Every finding on record at Avir at Pittsburg

Based on observation, interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two of thirteen residents (Residents #3 and #8) reviewed for reasonable accommodations. The facility failed to ensure Resident #8 and Resident #38 had a call light within reach. This failure could place residents at risk of possible falls, major injuries, hospitalization, and unmet needs.Findings include: Record review of Resident #8's face sheet dated 02/10/26 reflected a [AGE] year-old male who was admitted on [DATE]. Resident #8 had diagnoses which included: senile degeneration of brain (a progressive decline in cognitive function caused by structural brain changes, not normal aging), schizoaffective disorder (a chronic mental health condition combining psychotic symptoms with mood disorders episodes), depression and anxiety disorder. Record review of Resident #8's MDS assessment, dated 12/10/25, reflected Resident #8 was usually understood and usually understood by others. Resident #8's BIMS score was a 7, which indicated severe impaired cognition. Resident #8 was dependent on toileting and shower/ bathe. Resident #8 required moderate assistance with all ADLs. Resident #8 was always incontinent to bowel and bladder. Record review of Resident #8's care plan dated 9/24/25 reflected Resident #8 was at a high risk for falls related to incontinence, unaware of safety needs related to senile degeneration of the brain. The interventions included: be sure the resident's call light was within reach, encourage the resident to use it for assistance as needed, and provide prompt response to all requests for assistance. Record review of Resident #38's face sheet dated 02/11/26 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included: unspecified dementia (a cognitive decline severe enough to interfere with daily life), cognitive communication deficit (an impairment in communication), extrapyramidal movement disorder (medication-induced or disease-related movement disorder affecting the brain's motor system), history of falling, muscle wasting and atrophy, difficulty in walking, muscle weakness and unspecified lack of coordination. Record review of Resident #38's MDS, dated [DATE], reflected Resident #38 was understood and was understood by others. A BIMS score was not conducted for Resident #38. Resident #38 was independent of toileting and required partial assistance with ADLs. Resident #38 was always continent of bladder and bowel. Record review of Resident #38's care plan dated 06/13/25 reflected Resident #38 was a risk for fall due to unsteady gait, decreased balance, medications, and poor safety awareness. The interventions included: call light in reach in room and answered promptly, encourage and remind her to use call light to ask for assistance. During an observation on 02/09/26 at 10:38 A.M., Resident #38 was lying in bed resting. Resident 38's call light was on the floor at the head of her bed and not within reach. During an observation on 02/09/26 11:17 AM., Resident #8 was lying in bed resting. Resident #8's call light was not within reach; it was on the other side of the room. During an observation on 02/09/26 at 2:12 P.M., Resident #8 was lying in bed asleep. Resident #8's call light was not within reach. During an observation on 02/09/26 at 2:15 P.M., Resident #38 was not in her room. Resident #38's call light was on floor at the head of the resident's bed. During an observation on 02/10/26 at 10:06 A.M., Resident #38 was lying in bed, and her call light was on the floor at the head of her bed. Resident #38's call light was not within reach. During an observation on 02/10/26 at 10:08 A.M., Resident #8 was lying in bed asleep. Resident 8's call light was pinned to a cord across the room. The call light not within reach of Resident #8. During an observation on 02/11/26 at 9:34 A.M., Resident #38 was lying in bed and her call light on floor at the head of her bed. During an observation on 02/11/26 at 9:36 A.M., Resident #8 was lying in bed resting and his call light was on the opposite side of the room. Resident #8's call light was not within reach. During an interview on 02/11/26 at 9:45 A.M., CNA B said she agreed that Resident #8 and Resident #38's call lights were not accessible for the residents, and she had put the call lights where the residents could get to them. She said everyone was responsible for ensuring that the call lights were assessable for the residents. She said the negative effect of not having a call light assessable for the residents was if an emergency occurred and they needed assistance; they could not call for help. During an interview on 02/11/26 at 9:57 A.M., LVN A said the call lights should be accessible for the residents. She said everyone was responsible for ensuring that the call lights were assessable for the residents. She said a negative effect of not having the call lights assessable for a resident was if anything happened to the residents, they would not be able to call for help. During an interview on 02/11/26 at 12:00 P.M., the Assistant Director of Nursing said she expected for the residents' call lights to be within reach. She said everyone was responsible for ensuring that the call lights were accessible. She said the negative effect of the call lights not being assessable was the residents could be in need or distressed and could not call for help. During an interview on 02/11/2026 at 12:29 P.M., the Director of Nursing said she expected the call lights to be accessible and within reach at all times of the residents. She said all staff were responsible for ensuring the residents' call lights were assessable. She said the negative effect of call lights not being assessable was the residents may be unable to call for help in a reasonable manner and it may increase the risk of injury trying to assess the call light. During an interview on 02/11/2026 at 12:47 P.M., the Administrator said she expected the call lights to be accessible to the residents. She said all staff were responsible for ensuring the residents' call lights were assessable. She said the negative effect of not having the call light assessable was if a resident needed something and they could not access the call light, they cannot call for help. Record review of the facility's policy and procedure Call System, Residents dated January 2025, indicated. Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or centralized workstation.1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 2. Call system communication may be audible or visual. The system may be wired or wireless.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 14 residents reviewed for assessments. (Resident #44).The facility failed to complete an accurate resident assessment for Resident #44 by indicating the resident did not have any broken or missing teeth.This failure could place residents at risk of not having individual needs met and a decreased quality of life.Findings included:Record Review of Resident #44's face sheet, dated 11/28/2022, indicated an [AGE] year-old male admitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (a progressive lung disease that makes it difficult to breath), dementia (a syndrome characterized by a decline in cognitive function affecting memory, thinking, behavior and ability to perform everyday activities), hypertension (a common condition where the force of blood against the artery walls is consistently too high), Hyperlipidemia (a condition characterized by elevated levels of cholesterol in the blood, particularly low-density lipoprotein (LDL) often referred to as bad cholesterol.), Gastroesophageal reflux disease (a chronic condition where stomach acid flows back into the esophagus),pruritus (an irritating sensation that makes itch often caused by dry skin) and pulmonary embolism with acute cor pulmonale (a sudden increase in pressure in the pulmonary circulation).Record Review of Resident #44's Annual MDS assessment, dated 1/30/2025, indicated Resident #44 was understood and understood others. Resident #44 had a BIMS score of 13, which indicated his cognition was intact and was independent with ADLs. The Annual MDS did not indicate Resident #44 had missing or broken teeth.Record review of Resident #44's care plan, dated 01/30/2026, did not indicate he had any dental issues or pain.Record Review of Resident #44's MAR dated 2/1/2026-2/28/2026 indicated Resident #44 received Naproxen 220 mg 2 tablets by mouth every 8 hours as needed for pain.During an observation and interview on 2/9/2026 at 10:22 AM, Resident # 44 was sitting up in a wheelchair with observed oxygen tank in room. Resident #44 said he was independent with most activities and was no longer in therapy. He said he was having mouth pain from broken teeth and left ear pain. Resident #44 said he he had reported tooth and left ear pain months ago. He said he wanted to see a dentist because he had pain in the back of his mouth. He said he was not on a special consistency diet. Resident was observed to have broken and missing teeth.During an interview on 2/11/2026 at 8:40 AM, CNA D said Resident #44 required supervision only. She said she often checked on him to ensure he had his oxygen on. She said he was on a regular diet. CNA D said Resident #44 had never reported mouth pain to her, and she was unaware he had missing teeth. CNA D said if a resident was complaining of mouth pain, it could cause the resident to have a change in behavior, or he might eat less.During an interview on 2/11/2026 at 10:33 AM, LVN C said the nurses completed parts of the assessments for the MDS and care plans. She said the information was received from the resident. LVN C said the DON were responsible for the MDS and care plans. She said if an assessment were not captured on the MDS, it could negatively impact on the residents, and not be captured in a care plan. She said normally if something was missed, the DON would notify the nurse to get the MDS updated with the correct information. She said it could be a safety issue or a resident may have a delay in care.During an interview on 2/11/2026 at 10:59 AM, the ADON said the facility currently did not have an MDS nurse. She said the DON was responsible for the admission assessment. She said the initial assessment was completed by the nurse on duty. The ADON said the ADM, DON, and corporate staff worked together to complete the MDS. She said the MDS should match the resident's current condition. The ADON said she really did not know the duties of the MDS nurse.During an interview on 12/11/2026 at 11:27 AM, the DON said she had attempted to get Resident #44 an appointment with the visiting dental group, but they did not take his insurance, and the family would not cover the cost. She said she was getting someone to see him that day. The DON said the charge nurse was responsible for performing the initial assessment received from residents and family, and discharge paperwork from the hospital. The DON said missing teeth and dental issues should be documented on the MDS. She said it would be inaccurate on the MDS. She said the resident could have pain and reflect a weight loss if he quit eating certain foods, and placed him at risk for infection. The DON said the facility currently did not have a MDS nurse. She said the charge nurse were responsible for making sure the information was documented in their assessment when admitted or if there was a change in condition.During an interview on 2/11/2026 at 12:11 PM, the ADM said the facility changed EMR systems. The ADM said she expected the nurse/MDS nurse to assess the resident with accuracy on the MDS, so the care plan and interventions were individualized for the resident. She said if the assessment was not accurate, the resident may not receive proper care.Review of the facility's policy titled Resident Assessments dated March 2022 indicated, A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements.PPS assessments provide information about the clinical condition of beneficiaries receiving Part A SNF- level care in order to be reimbursed.1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements.admission assessment.Quarterly assessment.Annual assessment. Significant change in status assessment.significant correction to prior quarterly assessment.discharge assessment.2. The RAI manual (Chapter 2) provides detailed information on timing.3. A comprehensive assessment includes. completion of the Minimum Data Set (MDS), completion of the care area assessment (CAA) process.development of the comprehensive care plan. 7. All members of the care team, including licensed and unlicensed staff members, are asked to participate in the resident assessment process.8. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.9. All resident assessments completed within 15 months are maintained in the resident's active clinical record. The results of the assessments are used to develop, review, and revise the residents' comprehensive care plan.

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 objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 14 residents (Residents #4, #40, and #44) reviewed for comprehensive person-centered care plans.1. The facility failed to develop and implement the comprehensive person-centered care plan for Resident #4 by not documenting he was on enhanced barrier precautions.2. The facility failed to develop and implement the comprehensive person-centered care plan for Resident #40's use of anticonvulsant medications, seizure disorder, altered diet, and impaired ADL performance.3. The facility failed to develop and implement all relevant comprehensive person-centered care plans for Resident #44's besides advanced directive and oral health.These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.Findings include:1. Record review of Resident #4's face sheet dated 01/10/26 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included: multiple sclerosis (a chronic disease of the central nervous system), psoriasis (a skin disease that causes a rash with itchy) protein-calorie malnutrition.Record review of Resident #4's MDS assessment, dated 12/18/25, reflected Resident #4 was usually understood and usually understood by others. Resident #4's BIMS score was a 15, which indicated cognation was intact. Resident #4 was dependent on ADLs. Resident #4 was always incontinent to bowel and bladder. The 1 of 1 of unhealed pressure ulcers/ injuries at each stage: Stage 3: Full thickness tissue loss.Record review of Resident #4's care plan dated 12/16/25 reflected Resident #4 had a stage 3 pressure ulcer to the sacrum related immobility. Interventions included cleanse sacral wound with wound cleaner, pat dry, apply collagen sheet to wound bed, apply triad to peri wound, and cover with hydrocolloid dressing 3 times a week and as needed for soilage/ dislodgement. Care plan did not indicate Resident #4 was on enhanced barrier precautions, due to sacral wound.Record review of Resident #4's order summary report reflected cleanse sacral wound with wound cleanser, pat dry, apply medical grade honey fiber, and cover with bordered gauze daily and PRN for soilage/dislodgement. every evening shift for wound care, dated 02/06/26.During an interview on 02/11/26 at 9:57 AM, LVN A said she thought Resident #4's wound was cleared. She said on his orders the wound care said PRN, so she thought his wound was resolved. She said since Resident #4 had a wound, he was supposed to be on EBP. She said a negative effect of not following enhanced barrier precautions was the risk of spreading infection.During an interview on 02/11/26 at 12:00 PM, the ADON said since the facility did not have a MDS nurse, corporate was coming in the building doing MDS. She said Corporate, the Director of Nursing, and Administrator were responsible for updating the care plan. She said the negative effect of not updating the care plans could affect the residents' care the doctor ordered for them; it could make the situation worse.During an interview on 02/11/26 at 12:29 PM, the DON said she did not have an MDS nurse at that time, so any member of nursing staff, including herself, could have updated Resident #4's care plan for EBP. She said the negative effect of not updating the care plan could pose a risk of staff having a lack of knowledge that required extra precautions to prevent an increase in infection.During an interview on 02/11/26 at 12:47 PM, the Administrator said the facility did not have a treatment or MDS nurse, so she would say the infection preventionists, who was the Director of Nursing, was responsible for ensuring the EBP was on the care plan. She said the negative effect of not having the EBP of the resident's care plan would be the resident would not be receiving the proper care.2. Record review of Resident #40's face sheet, dated 2/11/2022, indicated an 80-year- old female readmitted on [DATE]with diagnoses which included Alzheimer's Disease (a brain disorder that destroys memory and thinking skills), Urinary Tract Infection (an infection in any part of the urinary system), Hyperlipidemia (a condition characterized by elevated levels of cholesterol in the blood, particularly low-density lipoprotein (LDL) often referred to as bad cholesterol.), and seizures (a sudden burst of electrical activity in the brain).Record review of Resident #40's Quarterly MDS, dated [DATE], indicated Resident #40 understood and was understood by others. Resident #40 had a BIMS score of 00, which indicated severely impaired cognition. Resident #40 required supervision to moderate assistance with ADLs. Resident #40 had a diagnosis of Seizure Disorder and was prescribed an anticonvulsant. The MDS indicated Resident #40 was on a mechanically altered diet.Record review of Resident #40's Care Plan, last revised on 1/30/2026 indicated the care plan did not include the resident's use of anticonvulsant medications, seizure disorder, altered diet, and impaired ADL performance.Record review of Resident #40's Order Summary Report dated 2/11/2026 indicated diagnoses including hypertension, seizures, pain, insomnia, muscle weakness. Resident #40 was on a regular, no added salt diet, pureed texture, regular liquids with whole milk and fortified food with all meals with each food item in separate bowls. The order summary report indicated Resident #40 resided on a secure unit to prevent potential injury due to wandering and elopement risk and was prescribed Levetiracetam (a medication used to help control certain types of seizures).Record review of Resident #40's MAR dated 2/1/2026-2/28/2026 indicated Resident #40 received Levetiracetam 100 mg/ml 5 ml by mouth two times daily related to seizures.During an observation on 2/9/2026 at 9:40 AM, Resident #40 was sitting in the main dining area on the secure unit playing with blocks at the table. Resident #40 was pleasantly confused, clean, and well-groomed with no signs of untimely care. Conversation was limited due to impaired thought organization.During an interview on 2/10/2026 at 11:10 AM, the RP said she had no concerns with care provided by the facility. She said Resident #40 was doing well with her medications and they were helping her. She said she was notified of potential side effects of medications, and she received updates on her care.During an interview on 2/11/2026 at 10:33 AM, LVN C said Resident #40 was encouraged to elevate her feet while she was sitting. She said she required her meals to be set up, and she was able to feed herself. LVN said Resident #40 was on a regular, no added salt pureed texture diet with regular liquids and she resided on the secure unit. LVN C said staff documented changes in condition and new physician orders on the 24-hour report. She said she reviewed the care plan. LVN C said the resident's diagnoses should be on the care plan to know why care was being performed. She said the care plan was based off the reports and assessments. LVN C said the interventions were different for each resident and should match what was going on with the resident. LVN C said the DON was responsible for the MDS and care plans. She said if a care plan and MDS was inaccurate, it could negatively impact the resident because the staff would not know what to monitor the resident for.During an interview on 2/11/2026 at 10:59 AM, the ADON said the care plan was created and started with the DON. She said it was a group effort. The ADON said the residents' diagnoses, interventions such as fall mats, dialysis, medications, code status and diet should be on the care plan. The ADON said the staff have a care plan meeting that was held on Thursdays, but she was not sure when the care plan meetings were held since the new corporate company took over. The ADON said the care plan should be updated when there was a significant change. The ADON said the DON and ADM were responsible for updating the care plan.During an interview on 2/11/2026 at 11:21 AM, the DON said Resident #40's care plan should have goals and interventions specific to her needs related to diagnoses and medications. She said the IDT was responsible for making sure the interventions and goals were updated. She said by not having the care plan updated, the staff may not provide the resident with resident centered care.During an interview on 2/11/2026 at 11:21 AM, the ADM said the care plan information was pulled from the MDS. She said she expected the MDS nurse and nurse to assess the residents with accuracy on the MDS so the care plan and interventions were individualized for each resident. She said if the assessment was not accurate, the resident might not receive proper care. 3. Record Review of Resident #44's face sheet, dated 11/28/2022, indicated an [AGE] year-old male admitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (a progressive lung disease that makes it difficult to breath), dementia (a syndrome characterized by a decline in cognitive function affecting memory, thinking, behavior and ability to perform everyday activities), hypertension (a common condition where the force of blood against the artery walls is consistently too high), Hyperlipidemia (a condition characterized by elevated levels of cholesterol in the blood, particularly low-density lipoprotein (LDL) often referred to as bad cholesterol.), Gastroesophageal reflux disease (a chronic condition where stomach acid flows back into the esophagus),pruritus (an irritating sensation that makes itch often caused by dry skin) and pulmonary embolism with acute cor pulmonale (a sudden increase in pressure in the pulmonary circulation).Record Review of Resident #44's Annual MDS, dated [DATE], indicated Resident #44 was understood and understood others. Resident #44 had a BIMS score of 13, which indicated he was cognitively intact and was independent with ADLs. The Annual MDS indicated Resident #44 had hypertension, Gastroesophageal reflex, hyperlipidemia, dementia, and Chronic Obstructive Pulmonary Disease. The MDS indicated resident was on an antiplatelet. The care areas triggered on the annual MDS were visual function and nutritional status.Record review of Resident #44's care plan, dated 01/30/2026, indicated full code status with interventions to encourage resident to verbalize and express wishes regarding personal decisions, ensure any questions were posed by the resident or representative regarding advanced care planning were answered timely and executed accordingly. There were no care plans related to Chronic Obstructive Pulmonary Disease, pain, or antiplatelet medication. The only Care areas triggered were visual function, nutritional status on the Annual MDS dated [DATE].Record review of Resident #44's order summary dated 2/9/2026 indicated diagnoses included Chronic Obstructive Pulmonary Disease, hyperlipidemia, dementia, hypertension , gastroesophageal reflux disease , pruritus , and pulmonary embolism with acute cor pulmonale (a sudden increase in pressure in the pulmonary circulation). Resident #44 was on a regular diet, with no added salt with regular liquids. The order summary report indicated that resident was prescribed antiplatelet (a medication used to prevent blood clots and reduce risk of heart attack and stroke), required oxygen and nebulizer treatments for Chronic Obstructive Pulmonary Disease.Record Review of Resident #44's MAR dated 2/1/2026-2/28/2026 indicated Resident #44 received the following medications:Aspirin 81 mg daily for pulmonary embolism with acute cor pulmonaleOxygen 2-4 liters via nasal cannula as needed for shortness of breath and maintain pulse oximeter (a non-invasive electronic device typically placed onto finger to measure the oxygen saturation level of the blood and heart rate) greater than 88 %.Umeclidinium-Vilanterol Inhalation Aerosol Powder 62.5-25 mcg/act 1 puff inhaled daily for Chronic Obstructive Pulmonary Disease.Albuterol nebulizer 0.083 % 1 vial inhaled via nebulizer every 4 hours as needed for shortness of breath related to Chronic Obstructive Pulmonary Disease.Naproxen 220 mg 2 tablets by mouth every 8 hours as needed for pain.During an observation and interview on 2/9/2026 at 10:22 AM, Resident # 44 was sitting up in a wheelchair with observed oxygen tank in room. Resident #44 said he was independent with most activities and was no longer attending therapy. Resident #44 said he was having mouth pain from broken teeth and left ear pain. He said he wanted to see a dentist because he had pain in the back of his mouth. He said he was not on a special consistency diet.During an interview on 2/11/2026 at 8:40 AM, CNA D said Resident #44 was supervision only. She said she checked on him to ensure he had his oxygen on. She said he was on a regular diet. CNA D said Resident #44 had never reported mouth pain to her, and she said she was unaware he had missing teeth. CNA D said if a resident was complaining of mouth pain, it could cause the resident to have a change in behavior, or he might eat less.During an interview on 2/11/2026 at 10:33 AM, LVN C said she completed the head-to-toe assessment on her residents. She said she was not aware Resident #44 had any mouth pain. LVN C said Resident #44 only had his code status on his care plan and said that it was an insufficient care plan. She said he should have more diagnoses and interventions on his care plan. LVN C said the orders for the residents should be on the care plan. She said orders such as diet, code status, and diagnoses would be on the care plan, so the staff knew why care was being performed. LVN C said the DON was responsible for the initial assessment and the care plan was based off the reports of the initial assessment. LVN C said the interventions were different for each resident and should match what was going on with the resident. She said the resident's diet, nutrition, interventions for diagnoses, and medications were on the care plan. She said if an area of concern was not captured on the MDS, the care area might not get entered on the care plan. LVN C said the DON was responsible for the MDS and care plans. LVN C said it could negatively impact a resident if the care plan were not in place or revised because the nursing staff would not know what to monitor, cause safety issues and a resident could have a delay in care.During an interview on 2/11/2026 at 10:59 AM, the ADON said she was not aware he needed to see a dentist and could be insurance issue. The ADON said the facility currently does not have a MDS nurse and the DON was putting in the orders and baseline care plan. The ADON said the care plans were created by the DON but said it was a group effort. The ADON said a resident's diagnoses, interventions, medications, code status, and diet should be on the care plan so the nurse staff would know how to care for the residents. She said the care plan should be revised when there was a significant change in condition or during the IDT meetings and during QAPI meetings. She said the DON and ADM were responsible for updating and revising the care plan. She said if the care plan was not initiated or revised, the residents may not receive the care they need resulting in a life-threatening outcome.During an interview on 12/11/2026 at 11:27 AM, the DON said she had attempted to get Resident #44 an appointment with the visiting dental group, but they did not take his insurance, and the family would not cover the cost. She said she was getting someone to see him today. The DON said Resident #44 should have goals and interventions specific to his needs. She said the facility had been on a different EMR system and the staff had to reenter all the residents' care plans. The DON said the facility currently did not have an MDS nurse, and corporate had been assisting with the MDS assessments. The DON said the charge nurse was responsible for performing the initial assessment based on information received from residents, family, and discharge paperwork from the hospital. The DON said the MDS triggered the care plan. She said she expected the care plans to be updated and revised as changes occurred. She said she also expected the care plan to be individualized. She said the Interdisciplinary Team was responsible for ensuring the interventions and goals were updated quarterly and when there were changes. She said not having a care plan in place could result in residents not receiving individualized care. During an interview on 2/11/2026 at 12:11 PM, the ADM said the facility changed EMR systems. The ADM said she expected the care plan to be revised and updated. She said the care plan was important so the staff would know how to provide care for the residents. She said she expected the staff to review the care plan at least one time each shift and for the care plan to be revised if a resident had a change in condition. She said the nurses, MDS nurse, and the IDT were responsible for ensuring the care plan were updated and accurate. The ADM said the staff go over updates in their morning meetings. She said if the care plan and assessment were not updated or accurate, the resident might not receive the care they need. Record review of the facility's policy titled Care Plans, Comprehensive Person-Center dated March 2022 indicated, .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.The interdisciplinary team in conjunction with the resident.7.The comprehensive, person-center care plan includes measurable objectives and timeframes.describes the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.residents goals upon admission and desired outcomes.builds on resident strengths.reflects currently recognized standards of practice for problem areas and conditions.9. Care plan interventions are chosen after data gathering.10. Assessments of residents are ongoing, and care plans are revised as information about the residents' condition changes.The interdisciplinary team reviews and updates the care plan when.significant change in condition.when the desired outcome is not met.at least quarterly, in conjunction with the required MDS assessment.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 13 residents (Resident #12) reviewed for quality of care.1. The facility failed to change the oxygen tubing and water reservoir for Resident #12's oxygen concentrator.2. The facility failed to ensure that oxygen filters were clean for Resident #12's oxygen concentrator.These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.Findings included:Record review of Resident #12's face sheet, dated 10/13/25 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included Chronic Obtrusive Pulmonary Disease (a progressive lung condition that blocks airflow, making it hard to breathe, and includes emphysema (damaged air sacs) and chronic bronchitis (inflamed airways), Hypokalemia (muscle weakness, cramps, fatigue, and constipation, along with heart palpitations, abnormal heart rhythms, lightheadedness, numbness, tingling, and sometimes confusion or frequent urination), Schizophrenia (a chronic, severe brain disorder that causes individuals to interpret reality abnormally, often resulting in hallucinations, delusions, and disorganized thinking).Record review of Resident #12's quarterly MDS assessment, dated 11/24/25, revealed Resident #12 had a BIMS score of 10, which indicated moderately impaired cognitionResident #12 required assistance or supervision with ADLs.Record review of Resident #12's care plan reflected a problem initiated on 11/18/2025 indicating that, Impaired gas exchange related to. Resident will maintain optimal gas exchange as evidenced by oxygen saturation within baseline for the resident, and alert, responsive mentation or no further reduction in mental status.Administer oxygen therapy as ordered.Record review of an order for Resident #12, dated 12/14/25, reflected that staff were to, Check oxygen concentrator filter for placement and clean filter every week or as needed.Record review of an order for Resident #12, dated 12/14/25, reflected that staff were to, Change oxygen tubing/water every week and as needed.During an observation and interview on 2/9/26 at 10:30 a.m. Resident #12 said he liked to use the black oxygen concentrator. He said he didn't like using the white oxygen concentrator in his room. He said the white one belonged to his old roommate, but she wasn't there at that time. He said he never used the white oxygen concentrator but regularly uses the black one. It was observed that the black concentrator electric cord was plugged into the wall, and the oxygen tubing and water reservoir was dated 12/22/25. It was observed that both oxygen concentrators had dirty filters and the machine itself was dirty.During an observation on 2/10/26 at 9:45 a.m. Resident #12 had two oxygen concentrators in his room. a black oxygen concentrator with a dirty filter, oxygen tubing dated 12/22/25, and an oxygen reservoir dated 12/22/25. The black oxygen concentrator was plugged into the wall's electrical outlet. The white oxygen concentrator was not plugged into the electrical outlet and not in use. Both concentrators had dirty filters. The oxygen tubing of the white concentrator was within date per orders. During an interview on 2/11/2026 at 10:20 a.m., LVN C said that it was the responsibility of nurses to change residents' oxygen tubing, water reservoir, and filters as ordered. She said that residents could be placed at risk of respiratory infections if they did not have their tubing, filters, or water reservoir changed regularly.During an interview on 2/11/26 at 11:25 a.m., the Director of Nurses said that it was the responsibility of facility nurses to ensure that resident's oxygen tubing was changed per orders and labeled with the new date. She stated that oxygen filters should be cleaned or replaced as ordered. She stated that residents could be placed at risk for respiratory infections if their oxygen tubing was not changed properly.During an interview on 2/11/26 at 11:36 a.m. with the Administrator, she said that it was the responsibility of nursing staff to change the oxygen tubing and filters for oxygen concentrators as it was ordered. She said that residents could be placed at risk for respiratory infections if they were not supplied with clean oxygen tubing. Record review of facility's policy titled Oxygen Administration revised in October of 2010 revealed that, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. The date and time that the procedure was performed.

Based on observation, record review, and interview, the facility failed to store all drugs and biologicals in locked compartments for 1 of 13 residents reviewed for pharmacy services. (Resident #26)The facility failed to ensure wound care treatment chemicals were not improperly stored in Resident #26 room.This failure could place residents at risk for adverse reactions.Findings included:Review of Resident # 26's face sheet, dated, 11/02/2022, reflected a [AGE] year-old male who was admitted on [DATE]. Resident #26 had diagnoses which included Parkinsonism (an umbrella term for a neurological syndrome characterized by motor symptoms like tremor, bradykinesia (slowness), rigidity, and postural instability), Vitamin Deficiency (occurs when the body does not get enough essential nutrients, leading to impaired function and potential long-term health issues), and Anxiety Disorder (a group of mental health conditions characterized by persistent, excessive, and irrational fear or worry that interferes with daily life).Review of Resident #26's Quarterly MDS assessment, dated 12/04/2025, reflected the resident had a BIMS score of 14, which indicated his cognition was intact. Resident #26 was independent with most of his ADLs.During an observation and interview on 2/9/26 at 1:51 p.m. Resident #26 had a bottle of liquid chemical wound cleanser in his room. He said it was for his neck and that he had a wound previously on his neck that needed skin cleanser. During an observation on 2/10/26 at 10:40 a.m. the bottle of liquid chemical wound cleanser remained in Resident #26's room. During an interview on 2/11/2026 at 10:20 a.m., LVN C said that wound care chemicals should be kept in the treatment cart or the medication cart. She said that residents should not have that left in their room as residents could be placed at risk of drinking the chemicals or getting the chemicals in their eyes or ears. She said that it was everyone's responsibility to ensure that potentially harmful chemicals were stored properly and out of reach of residents.During an interview on 2/11/26 at 11:25 a.m. with the DON, she said that wound care chemicals, or any type of medication or chemical, should be kept in the medication cart or the medication supply room. She said that every staff that entered residents' rooms were responsible to ensure prohibited items are not in the residents' rooms. She said that there could be a high risk of serious injury or harm if a resident misused a medication or chemical.During an interview on 2/11/26 at 11:36 a.m., the Administrator said that medications should not be left in a resident's room. She said that all staff were responsible for making sure residents did not have medications or chemicals in their room. She said that residents could be placed at risk of harm if they used the medication or chemical wrong.Record review of the facility's policy dated July of 2017 titled Safety and Supervision of Residents revealed, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Our facility-oriented approach to safety addresses risks for groups of residents.Implementing interventions to reduce accident risks and hazards shall include the following: Communicating specific interventions to all relevant staff; Assigning responsibility for carrying out interventions; Providing training, as necessary; Ensuring that interventions are implemented; and Documenting interventions.

Based on observations, interviews, and record reviews the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs for 1 of 13 residents (Residents #26) reviewed for receiving meals as prescribed.The facility failed to honor Resident #26's food preference of large portions according to his care plan and meal ticket.This deficient practice could place residents at risk of not receiving their meal to meet their needs for allergy aversions, unwanted weight loss, and meal textures and/or consistencies.Findings included:Review of Resident # 26's face sheet, dated, 11/02/2022, reflected a [AGE] year-old male who was admitted on [DATE]. Resident #26 had diagnoses which included Parkinsonism (an umbrella term for a neurological syndrome characterized by motor symptoms like tremor, bradykinesia (slowness), rigidity, and postural instability), Vitamin Deficiency (occurs when the body does not get enough essential nutrients, leading to impaired function and potential long-term health issues), and Anxiety Disorder (a group of mental health conditions characterized by persistent, excessive, and irrational fear or worry that interferes with daily life).Review of Resident #26's Quarterly MDS assessment, dated 12/04/2025, reflected the resident had a BIMS score of 14, which indicated his cognition was intact. Resident #26 did not have a weight loss or a weight gain.Review of Resident #26's Comprehensive Care Plan, with a problem initiated on 01/13/2026 reflected Resident #26 had unplanned/unexpected weight loss related to recent hospitalization following elective surgery. The goals was for the resident's weight to return to the baseline range by review date. An intervention was for Resident #26 to have large portions with all meals.Record review of Resident #26's lunch meal ticket dated 2/10/26 revealed that Resident #26 was to receive a large portion of food. Record review of Resident #26's weight records show that they did not have a significant weight loss.During an interview and observation on 2/9/26 at 1:51 p.m., Resident #26 said that he was upset with the portion size of his food. He said that the portions were too small. He said the taste was fine, but he required a larger sized portion of food. Resident #26 took out his phone and showed the surveyor pictures of past food without dates. The first photo showed a single fried egg and a biscuit. The second photo showed two slices of bread with a single slice of bologna with no condiments or cheese. During an observation and interview on 2/10/26 at 1:45 p.m., Resident #26 stated that he did not get double portioned food. He stated that he sometimes recieved double portions of his food but rarely. He said he requested double portions, and his meal ticket said double portions. He said that he was not satiated from the portion size of his food, and he knew that he would have to constantly remind the kitchen staff he receives double portions. He said he had taken a picture of his lunch today to show the surveyor his regular sized portion. Resident #26 showed the surveyor a photograph of today's lunch, chicken spaghetti green beans and garlic toast. Shown in the photo was a half slice of bread, a regular sized portion of spaghetti, and a regular sized scoop of green beans. During an interview on 2/11/26 at 10:32 a.m. the Dietary Manger said that it was a mistake that Resident #26 did not have large portions on his lunch meal on 2/10/26. She said that residents, whose meal ticket stated large portions, would receive a larger portion of food than normal portions. She said that residents could be placed at risk of weight loss if they were not given a larger portion when they requested them.During an interview on 2/11/26 at 11:25 a.m., the DON said that residents that required large portions shouldn't be given the normal portion size. She said that residents who received the wrong portion of food could be placed at risk for weight loss and a diminished quality of life. She said that it was the responsibility of kitchen staff and nurses to ensure that food quantity was served as ordered and care planned.During an interview on 2/11/26 at 11:36 a.m., the Administrator said that residents that received large portions should not be given a smaller portion of food. She said it was the responsibility of kitchen staff and nursing staff to ensure that residents that were ordered or requested large portions, received their large portions. She said that residents could be placed at risk of weight loss and diminished quality of life if given the wrong portion size of food.Record review of the facility's Resident Right Policy, dated October 2017 revealed that the purpose of the policy was, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.the multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional and psychosocial factors that affect eating and nutritional intake and utilization.A resident-centered diet and nutrition plan will be based on this assessment.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 13 residents (Residents #4) reviewed for infection control practices. The facility failed to ensure LVN A and CNA B applied enhanced barrier precautions when they washed Resident #4's hair on 02/10/26. This failure could place residents at risk for cross contamination and the spread of infection. Findings include: Record review of Resident #4's face sheet dated 01/10/26 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included: multiple sclerosis (a chronic disease of the central nervous system), psoriasis (a skin disease that causes a rash with itchy), and protein-calorie malnutrition. Record review of Resident #4's MDS assessment, dated 12/18/25, reflected Resident #4 was usually understood and usually understood by others. Resident #4's BIMs score was a 15, which indicated cognition was intact. Resident #4 was dependent on ADLs. The 1 of 1 of unhealed pressure ulcers/ injuries at each stage, during the look-back period: Stage 3: Full thickness tissue loss. Record review of Resident #4's care plan dated 12/16/25 reflected Resident #4 had a stage 3 pressure ulcer to the sacrum related to immobility. There was no care plan related to EBP. Record review of Resident #4's order summary report reflected an order for wound treatment, dated 02/06/26. During an observation on 02/10/26 at 10: 21 AM, LVN A started to wash Resident #4's hair with gloves on, but did not apply gown. During an observation on 02/10/26 at 10:22 AM, CNA B assisted LVN B with washing Resident #4's hair by holding his head with gloves on. CNA B did not apply a gown. Resident #4 had a sign in room and PPE for EBP. During an interview on 02/12/26 at 9:25 AM with Resident #4, he said when staff changed him, gave him a bed bath, and did his wound care, they did not put on their gowns. He said they just put on those gowns yesterday, because state was there. During an interview on 02/11/26 at 9:45 AM, CNA B agreed, she was supposed to have worn a gown yesterday when she was assisting with washing Resident #4's hair. She said staff were supposed to wear the gown and gloves, because Resident #4 had a wound. She said a negative effect of not wearing the gown would be an infection control issue. During an interview on 02/11/26 at 9:57 AM, LVN A said she thought Resident #4's wound was cleared. She said on his orders the wound care said PRN, so she thought his wound was resolved. She said since Resident #4 had a wound, he was supposed to be on EBP. She agreed, she should have worn PPE such as a gown while providing care for him. She said she should wear a gown and gloves to protect herself and others. She said a negative effect of not following enhanced barrier precautions was the risk of spreading infection. During an interview on 02/11/26 at 12:00 PM, the ADON said she expected staff to follow the enhanced barrier precaution procedure. She said she was responsible for ensuring PPE was in the resident's room, and in-servicing the staff on EBP. She said not following enhanced barrier precautions could put the resident and everyone at risk for infection. During an interview on 02/11/26 at 12:29 PM, the DON said she expected staff to wear gown and gloves while providing high contact care to residents on enhanced barrier precautions. She said any staff member entering the resident's room to provide high contact care was responsible for applying PPE and following EBP. She said the negative effect of not following enhanced barrier precautions increased the risk of infections for the residents and they were already comprised. During an interview on 02/11/26 at 12:47 PM, the Administrator said she expected for the staff to know who was on EBP and to apply PPE. She said the staff was responsible for following the EBP. She said a negative effect of not following EBP staff could transfer an infection to residents or cause cross contamination. Record review of the facility's policy and procedure Enhanced Barrier Precautions dated March 2024, indicated. Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. 1.Enhanced barrier precautions EBPs) are used as an infection prevention and to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact care activities that provide opportunities for transfer of MDROs to staff hands and clothing. 2.EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). 3. Example of high-contact resident care activities requiring the use of gown and gloves for EBPs include:. d. providing hygiene. 4. EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with CDC targeted or epidemiologically important MDRO, including. 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. A. Wounds generally include chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds), not shorter-lasting wounds like skin breaks or skin tears. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. 10. Staff are trained prior to caring for residents on EBPs.

Based on observation, record review and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 3 of 3 days reviewed (02/06/26, 02/07/26 and 02/08/26) for nursing services. The facility failed to post the required current daily staffing information on 02/06/26, 02/07/26 and 02/08/26. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included: During an observation on 02/09/26 at 8:48 AM, nurse staffing data was posted on a wall on entrance of the facility, easily visible, and was dated 02/05/26. During an interview on 02/11/26 at 12:00 PM, the ADON said she was responsible for updating the staff posting. She said usually updating the staff posting sign was the first thing she did in the morning, but she did not work on the weekend, so it had not been changed since Friday. She said when state entered the facility on Monday (02/09/26) the staffing post was dated 02/05/26. She said the staffing post was to show the accurate number of staff to take care of the residents in the facility. During an interview on 02/11/26 at 12:29 PM, the Director of Nursing said the ADON was responsible for updating the nurse staffing posting and it should be updated daily, where everyone could see it. She said generally, the ADON left the updated staff posting for the 10-6 nurse on the weekend to update the posting. She said the risk of not posting nurse staffing information was that no one would be aware of how many direct nursing staff were in the facility. During an interview on 02/11/26 at 12:47 PM, the Administrator said the ADON was responsible for updating the nurse staffing posting. She said the nurse staff posting should be updated every day and corrected if there was a change. She said the nurse staff posting was to inform anyone who entered the building the number of staff the facility had to take care of the residents. She said the risk of not posting nurse staffing information was staff, visitors, and residents would not know how many staff were in the facility. During an interview on 02/11/2026 at 12:55 PM., the Administrator said there was no policy to address the staffing post.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 3 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's baclofen (muscle relaxant) was administered as ordered on 10/23/2025 and 10/24/2025. This failure could place the residents at risk of not having medications available for use and medications errors.Findings included: Record review of Resident #1's face sheet dated 10/30/2025 indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included spinal stenosis (narrowing of the spinal canal with can lead to compression of the nerves and cause low back pain and discomfort), dementia (deterioration of memory, language, and other thinking abilities) and chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated he understood others and was understood by others. Resident #1's MDS assessment indicated he had a BIMS score of 14, which indicated his cognition was intact. The MDS assessment indicated Resident #1 was independent for eating and hygiene and required supervision for bathing. The MDS assessment indicated Resident #1 received scheduled and as needed pain medication. Record review of Resident #1's care plan revised 09/11/2025, indicated he had a diagnosis of muscle spasms, abnormal muscle movement and was at risk for adverse reactions to medication. Interventions included providing medications as ordered. Record review of Resident #1's Order Summary Report dated 10/30/2025 indicated he had an order for baclofen 5 mg give 1 tablet orally three times a day with a start date of 04/11/2025. Record review of Resident #1's October 2025 MAR indicated baclofen 1 tablet orally three times a day at 7 AM, 1 PM, and 7:00 PM. Resident #1's MAR indicated the baclofen was not administered on: 10/23/2025 at 1 PM. 10/24/2025 at 7 AM, 1 PM, and 7:00 PM. Record review of Resident #1's progress notes indicated: 10/23/2025, Baclofen 5 mg pending arrival from pharmacy, signed by LVN A. 10/24/2025, Baclofen 5 mg pending arrival from pharmacy, signed by LVN A. During an interview on 10/30/2025 at 9:34 AM, Resident #1 said around the middle of this month (October 2025), his baclofen was not administered two days. Resident #1 said LVN A told him his medication ran out, and she had called it in. LVN A said it was not delivered because the pharmacy said it was too early to fill it. Resident #1 said LVN A told him she could not administer it from the emergency medication kit because it did not contain it. During an interview on 10/30/2025 at 11:32 AM, LVN A said sometimes the residents' medications ran out. LVN A said if they did not have a resident's medication, they checked the emergency medications to see if it was available for administration, if it was not available, the residents did not receive their medication. LVN A said if they did not have a resident's medication they should contact the pharmacy, notify the DON and doctor. LVN A said Resident #1 ran out of his baclofen the previous week, and he did not receive it for maybe one day. LVN A said she had not notified the doctor because he did not miss that many doses. LVN A said if she did not administer the baclofen, it was because it was not in the emergency medications. LVN A said she had contacted the pharmacy and notified the DON Resident #1 did not have any baclofen for administration, and she had administered it when it was delivered. LVN A said Resident #1 did not suffer any side effects from not receiving the baclofen, and he had as needed pain medications that could be administered if he needed them. LVN A said it was important to administer medications as ordered to help manage the residents' conditions. During an observation and interview on 10/30/2025 at 2:43 PM, an observation of the emergency medications was made with the DON, and there were only baclofen 10 mg tablets available. The DON said earlier in the month Resident #1 had notified her he had not received his baclofen. The DON said she called the pharmacy, and they told her they had delivered a supply for one month earlier in the month. The DON said the nurses received the medications from the pharmacy, and the nurses were supposed to verify the amount received when they signed for the medications. The DON said she searched everywhere in the facility for the baclofen and did not find it. The DON said she called the pharmacy, notified them, and they sent the medication to the facility on [DATE]. The DON said the nurses did not notify her Resident #1 did not have any baclofen and they had not administered it. The DON said she found out about the baclofen when Resident #1 notified her. The DON said if the nurses would have notified her, they could have called the pharmacy to see if they could cut the 10 mg baclofen tablet in half to administer it to Resident #1. The DON said every morning they had a clinical meeting, and she pulled reports to see if any residents did not receive their medications. The DON said she did not catch that Resident #1 did not receive his baclofen as ordered. The DON said depending on the medication that was not administered, not administering medications could potentially cause an exacerbation of the residents' disease processes. During an interview on 10/30/2025 at 2:56 PM, a Pharmacy Technician with the facility's pharmacy indicated the DON called in a refill for Resident #1's baclofen on 10/24/25 and it was delivered 10/25/2025. The Pharmacy Technician said on 10/03/2025 the pharmacy delivered 90 tablets of baclofen 5 mg, which would have been a 30-day supply. The Pharmacy Technician said Resident #1 ran out of his medication approximately 4-5 days early. During an interview on 10/20/2025 at 4:26 PM, the Administrator said she was not aware of the doses of baclofen Resident #1 did not receive. The Administrator said she was notified by the DON Resident #1 did not have any baclofen, and the DON had ordered it and was going to have it delivered. The Administrator said her expectations were if the nurses had a medication that was not available, they should immediately notify the DON or her so they could call the pharmacy, have it delivered, and have the medication administered to the resident by their next scheduled dose. The Administrator said it was important for them to have the residents' medications available for administration to ensure the residents received the medications the doctor had prescribed. Record review of a pharmacy delivery receipt dated 10/03/2025 indicated 90 tablets of Baclofen 5 mg were delivered to the facility for Resident #1. Record review of the facility's policy titled, Administering Medications, revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders.

Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 8 (Resident #1) residents reviewed for abuse. 1.The facility failed to prevent MA A from physically abusing Resident #1 on 5/23/25 witnessed by Resident #2's family member. 2. The facility failed to protect other residents in the building from potential abuse when on 05/23/2025 the facility did not suspend MA A for 1 month after the incident leading to MA A's termination on 06/27/2025. The noncompliance was identified as PNC. The IJ began on 5/23/25 and ended on 6/30/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings included: 1. Record review of the face sheet dated 7/1/25 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, psychosis, restlessness and agitation, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident # 1 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #1 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated during the 7-day look back period, Resident #1 did not have any physical or verbal behaviors towards others. Record review of the care plan last updated 3/12/25 indicated Resident #1 had a diagnosis of anxiety and exhibited signs and symptoms of anxiety/behaviors of pacing and aggression. Record review of the PIR dated 6/23/25 indicated Resident #2's (another resident residing in the secured unit) family member reported to the DON that they witnessed MA A punch Resident #1 in the chest after Resident #1 kicked MA A on 5/23/25. The PIR indicated Resident #2's family member reported the incident to the former ADON on 5/27/25. The PIR indicated Resident #2's family member said the former ADON told them he had removed MA A from the secured unit, and that MA A would no longer be assigned to cover the secured unit. The PIR indicated Resident #2's family member said the reason they were disclosing this information now was because MA A had been assigned to an overnight shift on the unit on 6/20/25. The PIR indicated a skin assessment was performed on 6/23/25 on Resident #1, MA A was suspended and later terminated, safe surveys were completed, notifications were made to the NP and Resident #1's family, staff were in-serviced regarding abuse/neglect, mandatory notifications, and behavior management and de-escalation, and the former ADON was given a one-to-one in-service regarding abuse/neglect and mandatory notifications. During an interview on 7/1/25 at 11:28 a.m. the former ADON said he remembered on 5/23/25 he walked on to the secured unit and heard staff talking about something (He was not sure what was being discussed). He said he gathered it had something to do with MA A. The former ADON said he left the secured unit, and no one reported anything to him while he was on the unit. The former ADON said about 30 minutes later MA A was walking past his office and he asked her to come in and talk to him. The former ADON said he asked MA A what was going on. The former ADON said MA A told him she almost lost it on Resident #1 after he (Resident #1) kicked her, but she did not lose it and that the former ADON should be proud of her. The former ADON said MA A said Resident #2's family member had witnessed the incident. The former ADON said later (date not given) Resident #2's family member told him she had seen Resident #1 trip MA A. The former ADON said Resident #2's family member said it could have been bad and they did not know what would have happened if they had not witnessed the incident. The former ADON said Resident #2's family member had told him they did not feel MA A should be working on the secured unit. The former ADON said he changed MA A's work assignment and took her off the secured unit. The former ADON said he informed Resident #2's family member of who the abuse coordinator was, and they said they did not want to report anything. The former ADON said he did not report the incident to the Administrator due to nothing being specifically reported to him regarding abuse. The former ADON said he resigned from his ADON position, but had chose to remain at the facility as a charge nurse. During an interview on 7/1/25 at 11:38 a.m. MA A said on 5/23/25 she was walking around a table to sit down when Resident #1 tripped/kicked her, and she fell into the table. MA A said she pushed Resident #1 in the shoulder and told him no we don't do that. MA A said staff should never lay hands on a resident because it was considered abuse. MA A said she had just reacted that day and did not think anything of it because it was more of a push than a hit. During an interview on 7/1/25 at 1:05 p.m. Resident #2's family member said they witnessed the incident between MA A and Resident #1. Resident #2's family member said MA A was walking past Resident #1 when he kicked her in the butt. Resident #2's family member said MA A stumbled and almost fell. Resident #2's family member said when MA A regained her balance, she doubled up her fist and hit Resident #1 in the chest. Resident #2's family member said they reported the incident to the former ADON 4 days later and they did not know what came of it. Resident #2's family member said they had recently reported the incident to the Administrator because MA A was working on the secured unit again and they were afraid of what might happen if MA A was on the unit at night by herself with no witness. During an interview on 7/3/25 at 2:25 p.m. the Administrator said she expected staff to act professional and not hit the residents. The Administrator said all residents had the right to be safe from abuse. Record review of the facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy last revised April 2021 indicated Residents 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 the residents' symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: a. facility staff.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems.10. Protect residents from any further harm during investigations. The Administrator was notified on 7/1/25 at 4:45 p.m. that a Past Non-Compliance Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 7/1/25 at 4:52 p.m. The facility had corrected the noncompliance prior to surveyor entrance by the following: Suspending and Terminating MA A In-servicing staff regarding abuse and neglect, mandatory notifications, and behavior management and de-escalation. The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: Suspending and Terminating MA A In-servicing staff regarding abuse and neglect, mandatory notifications, and behavior management and de-escalation.The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: Record review of Record of Employee Counseling dated 6/27/25 indicated on 6/23/25 an allegation of abuse was made against MA A. The Record of Employee Counseling indicated MA A was immediately suspended on 6/23/25 pending investigation. The Record of Employee Counseling indicated the outcome of the investigation was that MA A, by her own statement, did place her hands on Resident #1's chest and push him. The Record of Employee Counseling indicated MA A was terminated on 6/27/25. Record review of Record of Employee Counseling dated 6/26/25 indicated the former ADON received written counseling regarding failing to notify the Administrator, abuse coordinator, of an allegation of abuse. The Record of Employee Counseling indicated the former ADON would immediately report any knowledge of allegations of abuse/neglect to the Administrator. Record review of in-services dated 6/23/25 indicated all staff were in-serviced regarding abuse and neglect and immediate notifications required to be made to the Administrator and DON Record review of in-services dated 6/30/25 indicated all staff were in-serviced regarding dementia, aggressive behaviors, and de-escalation of a situation.Staff interviewed (CNA B, LVN C, LVN D, CNA E, CNA F, CNA G, LVN H, Housekeeper J, CNA K, and the Director of Housekeeping) on 7/1/25 between 2:00 p.m. and 2:20 p.m. were able to name all types of abuse, what to do in the event of witnessed or reported abuse, and who the Abuse Coordinator was.Record review of the Skin assessment dated [DATE] indicated Resident #1 did not have any skin issuesRecord review of the Safe 'Surveys conduct on 6/23/25 indicated residents interviewed did not have any concerns or complaints, felt staff treated them with dignity and respect, felt safe and comfortable at the facility, had not witnessed or heard anyone be mistreated, and was not afraid of any resident or visitor.Observations made between 7/1/25 and 7/3/25 indicated staff treated resident with dignity and respect.Residents interviewed (Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) on 7/1/25 and 7/2/25 between 9:20 a.m. and 3:15 p.m. said they were treated well at the facility, were not scared of anyone in the facility, and no one in the facility had ever abused them physically or verbally. The noncompliance was identified as PNC. The IJ began on 05/23/2025 and ended on 06/23/2025. The facility had corrected the noncompliance before the survey began.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but , but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 8 (Resident #1) residents reviewed for abuse and neglect. The facility failed to ensure an allegation of abuse on 05/23/2025 was reported within 2 hours to the abuse coordinator on 5/27/25 when Resident #2's family member reported the abuse of Resident #1 to the former ADON. This failure to report resulted in MA A continuing to work with residents and being assigned to Resident #1's unit again on 06/20/2025. MA A continued to work until the family member reported the incident to the Administrator on 06/23/2025. The facility failed to report the allegation of abuse within 24 hours on 05/23/2025 when MA hit Resident #1. The facility failed to suspend MA A for 1 month after the incident. The noncompliance was identified as PNC. The IJ began on 5/23/25 and ended on 6/30/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings included: Record review of the face sheet dated 7/1/25 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, psychosis, restlessness and agitation, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident # 1 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #1 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated during the 7-day look back period Resident #1 did not have any physical or verbal behaviors towards others. Record review of the care plan last updated 3/12/25 indicated Resident #1 had a diagnosis of anxiety and exhibited signs and symptoms 0f anxiety/behaviors of pacing and aggression. Record review in TULIP on 7/1/25 indicated the incident of alleged abuse by MA A to Resident #1 that occurred on 5/23/25 was not reported to the state agency until 6/23/25. Record review of the PIR dated 6/23/25 indicated Resident #2’s family member reported to the DON that they witnessed MA A punch Resident #1 in the chest after Resident #1 kicked MA on 5/23/25. The PIR indicated Resident #2’s family member reported the incident to the former ADON on 5/27/25. The PIR indicated Resident #2’s family member said the former ADON told them he had removed MA A from the secured unit, and that MA A would no longer be assigned to cover the secured unit. The PIR indicated Resident #2’s family member said the reason they were disclosing this information now was because MA A had been assigned to an overnight shift on the unit on 6/20/25. The PIR indicated a skin assessment was performed on Resident #1, MA A was suspended and later terminated, safe surveys were completed, notifications were made to the NP and Resident #1’s family, staff were in-serviced regarding abuse/neglect, mandatory notifications, and behavior management and de-escalation, and the former ADON was given a one-to-one in-service regarding abuse/neglect and mandatory notifications. During an interview on 7/1/25 at 11:28 a.m. the former ADON said he remember on 5/23/25 he walked on to the secured unit and heard staff talking about something (He was not sure what was being discussed). He said he gathered it had something to do with MA A. The former ADON said he left the secured unit, and no one reported anything to him while he was on the unit. The former ADON said about 30 minutes later MA A was walking past his office and he asked her to come in and talk to him. The former ADON said he asked MA A what was going on. The former ADON said MA A told him she almost lost it on Resident #1 after he (Resident #1) kicked her, but she did not lose it and that the former ADON should be proud of her. The former ADON said MA A said Resident #2’s family member had witnessed the incident. The former ADON said later (date not given) Resident #2’s family member told him she had seen Resident #1 trip MA A. The former ADON said Resident #2’s family member said it could have been bad and they did not know what would have happened if they had not witnessed the incident. The former ADON said Resident #2’s family member had told him they did not feel MA A should be working on the secured unit. The former ADON said he changed MA A’s work assignment and took her off the secured unit. The former ADON said he informed Resident #2’s family member of who the abuse coordinator was, and they said they did not want to report anything. The former ADON said he did not report the incident to the Administrator due to nothing being specifically reported to him regarding abuse. The former ADON said he resigned from his ADON position but had chosen to remain at the facility as a charge nurse. l During an interview on 7/1/25 at 1:05 p.m. Resident #2’s family member said they witnessed the incident between MA A and Resident #1. Resident #2’s family member said MA A was walking past Resident #1 when he kicked her in the butt. Resident #2’s family member said MA A stumbled and almost fell. Resident #2’s family member said when MA A regained her balance, she doubled up her fist and hit Resident #1 in the chest. Resident #2’s family member said they reported the incident to the former ADON 4 days later and they did not know what came of it. Resident #2’s family member said they had recently reported the incident to the Administrator because MA A was working on the secured unit again and they were afraid of what might happen if MA A was on the unit at night by herself with no witness. During an interview on 7/3/25 at 2:25 p.m. the Administrator said she expected staff to act professional and not hit the residents. The Administrator said all residents had the right to be safe from abuse. The Administrator said she reported the incident of alleged abuse on 5/23/25 as soon as she found out about the incident on 6/23/25. The Administrator said she expected staff to immediately report any incidents of alleged or suspected abuse to her immediately. The Administrator said the importance of reporting abuse to the state agency in a timely manner was to aide in preventing further abuse and to protect the residents from abuse. Record review of the facility’s Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy last revised September 2022 indicated, “All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management….Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines…3. “Immediately” is defined as: a. withing two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in bodily injury…12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete…” The Administrator was notified on 7/1/25 at 4:45 p.m. that a Past Non-Compliance Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 7/1/25 at 4:52 p.m. The facility had corrected the noncompliance prior to surveyor entrance by the following: • Suspending and Terminating MA A• In-servicing staff regarding abuse and neglect, mandatory notifications, and behavior management and de-escalation. The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: • Record review of Record of Employee Counseling dated 6/27/25 indicated on 6/23/25 an allegation of abuse was made against MA A. The Record of Employee Counseling indicated MA A was immediately suspended on 6/23/25 pending investigation. The Record of Employee Counseling indicated the outcome of the investigation was that MA A, by her own statement, did place her hands on Resident #1’s chest and push him. The Record of Employee Counseling indicated MA A was terminated on 6/27/25.• Record review of Record of Employee Counseling dated 6/26/25 indicated the former ADON received written counseling regarding failing to notify the Administrator, abuse coordinator, of an allegation of abuse. The Record of Employee Counseling indicated the former ADON would immediately report any knowledge of allegations of abuse/neglect to the Administrator .• Record review of in-services dated 6/23/25 indicated all staff were in-serviced regarding abuse and neglect and immediate notifications required to be made to the Administrator and DON• Record review of in-services dated 6/30/25 indicated all staff were in-serviced regarding dementia, aggressive behaviors, and de-escalation of a situation.Staff interviewed (CNA B, LVN C, LVN D, CNA E, CNA F, CNA G, LVN H, Housekeeper J, CNA K, and the Director of Housekeeping) on 7/1/25 between 2:00 p.m. and 2:20 p.m. were able to name all types of abuse, what to do in the event of witnessed or reported abuse, and who the Abuse Coordinator was. Record review of the Skin assessment dated [DATE] indicated Resident #1 did not have any skin issues Record review of the Safe 'Surveys conduct on 6/23/25 indicated residents interviewed did not have any concerns or complaints, felt staff treated them with dignity and respect, felt safe and comfortable at the facility, had not witnessed or heard anyone be mistreated, and was not afraid of any resident or visitor. Observations made between 7/1/25 and 7/3/25 indicated staff treated resident with dignity and respect. Residents interviewed (Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) on 7/1/25 and 7/2/25 between 9:20 a.m. and 3:15 p.m. said they were treated well at the facility, were not scared of anyone in the facility, and no one in the facility had ever abused them physically or verbally. The noncompliance was identified as PNC. The IJ began on 05/23/2025 and ended on 06/23/2025. The facility had corrected the noncompliance before the survey began.

Based on interview and record review, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress from 1 of 11 staff members (MA A) and 1 of 8 residents (Resident #1) reviewed for abuse.The facility failed to protect residents from potential abuse when MA A was not suspended after an allegation of physical abuse was reported to the former ADON on 05/27/25. This failure to report resulted in MA A continuing to work with residents and being assigned to Resident #1's unit again on 06/20/2025. MA A continued to work until the family member reported the incident to the Administrator on 06/23/2025. The noncompliance was identified as PNC. The IJ began on 5/27/25 and ended on 6/30/25. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk for further abuse from a staff member. Findings included: Record review of the face sheet dated 7/1/25 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, psychosis, restlessness and agitation, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident # 1 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #1 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated during the 7-day look back period Resident #1 did not have any physical or verbal behaviors towards others. Record review of the care plan last updated 3/12/25 indicated Resident #1 had a diagnosis of anxiety and exhibited signs and symptoms 0f anxiety/behaviors of pacing and aggression. Record review of the PIR dated 6/23/25 indicated Resident #2’s family member reported to the DON that they witnessed MA A punch Resident #1 in the chest after Resident #1 kicked MA on 5/23/25. The PIR indicated Resident #2’s family member reported the incident to the former ADON on 5/27/25. The PIR indicated Resident #2’s family member said the former ADON told them he had removed MA A from the secured unit, and that MA A would no longer be assigned to cover the secured unit. The PIR indicated Resident #2’s family member said the reason they were disclosing this information now was because MA A had been assigned to an overnight shift on the unit on 6/20/25. The PIR indicated a skin assessment was performed on Resident #1, MA A was suspended and later terminated, safe surveys were completed, notifications were made to the NP and Resident #1’s family, staff were in-serviced regarding abuse/neglect, mandatory notifications, and behavior management and de-escalation, and the former ADON was given a one-to-one in-service regarding abuse/neglect and mandatory notifications. Record review of MA A’s daily timecard dated 5/23/25 through 6/23/25 indicated MA A worked on the following days:5/23/25-8.07 hours5/24/25-8.43 hours5/26/25-7.82 hours5/27/25-8.15 hours5/28/25-8.03 hours5/29/24-7.87 hours5/30/25-7.48 hours5/31/25-8.32 hours6/2/25-8.00 hours6/3/25-5.82 hours6/4/25-7.87 hours6/5/25-7.98 hours6/6/25-8.05 hours6/9/25-8.07 hours6/10/25-13.20 hours6/11/25-0.43 hours6/12/25-8.13 hours6/13/25-8.32 hours6/16/25-7.10 hours6/17/25-7.13 hours6/18/25-8.00 hours6/19/25-7.97 hours6/20/25-14.70 hours6/23/25-2.85 hoursThe daily timecard did not indicate where in the facility MA A had worked on these days. During an interview on 7/1/25 at 11:28 a.m. the former ADON said on 5/23/25 he walked on to the secured unit and heard staff talking about something. He said he gathered it had something to do with MA A. The former ADON said he left the secured unit and no one reported anything to him while he was on the unit. The former ADON said about 30 minutes later MA A was walking past his office and he asked her to come in and talk to him. The former ADON said he asked MA A what was going on. The former ADON said MA A told him she almost lost it on Resident #1 after he kicked her but she did not and that the former ADON should be proud of her. The former ADON said MA A said Resident #2’s family member had witnessed the incident. The former ADON said later (date not given) Resident #2’s family member told him she had seen Resident #1 trip MA A. The former ADON said Resident #2’s family member said it could have been bad and they did not know what would have happened if they had not witnessed the incident. The former ADON said Resident #2’s family member had told him they did not feel MA A should be working on the secured unit. The former ADON said he changed MA A’s work assignment and took her off the secured unit. The former ADON said informed Resident #2’s family member of who the abuse coordinator was and they said they did not want to report anything. The former ADON said he did not report the incident to the Administrator due to nothing being specifically reported to him regarding abuse. During an interview on 7/1/25 at 1:05 p.m. Resident #2’s family member said they witnessed the incident between MA A and Resident #1. Resident #2’s family member said MA A was walking past Resident #1 when he kicked her in the butt. Resident #2’s family member said MA A stumbled and almost fell. Resident #2’s family member said when MA A regained her balance, she doubled up her fist and hit Resident #1 in the chest. Resident #2’s family member said they reported the incident to the former ADON 4 days later and they did not know what came of it. Resident #2’s family member said they had recently reported the incident to the Administrator because MA A was working on the secured unit again and they were afraid of what might happen if MA A was on the unit at night by herself with no witness. During an interview on 7/3/25 at 2:25 p.m. the Administrator said she expected staff to act professional and not hit the residents. The Administrator said all residents had the right to be safe from abuse. The Administrator said she reported the incident of alleged abuse on 5/23/25 as soon as she found out about the incident on 6/23/25. The Administrator said she expected staff to immediately report any incidents of alleged or suspected abuse to her immediately The Administrator said the former ADON should have reported the alleged abuse to her immediately and that MA A should have been suspended on 5/27/25. The Administrator said the importance of reporting abuse to the state agency in a timely manner was to aide in preventing further abuse and to protect the residents from abuse. Record review of the facility’s Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy last revised April 2021 indicated “Residents 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 the residents’ symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: a. facility staff…5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems…10. Protect residents from any further harm during investigations…” Record review of the facility’s Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy last revised September 2022 indicated, “All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management….Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines…3. “Immediately” is defined as: a. withing two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does no involve abuse or result in bodily injury…12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete…”Record review of the Long-Term Care Regulatory Provider Letter issued 7/10/19 indicated, “…The facility becomes aware of, or receives, an allegation of suspected abuse, neglect, exploitation, or another reportable incident….Report the incident within 24 hours of within 2 hours depending on the incident. Complete an internal investigation of the incident, Take appropriate corrective action. Report the investigation findings within 5 working days from the initial report to HHSC on form 3613-A. Maintain evidence demonstrating results of all incidents for no less than three years after the reported allegation.” The Administrator was notified on 7/1/25 at 4:45 p.m. that a Past Non-Compliance Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 7/1/25 at 4:52 p.m. The facility had corrected the noncompliance prior to surveyor entrance by the following: • Suspending and Terminating MA A• In-servicing staff regarding abuse and neglect, mandatory notifications, and behavior management and de-escalation. The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: • Record review of Record of Employee Counseling dated 6/27/25 indicated on 6/23/25 an allegation of abuse was made against MA A. The Record of Employee Counseling indicated MA A was immediately suspended on 6/23/25 pending investigation. The Record of Employee Counseling indicated the outcome of the investigation was that MA A, by her own statement, did place her hands on Resident #1’s chest and push him. The Record of Employee Counseling indicated MA A was terminated on 6/27/25.• Record review of Record of Employee Counseling dated 6/26/25 indicated the former ADON received written counseling regarding failing to notify the Administrator, abuse coordinator, of an allegation of abuse. The Record of Employee Counseling indicated the former ADON would immediately report any knowledge of allegations of abuse/neglect to the Administrator .• Record review of in-services dated 6/23/25 indicated all staff were in-serviced regarding abuse and neglect and immediate notifications required to be made to the Administrator and DON• Record review of in-services dated 6/30/25 indicated all staff were in-serviced regarding dementia, aggressive behaviors, and de-escalation of a situation.Staff interviewed (CNA B, LVN C, LVN D, CNA E, CNA F, CNA G, LVN H, Housekeeper J, CNA K, and the Director of Housekeeping) on 7/1/25 between 2:00 p.m. and 2:20 p.m. were able to name all types of abuse, what to do in the event of witnessed or reported abuse, and who the Abuse Coordinator was. Record review of the Skin assessment dated [DATE] indicated Resident #1 did not have any skin issues Record review of the Safe 'Surveys conduct on 6/23/25 indicated residents interviewed did not have any concerns or complaints, felt staff treated them with dignity and respect, felt safe and comfortable at the facility, had not witnessed or heard anyone be mistreated, and was not afraid of any resident or visitor. Observations made between 7/1/25 and 7/3/25 indicated staff treated resident with dignity and respect. Residents interviewed (Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) on 7/1/25 and 7/2/25 between 9:20 a.m. and 3:15 p.m. said they were treated well at the facility, were not scared of anyone in the facility, and no one in the facility had ever abused them physically or verbally. The noncompliance was identified as PNC. The IJ began on 05/23/2025 and ended on 06/30/2025. The facility had corrected the noncompliance before the survey began.

Based on interview, and record review, the facility failed to ensure residents received mail delivered to the facility for 5 of 5 confidential residents reviewed for right to communication. The facility failed to ensure residents received their mail within 24 hours of delivery by the postal service. This failure could place residents at risk of potentially being denied their right and to receive and open mail in a timely manner and a diminished quality of life. Findings included: During a confidential group interview on 11/19/24 at 10:08 AM, 5 of 5 residents interviewed said mail was not being distributed on Saturdays. All 5 residents said they had not gotten mail on Saturdays in a long time. One of 5 residents interviewed said, The business office lady was not here on Saturday's so we do not get mail on weekends. During an interview on 11/19/24 at 10:47 AM, the BOM said residents got mail Monday through Friday. She said it was delivered in a lockbox outside the facility and she was the only one with a key to the lockbox. She said no one had a key on the weekends to get the mail so it could be delivered to the residents. She said she was hired in May of 2023 and the prior administrator gave her the key to the mailbox in June or July 2023. She said since that time (June or July of 2023) no resident had received mail on Saturdays because she did not work on weekends. She said residents were supposed to receive mail on Saturdays, but the prior administrator knew they did not. She said she did not know if the (current) new administrator or new DON knew residents were not getting mail on Saturdays. During an interview on 11/20/24 at 10:57 AM, the ADON said it was important for residents to get their mail on weekends because it was their right. She said not getting their mail could cause them to miss news and information important to them, or cause residents' distress and worry. During an interview on 11/20/24 at 12:33 PM, the DON said all residents should get mail Monday through Saturday. She said it was their right to receive mail or something they ordered timely. She said if they were waiting on an important document, they should be able to receive it timely. The DON said not receiving mail timely was a violation of resident's rights. She said she did not know residents were not receiving mail on Saturday, but the problem was fixed now. From now on, the facility will designate the weekend RN supervisor who will have a key to the mailbox so she will be able to get and deliver the mail to the residents on weekends. She said the weekend RN supervisor will also check the front door for packages. The DON said she would be the back-up person for the weekend RN supervisor. If the weekend RN supervisor could not deliver the mail, then she would. During an interview on 11/20/24 at 12:41 PM, the ADM said all residents should receive mail on weekdays and weekends because it was their right to receive their mail in a timely manner. She said she did not know residents were not getting mail on Saturday. She said she took responsibility for not checking on that. She said the BOM, was responsible for getting residents mail and delivering it, but she did not realize no one was delivering mail on Saturday's. The ADM said the risk of residents not getting mail in a timely manner was not hearing from their family, or they may have business type mail they needed. She said there was a risk of worry or distress if residents' were waiting on something to come in the mail. Record review of a Mail Distribution Policy dated 12/2020, provided by the DON indicated: Policy: To ensure that each patient's/resident/s personal mail (incoming and outgoing) is handled in a private and confidential manner. It is the facility's policy to: 1.Distribute all incoming mail to the addressed patient/resident unopened and within the same day on which it was d delivered to the Activity Department. If the patient/resident is incapable of receiving/managing his/her/personal mail, his/her mail should be promptly distributed to the patient's/resident's qualified legal representative. 2.Develop a system of delivering mailing patient's/resident's personal mail, involving the Activity Department and the person who receives the mail (i.e., the Receptionist, charge nurse, business office), and including provisions whereby the Activity Department is either informed that mail has arrived or is physically given the mail. Procedures: 1.The Activity Staff or Designee: A. Deliver personal mail to the patient's/resident's room within 24 hours of receipt .

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 04/07/24, 04/14/24, 04/20/24, 04/21/24, 06/01/24, 06/02/24, 06/29/24, and 06/30/24. This failure had the potential to place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters. Findings included: Record review of the facility's time sheets for 04/01/24 through 06/30/24 for RN coverage indicated that RN E worked the following days for the specified amount of time: 04/07/24 7.73 hours 04/14/24 7.65 hours 04/20/24 7.67 hours 4/21/24 7.60 hours 06/01/24 7.67 hours 06/02/24 7.37 hours 06/29/24 7.30 hours 06/30/24 7.65 hours The time sheets did not indicate any other RN working the identified days. During an interview on 11/20/24 at 09:29AM, the VP of operations said she was not aware of another RN working on the identified days when RN E worked less than 8 hours. During an interview on 11/20/24 at 12:30 PM, the ADON said she expected the RNs to stay on the clock for 8 hours. She said the RN clocked out for lunch and worked less than 8 hours. She said this was miscommunication of how long the RNs should be on the clock. During an interview on 11/20/24 at 12:43 PM, the DON said she expected the RN supervisor to be at the facility for 8 hours on the clock. She said from now on the nurse will be expected to work the consecutive 8 hours. She said if the nurse had to leave, she expected the nurse to contact her and she would come up to the facility and relieve her. During an interview on 11/20/24 at 12:47 PM, the Administrator said she expected the facility to have RN coverage for 8 hours a day for 7 days a week. Record review of the facility's undated policy, Nurse Staffing Requirements, stated: .The requirements for long-term care facilities require that nursing facilities provide 24-hour licensed nursing, provide a Registered Nurse (RN) for eight (8) consecutive hours a day, seven (7) days a week, and that there be a RN designated as Director of Nursing on a full-time basis.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. Expired food, milk, and beef flavoring, was not disposed of. 2. Frozen chicken was not labeled or dated. 3. Chicken, turkey, and ham was being thawed without being submerged under water or without water running. These failures could place residents who received meals from the kitchen at risk for food borne illness. The findings were: During an observation on [DATE] at 8:52 a.m., it was observed that a large bowl of chicken meat was being thawed in the kitchen sink without being submerged under water or running water running over the top. It was observed that cultured buttermilk with an expiration date of [DATE] was still in the milk refrigerator. It was observed that beef flavoring was out on a prep table with an expiration date of [DATE]. It was observed that tortillas and chicken was not labeled or dated. The chicken meat was in two, gallon sized plastic bags, with no date or label, and copious amounts of ice buildup inside the bag on the chicken meat. During an observation on [DATE] at 11:29 a.m., it was observed that two packages of turkey and one package of ham were observed thawing partially submerged underwater with no water running continuously. During an interview on [DATE] at 11:05 a.m., the Dietary Manager said that meat should not be thawed in a sink without being fully submerged and water running continuously to agitate the water. She said that food should be labeled and dated. She said that expired foods should be thrown away. She said that residents could be placed at risk for foodborne illness if these regulations were not followed . During an interview on [DATE] at 12:28 p.m., the Director of Nurses said that she expects that all kitchen staff follow facility policy and state regulations. She said she expects that if staff were to thaw meat it would be submerged underwater with water continuously running. She said that all expired items should be thrown out. She said that all food items should be labeled and date. She said that residents could be placed at risk for foodborne illness from eating food that was not properly prepared or stored. During an interview on [DATE] at 12:40 p.m., the Administrator said that she expects that her kitchen staff follow regulations and facility policy. She said all expired foods should be thrown away. She said all foods should be labeled and dated. She said that meats should be thawed properly and per regulations. She said that residents could be placed at risk of foodborne illness if they eat food that was not handled properly. Review of the facility document revised [DATE], Food Storage provided by the Dietary Manager revealed: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines Keep fresh meat, poultry, seafood, dairy products and most fresh fruit and vegetables in the refrigerator at an internal temperature of 41 F or less Once frozen food has been thawed, it must be maintained at 41 F or less prior to cooking.

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #32) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #32. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses (major depressive disorder and bipolar disorder) were present upon Resident #32's re-admitted on 04/20/23. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #32's face sheet, dated 11/18/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE], and readmitted most recently on 04/20/23. His diagnoses included major depressive disorder(a mood disorder that causes a persistent feeling of sadness and loss of interest) and bipolar disorder(a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Record review of Resident #32's annual MDS assessment, dated 09/10/24, indicated he had a BIMS score of 14, which indicated intact cognition. The MDS further indicated he received an antipsychotic medication and an antidepressant medication during the assessment window. Record review of Resident #32's PASRR Level 1 Screening, dated 11/02/22, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #32 did not have a mental illness. During an interview on 11/19/24 at 11:30 AM, the MDS Coordinator said she only found one PL1 form that was completed for Resident #32. She said it was incorrect and Resident #32 had the diagnoses of major depressive disorder and bipolar disorder at admission and the PL1 form should have indicated yes for mental illness. During an interview on 11/20/24 at 08:37 AM, the MDS Coordinator said that she completed a 1012 form and a new PL1 form related to Resident #32's mental illness diagnoses. She said Resident #32 should have had a positive PL1 on admit to the facility. She said it was unlikely he would qualify for PASRR services because he had not had any psych hospitalization s or contact with the police. During an interview on 11/20/24 at 12:47 PM, the Administrator said Resident #32 should have had a positive PASRR Level 1 form. She said it was possible that he could have received PASRR Services this entire time he had been in the facility. She said no one was responsible for checking over the PASRR forms after the MDS coordinator. Record review of the facility's undated policy, PASRR Services, stated: .In Texas, nursing facilities are required to adhere to the Preadmission Screening and Resident Review (PASRR) process, a federally mandated program designed to ensure that individuals with mental illness (MI), intellectual disability (ID), or developmental disability (DD) are appropriately placed and receive necessary services. Procedure: 1. PL1 Screening Form Completion: *Before admitting any individual, the referring entity must complete the PASRR Level I (PL1) Screening Form to identify potential MI, ID, or DD. The nursing facility should coordinate with the referring entity to ensure this form is completed. 2. Admission Protocols: *If the PL1 indicates no suspicion of MI, ID, or DD, the nursing facility can admit the individual through the routine admission process. *If the PL1 indicates a suspicion of MI, ID, or DD, the facility must ensure that a PASRR Evaluation (PE) is completed before admission, unless the admission qualifies as an expedited admission or an exempted hospital discharge .

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 1 residents (Resident #33) reviewed for appropriate treatment and services to prevent urinary tract infections (an infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine leave your body). The facility failed to ensure Resident #33's indwelling catheter (drains urine from your bladder into a bag outside your body) had a catheter securement device to anchor the catheter to his leg on 11/19/24. These failures could place residents at risk for urinary tract infections. Findings included: Record review of the undated face sheet indicated Resident #33 was a [AGE] year-old male that admitted [DATE] and readmitted [DATE]. Resident #33 had diagnoses that included: Obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from draining causing it to back up into the kidneys), hypertension (the force of blood against the artery walls is too high), and dementia (impairment of at least 2 brain functions, such as memory loss and judgment.) Record review of the significant change MDS dated [DATE] indicated Resident #33 had a BIMS score of 0, indicating severe cognitive impairment. The MDS indicated he required substantial/maximal assistance with toileting hygiene and partial to moderate assistance to roll left and right in bed. He had an indwelling catheter. Record review of the undated care plan indicated Resident #33 had dementia with behavioral disturbances. The care plan indicated he had a diagnosis of a bladder disorder for difficulty starting, stopping urinary flow, urinary retention, and UTI. Resident #33 had an indwelling catheter and was at risk for UTI, complications. The care plan indicated to provide catheter care per facility policy and PRN. Record review of Resident #33's physician's orders dated 6/5/24 indicated: Foley catheter strap in place every shift. Record review of Resident #33's MAR for October 2024 indicated: Foley catheter strap in place every shift. The MAR was initialed for every day of October 2024. Record review of Resident #33's MAR for November 2024 indicated: Foley catheter strap in place every shift. The MAR was initialed November 1-19, 2024. LVN B had initialed for the foley catheter strap for the day shift and evening shift on 11/19/24. During an observation and interview on 11/19/24 at 2:03 PM, CNA A provided catheter care for Resident #33. LVN B assisted with catheter care. Resident #33 did not have his foley catheter tubing anchored or secured to his leg. LVN B said she had not checked today to see if the foley had been anchored. She said it was important for the catheter to be anchored to his leg to prevent UTI's and so that it did not pull on his penis. She said the catheter tubing secured to his leg prevented friction to his penis. LVN B anchored the catheter to Resident #33's leg after catheter care. During an interview on 11/20/24 at 10:20 AM, CNA C said if a resident had a catheter they should have an anchor on their leg to prevent the catheter from tugging or pulling or coming out. She said the nurse was responsible for making sure the catheter securement device was in place. She said if a resident had a catheter and did not have it secured, she would tell the nurse. During an interview on 11/20/24 at 10:30 AM, LVN D said the nurses were responsible for making sure residents with a catheter had it secured. She said regarding Resident #33, it was especially important for him because he had pulled his catheter out in the past. She said the catheter securement helped to prevent tugging, UTI's, and backflow of urine (into the bladder.) She said she usually checked his catheter and placement once per shift. She said if a CNA noticed a resident with a catheter did not have it secured, the CNA should tell the nurse immediately. During an interview on 11/20/24 at 10:57 AM, the ADON said the nurses were responsible for making sure the catheter was secured and the nurse had to check off on the MAR that it was done. She said the catheter securement was for protection because it prevented UTI's, protected the flow of urine by gravity, and prevented pulling. During an interview on 11/20/24 at 12:33 PM, the DON said the nurse was responsible for making sure any catheter was secured. She said the LVN B should have checked to make sure the catheter was secured, and especially with Resident #33 because he would pull the catheter out. She said catheter securement should be checked periodically throughout the shift because of Resident #33 removing it from his leg. She said any nurse for him should check placement of the catheter securement device when they get start their shift. The DON said it was important for the catheter to be secured to prevent infection, dislodgement, and harm to the resident from pulling and/or tugging. She said the catheter tubing could get tangled on something, or the resident could pull on it. She said this was the only catheter she had in the building. She said she was in the process of doing an in-service for all nurses to check for placement at the start of their shift. During an interview on 11/20/24 at 12:41 PM, the ADM said it was the responsibility of the charge nurse or nurse to make sure a catheter was secured to a resident's leg. She said it was important because it would help it to stay in place and help prevent tugging and discomfort. She said the catheter being secured could help prevent Resident #33 from pulling it out. She said the risk of not having the catheter secured was injury, discomfort and maybe a UTI. She said she did not know if nurses had to sign off on the MAR regarding checking for the catheter securement. Record review of A Catheter Care, Urinary Policy dated 7/1/2020 provided by the DON indicated: Purpose The purpose of this procedure is to prevent catheter-associated urinary tract infections . Changing Catheters .2.Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) .

Based on observations, interviews, and record review, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs in 1 of 1 medication rooms reviewed for storage of medication (Front Medication Room). The facility failed to ensure Resident #1's lorazepam medication (controlled anti-anxiety medication) was locked behind 2 separate locks. The medication room was locked but the medication refrigerator and the lockbox inside the medication refrigerator were both unlocked. This failure could place residents who take narcotics that required refrigeration at risk of misappropriation of drugs. Findings included: Record review of Resident #1's face sheet, dated 11/20/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Record review of Resident #1's physician's orders, dated 11/20/24, indicated this order: *Lorazepam - Schedule IV concentrate; 2mg/mL; 0.5-1mL oral as needed. The start date was 10/02/24. During an observation and interview on 11/19/24 at 01:25PM, RN E unlocked and opened the front medication room door. She then opened the unlocked medication refrigerator. This surveyor then reached inside the refrigerator and opened a lockbox in the refrigerator. The lockbox was not locked. Inside the lock box was Resident #1's lorazepam concentrate medication. The DON was also present during this observation, and she said the lorazepam medication should have been locked in the lock box. During an interview on 11/20/24 at 12:30 PM, the ADON said she expected the controlled medications be behind two separate locks. She said the risk was that someone could take the medication. She said there a risk of a possible drug diversion. During an interview on 11/20/24 at 12:43 PM, the DON said her expectation was for the controlled medications to have two separate locks. She said the risk was that there could have been a possible drug diversion. During an interview on 11/20/24 at 12:47 PM, the Administrator said she expected the controlled medications to have at least 2 separate locks. She said the risk was a possible drug diversion. Record review of the facility's policy, Controlled medication storage, dated 11/13/18, stated: .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures a. The director of nursing and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed/and or certified nursing and pharmacy personnel have access to controlled medications. b. Medications listed in Schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose, separate from all other medications. Alternatively, in a unit dose system, Schedule III, IV, and V medications may be kept with other medications in the cart or in a separate locked drawer on the cart. The access key to controlled medications in not the same key giving access to other medications. The medication nurse on duty maintains possession of the key to controlled medication storage areas. Back-up keys to all medication storage areas, including those for controlled medications, are kept by the director of nursing .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure plaster on the ceiling in the kitchen was not peeling and loose piece hanging down over prep tables. The facility failed to ensure Cook A did not prepare pureed items near a trash can barrel with the lid partially open. These failures could place residents at risk of foodborne illness, food contamination, and ingestion of harmful material. Findings included: During an observation on 10/09/23 at 11:29 a.m., the ceiling in the kitchen had peeling popcorn plaster. The peeling popcorn plaster was cracked, and pieces were hanging over 2 prep tables. Cook A prepared pureed entrees for the lunch menu. Cook A brought some cooked noodles from the steam table to counter where the food processor was located. Next to the food processor, a trash can barrel with a partially opened lid was near it. Cook A stood by the trash barrel and prepared the pureed noodles, green beans, and chicken in the food processor. During an interview on 10/11/23 at 10:29 a.m., the DM said the ceiling in the kitchen did have peeling plaster. She said peeling plaster caused a problem with food and dishes. She said the plaster could fall in food and dishes. She said the plaster falling in food or on dishes could cause foodborne illnesses and ingestion germs which could make resident sick. She said the peeling plaster on the ceiling was cited every year during surveys. She said the facility was being renovated but the kitchen had not been worked on in a while. She said the trash can barrel being near the food processor during purees was not good practice. She said it created a potential danger zone. She said it had the potential to transfer germs and cause sickness. During an interview on 10/11/23 at 12:11 p.m., the DON said she had started at the facility April 2023. She said she did not know about the peeling plaster in the kitchen. She said the peeling plaster was a concern for the safety of the resident's food. During an interview on 10/11/23 at 12:46 p.m. the ADM said he had started at the facility August 2023. He said the peeling plaster on the ceiling was not safe, but it had been addressed. He said the kitchen needed to be updated but there was not enough time to block it off to fix it correctly. He said the peeling ceiling in the kitchen had been happening for a while, but he did not know for how long because he just started. During an interview on 10/11/23 at 1:05 p.m., Cook A said it was a good practice to do purees near a trash can barrel. She said because it was nasty. She said it was a potential sanitation hazard. She said she knew about safe sanitation practices from training. Record review of an undated facility's Food Preparation and Service policy indicated .food will be prepared and served using methods that are safe and sanitary .

Based on interviews and record reviews the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 15 residents ( Resident #12, Resident #37, Resident #40) reviewed for resident rights . 1.The facility failed to completely fill out the psychotropic consent for Resident #12's Zyprexa (is an antipsychotic that can treat schizophrenia and bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration)) to give informed consent. 2.The facility failed to get a follow up handwritten signature after telephone consent was received for Resident #12. 3.The facility failed to completely fill out the psychotropic consent for Resident #40's Seroquel (is an atypical antipsychotic that's used to improve mood, thoughts, and behaviors for people with schizophrenia and bipolar disorder) to give informed consent. 4.The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #40's responsible party/representative prior to administering Seroquel 100mg. 5. The facility failed to have the responsible party/representative sign psychotropic consents for Resident #12, Resident #37, and Resident #40. 6. The facility failed to ensure two nurses signed the psychotropic consents when a telephone consent was obtained for Resident #12 and Resident #40. 7. The facility failed to establish Resident #40's contact for informed consent for Depakote (is a medication known as an anticonvulsant that is used to treat the manic symptoms of bipolar disorder) and Seroquel. These failures could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. Findings included: 1. Record review of Resident #12's face sheet dated 10/09/23 indicated Resident #12 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Schizoaffective disorder (is a chronic mental health condition characterized primarily by symptoms of schizophrenia (is a serious mental illness that affects how a person thinks, feels, and behaves), such as hallucinations (involve sensing things such as visions, sounds, or smells that seem real but are not) or delusions (A belief or altered reality that is persistently held despite evidence or agreement to the contrary), and symptoms of a mood disorder, such as mania (is a period of extreme high energy or mood) and depression (the feelings of sadness are constant)) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). The face sheet indicated Resident #12's resident representative and responsible party was Family Member A. The face sheet indicated Resident #12's emergency contact was Family Member B. Record review of Resident #12's quarterly MDS assessment dated [DATE] indicated Resident #12 was sometimes understood and sometimes had the ability to understood others. The MDS indicated Resident #12 was unable to complete the BIMS assessment due to being rarely/never understood. The MDS indicated Resident #12 had short-and-long term memory loss with severely impaired cognitive skills for daily decision making. The MDS indicated Resident #12 required supervision for eating, limited assistance for bed mobility and transfer, extensive assistance for dressing, toilet use, and personal hygiene, and total dependence for bathing. The MDS indicated Resident #12 received antipsychotic within the 7-day review period. The MDS indicated Resident #12 received antipsychotic on a routine basis only and a gradual dose reduction (attempts for antipsychotics (unless clinically contraindicated) and tapering of other medications, when clinically) was attempted on 05/14/23. Record review of Resident #12's baseline care plan dated 11/17/22 indicated Resident #12 was a new admission to skilled nursing facility for long term care. Intervention included nursing staff will educate resident and/or responsible agent related to antipsychotic medications ordered. Consent will be obtained as indicated with possible adverse reaction/side effects reviewed. Record review of Resident #12's care plan dated 04/10/23 indicated Resident #12 was at risk for adverse consequence related to receiving antipsychotic medication Zyprexa (Olanzapine) for treatment of Schizophrenia. Intervention included assess/record effectiveness of drug treatment. Record review of Resident #12's care plan dated 04/10/23 indicated Resident #12 had impaired decision making related to Alzheimer's Dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Intervention included respect resident's rights to make decision (s). Record review of Resident #12's Physician Order Report dated 03/01/23-03/31/23 indicated Olanzapine (Zyprexa) 10 mg 1/2 tablet oral, give 1/2 tab by mouth twice a day, DX: Schizoaffective disorder, start date 11/17/22 and end date 05/19/23. Record review of Resident #12's Physician Order Report dated 06/01/23-06/30/23 indicated Olanzapine (Zyprexa) 5mg 1 tablet oral, give 1 tablet by mouth daily, DX: Schizoaffective disorder, start date 05/19/23 and no end date. Record review of Resident #12's MAR dated 05/01/23-05/31/23 indicated Olanzapine (Zyprexa) 10 mg 1/2 tablet oral, give 1/2 tab by mouth twice a day, DX: Schizoaffective disorder, start date 11/17/22 and end date 05/19/23. Record review of Resident #12's MAR dated 05/01/23-05/31/23 indicated Olanzapine (Zyprexa) 5mg 1 tablet oral, give 1 tablet by mouth daily, DX: Schizoaffective disorder, start date 05/19/23 and no end date. Record review of Resident #12's consent for use of Psychotropic medication dated 05/19/23 at 3:13 p.m., created and completed by ADON G, indicated .Include date, medication, dose, diagnosis for use, and drug category .Olanzapine .telephone consent given by Family Member B 05/19/23 . The consent did not include date, dose, diagnosis for use, or drug category. The telephone consent was given by the emergency contact not the responsible party/representative. The consent did not have a follow up handwritten consent by the responsible party/representative. Record review of Resident #12's consent for use of Psychotropic medication dated 05/19/23 at 3:13 p.m., created and completed by ADON G, indicated .Include date, medication, dose, diagnosis for use, and drug category .Olanzapine .telephone consent given by Family Member B 05/19/23 . Progress note . decrease Olanzapine 5mg twice a day to once a day .left message with ER contact Family Member B . The consent did not include date, dose, diagnosis for use, or drug category. The telephone consent was given by the emergency contact not the responsible party/representative. The consent was not signed by two nurse due to telephone consent being obtained. 2. Record review of Resident #37's face sheet dated 10/09/23 indicated Resident #37 was a [AGE] year-old male and admitted on [DATE] with diagnoses including depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and insomnia (is a sleep disorder in which you have trouble falling and/or staying asleep). The face sheet indicated Resident #37 was not responsible for self. The face sheet indicated Family Member C was the ER contact, but no responsible party/representative was indicated. Record review of Resident #37's quarterly MDS assessment dated [DATE] indicated Resident #37 was understood and understood others. The MDS indicated Resident #37 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #37 required supervision for bed mobility, transfer, dressing, eating, and bathing, and limited assistance for toilet use and personal hygiene. The MDS indicated Resident #37 received antianxiety within the 7-days assessment period. Record review of Resident #37's care plan dated 05/30/23 indicated Resident #37 received antianxiety medication Buspar for treatment of anxiety. Intervention included monitor resident's mood and response to medication. Record review of Resident #37's care plan dated 05/30/23 indicated Resident #37 had memory/recall problem related to confusion and forgetfulness. Intervention included ensure resident's area are free of hazards. Record review of Resident #37's care plan dated 09/15/23 indicated Resident #37 had diagnosis of depression and at risk for increased depression and side effects to medications, takes Zoloft. Intervention included provide medications as ordered. Record review of Resident #37's Physician Order Report dated 10/01/23 indicated Buspirone (Buspar) 10 mg, 1 tablet, oral, TID, DX: Generalized anxiety disorder, start date 08/07/23 and no end date. Record review of Resident #37's Physician Order Report dated 10/01/23 indicated Sertraline (Zoloft) 25 mg, 1 tablet, oral, once a day, DX: Depression, start date 09/15/23 and no end date. Record review of Resident #37's MAR dated 08/01/23-08/31/23 indicated Buspirone (Buspar) 10 mg, 1 tablet, oral, TID, DX: Generalized anxiety disorder, start date 08/07/23 and no end date. The MAR indicated Buspirone 5 mg, 2 tablets, oral, BID, DX: Insomnia, start date 06/28/23 and end date 08/03/23. The MAR indicated Buspirone 5 mg, 2 tablets, oral, TID, DX: Insomnia, start date 08/03/23 and end date 08/07/23. Record review of Resident #37's consent for use of Psychotropic medication dated 08/03/23 at 11:27 a.m., created and completed by LVN F, indicated .Buspar 10mg TID, 08/03/23, antidepressant, depression .signed by LVN F and LVN E . The consent did not have a resident/family signature. Record review of Resident #37's consent for use of Psychotropic medication dated 09/14/23 at 4:04 p.m., created and completed by LVN J, indicated .consent for Sertraline (Zoloft) .Sertraline . The consent indicated Resident #37 signed on the Facility Representative Signature and no date to indicate when the consent was signed. 3. Record review of Resident #40's face sheet dated 10/09/23 indicated Resident #40 was [AGE] year-old male and admitted on [DATE] and 09/07/23 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (is a feeling of fear, dread, and uneasiness), and unspecified psychosis (is when people lose some contact with reality). The face sheet indicated Resident #40 was not responsible for self. The face sheet indicated Friend D was the ER contact. Record review of Resident #40's quarterly MDS assessment dated [DATE] indicated Resident #40 was understood and understood others. The MDS indicated Resident #40 had a BIMS score of 00 which indicated severely impaired cognition and required limited assistance for bed mobility, transfer, eating, dressing, and extensive assistance for toilet use, personal hygiene, and total dependence bathing. The MDS indicated Resident #40 received antipsychotic within the 7-days assessment period and received on a routine basis. Record review of Resident #40's baseline care plan dated 07/20/22 indicated Resident #40 was a new admission to skilled nursing facility for long term care. Intervention included nursing staff will educate resident and/or responsible agent related to antipsychotic medications ordered. Consent will be obtained as indicated with possible adverse reaction/side effects reviewed. Record review of Resident #40's care plan dated 06/13/23 indicated Resident #40 was at risk for adverse consequence related to receiving antipsychotic medication Seroquel for treatment of psychosis. Intervention included monitor resident's behavior and response to medication. Record review of Resident #40's care plan dated 07/19/23 indicated Resident #40 had impaired decision making related to dementia. Intervention included support and reassured in new situations. Record review of Resident #40's Physician Order Report dated 02/01/23-02/28/23 indicated Quetiapine (Seroquel) 50 mg, 1 tablet, oral, at bedtime, DX: unspecified psychosis, start date of 01/11/23 and end date of 04/17/23. Record review of Resident #40's Physician Order Report dated 06/01/23-06/30/23 indicated Quetiapine (Seroquel) 50 mg, 1 tablet, oral, at bedtime, DX: unspecified psychosis, start date of 04/17/23 and end date of 07/19/23. Record review of Resident #40's Physician Order Report dated 08/01/23-08/31/23 indicated Seroquel (Quetiapine) 100 mg, 1 tablet, oral, at bedtime, DX: unspecified psychosis, start date of 07/19/23 and no end date. Record review of Resident #40's MAR dated 06/01/23-06/30/23 indicated Quetiapine (Seroquel) 50 mg, 1 tablet, oral, at bedtime, DX: unspecified psychosis, start date of 04/17/23 and end date of 07/19/23. Record review of Resident #40's MAR dated 08/01/23-08/31/23 indicated Seroquel (Quetiapine) 100 mg, 1 tablet, oral, at bedtime, DX: unspecified psychosis, start date of 07/19/23 and no end date. Record review of Resident #40's Physician Order Report dated 05/01/23-05/31/23 indicated Depakote Sprinkles 125 mg, 2 capsules (250 mg), oral, BID, DX: dementia, start date of 05/23/23 and end date of 06/28/23. Record review of Resident #40's Physician Order Report dated 06/01/23-06/30/23 indicated Depakote Sprinkles 125 mg, 3 tablets (375 mg), oral, BID, DX: dementia, start date of 06/28/23 and no end date. Record review of Resident #40's MAR dated 05/01/23-05/31/23 indicated Depakote Sprinkles 125 mg, 2 capsules (250 mg), oral, BID, DX: dementia, start date of 05/23/23 and end date of 06/28/23. Record review of Resident #40's MAR dated 06/01/23-06/30/23 indicated Depakote Sprinkles 125 mg, 3 tablets (375 mg), oral, BID, DX: dementia, start date of 06/28/23 and no end date. Record review of Resident #40's consent for use of Psychotropic medication dated 01/11/23 at 1:36 p.m., started and completed by the MDS Coordinator indicated .1/11/23 .Quetiapine (Seroquel) 50 mg . The consent did not have a signature by Resident #40 or telephone consent from Friend D. The consent had two nurses' signature but with no date to indicate when it was signed. Record review of the facility's computerized charting system on 10/10/23 reflected it did not address consent for Seroquel (Quetiapine) 100 mg for Resident #40 started on 07/19/23. Record review of Resident #40's consent for use of Psychotropic medication dated 05/24/23 at 5:45 p.m., started and completed by LVN F, indicated .increase in Depakote .5/23/23 .Depakote Sprinkles .250 mg .BID .Dementia .Antipsychotic . The consent did not have a signature by Resident #40 or telephone consent from Friend D. The consent was only signed by LVN F. Record review of Resident #40's consent for use of Psychotropic medication dated 05/24/23 at 5:38 p.m. but completed on 06/28/23 by LVN F, indicated .increase in Depakote .06/28/23 .Depakote Sprinkles .375 mg .BID .Dementia .Antipsychotic . The consent did not have a signature by Resident #40 or telephone consent from Friend D. The consent was signed by LVN E and LVN F. On 10/11/23, the DON was notified of missing consents for Resident #40's Seroquel started on 07/19/23. No consent was provided prior to exit. During an interview on 10/10/23 at 11:25 a.m., RN D said medication consents needed to be completed to make sure family knew all the information. She said the nurses were responsible to get consents for medications. She said new consent had to be done for dosage changes. She said two nurses had to sign the consent, when telephone consent was given. She said two nurse signatures verified the family had been updated on side effects and risk factors and consent was given. She said she thought only the responsible party could sign consents. On 10/10/23 at 2:27 p.m., attempted to contact LVN F by phone. Voicemail left with no call back prior to exit. During an interview on 10/10/23 at 2:59 p.m., the ADON G said the ADONs and LVNs were responsible to get consents for psychoactive medications. She said consent should be obtained as soon as possible. She said the previous DON told staff they only had to put the medication on the consents not the dosage, frequency, indicated for use or drug category. She said the Pharmacy consultation told them to fill out the dose in 2021 on the consents. She said all information needed to be filled out on the consent in case any of the information changed and the right information was told to the family or resident. She said two nurses signed for telephone consent. She said when telephone consent was obtained, the resident/family signature section should have who the telephone consent was given by. She said the RP had to give consent for the ER contact to give consent for medications. She said the RP should be contacted first to give consent. She said new consent had to be done with any new medication order. She said a new consent indicated the resident or RP was aware of the change and gave an informed consent. She said Resident #40 did not have family and Friend D, who he worked used to work, became his ER contact. She said she did not know who Resident #40's responsible party was since he was found on streets. She said she thought he going to be a ward of the State, but the process did not get started. She said Resident #12 family did visit and could have signed consents that were telephone consent. She said a medication was not supposed to be given without consent unless it was a medical emergency. During an interview on 10/11/23 at 10:57 a.m., LVN E said LVNs were responsible to notify the family or resident of the new medication order, get a signature from the doctor and resident. He said consents were to educate the resident on side effects and what the medication was for. He said when telephone consent was done, 2 nurses had to sign the consent. He said 2 nurses signatures said the information on the consent form was verified and correct. He said for a telephone consent, who the telephone consent was given by should be documented on the form. He said all areas on the consents needed to be filled out. He said if the resident had a RP, then the ER contact should not give consent for medications. He said all psychotropic medication required a consent. He said a new consent had to be done for medication, frequency, and dosage changes. He said the nurse who accepted the new order was responsible for getting a consent. He said consent forms needed to be filled out correctly to avoid mistakes, resident or RP and staff aware of what medication is being taken. He said documentation was important. He said if there was no RP listed, he would have to ask the DON for clarification on who could sign the consents. On 10/11/23 at 12:00 p.m., attempted to contact Resident #12's responsible party/representative by phone. A return phone call was not received prior to exit. During an interview on 10/11/23 at 12:11 p.m., the DON said she started at the facility April of the year. She said the charge nurses were responsible to get psychotropic medication consents. She said the consents should be obtained when the medication order is received. She said telephone consent had to be signed by two nurse and who they got telephone consent from should be documented. She said consents needed to be signed before medications were given. She said she did not know if telephone consent had to eventually signed by the RP in person. She said in the care plan meetings the DON, ADONs, and MDS coordinator looked at all obtained consents. She said if they found a problem with a consent, they had a red book with logged corrections a nurse needed to complete. She said the corrections had to be fixed by the next shift the nurse worked and then rescanned into the resident's chart. She said it was important for the resident or RP to make an informed consent by knowing the benefits, risk, and purpose of the medication. She said when informed consent was not given then the resident losses autonomy and choice. During an interview on 10/11/23 at 12:46 p.m., the ADM said he had been at the facility since August 2023. He said the DON should make sure the LVNs obtained consents for medications before they were given. He said he expected the consent to be filled out correctly and the DON should be making sure they were. He said he did not know the facility's process to establish a responsible party. He said it was important for the facility to know who a resident's responsible party was to know the resident's needs were being addressed. He said clinical advisors should be involved if the resident was unable to give consent. On 10/11/23 at 1:15 p.m., surveyor asked the DON and Regional Nurse to view the red book for consent log corrections. The red book was not provided prior to exit. Record review of a facility's Antipsychotic Medication Use policy dated 06/20 indicated .residents will only receive antipsychotic medication to treat specific conditions for which they are indicated and effective . The facility's policy did not address consent forms for antipsychotic medication use. Record review of a facility Resident Rights policy revised date of 06/20 revealed .federal and state laws guarantee certain basic rights to all residents of this facility .these rights include the resident's right to .be informed of, and participate in, his or her care planning and treatment .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for seven of seven residents (Resident #1, #3, #4, #5, #6, #7, and #8) reviewed for accidents and hazards in that: 1. The facility failed to ensure the gate in the courtyard was locked and the alarm was functioning after Resident #1 eloped. 2. The facility failed to follow their policy and monitor the alarms daily. 3. The facility failed to secure the side door on Hall 500 and there was no alarm on it. Resident #3, #4, #5, #6, #7, and #8 were in the facility at this time and were at risk of elopement. 4. The facility failed to monitor and supervise residents in the courtyard who were an elopement risk. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 08/23/23 at 03:52 PM. While the IJ was removed on 08/24/23 at 11:10 AM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place the residents at risk for serious harm, serious injury, or death. Findings included: 1. Record review of Resident #1's face sheet, dated 08/22/23, indicated she was an [AGE] year-old female, admitted on [DATE]. Her diagnoses included dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), diabetes mellitus type 2 (a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels), heart failure (a condition that occurs when the heart muscle doesn't pump blood as well as it should), and repeated falls. Record review of Resident #1's annual MDS assessment, dated 07/13/23, indicated she had a BIMS score of 04, which indicated severe cognitive impairment. The MDS indicated she exhibited behaviors of wandering at least 1-3 of 7 days of the assessment. Resident #1 required limited assistance with bed mobility, transfers, walking in room and the corridor, locomotion on and off unit, and eating. She required extensive assistance with dressing, toileting, and personal hygiene. She normally used a wheelchair as a mobility device. She required insulin injections and diuretic medications 7 of 7 days of the assessment. She used a wander/elopement alarm daily. Record review of Resident #1's physician's orders, dated 08/22/23, indicated she had this order: *May have Wanderguard bracelet. Verify placement each shift. Special instructions: left lower leg. Every Shift. The start date was 09/15/22. Record review of Resident #1's care plan, last edited 08/07/23, indicated a problem of resident is at risk for wandering around facility with/without purpose. Interventions included: *observe resident when out of room for wandering in/out of other rooms, wandering to unauthorized areas and provide redirection when needed. *wanderguard to ankle for safety *If wandering increases and places resident at risk for injury, or leaving facility, notify MD, RP, ADMIN, DON and assess, discuss possible need for secure unit/proper placement. *Maintenance to check all alarm functions Further record review of Resident #1's care plan, edited on 07/24/23, indicated a problem of potential for elopement resident verbalizing she needs to get out of building. She often believes she needs to leave to her her children to/from school. Interventions included: *Assess resident for use of wanderguard system, Wanderguard placed to left ankle. *Attempt to make resident feel secure/safe within facility *Re-direct if resident attempts to elope Record review of Resident #1's elopement risk assessment, completed on 07/11/23, indicated Resident #1 was at risk for elopement. The assessment indicated Resident #1 had a history of wandering. Record review of Resident #1's provider investigation report for her elopement incident indicated she told the staff after her elopement I am trying to get out of here to leave. Further review indicated Resident #1 was located at 1830 (6:30 pm) on 08/06/23, 15 minutes after RN A last saw her inside the building. 2. Record review of Resident #3's facesheet, dated 08/22/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included acute respiratory disease (a serious lung condition that causes low blood oxygen), delusional disorders (a type of mental health condition in which a person can't tell what's real from what's imagined), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Record review of Resident #3's annual MDS assessment, dated 05/18/23, indicated she had a BIMS score of 06, which indicated severe cognitive impairment. The MDS indicated she exhibited behaviors of wandering at least 4-6 of 7 days of the assessment. The MDS indicated her wandering put her at significant risk of getting to a potentially dangerous place. She required supervision assistance with bed mobility, transfers, walking in room and the corridor, and locomotion on and off unit. She required limited assistance with dressing, toileting, and personal hygiene. She did not use a mobility device such as a walker or wheelchair. She used a wander/elopement alarm daily. Record review of Resident #3's physician's orders, dated 08/23/23, indicated she had this order: *May have Wanderguard bracelet. Verify placement each shift. Special instructions: left lower leg. Every Shift. The start date was 05/09/23. Record review of resident #3's care plan, last edited on 08/18/23, indicated a problem of resident is at risk for wandering and elopement with/without purpose. Interventions included: *place in wandering book at each nurse's station, as well as in wanderguard bracelet for resident's own safety. *if resident is noted attempting to wander away from facility, attempt to redirect back to facility. Offer distraction for example food, activity, call family, and if they become agitated and continue to wander, seek assistance and continue to observe for safety until resident is back in building. * If wandering increases and places resident at risk for injury, or leaving facility, notify MD, RP, ADMIN, DON and assess, discuss possible need for secure unit/proper placement. Record review of resident #3's elopement risk assessment, dated 08/14/23, indicated Resident #3 was at risk for elopement. She exhibit behaviors of making statements she was leaving, and displayed behavior(s) that may indicate an attempt to leave. 3. Record review of Resident #4's face sheet, dated 08/23/23, indicated he was a [AGE] year-old male, admitted on [DATE]. His diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and anxiety (persistent and excessive worry that interferes with daily activities). Record review of Resident #4's quarterly MDS assessment, dated 08/07/23, indicated he had a BIMS score of 0, which indicated severe cognitive impairment. The MDS indicated he exhibited behaviors of wandering at least 1-3 of 7 days of the assessment. Resident #4 required limited assistance with bed mobility, transfers, walking in room and corridor, locomotion on and off unit, dressing and eating. He required extensive assistance with toileting and personal hygiene. He did not use a mobility device such as a walker or wheelchair. He required antipsychotic and diuretic medications 7 out of 7 days of the assessment. He used a wander/elopement alarm daily. Record review of Resident #4's physician's orders, dated 08/23/23, indicated he had this order: *May have wanderguard bracelet to right ankle, verify placement every shift. The start date was 02/01/23. Record review of Resident #4's care plan, last edited on 08/02/23, indicated a problem of potential for elopement, attempted to open door. Interventions included: *continue wanderguard to ankle *assess resident for use of wanderguard system, wanderguard placed to left ankle *Re-direct if resident attempts to elope Record review of Resident #4's elopement risk assessment, dated 08/05/23, indicated he was at risk for elopement. He exhibited behaviors of history of wandering into unsafe areas, making statements he was leaving, and displaying behaviors that may indicate an attempt to leave. 4. Record review of Resident #5's face sheet, dated 08/23/23, indicated she was a [AGE] year-old female, admitted on [DATE]. Her diagnoses included insomnia (common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep), schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), and Alzheimer's disease with late onset (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Record review of Resident #5's quarterly MDS, dated [DATE], indicated she did not have a BIMS score assessment because she was rarely/never understood. She exhibited behaviors of wandering at least 1-3 of 7 days of the assessment. She required supervision assistance with walking in room and corridor, locomotion on and off unit, and eating. She required limited assistance with bed mobility and transfers. She required extensive assistance with dressing, toileting, and personal hygiene. She did not use a mobility device such as a walker or wheelchair. The MDS indicated she did not use a wander/elopement alarm. Record review of Resident #5's physician's orders, dated 08/23/23, indicated she had this order: *May have wanderguard bracelet to right ankle, verify placement every shift. The start date was 11/18/22. Record review of Resident #5's care plan, edited on 06/13/23, indicated she had a problem of potential for elopement. Interventions included: *Attempt to make resident fell secure/safe within facility *Encourage resident to verbalize feelings *re-direct if resident attempts to elope *Wanderguard system placed to right ankle Record review of Resident #5's elopement risk assessment, completed on 07/14/23, indicated she was at risk for elopement. She displayed behaviors that may indicate an attempt to leave. 5. Record review of Resident #6's face sheet, dated 08/24/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), psychotic disorder with delusions (a disorder in which people who have it cannot tell what is real from what is imagined), anxiety disorder (persistent and excessive worry that interferes with daily activities), insomnia (common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep), and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). Her assigned room was on the 500 hall. Record review of Resident #6's annual MDS assessment, dated 07/11/23, indicated she had a BIMS score of 15, which indicated intact cognition. She exhibited behaviors of wandering at least 1-3 of 7 days of the assessment. She required limited assistance with all activities of daily living. She normally used a walker as a mobility device. The MDS indicated she did not use a wander/elopement alarm. Record review of Resident #6's physician's orders, dated 08/24/23, indicated she had this order: *Wanderguard bracelet. Check placement every shift. Special instructions: Rolling walker. The start date was 08/24/22. Record review of Resident #6's care plan, edited 07/17/23, indicated a problem of [Resident #6] is at risk for wandering around facility with/without purpose. Looking for her dog. Has history of leaving prior facility. Packs her belongings and makes statements about going to Tennessee. Wanderguard placed to rolling walker due to resident not keeping bracelet on wrist. Interventions included: *Observe resident when out of room for wandering in/out of other rooms, wandering to unauthorized areas and provide redirection as needed. *Wanderguard to bottom of walker for safety. Takes walker with her about facility. If wandering increases and resident is placed at risk for injury, or leaving facility, notify MD, RP, Admin, DON and assess, discuss possible need for secure unit/proper placement. *If resident is noted attempting to wander away from facility, attempt to redirect back to facility. Record review of Resident #6's elopement risk assessment, dated 07/31/23, indicated she was at risk for elopement. She exhibited behaviors of history of wandering. 6. Record review of Resident #7's face sheet, dated 08/23/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #7's significant change in status MDS assessment, dated 08/09/23, indicated she had a BIMS score of 0, which indicated severe cognitive impairment. The assessment indicated she exhibited behaviors of wandering daily. She required supervision assistance with walking in her room, locomotion on and off unit, and eating. She required limited assistance with bed mobility, transfers, walking in corridor, dressing, toileting, and personal hygiene. She normally used a walker as a mobility device. She received an anticoagulant medication 7 of 7 days of the assessment. She used a wander/elopement alarm daily. Record review of Resident #7's physician's orders, dated 08/23/23, indicated she had this order: *May have wanderguard bracelet. Verify placement every shift to L ankle. The start date was 04/26/23. Record review of Resident #7's care plan, edited 08/11/23, indicated she had a problem of Resident #7 is at risk for wandering around the facility with/without purpose, and requires use of a wanderguard. The interventions included: *Observe resident when out of room for wandering in/out of other rooms, wandering to unauthorized areas, and provide redirection as needed. *Wander guard for safety *If resident is noted attempting to wander away from facility, attempt to redirect back to facility. Further record review of Resident #7's care plan, edited 08/11/23, indicated a problem of potential for elopement. Interventions included: *Assess resident for use of wanderguard system. Wander guard bracelet on the left ankle. *Attempt to make resident feel secure/safe within facility. *re-direct if resident attempts to elope Record review of Resident #7's elopement risk assessment, dated 08/07/23, indicated she was at risk for elopement. She exhibited behaviors of making statements that she was leaving. 7. Record review of Resident #8's face sheet, dated 08/24/23, indicated she was an [AGE] year-old female, admitted to the facility 02/03/20. Her diagnoses included cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain, typically caused by disrupted blood supply to the brain), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and heatstroke (a condition caused by your body overheating, usually as a result of prolonged exposure to or physical exertion in high temperatures). Her assigned room was on the 500 hall. Record review of Resident #8's quarterly MDS assessment, dated 08/08/23, indicated she had a BIMS score of 0, which indicated severe cognitive impairment. The MDS indicated she exhibited behaviors of wandering 1-3 of 7 days of the assessment. She required limited assistance with locomotion off unit and eating. She required extensive assistance with bed mobility, transfers, locomotion on unit, dressing, toileting, and personal hygiene. She normally used a wheelchair as a mobility device. She used a wander/elopement alarm daily. Record review of Resident #8's physician orders, dated 08/24/23, indicated she had this order: *Wanderguard to left ankle. Verify placement every shift. The start date was 07/15/22. Record review of Resident #8's care plan, edited 08/10/23, indicated she had a problem of potential for elopement. Interventions included: *Attempt to make resident feel secure/safe within facility *Offer diversional activities such as snacks, fluids, or bingo during wandering episodes. *Re-direct if resident attempts to elope *wanderguard system applied to left ankle Record review of Resident #8's elopement risk assessment, dated 08/04/23, indicated she was at risk for elopement. She exhibited behaviors of history of wandering. During an interview on 08/23/23 at 12:08PM, RN A said she was the front station charge nurse on the day Resident #1 eloped. She said she was not assigned to Resident #1. She said a resident at the front door signaled to her that Resident #1 was outside in the parking lot propelling herself in her wheelchair. She said she went outside and was able to redirect Resident #1 back inside. She said she assessed her and she did not see any negative findings. She said she notified the DON of the elopement and put Resident #1 on 15 minute checks. She placed a CNA 1 to 1 with her for 45 minutes. She said she notified the MD and family. She said Resident #1 did not have other events after this for the rest of her shift. Before the elopement she had seen the resident moving around all over the building about 15 minutes before the elopement. She said after this she checked all the exterior door locks and alarms. She said the gate in the courtyard was open and the alarm was not making any noise. She said she closed and secured the gate. During an interview on 08/23/23 at 12:45PM, the Administrator said the gate was not locked before the elopement. He said it was latched the same way it was then. There was a latch in the ground and a latch across the gate. He said they did it this way to allow egress in case of a fire. During an interview on 08/23/23 at 12:50PM, RN A said when she was checking the gate in the smoking area on the day of Resident #1's elopement the gate in the smoking area was open and the alarm was broken and nonfunctional. She said she did not notify the Administrator or DON that the alarm was broken. She said she did not assign someone to the gate even though she knew the alarm was nonfunctional. She did not say why she did not notify administration or assign someone to the gate when asked by this surveyor. During an observation on 08/23/23 at 12:52PM, the Director of Clinical Services said they do not check on residents in the courtyard anymore. She said they used to check on them every hour as part of an old plan of corrections, but the QAPI team had decided it was no longer needed sometime before August 2023. During an interview on 08/23/23 at 12:55PM, the [NAME] President of Operations said he checked the courtyard gate and the alarm on 08/07/23. He said at that time the alarm was functional. He said the gate had two latches, one in the ground and one across the center of the gate. He said there was no lock on the gate. During an interview on 08/23/23 at 1:20PM, the DON said the gate and exterior doors were supposed to be locked. She said the maintenance man checked the gate and that the exterior doors were locked once a week. She said no one else checked the doors or gate more often than that. She said that the charge nurses were responsible for checking on any residents in the courtyard. She said there was no set frequency that they should check the courtyard for residents. She said they only had a wander guard alarm on the front door and the back door. She said there was no wanderguard on the other emergency exits at the end of the halls, or the courtyard gate. During an observation on 08/23/23 at 1:35PM, the gate to the smoker's courtyard was closed and latched. There were two latches on the gate. There was a lower latch that attached to the right side of the gate into the ground. There was another latch that attached the two sides of the gate that was a slide bolt style of latch. The gate was not locked. There was an alarm attached to the gate that sounded inside the courtyard door in the dining room of the facility. There was no wanderguard alarm. During an observation on 08/23/23 at 1:39PM, an exterior door on the 500 hall that was accessible to residents was unlocked and not alarmed. This surveyor was able to open the door and walk outside to the side of the building. There was no gate or fence outside. During an interview on 08/23/23 at 2:18PM, the Administrator said he had taken over the gate and door lock checks because the maintenance person was busy with the renovations in the facility. He said he checked the emergency exits and the courtyard gate every week on Monday. He said he checked that 500 hall side door every week on Monday as part of his gate and door lock checks. During an observation on 08/23/23 at 4:25PM, an extra wanderguard was brought near the front door. The wanderguard alarm did not sound when the wanderguard was brought near it. The front door alarm only sounded when the door was pushed on. The door was locked and required a code to exit. During an interview on 08/23/23 at 4:30PM, the Director of Clinical Services said the front door was locked because the wanderguard alarm was not functioning. She said someone was working on it today and was unable to fix it. During an interview on 08/24/23 at 8:20AM, the Director of Clinical Services said the front door wanderguard was not working on 08/23/23 because they had an outside company come in to upgrade it. She said it was not as loud as they would like so they decided to upgrade it. They had to take the board with them on 08/23/23 to make some repairs. She said they should be back on 08/24/24 to put the board back in and it should be fully repaired. She said in the meantime the door was locked and the residents cannot get out of it. During an interview on 08/24/23 at 11:26 AM, ADON B said the potential for the unlocked 500 hall side door being open was that a resident could walk out if they were not supervised. She said there was a risk of serious injury, serious harm, or death if they got out and were not found. During an interview on 08/24/23 at 11:31AM, ADON B said the potential for the unlocked 500 hall side door being open was that a resident could have eloped, and they could have gotten hurt. She said there was a potential for serious harm or serious injury. During an interview on 08/24/23 at 11:36AM, the DON said on 08/06/23 a resident notified RN A that Resident #1 was outside propelling herself in the parking lot. RN A redirected her inside and an assessment was performed. Resident #1 did not have any negative effects from being outside. Resident #1 had no complaints. RN A had no negative findings on assessment. RN A did a perimeter check on the building and increased supervision for Resident #1. She said the potential harm to a resident related to the 500 hall side door being open was death, especially with the heat. She said there was a driveway around the facility and residents could have been run over. She said a resident could fall or get lost. She said there was potential for serious harm, or serious injury. She said if RN A noticed the alarm was broken on the courtyard gate she would have expected her to notify the DON. She said she expected the nurse to assign someone to remain at the door to ensure a resident did not leave out of it while the alarm was broken. During an interview on 08/24/23 at 11:54AM, the Administrator said if a resident got out of the 500 hall side door there was potential for sunburn, heat stroke, heat exhaustion, falls, or death. He said there was potential for serious harm or serious injury. He said he expected the nurse to notify the administration if the alarm was broken. He expected her to assign someone to watch the gate if the alarm was broken. Record review of the facility's Door Weekly Testing sheet indicated the hall doors and the Smoker's courtyard gate was checked on 8/21/23. Record review of the facility's policy, signal device (wanderguard) and door alarm monitoring, dated February 2020, stated: Policy: At times, the facility admits and retains residents that are confused and have the tendency to wander about the facility. If the facility is equipped with a secured unit, these residents will normally be secured on this unit. However, some facilities do not have secured units and it becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their confusion. The facility must ensure the resident's safety while utilizing the least restrictive means available. To meet this need the facility will obtain information during pre-admission or admission conferences with the resident and family regarding any history of wandering or the potential for wandering. All instances of wandering or attempted elopement will be recorded in the medical record. A plan of care will be developed and implemented with specific approaches and goals for the wanderer. The resident's name, picture, and physical description are placed in the wander book located at the nurses' station. All staff are responsible for knowing whose name is in on the list and be able to recognize the resident and be able to intervene as necessary. Every new employee will be informed of the wandering policy at orientation. A monitoring device will placed on the resident according to the manufacturer's directions. Practice Guidelines: 1. Signal device testing: The signaling device (Wanderguard) will be tested daily . .2. Door Testing: Each monitored door should be inspected once each week by the Maintenance Supervisor and recorded on the test form. In most facilities, the monitored doors will sound several times per day. This in itself provides daily testing. a. A daily inspection should be made of the monitor to ensure that the indicator light is on and that the electrical connections are secure. Any door alarms that are not routinely operated at least once per shift should be activated at least once a day as a test . Record review of the facility's policy, safety and supervision of residents, dated June 2020, stated: .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . .Facility-Oriented approach to safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI review of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization . .Systems approach to safety 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, the adjusts interventions accordingly. 2. Resident supervision is a core component is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's addressed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is change in the resident's condition . The Administrator was notified of an IJ on 08/23/23 at 3:52PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 08/24/23 at 9:15 AM and included the following: Plan of Removal Issues: 1. The facility failed to: * The facility failed to ensure the gate in the courtyard was locked and the alarm was functioning. * The facility failed to follow their policy and monitor the alarms daily. * The facility failed to secure and lock the side door on Hall 500 and there was no alarm on it. Two residents who are at risk of elopement reside on Hall 500. * The facility failed to monitor and supervise residents in the courtyard who were an elopement risk. Plan of Removal 1. Immediate actions * The gate and the alarm in the courtyard were checked and functioned on 8/23/2023 at 4pm by the administrator. * All the alarms were checked to ensure proper functionality on 8/23/2023 at 4pm by the administrator. * The side door on Hall 500 was secured with an alarm on 8/23/2023 at 4pm by the administrator. * Policy was revised for Wander Guard daily checks and exit doors weekly. * Residents at risk for elopement will be monitored every hour to ensure not in courtyard unsupervised starting 8/23/2023 at 6pm. Staff will check functionality of the alarm on the gate every shift for three days, every day for 3 days, and return to weekly checks by the Administrator on 8/23/23. 2. Education (provided by DON, RNC, ADON) * The Administrator and Maintenance Director were in-serviced on monitoring door alarms and the Wander Guard system on 8/23/2023. The Wander Guard system is monitored daily, and the exit doors are monitored weekly by the Maintenance Director. This is documented on separate daily and weekly check-off systems and sheets. * All nurses were educated on monitoring and supervising residents in the courtyard who are an elopement risk every hour on 8/23/2023. All Nurses will be in-serviced prior to next working shift. 3. Medical Director - The Medical Director has been notified of the Immediate Jeopardy at 4pm. 4. QAPI Committee Review - An interim QAPI committee meeting was completed on 8/23/2023. 5. Plan of removal date: 8/23/2023 The surveyor verification of the Plan of Removal from 08/24/23 was as follows: During an observation on 08/24/23 at 9:27AM, this surveyor opened the gate in the smoker's courtyard and heard the alarm sound in the dining room. The administrator silenced the alarm once the gate was closed. During an observation on 08/24/23 at 9:29AM, this surveyor opened the 500 hall side door and heard the alarm sound in the 500 hall. The administrator silenced the alarm once the door was closed. During interviews conducted from 08/24/23 10:17AM through 11:14AM, 7 of 7 nurses in-serviced (including staff across both shifts that were LVNs and RNs) were interviewed. All staff said they received education on monitoring the gate and alarms, monitoring elopement risk residents in the courtyard, every 1 hour checks, keeping elopement risk residents in line of sight while in court yard, and assigning line of sight duties as needed to other staff. Record review of the facility's elopement risk courtyard monitor sheet, dated 08/23/23 and 08/24/23, indicated the faci[TRUNCATED]

Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) 1 of 3 (Resident #1) residents reviewed for notification of change. The facility did not notify the physician of Resident #1's decreased fluid intake, decreased urine output, increased confusion, or urinary analysis not being obtained which resulted in Resident #1 being admitted to the hospital with diagnoses of acute metabolic encephalopathy (a problem in the brain that encompasses delirium and the acute confusional state with causes including dehydration, malnutrition, and metabolic imbalances), dehydration, fluid depletion, and acute kidney injury (a condition in which kidneys suddenly cannot filter waste from the blood with causes including severe dehydration, low blood volume after bleeding, and excessive vomiting or diarrhea). This failure resulted in an identification of an Immediate Jeopardy (IJ) at 11:00 a.m. on 1/19/23. While the IJ was removed on 1/20/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not receiving care and services to meet resident needs. Findings include: 1. Record review of the consolidated physician orders dated 1/20/23 indicated Resident #1 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including diabetes, cognitive communication disorder, urinary tract infection, hypokalemia, and paranoid schizophrenia. The physician orders indicated Resident #1 had an order to document fluid intake every shift starting 5/31/21 and was discontinued on 1/19/23. The physician orders indicated Resident #1 had an order to document urine output every shift starting 5/31/21 and was discontinued on 1/19/23. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 usually understood others and usually made herself understood. The MDS indicated Resident #1 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required supervision with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The MDS indicated Resident #1 was occasionally incontinent. Record review of the care plan revised on 12/27/22 indicated Resident #1 had a potential fluid deficit related to diuretic use with intervention including obtain and monitor lab/diagnostic work as ordered, observe and document intake and output as per facility policy, monitor/document/report to the physician signs and symptoms of fluid deficits including but not limited to: decreased or no urine output, cracked lips, new onset of confusion, and fatigue/weakness. Record review of a dietician progress note dated 1/17/22 indicated Resident #1's estimated daily fluid needs were 2682 milliliters. The dietician progress note indicated Resident #1 had good intake. Record review of Resident #1's intake and output record indicated her average fluid intake for 12/31/22 through 1/06/23 was 487 milliliters and her averaged urine output was 216 milliners. The intake and output record indicated her average fluid intake for 1/07/23 through 1/13/23 was 297 milliliters and her average urine output was 1 milliliter. Record review of the nursing progress note dated 1/05/23 at 3:03 p.m. indicated Resident #1 received a new order for a UA. Record review of the nursing progress note dated 1/06/23 at 3:03 p.m. indicated Resident #1 was hard to arouse. The progress note indicated Resident #1 required spoon feeding by the nurse and only drank a small amount of water. Record review of the nursing progress note dated 1/09/23 at 1:13 p.m. indicated Resident #1 refused breakfast and lunch. The nursing progress note indicated Resident #1 drank 8 ounces of water. The nursing progress note indicated Resident #1 voided a small amount of urine. The nursing progress note indicated mouth care was performed on Resident #1. Record review of the nursing progress note dated 1/09/23 at 6:55 p.m. indicated Resident #1 refused her supper tray and consumed 4 ounces of water per nurse. The nursing progress note indicated Resident #1 had an incontinent episode and peri-care was performed. Record review of the nursing progress note dated 1/10/23 at 6:33 a.m. indicated Resident #1 did not void on the 10:00 p.m.- 6:00 a.m. shift. The nursing progress note indicated the nurse got Resident #1 to drink 8 ounces of water. Record review of the nursing progress note date 1/10/23 at 9:38 a.m. indicated Resident #1 refused breakfast. Record review of the nursing progress note dated 1/10/23 at 12:38 p.m. indicated Resident #1 refused lunch. The nursing progress note indicated Resident #1 would not open her eyes to verbal stimuli. The nursing progress noted indicated Resident #1 was assessed by the Medical Director. The nursing progress noted indicated Resident #1 received an order to transfer her to the emergency department for evaluation and treatment. Record review of the nursing progress noted dated 1/10/23 at 12:50 p.m. indicated Resident #1 was transferred to the emergency department via ambulance. Record review of Resident #1's hospital records dated 1/10/23 indicated she was admitted to the hospital with diagnoses of acute metabolic encephalopathy (a problem in the brain that encompasses delirium and the acute confusional state with causes including dehydration, malnutrition, and metabolic imbalances), dehydration, fluid depletion, and acute kidney injury (a condition in which kidneys suddenly cannot filter waste from the blood with causes including severe dehydration, low blood volume after bleeding, and excessive vomiting or diarrhea). The hospital records indicated Resident #1's sodium level was elevated with a level of 155 milliequivalents/liter (normal sodium level is 135-145 milliequivalents/Liter). The hospital records indicated Resident #1 was suffering from urinary retention and altered mental status upon arrival at the hospital. The hospital records indicated the nursing home staff noted Resident #1 had altered level of consciousness since 1/03/23 and progressively getting worse. The hospital records indicated the nursing home staff noted Resident #1 was not eating, drinking, or urinating. During an interview on 1/18/23 at 12:40 p.m. CNA B said signs and symptoms of dehydration included dry mouth and lethargy. CNA B said Resident #1 had a dry mouth, decreased urine output, and was lethargic. CNA B said she reported Resident #1's dry mouth, decreased urine output, and lethargy to the charge nurse. CNA B said she noticed Resident #1's change in condition on 1/09/23. During an interview on 1/18/23 at 12:53 p.m. LVN C said when a lab order was received for a UA a lab requisition should be completed and nurses should obtain the UA. LVN C said if a resident refused a UA the nurse should document the refusal in the electronic medical records. LVN C said signs and symptoms of dehydration included headache, dizziness, poor skin turgor, decreased urine output, dark urine, and confusion. During an interview on 1/18/23 at 12:58 p.m. LVN D said signs and symptoms of dehydration included lethargy, swollen tongue, not communicating, and decreased urination. LVN D said Resident #1 had signs and symptoms of dehydration including swollen tongue, not waking up, and not voiding. LVN D said she was aware Resident #1 had an order for a UA. LVN D said the UA was not obtained. LVN D said the UA was not obtained because Resident #1 was incontinent. LVN D said an in and out catheter was not attempted on Resident #1. During an interview on 1/18/23 at 1:06 p.m. The Medical Director said when he assessed Resident #1 on 1/10/23 while making rounds she looked very dehydrated. The [NAME] Director said he gave the order for Resident #1 to be sent to the emergency department on 1/10/23. The Medical Director said he was not aware whether the facility had notified him or his nurse practitioner of Resident #1's change in condition prior to him making rounds on 1/10/23. During an interview on 1/18/23 at 1:29 p.m. CNA A said she had reported Resident #1's change in condition to the charge nurse on 1/09/23. During an interview on 1/18/23 at 1:32 p.m. LVN D said she notified the physician on 1/10/23 of Resident #1's signs and symptoms of dehydration while he was in the facility making rounds. LVN D said she did not notify the physician or nurse practitioner that the UA was not obtained on Resident #1. During an interview on 1/18/23 at 1:43 p.m. the Nurse Practitioner said she was vaguely familiar with Resident #1. The Nurse Practitioner said she was aware of the order for the UA on Resident #1. The Nurse Practitioner said the order for the UA was wrote by the Psychiatric Nurse Practitioner. The Nurse Practitioner said she had been notified by an evening nurse the facility was unable to obtain the UA on Resident #1. The Nurse Practitioner said she recommended the facility perform an in and out catheterization on Resident #1 to obtain the UA. The Nurse Practitioner said she was not informed the in and out catheter had not been performed. The Nurse Practitioner said she expected to be informed if the in and out catheter was unsuccessful or unable to be performed. The Nurse Practitioner said she had not been notified of Resident #1's dehydration or change in condition. During an interview on 1/19/23 at 8:17 a.m. the Psychiatric Nurse Practitioner said she had ordered the UA on Resident #1 on 1/05/23. The Psychiatric Nurse Practitioner said she had ordered the UA on Resident #1 due to the nursing facility reporting increased hallucinations and an increase in incontinent episodes for 2-3 days. The Psychiatric Nurse Practitioner said she was not notified of the UA not being obtained on Resident #1. During an interview on 1/19/23 at 8:27 a.m. CNA B said she first noticed the change in condition with Resident #1 on 1/09/23. During an interview on 1/19/23 at 8:31 a.m. CNA A said Resident #1 had tried to drink 4-6 ounces of water by assistance from the nurse. CNA A said Resident #1 would not arouse to eat on 1/09/23. CNA A said on 1/05/23 or 1/06/23 Resident #1 required assistance with eating and drinking. CNA A said Resident #1 did not usually require assistance with eating and drinking. CNA A said Resident #1 usually drank lots of fluids, fed herself, and carried a pitcher of water at all times. CNA A said on 1/05/23 or 1/06/23 Resident #1 was not getting up or carrying around her water pitcher. CNA A said she reported the changes in Resident #1 to the charge nurse. During an interview on 1/19/23 at 8:40 a.m. LVN D said on 1/09/23 she noticed Resident #1 was not eating or drinking. LVN D said on 1/09/23 Resident #1 drank some water in the morning but would not arouse for food or fluid the rest of the day. LVN D said Resident #1 had been incontinent of bladder on 1/09/23 which was outside of her baseline. LVN D said she did not report to the physician Resident #1's decrease in food intake, decrease in fluid intake, increased need for assistance, or incontinence on 1/09/23 when she noticed the change in condition. Record review of the facility's undated Notification to Physician, Family, and others policy indicated, The facility will remain compliant with reporting guidelines as outlined by state and federal regulations. The facility will inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative and document in the residents' medical record where applicable, when there is: .A significant change in the resident's physical, mental, or psychosocial status .Notifications of non-life threatening issues will be considered timely if made within the context of the respective staff members regularly scheduled shift and as early as practicable. The closes time to the event is considered ideal. Notifications of serious injury or the potential for serious injury, life threatening events or the potential for life threatening events and any significant health issue must be made immediately . The Administrator was notified on 1/19/23 at 11:36 a.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 1/19/23 at 11:36 a.m. The facility's Plan of Removal was accepted on 1/19/23 at 4:33 p.m. and included: All residents with active physician orders Intake and Output monitoring were discontinued on 01/19/2023. Education (provided by DON or ADON) All nurses were in-serviced on Appropriately Notifying the Physician of changes in condition in a timely manner on 01/19/2023. This in-service includes competency checks by pre-test post-test. Each nurse will be in-serviced prior to returning to shift. This will be completed by 01/19/2023. Nursing will not return to shift without the in-service and pre-test post-test. All nurses were in-serviced on Policy and Procedure for obtaining a UA on 01/19/2023 which includes entering the UA as a one-time order. This in-service will be completed by 01/19/2023. Nurse administration in-serviced to assign fluid consumption and voiding by CNA as monitoring tasks unless I/O monitoring ordered by physician on 01/19/2023. All nurses were in-serviced on appropriately monitoring I&Os to include monitoring residents who are at risk for dehydration to ensure they are being assessed appropriately and not dehydrated 01/19/2023. This in-service will be completed by 01/19/2023. Nursing will not return to shift without the in-service. All nurses were in-serviced on Notifying the Physician if a UA is not obtained on 01/19/2023. Nursing will not return to shift without the in-service. On 1/20/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a randomly selected sample of residents indicated all residents reviewed who had an order for intake and output monitoring had that order discontinued on 1/19/23 Interviews of nursing staff (2-nurses on the 6:00 a.m.-2:00 p.m. shift; 1 nurse on the 7:00 a.m.- 3:00 p.m. shift, 2 nurses on the 8:00 a.m.- 5:00 p.m. shift, 2-nurses on the 2:00 p.m.- 10:00 p.m. shift; 1 nurse on the 10:00 p.m.- 6:00 a.m. shift) were performed. During these interviews' staff were able to correctly identify when to notify the physician of a resident's change in condition or unable to obtain labs; the appropriate procedure for obtaining a UA on a resident, and how to appropriately monitor resident's fluid intake and output who are at risk for dehydration. On 1/20/23 at 9:45 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to maintain acceptable parameters of hydration status for 1 of 3 (Resident #1) residents reviewed for nutrition and hydration The facility did not ensure Resident #1 was monitored for fluid intake per orders which resulted in her admission to the hospital with a diagnosis of severe dehydration. The facility did not ensure Resident #1 was monitored for urine output per orders which resulted in her admission to the hospital with a diagnosis of severe dehydration. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 11:00 a.m. on 1/19/23. While the IJ was removed on 1/20/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm or death related to abnormal electrolyte balances, dehydration, and kidney failure. Findings include: 1. Record review of the consolidated physician orders dated 1/20/23 indicated Resident #1 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including diabetes, cognitive communication disorder, urinary tract infection, hypokalemia, and paranoid schizophrenia. The physician orders indicated Resident #1 had an order to document fluid intake every shift starting 5/31/21 and was discontinued on 1/19/23. The physician orders indicated Resident #1 had an order to document urine output every shift starting 5/31/21 and was discontinued on 1/19/23. The medical records indicated Resident #1 had an order to obtain a urinary analysis (UA) on 1/05/23. The physician orders indicated Resident #1 had an order for furosemide (a diuretic used to treat fluid build-up that increases urination) 40mg daily starting 9/13/21. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 usually understood others and usually made herself understood. The MDS indicated Resident #13 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required supervision with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The MDS indicated Resident #1 was occasionally incontinent. Record review of the care plan revised on 12/27/22 indicated Resident #1 had a potential fluid deficit related to diuretic use with intervention including obtain and monitor lab/diagnostic work as ordered, observe and document intake and output as per facility policy, monitor/document/report to the physician signs and symptoms of fluid deficits including but not limited to: decreased or no urine output, cracked lips, new onset of confusion, and fatigue/weakness. Record review of a dietician progress note dated 1/17/22 indicated Resident #1's estimated daily fluid needs were 2682 milliliters. The dietician progress note indicated Resident #1 had good intake. Record review of Resident #1's intake and output record for 1/01/23 through 1/09/23 indicated her fluid intake had only been documented on the following dates and shifts: 1/02/23 at 1:01 a.m. 1/02/23 at 6:37 p.m. 1/03/23 at 1:15 am 1/04/23 at 1:27 a.m. 1/05/23 at 1:16 a.m. 1/06/23 at 1:19 a.m. 1/06/23 at 8:15 p.m. 1/07/23 at 7:05 p.m. 1/08/23 at 12:40 a.m. 1/08/23 at 10:09 a.m. 1/08/23 at 11:57 p.m. Record review of Resident #1's intake and output record for 1/01/23 through 1/09/23 indicated her urine output had only been documented on the following dates and shifts: 1/02/23 at 1:01 a.m. 1/02/23 at 6:44 p.m. 1/03/23 at 1:15 a.m. 1/04/23 at 1:27 a.m. 1/05/23 at 1:16 a.m. 1/06/23 at 1:19 a.m. 1/06/23 at 8:15 p.m. 1/07/23 at 7:02 p.m. 1/08/23 at 12:40 a.m. 1/08/23 at 10:09 a.m. 1/08/23 at 11:57 p.m. Record review of Resident #1's intake and output record indicated her average fluid intake for 12/31/22 through 1/06/23 was 487 milliliters and her averaged urine output was 216 milliners. The intake and output record indicated her average fluid intake for 1/07/23 through 1/13/23 was 297 milliliters and her average urine output was 1 milliliter. Record review of Resident #1's medication administration record (MAR) indicated she had not missed any doses of her furosemide 40 mg from 1/01/23 through 1/09/23. The MAR indicated Resident #1 did not receive her furosemide 40 mg on 1/10/23 due to her condition. Record review of the nursing progress note dated 1/05/23 at 3:03 p.m. indicated Resident #1 required spoon feeding by the nurse and only drank a small amount of water. Record review of the nursing progress note dated 1/09/23 at 1:13 p.m. indicated Resident #1 refused breakfast and lunch. The nursing progress note indicated Resident #1 drank 8 ounces of water. The nursing progress note indicated Resident #1 voided a small amount of urine. The nursing progress note indicated mouth care was performed on Resident #1. Record review of the nursing progress note dated 1/09/23 at 6:55 p.m. indicated Resident #1 refused her supper tray and consumed 4 ounces of water per nurse. Record review of the nursing progress note dated 1/10/23 at 6:33 a.m. indicated Resident #1 did not void on the 10:00 p.m.- 6:00 a.m. shift. The nursing progress note indicated the nurse got Resident #1 to drink 8 ounces of water. Record review of the nursing progress note date 1/10/23 at 9:38 a.m. indicated Resident #1 refused breakfast. Record review of the nursing progress note dated 1/10/23 at 12:38 a.m. indicated Resident #1 refused lunch. The nursing progress note indicated Resident #1 would not open her eyes to verbal stimuli. The nursing progress noted indicated Resident #1 was assessed by the Medical Director. The nursing progress noted indicated Resident #1 received an order to transfer her to the emergency department for evaluation and treatment. Record review of the nursing progress noted dated 1/10/23 at 12:50 p.m. indicated Resident #1 was transferred to the emergency department via ambulance. Record review of Resident #1's hospital records dated 1/10/23 indicated she was admitted to the hospital with diagnoses of acute metabolic encephalopathy (a problem in the brain that encompasses delirium and the acute confusional state with causes including dehydration, malnutrition, and metabolic imbalances), dehydration, fluid depletion, and acute kidney injury (a condition in which kidneys suddenly cannot filter waste from the blood with causes including severe dehydration, low blood volume after bleeding, and excessive vomiting or diarrhea). The hospital records indicated Resident #1's sodium level was elevated with a level of 155 milliequivalents/liter (normal sodium level is 135-145 milliequivalents/Liter). The hospital records indicated Resident #1 was suffering from urinary retention and altered mental status upon arrival at the hospital. The hospital records indicated the nursing home staff noted Resident #1 had altered level of consciousness since 1/03/23 and progressively getting worse. The hospital records indicated the nursing home staff noted Resident #1 was not eating, drinking, or urinating. During an interview on 1/18/23 at 12:44 p.m. CNA A said residents were monitored once every 8 hours for fluid intake and urine output. CNA A said Resident #1 was encouraged to drink often. CNA A said fluid intake was documented by estimating the size of the cups of fluid residents consumed. CNA A said urine output was estimated by how many wet briefs were changed during a shift or by asking continent residents how much they had urinated during a shift. CNA A said Resident #1 would not drink for 2 days. CNA A said signs and symptoms of dehydration included little to no urine output, chapped lips, tough skin, and lethargy. CNA A said Resident #1 had chapped lips. CNA A said Resident #1 always had chapped lips due to being a mouth breather. CNA A said she did not know why Resident #1's fluid intake or urine output had not been documented routinely. CNA A said fluid intake and urine output did not get documented when the CNAs ran out of time during their shift. During an interview on 1/18/23 at 12:40 p.m. CNA B said fluid intake and urine output should be documented every shift. CNA B said fluid intake was estimated and documented by the size of the cup of fluid the residents consumed. CNA B said urine output was estimated and documented by how many times a resident required a wet brief change or by measuring foley catheter contents. CNA B said if fluid intake or urine output was not documented it was due to the CNAs not charting. CNA B said signs and symptoms of dehydration included dry mouth and lethargy. CNA B said Resident #1 had a dry mouth, decreased urine output, and was lethargic. CNA B said she reported Resident #1's dry mouth, decreased urine output, and lethargy to the charge nurse. CNA B said she noticed Resident #1's change in condition on 1/09/23. During an interview on 1/18/23 at 12:53 p.m. LVN C said fluid intake and urine output was documented every shift by the CNAs. LVN C said if a resident had a foley catheter it was the nurse's responsibility to document urine output. LVN C said documenting fluid intake and urine output was listed in the electronic medical records under orders and was a physician's order. LVN C said she was unaware why fluid intake or urine output would not be documented. LVN C fluid intake and urine output should always be documented every shift. LVN C said the importance of documenting fluid intake and urine output was to monitor resident hydration status and could indicate a resident had a urinary tract infection. LVN C said signs and symptoms of dehydration included headache, dizziness, poor skin turgor, decreased urine output, dark urine, and confusion. During an interview on 1/18/23 at 12:58 p.m. LVN D said fluid intake and urine output should be monitored daily. LVN D said it was the nurse's and CNA's responsibility to document fluid intake and urine output every shift. LVN D said documenting fluid intake and urine output every shift was listed under the orders in the electronic medical records and was a physician's order. LVN D said the importance if documenting fluid intake and urine output was to monitor for dehydration. LVN D said signs and symptoms of dehydration included lethargy, swollen tongue, not communicating, and decreased urination. LVN D said Resident #1 had signs and symptoms of dehydration including swollen tongue, not waking up, and not voiding. During an interview on 1/18/23 at 1:06 p.m. the Medical Director said he would not have ordered fluid intake and urine output to be monitored in a nursing home. The Medical Director said if there was a physician order for fluid intake and urine output to be monitored he expected the nursing facility to follow the physician order. The Medical Director said when he assessed Resident #1 on 1/10/23 while making rounds she looked very dehydrated. The [NAME] Director said he gave the order for Resident #1 to be sent to the emergency department on 1/10/23. During an interview on 1/18/23 at 1:29 p.m. CNA A said she had reported Resident #1's change in condition to the charge nurse on 1/09/23. During an interview on 1/18/23 at 1:32 p.m. LVN D said she notified the physician on 1/10/23 of Resident #1's signs and symptoms of dehydration while he was in the facility making rounds. During an interview on 1/18/23 at 1:43 p.m. the Nurse Practitioner said she was vaguely familiar with Resident #1. The Nurse Practitioner said she had not been notified of Resident #1's dehydration or change in condition. During an interview on 1/19/23 at 8:17 a.m. the Psychiatric Nurse Practitioner said she had ordered the UA on Resident #1 on 1/05/23. The Psychiatric Nurse Practitioner said she had ordered the UA on Resident #1 due to the nursing facility reporting increased hallucinations and an increase in incontinent episodes for 2-3 days. The Psychiatric Nurse Practitioner said she was not notified of the UA not being obtained on Resident #1. During an interview on 1/19/23 at 8:27 a.m. CNA B said she first noticed the change in condition with Resident #1 on 1/09/23. During an interview on 1/19/23 at 8:31 a.m. CNA A said Resident #1 had tried to drink 4-6 ounces of water by assistance from the nurse. CNA A said Resident #1 would not arouse to eat on 1/09/21. CNA A said on 1/05/23 or 1/06/23 Resident #1 required assistance with eating and drinking. CNA A said Resident #1 did not usually require assistance with eating and drinking. CNA A said Resident #1 usually drank lots of fluids, fed herself, and carried a pitcher of water at all times. CNA A said on 1/05/23 or 1/06/23 Resident #1 was not getting up or carrying around her water pitcher. CNA A said she reported the changes in Resident #1 to the charge nurse. During an interview on 1/19/23 at 8:40 a.m. LVN D said on 1/09/23 she noticed Resident #1 was not eating or drinking. LVN D said on 1/09/23 Resident #1 drank some water in the morning but would not arouse for food or fluid the rest of the day. LVN D said Resident #1 had been incontinent on bladder on 1/09/23 which was outside of her baseline. LVN D said she did not report to the physician Resident #1's decrease in food intake, decrease in fluid intake, increased need for assistance, or incontinence on 1/09/23 when she noticed the change in condition. During an interview on 1/19/23 at 9:04 a.m. the Dietary Manager said the Dietician came to the facility monthly. During an interview on 1/19/23 at 9:54 a.m. the Dietary Manager said there had not been a dietician assessment on Resident #1 since 2022. The Dietary Manager said Resident #1 had not had an assessment from the Dietician because she had not had any triggers such as significant weight loss. During an interview on 1/19/23 at 10:55 a.m. the Dietician said she had been working at the facility since September 2022. The Dietician said she had not performed and assessment on Resident #1 since she began working at the facility. The Dietician said she had not performed an assessment on Resident #1 because she had not had any triggers from a nutritional standpoint. Record review of the facility's Intake, Measuring and Recording policy dated 6/2020 indicated, The purpose of this procedure is too accurately determining the amount of liquid a resident consumes in a 24-hour period. Verify that there is a physician's order for this procedure and/or that the procedure is being performed per facility policy .Record the fluid intake as soon as possible after the resident has consumed fluids. At the end of your shift total the amounts of all liquids the resident consumed. Record all fluid intake on the intake and output record . Record review of the facility's Output, Measuring and Recording policy dated 6/2020 indicated, The purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period. Verify there is a physician's order for this procedure and/or that the procedure is being performed per facility policy . Record review of the facility's undated Diets, Nutrition, and Hydration policy indicated, .The dietary manager, with assistance from the Dietician, will calculate daily fluid requirements for all residents with risk factors indicating a concern with fluid intake .Increased fluid needs may occur if the resident is suffering from one of the following: 1. Fever, 2. Dehydration, 3. Pressure Sores, 4. Burns, 5. Infections, 6. Urinary Tract Infection, 7. Hot Weather, 8. Vomiting, and 9. Diarrhea . The administrator was notified on 1/19/23 at 11:36 a.m. that an Immediate Jeopardy situation was identified due to the above failure. The administrator was provided the Immediate Jeopardy template on 1/19/23 at 11:36 a.m. The facility's Plan of Removal was accepted on 1/19/23 at 4:33 p.m. and included: All residents with active physician orders Intake and Output monitoring were discontinued on 01/19/2023. Education (provided by DON or ADON) All nurses were in-serviced on Appropriately Notifying the Physician of changes in condition in a timely manner on 01/19/2023. This in-service includes competency checks by pre-test post-test. Each nurse will be in-serviced prior to returning to shift. This will be completed by 01/19/2023. Nursing will not return to shift without the in-service and pre-test post-test. All nurses were in-serviced on Policy and Procedure for obtaining a UA on 01/19/2023 which includes entering the UA as a one-time order. This in-service will be completed by 01/19/2023. Nurse administration in-serviced to assign fluid consumption and voiding by CNA as monitoring tasks unless I/O monitoring ordered by physician on 01/19/2023. All nurses were in-serviced on appropriately monitoring I&Os to include monitoring residents who are at risk for dehydration to ensure they are being assessed appropriately and not dehydrated 01/19/2023. This in-service will be completed by 01/19/2023. Nursing will not return to shift without the in-service. All nurses were in-serviced on Notifying the Physician if a UA is not obtained on 01/19/2023. Nursing will not return to shift without the in-service. On 1/20/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a randomly selected sample of residents indicated all residents reviewed who had an order for intake and output monitoring had that order discontinued on 1/19/23 Interviews of nursing staff (2-nurses on the 6:00 a.m.-2:00 p.m. shift; 1 nurse on the 7:00 a.m.- 3:00 p.m. shift, 2 nurses on the 8:00 a.m.- 5:00 p.m. shift, 2-nurses on the 2:00 p.m.- 10:00 p.m. shift; 1 nurse on the 10:00 p.m.- 6:00 a.m. shift) were performed. During these interviews' staff were able to correctly identify when to notify the physician of a resident's change in condition or unable to obtain labs; the appropriate procedure for obtaining a UA on a resident, and how to appropriately monitor resident's fluid intake and output who are at risk for dehydration. On 1/20/23 at 9:45 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure laboratory services were obtained to meet the needs for 1 of 3 (Resident #1) residents reviewed for laboratory services. The facility did not ensure Resident #1 had a urinary analysis performed per orders which resulted in Resident #1 being admitted to the hospital with diagnoses of acute metabolic encephalopathy (a problem in the brain that encompasses delirium and the acute confusional state with causes including dehydration, malnutrition, and metabolic imbalances), dehydration, fluid depletion, and acute kidney injury (a condition in which kidneys suddenly cannot filter waste from the blood with causes including severe dehydration, low blood volume after bleeding, and excessive vomiting or diarrhea). This failure resulted in an identification of an Immediate Jeopardy (IJ) at 11:00 a.m. on 1/19/23. While the IJ was removed on 1/20/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the residents at risk of not receiving lab services as ordered and suffering from an undetected infection. Findings include: 1. Record review of the consolidated physician orders dated 1/20/23 indicated Resident #1 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including diabetes, cognitive communication disorder, urinary tract infection, hypokalemia, and paranoid schizophrenia. The physician orders indicated Resident #1 had an order to document fluid intake every shift starting 5/31/21 and was discontinued on 1/19/23. The physician orders indicated Resident #1 had an order to document urine output every shift starting 5/31/21 and was discontinued on 1/19/23. The medical records indicated Resident #1 had an order to obtain a urinary analysis (UA) on 1/05/23. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 usually understood others and usually made herself understood. The MDS indicated Resident #13 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required supervision with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The MDS indicated Resident #1 was occasionally incontinent. Record review of the care plan revised on 12/27/22 indicated Resident #1 had a potential fluid deficit related to diuretic use with intervention including obtain and monitor lab/diagnostic work as ordered, observe and document intake and output as per facility policy, monitor/document/report to the physician signs and symptoms of fluid deficits including but not limited to: decreased or no urine output, cracked lips, new onset of confusion, and fatigue/weakness. Record review of the nursing progress note dated 1/05/23 at 3:03 p.m. indicated Resident #1 received a new order for a UA. During an interview on 1/18/23 at 12:53 p.m. LVN C said when a lab order was received for a UA a lab requisition should be completed and nurses should obtain the UA. LVN C said if a resident refused a UA the nurse should document the refusal in the electronic medical records. During an interview on 1/18/23 at 12:58 p.m. LVN D said when a lab order for a UA was received it should be entered into the electronic medical records, a lab requisition should be completed and put into the lab book, and the nurses should collect the UA. LVN D said if a resident refused a lab it should be documented in the electronic medical records. LVN D said she was aware Resident #1 had an order for a UA. LVN D said the UA was not obtained. LVN D said the UA was not obtained because Resident #1 was incontinent. LVN D said an in and out catheter was not attempted on Resident #1. During an interview on 1/18/23 at 1:32 p.m. LVN D said she did not notify the physician or nurse practitioner that the UA was not obtained on Resident #1. During an interview on 1/18/23 at 1:43 p.m. the Nurse Practitioner said she was vaguely familiar with Resident #1. The Nurse Practitioner said she was aware of the order for the UA on Resident #1. The Nurse Practitioner said the order for the UA was wrote by the Psychiatric Nurse Practitioner. The Nurse Practitioner said she had been notified by an evening nurse the facility was unable to obtain the UA on Resident #1. The Nurse Practitioner said she recommended the facility perform an in and out catheterization on Resident #1 to obtain the UA. The Nurse Practitioner said she was not informed the in and out catheter had not been performed. The Nurse Practitioner said she expected to be informed if the in and out catheter was unsuccessful or unable to be performed. During an interview on 1/19/23 at 8:17 a.m. the Psychiatric Nurse Practitioner said she had ordered the UA on Resident #1 on 1/05/23. The Psychiatric Nurse Practitioner said she had ordered the UA on Resident #1 due to the nursing facility reporting increased hallucinations and an increase in incontinent episodes for 2-3 days. The Psychiatric Nurse Practitioner said she was not notified of the UA not being obtained on Resident #1. Record review of the facility's Lab and Diagnostic Test Results-Clinical Protocol dated 6/2020 indicated, The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process the test requisition and arrange for tests . The Administrator was notified on 1/19/23 at 11:36 a.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 1/19/23 at 11:36 a.m. The facility's Plan of Removal was accepted on 1/19/23 at 4:33 p.m. and included: All residents with active physician orders Intake and Output monitoring were discontinued on 01/19/2023. Education (provided by DON or ADON) All nurses were in-serviced on Appropriately Notifying the Physician of changes in condition in a timely manner on 01/19/2023. This in-service includes competency checks by pre-test post-test. Each nurse will be in-serviced prior to returning to shift. This will be completed by 01/19/2023. Nursing will not return to shift without the in-service and pre-test post-test. All nurses were in-serviced on Policy and Procedure for obtaining a UA on 01/19/2023 which includes entering the UA as a one-time order. This in-service will be completed by 01/19/2023. Nurse administration in-serviced to assign fluid consumption and voiding by CNA as monitoring tasks unless I/O monitoring ordered by physician on 01/19/2023. All nurses were in-serviced on appropriately monitoring I&Os to include monitoring residents who are at risk for dehydration to ensure they are being assessed appropriately and not dehydrated 01/19/2023. This in-service will be completed by 01/19/2023. Nursing will not return to shift without the in-service. All nurses were in-serviced on Notifying the Physician if a UA is not obtained on 01/19/2023. Nursing will not return to shift without the in-service. On 1/20/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a randomly selected sample of residents indicated all residents reviewed who had an order for intake and output monitoring had that order discontinued on 1/19/23 Interviews of nursing staff (2-nurses on the 6:00 a.m.-2:00 p.m. shift; 1 nurse on the 7:00 a.m.- 3:00 p.m. shift, 2 nurses on the 8:00 a.m.- 5:00 p.m. shift, 2-nurses on the 2:00 p.m.- 10:00 p.m. shift; 1 nurse on the 10:00 p.m.- 6:00 a.m. shift) were performed. During these interviews' staff were able to correctly identify when to notify the physician of a resident's change in condition or unable to obtain labs; the appropriate procedure for obtaining a UA on a resident, and how to appropriately monitor resident's fluid intake and output who are at risk for dehydration. On 1/20/23 at 9:45 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed (Resident #1) for accidents and supervision. 1. The facility failed to ensure staff were aware of how long Resident #1 was outside, exposed to the sun on 9/10/22 with temperatures around 88 degrees. 2. The facility failed to develop a care plan or have interventions in place to prevent Resident #1 from prolonged exposure to the sun. 3. The facility failed to ensure Resident #1 was dressed in long pants and shirt that she normally wore. The resident was dressed in a tank top and shorts which exposed her fragile skin to the sun. 4. The facility failed to follow their policy for wandering residents regarding intervention strategies. 5. The facility failed to ensure Resident # 1 had increased supervision for elopement and left the resident unattended in an area that was not locked. 6. The facility failed to have a care plan in place regarding her wander guard and potential elopement tendencies. An Immediate Jeopardy (IJ) situation was identified on 9/14/22 at 4:00 p.m. While the IJ was removed on 9/15/22 at 2:00p.m., the facility remained out of compliance at actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm, injury and possible death to residents left unattended in the heat without monitoring or supervision for an unknown length of time. Findings include: Record review of Resident #1's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis which included dementia without behavioral disturbances. Record review of Resident #1's quarterly MDS, dated [DATE], indicated a BIMS score of 8, which indicated the resident's mental status was moderately impaired. Resident #1's functional status indicated with balance during transitions and walking, she required the physical help of one person when moving from seated to standing position. She did not walk and required the assistance of one person when moving from surface to surface. She required the assistance of a walker or wheelchair for mobility. Record review of Resident #1's care plan, dated 2/5/22, indicated a problem of cognitive loss and dementia. The resident had long and short-term memory deficits. She had inattention and disorganized thinking that fluctuated. She could make her needs known but had difficulty finding words and completing sentences. Some of the approaches were to explain care procedures, observe for change in mental status, and decision-making ability and report to physician. Resident #1's care plan, dated 2/27/22, indicated a problem of ADL function. The resident used a wheelchair for mobility, could propel self about the facility and was propelled by the staff at times. One of the approaches was to assist the resident with mobility as needed. There were no care plan interventions regarding the resident's desire to sit outside in the sun, smoking, or her wander guard and elopement tendencies. The care plans last revision date was 8/31/22. Record review of Resident #1's nursing notes, dated 7/2/22 at 9:39 a.m., indicated she propelled herself down the walkway in the patio area to the gate and attempted to open the gate. When asked where she was going, she said, just out. Record review of Resident #1's nursing notes, dated 7/3/22 at 7:40 a.m., indicated Resident #1 propelled self out the dining room door to the patio area and to the gate off the fence and attempted to open gate. The staff intervened and assisted her back into the facility. She said she was going home. Record review of Resident #1's nursing notes, dated 7/3/22 at 8:31 a.m., indicated Resident #1 propelled self away from dining room table and was not eating breakfast, she attempted to go out the patio door unsupervised. She was redirected, ate about 75 percent of her breakfast, and tried to push door making an alarm sound. The nurse intervened, Resident #1 said she was going home. She was placed on 15-minute monitoring. Record review of Resident #1's elopement assessment, dated 7/14/22, indicated she was ambulatory in a wheelchair, exhibited Alzheimer's, symptoms, had a history of wandering into unsafe areas, and displayed behaviors that indicated an attempt to leave. The assessment indicated the resident was at risk for elopement. One of the interventions was to place a wander guard on the resident. Record review of Resident #1's computerized physician orders indicated, on 7/15/22, Resident #1 had a wander guard to the left ankle and to verify placement every shift. Record review of Resident #1's nursing note, dated 9/10/22 at 4:15 p.m., indicated at 4:30 p.m., a medication aide could not arouse Resident #1. Two nurses got vital signs at 4:35 p.m. blood pressure 90/40, pulse 123, blood sugar 220 and temperature was 98.8, 911 was called. EMTs exit with resident at 5:03 p.m. Record review of Resident #1's EMS report, dated 9/10/22, indicated they were dispatched to the facility on [DATE] at 4:44 p.m., they were enroute at 4:46 p.m., and arrived at the scene at 4:55 p.m. for a patient that got too hot. The patent was found sitting in a wheelchair between the dining area and the back patio door. Two staff members were standing near the patient with one of them fanning her with paper. When EMS walked around to the front side of the patient, she was found to be unresponsive, and slumped backwards in the chair with shallow but rapid respirations. When asked how long the patient had been like this, both staff members looked at EMS, shrugged their shoulders and held their hands out as if they had no clue. EMS insisted they figure out a better answer to how long the patient had been outside and when she was last seen as normal. Initial vitals were quickly taken where the patient was sitting, and she was hypotensive. Per staff the patient had wheeled herself outside at least one hour ago, when asked the state, she is normally alert and verbally communicates but is usually confused due to dementia. The EMS departure time was 5:11 p.m. Record Review of Resident #1's Emergency Department History and Physical, dated 9/10/22, indicated this [AGE] year-old female with a history or hypertension, [CONDITION(S)], [CONDITION(S)], diabetes, [CONDITION(S)], and dementia. She presented to the emergency room with hyperthermia of 103 degrees F, [CONDITION(S)] and alerted mental status. She was found unresponsive outside in her wheelchair and had been in the sun for a length but uncertain of the amount of time. On presentation her Glasgow Coma Scale was 4 (3 being the worst and 15 the best) Her right side was flaccid, and she had left sided deviation. However, she eventual improved and currently has a Glasgow coma [NAME] 9 (moderate.) She received IV fluids, IV Antibiotic and ice packs for cooling. She did not report feeling any pain, nausea, vomiting, or bowel problems. She was admitted for careful monitoring and treatment in the ICU. She had a defused (rash caused by hot or humid weather) sunburn on skin, from her head and chest down on her arms and legs. Sparing covered areas of skin Petechiae (tiny brown-purple spots due to bleeding under the skin) on thighs and 2 bullac (blisters) noted on left thigh. Record review of a nursing note, dated 9/14/22 at 6:57 p.m., indicated Resident #1 was admitted back to the facility. She presented with several blisters to her right arm, left upper chest, abdomen, left breast, left forearm, and bilateral thighs. The blisters were cleaned, triple antibiotic ointment was applied and covered with non-adherent pad and secured with dressing. During an observation on 9/13/22 at 9:20 a.m. of the smoking area revealed a patio area with two doors, leading outside from the dining room area. These doors did not have wander guard alarms on them. The patio area was covered and looked to be about 12 feet by 10 feet. It had chairs and tables and cigarette disposal area set up. There were a few chairs along the walkway. The area had a large fenced in courtyard area with a gate at the end of a walkway. That area had full exposure to the sun and no shade. The gate was not locked. It had a hook bolt latch on the double door gate to hold the two gates together. The one side of the gate had a security latch into the ground. The gate was hard to open. The one side would open about 8 inches without opening the latch to the ground on the other side. It was hard to open and close. Record review of the list of smoking times provided by the Administrator indicated the Smoke Schedule was: 9:00 a.m. 11:00 a.m. 1:30 p.m. 3:30 p.m. 7:00 p.m. Record review of the weather statement for the location of the facility provided by the Administrator dated 9/10/22 indicated the temperature was around 88 to 90 degrees that day. (Verification via internet.) During an interview on 9/13/22 at 9:22 a.m., Resident #2 was a smoker and sat on the patio. He said on 9/10/22 Resident #1 sat outside in the sun most of the day. He said the staff tried to get her back inside, but she went out again. He said she came in and out of the facility that day but spent most of the day outside in the sun. He said Resident #1 liked to sit in the sun and be close to the gate. She tried to get out the gate when no one was watching. She was an escape artist, he had seen her try to get out of the gate in the past. During an interview on 9/13/22 at 9:24 a.m., Resident #3 said she went out to smoke on a regular basis. Resident #1 was always trying to sneak away from the facility. She sat outside in the sun all the time. According to Resident #3, Resident #1 tried to open the gate and leave. During an interview on 9/13/22 at 9:26 a.m., Resident #4 said she noticed Resident #1 sat outside most of the day on 9/10/22 or 9/11/22 she could not remember which day, but it was the weekend. She said Resident #1 was hardheaded and liked to sit outside in the sun. During an interview on 9/13/22 at 9:28 a.m., Housekeeper A said she took the residents out to smoke on occasion on the patio. Resident #1 was a smoker and most of the time she would come back inside. If she would not listen, she would let some of the nursing staff know she would not come back in. Housekeeper A said Resident #1 was not supposed to be outside by herself. During an interview on 9/13/22 at 9:59 a.m. the Activity Director said she took the residents out to smoke at 11:00 a.m. and 1:30 p.m. during the week, she was not there on 9/10/22. The Activity Director said Resident #1 liked to go outdoors and come back in all the time. Resident #1 liked to stay outside, not in the covered area but in the sun. During an interview on 9/13/22 at 10:18 a.m., Resident # 5 said she knew Resident #1 was outside at 1:30 p.m. to smoke on 9/10/22. She did not know if she came back in after. Resident #5 said Resident #1 had on shorts and short sleeves that day, and that was unusual for her. Resident #1 always had on a long sleeve shirt and pants. During an interview and record review on 9/13/22 at 10:32 a.m. the DON stated Resident #1 rolled herself up and down the halls all day. She would go outside to the smoke area and back inside. Resident #1 was always cold and always wore long sleeves and long pants. She would sit in the sun, and when she was not outside, she would sit in the doorway to get sun. The DON said she had received a report from LVN N on Saturday, 9/10/22, that they sent Resident #1 to the hospital. LVN N had not told her why only she had altered mental status. On 9/12/22 the hospital called to say Resident #1 had hyperthermia. After reviewing the EMS record with the DON, she said it was unacceptable for the nurses to shrug their shoulders with no answer as to how long the resident had been outside. During a telephone interview on 9/13/22 at 11:10 a.m., LVN M said the staff told her they tried to get Resident #1 inside on 9/10/22. She did not know she was outside or how long she had been outside. LVN M said she was not her nurse, but MA Q went to the dining room door and called for a nurse. Resident #1 was outside she told them she needed to get her inside, they put ice packs on her neck and cool rags. She said the resident was hot from sitting in the sun, her skin was hot to the touch, she was not red, and she was not sweating. Resident #1's temperature was 99.1. LVN M said she notified Resident #1's nurse, LVN N. LVN M said she did not know what time it was. She was hot from sitting in the sun. Resident #1 had altered mental status and they called 911. LVN M said Resident #1 constantly tried to go out the door. On 9/10/22, Resident #1 went out and came back in constantly during breakfast. LVN M said Resident #1 was inside for lunch and that was the last time she saw Resident #1 until the MA called her to the door. LVN M said she knew Resident #1 tried to get out the gate one time in the past. During an interview on 9/13/22 at 11:20 a.m., CNA O said she got Resident #1 dressed for breakfast on 9/10/22. Resident #1 had on short pants and a short sleeve shirt. She said there was a jacket on the back of her chair. CNA O said Resident #1 moved around a lot and would not stay in one place. She said around 3:00 p.m. they went outside to smoke. Resident #1 was sitting in the sun. Resident #1 would always complain she was cold. CNA O said she had to move her away from some of the doors during the day because Resident #1 had the wander guard that would cause the door alarms to go off. CNA O said she always had to look for Resident #1 because she was hard to keep up with. Resident #1 had gone in an out the smoking area all day. CNA O said she did not remember giving her any water. According to CNA O when the smoke break was over Resident #1 came back inside. She said it was brought to her attention by MA Q on 9/10/22 about 4:20 p.m., Resident #1 was outside and unresponsive. She said they brought her back inside. Resident #1 was warm, but she was not sweating. She had her eyes closed and was slobbering from her mouth. They (CNA O, MA Q, LVN M, put ice on her and cold towels. The nurses, LVN N or LVN M called 911. During a telephone interview on 9/13/22 at 11:35 a.m., CNA P said Resident #1 kept going in an out of the facility all day on 9/10/22, and about 3:30 p.m. she was outside talking to her. CNA P said she told Resident #1 to come back inside, and she came in. The CNA said she went back to the front and Resident #1 must have gone back outside. CNA P said she did not know how long Resident #1 had been outside that day. She said Resident #1 went in and out all the time, they would try to keep her inside, however, it was a constant battle. Resident #1 could come in and go out on her own at the patio doors only. When she was called at about 4:30 p.m. on 9/10/22 to assist with Resident #1, the resident was hot when MA Q found her. She said when MA Q hollered for help, we all ran to try and help. Resident #1's skin was hot to the touch, and she was drooling from her mouth. During a telephone interview on 9/13/22 at 11:39 a.m., CNA R said she worked on 9/10/22. She said the only thing she observed was Resident #1 sitting outside in the sun. She said she would bring Resident #1 inside and she would go back out. CNA R said Resident #1 would go back and forth, after the smoke break. CNA R said the last time she saw Resident #1, was at the smoke break after lunch at about 1:30 p.m. and she was outside. The next time she saw her was when MA Q called for help around 5:00 p.m. During an interview and record review on 9/13/22 at 11:50 a.m., the DON said they tied to make sure all residents were in a safe environment. She said residents did not stay out too long and they made sure they were hydrated. Record review of the care plan with the DON revealed there was no care plan intervention regarding Resident #1 going outside repeatedly to sit in the sun. There was no care plan regarding Resident #1 being a wanderer, or a smoker. During an interview on 9/13/22 at 12:24 p.m., MA Q said Resident #1 could get outside on her own and would always say she was cold. MA Q said at breakfast, she did not know if Resident #1 was outside or not. She said at lunch she did see Resident #1 and she was fine. After the resident ate, she was at the back door. MA Q said she did not see Resident #1 go outside. The next time she saw Resident #1 was around 4:30 p.m. she was sitting alone outside in the sun in her wheelchair. MA Q said she called Resident #1's name and tapped her on the shoulder. The resident did not respond. She said Resident #1 was drooling from her mouth. She stepped to the door and hollered for a nurse. She said LVN M came out and helped her bring Resident #1 inside. LVN M tried to arouse Resident #1. Then LVN M called LVN N and they got her blood pressure. They told us to put cold towels on her neck and forehead. She was not sweating, she was not red, just hot. She had on shorts and a worn (old, loose around the neck) tee shirt, socks, and shoes. The neck of shirt was exposed. MA Q said she did not know how long Resident #1 had been outside. The EMTs tried to get an answer on how long from her and other staff and no one knew. She said she tried to keep Resident #1 gate, because she would try to get out sometimes and cars came around the back of the building driving fast. During an observation and interview on 9/13/22 at 4:12 p.m., Resident #1 was observed in her hospital bed. She had an IV bag connected. She was in good spirits and said she felt much better. She had two large bandaged on her right arm and her left arm from her wrist to elbow. She said the hospital staff told her she was out in the sun to long. She did not feel sick before that day, and then she was just sick. She said she did not know how long she was in the sun but had been out most of the afternoon. She had gone back in the building a few times but went back out. Resident #1 said she was cold. She did not remember if she had water or not. During an observation and interview on 9/13/22 at 4:20 p.m. with Hospital RN revealed Resident #1 had scattered areas of discolored skin on her shoulders, chest, and upper arms. There was an area on her right upper chest area that was about 3.5 to 4 inches long and about an inch wide. It was dark in color and had no skin on top of the area. The Hospital RN said the places where the bandages were, there were areas where the blisters had burst. The Hospital RN said Resident #1 had blisters and red marks on both arms, and on her left leg there was a cluster of blisters that had burst and were covered with a large bandage. She said she did not know how long the resident was in the sun, but it was likely more than 30 minutes due to the damage of her skin. During an interview on 9/14/22 at 9:00 a.m., the Administrator said an investigation into the incident on 9/10/22 with Resident #1 had determined she had be in and out of the smoking area most of the day. Around 3:45 p.m. she was brought in by CNA P and she must have gone back out. She said around 4:30 p.m. Resident #1 was discovered unresponsive by MA Q. LVN M said they applied cold packs to her neck and EMS was called. They added an incident report that was not completed on 9/10/22. Resident #1's care plan was also updated to include information about heat exhaustion. The Administrator said Resident #1 did participate in activities of her choice. She always said she was cold and would go in and out or sit in the doors so she could get sunshine. The Administrator said they did not know what happened on 9/10/22 until the hospital called on 9/12/22 to say Resident #1 had a hyperthermia (body temperature above normal). Then they started their investigation into the incident and called it in to the state survey agency. During an interview on 9/14/22 at 9:53 a.m., LVN B said she did not work on the hall with Resident #1. However, she knew she liked to exit seek a lot and she was a resident they tried to watch. During an interview on 9/14/22 at 9:55 a.m. the Activity Director said Resident #1 liked Bingo. She would watch them do the other activities sometimes but usually did not participate. She said Resident #1 liked activities with food, and entertainment. The Activity Director said on occasion you could distract Resident #1 with activities, but Bingo was her favorite. Resident #1 would almost always take food or drinks, and she loved popcorn. During an interview on 9/14/22 at 10:01 p.m., LVN C said she did not work on 9/10/22. She said Resident #1 was confused and a wanderer. She could self-propel herself. She was easily redirected and liked to be outside where she was found on 9/10/22. She required incontinent care and had a pressure area. She had on a wander guard so the doors would alarm if she tried to go out all the doors except the patio doors. She would go out the smoke area and sit in the sun. LVN C said sometimes Resident #1 was cognitively fine and other times she is confused. It depended on the time of day or her moods if she was cognitive or not. During an interview on 9/14/22 at 11:23 a.m., the DON said she had been in her position since 7/25/22 but had worked at the facility prior to being the DON. She said on 7/3/22 Resident #1 tried to get out one of the exit doors on one of the halls. She said there was no care plan for the elopement issues and the DON initiated an elopement care plan today (9/14/22). She also said there was no care plan about her smoking. During a telephone interview on 9/14/22 at 12:04 p.m. Resident #1's physician said he had already talked to the Administrator regarding Resident #1. He said Resident #1's skin was fragile but likely no more fragile than anyone else her age and in the nursing home population. He said it was hard to determine how long it may have taken for her to sunburn. It was dependent on the condition of her skin elasticity. It could have been an hour and maybe a half hour. He said she could also be on some medications that could have contributed to her being more susceptible to the sun. The physician said he did know Resident #1 liked to be outside and sit in the sun. The Physician said the Administrator said normally Resident #1 had on long sleeves and pants compared to the shorts and short sleeves she had on 9/10/22 which also contributed to her sunburn. . During an interview on 9/14/22 at 12:51 p.m., CNA G said she worked at the facility for two years. She was not there on 9/10/22. CNA G said Resident #1 was easily redirected, she would give her water, or push her to the door so she could sit in the sun. She said Resident #1 always said she was cold. CNA G said when she got Resident #1 dressed, she would always put her in long sleeves and pants, although Resident#1 did have a variety of clothes in her closet. This was determined to be in an Immediate Jeopardy (IJ) situation on 9/14/22 at 4:00 p.m. The Administrator and Regional nurse Consultant were notified. The Administrator and the Regional Nurse Consultant were provided with the IJ template on 9/14/22 at 4:00 p.m. The following Plan of Removal submitted by the facility was accepted on 09/15/2022 at 9:25 a.m.: (Plan of Removal 1. Immediate actions The resident's physician and responsible party were notified by the Director of Nursing on 09/14/2022. Care Plan was developed on 09/14/2022 with interventions in place to prevent the resident from prolonged exposure to the sun which include: o Assess and monitor residents' temperature o Contact Physician if signs and symptoms worsen o Educate Staff of signs and symptoms of hyperthermia o Encourage Resident to sit in a shaded area o Ensure adequate fluids are given and encourage resident to consume fluids o Monitor resident carefully for heat related symptoms Care Plan was developed on 09/14/2022 regarding her wander guard and potential elopement tendencies for [Resident #1]. Care Plan was developed on 09/15/2022 regarding resident's tendency for heat exhaustion/tendency to want to sit outside in the sun. Interventions include offering diversional activities such as food, music, bingo etc . An audit was conducted to ensure that any resident triggering for at risk for elopement had: o a care plan in place, and o a photo, face sheet, and care plan in the wandering resident book An audit was conducted to ensure that an elopement assessment was completed on all residents in the past quarter. An alarm was placed on the gate in the courtyard on 09/14/2022 to ensure no resident at risk for wandering could elope. Q 1-hour checks were initiated on residents in the courtyard area during daylight hours on 09/14/2022. 2. Education (provided by DON or ADON) ALL STAFF were trained on Avoiding Heat Exhaustion and Heat Stroke by the Director of Clinical Services on 09/14/2022. This will be completed by 09/15/2022 at 2:00 PM. Staff will not return to shift without completing this in-service. ALL STAFF were in-serviced on ensuring residents are dressed appropriately for all weather conditions by the Director of Clinical Services on 09/14/2022. This in-service will be completed by 09/15/2022 at 2:00PM. Staff will not return to shift without completing this in-service. ALL STAFF were in-serviced on the Wandering Resident Policy and Wandering Resident Book by the Director of Clinical Services on 09/14/2022. This in-service will be completed by 09/15/2022 at 2:00 PM. Staff will not return to shift without completing this in-service. ALL STAFF were in-serviced on resident specific information regarding: o Wearing a UV rated shirt o Wearing a sun hat o Applying sunscreen to resident o Encourage resident to sit in the shade This in-service will be completed by 09/15/2022 at 2:00 PM. Staff will not return to shift without completing this in-service. All nursing staff were in-serviced on performing Q 1-hour checks on residents in the courtyard area during daylight hours on 09/14/2022 by the Director of Clinical Services. This in-service will be completed by 09/15/2022 at 2:00 PM. Nursing will not return to shift without the in-service. 3. Medical Director - The Medical Director has been notified of the Immediate Jeopardy. 4. QAPI Committee Review - An interim QAPI committee meeting was completed on 9/14/2022. 5. Plan of removal date: 09/15/2022) During an interview on 9/15/22 at 9:26 a.m., the Administrator said they had in serviced staff on supervision of residents in the courtyard area from 8 a.m. to 8 p.m. The nurse at the front nurse's station was responsible for monitoring residents at least hourly. There was a book with monitoring sheets (attached) at the nurse's station. They had put an alarm on the courtyard gate (it was visible from the parking area.) They had placed two books at the two nurses' station with a list of wandering residents along with their pictures. They had UV shirts that said Ultraviolent protection factor 50 plus that was supposed to block 98 percent of the UV rays for Resident #1 on days they could not keep her inside. They had in-services on heat exhaustion and what to look for. They also included hypothermia and frost bite for the winter. All staff were in-serviced because at one time each discipline could be responsible for taking the residents out to smoke, housekeeping, dietary business office and nursing. During interviews on 9/15/22 staff listed below were able to verbalize they had been in- serviced on Avoiding Heat Exhaustion and Heat Stroke, residents wore appropriate clothing, policy for wandering residents, and the wandering resident books. They verbalized resident specific training regarding Resident #1 which included diversional activities such as food or activities and encouraging residents to drink fluids. Staff said they were in-serviced on a wandering resident and what actions to take if a resident could not be found. At 10:13 a.m. Activity Director At 10:37 a.m. LVN B- day shift At 10:49 a.m. LVN C- Day shift At 10:59 a.m. MA/CNA D -Day shift At11:07 a.m. BOM At 11:36 a.m. Housekeeper E At 11:39 a.m. Dietary Manager At 12:03 p.m. CNA F -day shift At 12:42 p.m. CNA G- day shift At 12:52 p.m. CNA H- day shift At 12:59 p.m. Housekeeper I At 1:24 p.m. CNA J-day shift At 1:30 p.m. RN K PRN - work all shifts At 1:47 p.m. LVN L- PRN - work all shifts The Administrator, DON, ADON, Regional Nurse Consultant and the Regional Vice President of Operations were informed the Immediate Jeopardy was removed on 9/15/22 at 3:00 p.m. The facility remained out of compliance at a severity level of actual harm that in not immediate and a scope of as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care consistent with professional standards of practice for 1 of 14 (Resident # 5) reviewed for respiratory care. The facility did not ensure Resident #5 had replacement laryngectomy supplies (laryngectomy replacement tube) in the facility or at the bedside and a bag valve mask (handheld device used to provide rescue breaths during cardiac pulmonary resuscitation) at the bedside. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 2:27 p.m. on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of respiratory infection, respiratory distress and respiratory failure. Findings included: 1.Record review of an undated face sheet indicated Resident #5 was an [AGE] year-old male, admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #5 had orders to suction each shift, laryngectomy tube care every morning, and cleanse stoma area with normal saline and pat dry each shift. Record review of the MDS dated [DATE] indicated Resident #5 usually understands and was usually understood. Resident #5's BIMS score was an 11 indicating moderate cognitive impairment. Resident #5 requires extensive assistance of one staff for bed mobility, dressing, toilet use, and personal hygiene. Resident #5 requires extensive assistance of two staff for transfers and total assistance of one staff with bathing. The MDS section other Major Surgery was marked involving the endocrine organs, neck, lymph nodes or thymus. Section O of the MDS indicated Resident #5 required suctioning over the last 14 days. Record review of the care plan dated [DATE] indicated Resident #5 had a laryngectomy and had a laryngectomy tube with a goal of no symptoms of infection around the stoma (airway opening) or any signs of respiratory distress. The care plan interventions for Resident #5 included clean or replace neck straps if the old one was dirty, nursing would monitor and assess the skin around the stoma for redness, drainage and signs of warmth, clean the stoma with normal saline pat dry and re-insert, clean laryngectomy tube with water and mild soap, monitor oxygen saturation, monitor for symptoms of infection around the stoma, nursing to ensure a suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at bedside at all times. During an observation and interview on initial tour on [DATE] at 10:45 a.m., Resident #5 was sitting in his wheelchair in his room. There was a suction machine sitting at bedside. There were no visible replacement tubes or oxygen available in the room . During an interview with LVN H she indicated there were no replacement tubes in the facility. LVN H indicated there was no oxygen nor a bag valve mask (mask with a bag used for rescue breathing) at bedside. LVN H indicated Resident #5's family had an extra replacement laryngectomy tube at home, but he had the replacement tube in use now. LVN H indicated the facility did not have the replacement tubes because of the expense she was told. LVN H indicated in an emergency she would have to call 911. On [DATE] at 11:30 a.m., a call and a message was placed to the Nurse Practitioner at his office with no return phone call received regarding Resident #5's laryngectomy tube and care needed. During a telephone interview on [DATE] at 11:35 a.m., the physician indicated Resident #5 was at risk to lose his airway due to a [MEDICATION(S)] plug. The physician indicated he expected Resident #5's airway to be maintained via the larygectomy tube using an AMBU bag until EMS could arrive. The physician indicated the facility did not have the training to sustain Resident #5's airway by using another airway sustaining device such as an endotracheal tube (a tube placed directly in the tracheal). During an interview on [DATE] at 11:40 a.m., the Administrator indicated the facility had no replacement tubes or emergency supplies but had suction at bedside. The Administrator indicated if anything went wrong with Resident #5, they would call EMS. During an interview on [DATE] at 11:42 a.m., the Regional Nurse, indicated it was not procedural to have a bag valve mask at bedside for Resident #5 . During an interview on [DATE] at 11:45 a.m., the DON indicated the laryngeal tube was to keep Resident #5's airway open. The DON indicated she was unsure why the facility had not purchased any replacement laryngeal tubes. During an interview on [DATE] at 11:50 a.m., the ADON indicated hopefully the extra laryngeal tube will arrive tomorrow [DATE]. The ADON indicated she believed the Administrator found a laryngeal tube in Dallas. During an interview on [DATE] at 12:50 p.m., LVN H indicated the NP wanted a [CONDITION(S)] kit at bedside and oxygen with humidification for Resident #5. Record review of a nursing note dated [DATE] indicated the NP ordered oxygen at ,d+[DATE] liters via nasal cannula if oxygen was below 90%, a concentrator at bedside along with bag mask, [CONDITION(S)] kit, and suction for Resident #5. Record review of in-services conducted in 2022 indicated there were no in-services provided to the staff related to Resident #5's laryngeal tube. The facility did conduct an in-service regarding respiratory training on [DATE] but the material did not reveal any in-service material on laryngectomy tubes or laryngectomy care. During an interview on [DATE] at 1:39 p.m., LVN H indicated if she activated EMS for Resident #5 it would take EMS ,d+[DATE] minutes to arrive and it would take 5 more minutes to get the local hospital. LVN H indicated if she had to administer rescue breathing (breaths supplied by a mask and bag) for Resident #5, she would apply the mask to his mouth and provide ventilation until EMS could get him out of the facility. During an interview on [DATE] at 1:44 p.m., the DON indicated the EMS response time would be 3 minutes and then another 3 minutes to the local emergency room . The DON indicated she would use the mask valve for respirations on the stoma site itself. The DON indicated the excess air would come out of Resident #5's mouth. The DON indicated the respiratory training in on [DATE] did not include laryngectomy training and the training was only verbal. The DON indicated no computer-based training or use of a manikin. During an interview on [DATE] at 1:47 p.m., LVN C indicated for rescue breathing for Resident #5 he would close his stoma off and perform regular cardiopulmonary resuscitation. LVN C indicated the laryngeal tube does not affect his breathing. LVN C indicated he had not cared for a laryngeal tube before now. The administrator was notified of [DATE] at 2:27 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The administrator was provided the Immediate Jeopardy template and a Plan of Removal was requested. During an interview on [DATE] at 8:45 a.m., the Administrator indicated the laryngeal replacement tube arrived last night and was in the resident's room. The facility's Plan of Removal was accepted on [DATE] at 10:29 a.m. and included: Summary: The facility failed to have the appropriate emergency supplies at bedside: a replacement laryngectomy tube, and an artificial manual breathing unit (Ambu) bag for 1 of 1 resident with a laryngeal tube. The facility failed to train staff and ensure staff competency for laryngectomy tube care. Issues: *The facility failed to have the appropriate supplies at bedside : a replacement laryngeal tube and an artificial manual breathing unit (Ambu) bag. *The facility failed to train staff and ensure staff competency for laryngectomy tube care. Immediate Actions: 1.The resident's physician and responsible party were notified by the Director on Nursing on [DATE]. All nurses were trained on appropriate laryngectomy tube care by the Director of Clinical Services on [DATE]. Ambu bag was placed at Resident #5's bedside on [DATE] An extra laryngectomy tube was obtained and placed at bedside at 9:30 p.m. on [DATE]. Plan was put in place until extra laryngectomy tube arrived as follows: *If tube comes out, clean and replace the tube. *If tube was unable to be replaced call 911. *While waiting on EMS (emergency medical services) to arrive: support the airway by monitoring secretions, suctioning as needed and monitoring oxygen saturations and completing a lung assessment. Provide supplemental oxygen with humidification as needed. 2.Education (provided by DON or ADON) *All nurses were in-serviced on appropriate laryngectomy tube care on [DATE]. This in-service includes competency checks by return demonstration. Each nurse will be in-serviced prior to return to shift. This will be completed by [DATE]. Nursing will not return to shift without the in-service and return demonstration. *All nurses were in-serviced on emergency procedures related to Cardiopulmonary Resuscitation of a person with a laryngectomy tube on [DATE] which includes appropriate placement of the Ambu (mask valve bag ventilation) over the laryngectomy to create a good seal. This in-service will be completed by [DATE]. *All nurses were in-serviced on items that need to be kept at bedside for a resident with a laryngectomy tube beginning [DATE] which includes Ambu bag and replacement laryngectomy tube. This in-service will be completed by [DATE]. Nursing will not return to shift without the in-service. *All nurses were in-serviced on what to do if laryngectomy tube was unable to be replaced on [DATE]. This in-service included: if tube comes out, clean and replace the tube. Additionally, if tube was unable to be replaced Call 911. Then, while waiting on EMS to arrive: Support the airway by monitoring secretions, suctioning as needed and monitoring oxygen saturation and completing a lung assessment, and supplemental oxygen with humidification as needed. This in-service will be completed by [DATE]. Nursing will not return to shift without the in-services. 3. The Medical Director had been notified of the Immediate Jeopardy. 4. An interim QAPI committee meeting was completed on [DATE]. During an observation on [DATE] at 8:25 a.m., Resident #5 was lying in his bed. The emergency care supplies and equipment including a [CONDITION(S)] kit, suction, Ambu bag, extra laryngeal tube, and oxygen. The suction machine and Ambu bag were sitting on a bedside table at the head of Resident #5's bed. The oxygen concentrator was stored in the room and the extra laryngeal tube was pinned under the overbed light at the head of Resident #5's bed. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to the Immediate Jeopardy (IJ) by: Interviews of the nursing staff (ADON; DON; 2 nurses on the 6:00 a.m.-2:00 p.m.; 3 agency nurses working various remove shifts; 1 nurse working 2:00 p.m. -10:00; and 2 nurses on the 10:00 p.m. -6:00 a.m.) were performed. During these interviews nurses stated correctly how to support Resident #5's airway until EMS arrived, and what items were needed at bedside to support Resident #5's airway. On [DATE] at 3:11 p.m., the Administrator was informed the IJ was removed: however, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Laryngectomy | [CONDITION(S)] Education, accessed on [DATE] A total laryngectomy is typically performed when the disease cannot be managed with more conservative measures. In a total laryngectomy the entire larynx is removed (including the vocal folds, hyoid bone, epiglottis, [CONDITION(S)] and cricoid cartilage and a few tracheal cartilage rings). The airway is separated from the nose, mouth and esophagus. The trachea is brought forward below the level of the larynx and is sutured to the base of the neck just above the sternal notch, creating a permanent opening in the neck called a stoma. Therefore, the individual does not breathe through the upper airway. Instead, breathing occurs through the stoma. Breathing, speech, and swallowing are significantly changed after the procedure. Since the stoma is the only passageway for breathing, it is important to maintain the airway and suction the trachea through the stoma as needed, using a sterile technique. It is also important to clean the stoma, as crusting of secretions may develop that can block or occlude the stoma. It is important to teach the patient, family and/or caregivers how to care for the stoma properly, and what to do in case of an emergency. A laryngectomy is a procedure which alters the anatomy of the upper airway and results in breathing that occurs only through the stoma. The entire larynx is removed during a total laryngectomy. In [CONDITION(S)], the upper airway is still intact. There is potential upper airway in patients with [CONDITION(S)]. Record review of an undated Laryngectomy Tube Care policy indicated the purpose of this procedure was to guide laryngectomy care. General Guidelines included: laryngectomy tubes should be changed as ordered and as needed, laryngectomy care should be provided as often as needed, at least once daily, a suction machine, supply of suction catheters, exam and sterile gloves, and flush solution must be available at the bedside at all times. rescue-breathing.pdf (d1a743corqz1mw.cloudfront.net) accessed on [DATE] Laryngectomees and other neck breathers are at great risk of getting inadequate acute care when they experience breathing difficulties or need cardiopulmonary resuscitation. It is essential that medical personnel learn to identify neck breathers and differentiate partial neck breathers from total neck breathers. Respiratory problems unique to neck breathers are [MEDICATION(S)] plugs, and foreign body aspiration. Although partial neck breathers inhale and exhale mainly through their stoma they still have a connection between their lungs, and their nose, and mouth. In contrast there is no such connection in total neck breathers. Both partial and total neck breathers should be ventilated through their [CONDITION(S)] site. However, the mouth needs to be closed and the nose sealed in partial neck breathers to prevent air escape. An infant or toddler bag valve mask should be used in ventilating through the stoma. Laryngectomees and other neck breathers are at great risk of getting inadequate acute care when they experience breathing difficulties or need cardiopulmonary resuscitation (CPR)1. Many of emergency department (ED) and emergency response services (EMS) personnel do not recognize a patient who is a neck breather, do not know how to administer oxygen to them in the proper way, and may erroneously give mouth-to-mouth breathing when mouth-to-stoma breathing is indicated. This can lead to devastating consequences because it can deprive sick people from the oxygen, they need to survive2. Prepare for Rescue Breathing The steps in rescuing a neck breather are to first determine their unresponsiveness; then activate the emergency medical services; position the person raising their shoulders; expose the neck and remove anything covering the stoma (filter, cloth) that may prevent access to the airway; secure the airway by checking the neck for a stoma, remove anything that blocks the airways such as the filter or HME if present; and clear any mucous from the stoma. It is not necessary to remove the stoma's housing unless it blocks the airway. In emergency situations, laryngectomy tubes and stoma buttons may be removed carefully if they are blocking the airway. The voice prosthesis should not be removed unless it is blocking the airway. The voice prosthesis generally does not interfere with breathing or suctioning. If the prosthesis is dislodged it should be removed and replaced with a catheter to prevent aspiration and fistula closure. If present the tracheal tube may need to be suctioned after insertion of ,d+[DATE] cc of sterile saline or removed (outer & inner) to clear any plugs. The stoma should be wiped and suctioned. The next step is to listen for breathing sounds over the stoma. The chest may fail to rise because the [CONDITION(S)] tube is blocked. If a [CONDITION(S)] tube is used for resuscitation, it should be shorter than the regular one so that it can fit the length of the trachea. Care should be used in inserting the tube so that it does not dislodge the voice prosthesis (see Figure 9). This may require the use of a tube with a smaller diameter Ventilation in neck breathers: The actual rescue breathing for neck breathers is generally similar to the one performed on normal individual with one major exception. In neck breathers ventilation and oxygen administration is done through the stoma (mouth to stoma, Figure 9 - left) or using a mask (infant/toddler or adult turned through 900, Figure 9 - right). It is useless to try mouth-to-mouth ventilation. The website https://pubmed.ncbi.nlm.nih.gov/ 261/ accessed on [DATE] stated .respiratory infections can result from the use of medical devices and respiratory supplies. These devices can contribute to the home care or hospice patient developing a respiratory infection by serving as a reservoir and supporting the growth of microorganisms and by directly infecting patients when this equipment becomes contaminated .Oxygen Therapy: Concentrator. The external filter on the concentrator should be washed with soap and water, air dried, and replaced on the oxygen concentrator minimally on a weekly basis .

Based on interview and record the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and the comprehensive care plan for 1 of 5 resident reviewed for laboratory services. (Resident #1) The facility did not maintain Resident #1's [MEDICATION NAME] (a medication used to control [MEDICAL CONDITION]) at a therapeutic level (the level of drug in the bloodstream that is most effective without causing any serious problems). Resident #1's most recent [MEDICATION NAME] level obtained on 6/8/19 indicated his [MEDICATION NAME] level was low at 6.8 (therapeutic level is 10-20). Resident #1 did not receive his [MEDICATION NAME] medication as ordered on [DATE] and was later transported to the emergency department after experiencing a [MEDICAL CONDITION]. Resident #1's [MEDICATION NAME] level was not checked by the facility until 9/24/19 after surveyor intervention. The residents [MEDICATION NAME] level on 9/24/19 was <3.0. This failure could place residents with [MEDICAL CONDITION] disorders at risk of not receiving therapeutic benefits of their medication, injury and death. Findings included: Physician orders dated 9/1/19 indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated the resident was to receive [MEDICATION NAME] 200 mg by mouth 4 times daily at 10 a.m., 2 p.m., 6 p.m. and 10 p.m. The physician orders did not include a laboratory order to monitor [MEDICATION NAME] levels. An MDS assessment dated [DATE] indicated Resident #1 was able to make himself understood to others and usually understood others. The MDS indicated his hearing was highly impaired and he required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. A care plan dated 8/1/19 indicated Resident #1 was at risk for [MEDICAL CONDITION] activity and a long-term goal indicated his medication levels would remain with-in therapeutic levels. Interventions included to obtain laboratory services as ordered, notify the physician of results and provide medications as ordered. A hospital visit provider note dated 9/9/19 indicated Resident #1 arrived at the emergency department by ambulance. The note indicated the resident was being transported from [MEDICAL TREATMENT] by a medical transport van when he yelled I have [MEDICAL CONDITION]. The driver of the van called EMS to transport the resident to the emergency department. A hospital nursing note dated 9/19/19 for Resident #1 indicated the following: *2:15 p.m. - rhythmic jerking of left side to entire body. Physician notified and [MEDICATION NAME] 2 mg (medication used to treat [MEDICAL CONDITION]) given IM (in the muscle). PO (by mouth) [MEDICAL CONDITION] medication ordered. *2:35 p.m. - patient continues to have rhythmic, jerking motions to left side of body. Physician notified. New order received for [MEDICATION NAME] 2 mg IV (intravenous) and IV [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]). *3:00 p.m. - patients SpO2 (measurement of oxygen in blood) decreased to 80% (normal range 95% to 100%) while having a [MEDICAL CONDITION]. Patient placed on NRB (non-rebreather mask (a device used to assist in the delivery of high concentration oxygen therapy). SpO2 increased to 97%. *4:10 p.m. - patient remained hypotensive (low blood pressure), SBP (systolic blood pressure) was in the 80's (normal range 90 to 120). A nurse procedure note from the hospital dated 9/9/19 at 2:40 p.m., indicated Resident #1 had an intravenous catheter (a small tube inserted into the vein in order to administer medication or fluids) inserted. A Medication Administration Record [REDACTED] *2:17 p.m. - [MEDICATION NAME] 2 mg intramuscular; one time dose; *2:19 p.m. - [MEDICATION NAME] 200 mg; 2 capsules; one time dose; *2:48 p.m. - [MEDICATION NAME] 2 mg IV; one time dose; and *3:09 p.m. - [MEDICATION NAME] 500 mg IV; one time dose. A hospital provider note dated 9/9/19 at 6:42 p.m. indicated Resident #1 was having a partial [MEDICAL CONDITION] of his arm. The note indicated Resident #1 had some weakness of his left hand where the [MEDICAL CONDITION] activity happened with a final diagnostic impression of [MEDICAL CONDITION] disorder and breakthrough (a seziure that occurs when [MEDICAL CONDITION] are otherwise well controlled) [MEDICAL CONDITION]. The note indicated Resident #1 would return to the nursing facility. During an interview on 9/24/19 at 9:45 a.m., Resident #1 said on 9/9/19 he was awoken at 4:00 a.m. and informed he would be leaving at 5:15 a.m. for [MEDICAL TREATMENT]. The resident said no one told him prior to that morning that his regularly scheduled [MEDICAL TREATMENT] appointment for 11:30 a.m. had been changed to 6:30 a.m. He said he usually took his [MEDICAL CONDITION] medications prior to going to [MEDICAL TREATMENT] but did not receive his medications before leaving the facility on 9/9/19. He said the medical transport van forgot about him and he waited for 2 hours to be picked up at [MEDICAL TREATMENT]. Resident #1 said he had a [MEDICAL CONDITION] in the medical transport van on the way back to the facility and the driver called 911. He said the ambulance transferred him to the local emergency department. He said he had another [MEDICAL CONDITION] in the emergency department. The most recent [MEDICATION NAME] level laboratory result for Resident #1 dated 6/8/19 indicated his [MEDICATION NAME] level was 6.8. The nursing notes from 6/8/19 to 9/24/19 did not indicate the NP or the physician was notified by phone of Resident #1's [MEDICATION NAME] level obtained on 6/8/19. During an interview on 9/24/19 at 12:40 p.m., LVN B said Resident #1 took [MEDICATION NAME] and should have a laboratory test ordered for a [MEDICATION NAME] level at least every three months. LVN B said Resident #1's most recent laboratory result for a [MEDICATION NAME] level was obtained on 6/8/19 and the results were low. She said Resident #1 was in the emergency roiagnom on [DATE] with [MEDICAL CONDITION] activity and he should have had a laboratory test to check his [MEDICATION NAME] level. LVN B said when laboratory tests were abnormal the results would be faxed and called to the NP or physician. She said the results of the abnormal laboratory and contact with the NP or physician should be documented in the nursing notes. During an interview on 9/24/19 at 12:50 p.m., LVN C said residents with orders for scheduled [MEDICATION NAME] should have a laboratory test to monitor [MEDICATION NAME] levels every 3 months. LVN C said Resident #1 was on [MEDICATION NAME] medication and the order did not include a [MEDICATION NAME] level order. During an interview on 9/24/19 at 1:00 p.m., the nurse practitioner said she was unable to recall notification of Resident #1's laboratory results for [MEDICATION NAME] levels on 6/8/19. She said a result of 6.8 was not within therapeutic range and she would have ordered a monthly laboratory test to monitor the dose of [MEDICATION NAME] he was prescribed. She said she would order a [MEDICATION NAME] level for Resident #1 for today 9/24/19. During an interview on 9/24/19 at 1:27 p.m., the DON said Resident #1 should have a laboratory test to monitor [MEDICATION NAME] levels at least every 3 months. She said the order for a weekly laboratory test for [MEDICATION NAME] was discontinued in (MONTH) 2019 and the order for [MEDICATION NAME] level every 3 months must have been deleted from the system as well. The DON said the laboratory test for the [MEDICATION NAME] level slipped through the cracks. The DON said the most recent laboratory test to monitor Resident #1's [MEDICATION NAME] level was obtained on 6/8/19 and it was low. The DON said she expected the charge nurse to follow up with the physician or nurse practitioner after a laboratory result was faxed and results were abnormal and document in the resident medical record. The DON said Resident #1 should have had a [MEDICATION NAME] level ordered after he returned from the hospital ER visit on 9/9/19. During an interview on 9/24/19 at 2:40 p.m., the administrator said Resident #1 should have a routine order for a laboratory test to monitor his [MEDICATION NAME]. The administrator said she expected charge nurses to obtain orders for routine laboratory test and report results to the physician or nurse practitioner. During a telephone interview on 9/30/19 at 8:47 a.m., the DON said Resident #1's [MEDICATION NAME] level obtained on 9/24/19 was <3.0. The DON said an order was received to recheck the [MEDICATION NAME] level on 9/30/19 and to change the time of administration for Resident #1's [MEDICAL CONDITION] medication to assure he received it prior to [MEDICAL TREATMENT]. The website https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=[MEDICATION NAME] accessed on 10/2/19 the following: .[MEDICATION NAME] (generic [MEDICATION NAME]) test monitors the level of [MEDICATION NAME] in your blood .Your healthcare provider must monitor your blood to make sure you are getting the correct dose. Too much can be toxic. Not enough leaves your [MEDICAL CONDITION] uncontrolled. You may have this test more often when you first start taking this medicine then regularly throughout treatment. You may need to repeat the test if the medicine doesn't control your [MEDICAL CONDITION] . The website https://www.americannursetoday.com/[MEDICATION NAME]-keep-patients-in-the-range-and-out-of-danger/ accessed on 10/2/19 indicated a patient's [MEDICATION NAME] (generic for [MEDICATION NAME]) level must stay in the therapeutic range and should therefore be monitored frequently. A subtherapeutic [MEDICATION NAME] level can result in breakthrough [MEDICAL CONDITION].

Based on interview and record the facility failed to ensure the medication regimen was free from significant medication errors for 1 of 5 residents reviewed for medications. (Resident #1) The facility did not administer Resident #1's physician ordered 10:00 a.m. dose of [MEDICATION NAME] (a medication used to control [MEDICAL CONDITION]) and [MEDICATION NAME] (a medication used to control [MEDICAL CONDITION]) on 9/9/19. The resident was transferred to a 6:30 a.m. [MEDICAL TREATMENT] appointment prior to receiving any medications. He was not picked up from [MEDICAL TREATMENT] until approximately 1:00 p.m. Resident #1 had a [MEDICAL CONDITION] in the medical transport van and was transferred to the local emergency department for treatment. This failure could place residents with [MEDICAL CONDITION] disorders at risk of not receiving therapeutic benefits of their medication, injury and death. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated the resident was to receive [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]) 200 mg by mouth 4 times daily at 10 a.m., 2 p.m., 6 p.m. and 10 p.m. and [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]) 500 mg by mouth 2 times daily at 10 a.m., and 9 p.m. An MDS assessment dated [DATE] indicated Resident #1 was able to make himself understood to others and usually understood others. The MDS indicated his hearing was highly impaired and he required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. The most recent laboratory result for Resident #1 dated 6/8/19 indicated his [MEDICATION NAME] level was 6.8 (therapeutic level is 10-20). A care plan dated 8/1/19 indicated Resident #1 was at risk for [MEDICAL CONDITION] activity and a long-term goal indicated his medication levels would remain with-in therapeutic levels. Interventions included to obtain laboratory services as ordered, notify the physician of results and provide medications as ordered. The care plan indicated Resident #1 had a communication deficit and read lips and used writing to communicate his needs. Interventions included allow the resident time to communicate and encourage use of gestures. A hospital visit provider note dated 9/9/19 indicated Resident #1 arrived at the emergency department by ambulance. The note indicated the resident was being transported from [MEDICAL TREATMENT] by a medical transport van when he yelled I have [MEDICAL CONDITION]. The driver of the van called EMS to transport the resident to the emergency department. A hospital nursing note dated 9/19/19 for Resident #1 indicated the following: *2:15 p.m. - rhythmic jerking of left side to entire body. Physician notified and [MEDICATION NAME] 2 mg (medication used to treat [MEDICAL CONDITION]) given IM (in the muscle). PO (by mouth) [MEDICAL CONDITION] medication ordered. *2:35 p.m. - patient continues to have rhythmic, jerking motions to left side of body. Physician notified. New order received for [MEDICATION NAME] 2 mg IV (intravenous) and IV [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]). *3:00 p.m. - patients SpO2 (measurement of oxygen in blood) decreased to 80% (normal range 95% to 100%) while having a [MEDICAL CONDITION]. Patient placed on NRB (non-rebreather mask - a device used to assist in the delivery high concentration oxygen therapy). SpO2 increased to 97%. *4:10 p.m. - patient remained hypotensive (low blood pressure), SBP (systolic blood pressure) was in the 80's (normal range 90 to 120). A nurse procedure note from the hospital dated 9/9/19 at 2:40 p.m., indicated Resident #1 had an intravenous catheter (a small tube placed in a vein used to administer medications or fluids) inserted. A Medication Administration Record [REDACTED] *2:17 p.m. - [MEDICATION NAME] 2 mg intramuscular; one-time dose; *2:19 p.m. - [MEDICATION NAME] 200 mg; 2 capsules; one-time dose; *2:48 p.m. - [MEDICATION NAME] 2 mg IV; one-time dose; and *3:09 p.m. - [MEDICATION NAME] 500 mg IV; one-time dose. A hospital provider note dated 9/9/19 at 6:42 p.m. indicated Resident #1 was having partial [MEDICAL CONDITION] of his arm. The note indicated Resident #1 had some weakness of his left hand where [MEDICAL CONDITION] activity happened with a final diagnostic impression of [MEDICAL CONDITION] disorder and breakthrough [MEDICAL CONDITION] (a [MEDICAL CONDITION] that occurs in someone whose [MEDICAL CONDITION] are otherwise controlled). The note indicated Resident #1 would return to the nursing facility. During an interview on 9/24/19 at 9:45 a.m., Resident #1 said on 9/9/19 he was awoken at 4:00 a.m. and informed he would be leaving for [MEDICAL TREATMENT] at 5:15 a.m. He said no one told him prior to that morning his regularly scheduled [MEDICAL TREATMENT] treatment had been changed or that he would be transported by a medical transport van rather than by the facility transport. He said he usually left the facility at 11:00 a.m. to get to his [MEDICAL TREATMENT] appointment at 11:30 am. Resident #1 said he did not receive his medications, including his [MEDICAL CONDITION] medications, prior to leaving the facility at approximately 5:30 a.m. He said the medical transport van forgot about him and he was not picked up from [MEDICAL TREATMENT] until approximately 1:00 p.m. He said he had a [MEDICAL CONDITION] while traveling from the [MEDICAL TREATMENT] clinic to the facility and the driver pulled over to the side of the road and called 911. Resident #1 said an ambulance transferred him to the hospital and he had another [MEDICAL CONDITION] in the emergency room . During an interview on 9/24/19 at 10:08 a.m., Resident #1's daughter said she was informed by a friend Resident #1 was transported to the emergency roiagnom on [DATE] due to having a [MEDICAL CONDITION]. The daughter said the resident did not receive his [MEDICAL CONDITION] medication prior to [MEDICAL TREATMENT] because he left the facility before 5:30 a.m. She said he usually had [MEDICAL TREATMENT] at 11:30 a.m. and on 9/9/19 he was scheduled for 6:30 a.m. She said neither she or the resident had been informed the [MEDICAL TREATMENT] appointment was changed. She said Resident #1 had a [MEDICAL CONDITION] in the van and another [MEDICAL CONDITION] while in the emergency room . During an interview on 9/24/19 at 12:35 p.m., LVN A said on 9/8/19 she was informed Resident #1 had to be up and ready for [MEDICAL TREATMENT] by 5 a.m. on 9/9/19. She said she did not administer his morning [MEDICAL CONDITION] medications because it was too early, and she did not have a physician order [REDACTED]. During an interview on 9/24/19 at 10:42 a.m., CNA D/ van driver said on 9/9/19 she was told to go to the [MEDICAL TREATMENT] center and pick up Resident #1. She said medical transportation had taken him to [MEDICAL TREATMENT] early and had given him a card to call when he was ready to be picked up. She said the resident was deaf and was not able to use the phone to call anyone. CNA D said when she arrived at the [MEDICAL TREATMENT] center at approximately 1:15 p.m. she was told medical transportation had picked him up 15 minutes prior to her arrival. CNA D said Resident #1 usually left the facility for [MEDICAL TREATMENT] at 10:30 a.m. and his appointment was at usually at 11:00 a.m. CNA D said Resident #1's treatment was usually 4 hours and 15 minutes. During an interview on 9/24/19 at 1:27 p.m., the DON said Resident #1 did not receive his [MEDICAL CONDITION] medication prior to going to the [MEDICAL TREATMENT] appointment on 9/9/19. She the resident did not receive his 10:00 a.m. dose of [MEDICATION NAME] or [MEDICATION NAME] on 9/9/19. She said the facility expected Resident #1 to return to the facility at 11:00 a.m. and his 10:00 a.m. medications, including his [MEDICATION NAME] and [MEDICATION NAME] would have been given at 11:00 a.m. She said Resident #1 did not return to the facility by 11:00 a.m. because the medical transport van did not pick him up on time. During an interview on 9/24/19 at 2:40 p.m., the administrator said they expected Resident #1 to return to the facility by 11:00 a.m. and his 10:00 a.m. medications would have been administered then. https://www.[MEDICAL CONDITION].com/learn/triggers-[MEDICAL CONDITION]/missed-medicines accessed on 10/5/19 indicated missing doses of [MEDICAL CONDITION] medicine is the most common cause of breakthrough [MEDICAL CONDITION]. Missed medicines can trigger [MEDICAL CONDITION] in people with both well-controlled and poorly controlled [MEDICAL CONDITION]. [MEDICAL CONDITION] can happen more often than normal, be more intense or develop into long [MEDICAL CONDITION] called [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is a medical emergency and can lead to death if the [MEDICAL CONDITION] aren't stopped. Missing does can also led to falls, injuries and other problems from [MEDICAL CONDITION] and changes in medicine levels.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to promote healing and prevent development of pressure injuries for 2 of 4 residents reviewed for pressure injury. (Residents #48 and #49) The facility did not provide repositioning, off-loading and a pressure relieving device for Resident #48 as indicated by his care plan. The resident developed 3 facility acquired stage 3 pressure injuries and 1 stage 2 pressure injury. The facility did not provide off-loading to Resident #49's heels. The resident developed a facility acquired deep tissue injury that worsened over time. This failure could place residents at risk for the development of new or worsening pressure injuries, decreased quality of care, and decreased quality of life. Findings included: 1.The consolidated physician orders [REDACTED].#48 was [AGE] years old, re-admitted [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED].#48's wheelchair and checked every shift to ensure the placement of the cushion starting 12/1/18. The physician orders [REDACTED]. *clean wound to left heel with normal saline or soap and water, apply collagen powder and hypochlorite gel then cover with non-border foam one time a day for wound healing for 30 days; *clean wound to right heel with normal saline or soap and water, apply collagen powder and hypochlorite gel then cover with non-border foam one time a day for wound healing for 30 days; *clean wound to right ischium with normal saline or soap and water. Apply calcium alginate and cover with [MEDICATION NAME] dressing on Monday, Wednesday and Friday for 30 days. A significant change MDS dated [DATE] indicated Resident #48 was at risk for pressure injury development and had no stage 1 or higher pressure injuries. The MDS indicated Resident #48 required maximum assistance to roll left and right and required extensive assistance with locomotion in wheelchair, dressing and personal hygiene. The MDS indicated Resident #48 was totally dependent on staff for transferring and toileting. The most recent MDS dated [DATE] indicated Resident #48 had 1 stage 3 pressure injury. The MDS indicated Resident #48 was totally dependent on staff for transfers and required extensive assistance with activities of daily living that included bed mobility, personal hygiene, toileting, dressing and locomotion with wheelchair. The MDS indicated that Resident #48 had moderate cognitive impairment, was understood and had the ability to understand others and had not exhibited rejection of care. The care plan dated 1/18/19 indicated Resident # 48 had pressure injuries and would refuse to lay down or reposition. The care plan indicated he would put pillows in his wheelchair. Interventions included; placement of a pressure relieving cushion at all times; elevating heels; to perform care as able; monitor skin status and report changes to. The care plan did not address interventions for refusal of care. A weekly pressure injury log dated 12/7/18 indicated Resident #48 had no pressure injuries. There were no pressure injury logs provided for 12/14/18, 12/21/18 or 12/28/18. A weekly non-pressure injury log dated 1/4/19 indicated Resident #48 had a venous ulcer to the left heel that measured 2 cm (centimeters) in length, 3 cm in width and 0.2 cm in depth. A weekly skin assessment dated [DATE] indicated Resident #48 had a stage 3 pressure injury to the left heel that measured 2 cm in length, 3 cm in width and 0.2 cm in depth. A weekly non-pressure injury log dated 1/11/19 indicated Resident #48 had a venous ulcer to the left heel that measured 2 cm in length, 3 cm in width and 0.2 cm in depth. A weekly skin assessment dated [DATE] indicated Resident #48 had a stage 3 pressure injury to the left heel that measured 2 cm in length, 3 cm in width and 0.2 cm in depth. A weekly pressure injury log dated 1/18/19 indicated Resident #48 had an unstageable deep tissue injury acquired on 1/18/19 to the right heel measuring 1.5 cm in length, 1.5 cm in width with no depth and a stage 3 pressure injury to the left heel that measured 4 cm in length, 4 cm in width and 0.5 cm in depth. There was no weekly pressure injury log provided for 1/25/19. A weekly skin assessment dated [DATE] indicated Resident #48 had an unstageable deep tissue injury to the right heel that measured 1.5 cm in length, 1.5 cm in width and with no depth, and a stage 3 pressure injury to the left heel that measured 2 cm in length, 3 cm in width and 0.2 cm in depth. A weekly pressure injury log dated 2/1/19 indicated Resident #48 had an unstageable deep tissue injury to the right heel measuring 1.5 cm in length, 1.5 cm in width with no depth, and a stage 3 pressure injury to the left heel that measured 4 cm in length, 4 cm in width and 0.5 cm in depth. A weekly skin assessment dated [DATE] indicated Resident #48 had unstageable deep tissue injury to the right heel measuring 1.3 cm in length 1.3 cm in width and 0.2 cm in depth and a stage 3 pressure ulcer to left heel that measured 2 cm in length, 3 cm in width, and .2 cm in depth. There was no weekly pressure log provided for 2/8/19. A weekly pressure injury log for 2/12/19 indicated Resident #48 had a stage 3 pressure injury to the left buttock (the facility identified the location of the wound incorrectly on this document, the wound location is the right ischium) that measured 3 cm in length x 3 cm in width x <0.2 and indicated it was acquired on 2/15/19. The log indicated Resident #48 had a stage 3 pressure injury on his left heel that measured 4 cm in length x 4 cm in width x 0.5 cm in depth and an unstaged pressure injury (no stage was given in the documentation) on his right heel that measured 1 cm in length x 1 cm in width, and had no depth. A weekly skin assessment dated [DATE] indicated Resident #48 had an unstaged pressure injury (no stage was given in the documentation) on his right heel that measured 1.2 cm in length x 1.2 cm in width, and had no depth, and a stage 3 pressure injury to his left heel that measured 1.8 cm in length, 2.8 cm in width and .2 cm in depth. There was no documentation regarding a wound to the right ischium. A weekly skin assessment for 2/21/19 was not provided. A wound physician note dated 2/22/19 indicated Resident #48 had a stage 3 pressure injury on his right ischium that measured 3.5 cm in length x 2.5 cm in width x 0.2 cm in depth; a stage 3 pressure injury on his left heel that measured 3.5 cm in length x 2.5 cm in width x 0.2 cm in depth; and a stage 3 pressure injury on his right heel that measured 2.5 cm in length x 3.5 cm in width x 0.2 cm in depth after all wounds were debrided. The note indicated to off load Resident #48's wound areas and to reposition him per facility policy. During an interview on 2/26/19 at 3:45 p.m., the wound care nurse said she was responsible for completing weekly skin assessments and completing both the weekly pressure injury log and the weekly non-pressure injury log. She said she documented a wound to the left buttock on Resident #48 on the weekly the pressure injury log dated 2/12/19, but the injury was on the right ischium. She said staff had been applying a barrier cream to his bottom because it had been red. She said Resident #48 had developed the stage 3 pressure injury on his right ischium after her last skin assessment on 2/7/19 as it developed on 2/15/19. During an observation and interview on 2/25/19 at 7:06 a.m., Resident #48 was sitting in his wheelchair. There was not a pressure relieving cushion in his wheelchair. Resident #48 said his butt was sore. Resident #48 said he sometimes had a cushion in his wheelchair and it helped, but he did not know where it was. Resident #48 said he would like to be repositioned at night because he got uncomfortable, but he was not repositioned. He said he used his call light to ask staff to help him reposition or get up out of the bed, but they did not always assist him. He said staff did not like to get him up and down during the night because they had to use the Hoyer lift. During an observation on 2/25/19 at 10:30 a.m., Resident #48 was sitting in his wheelchair, there was no pad or pillow in his wheelchair, and his heels were covered with compression hose and were resting on the floor. There were no leg or foot rest on the wheelchair. During an observation on 2/25/19 at 10:43 a.m., Resident #48 was lying on his back in his bed. He had compression hose covering his feet and his heels were pressing against the foot of the bed. During an observation on 2/25/19 at 11:32 a.m., Resident #48 was transferred with a Hoyer lift from his bed to his wheelchair by CNA F and CNA H. Resident #48's heels were resting on the floor. The CNAs did not place a cushion in his wheelchair and did not attempt to reposition or elevate his heels off the floor. During an observation and interview on 2/26/19 at 10:27 a.m., the wound care nurse provided wound care to Resident #48's stage 3 pressure injury on his right ischium that measured approximately 4.5 cm in length and 3.5 cm in width. The wound bed was bright red and there was a small amount of serous drainage and no odor. A new stage 2 pressure injury over the sacrum was observed. The pressure injury measured approximately 1 cm in length and 3 cm in width. The skin around the stage II pressure injury to sacrum (approximately 8cm in diameter) was red in color. The wound care nurse said Resident #48 stayed red in his sacral area and it was caused by pressure from sitting in his wheelchair. The wound care nurse stated the skin was broken a little and applied a barrier cream over the area. She did not measure the stage II pressure injury. There was no documentation of physician notification regarding the stage II pressure injury as of 2/27/19. The wound care nurse performed wound care to both the left and right heel. No measurements were taken. Both wounds had a small amount of serous drainage and no odor. Following wound care, the Resident #48 was positioned on his left side in the bed and his heels were not elevated off the bed. During an observation on 2/26/19 at 11:55 a.m., Resident #48 was lying on his left side with his heels resting on the mattress. During an observation on 2/26/19 at 2:53 p.m., Resident #48 was lying on his left side with his heels resting on the mattress. During an observation on 2/26/19 at 3:54 p.m., Resident #48 was lying in bed sleeping on his left side with his heels resting on the mattress. During an observation on 2/26/19 at 4:25 p.m., CNA D and CNA H transferred Resident #48 from his bed to his wheelchair and left his feet resting on the floor. During an observation and interview on 2/27/19 at 8;22 a.m., Resident #48 was sitting in his wheelchair with his heels resting on the floor. The pressure relieving cushion was in place. Resident #48 said he had been in the wheelchair all night. Resident #48 said he did not know why he had been sitting in the wheelchair all night. He said he didn't know if he pushed his call button for assistance. During an observation on 2/27/19 at 9:49 a.m., Resident #48 was lying in bed halfway on his left side with his heels resting on the mattress. He said no one had attempted to elevate his heels off the mattress. During an interview on 2/27/19 at 9:59 a.m., RN C said they sometimes elevated Resident #48's heels when he was in his bed, but he did not always lay in his bed. During an interview on 2/27/19 at 10:27 a.m., CNA B said they did not always reposition Resident #48 during the day. She said they attempted to reposition him every 2 hours. She said when staff attempted to reposition or transfer him he did not always want to do it at that time. She said he would refuse and request to repositioned or transferred later but staff could not always do it because they were busy. During an interview on 2/27/19 at 10:27a.m., CNA F said Resident #48 would not always let them put the cushion in the wheelchair and that he would refuse to allow staff to elevate his heels off the bed or floor. During an interview on 2/27/19 at 10:45 a.m., the wound care nurse said she expected Resident #48 to have a pressure relieving cushion in his wheelchair when he was in the chair. She said Resident #48 should be checked every 2 hours and an attempt should be made to reposition him and elevate his heels off the bed. She said sometimes he refused to get into bed. During an interview on 2/27/19 at 2:33 p.m., the DON said the staff knew what they were supposed to do when it came to pressure relieving interventions. She said she made rounds on the residents daily and she had rounded on residents daily to ensure staff were attempting pressure relieving interventions such as keeping the heels off the bed and repositioning the resident every 2 hours. She said at times Resident #48 would refuse care and the aides should notify the nurse when care was refused. The DON said if Resident #48 refused care it should be documented. The nursing notes dated 2/1/19 through 2/28/19 indicated Resident #48 refused to move from his wheelchair to his bed on 2/5/19, 2/7/19, and 2/20/19. There were no notes indicating Resident #48 refused to allow the cushion in his wheelchair, repositioning or to have his heels elevated. During an interview on 2/27/19 at 2:33 p.m., the administrator said if Resident #48 refused care, the staff should attempt to perform the intervention later. 2. The consolidated physician orders [REDACTED].#49 was [AGE] years old and readmitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED].# 49 was to have foot inspections every day shift. An order dated 2/21/19 indicated the wound physician could evaluate and treat for skin conditions as indicated. On 2/26/19 a wound care order indicated: Daily clean right heel with normal saline or soap and water. Apply Leptospermum honey to unstageable DTI, cover with dry protective dressing for 30 days one time a day for wound healing for 30 days. The MDS dated [DATE] indicated Resident #49 had to be cued to remember, could understand others and could be understood by others. The assessment indicated resident's hallucinations and behavior of rejection of care had improved, was independent with transfers and needed limited assistance with ADLs. The MDS indicated the resident had 1 unstageable DTI and was to have a pressure relieving device for his chair, pressure injury care and application of ointments/medication. The assessment indicated the resident was able to transfer in and out of bed with supervision. A care plan dated 2/11/19 indicated Resident #49 had an unstageable wound to his right heel. An intervention dated 2/26/19 indicated the resident was to be evaluated and treated as indicated by the wound care physician specialist. No interventions to off-load right heel or wound care measures were present. The care plan did not address refusal of care. An initial wound evaluation and management summary from Specialty Wound Physicians dated 2/22/2019 indicated Resident #49 had a wound on the right heel that was an unstageable DTI of at least 13 days duration. The report indicated the wound was caused by pressure and was 6 cm x 4 cm x 0 cm and had a light serous (clear) drainage. The coordination of care section indicated 50% of the practitioner's time was spent counseling and coordinating specific care measures with the resident and the wound care nurse about durable medical equipment, treatment and physical assessment. The report did not indicate the practitioner had performed debridement (the removal of damaged tissue or foreign objects from a wound). The summary indicated the recommendations were to off-load the wound and reposition per facility protocol. Nursing progress notes dated from 2/18/19 through 2/27/19 indicated Resident #49 had no behaviors or refusal of care noted during all three shifts each day. A weekly skin assessment dated [DATE] indicated Resident #49 had no skin issues. A weekly skin assessment dated [DATE] indicated Resident #49 had a deep tissue injury to the right heel measuring 3 X 3 X 0.2 cm. Description indicated the right heel had macerated skin around the wound bed area with a dry callous covering that appeared to have been picked opened in the wound bed area with dry, dark blood. The assessment indicated the skin prep appeared to be effective by causing the outer calloused looking area to dry and detach from the wound edges, with no odors, drainage or signs and symptoms of infection noted by the wound care nurse. During an observation on 2/25/19 at 8:41 a.m., Resident #49 was lying in bed on his left side with shoes on and his feet dangling off the side of the bed with no heel protector or pillows to off-load his right heel. There was no pressure relieving mattress on bed. During an observation on 2/25/19 at 11:10 a.m., Resident #49 was observed in the smoking area with shoes on and feet on the foot rest. His right heel was not off-loaded. During an observation on 2/25/19 at 2:45 p.m., Resident #49 was lying in bed on his left side with shoes on his feet and his feet dangling off the side of the bed with no heel protector or pillows to off load his right heel was noted. During an observation on 2/26/19 at 9:01 a.m., Resident #49 was in the smoking area with no-skid socks over a dressing showing above the sock line above ankle of his right foot. The right heel was not off-loaded and was resting on the floor. During an observation on 2/26/19 at 10:11 a.m., Resident #49 was lying in bed on his left side with his feet dangling off the side of the bed with no heel protector or pillows present to off-load his right heel. During an observation on 2/26/19 at 11:30 a.m., Resident #49 was in the smoking area with no-skid socks over both feet, feet resting on the smoking area floor with dirt and debris on cement floor. His right heel was not off-loaded. During an observation on 2/26/19 at 3:05 p.m., Resident #49 was lying in bed on his left side, his feet dangling off the side of the bed with no heel protector or pillows seen to off-load his right heel. During an observation on 2/27/19 at 8:20 a.m., Resident # 49 was in smoking area with socks over both feet and loose house shoes with his feet resting on the smoking area floor. His right heel was not off-loaded. During an observation on 2/27/19 at 10:30 a.m., Resident #49 was in smoking area with socks over both feet and loose house shoes with his feet on the smoking area floor. His right heel was not off-loaded. During an observation on 2/27/19 at 11:40 a.m. Resident #49 was in bed on his back. His right heel was lying flat on the mattress with no heel protector or pillows to off-load his right heel. During an observation on 2/27/19 at 1:20 p.m., Resident #49 was in bed lying on his back. His right heel was lying flat on the mattress with no heel protector or pillows to off-load his right heel. During an interview on the 2/26/19 at 2:20 p.m., the wound care nurse said Resident #49 had a DTI on his right heel. She said it was initially small and the resident was seen by the wound care practitioner and the wound was debrided by him taking the top rind of the wound off. She said the rind of the wound was the calloused-like skin that was separate from the wound. The wound care nurse said his wound was now being treated with medi-honey and a dry dressing since he had seen the wound care doctor on 2/22/19. During an observation and interview on the 2/27/19 at 10:05 a.m. the wound care nurse performed wound care on Resident #49's right heel. She said the wound care practitioner had debrided the wound and removed the dead skin. The right heel exhibited a dry dark purple area from Resident #49's middle, inner heel near the center of heel and inner foot, radiating out toward the side of the heel half way to the ankle and on the beginning of the back of the heel. It was approximately 7-8 cm long and 4-5 cm wide. There was a dark red area approximately 1.5 to 2 cm in diameter within the dark purple area toward the inside of the foot. There was no drainage noted. The wound care nurse completed the wound care and laid the resident's foot on the bed and did not off load his right heel. The wound care nurse said the primary care nurse practitioner had been handed a copy of the wound specialist report from the 2/22/19 visit but had not ordered off-loading for the right foot. She said when the specialist recommended something they had to get orders from the primary physician. She said they had not been off loading the resident's foot, but she knew the resident would not cooperate with keeping his foot elevated because he had a history of [REDACTED]. During a phone interview on 2/27/19 at 11:54 a.m., the wound care specialist said he had seen Resident #49 on 2/22/19 for the first time. He said without his notes he would only be able to answer limited questions. He said the wound was a DTI to the resident's right heel. He said when he performed a procedure like debridement, he always documented what he did and described it thoroughly. He said if he did not document that he debrided a wound bed on the 2/22/19 visit then he had not debrided it. During an interview and observation on 2/27/19 at 3:55 p.m., the DON said when a wound was identified the wound care nurse assessed the wound, notified the doctor to receive treatment orders. She said her expectation of care for a resident with a DTI on the heel was for the wound care nurse and physician to manage it. She said Resident #49 would not keep pillows under his feet if it had been ordered, because he had a history of [REDACTED]. She said the reason Resident #49's heel wound became bigger was because the wound care doctor had debrided it the week before. During an interview on 2/27/19 at 4:03 p.m., Resident #49's hospice nurse said she had been present when the wound care practitioner had evaluated the resident's right heel. She said the wound was a DTI and had been present for more than a week. She said the wound practitioner pulled a white, tissue off the wound bed and the wound had looked like it looks now. She said it could have been dead skin and he trimmed around the edges of the wound. She had not seen any blood or drainage. During an interview on 2/27/19 at 4:10 p.m., CNA F said they were not doing anything to offload Resident #49's heels. She said the only thing being done was what the wound care nurse was doing. During an interview on 2/27/19 at 4:20 p.m., the wound care nurse said she had measured the wound during her visit today and it measured 6.1 X 4 X 0 cm. The National Pressure Ulcer Advisory Panel - NPUAP Resources Educational and Clinical Resources NPUAP Pressure Injury Stages accessed on 3/5/2019 indicated the following: .Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4. An undated policy and procedure, The Pressure Ulcer, Prevention of indicated the procedure for preventing and caring for a pressure ulcer was as follows: .Procedure: 3. Develop care plan to eliminate or minimize risk factors; d. Pressure relief; e. refusal of care - explain care plan measures to resident; 7. Use appropriate support surface in the resident's bed or chair. 8. Use pressure reducing or relieving devices as necessary. 9. Use a foot cradle as necessary. 10. Establish a turning and positioning schedule in bed and chair to meet the resident's needs. 11. Position with appropriate surfaces to protect boney prominences. Goal: List measurable goal(s) to be accomplished. (If a pressure ulcer is present this may be resolution of the cause of the pressure ulcer or reduction or healing of the pressure ulcer.) Approaches to care planning: List treatment as ordered if necessary. List pressure reducing or relieving surfaces. List frequency of positioning. List behavior management if necessary.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 4 of 5 residents reviewed for accidents. (Resident #s 1, 2, 3, and 4) The facility did not secure Resident #1 in the facility van using the shoulder seat-belt while he sat in his wheelchair. Resident #1 fractured his right arm when he fell forward in the facility van after the van suddenly slowed down. Resident #1 was no longer independently mobile after this incident. The facility did not ensure Resident #s 2, 3, and 4 were not secured in the facility van after this incident. Resident #s 2, 3, and 4 said they were not secured in the facility van with both the lap seat-belt and the shoulder seat-belt. An Immediate Jeopardy situation was identified on 6/6/18. The Immediate Jeopardy was removed on 6/7/18. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place the 38 wheelchair-bound residents who had the potential to ride the facility van at risk for severe injury or death. Findings included: 1. Physician orders [REDACTED].#1's closed clinical record indicated Resident #1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1's cognition was intact. Resident #1 required total assistance with all ADLs. He had impairment of the left and right side on his lower and upper extremities. An incident report dated 5/23/18 indicated Resident #1 was transported from the discharging facility to this facility when CNA A had to suddenly press the brakes. The resident flinched his arm to brace himself, and then stated his arm was broken. CNA A notified the facility, then EMS transported Resident #1 to the emergency room (ER) for further evaluation. An emergency physician record dated 5/23/18 indicated Resident #1 was seen in the ER after the facility van braked to avoid a truck, and the resident was thrown out of his wheelchair. The resident had right shoulder pain. The resident was noted with a non-displaced humeral neck fracture (shoulder area). During a telephone interview on 6/6/18 at 11:07 a.m., Resident #1 said he was seated in his wheelchair in the facility van when a diesel truck pulled out in front of the van. He said CNA A hit her brakes and he tried to brace himself using the arm of the facility van seat. Resident #1 said he fell forward towards the floor and crushed his arm as he fell . Resident #1 said when his arm was crushed, all he could do was holler and scream. Resident #1 said CNA A stopped the van and helped Resident #1 into the floor and called 911. Resident #1 said he remembered CNA A putting a seatbelt over Resident #1's lap but did not remember a seatbelt across his shoulders. Resident #1 said they told me I had a seatbelt on across my shoulders, but I would not have fallen all the way forward if I had. During an observation and interview on 6/7/18 at 9:40 a.m., Resident #1 was in a different facility. Resident #1 said he used an electric wheelchair, which he was previously able to use independently and was only able to operate it using his right hand. Resident #1's right arm was in a sling and he had no use of his left arm. Resident #1 said since the incident, he could no longer control his wheelchair and was no longer independently mobile. After the interview, Resident #1 asked would you get an aide to come get me? During an interview on 6/7/18 at 9:22 a.m., CNA A said she drove down the interstate bringing Resident #1 as a new admission to this facility when a log truck pulled out in front of her. CNA A said she drove below the speed limit when the truck pulled out in front of her, but still had to brake suddenly to avoid hitting the truck. CNA A said when she hit her brakes, Resident #1 fell forward, but did not fall into the floor of the van. CNA A said Resident #1's right arm got twisted in the van seat as he fell forward, and said ow, ow, ow. CNA A said she pulled the van to the side of the road, and lowered Resident #1 to the floor. CNA A said she called the facility and EMS, who took Resident #1 to the ER. CNA A said Resident #1 was secured safely with all safety belts (4-point wheelchair straps, shoulder strap, and lap strap). CNA A said she was the primary van driver, but the BOM and activity director occasionally transported residents in the van. During an interview on 6/6/18 at 1:15 p.m., LVN D said Resident #1 was oriented to self, place, and situation, but was not oriented to the season. LVN D said to his knowledge, Resident #1 did not make any false allegations during his stay. LVN D said Resident #1 was able to answer questions reliably. During an interview on 6/6/18 at 8:25 a.m., the administrator and the DON said CNA A picked Resident #1 up from another nursing facility when a log truck pulled out in front of her. The administrator said CNA A reported she drove 60 or 65 miles an hour and the truck in front of her went 45 miles per hour. The DON and the administrator said Resident #1 and CNA A both said Resident #1 had on a lap belt and a shoulder belt. They said Resident #1 did not fall from the wheelchair when the van braked suddenly, and if he had not been wearing a shoulder belt he would have fallen into the floor of the van. The DON and the administrator said Resident #1 got his arm twisted somehow on the van seat when he braced himself, and he fractured his arm. 2. Physician orders [REDACTED].#2 was [AGE] years old, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2's cognition was intact. Resident #2 required extensive assistance with most ADLs. She had impairment on one side of her lower and upper extremities. During an observation and interview on 6/6/18 at 9:17 a.m., Resident #2 was in therapy wearing an upper body brace. Resident #2 said the same transport driver drove her all three times she rode in the facility van. CNA A walked past, and Resident #2 identified her as being the driver all three times. Resident #2 said when she rode in the van, CNA A did not secure her with a lap belt or a shoulder belt. Resident #2 said she questioned CNA A about it, and CNA A told her she did not need to wear the seatbelt because the brace she wore would keep her safe. During an interview on 6/6/18 at 9:22 a.m., CNA A said she was the primary van driver. CNA A said she always secured Resident #2 with the 4-point wheelchair straps, shoulder strap, and lap strap in the facility van. During an interview on 6/6/18 at 1:26 p.m., CNA B said Resident #2 was with it and was oriented to person, place, time, and situation. CNA B said she would believe her if she said a seatbelt was not used while riding in the van. She said Resident #2 did not have a history of making false allegations. During an interview on 6/6/18 at 10:58 a.m., CNA C said Resident #2 was coherent and was oriented to person, place, time, and situation. CNA C said she would believe her if she said a seatbelt was not used on the van. She said Resident #2 did not have a history of making false allegations. CNA C said Resident #2 was driving and everything before admission. A list provided by the DON on 6/6/18 dated 5/24/18 through 6/5/18 indicated Resident #2 rode in the facility van on 5/29/18 and 5/30/18. 3. Physician orders [REDACTED].#3 was [AGE] years old, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3's cognition was intact. Resident #3 required extensive assistance with most ADLs. She had impairment on one side of her lower and upper extremities. During an interview on 6/6/18 at 9:09 a.m., Resident #3 said when she rode in the facility van, she did not have a lap strap or a shoulder strap securing her. She said the only way her wheelchair was secured was by straps that hooked to the bottom of her wheelchair which kept her wheelchair from moving. Resident #3 was not able to name or describe the person who usually drove the facility van. During an interview on 6/6/18 at 9:22 a.m., CNA A said she always secured Resident #3 with the 4-point wheelchair straps, shoulder strap, and lap strap in the facility van. During an interview on 6/6/18 at 1:15 p.m., LVN D said Resident #3 was sometimes confused about situations. He gave an example of requesting water, when she really wanted ice. LVN D said Resident #3 was reliable enough he would believe her if she said a seatbelt was not used on the van. LVN D said Resident #3 did not have a history of making false allegations. During an interview on 6/6/18 at 1:26 p.m., CNA B said Resident #3 was pretty much with it and was oriented to person, place, time, and situation. CNA B said she would believe her if she said a seatbelt was not used on the van. She said Resident #3 did not have a history of making false allegations. During an interview on 6/6/18 at 10:58 a.m., CNA C said Resident #3 got confused sometimes. CNA C said Resident #3 hid her perfume in one of her drawers one time and forgot about it and accused someone of stealing it. She said other than that, Resident #3 had not made any false allegations and was always oriented to person, place, and time, and usually oriented to situation. CNA C said she would believe Resident #3 if she said a seatbelt was not used while riding in the van. During an interview on 6/6/18 at 11:55 a.m., the administrator said she talked to some residents after this van incident with Resident #1 regarding whether they felt safe riding in the van and whether they wore all seatbelts during transport. She said no issues were reported to her. She said those interviews were not documented and she did not recall specifically which residents she interviewed, but thought she interviewed Resident #3. A list provided by the DON on 6/6/18 dated 5/24/18 through 6/5/18 indicated Resident #3 rode in the facility van on 5/24/18. 4. Physician orders [REDACTED].#4 was [AGE] years old, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #4's cognition was moderately impaired. Resident #4 required limited assistance with most ADLs. During an interview on 6/6/17 at 8:46 a.m., Resident #4 said when he was fastened in, he usually wore a belt across his lap, but did not use the shoulder belt. He said he always refused to wear the shoulder strap because he never like to wear it. During an interview on 6/6/18 at 9:22 a.m., CNA A said she always offered to put the shoulder strap on Resident #4, but he refused. CNA A said she had not reported to anyone that Resident #4 refused to be transported while wearing his shoulder strap. During an interview on 6/6/18 at 11:55 a.m., the administrator and DON said they were not aware prior to today that any resident rode in the facility van without being secured by all the safety belts. They said as of today after the surveyor's entrance, they were made aware of only one resident who was not always secured with a seatbelt (Resident #4). The DON said if a resident refused to wear a seatbelt the correct way, it was their right to do so, but it needed to be reported to the ADON, DON, or administrator so it could be care planned. During an observation and interview on 6/6/18 at 1:59 p.m., the BOM said she occasionally transported residents in the facility van, but not often. The BOM said she transported Resident #4 in the van on either 5/17/18 or 5/24/18. The BOM said she made sure residents were safely secured in the van by hooking up as many seatbelts as I can. The BOM said when she secured Resident #4, she put the shoulder strap on him and Resident #4 told her the shoulder strap had never been used before. The BOM said she thought the comment was weird, thought the resident may have just been confused, and did not report the comment to anyone. The BOM said she was shown how to secure residents in the facility van by the previous administrator but had not received any additional training since then other than a written in-service. The BOM then demonstrated to surveyor how to secure a resident in the van, and when securing the bottom of the wheelchair, she secured the 4-point belt, and tightened the straps. The straps were visibly too loose. The BOM then used a wrong seatbelt connector (beige) from the upper right side of the van to connect to the lap belt (black) on the bottom left side of the van. With this method, the resident would be secured over their right shoulder, but would have nothing securing their lap to prevent them from sliding out of the wheelchair. The BOM said at that time she would ask the resident if they were comfortable before she exited the back of the van. After surveyor intervention, the BOM disconnected the seatbelts and attached the lap belt on the bottom left side of the van, to the lap belt connector secured to the middle of the floor on the van, and then secured the correct black shoulder strap from the left side of the van to the lap strap. This method would ensure the resident was secured by a lap belt and shoulder belt. The BOM did not remember how she secured Resident #4. The wheelchair was then shaken by the surveyor and was loose. The BOM said she would not have noticed the wheelchair was loose if the surveyor had not shaken it. The BOM said she did not shake the wheelchair to ensure it was secure when residents rode in the van because the weight of the residents would cause the wheelchair not to wiggle. A list provided by the DON on 6/6/18 dated 5/24/18 through 6/5/18 indicated Resident #4 rode in the facility van on 5/24/18 and 5/31/18. During an interview on 6/6/18 at 2:20 p.m., the administrator and DON said they were both unaware that any of their staff aside from CNA A (alleged perpetrator) had any knowledge of a resident not being secured in the van and would expect their staff to report such allegations to them. The administrator said the trainings done with the van drivers was written, and only CNA A was made to return demonstration since she was the one involved in the incident. During an interview on 6/6/18 at 1:09 p.m., the administrator said they did not have a policy in place related to the van. She said the facility used an in-service on van safety as their policy. (from 10/20/17) An Authorized Drivers in-service dated 10/20/17 indicated secure wheelchair at four points with the tie downs in the van. (two in the front and two in the rear) Secure the passenger with a safety strap. The administrator, DON, and ADON were notified on 6/6/18 at 5:12 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 6/6/18 at 7:39 p.m. and included: 1. An In-service will be initiated by the Administrator with all staff who transport residents with a hands-on demonstration of how to appropriately secure a wheelchair and residents in both vans. The in-service will include the importance of securing the wheelchairs and residents in the vans as well as what to do if residents refuse to be strapped in per laws. The in-service will be completed by 06/07/18 at 5 PM. Any van drivers not available by 06/07/18 by 5 PM will be in-serviced prior to driving the van. 2. All staff will be in-serviced by the ADON on reporting any issues or concerns that may affect resident safety during transportation, or anything else that may jeopardize resident safety. This in-service will be completed by 06/07/18 by 5 PM. Staff will not be allowed to work after that date until they are in-serviced appropriately. 3. The van will be inspected to ensure the van is properly equipped with safe and working equipment by 06/07/18 at 5 PM by the Maintenance Director. On 6/7/18, the surveyor confirmed the facility implemented their plan of removal to sufficiently to remove the Immediate Jeopardy by: During an interview on 6/7/18 at 1:15 p.m., the administrator said they began in-servicing the staff on reporting any issues or concerns that may affect resident safety, including during transportation. She said the in-service included wheelchair-bound residents not being allowed to ride in the facility van without being completely secured by a shoulder, lap, and wheelchair safety belt. She said the maintenance director was working on inspecting both facility vans and was given the task of inspecting the van weekly to ensure the van was properly equipped with safe and working equipment. She said three of the four van drivers were available and were re-trained on how to properly secure a wheelchair-bound resident into the facility van and were able to return demonstration. Six CNAs, five nurses, one housekeeper, one cook, the maintenance supervisor, and the business office manager said they were in-serviced to report any issues or concerns that may affect resident safety, including during transportation, to the administrator and DON. They said it was never okay for a wheelchair-bound resident to not be secured by the wheelchair straps, the lap belt, and the shoulder belt, even if they refused. The maintenance director, BOM, and CNA A (transportation drivers) demonstrated how to safely load and unload wheelchair-bound residents onto the facility van, and how to secure the wheelchair and the resident using all safety belts. The maintenance director said he was in-serviced to inspect both facility vans weekly to ensure the van was properly equipped with safe and working equipment. The maintenance director provided a weekly vehicle inspection sheet dated 6/7/18. On 6/7/17 at 3:52 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list provided by the ADON on 6/6/18 indicated 38 wheelchair-bound residents had the potential to ride in the facility van.

Based on observation, interview, and record review, the facility failed to ensure implementation of written policies and procedures to ensure 1 of 8 residents reviewed for neglect was free from neglect. (Resident #1) The facility failed to remove a hazardous chemical out of Resident #1's room after she was seen rubbing it into her eyes. The nurse did not report the incident to the oncoming shift, delaying physician notification and treatment for 21 hours. Resident #1 now is only able to see color and shapes. This failure contributed to Resident #1's eye injury and likely permanent [MEDICAL CONDITION]. An Immediate Jeopardy was determined to have existed from 06/11/17 through 06/12/17. This was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 28 residents with dementia or other delusional disorders at risk for severe injury or delays in medical treatment. Findings included: The facility's Abuse/Neglect Policy last updated November 2016 defined neglect as, .the failure to provide goods and services, necessary to avoid physical harm, mental anguish, or mental health illness . Computerized physician orders [REDACTED].#1 was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 was usually understood but had difficulty and required cueing for recall. Her vision was good and she could read fine print in newspapers and books. A care plan with an initiation date of 10/12/16 indicated Resident #1 had long and short term memory problems. She needed verbal cues for redirection. Resident #1 needed supervision for decision making. Interventions included to record behaviors and notify the physician of unusual behaviors. The care plan indicated the resident used glasses. One of the approaches was report to the physician any signs of acute eye problems. A care plan with an initiation date of 11/10/16 indicated Resident #1 liked to play dominos, participate in creative creations, and go out of the facility on trips. She enjoyed watching various TV programs, religious services, watching movies, and looking at magazines. Late entry nursing notes, written by LVN B, with an entry date of 6/12/17 at 11:15 p.m. to 11:33 p.m. indicated on 6/11/17 at 1:00 a.m. LVN B administered artificial tears to Resident #1's eyes due to the resident's complaints of irritation and itching. On 6/11/17 at 1:32 a.m., Resident #1 initiated her call light. Upon entering the room Resident #1 was wiping [MEDICATION NAME] (a pink colored topical antiseptic) in her eyes with her fingers. The resident did not know where she obtained the [MEDICATION NAME]. LVN B flushed the resident's eyes because the directions on the bottle indicated to flush the resident's eyes with cold water. The resident tolerated well and seemed to be relieved. Attempted to call NP, but was unsuccessful. According to the [MEDICATION NAME] website, www.[MEDICATION NAME].com, accessed 7/25/17, it indicated: Warnings For external use only When using this product *keep out of eyes, ears, and mouth. May cause serious and permanent eye injury if placed or kept in the eye during surgical procedures, or may cause [DIAGNOSES REDACTED] when instilled in the middle ear through perforated eardrums. *if contact occurs in any of these areas, rinse with cold water right away . During an telephone interview on 07/16/17 at 10:38 a.m., LVN B said she was on duty the night of 6/10-6/11/17 when Resident #1 rubbed the [MEDICATION NAME] in her eyes. She said she forgot to remove the bottle of [MEDICATION NAME] from the room after flushing Resident #1's eyes with water. She said she had not informed the oncoming shift nurse, documented, or informed the physician about the incident. During an interview on 7/16/17 at 7:19 a.m. LVN A said she arrived at work at 6 a.m. on 06/11/17 and relieved LVN B. She said LVN B did not tell her Resident #1 rubbed [MEDICATION NAME] in her eyes. LVN A said there was no incident report of the incident and there was no documentation of the incident in the nursing notes. She said on the morning of 06/11/17 between 8-9 a.m., she was called to Resident #1's room because Resident #1 was complaining of eye pain and complained she could not see. She said when she arrived in the room Resident #1 was holding her eyes, saying they hurt and she said she could not see. LVN A said, while she was assessing Resident #1, the housekeeper was sweeping Resident #1's room. She said when the housekeeper swept under the bed she found a bottle of [MEDICATION NAME] and asked if Resident #1 should have this in her room. She said she told the housekeeper no and took the bottle. LVN A said she asked Resident #1 if the bottle was hers and the resident said yes. LVN A said she asked Resident #1 if she put the contents of the bottle in her eyes and Resident #1 said no. LVN A said she called the NP and reported Resident #1's complaints and told her Resident #1 had drainage to her eyelids with crusting. She said it was not until the end of her 16 hour shift, on 06/11/17 at 10:35 p.m. when LVN B came to relieve her, that she learned Resident #1 had rubbed [MEDICATION NAME] in her eyes. She said the physician was not notified of the incident until 10:45 p.m. on the night of 06/11/17, 21 hours later after the incident occurred. Nursing notes written by LVN A dated 6/11/17 at 11:29 a.m. indicated Resident #1 complained of her eyes hurting and burning. She had some drainage to her eyelashes. The physician was called and ordered [MEDICATION NAME] 0.3-0.1 percent solution (treats bacterial infections/steroid) 1 drop to both eyes two times a day for 10 days. At 9:10 p.m., Resident #1 continued to keep her eyes closed and continued to rub her eyes. During an interview on 07/16/17 at 9:33 a.m., the housekeeper said she went into Resident #1's room on the morning of 06/11/17 to clean it and Resident #1 complained her eyes were hurting. She said reported Resident #1's complaints to LVN A. She said LVN A came to the room to check on Resident #1. The housekeeper said as she was sweeping under the bed, she found a bottle and asked LVN A if Resident #1 was supposed to have it in her room and LVN A said no and took the bottle. During an interview on 07/16/17 at 11:28 a.m., the ADON said she was not made aware of the incident until Monday 06/12/17. She said the 6-2 LVN for 06/12/17 told her that LVN B walked into Resident #1's room and found her rubbing [MEDICATION NAME] in her eyes. She said she looked and did not see an incident report. She said she called and spoke with LVN B over the phone. She said LVN B said she walked into Resident #1s room on 06/11/17 at 1:38 a.m. and Resident #1 had pink stuff on her fingers. LVN B said she saw a bottle of [MEDICATION NAME] on the bedside table and asked Resident #1 where she got it. Resident #1 told LVN B it was hers. She said she asked LVN B if she removed the [MEDICATION NAME] from Resident #1's room and she said she thought she did, but may have left it in the room. She said LVN B said she did not write an incident statement. She said she was told by the 6-2 charge nurse that the nurse practitioner wanted Resident #1 to be seen by an ophthalmologist as soon as possible. She said an appointment had been made for 9:00 a.m. that morning (6/12/17). The ADON said she did not see the bottle of [MEDICATION NAME]. She said the transportation driver called the facility and notified them the ophthalmologist referred Resident #1 to a cornea specialist in Dallas, TX. A nursing note dated 6/12/17 at 8:48 a.m. indicated Resident #1 needed an appointment to be seen by an eye doctor as soon as possible due to her rubbing [MEDICATION NAME] on her hands and rubbing her eyes. The resident's appointment was made for that day 6/12/17. A cornea specialist note dated 6/12/17 indicated Resident #1 presented with chemical burn in the right and left eye. The resident was at the nursing home and they said she got [MEDICATION NAME] in her eyes this morning. The nurse walked in and said the resident had the cleanser all over her hands and face. She had difficulty opening her eyes saying they hurt. The note indicated it was hard to get an accurate history because the patient had dementia. She went to the local eye doctor, they irrigated her eyes, and sent her here. The most recent MDS dated [DATE] indicated Resident #1 was usually understood but had difficulty and required cueing for recall. Her vision was severely impaired and she could see only light color or shapes. During an interview on 07/16/17 at 5:10 a.m., Resident #1 said she did not know what happened to her eyes. She said one of the nurses told her she put something in her eye, but she does not recall putting anything in her eye. Resident #1 said her eyes hurt and she could not see. A physician note dated 7/5/17 indicated the injury to Resident #1's eyes was severe and there was likely severe stem cell damage with a poor prognosis. The resident constantly removed the shields and rubbed her eyes. The patient was forgetful and may need a full time sitter to monitor her 24 hours. A physician note dated 7/14/17 indicated the severity of the injury to Resident #1's eyes was likely [MEDICAL CONDITION]. The resident was constantly rubbing her eyes and possibly causing more damage. The physician documented that the resident would do poorly due to mental status. She was non-compliant. There was worsening of both eyes since the resident washed her eyes out with [MEDICATION NAME] on 6/12/17. (sic) During an interview on 07/16/17 at 6:22 a.m., the administrator said he was the abuse coordinator. He said on the night of 06/10/17 LVN B found Resident #1 rubbing [MEDICATION NAME] in her eyes when she walked into Resident #1's room. He said the facility was unaware of how Resident #1 obtained a bottle of [MEDICATION NAME]. He said [MEDICATION NAME] was kept in the supply room and on the treatment cart. The administrator said he did not see the bottle of [MEDICATION NAME] found in Resident #1's room. He said the bottle was sent out with Resident #1 to her eye doctor appointment. During an interview on 07/16/17 at 6:25 a.m., the DON said Resident #1 was seen by an eye doctor in another town and he referred her to an eye specialist. She said Resident #1 was placed on one-on-one monitoring after the incident. The DON said the facility had not been able to provide one-on-one coverage for all shifts. She said there was no reason [MEDICATION NAME] should have been in Resident #1's room. She said the facility investigated the incident and was unable to determine how Resident #1 obtained the [MEDICATION NAME]. The DON said she did not see the bottle of [MEDICATION NAME] that was removed from Resident #1's room. During an interview on 07/16/17 at 5:07 a.m., CNA D said she was picking up extra shifts sitting with Resident #1 because the facility needed someone to sit with her to keep her from rubbing and scratching her eyes. She said Resident #1 had been on one-on-one monitoring for approximately one month. During an interview on 07/16/17 at 5:29 a.m., LVN C said Resident #1 had surgery on her eyes. She said Resident #1 rubbed [MEDICATION NAME] in her eyes back in June. She said she was not sure of the exact date because the incident occurred before she was hired. LVN C said [MEDICATION NAME] was kept on the treatment cart and in the supply room. She said both were kept locked. She said she had never seen the treatment cart or the supply room unlocked. On 7/16/17 at 2:50 p.m., the administrator, DON, and ADON were informed that an Immediate Jeopardy was determined to have existed from 06/11/17 through 06/12/17. The Immediate Jeopardy was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. The Immediate Jeopardy was removed on 06/12/17 because, prior to surveyor entrance, the facility had removed all medications and hazardous products from all resident rooms, had in-serviced all staff regarding reporting all incidents and keeping harmful products out of resident rooms, and had sent the resident for medical treatment. There were no hazardous products found unsecured or in resident rooms and the staff was aware of reporting and prevention measures. An in-service dated June 12, 2017 indicated all staff were in-serviced to remove from residents' rooms any medication, prescription creams, ointments, soaps, powders, hazardous items, or anything that indicated the item should be kept out of the reach of children. They were informed that all carts and rooms containing chemicals or medications were to be kept locked when a staff member was not directly accessing the area. During an interview on 07/16/17 at 2:43 p.m., the ADON said on 06/12/17 she and the administrator did inspections of all resident rooms and removed any items they felt could be dangerous or hazardous. She said during the in-services, the staff was told to immediately remove any items of this sort they may see in the residents' rooms. She said on 6/12/17 she counseled and in-serviced LVN B regarding reporting significant events to the on-coming shift, removal of hazardous chemical/items from the resident rooms, notifying the physician of significant changes of condition, completing accurate nursing notes and incident reports, and documenting pertinent information on the 24 hour nursing report. During a telephone interview on 07/16/17 at 10:38 a.m., LVN B said she had now been counseled regarding her failures in this matter and was in-serviced regarding proper reporting, documentation, removal of hazards, and physician notification. During an interview on 07/16/17 at 2:49 p.m., the administrator said the staff were in-serviced on removing potential hazardous and dangerous material from the residents' rooms and proper reporting. He also verified that LVN B was counseled multiple times in regards to the incident. During observations on 07/16/17 from 4:47 a.m. until exit, the treatment cart, supply room, housekeeping supply room, biohazard room and the medications carts were all observed to be locked with no hazardous items accessible. During an interview on 07/16/17 at 2:43 p.m., the ADON said the facility had 28 residents with dementia or other delusional disorders.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as possible for 1 of 8 residents reviewed for accident hazards. (Resident #1) The facility failed to remove hazardous chemicals out Resident #1's room after she was seen rubbing it into her eyes. The nurse did not report the incident to the oncoming shift, delaying physician notification and treatment for 21 hours. Resident #1 now only sees colors and shapes. This failure contributed to Resident #1's eye injury and likely permanent blindness. An Immediate Jeopardy was determined to have existed from 06/11/17 through 06/12/17. This was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 28 residents with dementia and other delusional disorders at risk for severe injury or delays in medical treatment. Findings included: Computerized physician orders [REDACTED].#1 was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 was usually understood but had difficulty and required cueing for recall. Her vision was good and she could read fine print in newspapers and books. A care plan with an initiation date of 10/12/16 indicated Resident #1 had long and short term memory problems. She needed verbal cues for redirection. Resident #1 needed supervision for decision making. An intervention was to record behaviors and notify the physician of unusual behaviors. The care plan indicated the resident used glasses. One of the approaches was report to the physician any signs of acute eye problems. A care plan with an initiation date of 11/10/16 indicated Resident #1 liked to play dominos, participate in creative creations, and go out of the facility on trips. She enjoyed watching various TV programs, religious services, watching movies, and looking at magazines. Late entry nursing notes, written by LVN B, with an entry date of 6/12/17 at 11:15 p.m. to 11:33 p.m. indicated on 6/11/17 at 1:00 a.m. LVN B administered artificial tears to Resident #1's eyes due to the resident's complaints of irritation and itching. On 6/11/17 at 1:32 a.m., Resident #1 initiated her call light. Upon entering the room Resident #1 was wiping Hibiclens (a pink colored topical antiseptic) in her eyes with her fingers. The resident did not know where she obtained the Hibiclens. LVN B flushed the resident's eyes because the directions on the bottle indicated to flush the resident's eyes with cold water. The resident tolerated well and seemed to be relieved. Attempted to call NP, but was unsuccessful. According to the Hibiclens website, www.hibiclens.com, accessed 7/25/17, it indicated: Warnings For external use only When using this product *keep out of eyes, ears, and mouth. May cause serious and permanent eye injury if placed or kept in the eye during surgical procedures, or may cause [DIAGNOSES REDACTED] when instilled in the middle ear through perforated eardrums. *if contact occurs in any of these areas, rinse with cold water right away . During an telephone interview on 07/16/17 at 10:38 a.m., LVN B said she was on duty the night of 6/10-6/11/17 when Resident #1 rubbed the Hibiclens in her eyes. She said she forgot to remove the bottle of Hibiclens from the room after flushing Resident #1's eyes with water. She said she had not informed the oncoming shift nurse, documented, or informed the physician about the incident. During an interview on 7/16/17 at 7:19 a.m. LVN A said she arrived at work at 6 a.m. on 06/11/17 and relieved LVN B. She said LVN B did not tell her Resident #1 rubbed Hibiclens in her eyes. LVN A said there was no incident report of the incident and there was no documentation of the incident in the nursing notes. She said on the morning of 06/11/17 between 8-9 a.m., she was called to Resident #1's room because Resident #1 was complaining of eye pain and complained she could not see. She said when she arrived in the room Resident #1 was holding her eyes, saying they hurt and she said she could not see. LVN A said, while she was assessing Resident #1, the housekeeper was sweeping Resident #1's room. She said when the housekeeper swept under the bed she found a bottle of Hibiclens and asked if Resident #1 should have this in her room. She said she told the housekeeper no and took the bottle. LVN A said she asked Resident #1 if the bottle was hers and the resident said yes. LVN A said she asked Resident #1 if she put the contents of the bottle in her eyes and Resident #1 said no. LVN A said she called the NP and reported Resident #1's complaints and told her Resident #1 had drainage to her eyelids with crusting. She said it was not until the end of her 16 hour shift, on 06/11/17 at 10:35 p.m. when LVN B came to relieve her, that she learned Resident #1 had rubbed Hibiclens in her eyes. She said the physician was not notified of the incident until 10:45 p.m. on the night of 06/11/17, 21 hours later after the incident occurred. Nursing notes written by LVN A dated 6/11/17 at 11:29 a.m. indicated Resident #1 complained of her eyes hurting and burning. She had some drainage to her eyelashes. The physician was called and ordered Tobradex 0.3-0.1 percent solution (treats bacterial infections/steroid) 1 drop to both eyes two times a day for 10 days. At 9:10 p.m., Resident #1 continued to keep her eyes closed and continued to rub her eyes. During an interview on 07/16/17 at 9:33 a.m., the housekeeper said she went into Resident #1's room on the morning of 06/11/17 to clean it and Resident #1 was complaining her eyes were hurting. She said she reported Resident #1's complaint to LVN A. She said LVN A came to the room to check on Resident #1. The housekeeper said as she was sweeping under the bed, she found a bottle and asked LVN A if Resident #1 was supposed to have it in her room and LVN A said no and took the bottle. During an interview on 07/16/17 at 11:28 a.m., the ADON said she was not made aware of the incident until Monday 06/12/17. She said the 6-2 LVN for 06/12/17 told her that LVN B walked into Resident #1's room and found her rubbing Hibiclens in her eyes. She said she looked and did not see an incident report. She said she called and spoke with LVN B over the phone. She said LVN B said she walked into Resident #1s room on 06/11/17 at 1:38 a.m. and Resident #1 had pink stuff on her fingers. LVN B said she saw a bottle of Hibiclens on the bedside table and asked Resident #1 where she got it. Resident #1 told LVN B it was hers. She said she asked LVN B if she removed the Hibiclens from Resident #1's room and she said she thought she did, but may have left it in the room. She said LVN B said she did not write an incident statement. She said she was told by the 6-2 charge nurse that the nurse practitioner wanted Resident #1 to be seen by an ophthalmologist as soon as possible. She said an appointment had been made for 9:00 a.m. that morning (6/12/17). The ADON said she did not see the bottle of Hibiclens. She said the transportation driver called the facility and notified them the ophthalmologist referred Resident #1 to a cornea specialist in Dallas, TX. A nursing note dated 6/12/17 at 8:48 a.m. indicated Resident #1 needed an appointment to be seen by an eye doctor as soon as possible due to her rubbing Hibiclens on her hands and rubbing her eyes. The resident's appointment was made for that day 6/12/17. A cornea specialist note dated 6/12/17 indicated Resident #1 presented with chemical burn in the right and left eye. The resident was at the nursing home and they said she got Hibiclens in her eyes this morning. The nurse walked in and said the resident had the cleanser all over her hands and face. She had difficulty opening her eyes saying they hurt. The note indicated it was hard to get an accurate history because the patient had dementia. She went to the local eye doctor, they irrigated her eyes, and sent her here. The most recent MDS dated [DATE] indicated Resident #1 was usually understood but had difficulty and required cueing for recall. Her vision was severely impaired and she could see only light color or shapes. During an interview on 07/16/17 at 5:10 a.m., Resident #1 said she did not know what happened to her eyes. She said one of the nurses told her she put something in her eye, but she does not recall putting anything in her eye. Resident #1 said her eyes hurt and she could not see. A physician note dated 7/5/17 indicated the injury to Resident #1's eyes was severe and there was likely severe stem cell damage with a poor prognosis. The resident constantly removed the shields and rubbed her eyes. The patient was forgetful and may need a full time sitter to monitor her 24 hours. A physician note dated 7/14/17 indicated the severity of the injury to Resident #1's eyes was likely blindness. The resident was constantly rubbing her eyes and possibly causing more damage. The physician documented that the resident would do poorly due to mental status. She was non-compliant. There was worsening of both eyes since the resident washed her eyes out with Hibiclens on 6/12/17. (sic) During an interview on 07/16/17 at 6:22 a.m., the administrator said he was the abuse coordinator. He said on the night of 06/10/17 LVN B found Resident #1 rubbing Hibiclens in her eyes when she walked into Resident #1's room. He said the facility was unaware of how Resident #1 obtained a bottle of Hibiclens. He said Hibiclens was kept in the supply room and on the treatment cart. The administrator said he did not see the bottle of Hibiclens found in Resident #1's room. He said the bottle was sent out with Resident #1 to her eye doctor appointment. During an interview on 07/16/17 at 6:25 a.m., the DON said Resident #1 was seen by an eye doctor in another town and he referred her to an eye specialist. She said Resident #1 was placed on one-on-one monitoring after the incident. The DON said the facility had not been able to provide one-on-one coverage for all shifts. She said there was no reason Hibiclens should have been in Resident #1's room. She said the facility investigated the incident and was unable to determine how Resident #1 obtained the Hibiclens. The DON said she did not see the bottle of Hibiclens that was removed from Resident #1's room. During an interview on 07/16/17 at 5:07 a.m., CNA D said she was picking up extra shifts sitting with Resident #1 because the facility needed someone to sit with her to keep her from rubbing and scratching her eyes. She said Resident #1 had been on one-on-one monitoring for approximately one month. During an interview on 07/16/17 at 5:29 a.m., LVN C said Resident #1 had surgery on her eyes. She said Resident #1 rubbed Hibiclens in her eyes back in June. She said she was not sure of the exact date because the incident occurred before she was hired. LVN C said Hibiclens was kept on the treatment cart and in the supply room. She said both were kept locked. She said she had never seen the treatment cart or the supply room unlocked. The facility's Abuse/Neglect Policy last updated November 2016 defined neglect as, .the failure to provide goods and services, necessary to avoid physical harm, mental anguish, or mental health illness . On 7/16/17 at 2:50 p.m., the administrator, DON, and ADON were informed that an Immediate Jeopardy was determined to have existed from 06/11/17 through 06/12/17. The Immediate Jeopardy was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. The Immediate Jeopardy was removed on 06/12/17 because, prior to surveyor entrance, the facility had removed all medications and hazardous products from all resident rooms, had in-serviced all staff regarding reporting all incidents and keeping harmful products out of resident rooms, and had sent the resident for medical treatment. There were no hazardous products found unsecured or in resident rooms and the staff was aware of reporting and prevention measures. An in-service dated June 12, 2017 indicated all staff were in-serviced to remove from residents' rooms any medication, prescription creams, ointments, soaps, powders, hazardous items, or anything that indicated the item should be kept out of the reach of children. They were informed that all carts and rooms containing chemicals or medications were to be kept locked when a staff member was not directly accessing the area. During an interview on 07/16/17 at 2:43 p.m., the ADON said on 06/12/17 she and the administrator did inspections of all resident rooms and removed any items they felt could be dangerous or hazardous. She said during the in-services, the staff was told to immediately remove any items of this sort they may see in the residents' rooms. She said on 6/12/17 she counseled and in-serviced LVN B regarding reporting significant events to the on-coming shift, removal of hazardous chemical/items from the resident rooms, notifying the physician of significant changes of condition, completing accurate nursing notes and incident reports, and documenting pertinent information on the 24 hour nursing report. During a telephone interview on 07/16/17 at 10:38 a.m., LVN B said she had now been counseled regarding her failures in this matter and was in-serviced regarding proper reporting, documentation, removal of hazards, and physician notification. During an interview on 07/16/17 at 2:49 p.m., the administrator said the staff were in-serviced on removing potential hazardous and dangerous material from the residents' rooms and proper reporting. He also verified that LVN B was counseled multiple times in regards to the incident. During observations on 07/16/17 from 4:47 a.m. until exit, the treatment cart, supply room, housekeeping supply room, biohazard room and the medications carts were all observed to be locked with no hazardous items accessible. During an interview on 07/16/17 at 2:43 p.m., the ADON said the facility had 28 residents with dementia or other delusional disorders.

Based on observation, interview, and record review, the facility failed to implement interventions based on the comprehensive assessment to prevent development and worsening of pressure injuries for 2 of 6 residents reviewed for pressure injury. (Residents #6 and #11) The facility did not accurately assess or provide appropriate interventions to prevent development of an avoidable, facility acquired pressure injury to Resident #6's left hip. Resident #6 developed a facility acquired Stage 2 pressure injury on his left hip that worsened to an unstageable pressure injury and a Stage 2 pressure injury on his right heel. The facility did not did not identify or assess a Stage 2 pressure injury on Resident #11's coccyx. The physician was not notified until after surveyor intervention. The failure could place 36 residents who were in the bed or chair all or most of the time at risk for developing pressure injuries or a decline in existing pressure injuries. Findings included: 1. Physician orders [REDACTED].#6 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. He was admitted with hospice. An admission Braden score dated 7/15/16 indicated Resident #6 was a high risk for pressure injury. The most recent MDS dated [DATE] indicated Resident #6 had severe cognitive impairment and was usually understood and usually understood others. He was totally dependent for all ADLs and extensive assist with bed mobility. Resident #6 was at risk for pressure injury and did not have unhealed pressure ulcers on admission. An undated care plan indicated: Resident #6 required assistance with ADLs and bed mobility. Interventions were to provide assistance with bed mobility, encourage and assist as needed to turn and reposition every 2 hours and as needed for comfort. Resident #6 was at risk for skin breakdown related to decreased mobility, incontinence, and nutritional status. He had blanchable redness to both hips. Interventions were [MEDICATION NAME] powder (antifungal) to his left hip. Staff were to encourage and assist resident to elevate his heels off the bed with pillows, encourage and provide assistance to turn and reposition every two hours and as needed for comfort, follow facility policies/protocols for the prevention/treatment of [REDACTED]. When providing care, observe skin for redness or open area and notify the nurse (date initiated 7/25/16). The Skin Assessment sheets dated 7/23/16, 7/31/16, 8/8/16, 8/13/16, 8/21/16 indicated Resident #6 was noted with an area with blanchable redness on his left hip. The Wound care sheets indicated Resident #6 had the following: *8/26/16 - Stage 2 pressure injury on his left hip measuring 1.0 cm x 2.0 cm x 0.1 cm, with serosanguinous, no odor, small drainage, wound bed beefy red, surrounding skin pink, surrounding tissue normal. A physician order [REDACTED].#6 ' s Stage 2 pressure injury with normal saline and apply Medi-honey with foam dressing one time a day. The Wound care sheets indicated Resident #6 had the following: *9/2/16 - Unstageable pressure injury on his left hip measuring 2.0 cm x 1.5 cm x 0.1 cm, no drainage, no odor, wound bed black, surrounding skin color pink, surrounding tissue normal. A physician order [REDACTED].#6 ' s unstageable pressure injury on his left hip with normal saline, apply a thin layer of Santyl ointment (topical debridement) to would bed, apply hydrogel gauze, then a 4x4 and secure with tape every day shift. An undated care plan indicated Resident #6 had an unstageable pressure injury on his left hip related to friction and immobility. Interventions were to assess for wound healing weekly and as needed, low air loss mattress (date initiated 8/26/16) and padded Geri-chair cover when up in Geri-chair (date initiated 9/2/16). The full length chair pad was not a pressure relief pad. The Wound care sheets indicated Resident #6 had the following: *9/9/16 - Unstageble pressure injury on his left hip measuring 2.0 cm x 1.5 cm x 0.1 cm, no drainage, no odor, wound bed black half of wound bed and pink half of wound bed, surrounding skin normal. A physician order [REDACTED].#6's unstageable pressure injury on his left hip with normal saline, apply moistened [MEDICATION NAME] AG (silver impregnated antimicrobial dressing), cover with 4x4 and secure every day shift. The Skin Assessment sheets indicated the following: *9/18/16 - Not staged pressure injury on his left hip, measuring 2.3 cm x 2.5 cm x 0.1 cm, wound bed noted to be half pink and has a black area. The Wound care sheets indicated Resident #6 had the following: *9/18/16 - Stage 2 pressure injury on his left hip measuring 2.0 cm x 2.5 cm x 0.1 cm, small serous drainage, no odor, wound bed black, surrounding skin pink, surrounding tissue normal. The Skin Assessment sheets indicated Resident #6 had the following: *9/25/16 - Not staged - pressure injury on his left hip measuring 2.0 cm x 2.5 cm x 0.1 cm, wound bed noted to have white-colored slough. The Wound care sheets indicated Resident #6 had the following: *9/23/16 - Stage 2 on his left hip measuring 2.0 cm x 2.4 cm x 0.1 cm, scant serous drainage, no odor, surrounding skin pink, surrounding tissue normal. There were no other wound care sheets addressing the resident ' s left hip pressure injury. The Skin Assessment sheets indicated Resident #6 had the following: *10/1/16 - Not staged - pressure injury on his left hip measuring 2.4 cm x 2.5 cm x 0.1 cm, wound bed noted to have white-colored slough. The Wound care sheets indicated Resident #6 had the following: *10/4/16 - Stage 1 pressure injury on his right hip measuring 1.0 cm x 1.0 cm x 0.1 cm, [DIAGNOSES REDACTED] (redness) to right hip, diffusely spread with non-blanchable area to very center over bony area. Skin intact. During observations on 10/3/16, the following was noted: *9:05 a.m., Resident #6 was sitting straight up in a Geri-chair (full length pad in Geri-chair, not pressure relief) at the dining room table with feet flat on the floor. He was wearing socks. *11:32 a.m., Resident #6 was sitting straight up in a Geri-chair at the dining room table with his feet flat on the floor wearing socks. *2:49 p.m., Resident #6 was lying in a low air-loss bed on his back. His heels were not off loaded from the mattress. During an observation on 10/4/16 at 8:26 a.m., Resident #6 was sitting straight up in a Geri-chair at the activity room table with his feet flat on the floor. He was wearing socks. During an observation and interview on 10/4/16 at 8:58 a.m., LVN F provided wound care for a pressure injury on Resident #6's left hip. The wound bed was pink in color with yellow slough covering ¾ of the wound bed. LVN F said the nurses did their own treatments and the ADON measured and staged all wounds every Friday. During an observation and interview on 10/4/16 at 10:30 a.m., LVN F assisted in a skin assessment of Resident #6. His heels were not elevated off of the bed. Resident #6 had a Stage 2 pressure injury on his right heel, approximately 0.5 x 0.5 cm red opened area with dry skin to peri-wound. LVN F said she did not know about this pressure injury. She said Resident #6 liked to sleep with a pillow between his legs. During an interview on 10/4/16 at 12:13 p.m., the DON said she was not aware Resident #6 had a pressure injury on his right heel. She said he sat up in a Geri-chair all day. During observations on 10/4/16, the following was noted: *12:08 p.m., Resident #6 was sitting straight up in a Geri-chair at the dining room table with his feet flat on the floor wearing socks. *2:16 p.m., Resident #6 was lying in bed on his left side with a pillow between his knees. His feet were not off loaded. *2:26 p.m., Resident #6 was lying in bed on his left side. A pillow was lying on the floor next to his bed. *3:42 p.m., Resident #6 was sitting straight up in a Geri-chair at the dining room table with his feet flat on the floor with his heels touching the foot rest of the Geri chair, wearing socks. During an interview on 10/4/16 at 2:26 p.m., CNA M said she put a pillow between Resident #6's knees in bed and he only wore socks when he was up in the Geri-chair. No interventions were in place for his heels. During observations on 10/5/16 the following was noted: *8:52 a.m., Resident #6 was sitting straight up in a Geri-chair on a full length pad that was not pressure relief, at the activity room table with his feet flat on the floor. He was wearing socks. *10:21 a.m., Resident #6 was sitting straight up in a Geri-chair at the activity room table with his feet flat on the floor with heels against foot rest on Geri chair, wearing socks. During an interview on 10/5/16 at 10:21 a.m., LVN F said Resident #6 was on a regular mattress when he was admitted in July. She said upon admission, his left hip was very red and looked like it was sheared. She said the only intervention upon admission was [MEDICATION NAME] (barrier cream) and [MEDICATION NAME] powder to his left hip. She said he did not get a low air loss mattress or a pad for his Geri-chair until after the pressure injury on his left hip opened on 8/26/16. She said the new pressure injury on his right heel measured 0.5 x 0.5 cm and the treatment was Medi-honey and a foam dressing. She said the ADON measured the new wound and documented it was a Stage 2. During an interview on 10/5/16 at 10:28 a.m., CNA G said Resident #6's left hip was really red before it opened to a pressure injury and staff applied [MEDICATION NAME] at that time. She said when Resident #6 admitted he had a regular mattress. CNA G said the low air loss mattress and pad to his Geri-chair were provided after the left hip became an open pressure injury. She said he never wore shoes, only socks. She said she was not aware Resident #6 had a pressure injury on his right heel. CNA G said she put a pillow between his knees in bed, but did nothing to protect his feet or heels when in the Geri-chair. During an interview on 10/5/16 at 11:17 a.m., the DON said she did not know what Resident #6's left hip looked like when he was admitted . During an interview on 10/5/16 at 11:22 a.m., the ADON said when Resident #6 was admitted he did not have a pressure injury. She said his left hip had blanchable redness. She said she did not look at a resident's skin until they developed an actual wound. She said when Resident #6 developed a Stage 2 pressure injury on his left hip on 9/10/16, a low air loss mattress was ordered, along with a pad for his Geri-chair. She said staff should turn, reposition, and offload residents' heels for prevention of pressure injuries. She said Resident #6 only wore socks and they had no interventions for his feet when he was up in his Geri-chair. During observation and interview on 10/5/16 at 11:36 a.m., Resident #6 was lying in bed on his back with his knees bent and feet flat on the bed. He was being shaved by the hospice aide. The hospice aide said Resident #6 was always up in the Geri-chair when she came to the facility. She said he only wore socks and his feet were always flat on the floor. During an interview on 10/5/16 at 11:39 a.m., LVN F said sometimes staff would recline Resident #6 in his Geri-chair, but he normally sat straight up. During observations on 10/5/16 the following was noted: *12:15 p.m., Resident #6 was sitting straight up in a Geri-chair at the dining room table eating lunch with his feet flat on the floor wearing socks. *1:27 p.m., Resident #6 was reclined back in a Geri-chair with knees bent and heels touching the back of the Geri-chair. His heels were not offloaded. *2:42 p.m., Resident #6 was brought to his room in his Geri-chair. He was transferred via Hoyer lift from Geri-chair to bed. His pants were soiled and smelled like pungent foul urine and the blue pad in his Geri-chair was wet with a strong urine odor. During an observation and interview on 10/5/16 at 2:42 p.m., LVN E assisted in observation of Resident #6's left hip wound. LVN E said the wound bed was pink/red, with yellow slough and was a Stage 2. She said the ADON measured and staged all pressure injuries. LVN E said she did not have any wound care training, and was responsible for applying a new dressing if the old one came off. During an interview on 10/5/16 at 2:51 p.m., the ADON said she measured and staged pressure injuries every Friday and applied new dressings. The ADON said she did not have any wound care training. She said Resident #6's left hip wound had yellow slough in the center and she assessed it as a Stage 2. After surveyor intervention the ADON said Resident #6's wound should be assessed as a Stage 3. She said the appearance of the wound when she assessed, measured, and staged it last Friday as a Stage 2 was the same as it looked today. She said her assessment was incorrect last Friday. During an interview on 10/5/16 at 2:55 p.m., the DON said she had not provided any wound care training to the nurses. During a telephone interview on 10/5/16 at 3:03 p.m., the Nurse Practitioner said she was notified of a decline in Resident #6 left hip wound on 9/2/16. She said she was at the facility on 9/7/16, but did not assess the wound because he was up in his Geri-chair. She said she had never seen Resident #6's left hip pressure injury. She said due to Resident #6 being a high risk for pressure injuries on admission, the low air loss mattress and pressure relieving pad for his Geri-chair should have been in place on admission. She said she could not answer why the facility waited so long to put the low air mattress in place. She said she did not expect residents to acquire an unstageable pressure injury just because they were on hospice care. 2. Physician orders [REDACTED].#11 was [AGE] years old, admitted on [DATE] on hospice with a [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #11 usually understands and was usually understood. He was totally dependent on staff for all ADLs. He required extensive assistance of two persons for transfers and was totally dependent for dressing, toilet use, personal hygiene, and bathing. Resident #11 was at risk for pressure injuries and did not have unhealed pressure injuries on admission. A care plan provided on 10/4/16 did not indicate Resident #11 was at risk for skin breakdown but did not indicate he had a pressure injury. An admission Braden score dated 9/1/16 indicated Resident #11 was a high risk for developing pressure injuries. During an observation on 10/3/16 at 9:52 a.m., Resident #11 was lying in bed on his back on a regular mattress. During an interview on 10/4/16 at 3:46 p.m., Resident #11 said he had a sore on his bottom. He was lying in his bed on his back. During an observation and interview on 10/4/16 at 3:50 p.m., CNAs C and D assisted in a skin assessment of Resident #11. He was lying in bed on his back and a stage 2 pressure injury on his coccyx area was identified. It was pink in color with normal surrounding skin and did not have a dressing on the area. They said the hospice nurse was responsible for his baths, but they provided his daily ADLs. CNAs C and D said they did not know Resident #11 had the pressure injury on his coccyx area. During an interview on 10/5/16 at 10:38 a.m., CNA A said she got Resident #11 dressed that morning (10/4/16) at 6:30 a.m. and noticed an open area on his coccyx area, but did not tell anyone. She said she knew to report changes in skin, but she got busy and did not notify anyone. During an interview on 10/4/16 at 4:05 p.m., LVN B said he was not notified of a pressure injury to Resident #11's coccyx area. A weekly skin assessment sheet dated 10/4/16 indicated Resident #11 had: *Stage 2 pressure injury on his coccyx area measuring 0.7 cm x 0.4 cm x 0.1 cm. A wound care sheet dated 10/4/16 indicated Resident #11 had: *Stage 2 pressure injury on his coccyx measuring 0.8 cm x 0.4 cm x 0.1 cm, wound clean, dry and with pink tissue to the wound bed. There was no odor or drainage. During an observation on 10/5/16 at 9:21 a.m., Resident #11 was sitting up in his wheelchair in the activity room watching television. During an interview on 10/4/16 at 4:24 p.m., the hospice nurse said she was not aware Resident #11 had a pressure injury on his coccyx area. She said Monday, Wednesday, and Friday were his shower days and Resident #11 received a shower on 10/3/16 by the hospice aide. She said the hospice aide did not tell her Resident #11 had a new pressure injury. During an interview on 10/4/16 at 4:03 p.m., the DON said she was not aware Resident #11 had a pressure injury on his coccyx area. During an interview on 10/5/16 at 11:27 a.m., the DON said the person who identified a change in a resident's skin, should notify their charge nurse and administration so a treatment could be started. A Pressure Ulcer/Skin Breakdown Clinical Protocol with a revised date of October 2010 indicated: the nursing staff and attending physician will assess and document an individual ' s significant risk factors for developing pressure sores: for example, immobility, recent weight loss, and a history of pressure ulcers .in addition the nurse shall assess and document/report the following: .full assessment of pressure sore including; presence of exudate or necrotic tissue .the physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage 1 pressure area that has not yet ulcerated at the surface .during resident visits, the physician will evaluate and document the progress of wound healing -especially for those with complicated, extensive, and or non-healing wounds . A undated Skin Assessment Procedure indicated each resident will be assigned a day of the week and shift for completion of skin assessment .For residents with pressure ulcers and/or complicated wounds a registered nurse and/or certified wound care nurse is to be present for the scheduled assessment and document findings . The NPUAP web site at <http://www.npuap.org/pr2.htm> notes that in February 2007 the NPUAP redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. NPUAP defined a Stage II pressure ulcer as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. A Stage III is defined as, Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The CMS 672 dated 10/3/16 indicated 36 residents were in the bed or chair all or most of the time.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for 1 of 8 residents reviewed for hospice services. (Resident #4) The facility did not coordinate services with the hospice agency regarding Resident #4's facility acquired stage III pressure sore on her left hip. This failure could place 8 residents who received hospice care at risk of not receiving adequate assessments and services. Findings included: A computerized physician order [REDACTED].#4 was [AGE] years old, and admitted [DATE] with [DIAGNOSES REDACTED]. A telephone order dated 12/3/14 indicated Resident #4 was admitted to hospice services on that day. A care plan dated 8/31/15 indicated Resident #4 was at risk for pressure sores. The care plan did not indicate Resident #4 had pressure sores. There was no care plan for coordination with hospice services. A wound care sheet dated 9/30/15 indicated the pressure to Resident #4's left hip was 3 centimeters (cm) x 3 cm and was unstageable. There was no other description of the pressure sore. A significant change MDS assessment dated [DATE] indicated Resident #4 was severely cognitively impaired. The MDS indicated she rarely made herself understood, and rarely understood others. She was totally dependent on staff for assistance with all ADLs and required two person assist for transfers. The MDS indicated Resident #4 had two stage II pressure sores on her left hip. The clinical record dated 1/1/15 to 10/28/15 for Resident #4 did not indicate an updated plan of care to address the two stage II pressure sores on her left hip or interventions to treat or prevent pressure sores from worsening. During an interview on 10/26/15 at 11:00 a.m., the DON said Resident #4 had a stage III pressure sore on her left hip. The DON said the pressure sore to Resident #4's left hip developed in the facility and was unstageable when it was discovered. A hospice note dated 10/13/15 indicated the pressure sore to Resident #4's left hip was declining and was a stage III with 20% slough and purulent drainage. The hospice note indicated the DON was aware of the condition of the pressure sore. A physician order [REDACTED].#4 was to have wound care to her left hip every 48 hours. Staff was to cleanse with Dakin's solution, pat dry, cut calcium alginate to fit wound bed, apply non-adhesive pad and transparent covering. A wound care sheet dated 10/25/15 indicated the pressure sore to Resident #4's right hip measured 6.5 cm x 2.5 cm x 0.5 cm and was a stage III. The pressure sore was described as having green edges, an odor, and redness around the wound. During an observation and interview on 10/26/15 at 8:00 a.m., Resident #4 was sitting up in her wheelchair eating breakfast. Her wheelchair did not have a pressure relief cushion. CNA D said Resident #4 had a pressure sore to her left hip and her bed had a standard pressure relieving mattress on it. CNA D said Resident #4 usually stayed up until after breakfast. During observation and interview on 10/26/15 at 11:45 a.m., the hospice RN provided wound treatment to Resident #4's left hip. The DON was present. Resident #4 was lying on a standard pressure relieving mattress. The wound measured approximately 6 cm x 4 cm x 0.4 cm. and presented a shallow crater. The wound bed edges were red and the base was covered with approximately 75% slough. The surrounding skin was intact, red, excoriated and non-blanching. There was no odor noted. The hospice RN said she was new to hospice and was not confident in performing wound care. During wound care observation on 10/26/15 at 11:10 a.m., the hospice RN contaminated clean wound care supplies after touching Resident #4's urine soaked pad. During an interview on 10/27/15 at 9:05 a.m., the DON said she did not intervene in the wound care provided to Resident #4 by the hospice RN because she did not know she could. The DON said she was not sure what part of the wound care was inappropriate. During an observation on 10/27/15 at 8:30 a.m., Resident #4 was up in her wheelchair in the dining room eating breakfast. There was not a cushion in her wheelchair. During an interview on 10/28/15 at 9:25 a.m., the DON said she assessed Resident #4's wound on 10/25/15 and noted the pressure sore had declined and was now a stage III. She did not have Resident #4 on an air mattress or have a cushion in her wheelchair because she did not know the pressure sore had declined. She said she did not read the hospice notes and did not remember the hospice RN reporting the pressure sore had declined to a stage III on 10/13/15. This was documented in the Hospice note on 10/13/15. During a telephone interview on 10/27/15 at 11:48 a.m., the patient coordinator for hospice said they attended care plan meetings when invited. She said Resident #4 was provided wound care as needed. The patient coordinator for hospice said the hospice nurse visited twice a week. She said if a wound treatment was due on a day the hospice nurse made her visit the hospice nurse assessed the wound and changed the dressing, otherwise the facility nurses provided wound care. The coordinator said they supplied mattresses and cushions, but the facility had not requested either for Resident #4. She said hospice policy is to supply a low air loss mattress for stage IV pressure sores, but if the facility feels the resident will benefit from an air mattress and the wound can heal the will supply at earlier stages. The policy and procedure titled Hospice Program revised February 2014 indicated the following: .Policy Interpretation and Implementation . .4. When a resident participates in a hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status . The CMS 672 indicated there were 8 residents receiving hospice services.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development and worsening of pressure sores for 1 of 3 residents reviewed for pressure sores (Resident #4). Resident #4 was admitted without pressure sores, but was at risk for the development of pressure sores. The resident developed a facility acquired stage III pressure sore on her left hip. The facility did not address or provide the resident with pressure relieving devices. These failures contributed to the development of new pressure sores to Resident #4. This failure could place 4 residents with pressure sores at risk for the development of new pressure sores and decline in existing pressure sores. Findings included: A computerized physician order [REDACTED].#4 was [AGE] years old, and admitted [DATE] with [DIAGNOSES REDACTED]. A telephone order dated 12/3/14 indicated Resident #4 was admitted to hospice services on that day A care plan dated 8/31/15 indicated Resident #4 was at risk for pressure sores. The care plan did not indicate Resident #4 had pressure sores. There was no care plan for coordination of hospice services. A significant change MDS assessment dated [DATE] indicated Resident #4 was severely cognitively impaired. The MDS indicated she rarely made herself understood, and rarely understood others. She was totally dependent on staff for assistance with all ADLs and required two person assist for transfers. The MDS indicated Resident #4 had two stage II pressure sores on her left hip. The clinical record dated 1/1/15 through 10/13/15 for Resident #4 did not indicate an updated care plan to address the two stage II pressure sores on her left hip or interventions to treat or prevent pressure sores from worsening. A hospice wound note dated 10/13/15 indicated the pressure sore to Resident #4's left hip was declining and was a stage III with 20% slough and purulent drainage. The hospice note indicated the DON was aware of the condition of the wound. A physician order [REDACTED].#4 was to have wound care to her left hip every 48 hours. Staff was to cleanse with Dakin's solution, pat dry, cut calcium alginate to fit wound bed, apply non-adhesive pad and transparent covering. A Braden scale dated 10/25/15 indicated Resident #4 was a high risk for pressure sore development. A facility wound care sheet dated 9/30/15 indicated the pressure to Resident #4's left hip was 3 centimeter (cm) x 3 cm and was unstageable. There was no other description of the pressure sore. A facility wound care sheet dated 10/25/15 indicated the pressure wound to Resident #4's right hip measured 6.5 centimeter (cm) x 2.5 cm x 0.5 cm and was a stage III. The wound was described as having .green edges, an odor, and redness around the wound . During an observation and interview on 10/26/15 at 8:00 a.m., Resident #4 was up in her wheelchair eating breakfast. Her wheelchair did not have a pressure relieving cushion. CNA D said Resident #4 had a pressure sore to her left hip and her bed had a standard pressure relieving mattress on it. CNA D said Resident #4 usually stayed up until after breakfast. During an interview on 10/26/15 at 11:00 a.m., the DON said Resident #4 had a stage III pressure sore on her left hip. The DON said the pressure sore to Resident #4's left hip developed in the facility and was unstageable when it was discovered. The DON said she did not implement an air mattress or wheelchair cushion at that time. During an observation and interview on 10/26/15 at 11:10 a.m., the hospice RN provided wound treatment to Resident #4's left hip. The DON was present. Resident #4 was lying on a standard pressure relieving mattress. The hospice RN placed clean supplies beside the resident on urine soiled sheets. The pressure sore was open and drained a moderate amount of blood tinged drainage on the sheet. The wound was approximately 6 cm x 4 cm x 0.4cm. It presented as a shallow crater. The wound bed was red around the edges and the base was covered with approximately 75% slough. The surrounding skin was intact, red, excoriated and non-blanching. There was no odor noted. The hospice RN laid dirty gauze on the bed beside the clean supplies and was preparing to open another dressing when the surveyor intervened asking that the urine saturated brief be removed and incontinent care be provided. During an observation and interview on 10/26/15 at 11:45 a.m., following incontinent care, the DON stood at the bedside while the hospice RN continued with the wound treatment. The hospice nurse obtained supplies from her tote and laid them beside the resident on the sheet without a barrier. The hospice RN did not wash her hands or change gloves after cleaning the wound. During an interview on 10/27/15 at 9:05 a.m., the DON said she did not intervene in the wound care provided to Resident #4 by the hospice RN because she did not know she could. The DON said she was not sure what part of the wound care was inappropriate. During an observation on 10/27/15 at 8:30 a.m., Resident #4 was up in her wheelchair in the dining room eating breakfast. There was not a pressure relieving cushion in her wheelchair. During an interview on 10/28/15 at 9:25 a.m., the DON said she assessed Resident #4's pressure sore on 10/25/15 and noted the pressure sore had declined and was now a stage III. She said she did not have Resident #4 on an air mattress or have a pressure relieving cushion in her wheelchair because she did not know the pressure sore had declined. She said she did not read the hospice notes and did not remember the hospice RN reporting the pressure sore had declined to a stage III on 10/13/15. During a telephone interview on 10/27/15 at 11:48 a.m., the patient coordinator for hospice said they attended care plan meetings when invited. She said Resident #4 was provided wound care as needed. The patient coordinator for hospice said the hospice nurse visited twice a week. She said if a wound treatment was due on a day the hospice nurse made her visit the hospice nurse assessed the wound and changed the dressing, otherwise the facility nurses provided wound care. The coordinator said they supplied mattresses and cushions, but the facility had not requested either for Resident #4. The policy titled Prevention of Pressure Ulcers revised February 2014 indicated the following: .General Preventative Measures 1. Identify risk factors for pressure ulcer development. 2. For a person in bed: a. Change position at least every two hours or more b. Determine if resident needs a special mattress. c. Raise head of bed as little and for as short of time as possible . At <http://www.npuap.org/resources/educational-and-clinical-resources accessed on 11/3/15> indicated the following: .Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable . .Additional Categories/Stages for the USA Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body ' s natural (biological) cover and should not be removed . The CMS 802 dated 10/26/15 indicated there were 4 residents with pressure sores that were at risk for developing or worsening of pressure sores.

Based on observation, interview, and record review, the facility failed to ensure the residents right to be free from physical abuse and involuntary seclusion for 2 of 3 residents reviewed for abuse (Resident #s1 and 2) Resident #1 was tied to the bed with a blanket, unable to get up. The facility did not investigate or put any preventive actions in place to prevent the reoccurrence of abuse. CNA B abused Resident #2. Resident #2 reported the abuse and the facility did not protect the resident from CNA B or investigate the allegation. An Immediate Jeopardy situation was identified on 9/8/15 at 11:30 p.m. The Immediate Jeopardy was removed on 9/9/15 at 12:45 p.m. The facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 48 residents at risk for abuse, harm or even death. Findings included: 1. Consolidated physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 s cognitive status was severely impaired. She required one person assist with bed mobility and two person assist with transfers. The MDS indicated Resident #1 required assistance with all ADLs. The care plan dated 7/9/15 indicated Resident #1 had problems of refusing care. She resisted care by refusing to allow staff to assist with ADLs such as dressing and grooming. The resident would kick and hit at times. The interventions included to allow the resident time to express feelings of anger or dissatisfaction. A nursing note dated 9/3/15 at 11:57 p.m., indicated CNA F called LVN G to Resident #1 room. Resident #1 was lying in her bed. Resident #1's blanket was tied to the bed rail with the resident in bed. LVN G documented she untied the blanket and Resident #1 began fighting LVN G and CNA F The note indicated LVN G and CNA F backed off to give Resident #1 time to settle down. According to the notes Resident #1 said she was in pain and pain medications were administered. During an interview on 9/8/15 at 9:03 p.m., LVN A said Resident #1 was feisty. She said Resident #1 always wanted to get out of bed and tried to get up by herself. LVN A said she heard CNA B tied Resident #1 in bed, and it was in the nurseing notes. A September 2015 time card for CNA B indicated she worked the day shift on 9/2/15, and day and evening shift on 9/3/15, day shift on 9/4/15, 9/7/15 and 9/8/15. During an observation on 9/8/15 at 9:05 p.m.,Resident #1 was lying in her bed asleep. There was a one fourth side rail raised and a fall mat on the floor. There was also a bed alarm in place. During an interview on 9/8/15 at 9:39 p.m., the regional nurse/RN said there was an allegation that staff tied a resident in bed. She said the administrator and DON were informed, did an investigation, and determined no abuse occurred. The regional nurse/RN said it was an issue with staff retaliating against other staff. During an interview on 9/8/15 at 9:48 p.m., CNA C said Resident #1 required total assistance with all ADLs. She said Resident #1 had strength on some days and was weak on others. CNA C said Resident #1 could be combative when she was gotten up. During a telephone interview on 9/8/15 at 10:08 p.m., CNA D said on 9/3/15 at approximately 10:30 p.m. CNA F came to get her. CNA D said CNA F told her when she walked in Resident #1's room the resident was tied to the bed and fighting, and needed her assistance. CNA D said Resident #1 was lying in bed with the blanket tied across her chest and neck. CNA D said Resident #1 was kicking her legs and fighting to get out of the bed. She said the blanket was restraining Resident #1 to the bed. CNA D said they reported the incident to LVN G. CNA D said she wrote a statement about the incident, but no one talked to her about the incident. During an observation and interview on 9/8/15 at 10:47 p.m., CNA F said on 9/3/15 at approximately 10:30 p.m., she was walking down the hall and heard a resident say, help me, help me. She went into Resident #1's room, but did not immediately see why the resident was in distress. CNA F said Resident #1's feet were dangling out of the bed, the blanket was across her chest, and wrapped around the side rail. CNA F said Resident #1 could not get out of the blanket. She said there was only one side rail up on Resident #1's bed. CNA F said the blanket on the other side of the bed were tucked under Resident #1 and the blanket on the side were tied to the outside of the rail. CNA F said Resident #1 could not have tied the blanket herself. CNA F demonstrated the blanket was tied by being looped over the outside of the rail and pulled into a loop. CNA F said if Resident #1 had the strength she could have thrown the covers back from the opposite side of the rail and been free. She said Resident #1 was trying to sit up and it only made the restraint tighter. CNA F said she requested assistance from CNA D because Resident #1 was struggling so. She said they informed LVN G and was told to let Resident #1 calm down some first, because the resident was really mad. CNA F said LVN G was able to untie the blanket after a few minutes. CNA F said she was called at home on 9/4/15 by the ADON to write a statement, but no one ever talked to her about the incident. During an interview on 9/8/15 at 10:35 p.m., the ADON said on 9/4/15, she received report that Resident #1 was tied to her bed. She reported the incident to the DON and she said okay. The ADON said she did not know what happened with the incident because she turned it over to the DON, and did nothing else in regard to the incident or the resident. She said the DON was terminated today (9/8/15.) The ADON said she told the administrator of the incident involving Resident #1 this morning (9/8/15.) An undated statement written by the ADON received on 9/9/15 indicated it was an incident summary for 9/4/15. The statement indicated the report was received at approximately 6:30 a.m., on 9/4/15, during shift report from the night nurse, Resident #1 was found lying in the bed with the blanket tied across her chest and neck. According to the statement the ADON assessed Resident #1 at that time and found no injuries. She reported the incident to the DON on 9/ 4/15 at approximately 8:15 a.m., but could not find an incident report from the night nurse. The statement indicated the ADON questioned staff who worked the 2-10 pm shift on 9/3/15 and found no evidence of malice at that time per interviews and the resident was safe. The administrator and corporate nurse were notified. During a telephone interview on 9/9/15 at 9:33 a.m., the former DON said she was aware of the incident with Resident #1. The former DON said she was told the incident would be handled by the Regional Nurse/RN and administrator. She said she did not believe CNA B was involved. She felt someone tried to set her up due to controversies at the facility between the staff. She did not conduct an in-service, obtain witness statements, or determine was involved in the incident in any way. During a telephone interview on 9/9/15 at 9:47 a.m., CNA B said she usually worked the day shift as the day shift, but on 9/3/15 she provided care for Resident #1 during the 2 p.m.-10 p.m. shift. She said the last time she saw Resident # 1 on 9/3/15 was approximately 9:00 p.m. She said did not tie Resident #1 to the bed. CNA B said she worked on 9/8/15 and no one said anything to her about the incident, she left her shift at 1:00 p.m., due to a family emergency. She said noone told not work with Resident #1. CNA B said she suspended regarding the incident with Resident #2 on 9/8/15 at 11:35 p.m. (after surveyor intervention.) During an interview on 9/9/15 at 11:10 a.m., the administrator/abuse coordinator said on 9/8/15 at approximately 10:00 a.m., the ADON informed him of the incident with Resident #1. He said he started an investigation at that time. He did not know if CNA B was suspended or not. 2. A consolidated physician order [REDACTED].#2, admitted [DATE], was [AGE] years with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was moderately cognitively impaired. She was dependent on one staff for all ADLs including dressing and hygiene. A care plan last revised on 3/9/15 indicated Resident # 2 required assistance with ADLs due to deficits related to amputation of both lower extremities. Interventions included .physical assistance with part of bathing/showering. Encourage the resident to bath self as able and provide assistance as needed to complete the task, while providing dignity and safety . During an interview on 9/9/15 at 11:20 a.m., Resident #2 said a couple of weeks ago CNA B sprayed hot water in her face. She said CNA B told her the shower hose was broken, but she thought CNAB sprayed her on purpose. Resident #2 said she told CNA B that she did not like being sprayed in the face because the water was hot and could have scared her face. Resident #2 said she told the DON about the incident the next morning. She said the DON said was going to look into it, but nothing was done. Resident #2 said CNA B said she was fat and needed to take two baths a day. During an interview on 9/8/15 at 9:54 p.m., CNA E said Resident #2 told her CNA B sprayed water in her face even after the resident asked CNA B to stop. CNA E could not remember the date and time the resident reported this to her. She said Resident #1 had a red spot on one of her cheeks. CNA E said she reported Resident #2's allegation to the DON, but could not remember the date and time she told her. She said the DON said Resident #2 was crazy, and they were all trying to get CNA B into trouble. CNA E said the shower head had been broken for months, and sprayed water out of the top, but unless you dropped it, it would not spray water in the resident's face. A grievance form dated 9/1/15 indicated Resident #2 complained the shower aide (CNA B) sprayed her in the face during her shower. The form indicated the shower head was discovered to be broken and sprayed uncontrollably. According to the form the shower head was fixed. A statement written by the social worker said the shower aide refused to write a statement. The grievance form indicated the issue was resolved. During an interview telephone on 9/9/15 at 9:47 a.m., CNA B said Resident #2 did say she intentionally sprayed her in the face with the shower head, but she denied spraying her, intentionally. She said the shower head was broken and it was an accident. She said she did not write a statement in regard to the incident. CNA B said she still provided care to Resident #2. CNA B said she suspended regarding the incident with Resident #2 on 9/8/15 at 11:35 p.m. (after surveyor intervention.) During an interview on 9/8/15 at 10:15 p.m., LVN H said Resident #2 said when CNA B gave her a shower the water was cold but she could not remember when it happened. She said Resident #2 complained she told CNA B, several times, the water was cold, but she continued to shower her. LVN H said Resident #2 alleged CNA B adjusted the water to hot and sprayed her in the face. She said Resident #2 told CNA B to stop, but CNA B sprayed her in the face again on purpose. LVN H said she wrote out a statement and tapped it to the door of the ADON. She said nothing was done. LVN H said the DON was aware of the incident and said the staff was just out to get CNA B, and nothing was done. During an interview on 9/8/15 at 10:35 p.m., the ADON said on 9/1/15, Resident #2 told her and the DON, CNA B intentionally sprayed water in her face. She said the DON took Resident #2 and met with her and CNA B alone. The ADON said when the former DON returned, she said Resident #2 was crazy. The ADON said the shower head was broken and sprayed water. She was unaware if the shower head was fixed. During a telephone interview on 9/9/15 at 9:33 a.m., the former DON said on 9/1/15 Resident #2 complained CNA B intentionally sprayed water in her face. She said she took Resident #2 to the shower room and interviewed CNA B and the resident together. CNA B said the shower head (a hold in your hand shower sprayer) was broken. The former DON said CNA B showed her where water shot out from the top of the shower head. She said CNA B denied intentionally spraying Resident #2 in the face. The former DON said Resident #2 said she did not want CNA B providing care to her because she felt it was intentional. The former DON said she got the maintenance man to fix the shower head that day, and completed a grievance form. A statement taken by the ADON on 9/9/15 indicated on 9/1/15, Resident #2 alleged .the shower aide, pointed the water directly at my face. I kept telling her it was cold, and then she made it hot and pointed the shower at my face and squirted me with it . The resident was assessed on 9/9/15 with no injuries. During an interview on 9/9/15 at 11:10 a.m., the administrator/abuse coordinator said all he knew about Resident #2 was there was a broken shower head. He thought that was the end of the story. He said the former DON did not report Resident #2 alleged CNA B sprayed her in the face with hot water on purpose. The Abuse Prohibition Policy and Procedure last revised July 2012 indicated: .The facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designee. Local law enforcement, the state survey agency will be notified in accordance with federal and state law. Investigation: The facility must have evidence that all violations, including allegations are thoroughly investigated. Reporting: All alleged violations involving mistreatment, neglect or abuse shall be reported immediately to the administrator or DON. The nurse must document all incidents of alleged abuse/neglect on the incident report and on the 24-hour report . The regional nurse and ADON were notified on 9/8/15 at 11:30 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 9/9/15 at 12:04 a.m., and included: 1. Alleged staff member involved in both incidents will be suspended until the conclusion of the investigation; if, upon completion of the investigation the alleged staff member is determined to be guilty, he/she will be terminated immediately and reported to their respective licensing boards; 2. All staff will be in-serviced on the following: date for completion, 9/9/2015. a.) abuse and neglect policy/procedure; b.) what should be reported immediately and to whom, the Abuse Coordinator or designee; c.) who the Abuse Coordinator is (the facility Administrator);d.) staff that are unable to be in-serviced (due to leave status, etc.), will be in-serviced prior to being allowed to work in the facility. 3. The facility will have evidence that all allegations are thoroughly investigated and documented; 4. All allegations of abuse and/or neglect will be reported immediately to the Administrator or DON; 5. Licensed nurses will document all incidents of alleged abuse and/or neglect on the Incident/Accident Report and on the 24 hour report; 6. Allegations of neglect and/or abuse will be reported to the State (DADS) within 24 hours of report if/when, following the immediate investigation, it is determined that the allegations are substantiated. The surveyors confirmed the plan of removal was implemented sufficiently to remove the Immediate Jeopardy by: On 9/9/15 at 12:30 p.m., interviews with 1 CNA, 1 Housekeeper, 1 medication aide, the social worker, and maintenance man were interviewed and were able to provide information regarding abuse and neglect reporting procedures. They were able to identify the abuse coordinator and able to provide information of different situational events related to abuse. The administrator and ADON were interviewed and able to provide information regarding the procedures to follow when an allegation of abuse was made. On 9/9/15 12:45 p.m., the administrator and two regional RNs were informed the Immediate Jeopardy was lifted; however, the facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 9/8/15 indicated 48 residents in the facility.

Based on observation, interview, and record review, the facility failed to investigate allegations of staff to resident abuse, did not protect the residents from further abuse and did not report allegations to state agency for 2 of 3 residents reviewed for abuse. (Resident #s1 and 2) Resident #1 was tied to the bed with a blanket, unable to get up. The facility did not investigate or put any preventive actions in place to prevent the reoccurrence of abuse. CNA B abused Resident #2. Resident #2 reported the abuse and the facility did not protect the resident from CNA B or investigate the allegation. The facility did not report these allegations of abuse to state agency or implement measures to protect the residents. An Immediate Jeopardy situation was identified on 9/8/15 at 11:30 p.m. The Immediate Jeopardy was removed on 9/9/15 at 12:45 p.m. The facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.This failure could place the census of 48 residents at risk for abuse, harm or even death. Findings included: 1. Consolidated physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 s cognitive status was severely impaired. She required one person assist with bed mobility and two person assist with transfers. The MDS indicated Resident #1 required assistance with all ADLs. The care plan dated 7/9/15 indicated Resident #1 had problems of refusing care. She resisted care by refusing to allow staff to assist with ADLs such as dressing and grooming. The resident would kick and hit at times. The interventions included to allow the resident time to express feelings of anger or dissatisfaction. A nursing note dated 9/3/15 at 11:57 p.m., indicated CNA F called LVN G to Resident #1 ' s room. Resident #1 was lying in her bed. Resident #1's blanket was tied to the bed rail with the resident in bed. LVN G documented she untied the blanket and Resident #1 began fighting LVN G and CNA F The note indicated LVN G and CNA F backed off to give Resident #1 time to settle down. According to the notes, Resident #1 said she was in pain and pain medications were administered. During an interview on 9/8/15 at 9:03 p.m., LVN A said Resident #1 was feisty. She said Resident #1 always wanted to get out of bed and tried to get up by herself. LVN A said she heard CNA B tied Resident #1 in bed, and it was in the nursing notes. A September 2015 time care for CNA B indicated she worked on 9/2/15 through 9/4/15, and 9/7 and 9/8/15. During an observation on 9/8/15 at 9:05 p.m., Resident #1 was lying in her bed asleep. There was a one fourth side rail raised and a fall mat on the floor. There was also a bed alarm in place. During an interview on 9/8/15 at 9:39 p.m., the regional nurse/RN said there was an allegation that staff tied a resident in bed. She said the administrator and DON were informed, did an investigation, and determined no abuse occurred. The regional nurse/RN said it was an issue with staff retaliating against other staff. During an interview on 9/8/15 at 9:48 p.m., CNA C said Resident #1 required total assistance with all ADLs. She said Resident #1 had strength on some days and was weak on others. CNA C said Resident #1 could be combative when she was gotten up. During a telephone interview on 9/8/15 at 10:08 p.m., CNA D said on 9/3/15 at approximately 10:30 p.m. CNA F came to get her. CNA D said CNA F told her when she walked in Resident #1's room the resident was tied to the bed and fighting, and needed her assistance. CNA D said Resident #1 was lying in bed with the blanket tied across her chest and neck. CNA D said Resident #1 was kicking her legs and fighting to get out of the bed. She said the blanket was restraining Resident #1 to the bed. CNA D said they reported the incident to LVN G. CNA D said she wrote a statement about the incident, but no one talked to her about the incident. During an observation and interview on 9/8/15 at 10:47 p.m., CNA F said on 9/3/15 at approximately 10:30 p.m., she was walking down the hall and heard a resident say, help me, help me. She went into Resident #1's room, but did not immediately see why the resident was in distress. CNA F said Resident #1's feet were dangling out of the bed, the blanket was across her chest, and wrapped around the side rail. CNA F said Resident #1 could not get out of the blanket. She said there was only one side rail up on Resident #1's bed. CNA F said the blanket on the other side of the bed was tucked under Resident #1 and the blanket on the side was tied to the outside of the rail. CNA F said Resident #1 could not have tied the blanket herself. CNA F demonstrated the blanket was tied by being looped over the outside of the rail and pulled into a loop. CNA F said if Resident #1 had the strength she could have thrown the covers back from the opposite side of the rail and been free. She said Resident #1 was trying to sit up and it only made the restraint tighter. CNA F said she requested assistance from CNA D because Resident #1 was struggling so. She said they informed LVN G and was told to let Resident #1 calm down some first, because the resident was really mad. CNA F said LVN G was able to untie the blanket after a few minutes. CNA F said she was called at home on 9/4/15 by the ADON to write a statement, but no one ever talked to her about the incident. During an interview on 9/8/15 at 10:35 p.m., the ADON said on 9/4/15, she received report that Resident #1 was tied to her bed. She reported the incident to the DON and she said okay. The ADON said she did not know what happened with the incident because she turned it over to the DON, and did nothing else in regard to the incident or the resident. She said the DON was terminated today (9/8/15.) The ADON said she told the administrator of the incident involving Resident #1 this morning (9/8/15.) An undated statement written by the ADON received on 9/9/15 indicated it was an incident summary for 9/4/15. The statement indicated the report was received at approximately 6:30 a.m., on 9/4/15, during shift report from the night nurse, Resident #1 was found lying in the bed with the blanket tied across her chest and neck. According to the statement the ADON assessed Resident #1 at that time and found no injuries. She reported the incident to the DON on 9/ 4/15 at approximately 8:15 a.m., but could not find an incident report from the night nurse. The statement indicated the ADON questioned staff who worked the 2-10 pm shift on 9/3/15 and found no evidence of malice at that time per interviews and the resident was safe. The administrator and corporate nurse were notified. During a telephone interview on 9/9/15 at 9:33 a.m., the former DON said she was aware of the incident with Resident #1. The former DON said she was told the incident would be handled by the Regional Nurse/RN and administrator. She said she did not believe CNA B was involved. She felt someone tried to set her up due to controversies at the facility between the staff. She did not conduct an in-service, obtain witness statements, or determine was involved in the incident in any way. During a telephone interview on 9/9/15 at 9:47 a.m., CNA B said she usually worked the day shift as the day shift, but on 9/3/15 she provided care for Resident #1 during the 2 p.m.-10 p.m. shift. She said the last time she saw Resident # 1 on 9/3/15 was approximately 9:00 p.m. She said did not tie Resident #1 to the bed. CNA B said she worked on 9/8/15 and no one said anything to her about the incident, she left her shift at 1:00 p.m., due to a family emergency. She said no one told her not to work with Resident #1. CNA B said she suspended regarding the incident with Resident #2 on 9/8/15 at 11:35 p.m. (after surveyor intervention.) During an interview on 9/9/15 at 11:10 a.m., the administrator/abuse coordinator said on 9/8/15 at approximately 10:00 a.m., the ADON informed him of the incident with Resident #1. He said he started an investigation at that time. He did not know if CNA B was suspended or not. 2. A consolidated physician order [REDACTED].#2, admitted [DATE], was [AGE] years with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was moderately cognitively impaired. She was dependent on one staff for all ADLs including dressing and hygiene. A care plan last revised on 3/9/15 indicated Resident # 2 required assistance with ADLs due to deficits related to amputation of both lower extremities. Interventions included .physical assistance with part of bathing/showering. Encourage the resident to bath self as able and provide assistance as needed to complete the task, while providing dignity and safety . During an interview on 9/9/15 at 11:20 a.m., Resident #2 said a couple of weeks ago CNA B sprayed hot water in her face. She said CNA B told her the shower hose was broken, but she thought CNA B sprayed her on purpose. Resident #2 said she told CNA B that she did not like being sprayed in the face because the water was hot and could have scared her face. Resident #2 said she told the DON about the incident the next morning. She said the DON said was going to look into it, but nothing was done. Resident #2 said CNA B said she was fat and needed to take two baths a day. During an interview on 9/8/15 at 9:54 p.m., CNA E said Resident #2 told her CNA B sprayed water in her face even after the resident asked CNA B to stop but she could not remember when the resident told her. She said Resident #1 had a red spot on one of her cheeks. CNA E said she reported Resident #2's allegation to the DON, but she could not remember the date and time she told the DON. She said the DON said Resident #2 was crazy, and they were all trying to get CNA B into trouble. CNA E said the shower head had been broken for months, and sprayed water out of the top, but unless you dropped it, it would not spray water in the resident's face. A grievance form dated 9/1/15 indicated Resident #2 complained the shower aide (CNA B) sprayed her in the face during her shower. The form indicated the shower head was discovered to be broken and sprayed uncontrollably. According to the form the shower head was fixed. A statement written by the social worker said the shower aide refused to write a statement. The grievance form indicated the issue was resolved. During an interview telephone on 9/9/15 at 9:47 a.m., CNA B said Resident #2 did say she intentionally sprayed her in the face with the shower head, but she denied spraying her, intentionally. She said the shower head was broken and it was an accident. She said she did not write a statement in regard to the incident. CNA B said she still provided care to Resident #2. CNA B said she suspended regarding the incident with Resident #2 on 9/8/15 at 11:35 p.m. (after surveyor intervention.) During an interview on 9/8/15 at 10:15 p.m., LVN H said on Resident #2 said when CNA B gave her a shower the water was cold. She could not remember the date and time Resident #2 told her this. She said Resident #2 complained she told CNA B, several times, the water was cold, but she continued to shower her. LVN H said Resident #2 alleged CNA B adjusted the water to hot and sprayed her in the face. She said Resident #2 told CNA B to stop, but CNA B sprayed her in the face again on purpose. LVN H said she wrote out a statement and tapped it to the door of the ADON. She said nothing was done. LVN H said the DON was aware of the incident and said the staff was just out to get CNA B, and nothing was done. During an interview on 9/8/15 at 10:35 p.m., the ADON said on 9/1/15, Resident #2 told her and the DON, CNA B intentionally sprayed water in her face. She said the DON took Resident #2 and met with her and CNA B alone. The ADON said when the former DON returned, she said Resident #2 was crazy. The ADON said the shower head was broken and sprayed water. She was unaware if the shower head was fixed. During a telephone interview on 9/9/15 at 9:33 a.m., the former DON said on 9/1/15 Resident #2 complained CNA B intentionally sprayed water in her face. She said she took Resident #2 to the shower room and interviewed CNA B and the resident together. CNA B said the shower head (a hold in your hand shower sprayer) was broken. The former DON said CNA B showed her where water shot out from the top of the shower head. She said CNA B denied intentionally spraying Resident #2 in the face. The former DON said Resident #2 said she did not want CNA B providing care to her because she felt it was intentional. The former DON said she got the maintenance man to fix the shower head that day, and completed a grievance form. A statement taken by the ADON on 9/9/15 indicated on 9/1/15, Resident #2 alleged .the shower aide, pointed the water directly at my face. I kept telling her it was cold, and then she made it hot and pointed the shower at my face and squirted me with it . The resident was assessed on 9/9/15 with no injuries. During an interview on 9/9/15 at 11:10 a.m., the administrator/abuse coordinator said all he knew about Resident #2 was there was a broken shower head. He thought that was the end of the story. He said the former DON did not report Resident #2 alleged CNA B sprayed her in the face with hot water on purpose. The regional nurse and ADON were notified on 9/8/15 at 11:30 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 9/9/15 at 12:04 a.m., and included: 1. Alleged staff member involved in both incidents will be suspended until the conclusion of the investigation; if, upon completion of the investigation the alleged staff member is determined to be guilty, he/she will be terminated immediately and reported to their respective licensing boards; 2. All staff will be in-serviced on the following: date for completion, 9/9/2015. a.) abuse and neglect policy/procedure; b.) what should be reported immediately and to whom, the Abuse Coordinator or designee; c.) who the Abuse Coordinator is (the facility Administrator);d.) staff that are unable to be in-serviced (due to leave status, etc.), will be in-serviced prior to being allowed to work in the facility. 3. The facility will have evidence that all allegations are thoroughly investigated and documented; 4. All allegations of abuse and/or neglect will be reported immediately to the Administrator or DON; 5. Licensed nurses will document all incidents of alleged abuse and/or neglect on the Incident/Accident Report and on the 24 hour report; 6. Allegations of neglect and/or abuse will be reported to the State (DADS) within 24 hours of report if/when, following the immediate investigation, it is determined that the allegations are substantiated. The surveyors confirmed the plan of removal was implemented sufficiently to remove the Immediate Jeopardy by: On 9/9/15 at 12:30 p.m., interviews with 1 CNA, 1 Housekeeper, 1 medication aide, the social worker, and maintenance man were interviewed and were able to provide information regarding abuse and neglect reporting procedures. They were able to identify the abuse coordinator and able to provide information of different situational events related to abuse. The administrator and ADON were interviewed and able to provide information regarding the procedures to follow when an allegation of abuse was made. On 9/9/15 12:45 p.m., the administrator and two regional RNs were informed the Immediate Jeopardy was lifted; however, the facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The Abuse Prohibition Policy and Procedure last revised July 2012 indicated: .The facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designee. Local law enforcement, the state survey agency will be notified in accordance with federal and state law. Investigation: The facility must have evidence that all violations, including allegations are thoroughly investigated. Reporting: All alleged violations involving mistreatment, neglect or abuse shall be reported immediately to the administrator or DON. The nurse must document all incidents of alleged abuse/neglect on the incident report and on the 24-hour report . The CMS 672 dated 9/8/15 indicated 48 residents in the facility.

Based on observation, interview, and record review the facility failed to implement their written policies and procedures to prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for 2 of 3 residents reviewed for abuse. (Resident #s1 and 2) Resident #1 was tied to the bed with a blanket, unable to get up. The facility did not investigate or put any preventive actions in place to prevent the reoccurrence of abuse. CNA B abused Resident #2. Resident #2 reported the abuse and the facility did not protect the resident from CNA B or investigate the allegation. The facility did not report these allegations of abuse to state agency. An Immediate Jeopardy situation was identified on 9/8/15 at 11:30 p.m. The Immediate Jeopardy was removed on 9/9/15 at 12:45 p.m. The facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 48 residents at risk for abuse, harm or even death. Findings included: The Abuse Prohibition Policy and Procedure last revised July 2012 indicated: .The facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designee. Local law enforcement, the state survey agency will be notified in accordance with federal and state law. Investigation: The facility must have evidence that all violations, including allegations are thoroughly investigated. Reporting: All alleged violations involving mistreatment, neglect or abuse shall be reported immediately to the administrator or DON. The nurse must document all incidents of alleged abuse/neglect on the incident report and on the 24-hour report . 1. Consolidated physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 s cognitive status was severely impaired. She required one person assist with bed mobility and two person assist with transfers. The MDS indicated Resident #1 required assistance with all ADLs. The care plan dated 7/9/15 indicated Resident #1 had problems of refusing care. She resisted care by refusing to allow staff to assist with ADLs such as dressing and grooming. The resident would kick and hit at times. The interventions included to allow the resident time to express feelings of anger or dissatisfaction. A nursing note dated 9/3/15 at 11:57 p.m., indicated CNA F called LVN G to Resident # ' S room. Resident #1 was lying in her bed. Resident #1's blanket was tied to the bed rail with the resident in bed. LVN G documented she untied the blanket and Resident #1 began fighting LVN G and CNA F The note indicated LVN G and CNA F backed off to give Resident #1 time to settle down. According to the notes Resident #1 said she was in pain and pain medications were administered. During an interview on 9/8/15 at 9:03 p.m., LVN A said Resident #1 was feisty. She said Resident #1 always wanted to get out of bed and tried to get up by herself. LVN A said she heard CNA B tied Resident #1 in bed, and it was in the nursing notes. A September 2015 time card for CNA B indicated she worked the day shift on 9/2/15, and day and evening shift on 9/3/15, day shift on 9/4/15, 9/7/15 and 9/8/15. During an observation on 9/8/15 at 9:05 p.m., Resident #1 was lying in her bed asleep. There was a one fourth side rail raised and a fall mat on the floor. There was also a bed alarm in place. During an interview on 9/8/15 at 9:39 p.m., the regional nurse/RN said there was an allegation that staff tied a resident in bed. She said the administrator and DON were informed, did an investigation, and determined no abuse occurred. The regional nurse/RN said it was an issue with staff retaliating against other staff. During an interview on 9/8/15 at 9:48 p.m., CNA C said Resident #1 required total assistance with all ADLs. She said Resident #1 had strength on some days and was weak on others. CNA C said Resident #1 could be combative when she was gotten up. During a telephone interview on 9/8/15 at 10:08 p.m., CNA D said on 9/3/15 at approximately 10:30 p.m. CNA F came to get her. CNA D said CNA F told her when she walked in Resident #1's room the resident was tied to the bed and fighting, and needed her assistance. CNA D said Resident #1 was lying in bed with the blanket tied across her chest and neck. CNA D said Resident #1 was kicking her legs and fighting to get out of the bed. She said the blanket was restraining Resident #1 to the bed. CNA D said they reported the incident to LVN G. CNA D said she wrote a statement about the incident, but no one talked to her about the incident. During an observation and interview on 9/8/15 at 10:47 p.m., CNA F said on 9/3/15 at approximately 10:30 p.m., she was walking down the hall and heard a resident say, help me, help me. She went into Resident #1's room, but did not immediately see why the resident was in distress. CNA F said Resident #1's feet were dangling out of the bed, the blanket was across her chest, and wrapped around the side rail. CNA F said Resident #1 could not get out of the blanket. She said there was only one side rail up on Resident #1's bed. CNA F said the blanket on the other side of the bed was tucked under Resident #1 and the blanket on the side was tied to the outside of the rail. CNA F said Resident #1 could not have tied the blanket herself. CNA F demonstrated the blanket was tied by being looped over the outside of the rail and pulled into a loop. CNA F said if Resident #1 had the strength she could have thrown the covers back from the opposite side of the rail and been free. She said Resident #1 was trying to sit up and it only made the restraint tighter. CNA F said she requested assistance from CNA D because Resident #1 was struggling so. She said they informed LVN G and was told to let Resident #1 calm down some first, because the resident was really mad. CNA F said LVN G was able to untie the blanket after a few minutes. CNA F said she was called at home on 9/4/15 by the ADON to write a statement, but no one ever talked to her about the incident. During an interview on 9/8/15 at 10:35 p.m., the ADON said on 9/4/15, she received report that Resident #1 was tied to her bed. She reported the incident to the DON and she said okay. The ADON said she did not know what happened with the incident because she turned it over to the DON, and did nothing else in regard to the incident or the resident. She said the DON was terminated today (9/8/15.) The ADON said she told the administrator of the incident involving Resident #1 this morning (9/8/15.) An undated statement written by the ADON received on 9/9/15 indicated it was an incident summary for 9/4/15. The statement indicated the report was received at approximately 6:30 a.m., on 9/4/15, during shift report from the night nurse, Resident #1 was found lying in the bed with the blanket tied across her chest and neck. According to the statement the ADON assessed Resident #1 at that time and found no injuries. She reported the incident to the DON on 9/ 4/15 at approximately 8:15 a.m., but could not find an incident report from the night nurse. The statement indicated the ADON questioned staff who worked the 2-10 pm shift on 9/3/15 and found no evidence of malice at that time per interviews and the resident was safe. The administrator and corporate nurse were notified. During a telephone interview on 9/9/15 at 9:33 a.m., the former DON said she was aware of the incident with Resident #1. The former DON said she was told the incident would be handled by the Regional Nurse/RN and administrator. She said she did not believe CNA B was involved. She felt someone tried to set her up due to controversies at the facility between the staff. She did not conduct an in-service, obtain witness statements, or determine was involved in the incident in any way. During a telephone interview on 9/9/15 at 9:47 a.m., CNA B said she usually worked the day shift as the day shift, but on 9/3/15 she provided care for Resident #1 during the 2 p.m.-10 p.m. shift. She said the last time she saw Resident # 1 on 9/3/15 was approximately 9:00 p.m. She said did not tie Resident #1 to the bed. CNA B said she worked on 9/8/15 and no one said anything to her about the incident, she left her shift at 1:00 p.m., due to a family emergency. She said noone told not work with Resident #1. CNA B said she suspended regarding the incident with Resident #2 on 9/8/15 at 11:35 p.m. (after surveyor intervention.) During an interview on 9/9/15 at 11:10 a.m., the administrator/abuse coordinator said on 9/8/15 at approximately 10:00 a.m., the ADON informed him of the incident with Resident #1. He said he started an investigation at that time. He did not know if CNA B was suspended or not. 2. A consolidated physician order [REDACTED].#2, admitted [DATE], was [AGE] years with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was moderately cognitively impaired. She was dependent on one staff for all ADLs including dressing and hygiene. A care plan last revised on 3/9/15 indicated Resident # 2 required assistance with ADLs due to deficits related to amputation of both lower extremities. Interventions included .physical assistance with part of bathing/showering. Encourage the resident to bath self as able and provide assistance as needed to complete the task, while providing dignity and safety . During an interview on 9/9/15 at 11:20 a.m., Resident #2 said a couple of weeks ago CNA B sprayed hot water in her face. She said CNA B told her the shower hose was broken, but she thought CNAB sprayed her on purpose. Resident #2 said she told CNA B that she did not like being sprayed in the face because the water was hot and could have scared her face. Resident #2 said she told the DON about the incident the next morning. She said the DON said was going to look into it, but nothing was done. Resident #2 said CNA B said she was fat and needed to take two baths a day. During an interview on 9/8/15 at 9:54 p.m., CNA E said Resident #2 told her CNA B sprayed water in her face even after the resident asked CNA B to stop. CNA E could not remember when the resident told her this. She said Resident #1 had a red spot on one of her cheeks. CNA E said she reported Resident #2's allegation to the DON but she could not remember the date and time she told her. She said the DON said Resident #2 was crazy, and they were all trying to get CNA B into trouble. CNA E said the shower head had been broken for months, and sprayed water out of the top, but unless you dropped it, it would not spray water in the resident's face. A grievance form dated 9/1/15 indicated Resident #2 complained the shower aide (CNA B) sprayed her in the face during her shower. The form indicated the shower head was discovered to be broken and sprayed uncontrollably. According to the form the shower head was fixed. A statement written by the social worker said the shower aide refused to write a statement. The grievance form indicated the issue was resolved. During an interview telephone on 9/9/15 at 9:47 a.m., CNA B said Resident #2 did say she intentionally sprayed her in the face with the shower head, but she denied spraying her, intentionally. She said the shower head was broken and it was an accident. She said she did not write a statement in regard to the incident. CNA B said she still provided care to Resident #2. CNA B said she suspended regarding the incident with Resident #2 on 9/8/15 at 11:35 p.m. (after surveyor intervention.) During an interview on 9/8/15 at 10:15 p.m., LVN H said Resident #2 said when CNA B gave her a shower the water was cold but she could not remember the date and time the resident told her this. She said Resident #2 complained she told CNA B, several times, the water was cold, but she continued to shower her. LVN H said Resident #2 alleged CNA B adjusted the water to hot and sprayed her in the face. She said Resident #2 told CNA B to stop, but CNA B sprayed her in the face again on purpose. LVN H said she wrote out a statement and tapped it to the door of the ADON. She said nothing was done. LVN H said the DON was aware of the incident and said the staff was just out to get CNA B, and nothing was done. During an interview on 9/8/15 at 10:35 p.m., the ADON said on 9/1/15, Resident #2 told her and the DON, CNA B intentionally sprayed water in her face. She said the DON took Resident #2 and met with her and CNA B alone. The ADON said when the former DON returned, she said Resident #2 was crazy. The ADON said the shower head was broken and sprayed water. She was unaware if the shower head was fixed. During a telephone interview on 9/9/15 at 9:33 a.m., the former DON said on 9/1/15 Resident #2 complained CNA B intentionally sprayed water in her face. She said she took Resident #2 to the shower room and interviewed CNA B and the resident together. CNA B said the shower head (a hold in your hand shower sprayer) was broken. The former DON said CNA B showed her where water shot out from the top of the shower head. She said CNA B denied intentionally spraying Resident #2 in the face. The former DON said Resident #2 said she did not want CNA B providing care to her because she felt it was intentional. The former DON said she got the maintenance man to fix the shower head that day, and completed a grievance form. A statement taken by the ADON on 9/9/15 indicated on 9/1/15, Resident #2 alleged .the shower aide, pointed the water directly at my face. I kept telling her it was cold, and then she made it hot and pointed the shower at my face and squirted me with it . The resident was assessed on 9/9/15 with no injuries. During an interview on 9/9/15 at 11:10 a.m., the administrator/abuse coordinator said all he knew about Resident #2 was there was a broken shower head. He thought that was the end of the story. He said the former DON did not report Resident #2 alleged CNA B sprayed her in the face with hot water on purpose. The regional nurse and ADON were notified on 9/815 at 11:30 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 9/8/15 at 12:04 p.m., and included: 1. Alleged staff member involved in both incidents will be suspended until the conclusion of the investigation; if, upon completion of the investigation the alleged staff member is determined to be guilty, he/she will be terminated immediately and reported to their respective licensing boards; 2. All staff will be in-serviced on the following: date for completion, 9/9/2015. a.) abuse and neglect policy/procedure; b.) what should be reported immediately and to whom, the Abuse Coordinator or designee; c.) who the Abuse Coordinator is (the facility Administrator); d.) staff that are unable to be in-serviced (due to leave status, etc.), will be in-serviced prior to being allowed to work in the facility. 3. The facility will have evidence that all allegations are thoroughly investigated and documented; 4. All allegations of abuse and/or neglect will be reported immediately to the Administrator or DON; 5. Licensed nurses will document all incidents of alleged abuse and/or neglect on the Incident/Accident Report and on the 24 hour report; 6. Allegations of neglect and/or abuse will be reported to the State (DADS) within 24 hours of report if/when, following the immediate investigation, it is determined that the allegations are substantiated. The surveyors confirmed the plan of removal was implemented sufficiently to remove the Immediate Jeopardy by: On 9/9/15 at 12:30 p.m., interviews with 1 CNA, 1 Housekeeper, 1 medication aide, the social worker, and maintenance man were interviewed and were able to provide information regarding abuse and neglect reporting procedures. They were able to identify the abuse coordinator and able to provide information of different situational events related to abuse. The administrator and ADON were interviewed and able to provide information regarding the procedures to follow when an allegation of abuse was made. On 9/9/15 12:45 p.m., the administrator and two regional RNs were informed the Immediate Jeopardy was lifted; however, the facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 9/8/15 indicated 48 residents in the facility.

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints which were not required to treat medical symptoms or utilized as a replacement for staff supervision for 1 of 3 residents reviewed for restraint use. (Resident #1) Resident #1 did not have medical justification to be tied in bed. Resident #1 was found with a blanket stretched across her body from her chest to her neck and tied to the side rail. The facility did not investigate or put any preventive actions in place to prevent the reoccurrence of restraint use. An Immediate Jeopardy situation was identified on 9/8/15 at 11:30 p.m. The Immediate Jeopardy was removed on 9/9/15 at 12:45 p.m. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 12 residents with behaviors at risk of unnecessary restriction of movement, lack of staff supervision, and injury or death. Findings included: Consolidated physician orders indicated Resident #1 was a [AGE] year old female, admitted [DATE] with [DIAGNOSES REDACTED]. There were no physician orders for restraint use. The most recent MDS dated [DATE] indicated Resident #1's cognitive status was severely impaired. She required one person assist with bed mobility and two person assist with transfers. The MDS indicated Resident #1 required assistance with all ADLs. The care plan dated 7/9/15 indicated Resident #1 had problems of refusing care. She resisted care by refusing to allow staff to assist with ADLs such as dressing and grooming. The resident would kick and hit at times. The interventions included to allow the resident time to express feelings of anger or dissatisfaction. There was no care plan for restraint use. A nursing note dated 9/3/15 at 11:57 p.m., indicated CNA F called LVN G to Resident #1 room. Resident #1 was lying in her bed. Resident #1's blanket was tied to the bed rail with the resident in bed. LVN G documented she untied the blanket and Resident #1 began fighting LVN G and CNA F. The note indicated LVN G and CNA F backed off to give Resident #1 time to settle down. According to the notes Resident #1 said she was in pain and pain medications were administered. During an interview on 9/8/15 at 9:03 p.m., LVN A said Resident #1 was feisty. She said Resident #1 always wanted to get out of bed and tried to get up by herself. LVN A said she heard CNA B tied Resident #1 in bed, and it was in the nursing notes. A September 2015 time card for CNA B indicated she worked the day shift on 9/2/15, and day and evening shift on 9/3/15, day shift on 9/4/15, 9/7/15 and 9/8/15. During an observation on 9/8/15 at 9:05 p.m., Resident #1 was lying in her bed asleep. There was a one fourth side rail raised and a fall mat on the floor. There was also a bed alarm in place. During an interview on 9/8/15 at 9:39 p.m., the regional nurse/RN said there was an allegation staff tied a resident in bed. She said the administrator and DON were informed, did an investigation, and determined no abuse occurred. The regional nurse/RN said it was an issue with staff retaliating against other staff. During an interview on 9/8/15 at 9:48 p.m., CNA C said Resident #1 required total assistance with all ADLs. She said Resident #1 had strength on some days and was weak on others. CNA C said Resident #1 could be combative when she was gotten up. During a telephone interview on 9/8/15 at 10:08 p.m., CNA D said on 9/3/15 at approximately 10:30 p.m. CNA F came to get her. CNA D said CNA F told her when she walked in Resident #1's room the resident was tied to the bed, fighting, and needed her assistance. CNA D said Resident #1 was lying in bed with the blanket tied across her chest and neck. CNA D said Resident #1 was kicking her legs and fighting to get out of the bed. She said the blanket was restraining Resident #1 to the bed. CNA D said they reported the incident to LVN G. CNA D said she wrote a statement about the incident, but no one talked to her about the incident. During an observation and interview on 9/8/15 at 10:47 p.m., CNA F said on 9/3/15 at approximately 10:30 p.m., she was walking down the hall and heard a resident say, help me, help me. She went into Resident #1's room, but did not immediately see why the resident was in distress. CNA F said Resident #1's feet were dangling out of the bed, the blanket was across her chest, and wrapped around the side rail. CNA F said Resident #1 could not get out of the blanket. She said there was only one side rail up on Resident #1's bed. CNA F said the blanket on the other side of the bed was tucked under Resident #1 and the blanket on the side was tied to the outside of the rail. CNA F said Resident #1 could not have tied the blanket herself. CNA F demonstrated the blanket was tied by being looped over the outside of the rail and pulled into a loop. CNA F said if Resident #1 had the strength she could have thrown the covers back from the opposite side of the rail and been free. She said Resident #1 was trying to sit up and it only made the restraint tighter. CNA F said she requested assistance from CNA D because Resident #1 was struggling so. She said they informed LVN G and was told to let Resident #1calm down some first, because the resident was really mad. CNA F said LVN G was able to untie the blanket after a few minutes. CNA F said she was called at home on 9/4/15 by the ADON to write a statement, but no one ever talked to her about the incident. During an interview on 9/8/15 at 10:35 p.m., the ADON said on 9/4/15, she received report that Resident #1 was tied to her bed. She reported the incident to the DON and she said okay. The ADON said she did not know what happened with the incident because she turned it over to the DON, and did nothing else in regard to the incident or the resident. She said the DON was terminated today (9/8/15.) The ADON said she told the administrator of the incident involving Resident #1 this morning (9/8/15.) An undated statement written by the ADON received on 9/9/15 indicated it was an incident summary for 9/4/15. The statement indicated the report was received at approximately 6:30 a.m., on 9/4/15, during shift report from the night nurse, Resident #1 was found lying in the bed with the blanket tied across her chest and neck. According to the statement the ADON assessed Resident #1 at that time and found no injuries. She reported the incident to the DON on 9/ 4/15 at approximately 8:15 a.m., but could not find an incident report from the night nurse. The statement indicated the ADON questioned staff who worked the 2-10 pm shift on 9/3/15 and found no evidence of malice at that time per interviews and the resident was safe. The administrator and corporate nurse were notified. During a telephone interview on 9/9/15 at 9:33 a.m., the former DON said she was aware of the incident with Resident #1. The former DON said she was told the incident would be handled by the Regional Nurse/RN and administrator. She said she did not believe CNA B was involved. She felt someone tried to set her up due to controversies at the facility between the staff. She did not conduct an in-service, obtain witness statements, or determine was involved in the incident in any way. During a telephone interview on 9/9/15 at 9:47 a.m., CNA B said she usually worked the day shift as the day shift, but on 9/3/15 she provided care for Resident #1 during the 2 p.m.-10 p.m. shift. She said the last time she saw Resident # 1 on 9/3/15 was approximately 9:00 p.m. She said did not tie Resident #1 to the bed. CNA B said she worked on 9/8/15 and no one said anything to her about the incident, she left her shift at 1:00 p.m., due to a family emergency. She said no one told her not to work with Resident #1. CNA B said she suspended regarding the incident with Resident #2 on 9/8/15 at 11:35 p.m. (after surveyor intervention.) During an interview on 9/9/15 at 11:10 a.m., the administrator/abuse coordinator said on 9/8/15 at approximately 10:00 a.m., the ADON informed him of the incident with Resident #1. He said he started an investigation at that time. He did not know if CNA B was suspended or not. The Restraint Devices, Physical policy dated 2006 indicated . the purpose of the policy was to ensure restraints of any type will not be used as punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff. Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . The regional nurse and ADON were notified on 9/8/15 at 11:30 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 9/9/15 at 12:04 a.m., and included: 1. Alleged staff member involved in both incidents will be suspended until the conclusion of the investigation; if, upon completion of the investigation the alleged staff member is determined to be guilty, he/she will be terminated immediately and reported to their respective licensing boards; 2. All staff will be in-serviced on the following: date for completion, 9/9/2015. a.) abuse and neglect policy/procedure; b.) what should be reported immediately and to whom, the Abuse Coordinator or designee; c.) who the Abuse Coordinator is (the facility Administrator); d.) staff that are unable to be in-serviced (due to leave status, etc.), will be in-serviced prior to being allowed to work in the facility. 3. The facility will have evidence that all allegations are thoroughly investigated and documented; 4. All allegations of abuse and/or neglect will be reported immediately to the Administrator or DON; 5. Licensed nurses will document all incidents of alleged abuse and/or neglect on the Incident/Accident Report and on the 24 hour report; 6. Allegations of neglect and/or abuse will be reported to the State (DADS) within 24 hours of report if/when, following the immediate investigation, it is determined that the allegations are substantiated. The surveyors confirmed the plan of removal was implemented sufficiently to remove the Immediate Jeopardy by: On 9/9/15 at 12:30 p.m., interviews with 1 CNA, 1 Housekeeper, 1 medication aide, the social worker, and maintenance man were interviewed and were able to provide information regarding abuse and neglect reporting procedures. They were able to identify the abuse coordinator and able to provide information of different situational events related to abuse. The administrator and ADON were interviewed and able to provide information regarding the procedures to follow when an allegation of abuse was made. On 9/9/15 12:45 p.m., the administrator and two regional RNs were informed the Immediate Jeopardy was lifted; however, the facility remained out of compliance a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 9/8/15 indicated 12 residents had behaviors.

Based on observations, interview and record review, the facility failed to develop and implement policies and procedures to prohibit neglect for 2 of 4 residents reviewed for neglect. (Residents #1 and #2) 1. Resident #1 was admitted [DATE], following surgery to his left ankle, with a cast on his leg. The facility did not adequately assess Resident #1 following surgery to his left ankle. Resident #1 developed gangrene (tissue death to his toes and foot), was sent to the hospital 12 days later, and required a left, above the knee, amputation. The facility did not inform the physician of the resident's admission until 7/13/15, did not obtain MD orders for cast/splint care, did not perform accurate assessments of the area, and did not ensure the resident went to his follow -up post-surgical appointment. This failure contributed to Resident #1 developing gangrene in his wound that resulted in an above the knee amputation. 2. Resident #2's open area to his toe worsened since first identified on 8/12/15. The facility did not perform timely skin assessments. An Immediate Jeopardy situation was identified that existed from 7/6/15 through 7/18/15. However, the facility remained out of compliance at a pattern of actual harm due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 13 residents identified with high risk of skin breakdown at risk for inadequate skin assessments, skin breakdown, infections, pain, and amputation. Findings included: 1.Electronic physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A hospital operative note dated 7/2/15 indicated Resident #1 had an ORIF (open reduction, internal fixation) of his left ankle fracture. A sterile dressing was applied followed by a well-padded splint. A hospital progress notes dated 7/4/15 indicated upon discharge Resident #1's left ankle, had present distal pulses, and was neurovascularly intact. (circulation was adequate). No redness and swelling to suggest [MEDICAL CONDITION] ([MEDICAL CONDITION]. The postoperative plan was non-weight bearing to the left lower extremity for 8-12 weeks due to his poorly controlled diabetes; wound check and suture removal in 2 weeks. There were no other physician orders [REDACTED]. There were no physician/hospital orders for the care and treatment of [REDACTED].#1's clinical record from his admission 7/6/15 through 7/18/15 . A nursing admission assessment dated [DATE] indicated Resident #1 made himself understood and understood others. He required extensive assistance with ADLs, and used a urinal/bedpan. He required only supervision with eating. Resident #1 had pedal pulses palpable bilaterally and 2+ swelling to his left lower leg. His left leg had a bi-valved cast (cast that is cut in half to detect or relieve pressure underneath, especially when a patient has decreased or no sensation in the portion of the body), wrapped with an ace bandage. The assessment indicated the nurse was unable to look at the surgical area due to his cast. Resident #1 was non-weight bearing to left lower leg. During an interview on 8/14/15 at 2:00 p.m., the DON presented a care plan for Resident #1 from a previous admission in 2013. An addendum to the care plan dated 8/13/15, after surveyor intervention, indicated Resident #1 often refused care, and was not compliant with his diet. There was no admission care plan in Resident #1's clinical record. During an interview on 8/14/15 at 2:45 p.m., LVN C said she could not really palpate pulses due to the cast. She said his toes were warm but said she did not document any additional assessment of his toes or feet in her nursing notes. Nursing notes for Resident #1 indicated the following: * 7/11/15 at 12:17 a.m. - reported feeling tired and having little energy, loss of appetite and difficulty concentrating. * 7/13/15 at 11:10 p.m. - skin concern bruises (no location documented). * 7/14/15 at 3:04 p.m.- (ankle) hurts a little more, appeared withdrawn from normal activities, frequently incontinent of bladder, reported feeling tired with little energy and loss of appetite, and difficulty concentrating. *7/15/15 at 10:00 a.m.- weight bearing as tolerated to lower extremities, frequently incontinent of bladder, and rash between thighs. *7/15/15 at 3:39 p.m.- Resident appears withdrawn, noted change of sleep pattern, reports feeling tired, reports moving and speaking slower, restless, rejecting care and loss of appetite. *7/17/15 at 10:52 a.m.- decreased balance, gait unsteady, occasional bladder incontinence, left lower extremity weight bearing as tolerated, non-weight bearing right lower extremity (sic) (wrong leg). Nursing notes from 7/6/15-7/17/15 indicated Resident #1 had normal bilateral pedal (foot) pulses. A physician progress notes [REDACTED].#1 was a new admission. The physician was not notified of his admission, until the week of 7/13/15. The progress note indicated the resident was independent at home until he fractured his ankle. It was documented Resident # 1 had no complaints, the resident said he was allowed to bear weight on his left extremity and bears weight in therapy. The progress note indicated Resident # 1 was non-compliant with diet and smoked. There was no documentation of an assessment of his foot, pulses or etc. During an interview on 8/13/15 at 2:00 p.m., Resident #1's physician said he was not notified of the resident's admission until approximately 10 days after Resident #1's admission. The physician said Resident #1's foot was covered and he did not look at his foot. He said the resident voiced no complaints. The physician said the padding on Resident #1's cast was coming loose and he thought the cast was a hard cast. The physician denied being contacted by therapy regarding any problems. He said he reviewed Resident #1's record and did not see thorough nursing assessments of the resident's foot in the chart. The physician said staff should have assessed for vascular complications every shift. Nursing notes for Resident #1 indicated the following: *7/18/15 at 8:49 a.m. - Pedal pulses equal/normal. *7/18/15 4:18 p.m. - blood glucose levels high. *7/18/15 at 6:30 p.m.- Family visiting, assessed Resident #1's left foot, great toe and second toe were black in coloration, skin non- blanchable, cool to touch and no capillary refill to either toe. Physician called, orders received to send to the emergency room . 7/18/15 at 7:52 p.m., - CNA F reported Resident #1 had refused care earlier in the shift, he was urinating in floor and placing urinal near his water pitcher, not changing his clothes or going to therapy. She had told the SW and LVN C of her concerns, the week before. During an interview on 8/13/15 at 3:10 p.m., LVN D said she worked on 7/18/15 when Resident #1 was sent to the hospital. LVN D denied seeing Resident #1's foot the morning of 7/18/15 because he was sleeping. She said later that day he went outside to smoke and his foot was covered with a blue surgical booty. LVN D said Resident #1 said he was fine and voiced no complaints. LVN D said the previous weekend 7/11-7/12/15, CNA F reported she was noticing some changes of condition with Resident #1 (ie. Urinating on the floor and refusing care). She said she encouraged the CNAs to share their concerns with administrative staff. LVN D said CNA F had reported her concerns to the SW and LVN C. LVN D said on 7/18/15 Resident #1's family came to visit him and approached her about his foot care. LVN D told them he did not have any orders for his foot, nor could she find any record that he had been seen for follow-up physician appointments since his admission. LVN D said she and LVN G assessed Resident #1's left foot and noted dark discoloration to his toes. LVN D said his great toe and second toe was visible but she could not visualize his 4th or 5th toe. She said after they assessed his foot, they notified the physician and sent him to the emergency room . During an interview on 8/13/15 at 4:40 p.m., CNA B said Resident #1 liked to be independent; he walked on his casted foot often, but could be redirected. CNA B said Resident #1 really declined after his admission. She said she reported this to LVN C. During an interview on 8/14/15 at 2:45 p.m., LVN C said Resident #1 was oriented and ambulated via his wheelchair. She said he was diabetic was non-compliant with his diet. LVN C said Resident #1 had a hard cast on his left foot, with an ace wrap around the cast. She said the tips of Resident #1's second and third toes were visible, but the rest of his foot was covered. LVN C said Resident #1 would stand up on his cast and had fallen during his stay, without injury. She said Resident #1 had complained of decreased feeling/sensation in his feet . LVN C said he had [MEDICAL CONDITION] (decreased feeling), and indicated this was normal due to his diabetes. LVN C said she could not really palpate pulses due to the cast, but said his toes were warm. She did not remove any of his dressings on his foot and thought his cast was a hard cast but had originally thought it was a bi-valve cast. LVN C said she did not document the temperature of Resident #1's toes in the nursing notes. She said the physician saw Resident #1 on 7/17/15, and had been called previously regarding insulin orders after the residents' admission. LVN C said she was unsure if the physician had been called when Resident #1 was admitted , but assumed he knew as he was called about insulin and made weekly rounds. LVN C said CNA E scheduled physician appointments for residents. She said she did not know if any of the follow-up physician's appointments had been made for Resident #1. LVN C denied seeing any decline in Resident #1 and felt his urinating on floor and spilling his urinal was normal for him. During an interview on 8/13/15 at 4:30 p.m., CNA E could not find any physician appointments scheduled for Resident #1. CNA E said according to his discharge physician's order [REDACTED]. CNA E said the nurses used to schedule physician appointments, but had been told she needed to make physician appointments. CNA E verified the nurses received the physician's order [REDACTED]. There was no documentation in Resident #1's nursing notes from 7/6/15 through 7/17/15 regarding skin temperature, capillary refill, color of skin or etc. until 7/18/15. An emergency department physician note dated 7/18/15 indicated Resident #1 was status [REDACTED]. The cast was removed with gangrene noted to the bottom of his foot, 1st and 5th toe, and a blister to the top of his foot. He was transferred to a larger hospital for treatment. A hospital discharge note indicated an admission date of [DATE] and a discharge date of [DATE]. The discharge [DIAGNOSES REDACTED]. During an interview on 8/13/15 at 11:30 a.m., LVN A said Resident #1 was not confused, was non-compliant with his diet and walking, and complained of some pain, usually generalized pain, not specific to his foot. He had a soft cast covered by an ace bandage. His toes were visible allowing for assessment of his pedal pulses and color of his toes. LVN A said she checked pedal pulses when she cared for him, but said she did not check capillary refill, skin temperature, or During an interview on 8/13/15 at 2:30 p.m., PTA J said she provided care to Resident #1 only once on 7/13/15. PTA J said Resident #1 ambulated on his left leg, but his orders were for him to be non-weight bearing. PTA J was unsure of the type of cast Resident #1 had on his left leg. (ie. Soft, bi-valved or hard cast) PTA J said Resident #1 had thick gauze and an ace wrap around his left leg, but did not know if it was a cast. She said Resident #1's foot was usually covered. PTA J said she did not observe Resident #1's foot. She said Resident #1 did not voice complaints with his foot or toes. During an interview on 8/13/15 at 4:10 p.m., the DON said Resident #1 was admitted she did not remember looking at his left foot. She said she thought he had a hard cast, but was not sure. The DON said she remembered Resident #1's cast padding was coming loose from the cast. She said Resident #1's physician was not notified for 8 or 9 days after his admission. The DON said Resident #1's physician should have been notified when he was admitted and the staff should have asked for orders for the cast and care of his leg. During an interview on 8/14/15 at 12:45 p.m., the DON said she had not conducted any in-services with staff regarding skin assessments, since Resident #1's admission and discharge. The DON verified she did not have a reliable system to ensure skin assessments were done but said she in-serviced the staff on notifying the physician of new admissions on 7/20/15. 2. Electronic physician orders [REDACTED].#2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 usually understood others and made himself understood. He required extensive assistance with ADLs, ambulated with supervision and was occasionally incontinent of bladder and frequently incontinent of bowel. He had no pressure sores, was at risk for developing pressure sores, and had a lesion on his foot. The care plan received for Resident #2 did not have any entry for risk of skin breakdown. The last skin assessment on the electronic charting s dated 7/23/15 indicated Resident #2 had no skin issues. A skin assessment dated [DATE] for Resident #2 indicated no skin issues. There were no current skin assessments were found for Resident #2. A nurse note dated 8/12/15 at 9:40 p.m., indicated Resident #2 was found with a raw area to the bottom of his left great toe. The area was 2.2 centimeters (cm), red with clear drainage. The hospice nurse was contacted and an order for [REDACTED].>During an interview on 8/13/15 at 11:10 a.m., LVN A said Resident #2 was not identified as having any skin concerns. During an observation and interview on 8/14/15 at 12:05 p.m., Resident #2 had an approximate 3-4 centimeter (cm) of skin peeling off his great toe on his right foot. There was a 2-3 cm dark area to the pad of his great toe. LVN A said the area was firm to touch with a callous around the darkened wound bed. There was no dressing on Resident #2's foot, when his sock was removed. During an interview on 8/14/15 at 12:45 p.m., the DON said skin assessments were not current and up to date. The DON said she had not conducted any in-services with staff regarding skin assessments since Resident #1's admission and discharge. She said she in-serviced the staff on notifying the physician of new admissions on 7/20/15. The DON said she thought the resident was identified on the CMS 672 as having a pressure sore was Resident #2. The resident Assessment Policy updated 1/21/15, said to examine extremities; condition of skin, abrasions, swelling discoloration, condition of toenails, color of extremities, temperature of extremities, tenderness/pain and circulation. The Abuse Policy updated 7/2012 indicated the following .assure that the staff assigned had knowledge of the individual resident's care needs. The neglect definition included: A failure of an individual to provide services, treatment or care to a resident which causes or could cause mental anguish/illness or physical injury, harm or death to a resident. During an interview on 8/18/15 at 11:45 a.m., the DON provided a list that identified 13 residents at high risk for skin breakdown.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit abuse/neglect/misappropriation to the state agency for 2 of 4 residents reviewed for abuse/neglect/misappropriation. (Resident #s1 and 2) 1. Resident #1 was admitted [DATE], following surgery to his left ankle, with a cast on his leg. The facility did not adequately assess Resident #1 following surgery to his left ankle. Resident #1 developed gangrene (tissue death to his toes and foot), was sent to the hospital 12 days later, and required a left, above the knee, amputation. The facility did not inform the physician of the resident's admission until 7/13/15, did not obtain MD orders for cast/splint care, did not perform accurate assessments of the area, and did not ensure the resident went to his follow -up post-surgical appointment. This failure contributed to Resident #1 developing gangrene in his wound that resulted in an above the knee amputation. 2. Resident #2's open area to his toe worsened since first identified on 8/12/15. The facility did not perform timely skin assessments. An Immediate Jeopardy situation was identified that existed from 7/6/15 through 7/18/15. However, the facility remained out of compliance at a pattern of actual harm due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 13 residents identified with high risk of skin breakdown at risk for inadequate skin assessments, skin breakdown, infections, pain, and amputation. Findings included: The Abuse Policy updated 7/2012 indicated the following .assure that the staff assigned had knowledge of the individual resident's care needs. The neglect definition included: A failure of an individual to provide services, treatment or care to a resident which causes or could cause mental anguish/illness or physical injury, harm or death to a resident. The resident Assessment Policy updated 1/21/15, said to examine extremities; condition of skin, abrasions, swelling discoloration, condition of toenails, color of extremities, temperature of extremities, tenderness/pain and circulation. 1.Electronic physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A hospital operative note dated 7/2/15 indicated Resident #1 had an ORIF (open reduction, internal fixation) of his left ankle fracture. A sterile dressing was applied followed by a well-padded splint. A hospital progress notes dated 7/4/15 indicated upon discharge Resident #1's left ankle had present distal pulses and was neurovascularly intact. (circulation was adequate). No redness and swelling to suggest [MEDICAL CONDITION] ([MEDICAL CONDITION]. The postoperative plan was non-weight bearing to the left lower extremity for 8-12 weeks due to his poorly controlled diabetes; wound check and suture removal in 2 weeks. There were no other physician orders [REDACTED]. There were no physician/hospital orders for the care and treatment of [REDACTED].#1's clinical record from his admission 7/6/15 through 7/18/15. A nursing admission assessment dated [DATE] indicated Resident #1 made himself understood and understood others. He required extensive assistance with ADLs, and used a urinal/bedpan. He required only supervision with eating. Resident #1 had pedal pulses palpable bilaterally and 2+ swelling to his left lower leg. His left leg had a bi-valved cast (cast that is cut in half to detect or relieve pressure underneath, especially when a patient has decreased or no sensation in the portion of the body), wrapped with an ace bandage. The assessment indicated the nurse was unable to look at the surgical area due to his cast. Resident #1 was non-weight bearing to left lower leg. During an interview on 8/14/15 at 2:45 p.m., LVN C said she could not really palpate pulses due to the cast. She said his toes were warm but said she did not document any additional assessment of his toes or feet in her nursing notes. Nursing notes for Resident #1 indicated the following: * 7/11/15 at 12:17 a.m. - reported feeling tired and having little energy, loss of appetite and difficulty concentrating. * 7/13/15 at 11:10 p.m. - skin concern bruises (no location documented). * 7/14/15 at 3:04 p.m.- (ankle) hurts a little more, appeared withdrawn from normal activities, frequently incontinent of bladder, reported feeling tired with little energy and loss of appetite, and difficulty concentrating. *7/15/15 at 10:00 a.m.- weight bearing as tolerated to lower extremities, frequently incontinent of bladder, and rash between thighs. *7/15/15 at 3:39 p.m.- Resident appears withdrawn, noted change of sleep pattern, reports feeling tired, reports moving and speaking slower, restless, rejecting care and loss of appetite. *7/17/15 at 10:52 a.m.- decreased balance, gait unsteady, occasional bladder incontinence, left lower extremity weight bearing as tolerated, non-weight bearing right lower extremity (sic) (wrong leg). Nursing notes from 7/6/15-7/17/15 indicated Resident #1 had normal bilateral pedal (foot) pulses. A physician progress notes [REDACTED].#1 was a new admission. The physician was not notified of his admission, until the week of 7/13/15. The progress note indicated the resident was independent at home until he fractured his ankle. It was documented Resident # 1 had no complaints, the resident said he was allowed to bear weight on his left extremity and bears weight in therapy. The progress note indicated Resident # 1 was non-compliant with diet and smoked. There was no documentation of an assessment of his foot, pulses or etc. During an interview on 8/13/15 at 2:00 p.m., Resident #1's physician said he was not notified of the resident's admission until approximately 10 days after Resident #1's admission. The physician said Resident #1's foot was covered and he did not look at his foot. He said the resident voiced no complaints. The physician said the padding on Resident #1's cast was coming loose and he thought the cast was a hard cast. The physician denied being contacted by therapy regarding any problems. He said he reviewed Resident #1's record and did not see thorough nursing assessments of the resident's foot in the chart. The physician said staff should have assessed for vascular complications every shift. Nursing notes for Resident #1 indicated the following: *7/18/15 at 8:49 a.m. - Pedal pulses equal/normal. *7/18/15 4:18 p.m. - blood glucose levels high. *7/18/15 at 6:30 p.m.- Family visiting, assessed Resident #1's left foot, great toe and second toe were black in coloration, skin non- blanchable, cool to touch and no capillary refill to either toe. Physician called, orders received to send to the emergency room . 7/18/15 at 7:52 p.m., - CNA F reported Resident #1 had refused care earlier in the shift, he was urinating in floor and placing urinal near his water pitcher, not changing his clothes or going to therapy. She had told the SW and LVN C of her concerns, the week before. During an interview on 8/13/15 at 3:10 p.m., LVN D said she worked on 7/18/15 when Resident #1 was sent to the hospital. LVN D denied seeing Resident #1's foot the morning of 7/18/15 because he was sleeping. She said later that day he went outside to smoke and his foot was covered with a blue surgical booty. LVN D said Resident #1 said he was fine and voiced no complaints. LVN D said the previous weekend 7/11-7/12/15, CNA F reported she was noticing some changes of condition with Resident #1 (ie. Urinating on the floor and refusing care). She said she encouraged the CNAs to share their concerns with administrative staff. LVN D said CNA F had reported her concerns to the SW and LVN C. LVN D said on 7/18/15 Resident #1's family came to visit him and approached her about his foot care. LVN D told them he did not have any orders for his foot, nor could she find any record that he had been seen for follow-up physician appointments since his admission. LVN D said she and LVN G assessed Resident #1's left foot and noted dark discoloration to his toes. LVN D said his great toe and second toe was visible but she could not visualize his 4th or 5th toe. She said after they assessed his foot, they notified the physician and sent him to the emergency room . During an interview on 8/13/15 at 4:40 p.m., CNA B said Resident #1 liked to be independent; he walked on his casted foot often, but could be redirected. CNA B said Resident #1 really declined after his admission. She said she reported this to LVN C. During an interview on 8/14/15 at 2:45 p.m., LVN C said Resident #1 was oriented and ambulated via his wheelchair. She said he was diabetic was non-compliant with his diet. LVN C said Resident #1 had a hard cast on his left foot, with an ace wrap around the cast. She said the tips of Resident #1's second and third toes were visible, but the rest of his foot was covered. LVN C said Resident #1 would stand up on his cast and had fallen during his stay, without injury. She said Resident #1 had complained of decreased feeling/sensation in his feet . LVN C said he had [MEDICAL CONDITION] (decreased feeling), and indicated this was normal due to his diabetes. LVN C said she could not really palpate pulses due to the cast, but said his toes were warm. She did not remove any of his dressings on his foot and thought his cast was a hard cast but had originally thought it was a bi-valve cast. LVN C said she did not document the temperature of Resident #1's toes in the nursing notes. She said the physician saw Resident #1 on 7/17/15, and had been called previously regarding insulin orders after the residents' admission. LVN C said she was unsure if the physician had been called when Resident #1 was admitted , but assumed he knew as he was called about insulin and made weekly rounds. LVN C said CNA E scheduled physician appointments for residents. She said she did not know if any of the follow-up physician's appointments had been made for Resident #1. LVN C denied seeing any decline in Resident #1 and felt his urinating on floor and spilling his urinal was normal for him. During an interview on 8/13/15 at 4:30 p.m., CNA E could not find any physician appointments scheduled for Resident #1. CNA E said according to his discharge physician's orders [REDACTED]. CNA E said the nurses used to schedule physician appointments, but had been told she needed to make physician appointments. CNA E verified the nurses received the physician's order [REDACTED]. There was no documentation in Resident #1's nursing notes from 7/6/15 through 7/17/15 regarding skin temperature, capillary refill, color of skin or etc. until 7/18/15. An emergency department physician note dated 7/18/15 indicated Resident #1 was status [REDACTED]. The cast was removed with gangrene noted to the bottom of his foot, 1st and 5th toe, and a blister to the top of his foot. He was transferred to a larger hospital for treatment. A hospital discharge note indicated an admission date of [DATE] and a discharge date of [DATE]. The discharge [DIAGNOSES REDACTED]. During an interview on 8/14/15 at 2:00 p.m., the DON presented a care plan for Resident #1 from a previous admission in 2013. An addendum to the care plan dated 8/13/15, after surveyor interventions, indicated Resident #1 often refused care, and was not compliant with his diet. There was no admission care plan in Resident #1's clinical record. During an interview on 8/13/15 at 11:30 a.m., LVN A said Resident #1 was not confused, was non-compliant with his diet and walking, and complained of some pain, usually generalized pain, not specific to his foot. He had a soft cast covered by an ace bandage. His toes were visible allowing for assessment of his pedal pulses and color of his toes. LVN A said she checked pedal pulses when she cared for him, but said she did not check capillary refill, skin temperature, or color of skin. During an interview on 8/13/15 at 2:30 p.m., PTA J said she provided care to Resident #1 only once on 7/13/15. PTA J said Resident #1 ambulated on his left leg, but his orders were for him to be non-weight bearing. PTA J was unsure of the type of cast Resident #1 had on his left leg. (ie. Soft, bi-valved or hard cast) PTA J said Resident #1 had thick gauze and an ace wrap around his left leg, but did not know if it was a cast. She said Resident #1's foot was usually covered. PTA J said she did not observe Resident #1's foot. She said Resident #1 did not voice complaints with his foot or toes. During an interview on 8/13/15 at 4:10 p.m., the DON said Resident #1 was admitted she did not remember looking at his left foot. She said she thought he had a hard cast, but was not sure. The DON said she remembered Resident #1's cast padding was coming loose from the cast. She said Resident #1's physician was not notified for 8 or 9 days after his admission. The DON said Resident #1's physician should have been notified when he was admitted and the staff should have asked for orders for the cast and care of his leg. During an interview on 8/14/15 at 12:45 p.m., the DON said she had not conducted any in-services with staff regarding skin assessments, since Resident #1's admission and discharge. The DON verified she did not have a reliable system to ensure skin assessments were done but said she in-serviced the staff on notifying the physician of new admissions on 7/20/15. 2. Electronic physician orders [REDACTED].#2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 usually understood others and made himself understood. He required extensive assistance with ADLs, ambulated with supervision and was occasionally incontinent of bladder and frequently incontinent of bowel. He had no pressure sores, was at risk for developing pressure sores, and had a lesion on his foot. The care plan received for Resident #2 did not have any entry for risk of skin breakdown. The last skin assessment on the electronic chartings dated 7/23/15 indicated Resident #2 had no skin issues. A skin assessment dated [DATE] for Resident #2 indicated no skin issues. There were no current skin assessments were found for Resident #2. A nurse note dated 8/12/15 at 9:40 p.m., indicated Resident #2 was found with a raw area to the bottom of his left great toe. The area was 2.2 centimeters (cm), red with clear drainage. The hospice nurse was contacted and an order for [REDACTED].>During an interview on 8/13/15 at 11:10 a.m., LVN A said Resident #2 did not have any skin concerns. During an observation and interview on 8/14/15 at 12:05 p.m., Resident #2 had an approximate 3-4 centimeter (cm) of skin peeling off his great toe on his right foot. There was a 2-3 cm dark area to the pad of his great toe. LVN A said the area was firm to touch with a callous around the darkened wound bed. There was no dressing on Resident #2's foot, when his sock was removed. During an interview on 8/14/15 at 12:45 p.m., the DON said skin assessments were not current and up to date. The DON said she had not conducted any in-services with staff regarding skin assessments since Resident #1's admission and discharge. She said she in-serviced the staff on notifying the physician of new admissions on 7/20/15. The DON said she did not know the resident identified on the CMS 672 as having a pressure sore, but thought it was Resident #2. During an interview on 8/18/15 at 11:45 a.m., the DON provided a list identifying 13 residents at high risk for skin breakdown

Based on observation, interview, and record review the facility failed to ensure nursing services met professional standards of quality for 2 of 4 residents reviewed for assessments. (Resident #s1 and 2) 1. Resident #1 was admitted [DATE], following surgery to his left ankle, with a cast on his leg. The facility did not adequately assess Resident #1 following surgery to his left ankle. Resident #1 developed gangrene (tissue death to his toes and foot), was sent to the hospital 12 days later, and required a left, above the knee, amputation. The DON not assess Resident #1's foot, ensure nursing was assessing his foot did not have a system to ensure skin assessments were done for Resident #2). The DON did not supervise nursing staff to ensure Resident #1 was receiving adequate care. She did not inform the physician of the resident's admission until 7/13/15, did not obtain physician orders [REDACTED]. LVN C did not contact the medical director for approximately 10 days after Resident #1's admission on 7/6/15. She, did not contact his orthopaedic physician for clarification of orders on how to assess Resident #1's foot/cast and did not ensure follow up physician appointments were made. This failure contributed to Resident #1 developing gangrene in his wound that resulted in an above the knee amputation. 2. Resident #2's open area to his toe worsened since first identified on 8/12/15. The facility did not perform timely skin assessments. An Immediate Jeopardy situation was identified that existed from 7/6/15 through 7/18/15. However, the facility remained out of compliance at a pattern of actual harm due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 13 residents identified with high risk of skin breakdown at risk for inadequate skin assessments, skin breakdown, infections, pain, and amputation. These failure contributed to Resident #1's gangrenous foot, hospitalization and above the knee amputation and placed 13 residents at risk for developing skin breakdown, infections, pain and hospitalization . Findings included: 1.Electronic physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A hospital operative note dated 7/2/15 indicated Resident #1 had an ORIF (open reduction, internal fixation) of his left ankle fracture. A sterile dressing was applied followed by a well-padded splint. A hospital progress notes dated 7/4/15 indicated upon discharge Resident #1's left ankle had present distal pulses and was neurovascularly intact (circulation was adequate). No redness and swelling to suggest [MEDICAL CONDITION] ([MEDICAL CONDITION]. The postoperative plan was non-weight bearing to the left lower extremity for 8-12 weeks due to his poorly controlled diabetes; wound check and suture removal in 2 weeks. There were no other physician orders [REDACTED]. There were no physician/hospital orders for the care and treatment of [REDACTED].#1's clinical record from his admission 7/6/15 through 7/18/15. A nursing admission assessment dated [DATE] indicated Resident #1 made himself understood and understood others. He required extensive assistance with ADLs, and used a urinal/bedpan. He required only supervision with eating. Resident #1 had pedal pulses palpable bilaterally and 2+ swelling to his left lower leg. His left leg had a bi-valved cast (cast that is cut in half to detect or relieve pressure underneath, especially when a patient has decreased or no sensation in the portion of the body), wrapped with an ace bandage. The assessment indicated the nurse was unable to look at the surgical area due to his cast. Resident #1 was non-weight bearing to left lower leg. During an interview on 8/14/15 at 2:45 p.m., LVN C said she could not really palpate pulses due to the cast. She said his toes were warm but said she did not document any additional assessment of his toes or feet in her nursing notes. Nursing notes for Resident #1 indicated the following: * 7/11/15 at 12:17 a.m. - reported feeling tired and having little energy, loss of appetite and difficulty concentrating. * 7/13/15 at 11:10 p.m. - skin concern bruises (no location documented). * 7/14/15 at 3:04 p.m.- (ankle) hurts a little more, appeared withdrawn from normal activities, frequently incontinent of bladder, reported feeling tired with little energy and loss of appetite, and difficulty concentrating. *7/15/15 at 10:00 a.m.- weight bearing as tolerated to lower extremities, frequently incontinent of bladder, and rash between thighs. *7/15/15 at 3:39 p.m.- Resident appears withdrawn, noted change of sleep pattern, reports feeling tired, reports moving and speaking slower, restless, rejecting care and loss of appetite. *7/17/15 at 10:52 a.m.- decreased balance, gait unsteady, occasional bladder incontinence, left lower extremity weight bearing as tolerated, non-weight bearing right lower extremity (sic) (wrong leg). Nursing notes from 7/6/15-7/17/15 indicated Resident #1 had normal bilateral pedal (foot) pulses. A physician progress notes [REDACTED].#1 was a new admission. The physician was not notified of his admission, until the week of 7/13/15. The progress note indicated the resident was independent at home until he fractured his ankle. It was documented Resident # 1 had no complaints, the resident said he was allowed to bear weight on his left extremity and bears weight in therapy. The progress note indicated Resident # 1 was non-compliant with diet and smoked. There was no documentation of an assessment of his foot, pulses or etc. During an interview on 8/13/15 at 2:00 p.m., Resident #1's physician said he was not notified of the resident's admission until approximately 10 days after Resident #1's admission. The physician said Resident #1's foot was covered and he did not look at his foot. He said the resident voiced no complaints. The physician said the padding on Resident #1's cast was coming loose and he thought the cast was a hard cast. The physician denied being contacted by therapy regarding any problems. He said he reviewed Resident #1's record and did not see thorough nursing assessments of the resident's foot in the chart. The physician said staff should have assessed for vascular complications every shift. Nursing notes for Resident #1 indicated the following: *7/18/15 at 8:49 a.m. - Pedal pulses equal/normal. *7/18/15 4:18 p.m. - blood glucose levels high. *7/18/15 at 6:30 p.m.- Family visiting, assessed Resident #1's left foot, great toe and second toe were black in coloration, skin non- blanchable, cool to touch and no capillary refill to either toe. Physician called, orders received to send to the emergency room . 7/18/15 at 7:52 p.m., - CNA F reported that Resident #1 had refused care earlier in the shift, he was urinating in floor and placing urinal near his water pitcher, not changing his clothes or going to therapy. She had told the SW and LVN C of her concerns, the week before. During an interview on 8/13/15 at 3:10 p.m., LVN D said she worked on 7/18/15 when Resident #1 was sent to the hospital. LVN D denied seeing Resident #1's foot the morning of 7/18/15 because he was sleeping. She said later that day he went outside to smoke and his foot was covered with a blue surgical booty. LVN D said Resident #1 said he was fine and voiced no complaints. LVN D said the previous weekend 7/11-7/12/15, CNA F reported she was noticing some changes of condition with Resident #1 (ie. Urinating on the floor and refusing care). She said she encouraged the CNAs to share their concerns with administrative staff. LVN D said CNA F had reported her concerns to the SW and LVN C. LVN D said on 7/18/15 Resident #1's family came to visit him and approached her about his foot care. LVN D told them he did not have any orders for his foot, nor could she find any record that he had been seen for follow-up physician appointments since his admission. LVN D said she and LVN G assessed Resident #1's left foot and noted dark discoloration to his toes. LVN D said his great toe and second toe was visible but she could not visualize his 4th or 5th toe. She said after they assessed his foot, they notified the physician and sent him to the emergency room . During an interview on 8/13/15 at 4:40 p.m., CNA B said Resident #1 liked to be independent; he walked on his casted foot often, but could be redirected. CNA B said Resident #1 really declined after his admission. She said she reported this to LVN C. During an interview on 8/14/15 at 2:45 p.m., LVN C said Resident #1 was oriented and ambulated via his wheelchair. She said he was diabetic was non-compliant with his diet. LVN C said Resident #1 had a hard cast on his left foot, with an ace wrap around the cast. She said the tips of Resident #1's second and third toes were visible, but the rest of his foot was covered. LVN C said Resident #1 would stand up on his cast and had fallen during his stay, without injury. She said Resident #1 had complained of decreased feeling/sensation in his feet . LVN C said he had [MEDICAL CONDITION] (decreased feeling), and indicated this was normal due to his diabetes. LVN C said she could not really palpate pulses due to the cast, but said his toes were warm. She did not remove any of his dressings on his foot and thought his cast was a hard cast but had originally thought it was a bi-valve cast. LVN C said she did not document the temperature of Resident #1's toes in the nursing notes. She said the physician saw Resident #1 on 7/17/15, and had been called previously regarding insulin orders after the residents' admission. LVN C said she was unsure if the physician had been called when Resident #1 was admitted , but assumed he knew as he was called about insulin and made weekly rounds. LVN C said CNA E scheduled physician appointments for residents. She said she did not know if any of the follow-up physician's appointments had been made for Resident #1. LVN C denied seeing any decline in Resident #1 and felt his urinating on floor and spilling his urinal was normal for him. During an interview on 8/13/15 at 4:30 p.m., CNA E could not find any physician appointments scheduled for Resident #1. CNA E said according to his discharge physician's orders [REDACTED]. CNA E said nurses used to schedule physician appointments, but had been told she needed to make physician appointments. CNA E said nurses received the physician's orders [REDACTED]. There was no documentation in Resident #1's nursing notes from 7/6/15 through 7/17/15 regarding skin temperature, capillary refill, color of skin or etc. until 7/18/15. An emergency department physician note dated 7/18/15 indicated Resident #1 was status [REDACTED]. The cast was removed with gangrene noted to the bottom of his foot, 1st and 5th toe, and a blister to the top of his foot. He was transferred to a larger hospital for treatment. A hospital discharge note indicated an admission date of [DATE] and a discharge date of [DATE]. The discharge [DIAGNOSES REDACTED]. During an interview on 8/14/15 at 2:00 p.m., the DON presented a care plan for Resident #1 from a previous admission in 2013. An addendum care plan dated 8/13/15, after surveyor intervention, indicated Resident #1 often refused care, and was not compliant with his diet. There was no admission care plan in Resident #1's clinical record. During an interview on 8/13/15 at 11:30 a.m., LVN A said Resident #1 was not confused, was non-compliant with his diet and walking, and complained of some pain, usually generalized pain, not specific to his foot. He had a soft cast covered by an ace bandage. His toes were visible allowing for assessment of his pedal pulses and color of his toes. LVN A said she checked pedal pulses when she cared for him, but said she did not check capillary refill, skin temperature, or color of skin. During an interview on 8/13/15 at 2:30 p.m., PTA J said she provided care to Resident #1 only once on 7/13/15. PTA J said Resident #1 ambulated on his left leg, but his orders were for him to be non-weight bearing. PTA J was unsure of the type of cast Resident #1 had on his left leg. (ie. Soft, bi-valved or hard cast) PTA J said Resident #1 had thick gauze and an ace wrap around his left leg, but did not know if it was a cast. She said Resident #1's foot was usually covered. PTA J said she did not observe Resident #1's foot. She said Resident #1 did not voice complaints with his foot or toes. During an interview on 8/13/15 at 4:10 p.m., the DON said Resident #1 was admitted she did not remember looking at his left foot. She said she thought he had a hard cast, but was not sure. The DON said she remembered Resident #1's cast padding was coming loose from the cast. She said Resident #1's physician was not notified for 8 or 9 days after his admission. The DON said Resident #1's physician should have been notified when he was admitted and the staff should have asked for orders for the cast and care of his leg. During an interview on 8/14/15 at 12:45 p.m., the DON said she had not conducted any in-services with staff regarding skin assessments, since Resident #1's admission and discharge. The DON verified she did not have a reliable system to ensure skin assessments were done, but in-serviced staff on notifying the physician of new admissions on 7/20/15. 2. Electronic physician orders [REDACTED].#2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 usually understood others and made himself understood. He required extensive assistance with ADLs, ambulated with supervision and was occasionally incontinent of bladder and frequently incontinent of bowel. He had no pressure sores, was at risk for developing pressure sores, and had a lesion on his foot. The care plan received for Resident #2 did not have any entry for risk of skin breakdown. The last skin assessment on the electronic charting s dated 7/23/15 indicated Resident #2 had no skin issues. A skin assessment dated [DATE] for Resident #2 indicated no skin issues. There were no current skin assessments were found for Resident #2. A nurse note dated 8/12/15 at 9:40 p.m., indicated Resident #2 was found with a raw area to the bottom of his left great toe. The area was 2.2 centimeters (cm), red with clear drainage. The hospice nurse was contacted and an order for [REDACTED].>During an interview on 8/13/15 at 11:10 a.m., LVN A said Resident #2 did not have any skin concerns. During an observation and interview on 8/14/15 at 12:05 p.m., Resident #2 had an approximate 3-4 centimeter (cm) of skin peeling off his great toe on his right foot. There was a 2-3 cm dark area to the pad of his great toe. LVN A said the area was firm to touch with a callous around the darkened wound bed. There was no dressing on Resident #2's foot, when his sock was removed. During an interview on 8/14/15 at 12:45 p.m., the DON said skin assessments were not current and up to date. The DON said she had not conducted any in-services with staff regarding skin assessments since Resident #1's admission and discharge. She said she in-serviced the staff on notifying the physician of new admissions on 7/20/15. The DON said she did not know which resident was identified on the CMS 672 as having a pressure sore, but thought it was Resident #2. The Resident Assessment Policy updated 1/21/15, said to examine extremities; condition of skin, abrasions, swelling discoloration, condition of toenails, color of extremities, temperature of extremities, tenderness/pain and circulation. The DON's job description updated 1/21/15 indicated the DON would provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department. This included assessing, directing and supervising residents' care needs. At http://www.bne.state.tx.us/rr_current/217-11.asp- accessed on 8/18/15 the following was indicated: Title 22 Part 11; Chapter 217- Rule 217:11 Standards of Nursing Practice .(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:. .(S) Make assignments to others that take into consideration client safety and that are commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made;. .(U) Supervise nursing care provided by others for whom the nurse is professionally responsible; and. During an interview on 8/18/15 at 11:45 a.m., the DON provided a list of 13 residents at high risk for skin breakdown.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 3 residents reviewed for skin assessments. (Resident #s1 and 2) 1. Resident #1 was admitted [DATE], following surgery to his left ankle, with a cast on his leg. The facility did not adequately assess Resident #1 following surgery to his left ankle. Resident #1 developed gangrene (tissue death to his toes and foot), was sent to the hospital 12 days later, and required a left, above the knee, amputation. The facility did not inform the physician of the resident's admission until 7/13/15, did not obtain physician orders [REDACTED]. This failure contributed to Resident #1 developing gangrene in his wound that resulted in an above the knee amputation. 2. Resident #2's open area to his toe worsened since first identified on 8/12/15. The facility did not perform timely skin assessments. An Immediate Jeopardy situation was identified that existed from 7/6/15 through 7/18/15. However, the facility remained out of compliance at a pattern of actual harm due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 13 residents identified with high risk of skin breakdown at risk for inadequate skin assessments, skin breakdown, infections, pain, and amputation. Findings included: 1.Electronic physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A hospital operative note dated 7/2/15 indicated Resident #1 had an ORIF (open reduction, internal fixation) of his left ankle fracture. A sterile dressing was applied followed by a well-padded splint. A hospital progress notes dated 7/4/15 indicated upon discharge Resident #1's left ankle had present distal pulses and was neurovascularly intact. (circulation was adequate). No redness and swelling to suggest [MEDICAL CONDITION] ([MEDICAL CONDITION]. The postoperative plan was non-weight bearing to the left lower extremity for 8-12 weeks due to his poorly controlled diabetes; wound check and suture removal in 2 weeks. There were no other physician orders [REDACTED]. There were no physician/hospital orders for the care and treatment of [REDACTED].#1's clinical record from his admission 7/6/15 through 7/18/15 . A nursing admission assessment dated [DATE] indicated Resident #1 made himself understood and understood others. He required extensive assistance with ADLs, and used a urinal/bedpan. He required only supervision with eating. Resident #1 had pedal pulses palpable bilaterally and 2+ swelling to his left lower leg. His left leg had a bi-valved cast (cast that is cut in half to detect or relieve pressure underneath, especially when a patient has decreased or no sensation in the portion of the body), wrapped with an ace bandage. The assessment indicated the nurse was unable to look at the surgical area due to his cast. Resident #1 was non-weight bearing to left lower leg. During an interview on 8/14/15 at 2:00 p.m., the DON presented a care plan for Resident #1 from a previous admission in 2013. An addendum to the care plan, after surveyor intervention, indicated Resident #1 often refused care, and was not compliant with his diet. There was no admission care plan in Resident #1's clinical record. During an interview on 8/14/15 at 2:45 p.m., LVN C said she could not really palpate pulses due to the cast. She said Resident #1's toes were warm, but did not document any additional assessment of his toes or feet in her nursing notes. Nursing notes for Resident #1 indicated the following: * 7/11/15 at 12:17 a.m. - reported feeling tired and having little energy, loss of appetite and difficulty concentrating. * 7/13/15 at 11:10 p.m. - skin concern bruises (no location documented). * 7/14/15 at 3:04 p.m.- (ankle) hurts a little more, appeared withdrawn from normal activities, frequently incontinent of bladder, reported feeling tired with little energy and loss of appetite, and difficulty concentrating. *7/15/15 at 10:00 a.m.- weight bearing as tolerated to lower extremities, frequently incontinent of bladder, and rash between thighs. *7/15/15 at 3:39 p.m.- Resident appears withdrawn, noted change of sleep pattern, reports feeling tired, reports moving and speaking slower, restless, rejecting care and loss of appetite. *7/17/15 at 10:52 a.m.- decreased balance, gait unsteady, occasional bladder incontinence, left lower extremity weight bearing as tolerated, non-weight bearing right lower extremity (sic) (wrong leg). Nursing notes from 7/6/15-7/17/15 indicated Resident #1 had normal bilateral pedal (foot) pulses. A physician progress notes [REDACTED].#1 was a new admission. The physician was not notified of his admission, until the week of 7/13/15. The progress note indicated the resident was independent at home until he fractured his ankle. It was documented Resident # 1 had no complaints, the resident said he was allowed to bear weight on his left extremity and bears weight in therapy. The progress note indicated Resident # 1 was non-compliant with diet and smoked. There was no documentation of an assessment of his foot, pulses or etc. During an interview on 8/13/15 at 2:00 p.m., Resident #1's physician said he was not notified of the resident's admission until approximately 10 days after Resident #1's admission. The physician said Resident #1's foot was covered and he did not look at his foot. He said the resident voiced no complaints. The physician said the padding on Resident #1's cast was coming loose and he thought the cast was a hard cast. The physician denied being contacted by therapy regarding any problems. He said he reviewed Resident #1's record and did not see thorough nursing assessments of the resident's foot in the chart. The physician said staff should have assessed for vascular complications every shift. Nursing notes for Resident #1 indicated the following: *7/18/15 at 8:49 a.m. - Pedal pulses equal/normal. *7/18/15 4:18 p.m. - blood glucose levels high. *7/18/15 at 6:30 p.m.- Family visiting, assessed Resident #1's left foot, great toe and second toe were black in coloration, skin non- blanchable, cool to touch and no capillary refill to either toe. Physician called, orders received to send to the emergency room . 7/18/15 at 7:52 p.m., - CNA F reported that Resident #1 had refused care earlier in the shift, he was urinating in floor and placing urinal near his water pitcher, not changing his clothes or going to therapy. She had told the SW and LVN C of her concerns, the week before. During an interview on 8/13/15 at 3:10 p.m., LVN D said she worked on 7/18/15 when Resident #1 was sent to the hospital. LVN D denied seeing Resident #1's foot the morning of 7/18/15 because he was sleeping. She said later that day he went outside to smoke and his foot was covered with a blue surgical booty. LVN D said Resident #1 said he was fine and voiced no complaints. LVN D said the previous weekend 7/11-7/12/15, CNA F reported she was noticing some changes of condition with Resident #1 (ie. Urinating on the floor and refusing care). She said she encouraged the CNAs to share their concerns with administrative staff. LVN D said CNA F had reported her concerns to the SW and LVN C. LVN D said on 7/18/15 Resident #1's family came to visit him and approached her about his foot care. LVN D told them he did not have any orders for his foot, nor could she find any record that he had been seen for follow-up physician appointments since his admission. LVN D said she and LVN G assessed Resident #1's left foot and noted dark discoloration to his toes. LVN D said his great toe and second toe was visible but she could not visualize his 4th or 5th toe. She said after they assessed his foot, they notified the physician and sent him to the emergency room . During an interview on 8/13/15 at 4:40 p.m., CNA B said Resident #1 liked to be independent; he walked on his casted foot often, but could be redirected. CNA B said Resident #1 really declined after his admission. She said she reported this to LVN C. During an interview on 8/14/15 at 2:45 p.m., LVN C said Resident #1 was oriented and ambulated via his wheelchair. She said he was diabetic was non-compliant with his diet. LVN C said Resident #1 had a hard cast on his left foot, with an ace wrap around the cast. She said the tips of Resident #1's second and third toes were visible, but the rest of his foot was covered. LVN C said Resident #1 would stand up on his cast and had fallen during his stay, without injury. She said Resident #1 had complained of decreased feeling/sensation in his feet . LVN C said he had [MEDICAL CONDITION] (decreased feeling), and indicated this was normal due to his diabetes. LVN C said she could not really palpate pulses due to the cast, but said his toes were warm. She did not remove any of his dressings on his foot and thought his cast was a hard cast but had originally thought it was a bi-valve cast. LVN C said she did not document the temperature of Resident #1's toes in the nursing notes. She said the physician saw Resident #1 on 7/17/15, and had been called previously regarding insulin orders after the residents' admission. LVN C said she was unsure if the physician had been called when Resident #1 was admitted , but assumed he knew as he was called about insulin and made weekly rounds. LVN C said CNA E scheduled physician appointments for residents. She said she did not know if any of the follow-up physician's appointments had been made for Resident #1. LVN C denied seeing any decline in Resident #1 and felt his urinating on floor and spilling his urinal was normal for him. During an interview on 8/13/15 at 4:30 p.m., CNA E could not find any physician appointments scheduled for Resident #1. CNA E said according to his discharge physician's orders [REDACTED]. CNA E said nurses used to schedule physician appointments, but had been told she needed to make physician appointments. CNA E said nurses received the physician's orders [REDACTED]. There was no documentation in Resident #1's nursing notes from 7/6/15 through 7/17/15 regarding skin temperature, capillary refill, color of skin or etc. until 7/18/15. An emergency department physician note dated 7/18/15 indicated Resident #1 was status [REDACTED]. The cast was removed with gangrene noted to the bottom of his foot, 1st and 5th toe, and a blister to the top of his foot. He was transferred to a larger hospital for treatment. A hospital discharge note indicated an admission date of [DATE] and a discharge date of [DATE]. The discharge [DIAGNOSES REDACTED]. During an interview on 8/13/15 at 11:30 a.m., LVN A said Resident #1 was not confused, was non-compliant with his diet and walking, and complained of some pain, usually generalized pain, not specific to his foot. He had a soft cast covered by an ace bandage. His toes were visible allowing for assessment of his pedal pulses and color of his toes. LVN A said she checked pedal pulses when she cared for him, but said she did not check capillary refill, skin temperature, or color of skin. During an interview on 8/13/15 at 2:30 p.m., PTA J said she provided care to Resident #1 only once on 7/13/15. PTA J said Resident #1 ambulated on his left leg, but his orders were for him to be non-weight bearing. PTA J was unsure of the type of cast Resident #1 had on his left leg. (ie. Soft, bi-valved or hard cast) PTA J said Resident #1 had thick gauze and an ace wrap around his left leg, but did not know if it was a cast. She said Resident #1's foot was usually covered. PTA J said she did not observe Resident #1's foot. She said Resident #1 did not voice complaints with his foot or toes. During an interview on 8/13/15 at 4:10 p.m., the DON said Resident #1 was admitted she did not remember looking at his left foot. She said she thought he had a hard cast, but was not sure. The DON said she remembered Resident #1's cast padding was coming loose from the cast. She said Resident #1's physician was not notified for 8 or 9 days after his admission. The DON said Resident #1's physician should have been notified when he was admitted and the staff should have asked for orders for the cast and care of his leg. During an interview on 8/14/15 at 12:45 p.m., the DON said she had not conducted any in-services with staff regarding skin assessments, since Resident #1's admission and discharge. The DON said she did not have a reliable system to ensure skin assessments were done but said she in-serviced the staff on notifying the physician of new admissions on 7/20/15. 2. Electronic physician orders [REDACTED].#2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 usually understood others and made himself understood. He required extensive assistance with ADLs, ambulated with supervision and was occasionally incontinent of bladder and frequently incontinent of bowel. He had no pressure sores, was at risk for developing pressure sores, and had a lesion on his foot. The care plan received for Resident #2 did not have any entry for risk of skin breakdown. The last skin assessment on the electronic charting s dated 7/23/15 indicated Resident #2 had no skin issues. A skin assessment dated [DATE] for Resident #2 indicated no skin issues. There were no current skin assessments were found for Resident #2. A nurse note dated 8/12/15 at 9:40 p.m., indicated Resident #2 was found with a raw area to the bottom of his left great toe. The area was 2.2 centimeters (cm), red with clear drainage. The hospice nurse was contacted and an order for [REDACTED].>During an interview on 8/13/15 at 11:10 a.m., LVN A said Resident #2 did not have any skin concerns. During an observation and interview on 8/14/15 at 12:05 p.m., Resident #2 had an approximate 3-4 centimeter (cm) of skin peeling off his great toe on his right foot. There was a 2-3 cm dark area to the pad of his great toe. LVN A said the area was firm to touch with a callous around the darkened wound bed. There was no dressing on Resident #2's foot, when his sock was removed. During an interview on 8/14/15 at 12:45 p.m., the DON said skin assessments were not current and up to date. The DON said she had not conducted any in-services with staff regarding skin assessments since Resident #1's admission and discharge. She said she in-serviced the staff on notifying the physician of new admissions on 7/20/15. The DON was unsure which resident was identified on the CMS 672 as having a pressure sore. The resident Assessment Policy updated 1/21/15, said to examine extremities; condition of skin, abrasions, swelling discoloration, condition of toenails, color of extremities, temperature of extremities, tenderness/pain and circulation. During an interview on 8/18/15 at 11:45 a.m., the DON provided a list that identified 13 residents at high risk for skin breakdown.

Based on observation, interview, and record review, the facility failed to ensure the drug regimen was free of unnecessary drugs for 1 of 9 residents reviewed for unnecessary medications. (Resident #10) Resident #10 was admitted on [DATE] and could ambulate and make his needs known. His medications were [MEDICATION NAME] and chloral hydrate. Two days later, following a psychiatric consult, his chloral hydrate was discontinued and his [MEDICATION NAME] was significantly increased. On [DATE] he was began on [MEDICATION NAME] orally three times daily and was administered additional injections of [MEDICATION NAME] on [DATE] and [DATE] for aggressive behavior. No further aggressive behaviors were noted on ,[DATE]-[DATE]. Following the medication increase, Resident #10 sustained multiple falls, could not ambulate or transfer himself, and had decreased food and fluid consumption. Five days post admission, Resident #10 was admitted to the ICU and placed on hospice care. Resident #10 died [DATE]. This failure contributed to Resident #10's rapid decline in health status and placed him at risk for serious harm, injury or death. This failure created an Immediate Jeopardy situation identified on [DATE]. The Immediate Jeopardy was removed on [DATE] at 1:05 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 44 residents who received [MEDICAL CONDITION] medications at risk of sedation, fall, decreased quality of life and even death. Findings included: Electronic physician orders dated ,[DATE] indicated Resident #10 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. The orders indicated Resident #10 was to receive [MEDICATION NAME] 125 mg twice daily and Chloral hydrate 1000 mg at night time. A physician's order dated [DATE] at 11:00 a.m., effective for [DATE] indicated Resident #10's choral hydrate was discontinued, [MEDICATION NAME] 500 mg every morning and 1000 mg every night was ordered. The comprehensive care plan dated [DATE] indicated Resident #10 had a history of [REDACTED].#10 to a calmer environment, do not argue, provide safety, and seek assistance if needed. Resident #10 was on the secure unit due to wandering and behavior disturbances. The care plan indicated on [DATE] Resident #10 was at risk for falls due to poor safety awareness, [MEDICAL CONDITION], and wandering constantly with periods of exhaustion. Approaches were to ensure Resident #10 had a chair before he attempted to sit, use of non-skid footwear, and he was encouraged to change positions slowly. The comprehensive care plan did not indicate Resident #10's use of antianxiety or [MEDICAL CONDITION] medications. A nursing note dated [DATE] on admission indicated Resident #10 was able to make his needs known and could understand others. Family reported oral intake was usually greater than 50%. He was independent with transfers, ambulation, eating, toileting, personal hygiene, and dressing. Resident #10 required supervision with bathing. A nursing note dated [DATE] at 1:13 p.m., indicated Resident #10 had numerous physical behaviors directed toward staff. He constantly wandered in and out of other residents' rooms. Resident #10 was continuously confused. Resident #10 had the potential to become combative and was easily agitated with aggressive tendencies. A nursing note dated [DATE] at 5:37 a.m., indicated Resident #10 was wandering around the unit. No other behaviors noted. A psychiatric consult report dated [DATE] indicated Resident #10 was referred for evaluation related to agitation, confusion, recent history of [MEDICAL CONDITION] with behavioral disturbances, and [MEDICAL CONDITION] with hallucinations. The note indicated Resident #10 was quick-stepping up and down the hall in the unit. The previous [MEDICAL CONDITION] medications were [MEDICATION NAME] 125 mg twice daily and chloral hydrate 1000 mg at night time. The note indicated Resident #10 spoke and said "I do not have any money." The NP documented Resident #10 was cooperative with cognition, was without delusions, emotionally stable, no paranoia, no fear and had physical, inappropriate, and disruptive behaviors. The evaluation recommendations were to discontinue the chloral hydrate and increase [MEDICATION NAME] 500 mg each morning and 1000 mg each night time and a [MEDICATION NAME] level in two weeks then every three months. A nursing noted dated [DATE] at 1:14 p.m., indicated Resident #10 had a new order to increase [MEDICATION NAME] to 500 mg each a.m. and 1000 mg each night. A nursing note dated [DATE] at 8:35 p.m., indicated Resident #10 was pacing up and down the hall, knocking on door glass, pulling and turning door handles asking to be let out, cursing because he could not get out, and then cursing the staff. The note indicated Resident #10 wanted out to go home and he had a sad look on his face. A nursing note dated [DATE] at 5:30 a.m., indicated Resident #10 attempted to get up out of bed unassisted, and fell . He had a 4 cm skin tear to the top of his right hand. Nursing notes dated [DATE] indicated Resident #10 attempted to sit on the floor at 11:22 a.m., 11:37 a.m., and 11:45 a.m. A nursing note at 5:11 p.m., indicated Resident #10 was lying on his left side in the hallway. He had a hematoma with a small abrasion to the right side of his head. A physician's order dated [DATE] at 5:30 p.m., indicated Resident #10 was ordered [MEDICATION NAME] 2 mg injection a one-time dose. A nursing note dated [DATE] at 5:32 p.m., indicated Resident #10 was administered [MEDICATION NAME] 2 mg/ml. A nursing note dated [DATE] at 6:15 p.m., indicated Resident #10's speech was slurred, he had no behaviors, no rejections of care, and he appeared withdrawn from normal activities of interest. A physician's order dated [DATE] at 3:00 p.m., indicated Resident #10 was ordered [MEDICATION NAME] 2 mg injection a one-time dose. The physician's order did not indicate a reason for administration. A nursing note dated [DATE] at 12:40 a.m., indicated Resident #10 had musculoskeletal weakness, unsteady gait, and decreased balance. A nursing note dated [DATE] at 1:00 a.m., indicated Resident #10 was sitting in a Geri-chair with no adverse reactions to [MEDICATION NAME]. A nursing note dated [DATE] at 8:26 a.m., indicated Resident #10 fell while walking in the hallway. A nursing note dated [DATE] at 9:15 a.m., indicated Resident #10 was drowsy and had a change in his pupillary reaction. A nursing note dated [DATE] at 9:30 a.m., indicated Resident #10's level of consciousness was not within his normal limits. He was in a drowsy state. A nursing note dated [DATE] at 11:30 a.m., indicated Resident #10 fell when his wife attempted to get him up. A nursing note dated [DATE] at 11:45 a.m., indicated Resident #10 was in a drowsy state and his level of consciousness was not his normal. A nursing note dated [DATE] at 12:15 p.m., indicated Resident #10's level of consciousness was not normal and he continued in a drowsy state. A nursing note dated [DATE] at 2:54 p.m., indicated Resident #10 was provided a new primary care physician who gave a new order for [MEDICATION NAME] 2 mg three times daily routinely. A nursing note dated [DATE] at 2:49 a.m., indicated Resident #10 was sedated. A nursing note dated [DATE] at 5:25 a.m., indicated Resident #10 was sedated. A nursing note dated [DATE] at 9:26 a.m., indicated Resident #10 had slurred/mumbled speech. He was rarely understood and rarely understands. During an interview on [DATE] at 11:20 p.m., LVN B said on [DATE] Resident #10 was in a very drowsy state. She said Resident #10 would attempt to stand and then fall because he could not control his leg movements. LVN B said she notified the DON and ADON that day of Resident #10's falls and requested the physician be notified. LVN B said she related these changes to his medication increase. LVN B said she did not notify the physician. A nursing note dated [DATE] at 1:54 a.m., indicated Resident #10 had no behaviors or rejection of care. A nursing note dated [DATE] at 8:43 a.m., indicated Resident #10 had no behaviors or rejection of care. A nursing note dated [DATE] at 9:20 a.m., indicated Resident #10 refused to eat. A nursing note dated [DATE] at 1:23 p.m., indicated Resident #10 refused to eat and drank ? cup of a supplement. A nursing note dated [DATE] at 5:54 p.m., indicated Resident #10 speech is slurred and speaking slower than normal. He had no behaviors. During an interview on [DATE] at 12:10 p.m., CNA S said she provided care for Resident #10 on the ,[DATE] pm shift on [DATE] and [DATE]. She said he was assisted up to the Geri-chair on [DATE] and he was unable to sit up in the chair on [DATE]. CNA S said Resident #10 had no behaviors and he did not eat well either day. CNA S said she notified the nurse. During an interview on [DATE] at 10:48 a.m., RN J (weekend supervisor) said she did not assess or monitor Resident #10's condition on [DATE] or [DATE]. During an interview on [DATE] at 11:04 a.m., LVN W said Resident #10 was getting in and out of bed, but was not combative on [DATE] and [DATE]. During an interview on [DATE] at 12:15 p.m., MA G said Resident #10 was sleepy over the weekend. She said she continued to administer the [MEDICATION NAME] and [MEDICATION NAME] medications. MA G said she did not notify the nurse of his condition. A nursing note dated [DATE] at 9:00 a.m., indicated Resident #10 refused to eat breakfast. A nursing note dated [DATE] at 1:34 p.m. (after surveyor intervention), indicated LVN E was unable to arouse Resident #10 by verbal or tactile stimuli enough to administer his medications. A nursing note dated [DATE] at 2:17 p.m., indicated Resident #10 refused to eat lunch and took only sips of water. During an interview on [DATE] at 1:05 p.m., LVN C said she provided care to Resident #10 on [DATE], [DATE], and [DATE]. She said Resident #10 was sleepy on the weekend. LVN C said she was not aware Resident #10 did not eat or drink well on the weekend. She said Resident #10's oral mucosa was dry but his skin turgor (a sign commonly used to assess for hydration) was still good. LVN C said she had not consulted with the physician regarding Resident #10's current condition or need to review his [MEDICAL CONDITION] medications. During an observation and interview on [DATE] at 7:15 a.m., Resident #10 was lying in bed. He was not alert, was unable to speak and did not respond to verbal stimuli. Resident #10 when touched by the staff would move his arms in a slow sweeping motion. Resident #10 was unshaven and disheveled. CNA/MA D said she provided care to Resident #10 on [DATE], [DATE], and [DATE] and he was too sleepy all weekend. CNA/MA D said Resident #10 was unable to eat and barely consumed fluids on her shift. During an observation on [DATE] at 12:05 p.m., Resident #10 remained asleep, and did not arouse with verbal stimuli. During an observation on [DATE] at 12:40 p.m., Resident #10 continued to be unarousable, and unable to speak. Resident 10's mouth hung open and his oral mucosa was very dry in appearance. During an observation and interview on [DATE] at 12:45 p.m., Resident #10's mouth was very dry, there was dark orange colored urine on his brief, his eyes were matted, and his face was flushed. LVN E said Resident #10 was sedated from his medications, she was going to hold the [MEDICATION NAME] and notify the charge nurse of Resident #10's condition. During an observation and interview on [DATE] at 12:50 p.m., Resident #10 was lying in his bed, and was offered a small bite of mashed potatoes. The potatoes rested on Resident #10's tongue. Resident #10 did not respond to food placed in his mouth. There were no attempts to chew or swallow the potatoes. CNA/MA D removed the mashed potatoes from Resident #10's mouth using a napkin. CNA/MA D attempted to provide Resident #10 a teaspoon of tea. Resident #10 was unable to swallow and coughed when the fluid was provided. During an interview on [DATE] at 11:48 a.m., CNA O said she provided ADL care for Resident #10 before he was transported to the hospital on [DATE]. CNA O said Resident #10 was unable to stand, required total care with bathing, and did not have aggressive behaviors. During an interview on [DATE] at 11:45 a.m., CNA F said she transported Resident #10 to the hospital on [DATE] in the facility van for admission to the behavioral unit. She said she took an extra staff member with her due to Resident #10's condition. CNA F said he was barely able to sit up in the chair and his head leaned backwards. CNA F said when she picked Resident #10 up from the hospital the day he was admitted , he was able to walk into the facility. During an interview on [DATE] at 1:15 p.m., the ADON said she had not assessed Resident #10's current condition or evaluated if he continued to need [MEDICAL CONDITION] medications. The Medication Administration Record [REDACTED] [MEDICATION NAME] 500 mg each morning on [DATE], [DATE] and [DATE]. [MEDICATION NAME] 1000 mg each night on [DATE], [DATE]. [MEDICATION NAME] 2 mg three times a day on [DATE], [DATE] and once on [DATE] without any documented behaviors The behavior monitoring flow sheet indicated Resident #10's behaviors were: *[DATE] restless, pacing *[DATE] wandering, aggression/combativeness *[DATE] wandering, aggression/combativeness, agitation (discontinued Chloral hydrate, increased [MEDICATION NAME] 500 mg each am and 1000mg each night) *[DATE] wandering, hallucinations/delusions, ([MEDICATION NAME] 2mg injection ordered) *[DATE] aggression/combativeness, agitation ([MEDICATION NAME] 2mg injection ordered and [MEDICATION NAME] 2 mg three times daily) *[DATE] no behaviors *[DATE] no behaviors *[DATE] no behaviors *no behaviors on [DATE], [DATE] and [DATE] and the record indicated redirection was used for the above behaviors. A meal intake record indicated Resident #10's meal consumption included: *[DATE] no breakfast or lunch and ,[DATE]% of evening meal and 240 ml fluid *[DATE] ,[DATE]% of breakfast with 240 ml fluid, ,[DATE]% lunch and 360 ml fluid, and ,[DATE]% evening meal and 400 ml fluid *[DATE] ,[DATE]% of breakfast and no fluids, ,[DATE] % lunch and no fluids, ,[DATE] % lunch 480 fluids. *[DATE] ,[DATE]% breakfast and no fluids, ,[DATE]% lunch 200 ml fluids, refused evening meal and 480 ml fluids. *[DATE] No meals consumed and 100 ml of fluids consumed with meals. *[DATE] No meals or fluids consumed *[DATE] No meals or fluids consumed A physicians order dated [DATE] at 2:00 p.m., indicated Resident #10 was to be transferred to a local hospital's behavioral unit. A hospital admission note [DATE] indicated Resident #10 was admitted to a local hospital with the [DIAGNOSES REDACTED]. During an interview on [DATE] at 9:53 a.m., Resident #10's daughter said her father just passed away. During an interview on [DATE] at 11:35 p.m., the DON said she was notified by LVN B of Resident #10's falls following the medication increase, but had no reply when asked what action she took. The DON said she did not notify the physician of Resident #10's decline in health status. During an interview on [DATE] at 12:00 p.m., the physician for the behavioral unit said Resident #10 was a very difficult case with how he responded to medications due to his [DIAGNOSES REDACTED]. The physician said the medication regimen he was provided on discharge was working well. She said Resident #10 left the psychiatric unit of the hospital very well managed on the medication regimen on discharge. The physician said the facility called the psychiatric unit for re-admittance, but there were no beds available. She said she recommended the facility place Resident #10 back on the medications that worked for him. The physician said [MEDICATION NAME] 500 mg in the morning and 1000 mg in the evening with [MEDICATION NAME] 2mg three times a day was a large dose for an elderly person. During an interview on [DATE] at 2:10 p.m., NP U for the psychiatric services said he evaluated Resident #10 due to behaviors. He said he made recommendations only. The NP said the resident's physician would have to order the medications to be administered. The NP said he was not notified by the facility of Resident #10's decreased behaviors for further recommendations to decrease the medications. During an interview on [DATE] at 2:50 p.m., NP V said Resident #10 was not accepted for care upon admission to the facility. He said he did not approve Resident #10's medication changes and advised the facility to find Resident #10 a physician. An undated policy and procedure Psychoactive Drug Monitoring indicated residents who receive antidepressant, hypnotic, antianxiety, or antipsychotic medications are monitored to evaluate the effectiveness of the medications. Every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects. (a) Residents receive a psychoactive medication only if designated medically necessary by the prescriber. The medical necessity is documented in the resident's medical record and in the care planning process. (d) Therapy with psychoactive drugs is initiated at a low dose and gradually increased as necessary whenever possible. Antianxiety dosage for [MEDICATION NAME] ([MEDICATION NAME]) indicated 2mg/day for the elderly. FDA.gov/drugs accessed [DATE] at 10:59 a.m., Due to a decrease in unbound clearance of valproate and possibly a greater sensitivity to somnolence in the elderly, the starting dose should be reduced in these patients. Dosage should be increased more slowly and with regular monitoring for fluid and nutritional intake, dehydration, somnolence, and other adverse reactions. Dose reductions or discontinuation of valproate should be considered in patients with decreased food or fluid intake and in patients with excessive somnolence. The ultimate therapeutic dose should be achieved on the basis of both tolerability and clinical response (see Warnings and Precautions (5.13)). The administrator and DON were notified on [DATE] at 2:30 p.m., that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was accepted on [DATE] at 1:05 p.m. and included: " * Nursing Administration will review twenty-four hour communication report for changes of condition, abnormal events or medication changes on a daily basis and the weekend supervisor to review on Saturday and Sunday. * All residents will be assessed; the 24 hours report will be reviewed for change of condition by [DATE] by 10 a.m. * All residents will have a head to toe assessment performed and findings documented by [DATE], 12 p.m. * Any resident noted with a change of condition will have physician and family notified and sent to ER for evaluation if indicated. * DON will in-service all staff regarding decline in condition with new [MEDICAL CONDITION] medications, side effects to report and adverse reactions. In-service for ,[DATE] p.m. shift will be conducted by [DATE], 4 p.m., 10 p.m-6 a.m. will be in-serviced via telephone [DATE], by 6 p.m. Weekend and PRN staff will be in-serviced via telephone by [DATE] by 5 p.m. * CNAs will notify their charge nurse per shift of any noted changes in resident condition or behavior. * Licensed nurse will document any new medications, effectiveness and the continued need for the medication every shift for 72 hours. * The QA committee will monitor all changes of condition daily for three weeks and monthly thereafter. " On [DATE], the surveyors confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: RN K was interviewed on [DATE] and able to identify accurately signs and symptoms of change of condition related to medications, what to do, who to notify and how to document the resident's condition change in the nursing progress notes and the 24 hour communication report. The weekend RN Supervisor J was interviewed on [DATE] and was unable to identify correctly, how to assess residents, how to document and etc. This was brought to the attention of the Administrator and the DON. They stated RN K was working the upcoming weekend (,[DATE]-,[DATE]) and on Monday [DATE] they would evaluate RN J's competency before she continued as weekend supervisor. 5 LVNs representing all three shifts (,[DATE], ,[DATE] and ,[DATE] ) were interviewed and could answer questions appropriately regarding change of condition, and verified they received in-service training. 7 CNAs and 2 MAs (representing all shifts; 3- ,[DATE], 2-,[DATE] and 3-,[DATE]) were interviewed and said they should notify their charge nurse if they identified residents with a change of condition or change in their behavior. The DON, ADONs, and Administrator said the census of 53 residents were assessed on [DATE] for changes of condition, staff were in-serviced on changes of condition with medication changes, and 24 hour reports were reviewed for medication changes and changes of condition. The administrator was informed the Immediate Jeopardy was removed on [DATE] at 1:05 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated 44 residents received antipsychotic medications.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent falls for 1 of 6 residents reviewed for accidents. (Resident #10) Resident #10 fell without injury on [DATE]. No new interventions were put into place to reduce the resident's risk for falls. On [DATE] Resident #10 fell out of bed and fractured her neck . This failure contributed to Resident #10's second fall with injury and hospitalization . This failure and could place 34 residents who were high fall risk at an increased risk for injuries. Findings included: Consolidated physician orders [REDACTED]. Resident #10's re-admission physician orders [REDACTED]. She had a fall mat at bedside, a bed alarm and ,[DATE] side rails up times 2, when in bed for repositioning assistance due to weakness. The most recent MDS assessment dated [DATE] indicated Resident #10 usually made herself understood and was able to understand others. She required extensive to total care for all of her ADLs. Resident #10 had limitation of both lower extremities. The MDS indicated she had fallen since admission without injury. A nursing care plan updated [DATE] indicated Resident #10 was at risk for falls. Interventions included "... anticipate the resident's needs, place call light in reach, use enabler bars for bed boundaries, ensure the resident wears appropriate footwear when in wheelchair, follow fall protocol, provide safe environment including adequate light, place bed in low position at night, place personal items in reach, and provide therapy for strengthening..." A fall management plan of care dated [DATE], updated [DATE] indicated Resident #10 had fallen getting out of bed on [DATE]. Interventions included "...obtain PT/OT screen, utilize two personal mechanical lift for transfers, place bed in low position and get out of bed when awake..." An Incident/Accident report dated [DATE] indicated the LVN had been called by a CNA to Resident #10's room, where she was found on the floor, on her buttocks with her head toward the foot of the bed. Resident #10 was alert, with confusion, and told the nurse she was trying to get out of bed to check on her husband (who is deceased ). The interventions to prevent re-occurrence were to keep the bed low, and get her out of bed as soon as possible. During an interview on [DATE] at 9:45 a.m., RN M said Resident #10 could turn from side to side independently. She said the 10 p.m.- 6 a.m. staff told her Resident #10 was able to change positions. Resident #10's therapy screen dated [DATE] (post fall), indicated no interventions for fall preventions were recommended, and no new therapy services were added. During an interview on [DATE] at 1:17 p.m., PTA O said Resident #10 had flexion contractures of her lower legs. PTA O said Resident #10 received therapy to help position her off of her pressure ulcer. She said Resident #10 was not receiving therapy due to her last fall. PTA O said Resident #10 was screened after her fall on [DATE] and no recommendations were made. She said therapy should have been recommended to help prevent future falls. On a fall risk assessment dated [DATE] Resident #10 scored a 14, which indicated she was at high risk for falls. (reference range - 10 or higher may represent a high risk for falls) The facility's investigation report dated [DATE] indicated Resident #10 had an injury of unknown origin that was reported to the state agency. The report indicated on [DATE] at 5:15 p.m., Resident #10 was found face down on the floor, complaining of neck pain. She was sent to the hospital and transferred to another hospital due to a fracture of the neck. Her hospital report dated [DATE] indicated she had a closed C2 (cervical) fracture and hemotoma left side of head. During an interview on [DATE] at 3:25 p.m., CNA J said she and CNA K turned Resident #10 on her right side in the bed on [DATE]. She said they placed a pillow beneath her right leg and a pillow to her back (not folded but flat). CNA J said she found Resident #10 on the floor, lying on her left side, with the left side of her face and both contracted knees facing the doorway. She said her left arm was beneath her. CNA J said the night shift staff told her Resident #10 tried to get out of bed sometimes, but they had not seen her move in bed. During an interview on [DATE] at 3:55 p.m., CNA K said she and CNA J turned/positioned Resident #10 in the bed on [DATE]. She said they placed a pillow under her knees, between her knees and flat behind her back. CNA K said they heard hollering and CNA J found Resident #10 lying on the floor. CNA K said Resident #10 was lying on her left side facing the door and her left arm was underneath her body. CNA K sad Resident #10 complained of her neck hurting. CNA K said staff had told her Resident #10 still thought she could walk and was "trying to get out of bed". CNA K said Resident #10 could straighten her legs out a little, but would draw them back up. During an interview on [DATE] at 4:15 p.m., Kitchen Aide L said she was Resident #10's grand-daughter and she was called to Resident #10's room on [DATE]. She said Resident #10 was lying on the floor. Kitchen Aide L said her grandmother fell a few months before. She said her grandmother had Alzheimer's and contractures but had strength in her left arm. Kitchen Aide L said her grandmother was normally total care, but would try to move and thought she could do things but she could not. Kitchen Aide L said Resident #10 could make her needs known. During an observation on [DATE] at 9:17 a .m., Resident #10's bed was a low air loss, low bed. The bed was approximately ,[DATE] feet from the top of the mattress to the ground (not in lowest position). When in the lowest position it measured 2 feet from the mattress to the ground. During an interview on [DATE] at 4:30 p.m., the DON said Resident #10's condition had declined since her last hospitalization from her fall in August. She said they used to get her up daily but did not get her up as much now. The DON said when Resident #10 was admitted to hospice on [DATE] they changed her bed and she was no longer in a bariatric bed with enabler bars. The DON said they had not attempted to use any other fall preventions. During an interview on [DATE] at 9:35 a .m., the DON said 34 residents were high risk for falls.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent development and worsening of pressure sores for 1 of 4 residents sampled for pressure sores. (Resident #5) Resident #5 was admitted without pressure sores, but was at high risk for the development of pressure sores. The resident developed 2 Stage ll and one Stage lll pressure sores. The facility did not provide pressure reduction devices per the care plan or accurately assess the pressure sores. These failures contributed to the development of new pressures sores and the worsening of an existing pressure sore for Resident #5 and could place 3 residents with pressure sores at risk for developing new pressure sores and a decline in existing pressure sores. Finding included: Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #5 was sometimes understood, had memory impairment, required total assistance with activities of daily living, was incontinent of bladder and bowel, and could not transfer independently. There were no pressure sores documented at the time of this assessment. Resident #5's care plans dated 9/7/11 indicated he was at risk for alteration in skin integrity. The care plan indicated he was to have pressure reduction devices for his mattress and wheelchair and required assistance with transfers and positioning. A Braden scale assessment dated [DATE] indicated Resident #5 was at high risk for skin breakdown. Skin assessment sheets completed by the treatment nurse dated 10/7/11 and 10/14/11, indicated Resident #5 ' s skin was clean, dry, and intact. The nursing notes dated 10/20/11 at 3:30 p.m. indicated Resident #5 developed a new open area to the right buttock. The area was described as broken skin. The nursing notes dated 10/21/11 at 12:00 a.m. indicated Resident #5 had an open area to the buttock. The nursing notes dated 10/21/11 at 1:00 p.m. indicated the physician was notified regarding Resident #5's excoriated buttock. A new order was obtained to apply [MEDICATION NAME] to the buttocks after every incontinent episode. The nursing notes dated 10/22/11 at 12:00 a.m. indicated Resident #5 had an open area to the buttocks. The nursing notes dated 10/22/11 at 6:30 p.m. indicated a concern was voiced by Resident #5's family that he was "raw on his backside." The nursing notes dated 10/23/11 indicated Resident #5 had been assessed by all three shifts as having open areas to the buttocks. During an observation and interview on 10/24/11 at 1:00 p.m., the treatment nurse said Resident #5 currently had excoriation to his buttocks and the current treatment was [MEDICATION NAME]. The resident was lying on a non-pressure relieving mattress. The pressure sore to the right upper buttock measured 4.0 cm x 1.5 cm with white slough in the center. The treatment nurse said the " white area" had not always been there. The pressure sore to the right lower buttock measured 3.0 cm x 2.5 cm and was red and open. The pressure sore to the left buttock measured 1.5 cm x 1.5 cm and was red and open. The treatment nurse said Resident #5's skin had worsened over the weekend from excoriation to 3 Stage II pressure sores. The treatment nurse cleaned all the pressure sores with normal saline and applied [MEDICATION NAME]. The nursing notes dated 10/24/11 at 2:00 p.m. noted a new order was obtained for [MEDICATION NAME] Ag, cover the wound with 4x 4 gauze and secure with tape daily. The weekly pressure ulcer healing record dated 10/24/11, untimed, indicated Resident #5 had a Stage II pressure sore to the right buttock, a Stage II to the left buttock. There was no documentation of the " white area " noted in the record. During the following observations on 10/24/11, Resident #5 did not have a pressure reducing mattress at 10:52 a.m., 11:20 a.m., or 3:04 p.m. During the following observations, Resident #5 was seated in his wheelchair without a pressure relieving device in his wheelchair on 10/24/11 at 1:00 p.m., and 10/25/11 at 9:15 a.m., 12:34 p.m., and 1:12 p.m. During an observation and interview on 10/25/11 at 1:12 p.m., the treatment nurse said the pressure sore to Resident #5's right upper buttock was a Stage ll. After the surveyor questioned the treatment nurse about the " white area " , the treatment nurse said the pressure sore would have to be classified as a Stage III instead of a Stage ll because it had white slough in the wound bed. The treatment nurse said the resident had two Stage II pressure sores to the right and left lower buttocks that were red and open. The nursing notes dated 10/25/11 at 1:40 p.m., noted the following: * Stage III pressure sore to the right upper buttock that measured 3.0 cm x 2.5 cm with an area of white slough that measured 2.0 cm x 1.5 cm in the middle of the wound bed. * Stage II pressure sore to the right lower buttock measured 3.0 cm x 2.5 cm. * Stage II pressure sore to the left lower buttock measured 1.5 cm x 1.5 cm. During an interview on 10/25/11 at 2:58 p.m., CNA J said on 10/22/11 during the 10:00 p.m. to 6:00 p.m. shift, she noted Resident #5's bottom was red and bruised. CNA J said one spot "might have been open." During an interview on 10/25/11 at 3:03 p.m., CNA K said she worked with Resident #5 on Saturday and Sunday (10/22/11 and 10/23/11) on the 6:00 a.m. to 2:00 p.m. shift. She said Resident #5's bottom worsened over the weekend. She said there was open skin that was "pink-like." CNA K said she applied a "Vaseline type cream" to the resident's buttocks. During an interview on 10/25/11 at 3:08 p.m., LVN L said she worked with Resident #5 on 10/21/11, 10/22/11, and 10/23/11 on the 2:00 p.m. to 10:00 p.m. shift. She said Resident #5's bottom did not look excoriated; it looked like a Stage II pressure sore to the right upper buttock. She said she remembered " white, marbled areas " to the wound bed. LVN L said the CNAs were applying [MEDICATION NAME] and checking for incontinence every hour. LVN L said the white area was noted to the wound bed on Friday or Saturday. LVN L said Resident #5 was on a non-pressure relieving mattress over the weekend, and was not placed on a low-air loss mattress until Monday, 10/24/11 following surveyor intervention. LVN L said she did not notify the physician regarding the worsening of Resident #5's pressure sores. During an interview on 10/25/11 at 3:15 p.m., CNA C said she worked with Resident #5 on the 2:00 p.m. to 6:00 a.m. shift on 10/23/11. She said the resident had an open pink and white sore on his right buttock. She said Resident #5 was on a regular mattress over the weekend. She said she did not see a pressure relieving cushion in Resident #5's chair. CNA C said she notified the charge nurse the pressure sore was worse. She said the nurse told her to make sure she applied the [MEDICATION NAME] to Resident #5's buttocks. During an interview on 10/25/11 at 3:32 p.m., LVN M said she worked with Resident #5 on Saturday and Sunday, 10/22/11 and 10/23/11, from 6:00 a.m. to 2:00 p.m. She said she had not seen Resident #5's pressure sore but was aware it was a Stage II. She said when a resident had a pressure sore they normally are placed on a low-air loss mattress. During an interview on 10/25/11 at 3:38 p.m., CNA N said she worked with Resident #5 on Friday, Saturday, and Sunday, 10/21/11, 10/22/11, and 10/23/11 from 6:00 a.m. to 2:00 p.m. She said Resident #5 had a "bedsore" that was open and red. CNA N said she got Resident #5 up for breakfast and there was no pressure relieving cushion in his chair. CNA N said the treatment nurse was aware of the "bedsore." During an interview on 10/25/11 at 4:20 p.m., the DON said Resident #5 should have a pressure relieving cushion in his wheelchair. She said she thought Resident #5 had excoriation to the buttocks, and was not aware the areas had opened and were now assessed as two Stage II pressure sores and a Stage III pressure sore with slough. Resident #5's clinical record contained no information regarding a change in treatment that addressed the worsening of the pressure sore to the right upper buttock from 10/20/11 to 10/24/11. laboratory results dated [DATE] indicated Resident #5 had a low [MEDICATION NAME] of 2.9 (reference range 3.5 - 5.7) and a low total protein of 6.3 (reference range 6.4 - 8.9). According to the Clinical Practice guideline #15, treatment of [REDACTED]. The state of the wound is correlated with the severity of nutritional deficits, particularly low protein intake or a below-normal serum [MEDICATION NAME]. " The following physician orders [REDACTED]. *Vitamin C (supplement for wound healing) 500 mg two times daily x 30 days. *Zinc (supplement for wound healing) 220 mg daily x 30 days. *Juven (supplement for wound healing) 1 packet two times daily x 14 days. The pressure ulcer prevention and skin care management policy revised 12/04 indicated, "A licensed nurse shall assess all pressure ulcers and contact the physician for treatment orders. " The Agency for Healthcare Policy and Research, Number 15 for treatment of [REDACTED]. Individuals who were in bed should not be positioned on the pressure ulcer. The National Pressure Ulcer Advisory Panel Website www.npuap.org/pr2.htm accessed on 10/27/11 indicated the following: Pressure Ulcer Definitiona pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer StagesSuspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. This stage should not be used to describe ...excoriation. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.Unstageable:Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. The CMS 672 dated 10/24/11 indicated 3 residents had pressure sores.