m CNA S returned at approximately 12:15 p.m. to see if CR #1 was eating his meal but he could not be located. Injury or adverse effect indicated yes and that CR #1 had irregular breathing upon arrival of EMS. Further evaluation and treatment was performed at the nearest acute care setting. Assessment time and date [DATE] at 2:30 p.m. Description of Assessment reflected an assessment was performed per EMS. CR #1 was transferred to Hospital P on [DATE] at 3:30 p.m. Record review of the facility reported incident dated [DATE], reflected in part, .The Weekend Supervisor [RN T] reported that [CR #1] was missing and could not be located. He was last seen 10:00 am. At 2:00 PM, the resident was found by 3 CNA's and the Charge Nurse in a neighborhood five minutes away from the facility. [CR #1] was assessed by hospital staff and admitted to the ICU due to suffering from a heat stroke. The Resident remains in the hospital Record Review of a written statement by Receptionist A revealed on [DATE] she buzzed CR #1 out of the facility at 10:00 a.m. Receptionist A statement reflected she did not recognize CR #1 as a facility resident and buzzed him out of the secured front entry around 10:00 a.m. on [DATE]. Receptionist A's statement reflected she had not been trained on the use of an elopement or wander guard binder or any exact policies or procedures regarding elopement. CR #1 did not trigger for wander guard, Record review of CR #1's nurse progress notes dated [DATE] at 2:45 p.m. reflected in part, .Nurse's Note-Note Text: 1pm During change of shift report, the (CNA S) assigned to [CR #1] notified writer resident was not accounted for. Writer (Weekend Supervisor/RN T) asked the aide (CNA S) when the last time she saw the resident. She (CNA S) stated she served him breakfast around 8am and later saw him at 10am. [CR#1's] lunch tray was delivered around 12 noon. At 12:15 [p.m.], she went back to his room and noticed his tray wasn't touched. Writer (Weekend Supervisor/RN T) immediately initiated the missing resident protocol by having all rooms and locations within the facility searched. The outside perimeters were searched for [CR# 1]. This Writer (Weekend Supervisor/RN T) notified the administrator of the situation. The Administrator stated she is enroute to the facility to assist. Writer interviewed all staff in all departments to determine if they had seen the resident. Statements were obtained from staff members working this shift. When interviewing the Receptionist (Receptionist A), she stated she did recall seeing the resident around 10am. Writer (Weekend Supervisor/RN T) retrieved a picture of the resident from electronic medical record for identifying purposes and had the staff search outside premises and proximal areas within the neighborhood. The local Police Department was notified, and a missing person report was generated by the police. Upon search, a charge nurse and other staff members from this facility located the resident at a nearby neighborhood. Emergency assistance called to examine the resident. Family was notified and informed of the resident missing and located. The resident will be taken to Hospital P for evaluation and treatment. Informed family additional information will be provided upon investigation. MD notified Record review of nurse progress on [DATE] at 4:00 p.m. reflected : Nurse's Note Late Entry: Note Text: Around 12:45 PM this writer was notified by CNA S she could not locate the resident. This writer (Charge Nurse/Agency Nurse/LVN M) asked CNA S to go check all rooms, restrooms, and outside areas to find the CR #'1. After charting some info into the computer this writer (Charge Nurse/Agency Nurse/LVN M) then went to find CNA S to see if she had located the resident. Around 1:15 PM this writer (Charge Nurse/Agency Nurse/LVN M) and the nurse manager (Weekend Supervisor/RN T) were having a discussion at the med cart and CNA S came back and stated, I do not see the resident. Immediately after being told that, this writer (Charge Nurse/Agency Nurse/LVN M) and the nurse manager (Weekend Supervisor/RN T) went to check all rooms and restrooms on other halls. This writer (Charge Nurse/Agency Nurse/LVN M) and the nurse manager (Weekend Supervisor/RN T) asked the receptionist (Receptionist A) if she had opened the door to let the resident walk out the door and she responded, No only two residents left the facility today and they have both returned. Once the nurses could not locate the resident the nurse manager (Weekend Supervisor/RN T) instructed some of the staff to get in their personal vehicles and search for CR #1. This writer (Charge Nurse/Agency Nurse/LVN M) drove around the area to look for the resident while the one other nurse, med aide, and two CNAs went in opposite directions. After going to local gas stations, parks, bus stations, and community streets, LVN M returned to the facility at approximately 1:50 PM. At that time, LVM notified the nurse manager (Weekend Supervisor/RN T) that she did not locate the resident. At this time a police officer was entering the facility and Weekend Supervisor/RN T was handing over documentation for the police to write up a report on the resident. This was also the time the nurse manager informed this writer (Charge Nurse/Agency Nurse/LVN M) that the receptionist withdrew her original statement telling her she let the resident out of the facility around 10:00 AM. Weekend Supervisor/RN T asked this writer (Charge Nurse/Agency Nurse/LVN M) to write a statement and advised this writer (Charge Nurse/Agency Nurse/LVN M) she was waiting for the Administrator to arrive and then the Administrator would call and notify the family. After the statement was given to Weekend Supervisor/RN T, this writer (Charge Nurse/Agency Nurse/LVN M) informed Weekend Supervisor/RN T that she (Charge Nurse/Agency Nurse/LVN M)) would go and look for resident one more time in the opposite direction. At Approximately 2:20 PM while driving more community streets, Charge Nurse/Agency Nurse/LVN M noticed a person lying on the sidewalk outside of a home on the intersection of [street names]. Upon getting out of the car and walking up to the CR #1 Charge Nurse/Agency Nurse/LVN M) asked him for his name and CR #1 did not respond. Charge Nurse/Agency Nurse/LVN M) then noticed that CR #1 was breathing but breathing regularly. Charge Nurse/Agency Nurse/LVN M immediately placed a call to 911. Call placed to facility to notify Weekend Supervisor/RN T that CR #1 had been located. Two CNAs and MDS arrived at the location where the resident was found to assist. Shortly after that, EMS arrived and worked on the resident and once CR#1 was stable he was transported to Hospital P. Upon arriving back at the facility, this writer (Charge Nurse/Agency Nurse/LVN M) was waiting in the lobby to speak with the Administrator. The Administrator was currently interviewing the CNA assigned to CR #1 and then she interviewed the receptionist. Next, the Administrator called this writer (Charge Nurse/Agency Nurse/LVN M) into the room to discuss the details of the incident. The Administrator told this writer (Charge Nurse/Agency Nurse/LVN M) to write an additional statement. The Administrator then went into her office to speak to the CR #1's family member on the phone. At this time no further documentation was requested. Record review of the EMS records dated [DATE] reflected in part the initial greet date/time was [DATE] at 3:12 p.m The EMS records reflected CR#1 resided at a nursing home and nursing home personnel had not seen him for at least 2 hours. He was then found lying outside in the grass. They reported CR #1 was hyposensitive, [CONDITION(S)] (fast heart rate), unresponsive and hypoxic (lower than normal oxygen) with an SPO2 in the 50's upon arrival. Record review of CR #1's hospital records with an admitted [DATE] and date of death [DATE] reflected in part that a [AGE] year-old male with a past history of hypertension, dementia who lived in a nursing home, memory care unit, was found outside with a temperature of 108 degrees Fahrenheit. The records reflected CR #1 was brought to the ER for further evaluation and within a few minutes went into V. tach arrest. CR #1 was resuscitated after about 4 minutes and intubated, sedated and had hypothermia. The records reflected the hospital's course to date indicated cardiac arrest ,d+[DATE] heat stroke and CR#1 underwent hypothermia (low body temperature) but no clinical signs of meaningful brain activity. This was discussed with CR #1's family, they wanted comfort care, including terminal extubation. This was done, and CR #1 expired. Sunburn with blisters were noted to the right side of CR #1's body. Record review of CR #1's hospital ICU notes dated [DATE] reflected in part CR #1 arrived via ambulance and his principal admitting diagnosis was heat stroke. Final coding summary reflected in part . cardiac arrest, heat stroke and sunstroke, brain death, burn of second degree of lower back, burn of second degree of shoulder, wrist hand, and exposure to excessive natural heat. Record review of CR #1's death packet from the hospital records dated [DATE] reflected in part, nursing Unit-ICU, date admitted [DATE] at 5:22 pm. CR #1 expired on [DATE] at 8:55 p.m. and his admitting diagnosis was heat stroke. An interview on [DATE] at 11:56 a.m. with an anonymous person regarding CR #1, the anonymous person said they were not provided the care requested or required for CR # 1 and that the Administrator and management were made aware of CR #1's medical conditions including CR #1's history of wandering but failed to provide supervision as promised. The anonymous person stated, [CR # 1] baked outside like a turkey and was all alone becoming emotional. An interview on [DATE] at 1:00 p.m. with LVN D, she said on [DATE] at around 12:45 p.m. she was told by CNA S that she could not find CR #1. She said she told CNA S to tell CR #1's nurse. She said CR #1 still could not be found after checking every room so she told Weekend Supervisor/RN T and Charge Nurse/Agency Nurse/ LVN M. An interview on [DATE] at 1:28 p.m. with CNA S, she stated she was CR #1's CNA and she s took CR #1 breakfast and he laid down and slept. She said CR #1 was independent with ambulating. She said she returned CR #1's room with his lunch tray and set-up the tray but he was not on his bed. She said she returned around 12:15 p.m. and CR #1 was still not there so she went to tell Charge Nurse/Agency Nurse/LVN M. She said she continued to search for CR #1 and that she told Charge Nurse/Agency Nurse/LVN M that she could not find CR #1 three times before Charge Nurse/Agency Nurse/LVN M she came to help. Interview on [DATE] at 2:03 p.m. with Medication Aide E, she said she last saw CR #1 at 10:00 a.m. when she gave him his supplement but there was documentation that the Charge Nurse/Agency Nurse/LVN M, gave CR #1 his supplement. An interview on [DATE] at 10:03 a.m. with LVN J, he said he performed the admission assessment and wandering assessment for CR #1. He said the hospital sent a folder/chart and the history and physical of the resident should be in the folder/chart. He said when a nurse gave him report he looks at the information sent from the hospital and the nurse did not tell him that CR #1 was a wander risk. He said he did not do the wander assessment because he was not told CR #1 was a wander risk. He stated he would have done the wander assessment if he were told about the risk. He added he would do a wandering risk assessment if a resident had a diagnosis of dementia. Record review at this time of CR #1's hospital discharge/history and physical record dated [DATE] revealed CR #1 had a previous history of wandering. LVN J stated, I don't remember, it's been too long. During an interview with Medical Records/Central Supply B on [DATE] at 10:26 a.m., she said she was made aware of CR #1 missing on [DATE] at 1:26 p.m. by the Weekend Supervisor/RN T. She said she went out searching for CR #1 arriving at the scene about 2 minutes before 3:00 p.m. and EMS, the Administrator and Charge Nurse/Agency Nurse/LVN M were already there. An interview on [DATE] at 12:57 p.m. with ADON H, she said LVN J completed the Admission and Wandering Risk Assessment for CR #1. She also said the nurses used a hospital transfer paper to admit residents but could not locate the document for CR #1. In an interview on [DATE] at 1:12 p.m. with Receptionist A, she said the day CR #1 eloped she did not know he was a resident, she thought he was family and buzzed CR #1 out at 10:00 a.m. She said she was formerly an Activity Assistant, and she would get to know residents while in that position. She said she did not know about a book at the front to identify residents and if there was a book no one told her. She stated she was aware now because she and the Administrator worked on it together after the incident. Interview and observation with Receptionist B on [DATE] at 9:48 a.m. revealed when asked where the elopement binder was, Receptionist B she did not know what the Surveyor was talking about. The Surveyor then asked Receptionist B for the resident wander guard binder the facility said they kept at the front desk since the incident with CR #1 and she said the binder was not at the desk and then said she needed to ask the Administrator. Receptionist B left the desk to ask the Administrator where it was kept. The Administrator returned to the front desk with Receptionist B and found a red binder called wander guard in a drawer at the front desk. The Administrator asked the Surveyor to give her time to look at the binder first and said she would bring the binder back for the Surveyor to review in a few minutes. Continued interview with Receptionist B at the front desk, who said she got confused by the term elopement binder and not wander guard. She said the way she checked if a resident was a wander risk was if they came to the front doors and got too close to them the wander guard alarm would sound. She said that was the way she checked to see if the wander guards were working for the residents. When asked if she checked each resident in the binder identified as a wander risk, she said no, only the residents that wandered to the front door. When asked who was responsible for updating the elopement/wander guard binder for at risk residents, she said it was the job of Medical Records. Receptionist B said she had not updated the elopement/wander guard binder and did not know when the elopement/wander guard binder had been updated or if it had been updated since the incident with CR #1 on [DATE]. Interview with Medical Records/Central Supply B on [DATE] at 10:07 a.m., she said she thought the Administrator had assigned her to update the elopement/wander guard binder kept at the front desk. She then said she was unsure who was specifically assigned to update the binder. She said it was a collaborative effort between the Receptionists, Social Worker, ADON and DON and the at- risk residents were discussed in the morning meetings but there was no DON or social worker currently and she was not sure who had been keeping up with updating the binder. Medical Records said she had not updated or handled the elopement/wander guard binder since [DATE]. She also said she did not think the binder had been updated since the incident on [DATE] with CR #1. Interview with the Administrator on [DATE] at 11:30 a.m., she said she updated the elopement/wander guard binder herself and that the facility identified the at-risk residents in their morning meetings with all department heads. When asked why a list she presented with current elopement/wander risk residents had 11 residents listed but the elopement/wander guard binder had 13 residents listed, she said she had been working on updating the binder when the Surveyor asked for it and that 2 residents had been discharged . She then corrected herself and said that 1 resident had been discharged and 1 resident was pending discharge and she had just had not gotten the chance to remove their information from the elopement/wander guard binder. Telephone interview with Agency Owner on [DATE] at 12:33 p.m. revealed her agency did not specifically train agency nurses or staff on elopement drills or what to do if a resident wandered or eloped. She said the individual facilities were responsible for training agency nurses/staff on their own policies, procedures, and protocols. She said Agency LVN A would not have had any training from her agency prior to her working the day of the incident with CR #1. In a telephone interview with Charge Nurse/Agency Nurse/LVN M, on [DATE] at 12:53 p.m. she said she had only worked at the facility twice and said the first time was on an overnight shift but could not recall the date. She said she was notified by a CNA around 12:,d+[DATE]:45 p.m. that CR #1 was missing. Charge Nurse/Agency Nurse/LVN M said at the time the CNA reported this, she was busy with another resident who had just returned from [CONDITION(S)], so she told the CNA to continue looking and come back after she had finished with the other resident. She said the CNA returned after ,d+[DATE] minutes and was still unable to find CR #1, so she stopped what she was doing and joined the search. Charge Nurse/Agency Nurse/LVN M said around that same time she and the CNA reported CR #1 as missing to the weekend supervisor. She said she had not been trained by the facility on their elopement drills, policies or procedures, but had started searching the bathrooms, other resident rooms and the outside perimeter of the facility before eventually getting in her car and searching for CR #1. She said she found CR #1 ,d+[DATE] blocks away from the facility and it was a warm, sunny day. Charge Nurse/Agency Nurse/LVN M said CR #1 was wearing black bottoms and had on a grey tee shirt and was lying on his left side face down with labored breathing. She said he was not responding and was unconscious but she did not notice any physical injuries at that time. She said she immediately called 911 and then the facility. She said she had 2 phones with her at the time and was making calls simultaneously. She said she remained with the resident and then 2 CNA's and the Administrator arrived and then 911. She said if she had not been dealing with the [CONDITION(S)] resident, she would have started to look for CR #1 sooner but wanted to finish with that task and resident first and had never worked that unit before. She said no one reported to her that CR #1 had a history of elopement or wandering, and she was not provided a list of those residents at risk, or she would have been monitoring CR #1 more closely. She said after the incident someone said that CR #1 would get confused sometimes and had a history of dementia. A telephone interview on [DATE] at 1:05 p.m. with the MDS Nurse/RN S, he said he remembered CR #1. He said he completed CR # 1's Admission MDS. He said when he evaluated CR #1, he did not see the record about CR #1's previous elopement. When the Surveyor asked about Section I of the MDS being blank and any other sources of documentation he used to complete the assessment, he stated, I don't know. I was there prn to fill in and do care plans. In a follow up interview with the Administrator on [DATE] at 1:16 p.m. she said Charge Nurse/Agency Nurse/LVN M had been trained on the facility's elopement/wander guard polices, practices and procedures and she would provide in-services. The Administrator returned and said she did not have training for Charge Nurse/Agency Nurse/LVN M. When asked why the admission MDS for CR #1 did not have any diagnoses in Section I she said she did not know and would have to look into that. The Administrator said the residents MDS' were being completed off-site at the time of CR #1's admission. When asked if CR #1's admission hospital records had been shared with staff and the MDS Coordinator at the time of his admission, she said she thought staff had access to the records. When asked why CR #1's initial elopement risk assessment did not identify him as being at risk, despite his admission hospital records reflecting he had a significant history for elopement and wandering which was the qualifying hospital stay for his facility admission. She said she did not know why staff had not identified that history upon CR #1's admission. The Administrator said that CR #1 had a diagnosis of dementia and had never tried to elope from the facility before the incident on [DATE]. Record review of the facility's policy and procedure entitled Emergency Procedure-Missing Resident revised [DATE] reflected in part .Resident elopement resulting in a missing resident is considered a facility emergency .Staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located. Record review of the facility's policy entitled Wandering and Elopements revised [DATE] reflected in part .the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm .If an employee observes a resident leaving the premises, he/she should attempt to prevent the resident from leaving the premises. Record review of the facility's policy entitled, Elopement/Missing Resident-Code Green no date provided read in part .Staff will respond in a timely and organized manner to search for a resident who has eloped or is missing when a resident is noted missing .the staff shall inform the DON or the Charge Nurse .The DON or Charge Nurse will then make the following announcement: Code Green all staff report to the nursing station three times. Record review of the facility's protocol entitled Front Desk Protocol' dated [DATE] reflected in part . if in doubt that it is a resident or visitor, question who they are visiting. Plan of Removal - Quality Care Immediate Action: The following actions have been taken regarding Quality of Care: [DATE] Plan of Removal The facility took the following corrective action: 1. CR #1 status - Resident was located ,d+[DATE] blocks from facility-by-facility nurse, 911 was called and CR#1 was taken to the hospital on [DATE]. CR #1 expired several days later; specific date is unknown. 2. Administrator reviewed facility's policy and procedure for elopement on [DATE] with no revisions noted. 3. Nurses were educated by the ADON on [DATE] regarding the Admission/Re-admission process which stressed the importance of reviewing transferring clinicals to determine any risk factors the resident may have and complete risk assessments accordingly. 100% Training will be completed with Nurses on [DATE]. Wandering Risk assessments are completed upon admission. Agency Nurses will be oriented to the Admission/Readmission process prior to their initial shift. Any Nurse not trained by [DATE] will not be allowed to work. Wandering risk and interventions are included on the admission and comprehensive care plans. Care plans of residents identified as a wandering risk were updated on [DATE]. 4. Education regarding the facility's elopement policy and procedure (Emergency Procedure - Missing Resident Procedure) was conducted with all staff (facility/contracted/agency) on [DATE]-[DATE] by the facility Administrator. Education completed on [DATE] with ongoing training in New Hire Orientation. Agency Company provided with training form accompanied with policies and procedures on [DATE]. Agency staff to be educated prior to their initial work schedule. This education included: Elopement and Wandering, Unusual Occurrence Reporting, Abuse & Neglect, and Front Desk Policy. Emergency Procedure - Missing Resident: Protocol Summary - o Alert staff of resident missing immediately following the initial search within the facility, but not more than 10 minutes o Note the time that the resident was discovered missing. o Report to the nursing station to see if the resident was signed out. o Notify the Administrator, Director of Maintenance, and Director of Nursing if not on the premises. o Report to the resident's unit for briefing and instruction. o Initiate a thorough search by staff members to locate the resident o If the search is unsuccessful, call the police to report the resident missing. o Notify the family/responsible party and attending physician if the resident is not found in the facility or the grounds. o When the resident is found: Notify all staff members. Examine the resident for injuries. Notify the attending physician of the resident's status. Contact the family/responsible person and inform of his/her status (ensure all the above steps are documented in the nursing notes). o Complete an incident report and follow the facility's incident reporting process. o Report the incident to the State Licensing and Certification Agency according to regulation. o Report the incident to the Quality Assurance/Risk/Safety Committee. o The Front Desk Personnel were in serviced on [DATE]-[DATE] to ensure all visitors on scanning in and obtaining a visitors' badge. At the conclusion of their visit to scan out of the kiosk. Signage is posted above the kiosk Instructing all visitors on the scanning process. 5. Wander risk assessments were completed by nursing leadership and charge nurses on all residents based on facility documentation and pertinent historical documentation on [DATE] to identify residents at risk for elopement. Care plans were reviewed for all at-risk residents to ensure all appropriate interventions were in place on [DATE]. As of [DATE] facility had eleven (11) residents identified as at risk for wandering/elopement. 6. Wander guard sensors were placed on all newly identified at-risk residents [DATE] by nursing leadership and charge nurses. Nursing leadership updated the care plans to reflect interventions (use of wander guard sensors, monitor whereabouts residents at risk, assess for risk for falls, fatigue, provide diversionary activities that engage residents). Staff were informed of updated care plans by Administrator and Nursing Leadership and a list of residents who were identified at risk for wandering was added on [DATE] to the dashboard of electronic health record (Point Click Care) for quick reference and identification. 7. Wander guard sensors for all residents previously identified as wanderer/elopement risk were checked on [DATE]. Wander guard placement is checked every shift and checked daily to ensure the sensor is functioning properly by the charge nurse on [DATE]. 8. Physicians and families and/or responsible parties of residents identified as wanderers and requiring wander guard sensors were notified by phone on [DATE] by nursing leadership or charge nurse 9. Pre-Admission process reviewed by Chief Nursing Officer on [DATE] to ensure diagnosis of Dementia and history of wandering/elopement were identified prior to admission. Preadmission Screening Form updated to include Wanders/History of Elopement and facility leadership team responsible for the review of documentation to complete the Pre-Admission Assessment / Screening (Admission Coordinator, Business Office Manager, Director of Nursing, Asst. Director of Nursing, MDS Coordinator, Director of Rehab, Social Worker, and Activity Director) trained on [DATE] by facility Administrator. 10. The Elopement Risk binder updated and placed at the front desk with facility elopement policy and procedure, resident face sheet, wandering assessment and picture of residents at risk for elopement on [DATE] by the facility Administrator. Facility staff, including receptionists/staff assigned to cover the front desk, were trained by the facility Administrator on the Elopement Risk binder by the Administrator [DATE]-[DATE]. Staff were instructed on using the elopement binder to identify residents at risk for wandering/elopement prior to unlocking the exterior door and allowing a resident to exit. Additionally, the list of at risk residents is located on the dashboard of the electronic health system/Point Click Care 11. Nurses were in serviced on Reviewing Preadmission Documents upon admission on [DATE] to ensure diagnosis and plan of care is individualized and meets the resident's safety needs by the facility administrator and nursing leadership. 12. Administrator notified the facility's Chief Executive Officer and Chief Nursing Officer, as well as the Medical Director of the IJ on [DATE]. 13. Root cause analysis was conducted [DATE] and identified issue related to comprehensive review of pre-admission documents to identify potential resident's safety risk factors and communicate, assess for, and address safety risk factors on initial care plan to ensure resident's needs are met. Facility administrator and nursing leadership conducted training to all staff to address areas identified. All Nurses will be trained by [DATE]. Any Nurse not trained by [DATE] will not be allowed to work. Agency staff will be orientated prior. Please see above trainings. QAPI meeting w [TRUNCATED]

Based on interview and record review, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 15 resident's (CR #1) reviewed for elopement and wandering. -The facility failed to ensure staff were competent in assessing residents for wandering or triggering for elopement. -The facility failed to ensure an Agency Nurse was competent in the facilities elopement/wandering policies and procedures. These failures could affect residents and place them at risk of a delay in implementing facility elopement/wandering procedures. Findings included: Record review of CR #1's face sheet revealed he was a [AGE] year-old that was admitted to the nursing facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of hospital records revealed CR #1 expired on [DATE]. Record review of CR #1's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Section I: Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section E revealed: Behavior present was disorganized thinking. CR #1 was capable of walking in room, walking in corridor, walking on and off unit with supervision requiring no assistive devices. Record review of CR #1's care plan initiated [DATE] did not reveal he was an elopement risk or wanderer. Record review of CR# 1's Admission Wandering assessment dated [DATE] revealed CR #1 was independent with no assist with mobility, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility 24-hour summary report dated [DATE] and to [DATE] revealed CR #1 was noted to not be in room for lunch, staff were alerted, search was initiated, and CR #1 was found in neighborhood. CR #1 was transferred to Hospital. Record review of the EMS records dated [DATE] reflected in part the initial greet date/time was [DATE] at 3:12 p.m. The EMS records reflected CR#1 resided at a nursing home and nursing home personnel had not seen him for at least 2 hours. He was then found lying outside in the grass. They reported CR #1 was hyposensitive, [CONDITION(S)] (fast heart rate), unresponsive and hypoxic (low oxygen rate) with an SPO2 in the 50's upon arrival. Record review of CR #1's hospital records with an admitted [DATE] and date of death [DATE] reflected in part that a [AGE] year-old male with a past history of hypertension, dementia who lived in a nursing home, memory care unit, was found outside with a temperature of 108 degrees Fahrenheit. The records reflected CR #1 was brought to the ER for further evaluation and within a few minutes went into V. tach arrest. CR #1 was resuscitated after about 4 minutes and intubated, sedated and had hypothermia. The records reflected the hospital's course to date indicated cardiac arrest ,d+[DATE] heat stroke and CR#1 underwent hypothermia (low body temperature) but no clinical signs of meaningful brain activity. This was discussed with CR #1's family, they wanted comfort care, including terminal extubation. This was done, and CR #1 expired. Sunburn with blisters were noted to the right side of CR#1's body. Record review of CR #1's hospital ICU notes dated [DATE] reflected in part CR #1 arrived via ambulance and his principal admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's death packet from the hospital records dated [DATE] reflected in part, nursing Unit-ICU, date admitted [DATE] at 5:22 pm. CR#1 expired on [DATE] at 8:55 p.m. and his admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A telephone interview with Agency owner on [DATE] at 12:33pm who said that her agency did not specifically train agency nurses or staff on elopement drills or what to do if a resident wanders or elopes. She said that the individual facilities were responsible for training agency nurses/staff on their own policies, procedures, and protocols. She said that Charge Nurse /Agency LVN M would not have had any training from her agency prior to her working the day of the incident with CR #1. In a telephone interview with Charge Nurse/Agency Nurse/LVN M, on [DATE] at 12:53pm she said that she had only worked at the facility twice and said the first time was on an overnight shift but could not recall the date. She said she was notified by a CNA around 12:,d+[DATE]:45 pm that CR #1 was missing. Charge Nurse/Agency Nurse/LVN M said at the time the CNA reported this, she was busy with another resident who had just returned from [CONDITION(S)], so she told the CNA to continue looking and come back after she had finished with the other resident. She said the CNA returned after ,d+[DATE] minutes and was still unable to find CR #1, so she stopped what she was doing and joined the search. Charge Nurse/Agency Nurse/LVN M said that around that same time she and the CNA reported CR #1 as missing to the weekend supervisor. She said she had not been trained by the facility on their elopement drills, policies or procedures, but had started searching the bathrooms, other resident rooms and the outside perimeter of the facility before eventually getting in her car and searching for CR #1. She said that she found CR # ,d+[DATE] blocks away from the facility and it was a warm, sunny day. Charge Nurse/Agency Nurse/LVN M said CR #1 was wearing black bottoms and had on a grey tee shirt and was lying on his left side face down with labored breathing. She said he was not responding, unconscious but did not notice any physical injuries at that time. She said she immediately called 911 and then facility. She said she had 2 phones with her at the time and was making calls simultaneously. She said she remained with the resident and then 2 CNA's, from the facility arrived and the Administrator and then 911. She said that if she had not been dealing with the [CONDITION(S)] resident, she would have started to look for CR #1 sooner but wanted to finish with that task and resident first and had never worked that unit before. She said that no one reported to her that CR #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said that after the incident someone said that CR #1 would get confused sometimes and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] An interview with Administrator on [DATE] at 1:16pm she said that Charge Nurse/Agency Nurse/LVN M had been trained on the facilities elopement/wander guard polices, practices and procedures and she would provide in-services. The Administrator returned and said she did not have training for Charge Nurse/Agency Nurse/LVN M. Record review of facility policy entitled Competency of Nursing Staff dated [DATE] reflected in part .licensed nurses .employed or contracted by the facility will participate in a facility-specific competency-based staff development program. Record review of the facility policy entitled Staff Development Program dated [DATE] reflected in part .all personnel must participate in initial orientation and regularly scheduled in-service training classes.

Based on observation and interview, and record review, the facility failed to immediately consult with the physician and notify the resident representative when the resident experienced a change in condition for 1 of 5 residents (Resident #1) reviewed for notification of changes in consulting physicians a change of condition: --The facility failed to notify the physician of x-ray results leading to Resident #1 being transferred 2 days later to the hospital, resulting in partial left foot amputation. These failures affected one resident and placed her at risk of not having the physician consulted and placed other residents at risk of not having physicians consulted concerning test results communicated which could cause hospitalization , surgeries, pain, and a decline in health. Findings included: Resident #1 Record review of Resident #1's Face Sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #1's Quarterly MDS dated [DATE] documented, in part: - She scored a 0 of 15 on her mental status exam (indicating severe cognitive impairment) - She was totally dependent of 1 staff for locomotion, and bathing. - She required extensive assistance and 1 staff physical assist with eating and toilet use. -Resident #1 required 2-person extensive assistance with bed mobility. -Skin conditions revealed infection control of the foot, pressure ulcer/injury care and application of dressings to feet. Staging was not identified for skin conditions. Record review of Resident #1's care plan, undated, revealed Resident #1 was care planned for diabetes Meletus with interventions to monitor/document/report to MD PRN for s/sx of infection to any open areas. She was care planned for the potential for pressure ulcer development and the goal was to have skin intact, free of redness, blisters or discoloration by/through review date. The interventions were to follow facility policies and protocols for the prevention/treatment of [REDACTED]. Monitor/document/report to MD PRN changes in skin status for CN. The care plan addressed Resident #1's actual impaired skin integrity with the goal being the impaired integrity will show signs of healing and remain free from infection by/through review date. The interventions were: .*Assess/record/monitor wound healing per MD orders. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. .*Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of Resident #1's Treatment Administration Orders dated 4/18/2020 revealed wound of the left toe was to be cleaned with wound cleanser, patted dry, apply [MEDICATION NAME] paint and dry dressing change. Dressing change was to be done daily every day shift. Record review of Resident #1's Skin observation tool dated 4/14/2020 revealed no new skin issues noted. Record review of Resident #1's Skin observation tool dated 4/21/2020 revealed left toe pressure sore treatment in progress. Record review of Resident #1's Radiology Results report date 4/28/2020 at 6:12 p.m. revealed Resident #1 had an x-ray examination date of 4/28/2020 at 5:07 p.m. and the procedure was for Foot AP and Lat 2V, The interpretation of the x-ray read: -Reason for study was Pain in Left foot -Results: fracture or destructive bone lesion is seen involving the distal medial aspect of the proximal phalanx of the first toe and base of the distal phalanx of the first toe with surrounding soft tissue swelling. There is diffuse osteopenia. The mid and distal phalanges of the second through fifth toes are not well seen. -Conclusion: Fracture or destructive bone lesion with pathologic fracture involving the phalanges of the first toe at the IP joint. Underlying osteo[DIAGNOSES REDACTED] or metastatic disease are possible etiologies. Recommend dedicated right first toe radiographs. Record review of Resident #1's Wound Care Physician Report dated 4/17/2020 signed at 9:04 a.m .wound left toe orders to cleanse/protect wound with normal saline, wound dressing to apply [MEDICATION NAME] or [MEDICATION NAME] iodine paint and dry dressing. The physician report order said to change dressing daily and pressure relief/offloading to off load the wound. The wound was acquired on 3/18/2020 at the facility. The wound is acute with the wound measurements: Length: (cm) 1.5, width: (cm) 1.5, depth: (cm) 0.1, hyper granulated: No, Area: (sq. cm) based on length and width 2.25, volume: (cm3) based on Area Depth 0.225. There was no change noted to the wound. The stage was unstageable pressure injury obscured full-thickness skin and tissue loss and the exudate was small. The exudate was serous. The peri wound skin appearance was normal for patient. Record review of Resident #1's Wound Care Physician Report dated 4/30/2020 at 4:01 p.m. revealed let toe pressure ulcer acquired on 3/18/2020 acquired at the facility. The wound is acute, not healed and the measurements for length: (cm) 3, Width: (cm) 6, depth: (cm) 0.1, not hypergranulated, area: (sq cm) based on length and width 18 and volume: (cm3) based on Area *D 1.8. The wound description revealed it was deteorating, exudate was moderate, exudate type was serous, surrounding skin color and skin was dark red/purple with peripheral tissue [MEDICAL CONDITION]. Moist yellow slough was present with 76-100%. The Assessment notes revealed the wound care doctor spoke to Primary Doctor and recommend higher level of care due to concern for soft tissue necrosis. Record review of Resident #1's Nurses Notes from 4/17- 4/29/2020 revealed there was no communication to physician concerning the x-ray results. Record review of SBAR Summary for Providers dated 4/28/2020 at 10:58 a.m. revealed a Change in Condition with functional status evaluation being other. Primary care provider feedback revealed provider responded with the following feedback: A. Recommendations: follow up with MD related to x-ray and rule out possible OA or gangrene. B. X-ray; C. New Intervention orders were x-ray, possible hospitalization . Record review of Resident #1's order summary report dated 5/8/2020 revealed: X-ray of the left Big toe confirmation dated 4/28/2020. Treatment #3 wound of the left toe clean with wound cleanser pat dry apply [MEDICATION NAME] paint and dry dressing change dressing daily every day shift with an order date of 4/18/2020. Record review of Resident #1's Nurse Note dated 4/30/2020 at 12:38 p.m. by the Unit Manager revealed he spoke with the wound care MD and wound care Nurse about the resident's condition, Right toe, and MD stated that wanted to send resident to hospital for MRI [DIAGNOSES REDACTED]. Record review of Resident #1's Nurse Note dated 4/30/2020 at 3:30 p.m. revealed Resident #1 was transported to local hospital via local ambulance company. Representative notified of transport and waited outside to follow ambulance to hospital. Record review of Resident #1's Hospital records dated 4/30/2020 at 5:59 p.m. revealed the chief complaint from Nursing Triage Note was for possible gangrene given on 4/30/2020 at 3:39 p.m. EMS states nursing home requested transport here for MRI because unable to get it outpatient. Left big toe with purulent malodorous drainage for several months. Further record review of Resident #1's Hospital records dated 5/4/2020 at 3:07 p.m. of the Procedure notes revealed the preoperative [DIAGNOSES REDACTED]. The description of procedure included once the skin incision was made, the metatarsals then underwent bony cuts in a cascade fashion. In an interview on 5/8/2020 at 11:30 a.m. with Wound Care Nurse she said Resident #1 was in the hospital for her toe. The resident had an unstageable wound and she had been off of work for a week, from 4/18/2020 to 4/27/2020 and she returned on 4/28/2020. The wound care nurse said the nurses were responsible to do wound care treatments while she was out. When she returned to work she noticed Resident #1's toe was swollen. She said the wound care physician did not come into the facility while she was out. The wound care physician came on 4/17/2020 and he did see Resident #1. The wound care Nurse said the primary care physician was consulted once she returned to work on 4/28/20 and found the change in condition in the wound. Attempted interview and Observation of Resident #1 on 5/8/2020 at 1:00 p.m. revealed she could not talk. Observation revealed her arms and legs were contracted and wound care nurse did perform treatment on Resident #1's left foot and right 2nd toe. In an interview on 5/8/2020 at 2:00 p.m. with Wound Care Nurse she said Resident #1's toe was swollen when she returned on 4/28/2020 and there was drainage. She called the Charge nurse and Unit Manager to look at Resident #1's toe. She did wound care the following day on 4/29/2020 and her toe was larger than it was the day before. The Wound Care Nurse said the Nurse's that were doing wound treatment should have seen the toe was swollen. The toe was not swollen when she left the faciity on [DATE] and the nurses should have seen that the toe was swollen. She said the Nurses could have prevented Resident #1's toe from being amputated. It was the left great toe. Resident #1's toe was found upon her return to be swollen with drainage, and on 4/28/2020 an x-ray was done. The wound Treatment Physician came on 4/30/2020 and said they needed to get the resident out to the hospital because it may be gangrene. Resident #1 receives wound care daily. The wound care physician did not come to the facility on [DATE], but he ordinarily comes to the facility every Thursday. Interview on 5/13/2020 at 9:18 a.m. with Wound Care Nurse stated she was out sick from 4/19/2020 until 4/27/2020. The staff nurses were assigned to do the wound care during this time. Before leaving on sick leave on 4/19/2020 her toe was intact, no swelling, no drainage. She said she returned to work on 4/28/2020. When she returned and went to do Resident #1's treatment she saw the Left great toe was swollen and draining serous drainage. She called the Unit manager and Charge Nurse to come and look at it. They both said what happened to her toe. She said we decided to get an X-Ray. She said the Next day when she saw Resident #1's toe on 4/29/2020 it looked the same as the previous day with no changes. On 4/30/2020 the wound care doctor came, and they went in to see the resident together. Her toe was much bigger, she had signs of pain such as grimacing, her left great toe was darker in color and had purulent drainage. They marked the area, so we could monitor the swelling, but we sent her to the hospital because we were worried about gangrene. The wound care doctor talked to the PCP and he agreed to send the resident to the hospital for evaluation. The facility tried to call the family member but could not get her it was later and after a few attempts they finally got a hold of her to tell her they sent the resident to the hospital. In continued interview the wound care nurse said prior to her going out sick on 4/18/2020 there was no swelling or drainage to Resident #1's left great toe. The Wound Care nurse said she was shocked to see it when she got back to the facility. When the Wound Care Nurse was asked should the changes to the resident's wound been identified prior to you returning to work and seeing it on 4/28/2020, she said--Yes, the changes should have been identified prior to her finding it. She said the kind of changes should have been assessed over this week was the increase grimacing, so she had an increase to pain to even gentle touch. She saw the changes immediately and said something. The nurses should have seen it and acted on the changes. Interview on 5/13/20 at 9:18 am the Wound Care nurse stated when the changes were first assessed, the facility should call the resident's physician to let him know and get diagnostic tests. When Resident #1's toe worsened on 4/30/2020 they sent her to the hospital and they amputated all her toes on the left foot. The Wound Care Nurse answered that believed her toes would have been saved with faster care. Record review of Resident #1's Nurse note dated 5/7/2020 at 8:32 p.m. revealed Resident #1 readmitted to the facility from the local hospital under the care of primary physician. On call was notified of the resident's arrival with the [DIAGNOSES REDACTED]. Observation of Resident #1 on 5/13/2020 at 9:40 a.m. revealed the resident was in isolation precaution due to being readmitted from the hospital only precautionary. Resident was in bed and the head of the bed was elevated. The resident has upper and lower contractures. She was positioned slightly on her right side. The resident was non-verbal but did track with her eyes and nodded no when asked if she had pain. Left foot amputated midway across the area of her arch. Dressing was dated 5/13/2020. Interview on 5/13/2020 at 11:03 a.m. with the Wound care doctor he stated Resident #1 does have [MEDICAL CONDITION], but he has her documented as having a pressure wound to her left great toe. The Wound Care Doctor said there were changes when he saw it again on 4/30/2020. If the toe had been assessed, it is difficult to answer if her toes could have been saved. In a phone interview on 5/13/2020 at 11:30 a.m. with Charge Nurse she confirmed she saw Resident #1's toe on 4/28/2020 when the wound care nurse called her in to see it along with Unit Manager it was discolored, draining and swollen. Interview on 5/13/2020 at 11:50 a.m. with CNA A said she did give her bed bathes before she went to the hospital. Did not notice that she was having pain. Did notice a smell that was a little strong to her foot. She was sweaty. LVN C was aware of it already because she spoke with her. Interview on 5/13/2020 at 12:20 p.m. with Unit Manager he said when he saw Resident #1's toe on 4/28/2020 her toe was swollen, discolored, meaning darker than before, there was no odor had slight serous drainage. The nurses should have noticed it when they assessed the wound. If they see a change the physicians need to be notified, the family needs to be called and it should be documented. Interview on 5/14/2020 at 11:05 a.m. with DON said he had been here since 5/6/2020 any changes in the wound should mainly be written on the SBAR form. If a change in condition is noted the physician should be notified. If there are orders, then it would be documented on the physician's orders [REDACTED]. There will always be a physician we can contact for the resident. If there are wound issues I would prefer to have the wound care physicians called first. In a telephone interview on 5/14/2020 at 1:05 p.m. with LVN B she said when changes are noted the SBAR for a change in condition should be completed, the physician should be notified. In an interview on 5/14/2020 at 1:22 p.m. with Wound Care Doctor he said that he did not come to the facility on [DATE] because he had been exposed to another facility with positive Covid-19 residents. The Doctor said he got tested and the results were negative. He did not tell the facility that he would send a replacement, but if the Wound Care Nurse had told him there was a problem he would have. The Doctor said the Wound Care Nurse did not call him when she saw Resident #1's wound on 4/28/2020 and he did not find out until he returned to the facility on [DATE]. He said if there was an immediate concern, the Wound Care Nurse would send him a picture and he would change his treatment or admit to a higher level of care. On 4/30/2020 he saw Resident #1's wound and prescribed a topical antibiotic and spoke with the Primary Care Doctor and sent her to the hospital. The Wound Care Doctor said he did not know the condition of the wound when the wound care Nurse found it, but the Primary Care Doctor ordered the x-ray. The Wound Care Doctor said the facility should have contacted him, and that he did not know the rationale as to why they contacted the Primary Care Doctor for the wound. In an observation and interview on 5/15/2020 at 10:51 a.m. with Charge Nurse she said nothing really happened with Resident #1. She said she did not notice Resident #1's toe had gotten worse. The toe looked stable at the time. Resident #1 had a boot, but it needed to be off loaded. If the Wound Care Nurse was off and she was on schedule she did the wound care. The Charge Nurse said she worked on the weekends on Friday, Saturday and Sunday. She said it was probably a misstep where she did not sign that she did wound care on 4/18/2020 and 4/27/2020. She said nothing stood out to make her think she needed to call the Doctor. There was no odor to the wound that day. On 4/27/2020 she probably just did not click point click care. On 4/28/2020, the Wound Care Nurse called her in the room to look at Resident #1's wound. Her toe was really swollen twice it's size. The Charge Nurse said the bottom of Resident #1's plantar region of her toes was dark purple. At first, they thought they had broken it. The toes were facing a different direction. Typically, Resident #1 was not verbal, and she nodded saying her toe hurt. The Charge Nurse said the toe looked painful and she did complete her assessment. They called for a stat x-ray, gave her 2 Tylenol and waited for x-ray results. The Charge Nurse said she did not see the x-ray results. The night nurse, LVN E that probably received the results. If the results are abnormal they call the on-call Physician to do the lab. She said she called the Nurse Practitioner when she saw Resident #1's toe but did not think to call the Wound Care Doctor. Observation of the Nurse Note with Charge notes revealed that she did not make any notes and could not find a note from LVN E notifying the Physician of the lab results. The Charge nurse said that she would have called the Physician to transfer Resident #1 out of the facility had she received the lab. Observation of hospital records revealed Resident #1 had malodorous drainage, and she said she did not know why the wound never smelled to her. The Charge Nurse said at this time she still had all of her other responsibilities. During an interview and record review on 5/15/2020 at 12:06 p.m. the DON said the x-ray indicated a fracture on 4/28/2020. He said the Physician should have been notified of the results. He said the notification of the physician was not noted in the nurse notes. He said there was no other place it could be documented and he could not explain why Resident #1 was not sent to the hospital two days later. In an interview on 5/15/2020 at 12:35 p.m. with Wound Care Nurse she said the local x-ray company would have called the facility Nurse and faxed over the results. She asked LVN C what the x-ray results showed, and fracture did not come up. The Physician should have been notified, but she does not know what happened. She said it would be in the Nursing Notes and it was LVN C's responsibility to notify. The Wound Care Nurse said she, Charge Nurse, Unit Manager, LVN C and LVN E all knew to be looking for the x-ray results. In a telephone interview on 5/15/2020 at 1:01 p.m. with Local X-ray company said the results were called in to the facility on [DATE] at 9:22 p.m. Interview on 5/15/2020 at 1:19 p.m. with LVN E she said she never knew anything about an x-ray for Resident #1. LVN E denied receiving an x-ray for the resident. She said she got report from the Charge Nurse saying that Resident #1's toe was black and blue on the bottom and a couple of days later the toe doubled in size. LVN E said the information regarding Resident #1 was given in report. LVN E said she did not know if the Charge Nurse put the information regarding Resident #1's toe in the 24- hour report. Record review of Facility Policy on Change in a Resident's Condition or Status dated November 2015 revealed: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of the changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. -The facility failed to assess and identify Resident #1's left toe wound condition. The facility failed to provide wound care as ordered. -Resident #1 was admitted to the hospital on [DATE] with wet gangrene resulting in amputation. These failures affected one resident and placed her at risk of declined care, and hospitalization . Findings included: Resident #1 Record review of Resident #1's Face Sheet revealed she was a [AGE] year-old female. She admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] revealed she had a BIMS of 0 on the mental status exam which indicated severe cognitive impairment. She required one-person total assist with locomotion and bathing. She required one-person extensive assist with eating and toilet use. Resident #1 required 2-person extensive assistance with bed mobility. Skin conditions revealed infection control of the foot, pressure ulcer/injury care and application of dressings to feet. Staging was not identified for skin conditions. Record review of Resident #1's care plan undated, revealed Resident #1 was care planned for diabetes meletus with interventions to monitor/document/report to MD PRN for s/sx of infection to any open areas. She was care planned for the potential for pressure ulcer development and the goal was to have skin intact, free of redness, blisters or discoloration by/through review date. The interventions were to follow facility policies and protocols for the prevention/treatment of [REDACTED]. Monitor/document/report to MD PRN changes in skin status for CN. The care plan addressed Resident #1's actual impaired skin integrity with the goal being the impaired integrity will show signs of healing and remain free from infection by/through review date. The interventions were: *Administer treatments as ordered and monitor for effectiveness. *Assess/record/monitor wound healing per MD orders. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. *Follow facility policies/protocols for the prevention/treatment of [REDACTED]. *Inform the resident/family/caregivers of any new area of skin breakdown. *Monitor dressing to ensure it is intact and adhering. Report lose dressing to Treatment nurse. *Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. *Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. *Site 3: Left toe: Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Record review of Resident #1's Treatment Administration Orders dated 4/18/2020 revealed wound of the left toe was to be cleaned with wound cleanser, patted dry, apply [MEDICATION NAME] paint and dry dressing change. Dressing change was to be done daily every day shift. Record review of Resident #1's Skin observation tool dated 4/14/2020 revealed no new skin issues noted. Record review of Resident #1's Skin observation tool dated 4/21/2020 revealed left toe pressure sore treatment in progress. Record review of Resident #1's Treatment Administration Record for April 2020 revealed on 4/18/2020 and 4/27/2020 there were no signatures indicating treatment was performed. During an interview on 5/15/2020 at 10:51 a.m. with Charge Nurse she said nothing happened with Resident #1. She said she did not notice Resident #1's toe had gotten worse. She said the toe looked stable at the time. She said Resident #1 had a boot, but it needed to be off loaded. She said she did the wound care when the Wound Care Nurse was off. She said the Charge Nurse said she worked on the weekends on Friday, Saturday and Sunday. She said it was probably a misstep where she did not sign that she did wound care on 4/18/2020 and 4/27/2020. She said nothing stood out to make her think she needed to call the Doctor. She said there was no odor to the wound that day. She said on 4/27/2020 she probably just did not click point click care. She said on 4/28/2020, the Wound Care Nurse called her in the room to look at Resident #1's wound. She said Resident #1's toe was really swollen twice it's size. She said the Charge Nurse said the bottom of Resident #1's plantar region of her toes was dark purple. She said at first, they thought they had broken it. She said the toes were facing a different direction. She said typically, Resident #1 was not verbal and she nodded saying her toe hurt. The Charge Nurse said the toe looked painful and she did complete her assessment. She said they called for a stat x-ray, gave 2 Tylenol and waited for x-ray results. The Charge Nurse said she did not see the x-ray results. She said the night nurse, LVN E probably received the results. If the results are abnormal hey call the on-call Physician to do the lab. She said she called the Nurse Practitioner but did not think to call the Wound Care Doctor. Observation of the Nurse Note with Charge notes revealed that she did not make any notes and could not find a note from LVN E notifying the Physician of the lab results. The Charge nurse said that she would have called the Physician to transfer Resident #1 out of the facility had she received the lab. Observation of hospital records revealed Resident #1 had malodorous drainage, and she said she did not know why the wound never smelled to her. The Charge Nurse said at this time she still had all of her other responsibilities. Record review of Resident #1's Wound Care Physician Report dated 4/17/2020 signed at 9:04 a.m . wound to left toe orders to cleanse/protect wound with normal saline, wound dressing to apply [MEDICATION NAME] or [MEDICATION NAME] iodine paint and dry dressing. Change dressing daily and pressure relief/offloading to off load the wound. The wound was acquired on 3/18/2020 at the facility. The wound is acute with the wound measurements: Length: (cm) 1.5, width: (cm) 1.5, depth: (cm) 0.1, hyper granulated: No, Area: (sq. cm) based on length and width 2.25, volume: (cm3) based on Area Depth 0.225. There was no change noted to the wound. The stage was unstageable pressure injury obscured full-thickness skin and tissue loss and the exudate was small. The exudate was serous. The peri wound skin appearance was normal for patient . Record review of Resident #1's wound care treatment sheet, and care plan revealed there was no care plan to address [MEDICAL CONDITION], hospital records, wound care physician progress notes [REDACTED]. Record review of Resident #1's Nurses Notes from 4/17- 4/29/2020 revealed there was no communication to physician concerning the x-ray results. Record review of facility 72-hour report from 4/27/2020 to 4/30/2020 at 6 (sic) for the 500 Hall did not reveal any notes for Resident #1. Record review of Resident #1's SBAR Summary for Providers dated 4/28/2020 at 10:58 a.m. signed by Charge Nurse revealed a Change in Condition with functional status evaluation being other. Primary care provider feedback revealed provider responded with the following feedback: A. Recommendations: follow up with MD related to x-ray and rule out possible OA or gangrene. B. X-ray; C. New Intervention orders were x-ray, possible hospitalization . Record review of Resident #1's Radiology Results report date 4/28/2020 at 6:12 p.m. read in part . Resident #1 had an x-ray examination date of 4/28/2020 at 5:07 p.m. and the procedure was for Foot AP and Lat 2V, The interpretation of x-ray read: -Reason for study was Pain in Left foot -Results: fracture or destructive bone lesion is seen involving the distal medial aspect of the proximal phalanx of the first toe and base of the distal phalanx of the first toe with surrounding soft tissue swelling. There is diffuse osteopenia. The mid and distal phalanges of the second through fifth toes are not well seen. -Conclusion: Fracture or destructive bone lesion with pathologic fracture involving the phalanges of the first toe at the IP joint. Underlying osteo[DIAGNOSES REDACTED] or metastatic disease are possible etiologies. Recommend dedicated right first toe radiographs . Record review of Resident #1's order summary report dated 5/8/2020 revealed: X-ray of the left Great toe confirmation dated 4/28/2020. Treatment #3 wound of the left toe clean with wound cleanser pat dry apply [MEDICATION NAME] paint and dry dressing change dressing daily every day shift with an order date of 4/18/2020. Record review of Resident #1's Nurse Note dated 4/29/2020 at 11:18 p.m. signed by LVN B revealed there were no signs of pain observed at this time. There was no documentation regarding Resident #1's left toe. Record review of Resident #1's Wound Care Assessment signed by wound care doctor and dated 4/30/2020 at 4:01 p.m. revealed let toe pressure ulcer acquired on 3/18/2020 acquired at the facility. The wound is acute, not healed and the measurements for length: (cm) 3, Width: (cm) 6, depth: (cm) 0.1, not hypergranulated, area: (sq cm) based on length and width 18 and volume: (cm3) based on Area *D 1.8. The wound description revealed it was deteorating, exudate was moderate, exudate type was serous, surrounding skin color and skin was dark red/purple with peripheral tissue [MEDICAL CONDITION]. Moist yellow slough was present with 76-100%. The Assessment notes revealed the wound care doctor spoke to Primary Doctor and recommend higher level of care due to concern for soft tissue necrosis. Record review of Resident #1's Nurse Note dated 4/30/2020 at 12:38 p.m. by the ADON revealed he spoke with the wound care MD and wound care Nurse about the resident's condition; Right toe, and MD stated that wanted to send resident to hospital for MRI [DIAGNOSES REDACTED]. Record review of Resident #1's Nurse Note dated 4/30/2020 at 3:30 p.m. revealed Resident #1 was transported to local hospital via local ambulance company. Family member notified of transport and waited outside to follow ambulance to hospital. Record review of Resident #1's hospital records dated 4/30/2020 at 5:59 p.m. revealed the chief complaint from Nursing Triage Note was for possible gangrene given on 4/30/2020 at 3:39 p.m. EMS states nursing home requested transport here for MRI because unable to get it outpatient. Left big toe with purulent malodorous drainage for several months. Further record review of Resident #1's hospital records dated 5/4/2020 at 3:07 p.m. of the procedure notes revealed the preoperative [DIAGNOSES REDACTED]. The description of procedure included once the skin incision was made, the metatarsals then underwent bony cuts in a cascade fashion. Attempted interview and Observation of Resident #1 on 5/8/2020 at 1:00 p.m. revealed she could not talk. Observation revealed her arms and legs were contracted and wound care nurse did perform treatment on Resident #1's left foot and right 2nd toe. During an interview on 5/8/2020 at 11:30 a.m. with Wound Care Nurse she said Resident #1 was in the hospital for her toe. She said the resident had an unstageable wound. She said she had been off from 4/18/2020 to 4/27/2020 and returned on 4/28/2020. She said the nurses were responsible to do wound care treatments while she was out. She said when she returned to work she noticed Resident #1's toe was swollen. She said the wound care physician did not come into the facility while she was out. She said the wound care physician came on 4/17/2020 and saw Resident #1. During an interview with the Administrator on 5/8/2020 at 1:30 p.m. she said the charge nurses did the wound treatments while the treatment nurse was out. During a follow-up interview on 5/8/2020 at 2:00 p.m. with Wound Care Nurse she said Resident #1's toe was swollen when she returned and there was drainage. The Wound Care Nurse said she called the Charge nurse and Unit Manager to look at Resident #1's toe. She said she did wound care the following day on 4/29/2020 and her toe was larger than it was the day before. She said while doing wound treatments she noticed that some of the residents did not have dressing over their wounds and some of had the date on them. The Wound Care Nurse said the dressing could have come off when the CNA's did care. She said Resident #1 did not have a dressing on her toe. She said Resident #1 did have a dressing on her shoulder and the other toe but not the big toe. She said she saw Resident #1 around 10:30 a.m. and the CNA's gave baths after breakfast. She said the toe was not swollen when she left the faciity on [DATE] and the nurses should have seen that the toe was swollen. The Wound Care Nurse said the Nurses that were doing wound care treatment while she was out could have prevented Resident #1's toe from being amputated. She said it was the left great toe. She said Resident #1's toe was found upon her return to be swollen with drainage, and on 4/28/2020 an x-ray was done. She said the wound Treatment Physician came on 4/30/2020 and said they needed to get the resident out to the hospital because it may be gangrene. She said Resident #1 was supposed to receive wound care daily. She said the wound care physician did not come to the facility on [DATE], but he ordinarily comes to the facility every Thursday. During a follow-up interview with Administrator on 5/8/2020 at 3:00 p.m. she said Resident #1 readmitted to the facility last night on 5/7/2020. Interview on 5/13/2020 at 9:18 a.m. with Wound Care Nurse stated she was out sick from 4/19/2020 until 4/27/2020. The staff nurses were assigned to do the wound care during this time. Before leaving on sick leave on 4/19/2020, Resident #1's toe was intact with no swelling or drainage. She said she returned to work on 4/28/2020. She said when she returned and had gone to complete Resident #1's treatment, she saw the left great toe was swollen and draining serous drainage. She called the unit manager and charge nurse to come and look at it. They both asked what happened to Resident #1's toe. We decided to get an X-Ray. The next day when she was Resident #1's toe on 4/29/2020 it looked the same as the previous day with no changes. On 4/30/2020 the wound care doctor came, and they went in to see the resident together. Her toe was much bigger, she had signs of pain such as grimacing, her left great toe was darker in color and had purulent drainage. They marked the area, so we could monitor the swelling, but we sent her to the hospital because we were worried about gangrene. The wound care doctor talked to the PCP and he agreed to send the resident to the hospital for evaluation. The facility tried to call the family member but could not get her it was later and after a few attempts they finally got a hold of her to tell her they sent the resident to the local hospital. In continued interview the wound care nurse said prior to her going out sick on 4/18/2020 there was no swelling or drainage to Resident #1's left great toe. The Wound Care nurse said she was shocked to see it when she got back to the facility. When the Wound Care Nurse was asked should the changes to the resident's wound been identified prior to you returning to work and seeing it on 4/28/2020, she said--Yes, the changes should have been identified prior to her finding it. She said the kind of changes should have been assessed over this week was the increase grimacing, so she had an increase to pain to even gentle touch. She saw the changes immediately and said something. The nurses should have seen it and acted on the changes. Interview on 5/13/20 at 9:18 am the Wound Care nurse stated when the changes were first assessed, the facility should call the resident's physician to let him know and get diagnostic tests. When Resident #1's toe worsened on 4/30/2020 they sent her to the hospital and they amputated all her toes on the left foot. The Wound Care Nurse answered that believed her toes would have been saved with faster care. Record review of Resident #1's Nurse note dated 5/7/2020 at 8:32 p.m. revealed Resident #1 readmitted to the facility from the local hospital under the care of primary physician. On call was notified of the resident's arrival with the [DIAGNOSES REDACTED]. Observation of Resident #1 on 5/13/2020 at 9:40 a.m. revealed the resident was in isolation precaution due to being readmitted from the hospital only precautionary. Resident was in bed and the head of the bed was elevated. The resident has upper and lower contractures. She was positioned slightly on her right side. The resident was non-verbal but did track with her eyes and nodded no when asked if she had pain. Left foot amputated midway across the area of her arch. Dressing was dated 5/13/2020. Interview on 5/13/2020 at 11:03 a.m. with the Wound care doctor he stated Resident #1 does have [MEDICAL CONDITION], but he has her documented as having a pressure wound to her left great toe. The Wound Care Doctor said there were changes when he saw it again on 4/30/2020. If the toe had been assessed, it is difficult to answer if her toes could have been saved. During an interview and record review on 5/13/2020 at 11:23 a.m. with LVN C she reviewed Resident #1's Treatment Administration Record and confirmed she did the wound care on 4/21/2020 and on 4/25/2020. She said the process of changing the dressing was to use hand hygiene, remove the old dressing, clean the wound by following the physician's orders [REDACTED]. If changes are found notify the physician and the family. She said she could not remember specifically if there was swelling, discoloration, drainage or odor. She said there was nothing different between what she saw on 4/21/2020 and 4/25/2020. In a phone interview on 5/13/2020 at 11:30 a.m. with Charge Nurse she confirmed she cared for Resident #1's wound on 4/19/2020 and 4/22/2020. She said while administering wound care she assessed the wound and Resident #1's pain level. She said Resident #1 had DTI to both feet. She said under Resident #1's toes the wound was not any better or worse from 4/19/2020 to 4/22/2020. She said Resident #1 had spots on her toes that were not ulcerations but more related to poor circulation. She said Resident #1 was contracted and nursing staff off loaded due to her wounds. She said the HOB was elevated due to tube feeding. The Charge Nurse said on 4/28/20 she saw Resident #1's toes when the wound care nurse called the Unit Manager and her to the room. She said it was discolored, draining and swollen. Record review of Resident #1's documentation Survey Report v2 for April 2020 revealed: CNA A provided care on 4/20/20, 4/21/2020, 4/26/2020 and 4/27/2020 CNA E provided care on 4/23/2020, 4/28/2020, 4/29/2020 Interview on 5/13/2020 at 11:50 a.m. with CNA A said she gave Resident #1 bed bathes before she went to the hospital. She said she did not notice that Resident #1 was having pain. CNA A said she did notice an odor coming from Resident #1's foot. She said Resident #1 was sweaty and LVN C was already aware of it already because she spoke with her. During an interview on 5/14/2020 at 1:35 p.m. with the Administrator she said the facility wound normally have someone to come in to do the wound or it would be divided among the nurses when the Wound Care Nurse is out of the facility. The Administrator said she gave the assignment while the wound care nurse was out to ADON A and the Unit Manager to do wound care. The previous DON was still at the facility and she was responsible to make sure it was done, but she left the faciity on [DATE]st. The Administrator said she asked the Previous DON every morning about treatments being done. The Administrator asked the Wound Care Doctor to get a replacement because he was in a building where there were positive Covid-19 residents. She said she told the Previous DON to check, but it is her fault because she didn't make sure they sent a replacement. The Administrator said she did not know what happened. Resident #1 had treatment on her feet, but she cannot explain why the Nurses did not identify the change in her feet. The Nurses should have documented a change in the nurse's notes. Wound Care contacted the Physician, the family, the Social worker and the ADON. The Charge Nurse contacted the attending Physician if there is an issue. She did not know why the Wound Care Physician was not contacted. The Administrator said follow up should have been done and they should have circled back to see if the treatment was done. She said they should have gotten the resident out to the hospital. The Administrator said there was no guaranty of consistency for 3 or 4 days if they would be able to identify the change in condition. The Administrator said they should have had one consistent nurse to do the wounds and she should have found the best candidate for it. Interview on 5/13/2020 at 12:20 p.m. with Unit Manager he said when he saw Resident #1's toe on 4/28/2020 her toe was swollen, discolored, meaning darker than before, there was no odor had slight serous drainage. The nurses should have noticed it when they assessed the wound. If they see a change the physicians need to be notified, the family needs to be called and it should be documented. In a follow-up interview on 5/14/2020 at 10:45 a.m. with Unit Manager he said when changes are seen the nurse should document it in two places which was in the note section on the change of condition form and the nurse's progress notes. Interview on 5/14/2020 at 11:05 a.m. with DON he said he had been employed since 5/6/2020 and any changes in the wound should mainly be written on the SBAR form. If a change in condition was noted the physician should be notified. He said if there are orders, then it would be documented on the physician's orders [REDACTED]. physician. There will always be a physician the facility can contact for the resident. He would prefer the wound care physicians to be called first if there were any wound issues. During an interview on 5/14/2020 at 11:23 a.m. with Wound Care Physician he said if he is not at the facility his company has other wound care physicians who will cover when he is off. When he saw Resident #1's toe on the 30th there was a big change from the time he saw it before. Resident #1's wounds are stable but the top half of her left foot was amputated. Observation on 5/14/2020 at 12:15 p.m. of Resident #1's wounds: All dressings C/D/I dated 5/14/2020 1- Right knee skin prep and left open to the air- dried and free of drainage and odor 2- Lateral right ankle calcium alginate and Santyl- clean with a pink base no odor or drainage. 3- Right second toe silver alginate clean dry no odor or drainage 4- Left ½ foot with steri strips and sutures in place. Well approximated. No drainage, discoloration or odor Left shoulder open with a pink base no odor or drainage. Record review of Resident #1's Treatment Administration Record for April 2020 revealed LVN B signed for treatment conducted on 4/20/2020, 4/24/2020, and 4/26/2020. In a phone interview on 5/14/2020 at 1:05 p.m. with LVN B she said she cared for the resident 1-2 times in that week. She said that she did not remember what Resident #1's toe's looked like and she had not received any 24-hour notes about changes to Resident #1. Not sure how many times she did treatment for [REDACTED]. When changes are noted the SBAR for a change in condition should be completed, the physician should be notified. In an interview on 5/14/2020 at 1:22 p.m. with Wound Care Doctor he said that he did not come to the facility on [DATE] because he had been exposed to another facility with positive Covid-19 residents. The Doctor said he got tested and the results were negative. He did not tell the facility that he would send a replacement, but if the Wound Care Nurse had told him there was a problem he would have. The Doctor said the Wound Care Nurse did not call him when she saw Resident #1's wound on 4/28/2020 and he did not find out until he returned to the facility on [DATE]. He said if there was an immediate concern, the Wound Care Nurse would send him a picture and he would change his treatment or admit to a higher level of care. On 4/30/2020 he saw Resident #1's wound and prescribed a topical antibiotic and spoke with the Primary Care Doctor and sent her to the hospital. The Wound Care Doctor said he did not know the condition of the wound when the wound care Nurse found it, but the Primary Care Doctor ordered the x-ray. The Wound Care Doctor said the facility should have contacted him, and that he did not know the rationale as to why they contacted the Primary Care Doctor for the wound. During an interview on 5/14/2020 at 2:47 p.m. with CNA D she said she gave Resident #1 a bath on 4/17/2020. Resident #1 received a daily bath. We cannot remove any bandage on the residents. CNA D did not remember if she had any bandages. There was no odor around her feet that she noticed. Interview on 5/14/2020 at 3:00 p.m. with LVN C she said the CNA's report to her. She checked the resident's temp daily she never had a temperature. The day the resident was sent out CNA E stated the there was an odor in the room. It was not documented and once they realized what the odor was it should have been documented. Resident #1 had a past history of [DIAGNOSES REDACTED] she would heal, and it would come back because of her medical history and [MEDICAL CONDITION] she is at high risk of complications. We do weekly skin assessment. Documentation should be in the nurses notes or the weekly skin assessments. Lack of communication could have been a problem not knowing what her wounds looked like. CNA E said the room smelled like a bowel movement. After wound care arrived and determined it was her toe. LVN C said if they had better communication they would have known what Resident #1's toe looked like. During an interview on 5/15/2020 at 10:00 a.m. with CNA A she said the last two times she bathed Resident #1 she was sweating. During an interview on 5/15/2020 at 10:15 a.m. with CNA E she said she was the one who found Resident #1's toe that day, on 4/28/2020 while she was bathing her, and her toes were not covered. She said it looked like Resident #1's toes were about to burst. CNA E said she approached the Wound Care Nurse and told her, and she asked the Charge Nurse if she had seen Resident #1's toes. Resident #1's toes were swollen on the outside, but open underneath. CNA E said Resident #1 had a boot on her foot, but she didn't have the bandage on the toe. She said there was no date on the bandage. The resident's toe was open and stinking. CNA E said she checked Resident #1's bed for a bandage and there was no bandage in the bed that she knew of. Resident #1 did not have sheets on her bed because it was an air mattress. She said within two days, Resident #1 was gone from the facility. CNA E said the first time she came to bathe Resident #1 her toe was swollen, but it got bigger. Resident #1's toes were not bandaged enough because it was not staying on her foot. On 4/23/2020, Resident #1's toes were covered, and the odor was not as strong. On 4/28/2020, Resident #1's toe had a bad odor and on 4/29/2020 there was a bad odor. Interview and record review on 5/15/2020 at 12:06 p.m. the DON said the x-ray indicated a fracture on 4/28/2020. He said the Physician should have been notified of the results. He said the notification of the physician was not noted in the nurse notes. The DON said there was no other place it could be documented and he could not explain why Resident #1 was not sent to the hospital two days later. In an interview on 5/15/2020 at 12:35 p.m. with Wound Care Nurse she said the local x-ray company would have called the facility Nurse and faxed over the results. She asked LVN C what the x-ray results showed, and fracture did not come up. The Physician should have been notified, but she does not know what happened. She said it would be in the Nursing Notes and it was LVN C's responsibility to notify. The Wound Care Nurse said she, Charge Nurse, Unit Manager, LVN C and LVN E all knew to be looking for the x-ray results. During a telephone interview on 5/15/2020 at 1:01 p.m. with a local X-ray company a representative said the results were called in to the facility on [DATE] at 9:22 p.m. Interview on 5/15/2020 at 1:19 p.m. with LVN E she said she never knew anything about an x-ray for Resident #1. LVN E denied receiving an x-ray for the resident. She said she got report from the Charge Nurse saying that Resident #1's toe was black and blue on the bottom and a couple of days later the toe doubled in size. LVN E said the information regarding Resident #1 was given in report. LVN E said she did not know if the Charge Nurse put the information regarding Resident #1's toe in the 24- hour report. Record review of facility's policy entitled Change in a Resident's Condition or Status dated November 2015 read in part .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of the changes in the resident's medical/mental condition and/or status (e.g, changes in level of care, billing/payments, resident rights, etc.) . Record review of facility's policy, entitled Pressure Ulcers/Skin Breakdown-Clinical Protocol revised April 2018 read in part .The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer (s). In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active [DIAGNOSES REDACTED].>

Based on observation, interview, and record review the facility failed to consult the residents's Physician for 1 of 14 (#11) residents when an accident, which resulted in injury, occurred and after a change of condition including resident complaints of pain in that: --Resident #11 had a change in condition of pain, documented 4/25/17, after another resident fell on her on 4/24/17. Her Physician/Nurse Practicioner was not consulted until 48 hours after the accident. X-rays revealed a right [MEDICAL CONDITION] on 4/27/17, 72 hours after the incident. --Resident #11's Nurse Practitioner was not consulted until 48 hours later on 4/26/17 when a physical therapist informed her Resident #11 had complaints of pain. This failure affected 1 resident and placed an additional 7 residents who required assistance with ambulation at risk of going without needed medical care which could result in pain, delayed treatment, hospitalization , delayed healing, and diminished quality of life. TX 349 /Intake# 7 Findings include: Resident #8 Record review of the admission record for Resident #8 revealed that she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #8's CAA Triggers Summary dated with an assessment reference date of 1/13/17 revealed she was assessed as not steady, only able to stabilize with staff assistance. Her vision was severely impaired. She triggered for activities of daily living in part due to requiring the extensive assistance with transfers and limited assistance with locomotion on and off the unit. The items were marked as having been care planned. Record review of Resident #8's plan of care revealed a plan dated 1/28/17 for being at risk for falls related to gait imbalance revealed one intervention of Follow facility fall protocol. There was no plan of care for her visual impairment. Record review of Resident #8's SBAR dated 4/24/17 12:18 p.m. revealed documentation of a fall with condition or symptom worse when pt (patient) is not assisted. RN 1 documented .I think the problem may be .PT (patient) IS RESTLESS . Record review of Resident #8's Falls Investigation Worksheet dated 4/24/17 revealed documentation that at 12:40 p.m. an incident occurred while the resident was eating lunch. The documentation revealed Resident #8 did require supervision. Resident #8 was documented as having fell on another resident. Recommendations/Interventions dated 4/24/17 with a '5 then written over the 4 in 24 revealed, .Morning meeting incident discussed with team. Manager gave assignments for dining room duties. No obvious injuries noted on resident. No facial grimacing while eating breakfast this A.M. 4/26/17 No adverse reaction noted from fall on 4/24/17. No bruising noted. Will continue s/p (status [REDACTED]. Record review of Resident #8's electronic Fall document, attached to her Falls Investigation Worksheet, dated as revised on 5/5/17 at 3:08 p.m. revealed she was ambulatory with assistance, confused, had gait imbalance, and impaired memory. The Predisposing Situation Factors documented on the fall report was, .Ambulating without Assist.pt (patient) disoriented and sometimes stands up at randam (sic), so she is being watched closely at all times. NURSE WAS DOWN THE HALL TO GET ANOTHER PT'S FOOD WHO WAS AT THE DINNING (sic) ROOM, BUT WHOSE TRAY WAS IN THE HALL BECAUSE SHE USUALLY EATS IN HER ROOM. BUT NURSE WAS CALLED TO URGENTLY RETURN TO DINNING (sic) ROOM BECAUSE OF A FALL. PT WAS SITTING IN HER CHAIR WHEN NURSE ARRIVED. FULL SET OF VITAL SIGNS TAKEN, FAMILY AND MD NOTIFIED, VITAL SIGNS WITHIN NORMAL REACH (sic), PT STABLE, DISORIENTED BUT NOT NEW ONSET. PT WAS ALREADY SITTIN GON (sic) HER WHEEL CHAIR (sic) WHEN NURSE ARRIVED. Record review of Resident #8's Fall Risk Evaluation dated 4/24/17 1:33 p.m. revealed the evaluation date was documented as 4/25/17 and the reason for assessment was Recent Falls. Documentation revealed no falls within the past 90 days. Her vision pattern was severely impaired. Her mobility was documented as being confined to a chair and disoriented. Her gait analysis was documented as exhibits loss of balance while standing, requires hands-on assistance to move from place to place, and uses an assistive device. Interventions were documented as, Assist resident with all ADL's. Assist with guidance while in area with others and when alone. Record review of Resident #8's revised plan of care dated 5/1/17 for, . visual function r/t (related to) [MEDICAL CONDITION] and occupation of the left eye, [MEDICAL CONDITION] . revealed the interventions of, .Significant Visual Impairment-Tell me where you are placing items. Be consistent. monitor/document/report to MD s/sx of acute eye problems. Her plan of care for being at risk for falls included the interventions of ensuring she was wearing appropriate footwear when ambulating or mobilizing in her wheelchair .following the facility fall protocol. There was no documentation interventions specifically for her unsteady gait on how the facility would ensure she received staff assistance or monitoring her for times when she would stand up and walk independently. The revised plan of care did not address her actual fall which occurred on 4/24/17 and did not include any intervention to assist her with guidance while in area with others and when alone. Record review of Resident #8's Significant Change MDS assessment dated [DATE] and an assessment reference date of 4/25/17, one day after her fall, revealed a BIMS (brief interview mental status) score of 09 indicating she had moderately impaired cognition. She was assessed as having severely impaired vision-no vision or sees only light, colors or shapes; eyes do not appear to follow objects. She was assessed as having no falls. She was assessed as requiring the extensive assistance of 1 staff for transfers, and locomotion on and off the unit. Her balance during transitions and walking was documented as not being assessed for moving from seated to standing position, walking, turning around, and moving on and off toilet. She was assessed as not steady during a surface-to-surface transfer. She used a wheelchair for mobility. She was 65 inches tall and weighed 170 pounds. She was on a therapeutic diet and required the extensive assistance of one staff for eating. Resident #11 Record review of the admission record for Resident #11 revealed that she was a [AGE] year old female. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #11's quarterly MDS assessment dated [DATE] revealed the resident to have a BIMS (brief interview mental status) score of 15 indicating she was cognitively intact. She was assessed as requiring the extensive assistance of two staff for bed mobility and transfers. She was totally dependent on 2 staff for transfers. She was totally dependent on one staff for toilet use. She had no deficits in hearing and speech including making herself understood and understanding others. She was assessed as having had two falls with no injury and one fall with an injury that was not major. She was 66 inches tall and weighed 221 pounds. Record review of Resident #11's electronic Fall document dated as revised on 5/2/17 at 10:56 a.m. and written by LVN 2 revealed, .Incident Description Resident observed in dining room and w/c (wheelchair) was tilted to the side and witness stated that another resident had hit the w/c their (sic) w/c and caused the incident, resident was laid to the floor and then they proceeded to use the hoyer lift to get resident back in chair. no (sic) injuries noted. It was noted the documentation revealed the resident's power of attorney was documented as being notified on 4/24/17 at 10:11 a.m. , more than 2 hours prior to the incident and that Physician A was documented as being notified on 4/24/17 at 10:10 a.m., also more than 2 hours prior to the incident. A telephone message was left for MD NP on 5/5/17 at 11:36 a.m. MD NP returned the call on 5/9/17 at 3:15 p.m. and she said she was in the facility on 4/24/17 during the hours of 7:30 a.m. to 2:30 p.m. She said she was not informed that Resident #11 had a fall or that she was complaining of pain on that day. She said she returned to the facility on [DATE] during the same hours, and was informed by a physical therapist that Resident #11 was complaining of pain. She said she examined Resident #11 and found her to be having breathing difficulties and leg pain. She said she ordered testing and X-rays of the resident's chest and leg. She said when she received the results of the X-rays and testing, she ordered the resident to be sent to the hospital for emergency treatment. She said she did not get a good explanation from the facility of how the resident had injured her leg. Record review of Resident #11's clinical record revealed a hand-written order dated 4/26/17 for -- 02 2 L NC, -- Vitals Q shift x 48 hours, -- CXR (chest x-ray), R (right) hip x-ray, EKG (electrocardiogram) STAT (immediately) Dx (diagnosis) [MEDICAL CONDITION] pain in R hip, [MEDICAL CONDITION], -- Tylenol 650 mg PO (oral) TID (three times a day) x 7 days Dx R hip pain -- CBC (complete blood count), BMP (basic metabolic profile), TSH ([MEDICAL CONDITION] stimulating hormone) STAT Dx [MEDICAL CONDITION]/>-- DC (discontinue) [MEDICATION NAME] 20 mg. Q 12 hours, -- [MEDICATION NAME] 50 mg PO Q 12 hours (hold for SBP (systolic blood pressure) <110, HR (heart rate) <60) -- Give [MEDICATION NAME] 50 mg PO x 1 now Dx increased HR -- EKG Dx [MEDICAL CONDITION]/>Record review of Resident #11's X-ray result dated 4/26/17 revealed, .Results: There is a fracture involving the right femoral trochanters with displacement.Conclusion: Right [MEDICAL CONDITION] as described above. During a telephone interview with Resident #11's doctor, Physician A, on 5/5/17 at 12:21 p.m. he said the facility would contact him through his Nurse Practitioner. He said the facility usually called the NP about resident incidents. He said according to his records his NP saw Resident #11 on 4/26/17. He said it was his understanding that there were no acute signs/symptoms with the resident at the time of the fall. Observation on 5/3/17 at 6:30 p.m. of Resident #11 revealed she was dressed in a hospital gown in bed with a meal tray in front of her. She was groomed and without odor. She was covered by a blanket, sitting up in bed eating. During an interview on 5/3/17 at 6:30 p.m. with Resident #11 in her hospital room on the ICU (intensive care unit) she said another resident fell over her as she was sitting in the assisted dining room and she wound up on the floor. She said she slid out of the seat of the wheelchair onto the floor so she was sitting on the floor with the wheelchair on her back with her legs forward. She said her right leg hurt immediately. She said the staff came in and used a hoyer lift to put her back in the wheelchair and she was then taken back to her room. Record review of the facility's Incident/Accident Monitoring Log dated April 2017 revealed documentation on 4/24/17 that during the evening shift Resident #11 was in the DR (dining room) and had a fall with injury and a fracture, the cause was documented as, .another resident walked into wheelchair causing wheelchair to flip. During an interview on 5/3/17 at 3:50 p.m. with CNA 1 she said that at the start of lunch (12:00 p.m.) on 4/24/17 she was standing outside of the assisted dining room when a visitor came to tell her that 2 residents were on the floor. She said she saw Resident #11 sitting on the floor with her legs extended and the wheelchair was positioned on her back with Resident #8's hands on top of Resident #11's legs on the floor. A nurse came and assessed Resident #8 and helped her to stand and walked her to sit in her wheelchair at the table. A nurse assessed Resident #11 while she was sitting on the floor and she helped her to lay down so the hoyer lift pad could be positioned under her in order to lift her back into her wheelchair. Record review of a typed statement signed by the Administrator dated 4/28/17 revealed, .status [REDACTED].#11). (Resident #11) sustained fall in Dining room on 4/24/17, just before the lunch meal service started. Family member (name) .was in the assisted dining room with her mother as the staff was assisting the residents in the dining room for lunch, exact time unknown. According to (name) another resident, name unknown got up from her wheelchair and started walking around in the dinning (sic), the resident looked to have lost her balance and fell on top of (Resident #11)'s lap causing the wheel chair (sic) to tip forward. No one seemed injured but I ran and got a CNA. The CNA came immediately along with another nurse and other staff to assist both residents. They got both resident (sic) up off the floor. Upon staff interviews, the residents were being assisted to the dining room for lunch when incident happened, but according to the family member, it happened really quickly. No injuries noted to either resident at the time. On 4/26/17, Resident (#11) began to c/o pain in right leg. X-rays collected and resident was found to have a right [MEDICAL CONDITION]. On 4/27/17, at approximately 4am, Administrator received a phone call regarding the results of xrays (sic) and was told by charge nurse that resident was going out to hospital. Administrator informed Nurse to notify family of results of xrays (sic). Post investigation, The Administrator found this incident not reportable to DADS based on DADS guidelines. Cause of injury was witnessed and there was not any neglect in care found on staff interviews. Resident has a history of falls. However incident was an accident caused by another resident with vision impairment. During an interview on 5/4/17 at 1:25 p.m. with Witness, revealed that she was in the assisted dining room with her family member during lunch on 4/24/17. She said she saw Resident #8, who she was aware had vision difficulties, get up out of her wheelchair and walk along the table while holding on to the table. She said when Resident #8 came to the end of the table she fell on top of Resident #11 who was seated in a wheelchair with her legs extended past the table (she was sitting parallel to the side of the table). She said Resident #8 used her hands to break her fall on Resident #11's legs causing Resident #8 to push Resident #11's legs downward causing her to fall on the floor. She said Resident #8 was on top of Resident #11's legs on the floor. She said there were no staff in the room at the time of the fall. She said she went out into the main dining room to tell staff of the fall. She said staff came in and helped Resident #11 back into her wheelchair. She said she did not hear the resident complain of pain at that time, just that she wanted to be off the floor and she was taken out of the room. Resident #8 was seated in her wheelchair and was also taken out of the room. During an interview on 5/5/17 at 10:27 a.m. with Resident #11's responsible party she said her last on-site visit with Resident #11 was on 4/3/17. She said she received a message from the ADON sent on 4/24/17 and received by her on 4/25/17 in the morning, informing her of an incident involving Resident #11 and another resident who was blind. She said she was told the blind resident bumped into and tipped Resident #11's wheelchair. She said she was as also informed Resident #11 was lowered to the floor and the staff used a hoyer lift to place her back in her wheelchair. She said she was told Resident #11 had no injuries. She said she received a call from Resident #11's family member on 4/27/17 who informed her that Resident #11 was in the hospital with pneumonia and a [MEDICAL CONDITION]. She said she went to the facility on [DATE] and reviewed Resident #11's chart which indicated that she had a slip from her wheelchair on 3/2/17, hit her head and was assessed. She said there were no notes in the chart about a fall on 4/24/17. Record review of a written statement dated 4/24/17 by the Central Supply Clerk revealed she was on Station 2 when she was told that a resident fell in the dining room. She went to the assisted dining room and saw Resident #8 bent over on Resident #11 who was on the floor. Her statement revealed she walked Resident #8 to a sitting area and then went to get RN 1. Once RN 1 was present they removed the wheelchair off of Resident #11's back and laid her flat on her back for the nurse to assess. Record review of a written statement dated 4/24/17 by LVN 2 revealed she was notified of a resident on the floor and went to the dining room and observed resident lying on the floor. she asked what happened and was told that another resident had bumped her chair and made the resident fall out of the chair. She wrote that the resident had no complaints of any injuries and was placed back in her wheelchair using a hoyer lift. During an interview with the DON on 5/5/17 at 4:10 p.m. he said when a resident had a fall, the person witnessing/finding the resident (if not a nurse) was to tell the nurse. The nurse was then to assess the resident in the position found for injury, obtain vitals, and provide first aid as needed. He said if the fall was not witnessed, neuro checks should be done per policy & procedures. He said if there was no injury, a post fall assessment was to be done within 72 hours, call the MD, and call the Responsible Party. He said documentation for the resident included an incident report, progress notes by the nurse, and SBAR (Situation, Background, Assessment, Recommendation) report in the computer. He said when PRN pain medications were given, there should be a documented follow-up of pain level for medication effectiveness. He said if a medication was not effective, the nurse was to notify the resident's doctor or nurse practitioner to ask for what should be done next and do a new Pain Assessment. He said nurses must call doctors about pain medication needs. Record review of the 24 Hour Summary dated 4/24/17 revealed there was no documentation of Resident #11 having Resident #8 fall on her knocking her to floor. Record review of the facility's Clinical Notification Manual for MD revealed there was no documentation of Resident #11's fall on 4/24/17. Record review of Resident #11's electronic progress notes dated 4/24/17 revealed administration notes: -- 13:36 (1:36 p.m.) Note Text: Triple Antibiotic Plus Ointment 1%, -- 19:09 (7:09 p.m.) Note Text: nurse apply cream Record review of Resident #11's MAR (medication administration record) for April 2017 revealed: -- 4/24/17 monitoring of pain every shift for day and evening with a score of 0 (none) Record review of Resident #11's electronic progress notes dated 4/25/17 revealed administration note: -- 10:31 (10:31 a.m.) Note Text: c/o pain to (Right) leg; There was no documentation of an assessment, pain level, type, aggravating or relieving factors, or of notification to the doctor or responsible party. Record review of Resident #11's MAR (medication administration record) for April 2017 revealed: -- 4/25/17 monitoring of pain every shift for day and evening with a score of 0 (none) -- 4/25/17 1023 (10:23 a.m.) pain level 5, Tylenol Tablet 325 mg ([MEDICATION NAME]) give 2 tablets by mouth every 4 hours as needed for pain - start date 9/20/16. Record review of Resident #11's progress note dated 4/25/17 15:59 (3:59 p.m.) documented her pain medication was effective. Record review of Resident #11's progress notes dated 4/26/17 revealed administration notes: --12:00 (12:00 p.m.) Note Text; (R) leg pain -- 13:50 (1:50 p.m.) Note Text: PRN Administration was: ineffective resident still c/o pain to (Right) leg Continued record review of Resident #11's progress notes revealed there was no documentation of her allegation of complaints of right leg pain on 4/24/17. Record review of Resident #11's MAR (medication administration record) for April 2017 revealed: -- 4/26/17 1031 (10:31 a.m.) pain level 6, [MEDICATION NAME]-[MEDICATION NAME] tablet 300-30 mg, give 1 tablet by mouth every 4 hours as needed for pain, start date 9/20/16. There was no documentation of a previous administration of the medication since 4/15/17 until 4/26/17. -- 4/26/17 1440 (2:40 p.m.) pain level 6, Tylenol Tablet 325 mg ([MEDICATION NAME]) give 2 tablets by mouth every 4 hours as needed for pain - start date 9/20/16. Record review of Resident #11's SBAR dated 4/26/17, two days after the incident, revealed documentation of Resident #11 having right leg pain that started on 4/26/17. The SBAR did not address the right leg pain documented in the progress note as occurring on 4/25/17 and as stated by the resident as starting on 4/24/17. Record review of the facility's policy and procedure updated 10/2015 for Fall Prevention Program revealed, .After a fall occurs, a post-fall investigation is initiated within 24 hours (sic) . Care Plan: A current care plan for fall risk management and injury prevention includes: .Interventions reviewed and updated based on the findings of the reassessments and/or post-fall investigations including: *Individualized interventions which are re-evaluated and updated to prevent or minimize the risk of falls * Individualized dated interventions based on causal factors (if a fall occurred) and/or identified risk factors . The CMS 672 revealed 8 residents who required ambulation with assistance or assistive device.

Based on observation, interview, and record review the facility failed to ensure 2 of 14 residents (#8 and #11) reviewed for accidents and supervision received adequate supervision to prevent accidents in that: --Resident #8, who had a severe visual impairment and unsteady gait, was left unsupervised in the dining room. Resident #8 fell on Resident #11. Resident #11 complained of pain immediately. Resident #11 was found to have a hip fracture 72 hours after the incident. This failure affected 2 residents and placed an additional 6 residents who required assistance with ambulation at risk of avoidable injury due to lack of supervision. TX 349 /Intake# 7 Findings include: Resident #8 Record review of the admission record for Resident #8 revealed that she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #8's CAA Triggers Summary dated with an assessment reference date of 1/13/17 revealed she was assessed as not steady, only able to stabilize with staff assistance. Her vision was severely impaired. She triggered for activities of daily living in part due to requiring the extensive assistance with transfers and limited assistance with locomotion on and off the unit. The items were marked as having been care planned. Record review of Resident #8's plan of care revealed a plan dated 1/28/17 for being at risk for falls related to gait imbalance revealed one intervention of Follow facility fall protocol. There was no plan of care for her visual impairment. Record review of Resident #8's SBAR dated 4/24/17 12:18 p.m. revealed documentation of a fall with condition or symptom worse when pt (patient) is not assisted. RN 1 documented .I think the problem may be .PT (patient) IS RESTLESS . Record review of Resident #8's Falls Investigation Worksheet dated 4/24/17 revealed documentation that at 12:40 p.m. an incident occurred while the resident was eating lunch. The documentation revealed Resident #8 did require supervision. Resident #8 was documented as having fell on another resident. Recommendations/Interventions dated 4/24/17 with a '5 then written over the 4 in 24 revealed, .Morning meeting incident discussed with team. Manager gave assignments for dining room duties. No obvious injuries noted on resident. No facial grimacing while eating breakfast this A.M. 4/26/17 No adverse reaction noted from fall on 4/24/17. No bruising noted. Will continue s/p (status [REDACTED]. Record review of Resident #8's electronic Fall document, attached to her Falls Investigation Worksheet, dated as revised on 5/5/17 at 3:08 p.m. revealed she was ambulatory with assistance, confused, had gait imbalance, and impaired memory. The Predisposing Situation Factors documented on the fall report was, .Ambulating without Assist.pt (patient) disoriented and sometimes stands up at randam (sic), so she is being watched closely at all times. NURSE WAS DOWN THE HALL TO GET ANOTHER PT'S FOOD WHO WAS AT THE DINNING (sic) ROOM, BUT WHOSE TRAY WAS IN THE HALL BECAUSE SHE USUALLY EATS IN HER ROOM. BUT NURSE WAS CALLED TO URGENTLY RETURN TO DINNING (sic) ROOM BECAUSE OF A FALL. PT WAS SITTING IN HER CHAIR WHEN NURSE ARRIVED. FULL SET OF VITAL SIGNS TAKEN, FAMILY AND MD NOTIFIED, VITAL SIGNS WITHIN NORMAL REACH (sic), PT STABLE, DISORIENTED BUT NOT NEW ONSET. PT WAS ALREADY SITTIN GON (sic) HER WHEEL CHAIR (sic) WHEN NURSE ARRIVED. Record review of Resident #8's Fall Risk Evaluation dated 4/24/17 1:33 p.m. revealed the evaluation date was documented as 4/25/17 and the reason for assessment was Recent Falls. Documentation revealed no falls within the past 90 days. Her vision pattern was severely impaired. Her mobility was documented as being confined to a chair and disoriented. Her gait analysis was documented as exhibits loss of balance while standing, requires hands-on assistance to move from place to place, and uses an assistive device. Interventions were documented as, Assist resident with all ADL's. Assist with guidance while in area with others and when alone. Record review of Resident #8's revised plan of care dated 5/1/17 for, . visual function r/t (related to) Blindness and occupation of the left eye, Glaucoma . revealed the interventions of, .Significant Visual Impairment-Tell me where you are placing items. Be consistent. monitor/document/report to MD s/sx of acute eye problems. Her plan of care for being at risk for falls included the interventions of ensuring she was wearing appropriate footwear when ambulating or mobilizing in her wheelchair .following the facility fall protocol. There was no documentation interventions specifically for her unsteady gait on how the facility would ensure she received staff assistance or monitoring her for times when she would stand up and walk independently. The revised plan of care did not address her actual fall which occurred on 4/24/17 and did not include any intervention to assist her with guidance while in area with others and when alone. Record review of Resident #8's Significant Change MDS assessment dated [DATE] and an assessment reference date of 4/25/17, one day after her fall, revealed a BIMS (brief interview mental status) score of 09 indicating she had moderately impaired cognition. She was assessed as having severely impaired vision-no vision or sees only light, colors or shapes; eyes do not appear to follow objects. She was assessed as having no falls. She was assessed as requiring the extensive assistance of 1 staff for transfers, and locomotion on and off the unit. Her balance during transitions and walking was documented as not being assessed for moving from seated to standing position, walking, turning around, and moving on and off toilet. She was assessed as not steady during a surface-to-surface transfer. She used a wheelchair for mobility. She was 65 inches tall and weighed 170 pounds. She was on a therapeutic diet and required the extensive assistance of one staff for eating. Resident #11 Record review of the admission record for Resident #11 revealed that she was a [AGE] year old female. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #11's quarterly MDS assessment dated [DATE] revealed the resident to have a BIMS (brief interview mental status) score of 15 indicating she was cognitively intact. She was assessed as requiring the extensive assistance of two staff for bed mobility and transfers. She was totally dependent on 2 staff for transfers. She was totally dependent on one staff for toilet use. She had no deficits in hearing and speech including making herself understood and understanding others. She was assessed as having had two falls with no injury and one fall with an injury that was not major. She was 66 inches tall and weighed 221 pounds. Record review of Resident #11's electronic Fall document dated as revised on 5/2/17 at 10:56 a.m. and written by LVN 2 revealed, .Incident Description Resident observed in dining room and w/c (wheelchair) was tilted to the side and witness stated that another resident had hit the w/c their (sic) w/c and caused the incident, resident was laid to the floor and then they proceeded to use the hoyer lift to get resident back in chair. no (sic) injuries noted. It was noted the documentation revealed the resident's power of attorney was documented as being notified on 4/24/17 at 10:11 a.m. , more than 2 hours prior to the incident and that Physician A was documented as being notified on 4/24/17 at 10:10 a.m., also more than 2 hours prior to the incident. A telephone message was left for MD NP on 5/5/17 at 11:36 a.m. MD NP returned the call on 5/9/17 at 3:15 p.m. and she said she was in the facility on 4/24/17 during the hours of 7:30 a.m. to 2:30 p.m. She said she was not informed that Resident #11 had a fall or that she was complaining of pain on that day. She said she returned to the facility on [DATE] during the same hours, and was informed by a physical therapist that Resident #11 was complaining of pain. She said she examined Resident #11 and found her to be having breathing difficulties and leg pain. She said she ordered testing and X-rays of the resident's chest and leg. She said when she received the results of the X-rays and testing, she ordered the resident to be sent to the hospital for emergency treatment. She said she did not get a good explanation from the facility of how the resident had injured her leg. Record review of Resident #11's clinical record revealed a hand-written order dated 4/26/17 for -- 02 2 L NC, -- Vitals Q shift x 48 hours, -- CXR (chest x-ray), R (right) hip x-ray, EKG (electrocardiogram) STAT (immediately) Dx (diagnosis) Tachycardia, pain in R hip, hypoxia, -- Tylenol 650 mg PO (oral) TID (three times a day) x 7 days Dx R hip pain -- CBC (complete blood count), BMP (basic metabolic profile), TSH (thyroid stimulating hormone) STAT Dx Tachycardia -- DC (discontinue) Metoprolol 20 mg. Q 12 hours, -- Metoprolol 50 mg PO Q 12 hours (hold for SBP (systolic blood pressure) <110, HR (heart rate) <60) -- Give Metoprolol 50 mg PO x 1 now Dx increased HR -- EKG Dx tachycardia Record review of Resident #11's X-ray result dated 4/26/17 revealed, .Results: There is a fracture involving the right femoral trochanters with displacement.Conclusion: Right hip fracture as described above. Observation on 5/3/17 at 6:30 p.m. of Resident #11 revealed she was dressed in a hospital gown in bed with a meal tray in front of her. She was groomed and without odor. She was covered by a blanket, sitting up in bed eating. During an interview on 5/3/17 at 6:30 p.m. with Resident #11 in her hospital room on the ICU (intensive care unit) she said another resident fell over her as she was sitting in the assisted dining room and she wound up on the floor. She said she slid out of the seat of the wheelchair onto the floor so she was sitting on the floor with the wheelchair on her back with her legs forward. She said her right leg hurt immediately. She said the staff came in and used a hoyer lift to put her back in the wheelchair and she was then taken back to her room. Record review of the facility's Incident/Accident Monitoring Log dated April 2017 revealed documentation on 4/24/17 that during the evening shift Resident #11 was in the DR (dining room) and had a fall with injury and a fracture, the cause was documented as, .another resident walked into wheelchair causing wheelchair to flip. During an interview on 5/3/17 at 3:50 p.m. with CNA 1 she said that at the start of lunch (12:00 p.m.) on 4/24/17 she was standing outside of the assisted dining room when a visitor came to tell her that 2 residents were on the floor. She said she saw Resident #11 sitting on the floor with her legs extended and the wheelchair was positioned on her back with Resident #8's hands on top of Resident #11's legs on the floor. A nurse came and assessed Resident #8 and helped her to stand and walked her to sit in her wheelchair at the table. A nurse assessed Resident #11 while she was sitting on the floor and she helped her to lay down so the hoyer lift pad could be positioned under her in order to lift her back into her wheelchair. During an interview on 5/3/17 at 4:30 p.m. with the Administrator she said she did not report Resident #11's fall because it had been witnessed by a visitor and was therefore, not reportable to the State. She said she considered the resident being sent out to the hospital several days later to be part of that original incident. Record review of a typed statement signed by the Administrator dated 4/28/17 revealed, .status [REDACTED].#11). (Resident #11) sustained fall in Dining room on 4/24/17, just before the lunch meal service started. Family member (name) .was in the assisted dining room with her mother as the staff was assisting the residents in the dining room for lunch, exact time unknown. According to (name) another resident, name unknown got up from her wheelchair and started walking around in the dinning (sic), the resident looked to have lost her balance and fell on top of (Resident #11)'s lap causing the wheel chair (sic) to tip forward. No one seemed injured but I ran and got a CNA. The CNA came immediately along with another nurse and other staff to assist both residents. They got both resident (sic) up off the floor. Upon staff interviews, the residents were being assisted to the dining room for lunch when incident happened, but according to the family member, it happened really quickly. No injuries noted to either resident at the time. On 4/26/17, Resident (#11) began to c/o pain in right leg. X-rays collected and resident was found to have a right hip fracture. On 4/27/17, at approximately 4am, Administrator received a phone call regarding the results of xrays (sic) and was told by charge nurse that resident was going out to hospital. Administrator informed Nurse to notify family of results of xrays (sic). Post investigation, The Administrator found this incident not reportable to DADS based on DADS guidelines. Cause of injury was witnessed and there was not any neglect in care found on staff interviews. Resident has a history of falls. However incident was an accident caused by another resident with vision impairment. During an interview on 5/4/17 at 1:25 p.m. with Witness, revealed that she was in the assisted dining room with her family member during lunch on 4/24/17. She said she saw Resident #8, who she was aware had vision difficulties, get up out of her wheelchair and walk along the table while holding on to the table. She said when Resident #8 came to the end of the table she fell on top of Resident #11 who was seated in a wheelchair with her legs extended past the table (she was sitting parallel to the side of the table). She said Resident #8 used her hands to break her fall on Resident #11's legs causing Resident #8 to push Resident #11's legs downward causing her to fall on the floor. She said Resident #8 was on top of Resident #11's legs on the floor. She said there were no staff in the room at the time of the fall. She said she went out into the main dining room to tell staff of the fall. She said staff came in and helped Resident #11 back into her wheelchair. She said she did not hear the resident complain of pain at that time, just that she wanted to be off the floor and she was taken out of the room. Resident #8 was seated in her wheelchair and was also taken out of the room. During an interview on 5/5/17 at 10:27 a.m. with Resident #11's responsible party she said her last on-site visit with Resident #11 was on 4/3/17. She said she received a message from the ADON sent on 4/24/17 and received by her on 4/25/17 in the morning, informing her of an incident involving Resident #11 and another resident who was blind. She said she was told the blind resident bumped into and tipped Resident #11's wheelchair. She said she was as also informed Resident #11 was lowered to the floor and the staff used a hoyer lift to place her back in her wheelchair. She said she was told Resident #11 had no injuries. She said she received a call from Resident #11's family member on 4/27/17 who informed her that Resident #11 was in the hospital with pneumonia and a fractured hip. She said she went to the facility on [DATE] and reviewed Resident #11's chart which indicated that she had a slip from her wheelchair on 3/2/17, hit her head and was assessed. She said there were no notes in the chart about a fall on 4/24/17. During a telephone interview with Resident #11's doctor, Physician A, on 5/5/17 at 12:21 p.m. he said the facility would contact him through his Nurse Practitioner. He said the facility usually called the NP about resident incidents. He said according to his records his NP saw Resident #11 on 4/26/17. He said it was his understanding that there were no acute signs/symptoms with the resident at the time of the fall. Record review of a written statement dated 4/24/17 by the Central Supply Clerk revealed she was on Station 2 when she was told that a resident fell in the dining room. She went to the assisted dining room and saw Resident #8 bent over on Resident #11 who was on the floor. Her statement revealed she walked Resident #8 to a sitting area and then went to get RN 1. Once RN 1 was present they removed the wheelchair off of Resident #11's back and laid her flat on her back for the nurse to assess. Record review of a written statement dated 4/24/17 by LVN 2 revealed she was notified of a resident on the floor and went to the dining room and observed resident lying on the floor. she asked what happened and was told that another resident had bumped her chair and made the resident fall out of the chair. She wrote that the resident had no complaints of any injuries and was placed back in her wheelchair using a hoyer lift. During an interview with the DON on 5/5/17 at 4:10 p.m. he said when a resident had a fall, the person witnessing/finding the resident (if not a nurse) was to tell the nurse. The nurse was then to assess the resident in the position found for injury, obtain vitals, and provide first aid as needed. He said if the fall was not witnessed, neuro checks should be done per policy & procedures. He said if there was no injury, a post fall assessment was to be done within 72 hours, call the MD, and call the Responsible Party. He said documentation for the resident included an incident report, progress notes by the nurse, and SBAR (Situation, Background, Assessment, Recommendation) report in the computer. He said when PRN pain medications were given, there should be a documented follow-up of pain level for medication effectiveness. He said if a medication was not effective, the nurse was to notify the resident's doctor or nurse practitioner to ask for what should be done next and do a new Pain Assessment. He said nurses must call doctors about pain medication needs. Record review of the 24 Hour Summary dated 4/24/17 revealed there was no documentation of Resident #11 having Resident #8 fall on her knocking her to floor. Record review of the facility's Clinical Notification Manual for MD revealed there was no documentation of Resident #11's fall on 4/24/17. Record review of the facility's policy and procedure updated 10/2015 for Fall Prevention Program revealed, .After a fall occurs, a post-fall investigation is initiated within 24 hours (sic) . Care Plan: A current care plan for fall risk management and injury prevention includes: .Interventions reviewed and updated based on the findings of the reassessments and/or post-fall investigations including: *Individualized interventions which are re-evaluated and updated to prevent or minimize the risk of falls * Individualized dated interventions based on causal factors (if a fall occurred) and/or identified risk factors . The CMS 672 revealed 8 residents who required ambulation with assistance or assistive device.

Based on observation, interview and record review, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrate that they were unavoidable and a resident having pressure sores receives necessary treatment and services to promote healing for 1 of 6 residents (Residents #2 ) reviewed for pressure sores in that; -Resident # 2 developed a facility acquired unstageable pressure sore to his sacrum which became infected. These failures affected 1 resident and placed 9 additional residents who have pressure sores at risk for developing more pressure sores, infection and or worsening of the existing pressure sores. Intake numbers: 8 Findings include: Resident #2 Record review of Resident # 2's admission record revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident # 2's Admission Minimum Data Set ((MDS) dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 11 (moderate impairment), no skin issues but at risk of developing pressure ulcer, he required total assistance with 1 to 2 persons support with locomotion on and off unit and eating; he also needed extensive assistance with 1 to 2 persons support for bed mobility, transfer, personal hygiene, toilet use, bathing and dressing. Resident #2 was non-ambulatory and always incontinent of bowel and bladder. Record review of Resident # 2 ' s Plan of Care (POC) revealed he was care planned for having an unstageable wound of his right buttock/sacrum related to immobility, urinary and bowel incontinence initiated on 5/21/16 and activities of daily living self-care performance deficit related to stroke initiated on 6/1/16. Some specific interventions included: --monitor/document/report to MD as needed changes in skin status --use lifting device, draw sheet etc. to reduce friction --see ADL care plan for . for need for assistance for bed mobility, turning and repositioning -- total assist with bed mobility via 2 person -- total assist with transfers via 2 person Observation of Resident #2 on 6/2/16 at 3.40 p.m.in his room revealed him in bed with eyes closed and in no apparent distress. He was neatly dressed and well groomed. Resident ' s room was clean and well-arranged and oxygen in use. Record review of Resident # 2 ' s Admission notes documented by the ANur dated 5/20/16 at 22.31 revealed no skin problem noted. Record review of Resident #2 ' s Situation, Background, Appearance and Review(SBAR) communication form dated 5/17/16 revealed LVN C reported resident had an unstageable pressure ulcer on his sacrum, MD was notified and Wound Care was consulted. physician's orders [REDACTED]. Record review of Resident #2 ' s of medical record revealed that the Initial Wound Evaluation by his wound doctor dated 5/24/15 showed resident had an unstageable necrosis pressure sore to his sacrum measured as follows - Length 10.4 cm, Width 9.6 cm, Depth not measurable cm, thick adherent devitalized necrotic tissue 100%, Surface area 99.84 sq. cm, odor present and exudate - moderate serous. Wound debrided via surgical excision and removed necrotic tissue. Wound Care physician's orders [REDACTED]. Doxcycline 100 mg BID x 14 days.[MEDICATION NAME] mg BID x 10 days. Record review of Resident # 2 ' s laboratory report of wound culture dated 6/4/16 revealed resident had infection (Pseudomonas aeruginosa - moderate growth and Gram-negative rods #2- many colonies noted) to his sacral wound requiring treatment with antibiotics and subsequent transfer to the hospital on [DATE]. Record review of Resident #2 ' s hospital medical record revealed she was admitted to the Emergency Department on 6/7/16 with an unstageable sacral decubitus . Wound Care Consultation notes with assessment/measurement as follows: Stage IV Sacral wound Wound is approximately 95% slough and yellow necrosis There is bone exposure Moderate to large amount of serosanguinous exudate Sacrum stage IV measuring: Length 10.0cm x Width 8.0cm x Depth 1.5cm Wound bed slough, bone palpable, granulating tissue at edges, large amount of serous exudate, edges undefined and undermining 10:00-2:00 @ 1.0cm. During an interview on 6/16/16 at 4:45 p.m. MDS/LVN she said Resident # 2 was admitted to the facility on [DATE] without a pressure sore. She said Resident # 2 was discovered to have a large facility acquired unstageable pressure sore on 05/17/2016. During an interview on 6/16/16 at 5:30 p.m. the DON she said Resident # 2 was discovered to have a large facility acquired unavoidable sacral wound on 05/17/2016. She said Resident # 2 was a huge man (218 pounds) who was not mobile and was incontinent of bowel and bladder. She said Resident # 2's wound was discovered to be infected on 06/04/2016 after the physician had ordered wound cultures. She said Resident # 2 was turned every two hours and he was up out of his bed to the chair daily. During a telephone interview on 6/16/16 at 5:45 p.m. LVN C said that he discovered the wound on 5/17/16 during a weekly skin assessment. He said the wound started like sheering and progressed to an unstageable. He said the physician stages the wounds in the facility. During an interview on 6/30/16 at 12:22 p.m. the DON she said treatment of [REDACTED]. During a second telephone interview on 6/30/16 at 2:38 p.m. LVN C said that a CNA called him to Resident #2 ' s room while they were performing care and notified him of the wound to his sacrum. He said he assessed the wound, called the MD and contacted a family member. During an interview on 6/30/16 at 3:00 p.m. the DON when asked who did wound treatments when WCN was not available during the week, she said that the Unit managers did the treatments. Record review of the facility's policy and procedure on Skin Management system revised on 3/2016 read in part a head to toe body evaluation will be completed on every resident up admission or readmission and weekly thereafter, these evaluations will be documented on the Weekly Skin Integrity Review . responsible party will be notified at the onset of an identified area, documentation of the notification is to be in the Nurses notes in the clinical record .routine weekly checks will be completed on every resident, if a new pressure sore is noted, a Ulcer, Surgical Site treatment and Progress Record form will be started, notification of Physician and RP must be documented in the nurses notes, Braden Scale will be completed upon admission, admission/readmission, weekly x3 weeks, change in condition and then quarter thereafter on the Braden Scale form . The CMS Form 672 listed 11 residents as having pressure ulcers.

Based on interview and record review, the facility failed to immediately consult with the physician and notify family when 1 of 18 residents (CR#1) reviewed for a change in condition was bleeding and had to go to the hospital in that: --LVN C did not consult the physician and call the responsible party when CR #1 was actively bleeding for four hours. CR #1 was admitted to the hospital and received two units of red blood cells. An Immediate Jeopardy (IJ) was identified on 1/15/16. While the IJ was removed on 1/20/16, the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not immediate jeopardy due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected one former resident and placed 24 additional residents on blood thinners, at risk of injury, delayed treatment, hospitalization , or death in the event of a change in health condition. Intake # 2 Findings include: Record review of Closed Record (CR) #1's admission sheet revealed she is an [AGE] year old who was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR#1's quarterly MDS with an ARD of 9/29/15 revealed she was assessed as scoring an 8 out of 15 on her brief interview for mental status indicating moderately impaired cognitive skills for daily decision making. She required the extensive assistance of 2 staff for bed mobility, transfers, and toilet use. She required the extensive assistance of one staff for dressing, eating, and personal hygiene. She was totally dependent on 1 staff for locomotion. She had no limitations in her functional range of motion. She had an indwelling urinary catheter and was always incontinent of bowel. She had a stage IV pressure ulcer that was present upon admission. Record review of CR#1's 12/2/15 physician order [REDACTED]. Record review of the complaint intake revealed the concern that on 12/30/15 CR#1 had been bleeding in the facility at approximately 2:00 p.m. and CR#1 went without treatment until the evening shift came to work at 06:00 pm. Record review of CR#1's health status note dated 12/30/15 at 3:15 p.m. revealed, .This nurse summoned to resident's room, per CNA. Resident noted bleeding from her vagina (clots noted). Call placed to (Medical Director) and (Hospice Agency F). Awaiting return call from both parties. The note had been entered by LVN C. The next note, also by LVN C, on 12/30/15 was timed 5:15 p.m. which read, .V/S (vital signs) are as follows: T (temperature)-97.2, P (pulse)-76, R (respirations)-18, B/P (blood pressure)- 132/74. There were no additional notes by LVN C on 12/30/15. During an interview on 1/13/16 at 3:36 p.m. with LVN C she said CR#1 was transferred to the hospital due to bleeding from her vagina with clots. She said CR#1 used to have a suprapubic catheter that had been changed out to a regular indwelling urinary catheter. She said the indwelling urinary catheter was in place when the resident was sent out. When asked if CR#1 was on any blood thinners she said, No. When asked if she had been aware of CR#1's indwelling urinary catheter being dislodged 2 days prior (on 12/28/15) she said, I have no idea. She said CR#1 was bleeding during her shift. She said she tried to report it to the resident's family members but got no answer. She said she called the Medical Director. She said the Medical Director told her to try to contact the family and monitor the bleeding. She said she continued to try to reach the family. She said she understands the bleeding started again on the evening shift and CR#1 was sent out. The next health status note was by LVN G dated 12/30/15 and timed 11:56 p.m. The note read, .Late Entry- 6:15 p.m.-Called into room per CNA noted that she has a large amt (amount) of vaginal bleeding with clots noted to her pubic area 98.4- 70- 18- 124.66 B/S 124 O2 sat 94% she is alert and talkative on round. 6:30 p.m.- CR#1's family member called and informed him of CR #1's vaginal bleeding with clots and he was told @ this time that we are going to send her to the hospital ,he stated to send her to (Hospital H) in the Medical Center per 911 6:40 p.m. (Hospice Agency F) called and spoke with (hospice employee name) about her being sent to the hospital 6:45 p.m.- Medical Director called and informed of her bleeding and that she will be going to the hospital per 911 per the family request, he stated that she needs not to go per 911 but by regular transport,he was informed that the family requested 911, his reply was that's not needed. 7:10 p.m.-Emergency Management Services (EMS) here report given pt. placed on stretcher and transported to (Hospital H) hospital.Pt remains alert and talkative. 7:22 p.m.-family member here he was told that she is on her way to the hospital and he left. Record review of CR#1's computerized and paper chart revealed there was no documentation of an assessment, SBAR, or notification to her responsible party of her bleeding prior to LVN G's note for the late entry at 6:30 p.m. There was no documentation of the Medical Director or of Hospice Agency F being consulted. There was a note which read awaiting return phone calls from the Medical Director and Hospice Agency F. During an interview on 1/14/16 at 2:24 p.m. with CNA E she was asked to describe what happened with CR#1 on 12/30/15. She said she came on shift at 2:00 p.m. and went into CR#1's room at approximately 2:15 p.m. She said she spoke to the resident and CR#1 told her she was ok. She said she then lifted the sheet to turn CR #1. She said there was blood on CR#1's gown and sheet that was dry. She said CR#1's brief had turned purple and it was .full of blood. She said, The outside of the brief had turned purple it was so full. She said she got LVN C and took her to CR#1's room. She said LVN C kept trying to tell her (CNA E) what could cause it and told her to clean the resident up. At 4:45 p.m. she checked on the resident again and she had blood clots again and blood was stuck in CR#1's pubic hair. She said CR#1 had, .chunks of blood, the first time she was found bleeding. She then stopped and thought and corrected herself saying the second episode of bleeding was at 3:15 p.m., not 4:45 p.m. She said she reported it to LVN C again and LVN C told her to clean her up again. She said she checked on the resident again around 4:45 p.m. or 5:15 p.m. and this time there was heavy bleeding. She said LVN G had come in early and she went to LVN G and LVN C and reported the bleeding. She said LVN G came in the room with her and then called EMS. She said the bleeding had not stopped. She said the bleeding never stopped. She said she thought the blood was draining from the vagina. She said you could see the clots of blood draining out as she cleaned. During an interview on 1/14/16 10:17 a.m. with the Administrator, Interim DON, ADON, and Corporate Nurse, when asked what should be done if a return call is not received from a doctor or agency, the Interim DON said if hospice does not call back, you should call the physician. The Corporate Nurse said she would have called the physician first and then the hospice and family. The Administrator said the prior DON was in the building when CR#1 had the change in condition. The Interim DON said the prior DON was not made aware of the change in condition until CR#1 was leaving the facility. The Corporate Nurse said the facility follows physician orders [REDACTED]. The Administrator and DON said the facility had not inserviced the staff following this incident. The ADON said LVN C had told her that she attempted to contact Hospice Agency F. The Administrator said LVN C had a CNA monitor CR#1. The Interim DON and Corporate Nurse said LVN C should have attempted contact with the doctor and hospice again after 15 minutes. The Corporate Nurse said 15 minutes is the standard. The Administrator said the prior DON's last day of work was 12/31/15. She said their last Quality Assurance meeting was held in December 2015 and no meeting was scheduled for January 2016. She said the incident with CR#1 had not been identified by the Quality Assurance Committee. The Administrator said if the prior DON investigated the incident the investigation report would be in his office. The facility did not provide surveyor with an investigation report on this incident prior to exit on 01/20/2016. During a telephone interview on 1/14/16 at 12:01 p.m. with the prior DON he said on 12/30/15 after hours (after 5:00 p.m.), LVN G came to him and told him CR#1 was bleeding. He said he told her to call EMS. He said he was told sometime between 5:00 p.m. and 6:00 p.m. He said LVN G told him it was, .regular bleeding vaginally. He said she had already called EMS and they were on their way. When asked if he was certain he had not been told earlier he said, Absolutely not, not at all. He said to his recollection, CR#1 was on [MEDICATION NAME] and a blood thinner and that is why he agreed with the nurse to call EMS. He said when notified of a change in a resident's status he will do an assessment. He said if there is no response after you attempt to consult with the medical director you are to try again within twenty minutes. He said the DON, Administrator, and medical director should have been called immediately after CR #1's change in condition. He said the CR #1's change in condition should have been documented by LVN #C. During a telephone interview on 1/14/16 at 12:22 p.m. with Hospice Nurse I, she confirmed that she was the nurse who came to the facility on [DATE] when CR#1's indwelling urinary catheter had been dislodged. She said she assessed the resident and there was no bleeding. She said it was protocol to leave the catheter out for 24 hours and then reinsert it. She said she was not the nurse that would have been called on 12/30/15. She said CR#1's assigned case manager was Hospice Nurse J. During a telephone interview on 1/14/16 at 12:48 p.m. with the Medical Director he said he was called on 12/30/15 and told CR#1 had vaginal bleeding. He said he was called about CR#1 around 07:00 pm. He said he did not feel CR#1 needed to be sent via EMS. He said if he was called they should have documented it He said even if the bleeding had stopped CR #1 should have been sent out due to the fact that she was on blood thinners. During a telephone interview on 1/14/16 at 1:33 p.m. with Hospice Nurse J she said she was not called about CR#1 on 12/30/15 but that she knew the agency was called the night of 12/30/15. She said no calls were received from the facility that day until 6:40 p.m. She said the ADON told her the following day that CR#1 had heavy bleeding with clots from the vagina. During an interview on 1/14/16 at 1:43 p.m. with LVN C she said she was told around 3:00 p.m. that CR#1 was bleeding. When asked how she determined where the bleeding was coming from she said by moving the brief around. She said she asked the CNA to inform her if CR #1 began to bleed again. She said the on-call hospice nurse told her to reach the family and ask them what they wanted her to do. When asked who the on-call hospice nurse was she said she did not know. She said she told the hospice nurse that CR#1 was on blood thinners. She said she documented the incident. When asked if it was the standard to document who you spoke to she said it was. She said she spoke to the Medical Director and remembered that he answered the phone. She said the Medical Director told her to contact the family and gave her no orders. She said she spoke to the Medical Director at about 3:15 p.m. on 12/30/15. She said she did not hear from the family. When asked why her documentation read that she attempted to call the Medical Director but the note read that she was awaiting a response from him she said, I don't know. She said while she was giving report to LVN G, CNA E came and told her the bleeding had started again. She said she had not tried to recontact the Medical Director or Hospice Agency F. She said she did not hear from the family. She said, I'll put it this way, if she weren't a hospice patient, I would have notified the doctor and family. With her being a hospice patient, you don't know what the family might want. She said, With hospice patients there's not normally transfers to the hospital. Not unless there is a fracture, other circumstances. She said she did not notify the DON of CR #1's change in condition. She said it is policy to notify the DON if a resident has a change in condition. She said she did not have a reason for not notifying the DON. She said CNA E informed her two times that CR #1 was bleeding. She said Hospice Agency F had called her back within 5 minutes. She said she did not have the prior DON's phone number. She said the facility only posts the DON's phone number at Station I (she works Station II). During an interview on 1/14/16 at 3:58 p.m. with the Corporate Nurse she said they could not find a policy and procedure for blood thinners. During an interview on 1/15/16 at 1:38 p.m. with the Corporate Nurse she said they did not have a policy and procedure on a change in condition. She said they use the INTERACT form. The INTERACT was used to communicate, evalulate, and communicate a resident's change in condition. During a telephone interview on 1/15/16 at 2:14 p.m. with LVN G she said she had come in and was about to make rounds when a CNA reported to her that CR#1 was bleeding. She said she assessed the resident and there were blood clots. She said she got the ADON and sent the resident out. She said the day shift nurse had reported to her that CR#1 had two episodes of bleeding that day. She said LVN C told her she had called a hospice nurse. She said LVN C did not tell her if she had called a doctor. When asked what the procedure is for such a situation she said you call the doctor and let the doctor know then call the family after you get orders. She said for a hospice resident you would normally contact the hospice. She said hospice will then send a nurse to assess the resident. She said in an emergency hospice will advise the resident to be sent to the hospital. She said LVN C told her that she spoke to hospice and they were going to send a nurse out. When asked if LVN C told her who she spoke to she said no. She said when she called CR#1's family member he told her he did not know about the bleeding. She said the family member wanted CR#1 sent out via 911. She said she then called the Medical Director and let him know. She said the Medical Director said it was not that critical and that she could go out via regular transport. She said she had not been told that the bleeding was originally detected at 02:15 pm. She said she ADON had not been notified of CR #1's change in condition. She said a change in condition should also be reported to the ADON. During a telephone interview on 1/15/16 at 2:59 p.m. with Hospice Nurse J she said she worked 12/30/2015. She said a change in condition of one of her patients would have been reported to her. She said the call would have been sent to her. Record review of LVN C's employee file revealed her date of hire was 9/30/14. Her file contained two written disciplinary forms dated 3/20/15 and 5/8/15. Record review of LVN C's 3/20/15 Disciplinary Warning Notice revealed the following date and explanation of incident/occurrence: .1. Resident have order for ear ggts (sic) (drops). a week ago that was not carried out 2. MD order for C&S (culture and sensitivity) of the wound, not done 3. Resident going to an appt. (appointment) was not set appropriate transport to accommodate residents needs. 4. Overall, poor job performance. The Corporate Nurses signature stamp was on the form with the date of 3/20/15 as the Department Head Signature. Record review of LVN C's 5/8/15 Disciplinary Warning Notice revealed it was her 2nd warning and revealed, .date and explanation of incident/occurrence: Nurse failed to report an abnormal xray to MD (Medical Doctor). Nurse reported xray was negative to MD and ADON. Record review of LVN C's in-servicing records revealed she had received in-services for the SBAR on 2/24/15 and 3/2/15. She had received in-services on abuse/neglect on 1/28/15 and 3/18/15. During an interview on 1/15/16 at 3:06 p.m. with the Corporate Nurse, Administrator, and Acting Director of Nurses the Corporate Nurse confirmed it was her signature on the 3/20/15 Disciplinary Warning Notice for LVN C. When asked how they monitor staff with a history of disciplinary warnings the Administrator and Acting Director of Nurses said they were not employed by the facility during that time. They did not respond give a response as to if there was a system to monitor staff. The Corporate Nurse said she is not in the facility daily. During an interview on 1/19/16 at 11:39 a.m. with the Corporate Nurse she said there was no documentation of an SBAR having been done for CR#1. The Administrator, the Acting Director of Nurses and the Corporate Nurse were notified on 1/15/16 at 3:06 p.m. that an Immediate Jeopardy (IJ) had been identified based on the above failures. A Plan of Removal (PoR) was submitted on 1/16/16. After revisions, it was accepted on 1/19/16 at 4:22 p.m. The PoR included: 1. On 1/15/16, Nurse Managers, Licensed Nurses and the Acting Director of Nursing immediately assessed current residents in the facility; including those residents with indwelling catheters, those with anticoagulant therapy, and those receiving Hospice services in order to ensure any changes in conditions were identified. Should a change in condition be noted, the physician and responsible party will be notified; necessary intervention will be implemented; documentation in the clinical record ; and the identified change will be care planned. 2. The Acting Director Nursing, assistant Director of Nursing immediately began educating staff (RNs, LVNs, CNAs, and MAs) on the following starting 1/15/16: A) Recognizing changes in condition. In the event of a change in a resident condition, the nurse will notify the resident's attending physician and family when there has been an incident, bleeding, significant change in resident physical, emotional or mental status, need to alter the resident medical treatment, refusal of treatment or medication, or the need to transfer the resident to the hospital. . b) Assessment of the resident's change in condition, immediately communicating change in the resident's condition to the physician by phone following the assessment, documenting on the appropriate form. c) Notifying the attending physician and the resident's responsible party by phone. If unable to reach the attending physician or nurse practitioner on the first call, continue to call every 15 minutes thereafter until a response is obtained. d) If staff is unable to reach the resident's attending physician after 2 calls, immediately notify the medical director and your supervisor. e) When to call 911 based on the resident's change in condition. . h) Monitoring residents for bleeding when they receive ordered Anticoagulants/blood thinners. . k) Educate licensed staff on monitoring residents receiving blood thinners for bruising and bleeding. The education will continue each shift prior to the start of the staff members' shift. Those on FMLA and paid time off will be completed prior to the beginning of their next shift by the Acting Director of Nursing, Assistant Director of Nursing, Regional Nurse. . The Surveyors confirmed that the PoR had been sufficiently implemented to remove the IJ by: On 1/15/16 at 2:25 p.m., LVN D described described ways that she would know that one of her residents experienced a change in condition. She gave examples of signs and symptoms. She said that she would assess the resident, document the resident's condition and consult with the resident's physician. On 1/15/16 at 2:40 p.m., LVN O said that she would recognize a change in her resident's conditions because she sees them every day. She described signs and symptoms that would enable her to recognize changes in condition. She said that she would first assess them, including take their vital signs. Then, she would call the doctor for orders. She would have already checked the PRN orders for treatments. On 1/19/16 at 10:30 a.m., RN B described ways that she would recognize a change in condition of one of her residents. When she noticed a change in her residents, she first assessed her residents and documented the change of condition on the SBAR. She would have all of this information available when she called the doctor for orders. She would also call the responsible party. On 1/19/16 at 10:45 a.m., LVN A said she would recognize if a resident was experiencing a change in condition if he or she was lethargic, had a change in vital signs, had a change in the amount or type of talking, had a change in eating or posture. She said that she would assess the resident and document her findings on the SBAR form. She would call the doctor, family and the hospice provider. On 1/19/16 at 2:30 p.m., LVN D said that she had received the following training over the last week: How to manage residents receiving anticoagulants, which included checking for bruises and bleeding and how to assess and report these as changes in condition. She was trained how to document using the SBAR. She had training on how and when to communicate with the residents' physicians and the hospice providers. During an interview on 1/20/16 at 10:48 a.m. with the Administrator when asked how she thought this immediate jeopardy/substandard quality of care came about she said from record review it looked like it was a nursing assessment of a resident that was on an anticoagulant being the primary reason. She said assessment, notification and follow up were contributing factors. When asked if she had been aware of the situation prior to surveyors coming in she said only that the resident had gone out to the hospital. During an interview on 1/20/16 at 11:03 a.m. with the Acting Director of Nurses when asked how they ensure nurses were competent in their skills she said they do annual skills checks. When asked what type of plan was in place for when a resident starts bleeding she said they get up, assess the resident, and call the doctor. She said they follow the INTERACT and SBAR to help them complete their evaluation on that resident. When asked how she thought this immediate jeopardy/substandard quality of care came about she said, I really think it happened throughout the transition of the prior DON leaving and not knowing how extensive her situation was. She said she thought if the prior DON would have stayed they would have identified the problem. She said if felt like the nurse did not do what she was supposed to do. On 1/20/16 at 2:35 p.m., LVN A said she had received the following training over the last week: training in how to monitor residents receiving anticoagulant therapy; abuse and neglect; and how to recognize, assess, and document changes in condition. She said that once she assessed a patient's change in condition, she would document the information on the SBAR form and call the doctor. She described the training. On 1/20/16 at 2:35 p.m., RN C said that she received a lot of training over the last week. She received training about how to manage the residents receiving services from hospice providers and what to do when these residents have changes in conditions. They were trained on the interact system and how to complete the SBAR. They were trained on abuse and neglect, indwelling catheter care, and how to manage patients receiving anticoagulant therapy. She described the training. Record review of the training completed between 1/15/16 and 1/19/16 revealed all of the nursing staff, certified nurse aides, and medication aides listed on the active staff list provided attended in service training classes. Record review of the undated INTERACT For Nurses INTERVENTIONS TO REDUCE ACUTE CARE TRANSFERS SBAR/CARE PATHS/CHANGE IN CONDITION CARDS EARLY WARNING TOOL revealed, .*This program's intention is to improve the early identification, evaluation and communication of resident changes in status/condition and, thus, reduce the frequency of transfers to the acute hospital. Record review of the facility's undated policy and procedure for Resident Assessment Policy revealed it addressed completing the MDS assessments but did not address assessments during a resident change in condition outside of a qualifier for a new MDS assessment to be generated. The Administrator and the Acting Director of Nurses were informed on 1/20/16 at 2:59 p.m. that the IJ was removed; however, the facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy at a scope identified at a pattern due to the facility requiring more time to monitor the plan of removal for its effectiveness. The facility's report of residents receiving anticoagulants dated 1/19/16 listed 25 residents receiving anticoagulants.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for 1of 18 residents reviewed for neglect (CR #1) in that: --LVN C did not assess CR #1, consult with the physician for treatment orders, or call the responsible party for approximately four hours while CR#1 was actively bleeding. CR #1 was admitted to the hospital and received blood. An Immediate Jeopardy (IJ) was identified on 1/15/16. While the IJ was removed on 1/20/16, the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not immediate jeopardy due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 1 former resident and placed 24 additional residents on blood thinners at greater risk of injury, delayed treatment, hospitalization , or death in the event of a change in health condition. Intake # 2 Findings include: Findings include: Record review of Closed Record (CR) #1's admission sheet revealed she is an [AGE] year old who was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR#1's quarterly MDS with an ARD of 9/29/15 revealed she was assessed as scoring an 8 out of 15 on her brief interview for mental status indicating moderately impaired cognitive skills for daily decision making. She required the extensive assistance of 2 staff for bed mobility, transfers, and toilet use. She required the extensive assistance of one staff for dressing, eating, and personal hygiene. She was totally dependent on 1 staff for locomotion. She had no limitations in her functional range of motion. She had an indwelling urinary catheter and was always incontinent of bowel. She had a stage IV pressure ulcer that was present upon admission. Record review of CR#1's 12/2/15 physician order [REDACTED]. Record review of the complaint intake revealed the concern that on 12/30/15 CR#1 had been bleeding in the facility at approximately 2:00 p.m. and CR#1 went without treatment until the next shift came in. Record review of CR#1's health status note dated 12/30/15 at 3:15 p.m. revealed, .This nurse summoned to resident's room, per CNA. Resident noted bleeding from her vagina (clots noted). Call placed to (Medical Director) and (Hospice Agency F). Awaiting return call from both parties. The note had been entered by LVN C. The next note, also by LVN C, on 12/30/15 was timed 5:15 p.m. which read, .V/S (vital signs) are as follows: T (temperature)-97.2, P (pulse)-76, R (respirations)-18, B/P (blood pressure)- 132/74. There were no additional notes by LVN C on 12/30/15. The next health status note was by LVN G dated 12/30/15 and timed 11:56 p.m. The note read, .Late Entry- At 06:15 p.m., LVN G was called into room of Resident CR #1. CR #1 was noted to have a large amount of vaginal bleeding with clots. 98.4- 70- 18- 124.66 B/S 124 O2 sat 94% she is alert and talkative on round. At 6:30 p.m. family member was notified of change in Resident #1 health status and that CR #1 was being sent out to the hospital. Family member requested that CR#1 be sent to hospital by emergency medical service. At 06:40 p.m. hospice was informed that CR #1 was being sent out of facility to hospital due to vaginal bleeding. At 06:45 p.m. medical director was notified of CR #1's vaginal bleeding. Medical Director gave order to transport CR #1 to hospital by regular transport. Medical Director said that he did not feel CR #1 needed to be transported to the hospital by emergency medical service despite family's request. During an interview on 1/13/16 at 3:36 p.m. with LVN C she said CR#1 was transferred to the hospital due to bleeding from her vagina with clots. She said the indwelling urinary catheter was in place when the resident was sent out. When asked if CR#1 was on any blood thinners she said, No. She said CR#1 was bleeding during her shift. She said she tried to report it to the resident's family members but got no answer. She said she called the Medical Director. She said the Medical Director told her to try to contact the family and monitor the bleeding. She said she continued to try to reach the family. She said she understands the bleeding started again on the evening shift and CR#1 was sent out. Record review of CR#1's computerized and paper chart revealed no documentation of CR #1 vagianl bleeding prior to LVN G's note for the late entry at 6:30 p.m. There was not documentation of an assessment by LVN C. There was no documentation of the Medical Director or of Hospice Agency F being consulted. There was a note which read awaiting return phone calls from the Medical Director and Hospice Agency F. During an interview on 1/14/16 at 2:24 p.m. with CNA E she was asked to describe what happened with CR#1 on 12/30/15. She said she came on shift at 2:00 p.m. and went into CR#1's room at approximately 2:15 p.m. She said she spoke to the resident and CR#1 told her she was ok. She said she then lifted the sheet to turn CR #1. She said there was blood on CR#1's gown and sheet that was dry. She said CR#1's brief had turned purple and it was .full of blood. She said, The outside of the brief had turned purple it was so full. She said she got LVN C and took her to CR#1's room. She said LVN C kept trying to tell her (CNA E) what could cause it and told her to clean the resident up. At 4:45 p.m. she checked on the resident again and she had blood clots again and blood was stuck in CR#1's pubic hair. She said CR#1 had, .chunks of blood, the first time she was found bleeding. She then stopped and thought and corrected herself saying the second episode of bleeding was at 3:15 p.m., not 4:45 p.m. She said she reported it to LVN C again and LVN C told her to clean her up again. She said she checked on the resident again around 4:45 p.m. or 5:15 p.m. and this time there was heavy bleeding. She said LVN G had come in early and she went to LVN G and LVN C and reported the bleeding. She said LVN G came in the room with her and then called EMS. She said the bleeding had not stopped. She said the bleeding never stopped. She said she thought the blood was draining from the vagina. She said you could see the clots of blood draining out as she cleaned. During an interview on 1/14/16 10:17 a.m. with the Administrator, Interim DON, ADON, and Corporate Nurse, when asked what should be done if a return call is not received from a doctor or agency, the Interim DON said if hospice does not call back, staff should call the physician. The Administrator said the prior DON was in the building when CR#1 had the change in condition. The Interim DON said the prior DON was not made aware of the change in condition until CR#1 was leaving the facility. The Corporate Nurse said the facility follows physician orders [REDACTED]. The Administrator and DON said the facility had not inserviced the staff following this incident. The ADON said LVN C had told her that she attempted to contact Hospice Agency F. The Administrator said LVN C had a CNA monitor CR#1. The Interim DON and Corporate Nurse said LVN C should have attempted contact with the doctor and hospice again after 15 minutes. The Corporate Nurse said 15 minutes is the standard. The Administrator said the prior DON's last day of work was 12/31/15. She said their last Quality Assurance meeting was held in December 2015 and no meeting was scheduled for January 201 The facility did not provide surveyor with an investigation report on this incident prior to exit on 01/20/2016. During a telephone interview on 1/14/16 at 12:01 p.m. with the prior DON he said on 12/30/15 after hours (after 5:00 p.m.), LVN G came to him and told him CR#1 was bleeding. He said he told her to call EMS. He said he was told sometime between 5:00 p.m. and 6:00 p.m. He said LVN G told him it was, .regular bleeding vaginally. He said she had already called EMS and they were on their way. He said the next day, 12/31/15, was his last day to work there and that a family member of CR#1 had come in and told him CR#1 had to receive 2 units of packed red blood cells at the hospital and was stable. He said to his recollection, CR#1 was on [MEDICATION NAME] and a blood thinner and that is why he agreed with the nurse to call EMS. He said when notified of a change in a resident's status he will do an assessment. He said he should have been notified of the change in CR #1's change in condition. He said the Medical Director and Administrator should also have been notified of the change in CR#1's condition He said even if the bleeding stopped you should attempt to recontact the physician within twenty minutes. He said it was not brought to his attention. During a telephone interview on 1/14/16 at 12:48 p.m. with the Medical Director he said he was called on 12/30/15 and told CR#1 had vaginal bleeding. He said he was called about CR#1 around 07:00 pm. He said he did not feel CR#1 needed to be sent to the hospital via EMS but via regular transport. He said if he was called they should have documented. He said Resident CR #1 was on blood thinners and needed to go to the hospital for evaluation. During a telephone interview on 1/14/16 at 1:33 p.m. with Hospice Nurse J she said the hospice agency was notified around 06:40 pm on 12/30/2015 about CR #1's vaginal bleeding. During an interview on 1/14/16 at 1:43 p.m. with LVN C she said she was told around 3:00 p.m. that CR#1 was bleeding. When asked how she determined where the bleeding was coming from she said by moving the brief around. She said she asked the CNA to inform her if CR #1 began to bleed again. She said the on-call hospice nurse told her to reach the family and ask them what they wanted her to do. When asked who the on-call hospice nurse was she said she did not know. She said she told the hospice nurse that CR#1 was on blood thinners. She said she documented the incident. When asked if it was the standard to document who you spoke to she said it was. She said she spoke to the Medical Director and remembered that he answered the phone. She said the Medical Director told her to contact the family and gave her no orders. She said she spoke to the Medical Director at about 3:15 p.m. on 12/30/15. She said she did not hear from the family. When asked why her documentation read that she attempted to call the Medical Director but the note read that she was awaiting a response from him she said, I don't know. She said while she was giving report to LVN G, CNA E came and told her the bleeding had started again. She said she had not tried to recontact the Medical Director or Hospice Agency F. She said she did not hear from the family. She said, I'll put it this way, if she weren't a hospice patient, I would have notified the doctor and family. With her being a hospice patient, you don't know what the family might want. She said, With hospice patients there's not normally transfers to the hospital. Not unless there is a fracture, other circumstances. She said she did not notify the DON of CR #1's change in condition. She said it is policy to notify the DON if a resident has a change in condition. She said she did not have a reason for not notifying the DON. She said CNA E informed her two times that CR #1 was bleeding. She said Hospice Agency F had called her back within 5 minutes. She said she did not have the prior DON's phone number. She said the facility only posts the DON's phone number at Station I (she works Station II). During an interview on 1/14/16 at 3:58 p.m. with the Corporate Nurse she said they could not find a policy and procedure for blood thinners. During an interview on 1/15/16 at 1:38 p.m. with the Corporate Nurse she said they did not have a policy and procedure on a change in condition. She said they use the INTERACT form. The INTERACT form was used to identify, evaluate, and communicate a resident's change in condition. During a telephone interview on 1/15/16 at 2:14 p.m. with LVN G she said a CNA reported to her that CR #1 was bleeding at the beginning of her evening shift She said she assessed the resident and there were blood clots. She said she got the ADON and sent the resident out. She said the day shift nurse had reported to her that CR#1 had two episodes of bleeding that day. She said LVN C told her she had called a hospice nurse. She said if a resident has a change in condition you should consult the physician and notify the family. She said CR #1's hospice would also have been notified. She said LVN C told her that she spoke to hospice and they were going to send a nurse out. When asked if LVN C told her who she spoke to she said no. She said CR#1's family member told her he did not know about the bleeding. She said called the Medical Director. She said the Medical Director ordered CR #1 to be transported to the hospital via regular transport. She said she had not been told that the bleeding was originally detected at 02:15 pm. She said she ADON had not been notified of CR #1's change in condition. She said a change in condition should also be reported to the ADON. During a telephone interview on 1/15/16 at 2:59 p.m. with Hospice Nurse J she said she worked 12/30/2015. She said a change in condition of one of her patients would have been reported to her. She said the call would have been sent to her. Record review of LVN C's employee file revealed her date of hire was 9/30/14. Her file contained two written disciplinary forms dated 3/20/15 and 5/8/15. Record review of LVN C's 3/20/15 Disciplinary Warning Notice revealed the following date and explanation of incident/occurrence: .1. Resident have order for ear ggts (sic) (drops). a week ago that was not carried out 2. MD order for C&S (culture and sensitivity) of the wound, not done 3. Resident going to an appt. (appointment) was not set appropriate transport to accommodate residents needs. 4. Overall, poor job performance. Record review of LVN C's 5/8/15 Disciplinary Warning Notice revealed it was her 2nd warning and revealed, .date and explanation of incident/occurrence: Nurse failed to report an abnormal xray to MD (Medical Doctor). Nurse reported xray was negative to MD and ADON. She had received in-services on abuse/neglect on 1/28/15 and 3/18/15. During an interview on 1/19/16 at 11:39 a.m. with the Corporate Nurse she said there was no documentation of an SBAR having been done for CR#1. During a telephone interview on 1/20/16 at 8:41 a.m. with family member he said he was notified of CR#1 bleeding on 12/30/15 at 06:05 pm. The Administrator, the Acting Director of Nurses and the Corporate Nurse were notified on 1/15/16 at 3:06 p.m. that an Immediate Jeopardy (IJ) had been identified based on the above failures. A Plan of Removal (PoR) was submitted on 1/16/16. After revisions, it was accepted on 1/19/16 at 4:22 p.m. The PoR included: 1. On 1/15/16, Nurse Managers, Licensed Nurses and the Acting Director of Nursing immediately assessed current residents in the facility; including those residents with indwelling catheters, those with anticoagulant therapy, and those receiving Hospice services in order to ensure any changes in conditions were identified. Should a change in condition be noted, the physician and responsible party will be notified; necessary intervention will be implemented; documentation in the clinical record ; and the identified change will be care planned. 2. The Acting Director Nursing, assistant Director of Nursing immediately began educating staff (RNs, LVNs, CNAs, and MAs) on the following starting 1/15/16: A) Recognizing changes in condition. In the event of a change in a resident condition, the nurse will notify the resident's attending physician and family when there has been an incident, bleeding, significant change in resident physical, emotional or mental status, need to alter the resident medical treatment, refusal of treatment or medication, or the need to transfer the resident to the hospital. . b) Assessment of the resident's change in condition, immediately communicating change in the resident's condition to the physician by phone following the assessment, documenting the assessment in Interact, using SBAR and Stop and Watch forms. c) Notifying the attending physician and the resident's responsible party by phone. If unable to reach the attending physician or nurse practitioner on the first call, continue to call every 15 minutes thereafter until a response is obtained. d) If staff is unable to reach the resident's attending physician after 2 calls, immediately notify the medical director and your supervisor. e) When to call 911 based on the resident's change in condition. . g) Timely implementation of intervention for residents who have a change in conation. h) Monitoring residents for bleeding when they receive ordered Anticoagulants/blood thinners. i) Abuse and Neglect training. j) Licensed nurses will be educated on the utilization of the 24 hour report for communicating changes in condition. k) Educate licensed staff on monitoring residents receiving blood thinners for bruising and bleeding. The education will continue each shift prior to the start of the staff members' shift. Those on FMLA and paid time off will be completed prior to the beginning of their next shift by the Acting Director of Nursing, Assistant Director of Nursing, Regional Nurse. . The Surveyors confirmed that the PoR had been sufficiently implemented to remove the IJ by: On 1/15/16 at 2:25 p.m., LVN D described how she would recognize if one of her residents had been neglected or had a change in condition. If she noted a change in condition, she gave several examples, she would assess the resident, complete the documentation using the SBAR form, and call the doctor and responsible party. She said she would report any situation of resident neglect to the person in charge, and then the abuse prevention coordinator. On 1/15/16 at 2:40 p.m., LVN O said that she would recognize a change in her resident's neglect or conditions because she sees them every day. She described signs and symptoms of a change of condition. Then she would document the results of her assessment and what she did for the resident. She said if one of her residents had been neglected, she would notify the Administrator as well as the doctor and the family. On 1/19/16 at 10:30 a.m., RN B described signs and symptoms of changes in resident condition. She described how she would recognize if a resident had been neglected. When she noticed a change in her residents, she first assessed her residents and documented the change of condition on the SBAR. She would have all of this information available when she called the doctor for orders. She would also call the responsible party. She would report any neglect to the Administrator. On 1/19/16 at 10:45 a.m., LVN A described how she would recognize if one of her residents was experiencing a change in condition. She described how she would recognize if one of her residents was neglected. She said she would report any suspected neglect. During an interview on 1/20/16 at 10:48 a.m. with the Administrator when asked how she thought this immediate jeopardy/substandard quality of care came about she said from record review it looked like it was a nursing assessment of a resident that was on an anticoagulant being the primary reason. She said assessment, notification and follow up were contributing factors. When asked if she had been aware of the situation prior to surveyors coming in she said only that the resident had gone out to the hospital. During an interview on 1/20/16 at 11:03 a.m. with the Acting Director of Nurses when asked how they ensure nurses were competent in their skills she said they do annual skills checks. When asked what type of plan was in place for when a resident starts bleeding she said they get up, assess the resident, and call the doctor. She said they follow the INTERACT and SBAR to help them complete their evaluation on that resident. When asked how she thought this immediate jeopardy/substandard quality of care came about she said, I really think it happened through the transition of the prior DON leaving and not knowing how extensive her situation was. She said she thought if the prior DON would have stayed they would have identified the problem. She said if felt like the nurse did not do what she was supposed to do. On 1/20/16 at 2:35 p.m., LVN A said she had additional training in abuse and neglect prevention this week. Record review of the training completed between 1/15/16 and 1/19/16 revealed all of the nursing staff, certified nurse aides, and medication aides listed on the active staff list provided attended in service training classes. Record review of the facility's undated policy Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property revealed, . Each resident has the right to be free from mistreatment, neglect . Record review of the undated INTERACT For Nurses INTERVENTIONS TO REDUCE ACUTE CARE TRANSFERS SBAR/CARE PATHS/CHANGE IN CONDITION CARDS EARLY WARNING TOOL revealed, .*This program's intention is to improve the early identification, evaluation and communication of resident changes in status/condition and, thus, reduce the frequency of transfers to the acute hospital. The Administrator and the Acting Director of Nurses were informed on 1/20/16 at 2:59 p.m. that the IJ was removed; however, the facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy at a scope identified at a pattern due to the facility requiring more time to monitor the plan of removal for its effectiveness. The facility's report of residents receiving anticoagulants dated 1/19/16 listed 25 residents receiving anticoagulants

Based on interview and record review, the facility failed to provide services that meet professional standards for 1 of 18 residents (CR#1) reviewed for change in condition in that: --LVN C did not collect data and perform a focused nursing assessment and did not participate in the planning of CR#1's nursing care needs by failing to consult with the physician when CR #1 was actively bleeding. CR #1 was admitted to the hospital and received blood. An Immediate Jeopardy (IJ) was identified on 1/15/16. While the IJ was removed on 1/20/16, the facility remained out of compliance at a scope of pattern and level of no actual harm, but risk for more than minimal harm because the facility needed to continue to monitor the staff. This failure affected one prior resident and placed 27 residents assigned to station 1 at risk of injury, delayed treatment, or hospitalization in the event of a change in health condition. Intake # 2 Findings include: Record review of the Texas Board of Nursing Practice Act 2013 revealed: Vocational nursing means a directed scope of nursing practice, including the performance of an act that requires specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing. The term does not include acts of medical [DIAGNOSES REDACTED]. Vocational nursing involves:(A) collecting data and performing focused nursing assessments of the health status of an individual; (B) participating in the planning of the nursing care needs of an individual; .(E) assisting in the evaluation of an individual's response to a nursing intervention and the identification of an individual's needs; and . http://www.bne.state.tx.us/laws_and_rules_nursing_practice_act_2013.asp Record review of Closed Record (CR) #1's admission sheet revealed she was an [AGE] year old who was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR#1's quarterly MDS with an ARD of 9/29/15 revealed she was assessed as scoring an 8 out of 15 on her brief interview for mental status indicating moderately impaired cognitive skills for daily decision making. She required the extensive assistance of 2 staff for bed mobility, transfers, and toilet use. She required the extensive assistance of one staff for dressing, eating, and personal hygiene. She was totally dependent on 1 staff for locomotion. She had no limitations in her functional range of motion. She had an indwelling urinary catheter and was always incontinent of bowel. She had a stage IV pressure ulcer that was present upon admission. Record review of CR#1's 12/2/15 physician order [REDACTED]. Record review of the complaint intake revealed the concern that on 12/30/15 CR#1 had been bleeding in the facility at approximately 2:00 p.m. and CR#1 went without treatment until the next shift came in. Record review of CR#1's health status note dated 12/30/15 at 3:15 p.m. revealed, .This nurse summoned to resident's room, per CNA. Resident noted bleeding from her vagina (clots noted). Call placed to (Medical Director) and (Hospice Agency F). Awaiting return call from both parties. The note had been entered by LVN C. The next note, also by LVN C, on 12/30/15 was timed 5:15 p.m. which read, .V/S (vital signs) are as follows: T (temperature)-97.2, P (pulse)-76, R (respirations)-18, B/P (blood pressure)- 132/74. There were no additional notes by LVN C on 12/30/15. The next health status note was by LVN G dated 12/30/15 and timed 11:56 p.m. The note read, .Late Entry- 6:15 p.m.-Called into room per CNA noted that she has a large amt (amount) of vaginal bleeding with clots noted to her pubic area 98.4- 70- 18- 124.66 B/S 124 O2 sat 94% she was alert and talkative on round. 6:30 p.m.- CR#1's family member called and informed him of CR #1's vaginal bleeding with clots and he was told @ this time that we are going to send her to the hospital ,he stated to send her to (Hospital H) in the Medical Center per 911 6:40 p.m. Hospice Agency F called and spoke with (hospice employee name) about her being sent to the hospital 6:45 p.m.- Medical Director called and informed of her bleeding and that she will be going to the hospital per 911 per the family request, he stated that she needs not to go per 911 but by regular transport,he was informed that the family requested 911 ,his reply was that's not needed. 7:10 p.m.-Emergency Medical Services (EMS) here report given pt. placed on stretcher and transported to (Hospital H) hospital. Pt remains alert and talkative. 7:22 p.m.-Family member here he was told that she is on her way to the hospital and he left. 7:30 p.m.-(hospice employee name) from Hospice Agency F called and stated that they will have to provoke (sic) her care,and let the on coming nurse to call them when she returns. During an interview on 1/13/16 at 3:36 p.m. with LVN C she said CR#1 was transferred to the hospital due to bleeding from her vagina with clots. She said CR#1 used to have a suprapubic catheter that had been changed out to a regular indwelling urinary catheter. She said the indwelling urinary catheter was in place when the resident was sent out. When asked if CR#1 was on any blood thinners she said, No. When asked if she had been aware of CR#1's indwelling urinary catheter being dislodged 2 days prior (on 12/28/15) she said, I have no idea. She said CR#1 was bleeding during her shift. She said she tried to report it to the resident's family members but got no answer. She said she called the Medical Director. She said the Medical Director told her to try to contact the family and monitor the bleeding. She said she continued to try to reach the family. She said she understands the bleeding started again on the evening shift and CR#1 was sent out. Continued review of CR#1's computerized and paper chart revealed there was no documentation of an assessment, SBAR, or notification to her responsible party of her bleeding prior to LVN G's note for the late entry at 6:30 p.m. There was no documentation of the Medical Director or of Hospice Agency F being consulted. There was a note which read awaiting return phone calls from the Medical Director and Hospice Agency F. During an interview on 1/14/16 at 2:24 p.m. with CNA E she was asked to describe what happened with CR#1 on 12/30/15. She said she came on shift at 2:00 p.m. and went into CR#1's room at approximately 2:15 p.m. She said she spoke to the resident and CR#1 told her she was ok. She said she then lifted the sheet to turn CR #1. She said there was blood on CR#1's gown and sheet that was dry. She said CR#1's brief had turned purple and it was .full of blood. She said, The outside of the brief had turned purple it was so full. She said she got LVN C and took her to CR#1's room. She said LVN C kept trying to tell her (CNA E) what could cause it and told her to clean the resident up. At 4:45 p.m. she checked on the resident again and she had blood clots again and blood was stuck in CR#1's pubic hair. She said CR#1 had, .chunks of blood, the first time she was found bleeding. She then stopped and thought and corrected herself saying the second episode of bleeding was at 3:15 p.m., not 4:45 p.m. She said she reported it to LVN C again and LVN C told her to clean her up again. She said she checked on the resident again around 4:45 p.m. or 5:15 p.m. and this time there was heavy bleeding. She said LVN G had come in early and she went to LVN G and LVN C and reported the bleeding. She said LVN G came in the room with her and then called 911. She said the bleeding had not stopped. She said the bleeding never stopped. She said she thought the blood was draining from the vagina. She said she could see the clots of blood draining out as she cleaned. During an interview on 1/14/16 10:17 a.m. with the Administrator, Interim DON, ADON, and Corporate Nurse, when asked what should be done if a return call is not received from a doctor or agency, the Interim DON said if hospice does not call back, the nurse should call the physician. The Corporate Nurse said she would have called the physician first and then the hospice and family. The Administrator said the prior DON was in the building when CR#1 had the change in condition. The Interim DON said the prior DON was not made aware of the change in condition until CR#1 was leaving the facility. The Corporate Nurse said the facility follows physician orders [REDACTED]. The Administrator and DON said the facility had not inserviced the staff following this incident. The ADON said LVN C had told her that she attempted to contact Hospice Agency F. The Administrator said LVN C had a CNA monitor CR#1. The Interim DON and Corporate Nurse said LVN C should have attempted contact with the doctor and hospice again after 15 minutes. The Corporate Nurse said 15 minutes is the standard. The Administrator said the prior DON's last day of work was 12/31/15. She said their last Quality Assurance meeting was held in December 2015 and no meeting was scheduled for January 2016. She said the incident with CR#1 had not been identified by the Quality Assurance Committee. The Administrator said if the prior DON investigated the incident the investigation report would be in his office. The facility did not provide surveyor with an investigation report on this incident prior to exit on 01/20/2016. During a telephone interview on 1/14/16 at 12:01 p.m. with the prior DON he said on 12/30/15 after hours (after 5:00 p.m.), LVN G came to him and told him CR#1 was bleeding. He said he told her to call 911. Prior DON said he did not recall anyone informing him earlier that day that CR #1 was bleeding. He said he was told sometime between 5:00 p.m. and 6:00 p.m. He said LVN G told him it was, .regular bleeding vaginally. He said she had already called 911 and they were on their way. When asked if he was certain he had not been told earlier he said, Absolutely not, not at all. He said the next day, 12/31/15, was his last day to work there and that a family member of CR#1 had come in and told him CR#1 had to receive 2 units of packed red blood cells at the hospital and was stable. He said to his recollection, CR#1 was on [MEDICATION NAME] and a blood thinner and that is why he agreed with the nurse to call 911. He said when notified of a change in a resident's status he will do an assessment. He said what nurses do depends on what the nurse sees in the assessment and review of medications. He said if there is no response, the nurse is supposed to try to contact the Medical Director. He said he and the Administrator should have been called. He said even if the bleeding stopped, the nurse should attempt to re-contact the physician within twenty minutes. He said he should have been told immediately about CR #1's change in condition. He said it was not brought to his attention. He said all residents including those on hospice are to be treated the same. He said, .absolutely . still to receive treatment if bleeding. During a telephone interview on 1/14/16 at 12:22 p.m. with Hospice Nurse I, she confirmed that she was the nurse who came to the facility on [DATE] when CR#1's indwelling urinary catheter had been dislodged. She said she assessed the resident and there was no bleeding. She said it was protocol to leave the catheter out for 24 hours and then reinsert it. She said she was not the nurse that would have been called on 12/30/15. She said CR#1's assigned case manager was Hospice Nurse J. During a telephone interview on 1/14/16 at 12:48 p.m. with the Medical Director he said he was called on 12/30/15 and told CR#1 had vaginal bleeding. He said he was called about CR#1 around 07:00 p.m He said he did not feel CR#1 needed to be sent via EMS, but agreed that she needed to go to the hospital via regular transport. He said if he was called they should have documented it. When asked about the source of the bleeding he said, the source of the bleeding would not have mattered. He said if there were clots present she should have been sent out. He said even if the bleeding had stopped she still should have been sent out due to the fact that she was on blood thinners. During a telephone interview on 1/14/16 at 1:33 p.m. with Hospice Nurse J she said she was not called about CR#1 on 12/30/15 but that she knew the agency was called the night of 12/30/15. She said no calls were received from the facility that day until 6:40 p.m. She said the ADON told her the following day that CR#1 had heavy bleeding with clots from the vagina. During an interview on 1/14/16 at 1:43 p.m. with LVN C she said she was told around 3:00 p.m. that CR#1 was bleeding. When asked how she determined where the bleeding was coming from she said by moving the brief around. She said the blood had pooled and clotted over the vagina. She said she did see CR#1 after the aide had cleaned her up and that she told the aide to let her know if there was anymore bleeding. She said the on-call hospice nurse told her to reach the family and ask them what they wanted her to do. She said that she did not know who the on-call hospice nurse was. She said she hold the hospice nurse that CR#1 was on blood thinners. She said she documented the incident. She said that it was the standard practice to document to whom the nurse spoke. She said that the blood clots were the smaller than a grape but larger than a raisin. She said she spoke to the Medical Director and remembered that he answered the phone. She said the Medical Director told her to contact the family, but gave her no orders. She said she spoke to the Medical Director at about 3:15 p.m. on 12/30/15. She said she did not hear from the family. When asked why her documentation read that she attempted to call the Medical Director but the note read that she was awaiting a response from him she said, I don't know. She said the Medical Director usually does answer his phone. She said while she was giving report to LVN G, CNA E came and told her the bleeding had started again. She said she had not tried to re-contact the Medical Director or Hospice Agency F. She said she did not hear from the family. She said, I'll put it this way, if she weren't a hospice patient, I would have notified the doctor and family. With her being a hospice patient, you don't know what the family might want. She said, With hospice patients there's not normally transfers to the hospital. Not unless there is a fracture, other circumstances. When asked for other examples she said she could not think of any due to she was nervous. When asked if she had notified the DON at the time of CR#1's change in condition she said no and at that .at that point was just trying to handle it on my station. She said she was busy and .had a lot going on. She said it is policy to notify the DON if a resident has a change in condition. she said she did not have a reason for not notifying the DON. She said she had .three or four people on their lights wanting pain medicine. She said she was notified by CNA E .those two times were the only two times about CR #1's bleeding. When asked to clarify that from being notified at 3:00 p.m., she went to the room, assessed the resident, went back to the nurses' station and called the Medical Director, Hospice, and family. She said that she spoke to hospice and the Medical Director and was documenting by 3:15 p.m. She said that she was moving pretty fast. You move pretty fast in those types of situations. But that's nursing, you have your good days and your not so good days. She said Hospice Agency F had called her back within 5 minutes. When asked again if she was supposed to have notified her DON she said she had to stick close by the phone. She said she did not have the prior DON's phone number. She said the facility only posts the DON's phone number at Station I (she works Station II). She said she was pretty sure LVN G notified the DON. When asked if she documented the Medical Director's order to contact the family and see what they wanted to do, she said, I really don't remember. Observation of the Station II nurse's station on 1/20/16 at 11:18 a.m. and of Station I on 1/20/16 at 11:21 a.m. revealed a worn piece of paper taped to the station walls which contained the extension number for department heads in the building, including the DON at both stations. During an interview on 1/14/16 at 3:58 p.m. with the Corporate Nurse she said they could not find a policy and procedure for blood thinners. During an interview on 1/15/16 at 1:38 p.m. with the Corporate Nurse she said they did not have a policy and procedure on a change in condition. She said they use the INTERACT form. The INTERACT form is used to identify, evaluate, and communicate when a resident has a change in condition. During a telephone interview on 1/15/16 at 2:14 p.m. with LVN G she said she had come in and was about to make rounds when a CNA reported to her that CR#1 was bleeding. She said she assessed the resident and there were blood clots. She said she got the ADON and sent the resident out to the hospital. She said the day shift nurse had reported to her that CR#1 had two episodes of bleeding that day. She said LVN C told her she had called a hospice nurse. She said LVN C did not tell her if she had called a doctor. When asked what the procedure is for such a situation she said the nurse should call the doctor and let the doctor know then call the family after the nurse gets orders. She said a change in condition should also be reported to the ADON. During a telephone interview on 1/15/16 at 2:59 p.m. with Hospice Nurse J she said she worked 12/30/2015. She said a change in condition of one of her patients would have been reported to her. She said the call would have been sent to her. Record review of LVN C's employee file revealed her date of hire was 9/30/14. Her file contained two written disciplinary forms dated 3/20/15 and 5/8/15. Record review of LVN C's 3/20/15 Disciplinary Warning Notice revealed the following date and explanation of incident/occurrence: .1. Resident have order for ear ggts (sic) (drops). a week ago that was not carried out 2. MD order for C&S (culture and sensitivity) of the wound, not done 3. Resident going to an appt. (appointment) was not set appropriate transport to accommodate residents needs. 4. Overall, poor job performance. The Corporate Nurses signature stamp was on the form with the date of 3/20/15 as the Department Head Signature. Record review of LVN C's 5/8/15 Disciplinary Warning Notice revealed it was her 2nd warning and revealed, .date and explanation of incident/occurrence: Nurse failed to report an abnormal xray to MD (Medical Doctor). Nurse reported xray was negative to MD and ADON. Record review of LVN C's in-servicing records revealed she had received in-services for the SBAR on 2/24/15 and 3/2/15. She had received in-services on abuse/neglect on 1/28/15 and 3/18/15. During an interview on 1/15/16 at 3:06 p.m. with the Corporate Nurse, Administrator, and Acting Director of Nurses the Corporate Nurse confirmed it was her signature on the 3/20/15 Disciplinary Warning Notice for LVN C. When asked how they monitor staff with a history of disciplinary warnings the Administrator and Acting Director of Nurses said they were not employed by the facility during that time. They did not respond give a response as to if there was a system to monitor staff. The Corporate Nurse said she is not in the facility daily. During an interview on 1/19/16 at 11:39 a.m. with the Corporate Nurse she said there was no documentation of an SBAR having been done for CR#1. During a telephone interview on 1/20/16 at 8:41 a.m. with Family Member he said he was notified of CR#1 bleeding on 12/30/15. He said he was called at 6:05 p.m. on 12/30/15. He said he was told that the neck of her urethra was torn. During a telephone interview on 1/22/16 at 9:02 a.m. with Urologist M he was asked if he could confirm that the source of CR#1's bleeding was a urethral tear. He said, Yeah, most likely. Record review of CR#1's Hospitalist Discharge Summary from Hospital H dated 1/3/16 revealed a discharge [DIAGNOSES REDACTED]. The summary revealed, .Hospital Course 80 y/o (year old) female .afib ([MEDICAL CONDITION]) on Xarelto .renal stones .presents with gross hematuria. Pt (patient) family member states that foley (indwelling urinary catheter) accidentally came out with balloon still inflated approx (approximately) 2 days prior to admission and pt noted to have gross hematuria that started on 12/30 at skilled nursing facility. Urology evaluated pt in ED (emergency department) and placed large bore foley to compress any urethral bleeding. Pt noted to have hgb (hemoglobin) 7.3 on admission, and started on 2 units of PRBCs (packed red blood cells) in ED. (1) Pt was monitored and urology followed. Hematuria resolved with anticoagulation held. The Administrator, the Acting Director of Nurses and the Corporate Nurse were notified on 1/15/16 at 3:06 p.m. that an Immediate Jeopardy (IJ) had been identified based on the above failures. A Plan of Removal (PoR) was submitted on 1/16/16. After revisions, it was accepted on 1/19/16 at 4:22 p.m. The PoR included: 1. On 1/15/16, Nurse Managers, Licensed Nurses and the Acting Director of Nursing immediately assessed current residents in the facility; including those residents with indwelling catheters, those with anticoagulant therapy, and those receiving Hospice services in order to ensure any changes in conditions were identified. Should a change in condition be noted, the physician and responsible party will be notified; necessary intervention will be implemented; documentation in the clinical record ; and the identified change will be care planned. 2. The Acting Director Nursing, assistant Director of Nursing immediately began educating staff (RNs, LVNs, CNAs, and MAs) on the following starting 1/15/16: A) Recognizing changes in condition. In the event of a change in a resident condition, the nurse will notify the resident's attending physician and family when there has been an incident, bleeding, significant change in resident physical, emotional or mental status, need to alter the resident medical treatment, refusal of treatment or medication, or the need to transfer the resident to the hospital. a) Recognizing changes in condition, examples: . b) Assessment of the resident's change in condition, immediately communicating change in the resident's condition to the physician by phone following the assessment, documenting the assessment in Interact, using SBAR and Stop and Watch forms. c) Notifying the attending physician and the resident's responsible party by phone. If unable to reach the attending physician or nurse practitioner on the first call, continue to call every 15 minutes thereafter until a response is obtained. d) If staff is unable to reach the resident's attending physician after 2 calls, immediately notify the medical director and your supervisor. e) When to call 911 based on the resident's change in condition. f) Documentation of the change in condition in the resident's clinical records and on the 24 hour report/ change in condition report. g) Timely implementation of intervention for residents who have a change in conation. h) Monitoring residents for bleeding when they receive ordered Anticoagulants/blood thinners. . The education will continue each shift prior to the start of the staff members' shift. Those on FMLA and paid time off will be completed prior to the beginning of their next shift by the Acting Director of Nursing, Assistant Director of Nursing, Regional Nurse. . The Surveyors confirmed that the PoR had been sufficiently implemented to remove the IJ by: On 1/15/16 at 2:25 p.m., LVN D described described ways that she would know that one of her residents experienced a change in condition. She gave examples of signs and symptoms. She said that she would assess the resident, document the resident's condition and consult with the resident's physician. On 1/15/16 at 2:40 p.m., LVN O said that she would recognize a change in her resident's conditions because she sees them every day. She described signs and symptoms that would enable her to recognize changes in condition. She said that she would first assess them, including take their vital signs. Then, she would call the doctor for orders. She would have already checked the PRN orders for treatments. On 1/19/16 at 10:30 a.m., RN B described ways that she would recognize a change in condition of one of her residents. When she noticed a change in her residents, she first assessed her residents and documented the change of condition on the SBAR. She would have all of this information available when she called the doctor for orders. She would also call the responsible party. On 1/19/16 at 10:45 a.m., LVN A said she would recognize if a resident was experiencing a change in condition if he or she was lethargic, had a change in vital signs, had a change in the amount or type of talking, had a change in eating or posture. She said that she would assess the resident and document her findings on the SBAR form. She would call the doctor, family and the hospice provider. On 1/19/16 at 2:30 p.m., LVN D said that she had received the following training over the last week: How to manage residents receiving anticoagulants, which included checking for bruises and bleeding and how to assess and report these as changes in condition. She was trained how to document using the SBAR. She had training on how and when to communicate with the residents' physicians and the hospice providers. During an interview on 1/20/16 at 10:48 a.m. with the Administrator when asked how she thought this immediate jeopardy/substandard quality of care came about she said from record review it looked like it was a nursing assessment of a resident that was on an anticoagulant being the primary reason. She said assessment, notification and follow up were contributing factors. When asked if she had been aware of the situation prior to surveyors coming in she said only that the resident had gone out to the hospital. During an interview on 1/20/16 at 11:03 a.m. with the Acting Director of Nurses when asked how they ensure nurses were competent in their skills she said they do annual skills checks. When asked what type of plan was in place for when a resident starts bleeding she said they get up, assess the resident, and call the doctor. She said they follow the INTERACT and SBAR to help them complete their evaluation on that resident. When asked how she thought this immediate jeopardy/substandard quality of care came about she said, I really think it happened through the transition of the prior DON leaving and not knowing how extensive her situation was. She said she thought if the prior DON would have stayed they would have identified the problem. She said if felt like the nurse did not do what she was supposed to do. On 1/20/16 at 2:35 p.m., LVN A said she had received the following training over the last week: training in how to monitor residents receiving anticoagulant therapy; abuse and neglect; and how to recognize, assess, and document changes in condition. She said that once she assessed a patient's change in condition, she would document the information on the SBAR form and then call the doctor. The anticoagulant training included how to monitor for bleeding. One of the things they do for many of the residents currently receiving anticoagulant therapy running routine laboratory tests like a weekly PT/INR. She said that there should be no difference in how residents receiving services from hospice providers. On 1/20/16 at 2:35 p.m., RN C said that she received a lot of training over the last week. She received training about how to manage the residents receiving services from hospice providers and what to do when these residents have changes in conditions. They were trained on the interact system and how to complete the SBAR. They were trained on abuse and neglect, indwelling catheter care, and how to manage patients receiving anticoagulant therapy. She described the contents of the training. They are supposed to notify the doctor, family, and hospice provider if appropriate. Record review of the training completed between 1/15/16 and 1/19/16 revealed all of the nursing staff, certified nurse aides, and medication aides listed on the active staff list provided attended in service training classes. Record review of the undated INTERACT For Nurses INTERVENTIONS TO REDUCE ACUTE CARE TRANSFERS SBAR/CARE PATHS/CHANGE IN CONDITION CARDS EARLY WARNING TOOL revealed, .*This program's intention is to improve the early identification, evaluation and communication of resident changes in status/condition and, thus, reduce the frequency of transfers to the acute hospital. . * All sections of the SBAR must be completed prior to contacting the provider. Always, have the chart and SBAR in front of you, when you are communicating with the provider. The one complaint we hear most often is that the nurses don't have the information the Physician needs to make an informed decision regarding the resident's care. You will, now, be a shining star in their eyes! * Once you have completed your communication with the provider, you turn the SBAR over and write your progress notes, rather than having to go back into the chart. * The SBAR is, then, placed in the resident's file under Nurse Notes. * If, in the course of events, the resident's condition does not improve and hospitalization becomes necessary, make a copy of the SBAR and send along with all the other transfer documents, so the hospital can see what has, already, been done in the facility. Record review of the facility's undated policy and procedure for Documentation revealed, .When the facility transfers or discharges a resident under any of the above circumstances, appropriate documentation shall be made in the resident's clinical record. The attending physician shall document the reason for transfer/discharge when a resident is transferred or discharged for reasons 1, 2, and 4 above. Record review of the facility's undated policy and procedure for Contents of the Clinical Record revealed, .Clinical records will contain sufficient information to identify and care for the resident.Also, the record will contain sufficient information to record the residents' assessments, the comprehensive, interdisciplinary plan of care and services provided; .signed and dated clinical documentation from all health care practitioners involved in the resident's care, .Observations made by nursing personnel will show at least the following: items specified on the Minimum Data Set (MDS); current information including PRN (as needed) medications and results; treatments and any notable results; physical complaints, changes in clinical signs and behavioral status, and all incidents or accidents; .Clinical Records .Clinical records are maintained on each resident in ac

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 18 residents (CR#1) when a change in condition occurred in that: --LVN C did not consult the doctor and call the responsible party when CNA E reported that CR #1 was actively bleeding. CR#1 had to be admitted to the hospital to receive blood. An Immediate Jeopardy (IJ) was identified on 1/15/16. While the IJ was removed on 1/20/16, the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not immediate jeopardy due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected one former resident and placed 24 additional residents on blood thinners, at risk of injury, delayed treatment, hospitalization , or death in the event of a change in condition. Intake # 2 Findings include: Record review of Closed Record (CR) #1's admission sheet revealed she is an [AGE] year old who was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR#1's quarterly MDS with an ARD of 9/29/15 revealed she was assessed as scoring an 8 out of 15 on her brief interview for mental status indicating moderately impaired cognitive skills for daily decision making. She required the extensive assistance of 2 staff for bed mobility, transfers, and toilet use. She required the extensive assistance of one staff for dressing, eating, and personal hygiene. She was totally dependent on 1 staff for locomotion. She had no limitations in her functional range of motion. She had an indwelling urinary catheter and was always incontinent of bowel. She had a stage IV pressure ulcer that was present upon admission. Record review of CR#1's 12/2/15 physician order [REDACTED]. Record review of the complaint intake revealed the concern that on 12/30/15 CR#1 had been bleeding in the facility at approximately 2:00 p.m. and CR#1 went without treatment until the next shift came in. Record review of CR#1's health status note dated 12/30/15 at 3:15 p.m. revealed, .This nurse summoned to resident's room, per CNA. Resident noted bleeding from her vagina (clots noted). Call placed to (Medical Director) and (Hospice Agency F). Awaiting return call from both parties. The note had been entered by LVN C. The next note, also by LVN C, on 12/30/15 was timed 5:15 p.m. which read, .V/S (vital signs) are as follows: T (temperature)-97.2, P (pulse)-76, R (respirations)-18, B/P (blood pressure)- 132/74. There were no additional notes by LVN C on 12/30/15. The next health status note was by LVN G dated 12/30/15 and timed 11:56 p.m. The note read, .Late Entry- 6:15 p.m.-Called into room per CNA noted that she has a large amt (amount) of vaginal bleeding with clots noted to her pubic area 98.4- 70- 18- 124.66 B/S 124 O2 sat 94% she is alert and talkative on round. 6:30 p.m.- CR #1's family member called and informed him of CR #1's vaginal bleeding with clots and he was told @ this time that we are going to send her to the hospital ,he stated to send her to (Hospital H) in the Medical Center per 911 6:40 p.m. (Hospice Agency F) called and spoke with (hospice employee name) about her being sent to the hospital 6:45 p.m.- Medical Director called and informed of her bleeding and that she will be going to the hospital per 911 per the family request, he stated that she needs not to go per 911 but by regular transport,he was informed that the family requested 911 ,his reply was that's not needed. 7:10 p.m.-Emergency Medical Services (EMS) here report given pt. placed on stretcher and transported to (Hospital H) hospital.Pt remains alert and talkative. 7:22 p.m.-Family member here he was told that she is on her way to the hospital and he left. 7:30 p.m.-Hospice employee from Hospice Agency F called and stated that they will have to provoke (sic) her care,and let the on coming nurse to call them when she returns. During an interview on 1/13/16 at 3:36 p.m. with LVN C she said CR#1 was transferred to the hospital due to bleeding from her vagina with clots. She said CR #1 was not on blood thinners. She said CR#1 was bleeding during her shift. She said she tried to report it to the resident's family but got no answer. She said she called the Medical Director. She said the Medical Director told her to try to contact the family and monitor the bleeding. She said she continued to try to contact the family. Record review of CR#1's computerized and paper chart revealed there was no documentation prior to LVN G's note for the late entry at 6:30 p.m. on 12/30/2015 There was no documentation of the Medical Director or of Hospice Agency F being consulted. There was a note which read awaiting return phone calls from the Medical Director and Hospice Agency F. Record review of CR #1's care plan dated 11/13/2015 revealed that CR #1 was not care planned for blood thinners and anticoagulant therapy. During an interview on 1/14/16 at 2:24 p.m. with CNA E she was asked to describe what happened with CR#1 on 12/30/15. She said she came on shift at 2:00 p.m. and went into CR#1's room at approximately 2:15 p.m. She said she spoke to the resident and CR#1 told her she was ok. She said she then lifted the sheet to turn CR #1. She said there was blood on CR#1's gown and sheet that was dry. She said CR#1's brief had turned purple and it was .full of blood. She said, The outside of the brief had turned purple it was so full. She said she got LVN C and took her to CR#1's room. She said LVN C kept trying to tell her (CNA E) what could cause it and told her to clean the resident up. At 4:45 p.m. she checked on the resident again and she had blood clots again and blood was stuck in CR#1's pubic hair. She said CR#1 had, .chunks of blood, the first time she was found bleeding. She then stopped and thought and corrected herself saying the second episode of bleeding was at 3:15 p.m., not 4:45 p.m. She said she reported it to LVN C again and LVN C told her to clean her up again. She said she checked on the resident again around 4:45 p.m. or 5:15 p.m. and this time there was heavy bleeding. She said LVN G had come in early and she went to LVN G and LVN C and reported the bleeding. She said LVN G came in the room with her and then called EMS. She said the bleeding had not stopped. She said the bleeding never stopped. She said she thought the blood was draining from the vagina. She said you could see the clots of blood draining out as she cleaned. During an interview on 1/14/16 10:17 a.m. with the Administrator, Interim DON, ADON, and Corporate Nurse, when asked what should be done if a return call is not received from a doctor or agency, the Interim DON said if hospice does not call back, the physician should be called. The Administrator said the prior DON was in the building when CR#1 had the change in condition. The Interim DON said the prior DON was not made aware of the change in condition until CR#1 was leaving the facility. The Corporate Nurse said the facility follows physician orders [REDACTED]. The Administrator and DON said the facility had not inserviced the staff following this incident. The ADON said LVN C had told her that she attempted to contact Hospice Agency F. The Administrator said LVN C had a CNA monitor CR#1. The Interim DON and Corporate Nurse said LVN C should have attempted contact with the doctor and hospice again after 15 minutes. The Corporate Nurse said 15 minutes is the standard. She said their last Quality Assurance meeting was held in December 2015 and no meeting was scheduled for January 2016. She said the incident with CR#1 had not been identified by the Quality Assurance Committee. The Administrator said if the prior DON investigated the incident the investigation report would be in his office. During a telephone interview on 1/14/16 at 12:01 p.m. with the prior DON he said on 12/30/15 after hours (after 5:00 p.m.), LVN G came to him and told him CR#1 was bleeding. He said he told her to call 911. Prior DON said he did not recall anyone informing him earlier that day that CR #1was bleeding. He said he was told sometime between 5:00 p.m. and 6:00 p.m. He said LVN G told him it was, .regular bleeding vaginally. He said she had already called 911 and they were on their way. When asked if he was certain he had not been told earlier he said, Absolutely not, not at all. He said the next day, 12/31/15, was his last day to work there and that a family member of CR#1 had come in and told him CR#1 had to receive 2 units of packed red blood cells at the hospital and was stable. He said to his recollection, CR#1 was on [MEDICATION NAME] and a blood thinner and that is why he agreed with the nurse to call 911. He said when notified of a change in a resident's status he will do an assessment. He said if there is no response you are supposed to try to contact the Medical Director. He said he should have been called and the Administrator. He said even if the bleeding stopped you should attempt to recontact the physician within twenty minutes. He said he should have been told immediately about CR #1's change in condition. He said it was not brought to his attention. He said all residents including those on hospice are to be treated the same. He said, .absolutely . still to receive treatment if bleeding. During a telephone interview on 1/14/16 at 12:22 p.m. with Hospice Nurse I, she confirmed that she was the nurse who came to the facility on [DATE] when CR#1's indwelling urinary catheter had been dislodged. She said she assessed the resident and there was no bleeding. She said it was protocol to leave the catheter out for 24 hours and then reinsert it. She said she was not the nurse that would have been called on 12/30/15. She said CR#1's assigned case manager was Hospice Nurse J. During a telephone interview on 1/14/16 at 1:33 p.m. with Hospice Nurse J she said she was not called about CR#1 on 12/30/15 but that she knew the agency was called the night of 12/30/15. She said no calls were received from the facility that day until 6:40 p.m. She said the ADON told her the following day that CR#1 had heavy bleeding with clots from the vagina. During a telephone interview on 1/14/16 at 12:48 p.m. with the Medical Director he said he was called on 12/30/15 and told CR#1 had vaginal bleeding. He said he was called about CR#1 around 07:00 pm. He said he did not feel CR#1 needed to be sent via 911 but agreed that she needed to go to the hospital via regular transport. He said if he was called they should have documented it. When asked about the source of the bleeding he said, the source of the bleeding would not have mattered. He said if there were clots present she should have been sent out. He said even if the bleeding had stopped she still should have been sent out due to the fact that she was on blood thinners. During an interview on 1/14/16 at 1:43 p.m. with LVN C she said she was told around 3:00 p.m. that CR#1 was bleeding. When asked how she determined where the bleeding was coming from she said by moving the brief around. She said she asked the CNA to inform her if CR #1 began to bleed again. She said the on-call hospice nurse told her to reach the family and ask them what they wanted her to do. When asked who the on-call hospice nurse was she said she did not know. She said she told the hospice nurse that CR#1 was on blood thinners. She said she documented the incident. When asked if it was the standard to document who you spoke to she said it was. She said she spoke to the Medical Director and remembered that he answered the phone. She said the Medical Director told her to contact the family and gave her no orders. She said she spoke to the Medical Director at about 3:15 p.m. on 12/30/15. She said she did not hear from the family. When asked why her documentation read that she attempted to call the Medical Director but the note read that she was awaiting a response from him she said, I don't know. She said while she was giving report to LVN G, CNA E came and told her the bleeding had started again. She said she had not tried to recontact the Medical Director or Hospice Agency F. She said she did not hear from the family. She said, I'll put it this way, if she weren't a hospice patient, I would have notified the doctor and family. With her being a hospice patient, you don't know what the family might want. She said, With hospice patients there's not normally transfers to the hospital. Not unless there is a fracture, other circumstances. She said she did not notify the DON of CR #1's change in condition. She said it is policy to notify the DON if a resident has a change in condition. She said she did not have a reason for not notifying the DON. She said CNA E informed her two times that CR #1 was bleeding. She said Hospice Agency F had called her back within 5 minutes. She said she did not have the prior DON's phone number. She said the facility only posts the DON's phone number at Station I (she works Station II). During an interview on 1/14/16 at 3:58 p.m. with the Corporate Nurse she said they could not find a policy and procedure for blood thinners. During an interview on 1/15/16 at 1:38 p.m. with the Corporate Nurse she said they did not have a policy and procedure on a change in condition. She said they use the INTERACT form. The INTERACT form was used to identify, evaluate, and communicate a resident's change in condition. During a telephone interview on 1/15/16 at 2:14 p.m. with LVN G she said she had come in and was about to make rounds when a CNA reported to her that CR#1 was bleeding. She said she assessed the resident and there were blood clots. She said she got the ADON and sent the resident out. She said the day shift nurse had reported to her that CR#1 had two episodes of bleeding that day. She said LVN C told her she had called a hospice nurse. She said LVN C did not tell her if she had called a doctor. When asked what the procedure is for such a situation she said you call the doctor and let the doctor know then call the family after you get orders. She said for a hospice resident you would normally contact the hospice. She said hospice will then send a nurse to assess the resident. She said in an emergency hospice will advise the resident to be sent to the hospital. She said LVN C told her that she spoke to hospice and they were going to send a nurse out. When asked if LVN C told her who she spoke to she said no. She said when she called CR#1's family member he told her he did not know about the bleeding. She said the family member wanted CR#1 sent out via 911. She said she then called the Medical Director and let him know. She said the Medical Director said it was not that critical and that she could go out via regular transport. She said she had not been told that the bleeding was originally detected at 02:15 pm. She said she ADON had not been notified of CR #1's change in condition. She said a change in condition should also be reported to the ADON. During a telephone interview on 1/15/16 at 2:59 p.m. with Hospice Nurse J she said she worked 12/30/2015. She said a change in condition of one of her patients would have been reported to her. She said the call would have been sent to her. Record review of LVN C's employee file revealed her date of hire was 9/30/14. Her file contained two written disciplinary forms dated 3/20/15 and 5/8/15. Record review of LVN C's 3/20/15 Disciplinary Warning Notice revealed the following date and explanation of incident/occurrence: .1. Resident have order for ear ggts (sic) (drops). a week ago that was not carried out 2. MD order for C&S (culture and sensitivity) of the wound, not done 3. Resident going to an appt. (appointment) was not set appropriate transport to accommodate residents needs. 4. Overall, poor job performance. Record review of LVN C's 5/8/15 Disciplinary Warning Notice revealed it was her 2nd warning and revealed, .date and explanation of incident/occurrence: Nurse failed to report an abnormal xray to MD (Medical Doctor). Nurse reported xray was negative to MD and ADON. Record review of LVN C's in-servicing records revealed she had received in-services for the SBAR (Situation Background Assessment) on 2/24/15 and 3/2/15. She had received in-services on abuse/neglect on 1/28/15 and 3/18/15. During an interview on 1/15/16 at 3:06 p.m. with the Corporate Nurse, Administrator, and Acting Director of Nurses the Corporate Nurse confirmed it was her signature on the 3/20/15 Disciplinary Warning Notice for LVN C. When asked how they monitor staff with a history of disciplinary warnings the Administrator and Acting Director of Nurses said they were not employed by the facility during that time. They did not respond give a response as to if there was a system to monitor staff. The Corporate Nurse said she is not in the facility daily. During an interview on 1/19/16 at 11:39 a.m. with the Corporate Nurse she said there was no documentation of an SBAR having been done for CR#1. During a telephone interview on 1/20/16 at 8:41 a.m. with family member he said he was notified of CR#1's bleeding on 12/30/15 at 06:05 pm. The Administrator, the Acting Director of Nurses and the Corporate Nurse were notified on 1/15/16 at 3:06 p.m. that an Immediate Jeopardy (IJ) had been identified based on the above failures. A Plan of Removal (PoR) was submitted on 1/16/16. After revisions, it was accepted on 1/19/16 at 4:22 p.m. The PoR included: 1. On 1/15/16, Nurse Managers, Licensed Nurses and the Acting Director of Nursing immediately assessed current residents in the facility; including those residents with indwelling catheters, those with anticoagulant therapy, and those receiving Hospice services in order to ensure any changes in conditions were identified. Should a change in condition be noted, the physician and responsible party will be notified; necessary intervention will be implemented; documentation in the clinical record ; and the identified change will be care planned. 2. The Acting Director Nursing, assistant Director of Nursing immediately began educating staff (RNs, LVNs, CNAs, and MAs) on the following starting 1/15/16: A) Recognizing changes in condition. In the event of a change in a resident condition, the nurse will notify the resident's attending physician and family when there has been an incident, bleeding, significant change in resident physical, emotional or mental status, need to alter the resident medical treatment, refusal of treatment or medication, or the need to transfer the resident to the hospital. a) Recognizing changes in condition, examples were provided. b) Assessment of the resident's change in condition, immediately communicating change in the resident's condition to the physician by phone following the assessment, documenting the assessment in Interact, using SBAR and Stop and Watch forms. c) Notifying the attending physician and the resident's responsible party by phone. If unable to reach the attending physician or nurse practitioner on the first call, continue to call every 15 minutes thereafter until a response is obtained. d) If staff is unable to reach the resident's attending physician after 2 calls, immediately notify the medical director and your supervisor. e) When to call 911 based on the resident's change in condition. f) Documentation of the change in condition in the resident's clinical records and on the 24 hour report/ change in condition report. g) Timely implementation of intervention for residents who have a change in conation. h) Monitoring residents for bleeding when they receive ordered Anticoagulants/blood thinners. i) Abuse and Neglect training. j) Licensed nurses will be educated on the utilization of the 24 hour report for communicating changes in condition. k) Educate licensed staff on monitoring residents receiving blood thinners for bruising and bleeding. The education will continue each shift prior to the start of the staff members' shift. Those on FMLA and paid time off will be completed prior to the beginning of their next shift by the Acting Director of Nursing, Assistant Director of Nursing, Regional Nurse. B) Licensed nurses will be re-educated on the procedures and utilization of the 24 hour report to report changes in condition. New orders will be reviewed in the Morning Clinical Meeting which is attended by the interdisciplinary team to identify residents with changes in condition. The residents' records will be reviewed for documentation on the SBAR along with the immediate physician and responsible party notification. Care plans will be reviewed for updates related to changes in resident conditions. The Acting Director of Nursing and the Assistant Director of Nursing will make resident rounds to ensure that residents with changes in condition are identified on residents to include those with indwelling catheters, those receiving anticoagulant therapy and those receiving hospice services. Review of the 24 hour report for changes of condition was initiated on 1/16/16. Nursing will monitor and document changes in condition utilizing the change in condition/Acute hospitalization form. The Surveyors confirmed that the PoR had been sufficiently implemented to remove the IJ by: On 1/15/16 at 2:25 p.m., LVN D described described ways that she would know that one of her residents experienced a change in condition. She gave examples of signs and symptoms. She said that she would assess the resident, document the resident's condition and consult with the resident's physician. She described how she would recognize if a resident was neglected and that she would report it the Abuse Prevention Coordinator. On 1/15/16 at 2:40 p.m., LVN O said that she would recognize a change in her resident's conditions because she sees them every day. She described signs and symptoms that would enable her to recognize changes in condition. She said that she would first assess them, including take their vital signs. Then, she would call the doctor for orders. She would have already checked the PRN orders for treatments. She described how she would recognize if a resident was neglected and that she would report it the Administrator. On 1/19/16 at 10:30 a.m., RN B described ways that she would recognize a change in condition of one of her residents. When she noticed a change in her residents, she first assessed her residents and documented the change of condition on the SBAR. She would have all of this information available when she called the doctor for orders. She would also call the responsible party. She described how she would recognize if a resident was neglected and that she would report it the Administrator. On 1/19/16 at 10:45 a.m., LVN A said she would recognize if a resident was experiencing a change in condition if he or she was lethargic, had a change in vital signs, had a change in the amount or type of talking, had a change in eating or posture. She said that she would assess the resident and document her findings on the SBAR form. She would call the doctor, family and the hospice provider. She described how she would recognize if a resident was neglected and that she would report it the Demonstrator. On 1/19/16 at 2:30 p.m., LVN D said that she had received the following training over the last week: How to manage residents receiving anticoagulants, which included checking for bruises and bleeding and how to assess and report these as changes in condition. She was trained how to document using the SBAR. She had training on how and when to communicate with the residents' physicians and the hospice providers. She described how she would recognize if a resident was neglected and that she would report it. During an interview on 1/20/16 at 10:48 a.m. with the Administrator when asked how she thought this immediate jeopardy/substandard quality of care came about she said from record review it looked like it was a nursing assessment of a resident that was on an anticoagulant being the primary reason. She said assessment, notification and follow up were contributing factors. When asked if she had been aware of the situation prior to surveyors coming in she said only that the resident had gone out to the hospital. During an interview on 1/20/16 at 11:03 a.m. with the Acting Director of Nurses when asked how they ensure nurses were competent in their skills she said they do annual skills checks. When asked what type of plan was in place for when a resident starts bleeding she said they get up, assess the resident, and call the doctor. She said they follow the INTERACT and SBAR to help them complete their evaluation on that resident. When asked how she thought this immediate jeopardy/substandard quality of care came about she said, I really think it happened through the transition of the prior DON leaving and not knowing how extensive her situation was. She said she thought if the prior DON would have stayed they would have identified the problem. She said if felt like the nurse did not do what she was supposed to do. On 1/20/16 at 2:35 p.m., LVN A said she had received the following training over the last week: training in how to monitor residents receiving anticoagulant therapy; abuse and neglect; and how to recognize, assess, and document changes in condition. She said that once she assessed a patient's change in condition, she would document the information on the SBAR form and then call the doctor. She described the training. On 1/20/16 at 2:35 p.m., RN C said that she received a lot of training over the last week. She received training about how to manage the residents receiving services from hospice providers and what to do when these residents have changes in conditions. They were trained on the interact system and how to complete the SBAR. She described the training They are supposed to notify the doctor, family, and hospice provider if appropriate. Record review of the training completed between 1/15/16 and 1/19/16 revealed all of the nursing staff, certified nurse aides, and medication aides listed on the active staff list provided attended in service training classes. Record review of the undated INTERACT For Nurses INTERVENTIONS TO REDUCE ACUTE CARE TRANSFERS SBAR/CARE PATHS/CHANGE IN CONDITION CARDS EARLY WARNING TOOL revealed, .*This program's intention is to improve the early identification, evaluation and communication of resident changes in status/condition and, thus, reduce the frequency of transfers to the acute hospital. . * All sections of the SBAR must be completed prior to contacting the provider. Always, have the chart and SBAR in front of you, when you are communicating with the provider. The one complaint we hear most often is that the nurses don't have the information the Physician needs to make an informed decision regarding the resident's care. You will, now, be a shining star in their eyes! * Once you have completed your communication with the provider, you turn the SBAR over and write your progress notes, rather than having to go back into the chart. * The SBAR is, then, placed in the resident's file under Nurse Notes. * If, in the course of events, the resident's condition does not improve and hospitalization becomes necessary, make a copy of the SBAR and send along with all the other transfer documents, so the hospital can see what has, already, been done in the facility. Record review of the facility's undated policy and procedure for Contents of the Clinical Record revealed, .Clinical records will contain sufficient information to identify and care for the resident.Also, the record will contain sufficient information to record the residents' assessments, the comprehensive, interdisciplinary plan of care and services provided; .signed and dated clinical documentation from all health care practitioners involved in the resident's care, .Observations made by nursing personnel will show at least the following: items specified on the Minimum Data Set (MDS); current information including PRN (as needed) medications and results; treatments and any notable results; physical complaints, changes in clinical signs and behavioral status, and all incidents or accidents; .Clinical Records .Clinical records are maintained on each resident in accordance with accepted professional standards's and practices. Clinical records are complete, accurately documented, readily accessible and systematically organized. The Administrator and the Acting Director of Nurses were informed on 1/20/16 at 2:59 p.m. that the IJ was removed; however, the facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy at a scope identified at a pattern due to the facility requiring more time to monitor the plan of removal for its effectiveness. The facility's report of residents receiving anticoagulants dated 1/19/16 listed 25 residents receiving anticoagulants.

Based on interview and record review, the facility failed to provide care and services according to the written plan of care for 1 of 14 residents reviewed for physician orders [REDACTED].# 5). CR# 5 did not receive the necessary [MEDICAL TREATMENT] treatments from 10/29/14 to 11/6/14, as ordered by the physician. This failure affected 1 resident, who was sent to the hospital for immediate [MEDICAL TREATMENT] after lab resuslts were critically high, and placed 105 residents at risk of not receiving care and services as needed according to physician's orders [REDACTED]. # 6, # 5 Findings include: Record review of the face sheet for CR # 5 revealed a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR#5 ' s Admission Evaluation and Interim Care Plan dated 10/29/14 revealed an admitting [DIAGNOSES REDACTED]. Admitting vital signs were as follows: blood pressure: 112/77, pulse 71 and respirations 18. Under the heading of elimination, explanation it read [MEDICAL CONDITION] with [MEDICAL TREATMENT] Tuesday, Thursday and Saturday. Left AV fistula (access to receive [MEDICAL TREATMENT]). Under section G, "List Diagnosis/Problems, Current Needs" it read [MEDICAL CONDITION] with [MEDICAL TREATMENT]. Record review of CR #5's comprehensive care plan dated 10/29/14 revealed a focus of, I need [MEDICAL TREATMENT] related to End Stage [MEDICAL CONDITION]." Record review of CR#5 ' s admission orders [REDACTED]. There was no order for [MEDICAL TREATMENT]. Record review of CR#5 ' s lab results dated 10/30/14 (day after admission to the facility) revealed the following: Potassium level-4.0 (this is within normal range). Record review of CR#5 ' s nurses notes dated 11/4/14 revealed a call from ... [MEDICAL TREATMENT] requesting the whereabouts of (CR #5)...reported that she has a chair time of 10 AM Tuesday-Thursday-Saturday...this nurse requests a later time for today, caller states "we'll just start on Thursday." Record review of CR#5 ' s nurses notes dated 11/5/14 (no time documented other than day shift) revealed call placed to doctor regarding patient missing three [MEDICAL TREATMENT] visits...ordered a STAT (immediate) BMP (Basic Metabolic Panel-a blood test). Record review of CR#5 ' s lab results dated 11/05/14 revealed the following: Potassium level-7.0 (This was a critical high result, normal level-3.6-5.2) BUN-110 (This was a critical high result, normal level-7-17). CR- 13.6 (This was a critical high result-normal level 0.5-1.0). Record review of CR#5 ' s nurses notes dated 11/6/14 revealed pts potassium (K+) level was 7, along with several other abnormal labs included in the STAT BMP...call placed to 911 emergency rescue...V/S taken as follows; T 97.2, P 84, B/P 216/82. Respirations are labored...Dr notified...Pt was transported to hospital for immediate [MEDICAL TREATMENT]." Record review of CR#5 ' s telephone order dated 11/6/14 (not timed) revealed send (CR#5) to hospital for immediate [MEDICAL TREATMENT]. Record review of CR #5 ' s transfer form dated 11/06/14 revealed reason for transfer: " urgently needs to be dialyzed " . ..blood pressure 216/82. Record review of CR #5's hospital records revealed the following: Initial Renal Consult Note dated 11/06/14 read in part... sent from nursing home...patient have been missing her [MEDICAL TREATMENT] three times (SIC) -center refused patient today because of abnormal labs...History of Present Illness...unclear reasons she did not continue [MEDICAL TREATMENT]...Last time she received [MEDICAL TREATMENT] was 10/28/14. She developed hypertension (190s/110s), shortness of breath...initial labs CR (creatnine) was 13.6, BUN (Blood, Urea, Nitrogen) 121, potassium 7.5 (CR and BUN are lab tests that measure kidney function)...She was given calcium [MEDICATION NAME], insulin, [MEDICATION NAME] and [MEDICATION NAME] ... Respiratory rate was 30 with Oxygen Saturation level of 94% on 5 liters of oxygen ... In an interview on 11/19/14 at 4 pm, the Director of Nursing (DON) stated the admitting nurse did not write the orders for [MEDICAL TREATMENT] for CR # 5, did not arrange for transportation to the [MEDICAL TREATMENT] Center, or communicate the [MEDICAL TREATMENT] order to the oncoming nurse. She said the [MEDICAL TREATMENT] Center would not take her on 11/4 because she missed her chair time, and would not take her until 11/6/14. She further said the resident was not in distress on 11/4/14 and would have been OK if she had [MEDICAL TREATMENT] on that day. In an interview with the Administrator on 12/11/14 at 10:30 am, she stated that CR # 5 was discharged to the hospital and did not come back to the facility. CMS 672 listed a census of 105.

Based on observation, interview and record review, the facility failed to provide care and services to attain or maintain the highest practipable physical, mental, psychological well being for 1 of 14 residents (CR #5) reviewed for quality of care. CR# 5 did not receive necessary [MEDICAL TREATMENT] treatments from 10/29/14 to 11/6/14, resulting in respiratory distress and admission to the hospital. This failure affected 1 resident and placed 8 residents receiving [MEDICAL TREATMENT] treatments, at risk of not receiving care and services as needed causing a decline in the resident's health and well being. # 6 and # 5 Findings include: Record review of the face sheet for CR # 5 revealed a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR#5 ' s admission orders [REDACTED]. There was no order for [MEDICAL TREATMENT]. Record review of CR#5 ' s Admission Evaluation and Interim Care Plan dated 10/29/14 revealed an admitting [DIAGNOSES REDACTED]. Admitting vital signs were as follows: blood pressure: 112/77, pulse 71 and respirations 18. Under the heading of elimination, explanation it read [MEDICAL CONDITION] with [MEDICAL TREATMENT] Tuesday, Thursday and Saturday. Left AV fistula (access to receive [MEDICAL TREATMENT]). Under section G, "List Diagnosis/Problems, Current Needs" it read [MEDICAL CONDITION] with [MEDICAL TREATMENT]. Record review of CR #5's comprehensive care plan dated 10/29/14 revealed a focus of, I need [MEDICAL TREATMENT] related to End Stage [MEDICAL CONDITION]." Record review of CR#5 ' s lab results dated 10/30/14 (day after admission to the facility) revealed the following: Potassium level-4.0 (this is within normal range). Record review of CR#5 ' s nurses notes dated 11/4/14 revealed a call from ... [MEDICAL TREATMENT] requesting the whereabouts of (CR #5)...reported that she has a chair time of 10 AM Tuesday-Thursday-Saturday...this nurse requests a later time for today, caller states "we'll just start on Thursday." Record review of CR#5 ' s nurses notes dated 11/5/14 (no time documented other than day shift) revealed call placed to doctor regarding patient missing three [MEDICAL TREATMENT] visits...ordered a STAT (immediate) BMP (Basic Metabolic Panel-a blood test). Record review of CR#5 ' s lab results dated 11/05/14 revealed the following: Potassium level-7.0 (This was a critical high result, normal level-3.6-5.2) BUN-110 (This was a critical high result, normal level-7-17). CR- 13.6 (This was a critical high result-normal level 0.5-1.0). Record review of CR#5 ' s nurses notes dated 11/6/14 revealed pts potassium (K+) level was 7, along with several other abnormal labs included in the STAT BMP...call placed to 911 emergency rescue...V/S taken as follows; T 97.2, P 84, B/P 216/82. Respirations are labored...Dr notified...Pt was transported to hospital for immediate [MEDICAL TREATMENT]." Record review of CR#5 ' s telephone order dated 11/6/14 (not timed) revealed send (CR#5) to hospital for immediate [MEDICAL TREATMENT]. Record review of CR #5's hospital records revealed the following: Initial Renal Consult Note dated 11/06/14 read in part... sent from nursing home...patient have been missing her [MEDICAL TREATMENT] three times (SIC) -center refused patient today because of abnormal labs...History of Present Illness...unclear reasons she did not continue [MEDICAL TREATMENT]...Last time she received [MEDICAL TREATMENT] was 10/28/14. She developed hypertension (190s/110s), shortness of breath...initial labs CR (creatnine) was 13.6, BUN (Blood, Urea, Nitrogen) 121, potassium 7.5 (CR and BUN are lab tests that measure kidney function)...She was given calcium [MEDICATION NAME], insulin, [MEDICATION NAME] and [MEDICATION NAME] ...Respiratory rate was 30 with Oxygen Saturation level of 94% on 5 liters of oxygen ... Record review of CR #5 ' s transfer form dated 11/06/14 revealed reason for transfer: " urgently needs to be dialyzed " . ..blood pressure 216/82. Record review of hospital records dated 11/6/14 revealed CR # 5 was admitted into the hospital with [DIAGNOSES REDACTED]. Patient was experiencing hypertension, shortness of breath, and had abnormal labs on admission. Lab results on admission were: Creatinine 13.6; BUN 121; Potassium 7.5. Nephrology was consulted to resume [MEDICAL TREATMENT]. In an interview on 11/19/14 at 4 pm, the Director of Nursing (DON) stated the admitting nurse did not write the orders for [MEDICAL TREATMENT] for CR # 5, did not arrange for transportation to the [MEDICAL TREATMENT] Center, or communicate the [MEDICAL TREATMENT] order to the oncoming nurse. She said the [MEDICAL TREATMENT] Center would not take her on 11/4 because she missed her chair time, and would not take her until 11/6/14. She further said the resident was not in distress on 11/4/14 and would have been OK if she had [MEDICAL TREATMENT] on that day. In an interview with the Administrator on 12/11/14 at 10:30 am, she stated that CR # 5 was discharged to the hospital and did not come back to the facility. CMS 672 listed 8 residents receiving [MEDICAL TREATMENT].